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Health Care Trends

Trend Data On Medical Encounters: Tracking A Moving Target

Abstract

 
The National Health Care Survey (NHCS), conducted by the National Center for Health Statistics, consists of separate data collection activities that can be used to track the number and content of health care encounters in the United States. Tracking even something as simple as the number of encounters, however, is complicated by the fact that the content of these encounters changes over time. Results from the NHCS indicate that the U.S. population has been receiving more drugs, more cardiac procedures, more ambulatory surgery, more therapies in nursing homes, and more home health care over time. Policymakers and researchers who examine health care trends should be wary about judging whether the number or length of encounters is positive or negative without also examining the content of these encounters.

New and emerging technologies, including drugs, devices, procedures, and tests, have changed patterns of care and sites where care is provided. The growth of ambulatory surgery has been influenced by improvements in anesthesia and analgesia and by the development of noninvasive or minimally invasive techniques. Procedures that formerly required a few weeks of convalescence now require only a few days.¹ New drugs can cure or lengthen the course of previously fatal or debilitating diseases, although often at enormous cost. Use of new technologies in the home, including parenteral nutrition, chemotherapy, antibiotic therapy, anticoagulation infusions, transfusion of blood and blood products, oxygen therapy, and home dialysis, also has spurred shifts in the site of care.²

The effects of changing market forces, such as the aging of the population, and major changes in health care financing and organization cannot be ignored. The growth of managed care and payment mechanisms employed by these organizations has had a major impact on use of health care. Efforts by employers to increase managed care enrollment, as well as major Medicare and Medicaid cost containment efforts such as the prospective payment system (PPS) for hospitals and the resource-based relative value scale (RBRVS) for physician payment have created incentives to shift sites of services provided.³ They also have created incentives to provide services differently —for example, the increase in capitated payment and the need to use gatekeepers have been associated with a changing mix of primary and specialty care.⁴

Health care use has changed as the population ages, its sociodemographic makeup shifts, and the prevalence and incidence of different diseases evolve. During the past fifteen years new diseases such as human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and hepatitis C have emerged as new public health threats without hope of cure.⁵ New treatments for these diseases have increased longevity and reduced disease-related disabilities. Hospitalization for chronic diseases associated with end-stage cardiovascular disease, musculoskeletal disease, frailty, and iatrogenic aspects of institutionalization are also increasing, which affects the need for associated health care services.⁶

In the face of these numerous and far-reaching changes, are patients receiving more or different medical care services than they did fifteen years ago? Health care costs have certainly gone up, but what is being provided for these increased costs? Are more or different procedures or tests being performed during physician visits, hospitalizations, or other health care encounters? Are encounters longer or shorter, on average? Has the rise in ambulatory services reduced the amount of institutional or inpatient care?

To address these questions and others, this paper presents trends in patients’ use of major health care services. We need to know where we have been, where we may be going, and what drives change, to better organize the health care infrastructure in terms of supply of services, eliminating barriers to care for specific populations, improving quality of care, and forecasting health care costs.

Data And Methods

Top Data And Methods How Has Medical Care... What Lies Beneath The... Discussion NOTES

 
Most data reported here come from the National Health Care Survey (NHCS), a collection of six major data collection activities described in Exhibit 1. These data are the only data source on the content of health care encounters obtained directly from provider records for a representative sample of all Americans. Other surveys that collect provider data either are not nationally representative (for example, the Hospital Cost and Utilization Project, or HCUP), sample only specific populations (for example, the Medicare Current Beneficiary Survey, or MCBS), or collect data from household respondents and not from medical records (for example, the National Health Interview Survey, NHIS; the Medical Expenditure Panel Survey, MEPS; and the Community Tracking Study, CTS). Health Care Financing Administration (HCFA) program data provide important information on trends, but data are limited to persons covered under HCFA programs and their covered services. Data obtained directly from providers are more reliable sources of the actual number and content of encounters than are available directly from patients or their household proxies.

The National Ambulatory Medical Care Survey (NAMCS) consists of a nationally representative sample of visits to office-based physicians, not federally employed, who are primarily engaged in direct patient care.⁹ Physicians in anesthesiology, pathology, and radiology are excluded from the survey. Its counterpart, the National Hospital Ambulatory Medical Care Survey (NHAMCS), consists of a national sample of visits to the emergency and outpatient departments of general and short-stay hospitals, exclusive of federal, military, and VA hospitals. Only NHAMCS data collected from emergency departments (EDs) are presented here. Data are also combined for two consecutive years to provide more statistically reliable estimates for each time period.

The National Nursing Home Survey (NNHS) and the National Home and Hospice Care Survey (NHHCS) provide estimates of nursing home and home health service use regardless of agency certification by Medicare or Medicaid and patient funding source.¹⁰ Although the NHHCS included patients from both hospices and home health agencies, data presented here include only home health patients. Data from these two surveys provide both point-in-time estimates of patients (from the current resident sample) and annual estimates of encounters (from the discharge sample).

Health care encounter data (doctor visits, ED or outpatient department visits, or discharges from hospitals, nursing homes, and home health agencies) from provider surveys represent events, not persons. For example, persons who visited a physician more than once during a seven-day period of data collection were included multiple times in the list from which the sample was drawn, as were discharges from hospitals, nursing homes, home health agencies, and hospices during the one-year period of data collection. Utilization rates of health care events per capita (or per population) represent the magnitude of health care use by a particular population that can be compared across various population groups, but they cannot be used to examine the amount or type of care provided to individuals within a particular population group.

All differences noted are statistically significant at the p < .05 level using either weighted linear regression techniques or Bonferroni tests for trends among multiple comparisons. When data from only two years are compared, differences are tested using the two-tailed Z-test. Individual standard error estimates were computed using the SUDAAN software.¹¹

How Has Medical Care Use Changed Over The Past Fifteen Years?

Top Data And Methods How Has Medical Care... What Lies Beneath The... Discussion NOTES

 
Since 1985 the general trends indicate that hospital discharge rates overall have been decreasing, nursing home discharge rates and home health episodes have been increasing, and physician visit rates have not changed much (Exhibit 2).

Exhibit 3 shows that the trends in overall use of physician services mask large changes in encounter rates among the elderly. The visit rate increased for the population over age sixty-five and the increase was greater for black elderly persons (data not shown), for whom the visit rate increased 61 percent from an average of 3.5 per person in 1985 to 5.6 per person in 1997–98. The mean age of patients in office-based encounters increased from 39.6 in 1985 to 42.7 in 1997–98 (data not shown).

The rate of nursing home discharges per 1,000 persons, and for the elderly in particular, increased more rapidly than did utilization rates for other types of health care encounters.¹⁶ Medicare program data show an increase in the Medicare skilled nursing facility (SNF) benefit of ten per 1,000 Medicare enrollees served in 1985 to forty-six per 1,000 in 1997. The statistic that measures the volume of patients, however, should be viewed in the context of trends in the rate of persons who currently reside in nursing homes, who are excluded from the discharge estimates. The rate of nursing home residency has actually decreased slightly, from 6.2 per 1,000 persons in 1985 to 5.9 per 1,000 in 1995, although it rose again slightly between 1995 and 1997. These trends occurred along with a decrease in the number of nursing homes (from 19,100 in 1985 to 17,259 in 1998) but an increase in the number of nursing home beds (from 1.6 million beds in 1985 to 1.8 million in 1998).¹⁷

Between 1992 and 1996 home health care also expanded rapidly, from twelve to thirty episodes per 1,000 population, but declined in 1998.¹⁸ Similar trends are observed using Medicare program data, which show an increase in use of the Medicare home health benefit —40 per 1,000 enrollees received home health agency services in 1985, and 106 per 1,000 did so in 1997.¹⁹ The number of agencies providing home and hospice care services also increased dramatically between 1992 (8,000 agencies) and 1998 (16,500 agencies) to meet the increasing demand.²⁰

What Lies Beneath The Basic Utilization Trends?

Top Data And Methods How Has Medical Care... What Lies Beneath The... Discussion NOTES

 
Utilization rates are an important indicator of what general types of care specific populations seek, and they provide an indication of how services may be shifting from one site to another. They do not, however, tell us much about exactly what services are being provided, which can serve as a proxy for either access to specific services or quality of care. A visit in a physician’s office could include tests, procedures, and even surgery, or it could consist entirely of a discussion with a physician. A hospital or nursing home stay could be for diagnostic, palliative, or recuperative care, or for medical or surgical interventions. Similarly, home health agency or nursing home episodes contain very high technological care, therapy, counseling, personal care, palliative care, or some combination of these services. The following section provides examples of trends in the duration and content of specific encounters that have major cost, quality, access, or provider productivity implications.

Physician visits. Researchers have found that the reported duration of physician office visits to primary care physicians actually increased slightly for both children and adults between 1978 and 1994.²¹ More recent NAMCS data show that for all office-based physician visits, in 1985 the average time spent with a physician was 16.5 minutes, while in 1997–98 this figure had risen to 18.4 minutes.

NAMCS and NHAMCS give us some clues about changes in content of visits to physicians over time. The number of medications mentioned at office visits as either prescribed, continued, or provided and recorded on patients’ medical records has increased from 665 million in 1980 to 1,106 million in 1997–98 (an increase of more than 60 percent). The drug-mention rate has also increased, which implies that physicians prescribed more medications per visit in 1998 (136.9 per 100 visits) than they did in 1985 (109.0 per 100 visits).

For seniors, the percentage of physician visits with five or more medications mentioned during a particular visit has increased from 5.5 percent to 13.2 percent. MCBS data show an increase in the annual number of prescriptions per Medicare beneficiary from 16.6 in 1992 to 19.5 in 1996.²²

Researchers have used NAMCS data to describe changes in types of drugs mentioned by office-based physicians, including increased prescribing of antidepressants by office-based psychiatrists, especially for patients with less severe psychiatric disorders, and psychotropic medications prescribed for preschoolers in 1991 and 1995.²³ Trends such as these do not emerge unless specific subpopulations, conditions, or medicines are analyzed separately.

For example, the leading psychotropic medications prescribed in 1997–98 included alprazolam (Xanex) and fluoxetine (Prozac), whereas in 1980–81 diazepam (Valium) was heavily used. NAMCS data also show changes in drug mentions for antibiotics at visits made by children. Although the antibiotic drug mention rate for children’s visits increased between 1980–81 and 1989–90, it has decreased about 25 percent between 1989–90 and 1997–98.²⁴

NAMCS data do not show large changes in the percentage of physician office visits for different conditions since 1985. The relative proportion of visits for asthma, diabetes, and glaucoma has increased, whereas visits for otitis media, essential hypertension, and vaginal yeast infections have decreased (data not shown). There has been no change for some conditions such as prostatitis or visits by children for general medical exams.

Hospital discharges. There was an overall decline in hospital length-of-stay since 1970, representing a 30 percent decrease in hospital inpatient days. The decline was largest for people age forty-five and older, and particularly large for those older than age seventy-five. Between 1970 and 1998 average length-of-stay declined from 13.2 to 6.3 days for persons ages seventy-five to eighty-four, and 13.7 to 6.4 days for persons age eighty-five and older.²⁵

Hospital length-of-stay did not decline greatly for children under age fifteen but did for the population ages fifteen through forty-four (from 5.7 to 3.7 days), in part a result of declining stays for childbirth. The trend in decreasing length-of-stay after childbirth appears to have reversed, however. After decreasing from 3.8 days in 1980 to 2.1 days in 1995, the average stay for childbirth increased to 2.4 days in 1997. This increase was primarily the result of a reduction in the number of very short stays for childbirth.²⁶

For most procedure categories, there was a steady decline in the rate of procedures performed in hospitals (Exhibit 4). The procedure rate for nervous system disorders has not changed significantly since 1985. Rates of obstetrical procedures went up over this period. The rate of cardiovascular procedures, however, more than doubled during this period (rising 108 percent) and increased even more rapidly for the population age sixty-five and older, rising from 364 per 10,000 elderly to 892 per 10,000 in 1998.²⁷ Rates of angioplasty alone rose 218 percent for the elderly between 1990 and 1998.

In short, a very different mix of operations were performed during inpatient hospitalizations in 1998 than in 1985, with a considerable increase in cardiac procedures and less complex procedures shifting to ambulatory sites of care. Both total and Medicare costs per discharge, adjusted for inflation, have been increasing for most of the 1990s, although decreasing length-of-stay seems to be associated with a reduction in the rate of cost increases.²⁹

Long-term care and postacute care services. The average duration of nursing home stays also fell. When residents of nursing homes were sampled, their stays from the date of admission to the date of the interview decreased, from an average of 1,059 days in 1985 to 899 in 1997. Although these stays are, by definition, incomplete since they underestimate days until discharge, this declining average length-of-stay together with the increasing number of persons discharged from nursing homes lowers the overall stays of this institutionalized population. A much higher percentage of discharges had short stays (less than three months) than did residents. Among nursing home discharges, the percentage of short-stay patients increased from 52 percent in 1984–85 to 67 percent in 1996–97. Among residents, the comparable percentages were 13 and 18 percent. The average length-of-stay for people discharged from nursing homes decreased from 401 days in 1984–85 to 276 days in 1996–1997.³⁰

Nursing home patients were more disabled and received more services in 1997 than they did in 1985 (Exhibit 5). Nursing home residents in 1997 were more likely to be incontinent and to have limitations in activities of daily living (ADLs) including inabilities to bathe, dress, or feed themselves than nursing home current residents in past years. During this time period, the percentage of nursing home residents relying on Medicare as their primary payment source increased from 2 percent in 1985 to 14 percent in 1997.

View larger version (14K): [in this window] [in a new window] EXHIBIT 5 Change In Percentage Of Nursing Home Residents Having Selected Health Status Indicators Or Receiving Specific Therapies, 1985 And 1997

The content of home health episodes also has changed over time. The percentage of home health patients who received homemaker services, for example, peaked at 26 percent in 1996, when Medicare payment was most generous, and dropped back to 22 percent in 1998. Similarly, more patients received "high-technology care" in 1996 (11.2 percent), which was an increase from the 2.9 percent of 1994, but this percentage decreased to 7.4 percent in 1998.³¹

Discussion

Top Data And Methods How Has Medical Care... What Lies Beneath The... Discussion NOTES

 
The amount and type of health care provided to the U.S. population has clearly evolved over time. Health care expenditures in general are rising, even in settings without substantial increases in utilization rates.³² But to address the question raised in the introduction, what are we getting for our money? Some answers provided include more drugs, more cardiac procedures (especially among the elderly), more ambulatory surgery, more therapies in nursing homes, and more home health care and discharges from nursing homes.

The trends selected here illustrate important changes in the provision of health care services. Trends in general, however, must be analyzed within the context of a changing policy, epidemiological, and sociodemographic environment. Of greater interest tomost analysts, therefore, is why care might be changing, whether the changes reflect desirable or undesirable patterns of care, and how policies can be used to motivate more efficient, effective, and equitably distributed services.

Trend data can clearly show correlations of utilization with changes in payment policies. Perhaps the most striking example of this is the correlation between Medicare payment policy with use of specific nursing home and home health care services. Medicare rules for eligibility and coverage of home health services expanded availability in the late 1980s, with rapid growth in the 1990s resulting from more visits per user and an increase in users, as well as an increase in supply.³³ In response to this growth, provisions in the Balanced Budget Act (BBA) of 1997 sought to contain Medicare home health costs through a PPS and other interim measures, with a corresponding decline in use of services evident in the 1998 data, and a decline in the percentage of home health care users who received both therapies and homemaker services.³⁴

Similarly, the Medicare emphasis on postacute rehabilitative care, rather than "long-term care," is clearly associated with the decrease in nursing home length-of-stay and the change in the distribution of nursing home patients toward more high-acuity short stays that substituted for longer hospital stays, especially among the very old.³⁵ This strong correlation of more or less generous payment policy with utilization may be problematic. It could indicate either that there is unmet need that emerges, or that unnecessary care is provided, when payment policy is more generous. One would hope that utilization would be more strongly correlated with need than with payment policy. In either case, further investigation seems warranted.

Trend data also are extremely useful in examining effects of changes in patterns of care and how they may affect cost of care. Changes in the types of pharmaceuticals recorded at physician visits made by persons age sixty-five and older, for example, can reflect the introduction of new drugs, changes in prescribing patterns as a result of guidelines or new research, patient demand, or other factors. The trend in the increasing number of medicines mentioned during physician office visits to seniors is particularly important in light of increased focus on the rising cost of medications for the elderly, already one of the major cost burdens they face and a benefit not currently covered under the standard Medicare package—although increasingly covered by Medicaid. Newly introduced drugs such as the many new cardiac drugs on the market, which are still under patent, also can greatly raise costs to consumers.³⁶

Trends in the provision of specific services, procedures, or medicines can be used to examine issues related to quality and how it is changing over time. The decrease in antibiotic prescribing for children coincides with national campaigns to educate physicians and patients on the appropriate use of antibiotics, since overuse drives the spread of antibiotic resistance.³⁷ Increased inoculations for flu and pneumonia in nursing homes also may indicate that this care is improving, on average—by definition a desirable outcome.

It does seem clear that with the exception of inpatient hospital stays, there do not seem to be dramatic decreases in the total number of encounters over time, and encounters appear to be more, not less, intense. The number of physician visits has not decreased, nor has the number of nursing home events overall.

Even for inpatient hospital care, where the rate of discharges per population and length-of-stay have declined, there is evidence that the remaining stays are more resource intensive and costly than in the past. At the same time, hospital productivity as measured by the American Hospital Association’s adjusted admissions per full-time equivalent employee reached an all-time high in 1998.³⁸ Higher hospital case-mix also was accompanied by a shift of lower-intensity cases to other settings (for example, home health agencies or nursing homes) to complete the episode of care. Despite all of these changes, the rate of in-hospital death, one measure of the severity of the condition being treated, remained stable from 1985 to 1998 (2.7 percent to 2.6 percent of discharges).

The elderly population, in particular, is receiving more care over time—more drugs on an ambulatory basis, more inpatient cardiac care, and more home health care and nursing home services—than in the past.³⁹ This increase in services is correlated with, although not necessarily caused by, an increase in longevity, arguably with greater functioning or quality of life at older ages but also with increased total costs per person and a greater financial burden on public programs.

One last caution: This analysis should make it clear that analysts interested in examining changes in encounters over time must be aware that encounters are "moving targets" that expand or shrink in content. Encounter-level survey data can raise questions, although they must be investigated with more in-depth studies that contain specific need and outcome measures that can be used to help target specific policy solutions. We must continue, however, to try to measure the amount and content of health care we receive, even as the very health care we receive is evolving.

Editor's Notes

 
Amy Bernstein is director of the Development and Analysis Group, Division of Health Care Statistics, National Center for Health Statistics, in Hyattsville, Maryland. Esther Hing is a survey statistician there; Catharine Burt is chief of the Ambulatory Care Statistics Branch; and Margaret Hall is a health statistician.

The views expressed are those of the authors and do not represent the views of the National Center for Health Statistics.

NOTES

Top Data And Methods How Has Medical Care... What Lies Beneath The... Discussion NOTES

 

1. D. Detmer and A. Gelijns, "A More Cost-Effective Treatment Strategy," Archives of Surgery (February 1994): 123–127; and K. Lumsdon, "New Surgical Technologies Reshape Hospital Strategies," Hospitals (May 1992): 30–33.
2. J.M. Keenan and J.E. Fanale, "Home Care: Past and Present, Problems and Potential," Journal of the American Geriatrics Society 37, no. 11 (1989): 1076–1083.
3. National Center for Health Statistics, Health, United States (Hyattsville, Md.: Public Health Service, 1995 and 2000); and A. Okunade and A.P.Miles, "Medicare Physician Payment Reform and the Utilization of Cardiovascular Procedures," Journal of Health and Social Policy 11, no. 1 (1999): 37–52.
4. B.H. Gilman, "Hospital Response to DRG Refinements: The Impact of Multiple Reimbursement Incentives on Inpatient Length of Stay," Health Economics (June 2000): 277–294; and C. Chaix-Couturier et al., "Effects of Financial Incentives on Medical Practice: Results from a Systematic Review of the Literature and Methodological Issues," International Journal of Quality Health Care (April 2000): 133–142.
5. Centers for Disease Control, Center for Infectious Diseases and Prevention, "Update: Trends in AIDS Incidence, Deaths, and Prevalence—United States, 1996," Morbidity and Mortality Weekly Report 46 (1997): 165–173.
6. M.N. Haan et al., "The Impact of Aging and Chronic Disease on Use of Hospital and Outpatient Services in a Large HMO: 1971–1991," Journal of the American Geriatrics Society 45, no. 6 (1997): 667–674.
7. M.J. Hall and J. Popovic, 1997 Summary: National Hospital Discharge Survey, Advance Data from Vital and Health Statistics no. 308 (Hyattsville, Md.: NCHS, 1999).
8. T. McLemore and L. Lawrence, Plan and Operation of the National Survey of Ambulatory Surgery, Vital and Health Statistics Series 1, no. 37 (Hyattsville, Md.: NCHS, 1997).
9. D.A. Woodwell, National Ambulatory Medical Care Survey: 1998 Summary, Advance Data from Vital and Health Statistics no. 315 (Hyattsville, Md.: NCHS, 2000); and L.F. McCaig and T. McLemore, Plan and Operation of the National Hospital Ambulatory Medical Care Survey, Vital and Health Statistics Series 1, no. 34 (Hyattsville, Md.: NCHS, 1994).
10. C. Gabrel, An Overview of National Nursing Home Facilities: Data from the 1997 National Nursing Home Survey, Advance Data from Vital and Health Statistics no. 311 (Hyattsville, Md.: NCHS, 2000); and B.J. Haupt, Development of the National Home and Hospice Care Survey, Vital and Health Statistics Series 1, no. 33 (Hyattsville, Md.: NCHS, 1994).
11. B.V. Shah, B.G. Barnwell, and G.S. Bieler, SUDAAN User’s Manual, Release 7.0 (Research Triangle Park, N.C.: Research Triangle Institute, 1996). More detail about all of the NHCS surveys, including downloadable publications, can be found on the NCHS Web site, <www.cdc.gov/nchs/nhcs.htm>.
12. NCHS, Health, United States, 1995 and 2000. Trends for ED visits begin in 1992.
13. R.N. Weinick, S.H. Zuvekas, and J.W. Cohen, "Racial and Ethnic Differences in Access to and Use of Health Care Services, 1977–1996," Medical Care Research and Review 57, Supplement 1 (2000): 36–54.
14. G.F. Anderson, N. Zhang, and C. Worzala, "Hospital Expenditures and Utilization: The Impact of HMOs," American Journal of Managed Care ( July 1999): 853–864.
15. NCHS, Health, United States, 2000.
16. Nursing home utilization rates for current residents and discharged residents for 1995 in Exhibits 1 and 2 differ from previously published NCHS reports because of differences in the definition and imputation of the age variable.
17. NCHS, Health, United States, 2000; and E. Hing, The National Nursing Home Survey, 1985 Summary for the United States, Vital and Health Statistics Series 13, no. 97 (Hyattsville, Md.: NCHS, 1989).
18. C. Cowan et al. "National Health Expenditures, 1998," Health Care Financing Review (Winter 1999): 165–210.
19. Health Care Financing Administration, 1999 HCFA Statistics (Baltimore: HCFA, April 2000).
20. NCHS, "Home and Hospice Care," 8 December 1998, <www.cdc.gov/nchs/datawh/statab/pubd/ad297tb1.htm> (24 November 2000); and <www.cdc.gov/nchs/about/major/nhhcsd/nhhcscope98.htm> (24 November 2000).
21. T.G. Ferris et al., "Changes in the Daily Practice of Primary Care for Children," Archives of Pediatric and Adolescent Medicine 152, no. 3 (1998): 227–233; and R.S. Stafford et al., "Trends in Adult Visits to Primary Care Physicians in the United States," Archives of Family Medicine 8, no. 1 (1999): 26–32.
22. U.S. Department of Health and Human Services, Report to the President: Prescription Drug Coverage, Spending, Utilization, and Prices, April 2000, <www.aspe.hhs.gov/health/reports/drugstudy/index.htm> (28 November 2000).
23. M. Olfsen and G.L. Klerman, "Trends in the Prescription of Antidepressants by Office-Based Psychiatrists," American Journal of Psychiatry 4, no. 150 (1993): 571–577.
24. C. Twomey, "Antibiotic Resistance—An Alarming Health Care Issue," Association of Operating Nurses Journal 72, no. 1 (2000): 64–75, 76–80; and L.F. McCaig and J.M. Hughes, "Trends in Antimicrobial Drug Prescribing among Office-Based Physicians in the United States," Journal of the American Medical Association 273, no. 3 (1995): 214–219.
25. J.R. Popovic and L.J. Kozak, National Hospital Discharge Survey: Annual Summary, 1998, Vital and Health Statistics Series 13, no. 148, Pub. no. (PHS)2000–1719 (Hyattsville, Md.: NCHS, September 2000).
26. NCHS, "Longer Hospital Stays for Childbirth," 12 September 2000, <www.cdc.gov/nchs/products/pubs/pubd/hestats/hospbirth.htm> (13 December 2000).
27. C.J. Pepine and A. Pepine, "Intervention Therapy for Coronary Artery Disease in the Elderly," Cardiovascular Clinics 22, no. 2 (1992): 175–187; and A.G. Violaris and G.D. Angelini, "Myocardial Revascularization in the Elderly: Complementary Roles for Coronary Angioplasty and Bypass Grafting," International Journal of Cardiology 44, no. 1 (15March 1994): 53–55.
28. J.L. Warren et al., "Trends and Outcomes of Out-Patient Mastectomy in Elderly Women," Journal of the National Cancer Institute 90, no. 11 (1998): 833–840.
29. Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 1999).
30. E. Hing, E. Sekscenski, and G. Strahan, The National Nursing Home Survey: 1985 Summary for the United States, Vital and Health Statistics Series 13, no. 97 (Hyattsville, Md.: NCHS, January 1989); and authors’ calculation for 1996–1997.
31. That is, parenteral nutrition, chemotherapy, antibiotic therapy, anticoagulation infusions, transfusion of blood and blood products, oxygen therapy, or home dialysis. Changes in question wording during these data years may also account the differences in percentage of residents receiving "high technology care."
32. Cowan et al, "National Health Expenditures, 1998."
33. H.L. Komisar and J. Feder, The Balanced Budget Act of 1997: Effects on Medicare’s Home Health Benefit and Beneficiaries Who Need Long-Term Care (New York: Commonwealth Fund, February 1998).
34. Ibid.
35. C. Bishop and K.C.Skwara, "Recent Growth of Medicare Home Health," Health Affairs (Fall 1993): 95–110.
36. R. Bradley et al., "National Health Expenditures, 1997," Health Care Financing Review 20, no. 1 (1998): 83–126; and DHHS, Report to the President.
37. Twomey, "Antibiotic Resistance";; McCaig and Hughes, "Trends in Antimicrobial Drug Prescribing"; and L.F. McCaig, K.E. Besser, and J.M. Hughes, "Decline in Pediatric Antimicrobial Drug Prescribing among Office-Based Physicians in the United States, 1989–98" (Paper presented at the thirty-eighth meeting of the Infectious Disease Society of America, September 2000).
38. J. Ashby, S. Guterman, and T. Greene, "An Analysis of Hospital Productivity and Product Change," Health Affairs (Sep/Oct 2000): 197–205.
39. J. Lubitz et al., "Three Decades of Health Care Use by the Elderly, 1965–1998," Health Affairs (Mar/Apr 2001): 19–32.

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