Ask the Expert: Dr. Julia Holmes, Health, United States

Since 1975, Health, United States has presented national trends on the health of the Nation, including infant mortality, life expectancy, morbidity and health status, risk factors such as smoking and obesity, utilization of health care, health insurance coverage, supply of health care resources, and national expenditures for health. Compiled annually by the National Center for Health Statistics, this report is submitted by the Secretary for Health and Human Services to the President and the Congress of the United States. We spoke with Dr. Julia Holmes, Branch Chief, Analytic Studies, Office of Analysis & Epidemiology, about Health, United States.

Q: How did this report come about?

A: Section 308 of the Public Health Service Act requires the Secretary of the Department of Health and Human Services (HHS) to submit to the President and to Congress an annual report on: 1) health care costs and financing trends, 2) health resources, 3) utilization of health resources, and 4) the health of the nation’s people. NCHS was tasked to compile the data for this annual report.

Q:This is such a massive undertaking. How long does it take to gather all this information and produce the report?

A: It takes close to 1 year to complete and involves many agencies and organizations. Much of the data presented in Health, United States come from NCHS data systems: the National Health Interview Survey, National Health and Nutrition Examination Survey, National Vital Statistics System, National Survey of Family Growth, and the National Health Care Surveys. But a good number of our tables come from other federal agencies such as the Centers for Medicaid and Medicare Services , the Agency for Healthcare Research and Quality , and the U.S. Census Bureau. Health, United States also collects and integrates data from nonfederal sources, for example, the American Association of Colleges of Pharmacy, the Organization for Economic Cooperation and Development, and the Association of Schools of Public Health .

Every year we update existing tables by including additional years of data, and we create new tables on an emerging health topic, such as the percentage of the population with one or more chronic conditions. We also develop a Chartbook that summarizes some of the more interesting findings from the tables and includes a special feature on a timely and relevant public health issue. The Health, United States, 2012 special feature focused on emergency care in the United States: for example, who uses the emergency room, what conditions or circumstances bring them to the emergency room, and what services are provided while there. Each special feature employs graphs and text to answer important public health questions.

We also annually review and update an extensive report appendix that describes each of the more than 50 data sources and any methodological or survey changes in the preceding year that could affect the data. A substantial technical appendix that details statistical methods and definitions also is reviewed and updated each year. In addition, Health, United States staff spend a great deal of time checking and re-checking appendix, table, and reference links to make sure they all work correctly. We estimate that approximately 6,000–6,500 report links must be either updated or created and checked each year.

And, finally, we go through a comprehensive review and clearance process through HHS and through other collaborating agencies and organizations. Getting the 650 pages of Health, United States disseminated for review, allowing sufficient time for our partners to complete their review, and responding to review comments adds to the total annual production process.

Q: What’s new with Health, United States?

A: We have added several new features in recent years. Health, United States, 2009 included a companion product: the Health, United States 2009: In Brief, which was developed in response to Dr. Tom Frieden’s request that Health, United States include a kind of executive summary that presented key health statistics from the larger report and introduced the special feature. The In Brief has been a great success and has extended the usefulness of Health, United States to many audiences. Our newest innovation is an interactive version of the Health, United States: In Brief. Developed in collaboration with the National Library of Medicine, the interactive website enables users to view, create, and export charts and tables; incorporate additional data from the full Health, United States report; and easily link to related web pages. Users of the interactive website can go beyond the charts displayed in the Health, United States In Brief and design their own charts. NCHS is the first to use this tool for data dissemination and has included this interactive format for both the 2011 and 2012 Health, United States In Brief.

Another important feature of Health, United States is that we update tables on the web continuously throughout the year. For example, if a new year of mortality data becomes available in the middle of the report cycle, we update the tables on the web with the new data year. We remain committed to looking for additional ways to make Health, United States timely and relevant.

Q: How do you decide what the special topic will be?

A: Selecting the special topic is a multifaceted process. We consider several different criteria in selecting a special topic. First, is it a timely public-health issue of interest both to the general public, to the health policy community, and to congressional staff? Second, is there recent data available? We would not want to focus on a topic where the data are not current or do not enable us to do some trend analyses. We also try to vary the special feature topics and not repeat a topic that has been done in the prior 5 years. We then map out 10 tentative graphs for the proposed topic to determine whether we have the data to answer key questions related to the topic area. Health, United States staff and NCHS senior leadership consider all these criteria in making a final decision about the special feature.

Q: Working with agencies both within HHS and outside the department, this is an incredibly broad spectrum of federal agencies and organizations. Is it difficult, getting all these people collaborating on one project?

A: Health, United States is incredibly lucky to have such wonderful partners and collaborators. We rely on our data partners within NCHS, across CDC and HHS, and other federal and nonfederal organizations to provide new data each year. We also ask them to update the technical notes and indices associated with their particular data source so that Health, United States can provide up-to-date information on data system changes that could affect the data estimates in the report. And, of course, key to the success of Health, United States is NCHS’ Office of Information Services (OIS), which creates and publishes the print and web versions of Health, United States and its related products. They work very closely with Health, United States staff to ensure a superior product for both the print and web versions, and always do a superb job.

Q: What do you see as the biggest questions going forward for Health, United States? You’re looking at people moving more and more to the electronic delivery system. Will the printed book become a mere formality, and will you embrace using electronic delivery to keep tables updated continuously?

A: A key issue for us is that although Congress is the primary audience for this report, we have multiple users who access information in different ways. Many people access Health, United States via the NCHS website, while others continue to want the print version to use as a desk reference. Over the years we have reduced the number of printed copies: for Health, United States 2012, we only printed 965 copies, and, of course, of those, 536 go to the President of the United States and each member of Congress. However, because we have users with different preferences we have made it a priority to design a user-friendly website for all Health, United States products, and we will continue to work with OIS to ensure that user needs are met through innovative web and print products.