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1999 HCUP Nationwide Inpatient Sample (NIS) Design Report

Figure 1: Map of the United States broken out by color

HCUP Nationwide Inpatient Sample 

Design of the HCUP Nationwide Inpatient Sample, 1999

October 31, 2001

TABLE OF CONTENTS

TABLES

INTRODUCTION

The Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) was developed to provide analyses of hospital utilization, charges and quality of care across the United States. The target universe includes all acute-care discharges from all community hospitals in the United States. The NIS comprises all discharges from a sample of hospitals in this target universe. The 1999 NIS includes data for calendar year 1999. Previous years covered 1988 through 1998. Table 1 shows the number of states, hospitals and discharges in each year.

Table 1: Number of NIS States, Hospitals and Discharges, by Year
Calendar Year States Sample Hospitals Sample Discharges
(Millions)
1988–1992 8–11 758–875 5.2–6.2
1993 17 913 6.5
1994 17 904 6.4
1995 19 938 6.7
1996 19 906 6.5
1997 22 1012 7.1
1998 22 984 6.8
1999 24 984 7.2

Potential research issues focus on both discharge- and hospital-level outcomes. Discharge outcomes of interest include trends in inpatient treatments with respect to:

Hospital outcomes of interest include:

These and other outcomes are of interest for the nation as a whole and for policy-relevant inpatient subgroups defined by geographic regions, patient demographics, hospital characteristics, physician characteristics, and pay sources.

This report provides a detailed description of the NIS 1999 sample design, as well as a summary of the resultant hospital sample. Sample weights were developed to obtain national estimates of hospital and inpatient parameters. These weights and other special-use weights are described in detail. Tables include cumulative information for all previous NIS releases to provide a longitudinal view of the database.

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THE NIS HOSPITAL UNIVERSE

The hospital universe is defined by all hospitals located in the U.S. that were open during any part of the calendar year and that were designated as community hospitals in the American Hospital Association (AHA) Annual Survey of Hospitals. For purposes of the NIS, the definition of a community hospital is that used by the AHA: "all nonfederal short-term general and other specialty hospitals, excluding hospital units of institutions." Consequently, Veterans Hospitals and other federal hospitals (Department of Defense and Indian Health Service) are excluded. Beginning with the 1998 NIS, rehabilitation hospitals were excluded from the NIS hospital universe because the type of care provided, and the characteristics of the discharges from these hospitals, were markedly different from other short-term hospitals. Table 2 shows the number of universe hospitals for each year based on the AHA Annual Survey.

Table 2: Hospital Universe1
Year Number of Hospitals
1988 5,607
1989 5,548
1990 5,468
1991 5,412
1992 5,334
1993 5,313
1994 5,290
1995 5,260
1996 5,182
1997 5,113
1998 4,915
1999 4,859

Hospital Merges, Splits, and Closures

All U.S. hospital entities that were designated community hospitals in the AHA hospital file, except rehabilitation hospitals, were included in the hospital universe. Therefore, if two or more community hospitals merged to create a new community hospital, the original hospitals and the newly formed hospital were all considered separate hospital entities in the universe for the year of the merge. Likewise, if a community hospital split, the original hospital and all newly created community hospitals were separate entities in the universe for the year of the split. Finally, community hospitals that closed during a year were included as long as they were in operation during some part of the calendar year.

Stratification Variables

The NIS sampling strata were defined based on five hospital characteristics contained in the AHA hospital files. In order to improve the representativeness of the NIS, given the expansion of the number of contributing states, the sampling and weighting strategy was evaluated and revised for the 1998 and future years NIS. This included changes to the definitions of the strata variables. A full description of this process can be found in the report Changes in NIS Sampling and Weighting Strategy for 1998, which will be available later in 2001. A description of the sampling procedures and definitions of strata variables used from 1988 through 1997 can be found in the report: Design of the HCUP Nationwide Inpatient Sample, Release 6. Beginning with the 1998 NIS, the stratification variables were defined as follows:

  1. Geographic Region – Northeast, Midwest, West, and South . This is an important stratification variable because practice patterns have been shown to vary substantially by region. For example, lengths of stay tend to be longer in East Coast hospitals than in West Coast hospitals.

  2. Control – government nonfederal (public), private not-for-profit (voluntary), and private investor-owned (proprietary). These types of hospitals tend to have different missions and different responses to government regulations and policies. When there were enough hospitals of each type to allow it, hospitals were stratified as public, voluntary, and proprietary. This stratification was used for southern rural, southern urban nonteaching, and western urban nonteaching hospitals. For smaller strata — the north central rural and western rural hospitals — a collapsed stratification of public versus private was used, with the voluntary and proprietary hospitals combined to form a single “private” category. For all other combinations of region, location and teaching status, no stratification based on control was advisable given the number of hospitals in these cells.

  3. Location — urban or rural. Government payment policies often differ according to this designation. Also, rural hospitals are generally smaller and offer fewer services than urban hospitals.

  4. Teaching Status — teaching or nonteaching. The missions of teaching hospitals differ from nonteaching hospitals. In addition, financial considerations differ between these two hospital groups. Currently, the Medicare DRG payments are uniformly higher to teaching hospitals than to nonteaching hospitals. A hospital is considered to be a teaching hospital if it has an AMA-approved residency program, is a member of the Council of Teaching Hospitals (COTH) or has a ratio of full-time equivalent interns and residents to beds of .25 or higher.

  5. Bed Size — small, medium, and large. Bed size categories are based on hospital beds, and are specific to the hospital's region, location and teaching status, as shown in Table 3.
Table 3. Bed Size Categories, by Region
Location and Teaching Status Hospital Bed Size
Small Medium Large
NORTHEAST
Rural 1-49 50-99 100+
Urban, non-teaching 1-124 125-199 200+
Urban, teaching 1-249 250-424 425+
MIDWEST
Rural 1-29 30-49 50+
Urban, non-teaching 1-74 75-174 175+
Urban, teaching 1-249 250-374 375+
SOUTH
Rural 1-39 40-74 75+
Urban, non-teaching 1-99 100-199 200+
Urban, teaching 1-249 250-449 450+
WEST
Rural 1-24 25-44 45+
Urban, non-teaching 1-99 100-174 175+
Urban, teaching 1-199 200-324 325+

The bed size cutoff points were chosen so that approximately one-third of the hospitals in a given region, location and teaching status combination would be in each bed size category (small, medium or large). Different cutoff points for rural, urban nonteaching, and urban teaching hospitals were used because hospitals in those categories tend to be small, medium, and large, respectively. For example, a medium-sized teaching hospital would be considered a rather large rural hospital. Further, the size distribution is different among regions for each of the urban/teaching categories. For example, teaching hospitals tend to be smaller in the West than they are in the South. Using differing cutoff points in this manner avoids strata with small numbers of hospitals in them.

Rural hospitals were not split according to teaching status, because rural teaching hospitals were rare. For example, in 1999 there were only 63 rural teaching hospitals, a little over 1% of the total hospital universe. The bed size categories were defined within location and teaching status because they would otherwise have been redundant. Rural hospitals tend to be small; urban nonteaching hospitals tend to be medium-sized; and urban teaching hospitals tend to be large. Yet it was important to recognize gradations of size within these types of hospitals. For example, in serving rural discharges, the role of "large" rural hospitals (particularly rural referral centers) often differs from the role of "small" rural hospitals.

To further ensure geographic representativeness, implicit stratification variables included state and three-digit zip code (the first three digits of the hospital's five-digit zip code). The hospitals were sorted according to these variables prior to systematic random sampling.

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HOSPITAL SAMPLING FRAME

The universe of hospitals was established as all community hospitals located in the U.S. with the exception, beginning in 1998, of rehabilitation hospitals. However, it was not feasible to obtain and process all-payer discharge data from a random sample of the entire universe of hospitals because it would have been too costly to obtain data from individual hospitals, and it would have been too burdensome to process each hospital's unique data structure.

Therefore, the NIS sampling frame was constructed from the subset of universe hospitals that released their discharge data for research use. Two sources for all-payer discharge data were state agencies and private data organizations, primarily state hospital associations. At the time the 1999 sample was drawn, the Agency for Healthcare Research and Quality (AHRQ) had agreements with 24 data sources that maintain statewide, all-payer discharge data files to include their data in the HCUP databases. Prior years of HCUP included fewer states, as shown in Table 4.

Table 4. States in the Frame for NIS Releases
Years States in the Frame
1988 California, Colorado, Florida, Iowa, Illinois, Massachusetts, New Jersey, and Washington
1989-1992 Add Arizona, Pennsylvania, and Wisconsin
1993 Add Connecticut, Kansas, Maryland, New York, Oregon, South Carolina
1994 No new additions
1995 Add Missouri, Tennessee
1996 No new additions
1997 Add Georgia, Hawaii, and Utah
1998 No new additions
1999 Add Maine, Virginia

The list of the entire frame of hospitals was composed of all AHA community hospitals in each of the frame states that could be matched to the discharge data provided to HCUP. If an AHA community hospital could not be matched to the discharge data provided by the data source, it was eliminated from the sampling frame (but not from the target universe). Further restrictions were put on the sampling frames for Georgia, Hawaii, Illinois, South Carolina, Missouri, and Tennessee.

The Illinois Health Care Cost Containment Council stipulated that no more than 40 percent of the discharges provided by Illinois could be included in the database for any calendar quarter. Consequently, a systematic random sample of 70 percent of Illinois hospitals was drawn for the 1999 NIS sampling frame. This prevented the NIS sample from including more than 40 percent of Illinois discharges.

Georgia, Hawaii, South Carolina and Tennessee stipulated that only hospitals that appear in sampling strata with two or more hospitals from the state were to be included in the NIS. Due to this restriction, one Georgia hospital, three Hawaii hospitals, and four South Carolina hospitals were excluded from the 1999 NIS sampling frame. All hospitals from Tennessee were in strata with at least two hospitals, and thus all remained in the sampling frame. Two additional South Carolina hospitals, although in sampling strata with other hospitals, were removed from the sampling frame due to unique characteristics that would make them identifiable. After these restrictions were applied, the 1999 sampling frame included 152 Georgia hospitals, 16 Hawaii hospitals, 54 South Carolina hospitals and 107 Tennessee hospitals.

Missouri stipulated that only hospitals that had signed releases for public use should be included in the NIS. For 1999, thirty-three Missouri hospitals signed releases for confidential use only. These hospitals were excluded from the sampling frame, leaving 73 hospitals in the 1999 frame.

The number of frame hospitals for each year is shown in Table 5.

Table 5. Hospital Frame
Year Number of Hospitals
1988 1,247
1989 1,658
1990 1,620
1991 1,604
1992 1,591
1993 2,168
1994 2,135
1995 2,284
1996 2,268
1997 2,452
1998 2,438
1999 2,520

HOSPITAL SAMPLE DESIGN

Design Requirements

The NIS is a stratified probability sample of hospitals in the frame, with sampling probabilities calculated to select 20 percent of the universe contained in each stratum. The overall objective was to select a sample of hospitals generalizable to the target universe, which includes hospitals outside the frame (i.e., having zero probability of selection). Moreover, this sample was to be geographically dispersed, yet drawn from the subset of states with inpatient discharge data that agreed to provide such data to the project.

It should be possible, for example, to estimate DRG-specific average lengths of stay over all U.S. hospitals using weighted average lengths of stay, based on averages or regression estimates from the NIS. Ideally, relationships among outcomes and their correlates estimated from the NIS should generally hold across all U.S. hospitals. However, since only 24 states contributed data to this 1999 release, some estimates may differ from estimates from comparative data sources. When possible, estimates based on the NIS should be checked against national benchmarks, such as Medicare data or data from the National Hospital Discharge Survey to determine the appropriateness of the NIS for specific analyses.

The target sample size was 20 percent of the total number of community hospitals in the U.S. for 1999. This sample size was determined by AHRQ based on their experience with similar research databases.

Alternative stratified sampling allocation schemes were considered. However, allocation proportional to the number of hospitals is preferred for several reasons:

Overview of the Sampling Procedure

Once the universe of hospitals was stratified, up to 20 percent of the total number of U.S. hospitals was randomly selected within each stratum. If too few frame hospitals were in the stratum, then all frame hospitals were selected for the NIS, subject to sampling restrictions specified by states. To simplify variance calculations, at least two hospitals were drawn from each stratum. If fewer than two frame hospitals were contained in a stratum, then that stratum was merged with an “adjacent” stratum containing hospitals with similar characteristics.

A systematic random sample was drawn from each stratum, after sorting hospitals by state within each stratum, then by the three-digit zip code (the first three digits of the hospital's five-digit zip code) within each state, and then by a random number within each three-digit zip code. These sorts ensured further geographic generalizability of hospitals within the frame states, and random ordering of hospitals within three-digit zip codes.

Generally, three-digit zip codes that are near in value are geographically near within a state. Furthermore, the U.S. Postal Service locates regional mail distribution centers at the three-digit level. Thus, the boundaries tend to be a compromise between geographic size and population size.

Ten Percent Subsamples

Two nonoverlapping 10 percent subsamples of discharges were drawn from the NIS file for each year. The subsamples were selected by drawing every tenth discharge starting with two different starting points (randomly selected between 1 and 10). Having a different starting point for each of the two subsamples guaranteed that they would not overlap. Discharges were sampled so that 10 percent of each hospital's discharges in each quarter were selected for each of the subsamples. The two samples can be combined to form a single, generalizable 20 percent subsample of discharges.

Change to Hospital Sampling Procedure beginning with the 1998 NIS

Beginning with the 1998 NIS sampling procedures, all frame hospitals within a stratum have an equal probability of selection for the sample, regardless of whether they had been in prior NIS samples. This deviates from the procedure used for earlier samples, which maximized the longitudinal component of the NIS series.

Further description of the sampling procedures for earlier releases of the NIS can be found in the report: Design of the HCUP Nationwide Inpatient Sample, Release 6. For a description of the development of the new sample design for the 1998 NIS and later, see the report: Changes in NIS Sampling and Weighting Strategy for 1998.

Zero-Weight Hospitals

Beginning with the 1993 NIS, the NIS samples no longer contain no zero-weight hospitals. For a description of zero-weight hospitals in the 1998-1992 samples, see the report: Design of the HCUP Nationwide Inpatient Sample, Release 1.

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FINAL HOSPITAL SAMPLE

Table 6 shows the annual numbers of hospitals and discharges in each year of the NIS. For the 1988-1992 NIS, zero-weight hospitals were maintained to provide a longitudinal sample, so figures are presented for both the regular NIS sample and the total sample.

Table 6: Number of Sample Hospitals and Discharges, by Year
Regular Sample Total Sample
Year Number of Hospitals Number of Discharges Number of Hospitals Number of Discharges
1988 758 5,242,904 759 5,265,756
1989 875 6,067,667 882 6,110,064
1990 861 6,156,638 871 6,268,515
1991 847 5,984,270 859 6,156,188
1992 838 6,008,001 856 6,195,744
1993 913 6,538,976 - -
1994 904 6,385,011 - -
1995 938 6,714,935 - -
1996 906 6,542,069 - -
1997 1,012 7,148,420 - -
1998 984 6,827,350 - -
1999 984 7,198,929 - -

Table 7 shows a summary of the 1999 NIS hospital sample by geographic region. For each geographic region, Table 7 shows the number of:

Table 7. Number of Hospitals in the 1999 Universe, Frame, Target, Sample and Shortfall by Region
Hospital Region Universe Frame % of Universe in Frame Target Sample Shortfall
Northeast 675 613 90.3% 136 138 -2
Midwest 1,407 568 40.4% 282 286 -4
South 1,861 637 34.2% 373 370 3
West 912 702 77.0% 183 190 -7
Total 4,859 2,520 51.9% 972 984 -12

For example, in 1999 the Northeast region contained 679 hospitals in the universe. It also contained 613 hospitals in the frame, of which 138 hospitals were drawn for the sample. This was two more than the target sample size of 136 hospitals. In the south, there was a shortfall of 3 hospitals indicating that the frame did not provide an adequate number of hospitals to reach the target sample size.

Table 8 shows a summary of the estimated population on July 1, 1999, of the U.S., and of states in the 1999 NIS, by geographic region, based on U.S. Census Bureau population estimates released on the Internet on December 29, 1999. For each geographic region Table 8 shows:

Table 8. Percentage of U.S. Population in 1999 NIS States, by Region
Region Estimated U.S. Population Population of 1999 NIS States Percent of U.S. Population in 1999 NIS States
Northeast 51,829,962 49,044,269 94.6%
Midwest 63,242,284 28,370,619 44.9%
South 96,468,455 44,313,301 45.9%
West 61,150,112 54,367,434 88.9%
Total 272,690,813 176,095,623 64.6%

For example, the estimated population of the Northeast region on July 1, 1999 was 51,829,962. The estimated population on July 1, 1999, of states in the Northeast region that were included in the 1999 NIS was 49,044,269. This represents 94.6% of the total Northeast region population. The percentage of estimated U.S population included in states in the 1999 NIS was almost as high in the West (88.9%), but was lower in the South (45.9%) and Midwest (44.9%).

Table 9 shows the number of hospitals in the universe, frame, and sample for each state in the sampling frame for 1999. The difference between the universe and the frame represents the difference in the number of community hospitals in the 1999 AHA Annual Survey of Hospitals and the number of community hospitals for which data were supplied to HCUP in all states except Georgia, Hawaii, Illinois, Missouri and South Carolina.

Table 9. Number of Hospitals in the 1999 Universe, Frame, and Sample for States in the Sampling Frame
State Hospital Universe Frame Size Sample
AZ 58 55 13
CA 390 384 95
CO 65 65 18
CT 34 31 6
FL 195 192 98
GA 153 152 100
HI 22 16 4
IA 115 115 54
IL 195 136 70
KS 135 122 58
MA 72 68 15
MD 48 47 23
ME 36 34 11
MO 119 73 38
NJ 76 75 17
NY 215 214 46
OR 59 58 18
PA 195 191 43
SC 62 54 34
TN 114 107 68
UT 41 40 17
VA 87 85 47
WA 85 84 25
WI 122 122 66
TOTAL 2,693 2,520 984

Distribution of Sample Hospitals by State, NIS 1999Figure 1: Regional map of United States of America showing numbers of hospitals sampled by state

The above map shows that hospitals were sampled throughout each region of the United States. It also shows the effect of stratification on the sample. In the Northeast and West, where a higher proportion of states are represented, relatively fewer hospitals are sampled from each state than in the South and Midwest, where the proportion of states in the NIS is lower. The number of hospitals and discharges by state and region are shown in Table 10 below.

Table 10. Number of Hospitals and Discharges in the Sample by State and Region
REGION State Number Hospitals in Sample Number Discharges in Sample
Midwest Iowa 54 204,178
Illinois 70 585,800
Kansas 58 155,474
Missouri 38 322,494
Wisconsin 66 343,345
Northeast Connecticut 6 81,302
Maine 11 161,549
Massachusetts 15 63,916
New Jersey 17 223,290
New York 46 473,191
Pennsylvania 43 362,735
South Florida 98 949,203
Georgia 100 504,592
Maryland 23 299,785
South Carolina 34 210,717
Tennessee 68 436,039
Virginia 47 411,218
West Arizona 13 113,248
California 95 868,335
Colorado 18 110,303
Hawaii 4 22,252
Oregon 18 96,230
Utah 17 65,887
Washington 25 13,346
Total   984 7,198,929

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SAMPLING WEIGHTS

Although the sampling design was simple and straightforward, it is necessary to incorporate sample weights to obtain state and national estimates. Therefore, sample weights were developed separately for hospital- and discharge-level analyses. Hospital-level weights were developed to weight NIS sample hospitals to the hospital universe. Similarly, discharge-level weights were developed to weight NIS sample discharges to the hospital universe.

Hospital Weights

Hospital weights to the universe were calculated by post-stratification. For each year, hospitals were stratified on the same variables that were used for sampling: geographic region, urban/rural location, teaching status, bed size, and control. The strata that were collapsed for sampling were also collapsed for sample weight calculations. Within stratum s, each NIS sample hospital's universe weight was calculated as:

Ws(universe) = Ns(universe) ÷ Ns(sample),

where Ws(universe) was the hospital universe weight, and Ns(universe) and Ns(sample) were the number of community hospitals within stratum s in the universe and sample, respectively. Thus, each hospital's universe weight (HOSPWT) is equal to the number of universe hospitals it represented during that year. Since 20% of the hospitals in each stratum were sampled when possible, the hospital weights are usually around five.

Discharge Weights

The calculations for discharge-level sampling weights were similar to the calculations of hospital-level sampling weights. The discharge weights usually are constant for all discharges within a stratum.

The only exceptions were for strata with sample hospitals that, according to the AHA files, were open for the entire year but contributed less than their full year of data to the NIS. For those hospitals, we adjusted the number of observed discharges by a factor of 4 ÷ Q, where Q was the number of calendar quarters for which the hospital contributed discharges to the NIS. For example, when a sample hospital contributed only two quarters of discharge data to the NIS, the adjusted number of discharges was double the observed number. This adjustment was done only for weighting purposes. The NIS dataset only includes the actual (unadjusted) number of observed discharges.

With that minor adjustment, each discharge weight is essentially equal to the number of AHA universe discharges that each sampled discharge represented in its stratum. This calculation was possible because the number of total discharges was available for every hospital in the universe from the AHA files. Each universe hospital's AHA discharge total was calculated as the sum of newborns and hospital discharges.

Discharge weights to the universe were calculated by post-stratification. Hospitals were stratified just as they were for universe hospital weight calculations. Within stratum s, for hospital i, each NIS sample discharge's universe weight was calculated as:

DWis(universe) = [DNs(universe) ÷ ADNs(sample)] * (4 ÷ Qi),

where DWis(universe) was the discharge weight; DNs(universe) was the number of discharges from community hospitals in the universe within stratum s; ADNs(sample) was the number of adjusted discharges from sample hospitals selected for the NIS; and Qi was the number of quarters of discharge data contributed by hospital i to the NIS (usually Qi = 4). Thus, each discharge's weight (DISCWT) is equal to the number of universe discharges it represented in stratum s during that year. Since all discharges from 20% of the hospitals in each stratum were sampled when possible, the discharge weights are usually around five.

Discharge Weights for 10 Percent Subsamples

In the 10 percent subsamples, each discharge had a 10 percent chance of being drawn. Therefore, the discharge weights contained in the Hospital Weights file can be multiplied by 10 for each of the subsamples, or multiplied by 5 for the two subsamples combined.

DATA ANALYSIS

Variance Calculations

It may be important for researchers to calculate a measure of precision for some estimates based on the NIS sample data. Variance estimates must take into account both the sampling design and the form of the statistic. The sampling design was a stratified, single-stage cluster sample. A stratified random sample of hospitals (clusters) were drawn and then all discharges were included from each selected hospital.

If hospitals inside the frame were similar to hospitals outside the frame, the sample hospitals can be treated as if they were randomly selected from the entire universe of hospitals within each stratum. Standard formulas for a stratified, single-stage cluster sampling without replacement could be used to calculate statistics and their variances in most applications.

A multitude of statistics can be estimated from the NIS data. Several computer programs are listed below that calculate statistics and their variances from sample survey data. Some of these programs use general methods of variance calculations (e.g., the jackknife and balanced half-sample replications) that take into account the sampling design. However, it may be desirable to calculate variances using formulas specifically developed for some statistics.

These variance calculations are based on finite-sample theory, which is an appropriate method for obtaining cross-sectional, nationwide estimates of outcomes. According to finite-sample theory, the intent of the estimation process is to obtain estimates that are precise representations of the nationwide population at a specific point in time. In the context of the NIS, any estimates that attempt to accurately describe characteristics (such as expenditure and utilization patterns or hospital market factors) and interrelationships among characteristics of hospitals and discharges during a specific year from 1988 to 1999 should be governed by finite-sample theory.

Alternatively, in the study of hypothetical population outcomes not limited to a specific point in time, analysts may be less interested in specific characteristics from the finite population (and time period) from which the sample was drawn, than they are in hypothetical characteristics of a conceptual "superpopulation" from which any particular finite population in a given year might have been drawn. According to this superpopulation model, the nationwide population in a given year is only a snapshot in time of the possible interrelationships among hospital, market, and discharge characteristics. In a given year, all possible interactions between such characteristics may not have been observed, but analysts may wish to predict or simulate interrelationships that may occur in the future.

Under the finite-population model, the variances of estimates approach zero as the sampling fraction approaches one, since the population is defined at that point in time, and because the estimate is for a characteristic as it existed at the time of sampling. This is in contrast to the superpopulation model, which adopts a stochastic viewpoint rather than a deterministic viewpoint. That is, the nationwide population in a particular year is viewed as a random sample of some underlying superpopulation over time. Different methods are used for calculating variances under the two sample theories. The choice of an appropriate method for calculating variances for nationwide estimates depends on the type of measure and the intent of the estimation process.

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Computer Software for Variance Calculations

The hospital weights will be useful for producing hospital-level statistics for analyses that use the hospital as the unit of analysis, and the discharge weights will be useful for producing discharge-level statistics for analyses that use the discharge as the unit of analysis. The discharge weights would be used to weight the sample data in estimating population statistics.

In most cases, computer programs are readily available to perform these calculations. Several statistical programming packages allow weighted analyses.2 For example, nearly all SAS (Statistical Analysis System) procedures incorporate weights. In addition, several statistical analysis programs have been developed that specifically calculate statistics and their standard errors from survey data. Version 8 of SAS contains procedures (PROC SURVEYMEANS and PROC SURVEYREG) for calculating statistics based on specific sampling designs. Also, OSIRIS IV, developed at the University of Michigan, and SUDAAN, developed at the Research Triangle Institute, do calculations for numerous statistics arising from the stratified, single-stage cluster sampling design. An example of using SUDAAN to calculate variances in the NIS is presented in the report: Calculating Variances Using Data from the HCUP Nationwide Inpatient Sample.3 For an excellent review of programs to calculate statistics from survey data, visit the following website: http://www.hcp.med.harvard.edu/statistics/survey-soft/. Exit Disclaimer

The NIS database includes a Hospital Weights file with variables required by these programs to calculate finite population statistics. In addition to the sample weights described earlier, hospital identifiers (Primary Sampling Units or PSUs), stratification variables, and stratum-specific totals for the numbers of discharges and hospitals are included so that finite-population corrections (FPCs) can be applied to variance estimates.

In addition to these subroutines, standard errors can be estimated by validation and cross-validation techniques. Given that a very large number of observations will be available for most analyses, it may be feasible to set aside a part of the data for validation purposes. Standard errors and confidence intervals can then be calculated from the validation data.

If the analytical file is too small to set aside a large validation sample, cross-validation techniques may be used. For example, tenfold cross-validation would split the data into ten equal-sized subsets. The estimation would take place in ten iterations. In each iteration, the outcome of interest is predicted for one-tenth of the observations by an estimate based on a model fit to the other nine-tenths of the observations. Unbiased estimates of error variance are then obtained by comparing the actual values to the predicted values obtained in this manner.

Finally, it should be noted that a large array of hospital-level variables are available for the entire universe of hospitals, including those outside the sampling frame. For instance, the variables from the AHA surveys and from the Medicare Cost Reports are available for nearly all hospitals. To the extent that hospital-level outcomes correlate with these variables, they may be used to sharpen regional and nationwide estimates.

As a simple example, each hospital's number of cesarean sections would be correlated with their total number of deliveries. The number of cesarean sections must be obtained from discharge data, but the number of deliveries is available from AHA data. Thus, if a regression can be fit predicting cesarean sections from deliveries based on the NIS data, that regression can then be used to obtain hospital-specific estimates of the number of cesarean sections for all hospitals in the universe.

Longitudinal Analyses

Hospitals that continue in the NIS for multiple consecutive years are a subset of the hospitals in the NIS for any one of those years. Consequently, longitudinal analyses of hospital-level outcomes may be biased if they are based on any subset of NIS hospitals limited to continuous NIS membership. In particular, such subsets would tend to contain fewer hospitals that opened, closed, split, merged, or changed strata. Further, the sample weights were developed as annual, cross-sectional weights rather than longitudinal weights. Therefore, different weights might be required, depending on the statistical methods employed by the analyst.

One approach to consider in hospital-level longitudinal analyses is to use repeated-measure models that allow hospitals to have missing values for some years. However, the data are not actually missing for some hospitals, such as those that closed during the study period. In any case, the analyses may be more efficient (e.g., produce more precise estimates) if they account for the potential correlation between repeated measures on the same hospital over time, yet incorporate data from all hospitals in the sample during the study period.

Discharge Subsamples

The two nonoverlapping 10 percent subsamples of discharges were drawn from the NIS file for each year for several reasons pertaining to data analysis. One reason for creating the subsamples was to reduce processing costs for selected studies that will not require the entire NIS. Another reason is that the two subsamples may be used to validate models and obtain unbiased estimates of standard errors. That is, one subsample may be used to estimate statistical models, and the other subsample may be used to test the fit of those models on new data. This is a very important analytical step, particularly in exploratory studies, where one runs the risk of fitting noise.

For example, it is well known that the percentage of variance explained by a regression, R2, is generally overestimated by the data used to fit a model. The regression model could be estimated from the first subsample and then applied to the second subsample. The squared correlation between the actual and predicted value in the second subsample is an unbiased estimate of the model's true explanatory power when applied to new data.

ENDNOTES

  1. Most AHA surveys do not cover a January-to-December calendar year for every hospital. The number of hospitals for 1988-1991 are based on the HCUP calendar-year version of the AHA Annual Survey files. To create a calendar-year reporting period, data from the AHA surveys must be apportioned in some manner across calendar years. Survey responses were converted to calendar-year periods for 1988-1991 by merging data from adjacent survey years. The number of hospitals for 1992-1999 are based on the AHA Annual Survey files.

  2. Carlson, B.L., A.E. Johnson, and S.B. Cohen (1993). An Evaluation of the Use of Personal Computers for Variance Estimation with Complex Survey Data. Journal of Official Statistics, Vol. 9, No. 4, 795-814.


  3. Duffy, S.Q. and J.P. Sommers (1996, March). Calculating Variances Using Data from the HCUP Nationwide Inpatient Sample. Rockville, MD: Agency for Health Care Policy and Research.

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Internet Citation: 1999 NIS Design Report. Healthcare Cost and Utilization Project (HCUP). May 2016. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/db/nation/nis/reports/NIS_1999_Design_Report.jsp.
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