Vital and

Health Statistics

Advance Data

From Vital and

Health Statistics:

Numbers 261–270

Series 16:

Compilations of Advance Data

From Vital and Health Statistics

Noi 27

Data in this report from health and demographic surveys present statistics by age and

other variables on injury reiated visits to hospital emergency departments; ofice visits

for giaucoma and office visits to neurologists; the relationship between cigarette

smoking and other unheaithy behaviors among our Nation’s youth; 1993 summaries of

the National Hospitai Discharge Survey, Nationai Hospitai Ambulatory Medicai Care

Survey, and the Nationai Ambulatory Medical Care Survey; urban and rural

classification of nationai heaith providers; and characteristics of prepaid pian visits of

office-based physicians, ,Estimatesare based on the civiiian noninstitutionaiized

population of the United States, These reports were originally pubiished in 19?5,

U,.% DEPARTMENT OF HEALTH AND HUMAN SERVICES

Publlc Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics

Hyattsvllle, Maryland

April 1996

DHHS Publlcatlon No. (PHS) 96-1886
-.

Copyright Information

‘ All material appearing in this report is in the pubiii domain and may be

repnxkad or copied without parrnission citatiin as to source, however, is

appreoiatad.

Suggested clfation

statistics; numbers 261-270. National Canter for Health Statistics. Vii Health

Stat 16(27). 19S6.
National Center for Health Statistics 

Jack R. Anderson, Acting Director 

Jennifer H. Madans, Ph.D., Acting Deputy Director 

Jacob J. Feldman, Ph.D., Associate Director for Analysis, 

Epidemiology, and Health Promotion 

Gail F. Fisher, Ph.D., Associate Director for Planning and 

Extramural Programs 

Jack R. Anderson, Acting 

International Statistics 

Associate Director for 

Stephen E. Nieberding, Associate Director for 

Management 

Charles J. Rothwell, Associate Director for Data 

Processing and Services 

Monroe G. Sirken, Ph.D., Associate Director for Research 

and Methodology 
Injury-Related Vkits to Hospital Emergency Departments: United States, 1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. 261

Office Visits for Glaucoma: United States, 1991–92 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. 262

Relationship Between Cigarette Smoking and Other Unhealthy Behaviors Among Our Nation’s Youtk United States,

1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. 263

1993 Summary: National Hospital Discharge Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No.264

Underreporting of Race in the National Hospital Discharge Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. 265

Urban and Rural Chissiikation of National Health Provider Inventory Providers: United States, 1991 . . . . . . . . . . . . . . No. 266

Office Visits to Neurologist United States, 1991-92 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “..”””””” . . . . . . . . No. 267

National Hospital Ambulatory Medical Care Survey: 1993 Outpatient Department Summary . . . . . . . . . . . . . . . . . . . . . No. 268

Characteristks of Prepaid Plan Visits to Office-Based Physicians: United States, 1991 . . . . . . . . . . . . . . . . . . . . . . . . . . . No. 269

National Ambulatory Medicdtie Swey:1993S~arY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. 270
Number 261 ● Februaty 1, 1995

Advance

Data w

From Vital and Health Statistics of the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Centerfor HealthStatistics

Injury-Related Visits to Hospital Emergency Departments:

United States, 1992

by Catharine W. Burt, Ed. D., Division of Health Care Statistics

During the 12-month period from

January 1992 through December 1992,

an estimated 89.8 million visits were

made to hospital emergency

departments. Of these, 34.0 million

visits (37.8 percent) were iujnry related.

T& report summarizes injury data

horn the 1992 National Hospital

Ambulatory Medkal Care Survey

(NHAMCS), a national probabtity

sample survey conducted by the

Division of Health Care Statistics,

Centers for Dkease Control and

Prevention. Statistics are presented on

patient and v~lt chmactrxistics of injury

visits to hospital emergency departments

in the United States. An earlier report

presents a general overview of tidings

from the iirst year of the NHAMCS

emmgency data (l).

The National Center for Health

Statistics inaugurated the NHAMCS in

December 1991 to gather and

disseminate information about the health

care provided by hospital emergency

and outpatient departments to the

population of the United States. The

survey, which is endorsed by the

American Hospital Association, the

Emergency Nurses Association, and the

American College of Emergency

Physicians, collected data on more than

36,000 visits to emergency departments

(ED) in non-Federal, short-stay and

general hospitals.

Because the estimates presented in

this report me based on a sample rather

than on the entire universe of hospital

ED visits, they are subject to sampling

variability. The technical notes found at

the end of this report include a brief

overview of the sample design used in

the 1992 NHAMCS and an explanation

of sampling errors. A detailed

description of the 1992 NHAMCS

sample &sign and survey methodology

has been published (2).

The ED Patient Record is used by

hospitals participating in the NHAMCS

to record information about patient

visits. This form is reproduced in figure

1 and is intended to serve as a reference

for readers as they review the survey

findings presented in this document. For

this repo~ a v~lt was considered to be

injury related if “injury, first visit” or

“injury, follow-up” was recorded in

item 9 or if a cause of injury was

provided in item 10. Data for item 9

were missing on less than 1.5 percent of

the xwxmky missing responses to this

item were not imputed. Visits not

specified as injury related in item 9 but

had a cause of injury provided in item

10 accounted for 6.3 percent of the

visits in this analysis.

Data highlights

● m 1992, 34 million ED visits

●

●

●

●

●

●

●

(37.8 percent) were injury related.

There were 13.5 injury visits to

hospital emergency departments for

every 100 persons in the population.

Males had a signilicsntly higher rate of

injmy-mlated vMts than females had.

Accidental falls and motor vehicle

accidents were the leading causes of

injuries resulting in visits to an

emergency department. Together, they

accounted for 41 percent of s@ed

causes of injury. They represent

13 percent of all visits to an

emergency department.

Persons in the age groups under

15 y- and 65 y- and OWX had

higher mtes of visit for accidental falk

Compaled with those 15=24 y2544 y- and 45-64 years of age.

“open wound of head” was the most

frequent principal diagnosis for

injury-related ED visits.

Wound care was performed at

one-third of the injury-mkued visits.

Medkation was administered or

prescribed at the majority of injuryrekted visits, with general analgesics

most commonly mentioned.

Over 9.2 billion dollars were spent on

injury-related ED visits in 1992.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics cm

CENTERS FOR DIS=E CONTROL

AND PWVENllON
9 HW.s..”- Arhranmt ~atn ---- Nn- ..-. 261 -- . ● F@bruarv . -- . --..,---- 1.1995 #

8.DATE OF VISIT 6.SEX 6. RACE .7. ETHNICITY 8. EXPECTEDSOURCE(S)OF PAYMENT 9, MAJORREASON

(Check QI1that apply) FOR THISVISIT

~ , ❑ ~m,,e

I (_J White (Check one)

20 Slack 1 D Hupmic I ❑ Madie#e s D Fl~l~{$ther 1 a Injury, first visit

3 a AtiwWacific 2 D Medicaid

L DATE OF BIRTH Islander

2 ❑ injury, follow-rap

2 ❑ Male z ❑ Not

30 &%m3nt

6 ❑ Patient paid

4 ❑ $d$arr

3 D Illnaee, first visit

Hispanic 7 ❑ No charge

1 I

4 a Illnass, follow-up

Wmth Dav Year Eskimo/ 4 a ~~:&i*l 8 ❑ Other

Aleut 5 a 0t5wr reaaon

10.CAUSEOF INJURY 11.PATIENT’SCOMPLAINTS), SYMPTOM(S).OR OTHER 12.PHYSICIAN’SDIAGNOSES

(Complete ~injury is marked REASON(S)FOR THISVISIT (Inpatient’s own words)

m 9. De.rcnhe cause mad

ploce of injury.) .

a. Principal dlagnosl$/

a. Moat important:

problem associated

with item 1la.

b. Othec b. Other:

c. Other: c. Other:

I

13.URGENCYOF THIS VISIT 15.DIAGNOSTIC/SCREENINGSERVICES 16.PROCEDURES(Check .11provided on this uivit)

(Check only one) (Check .[1 ordered or provfded.)

1 ❑ Urgarrt/Emcrgmt I D None

I ~ None 6 0 Wound core

7 D Chad x.ray

z ❑ Endomchcal

2 D Blood pressurw ahaek

7 ❑ Eye/ENTcar.

2 D Nonwmant 9 l_J Extremity x.rav iratubatlon

3 a Urirrdysis IO ❑ CTseardMRl 30 CPR

8 D Orthopadlc care

14.ISPROBLEMALCOHOL- 9 ❑ Bladdar mtfratw

OR DRUG-RELATED? 4 a HIV serolow Ii o otw~~gnostk 4 a IV fluids

!0 O Lunrb.rp.rrcturu

6 0 Dthar blood taat

12 fJ Other (SPecIYY)

s O NG tube/

I D Ntitlmr a O EKG gastric Iwaee

2 ~ Alcohol-relamd 7 (J Marital ataw..xarn II ❑ Other(s) (SPCWY)

3 0 Omg.ra12ted

4nBoth

17.MEDICATION 18.DISPOSITIONTHISVISIT

(Reeord all new or continued medieatton ordered, administered. orprtxrided

19.PROVIDERSSEEN

(Check all thatappiy) THIS VISIT

at thie visit. Use the earne brand name or generic nome entered on any Rx (Check all that apply)

or medical record. Include irnmunieotbna and deaenaitiehg agents.) I a Return to ED PRN

❑ Nwra

1 ❑ ReskJetat/lntarrt

2 n Return to ED - appakrtnmrt

3 0 R~rn to referring physicim

2 ~ Staff physician

1. 4 U Rfir tO .tkr wsician/c\inic 3 ❑ Othar physician

5 ❑ Mmit to hos9ital 4 ❑ Physicim ateistant

2.

6 ❑ Tranafar to other facillty

5 ~ Nursa practitioner

3.

7 ~ ODA/diad in ED

6 D Ragiatared numc

8 0 Left AMA

9 ❑ No followup falanned 7 l--J ULaad Pr4cttml

$.

IO O Othar (Specify) 8 ❑ Nurse’s aide

5.

Figure 1. National Hospital Ambulatory Medical Care Survey Emergency Department Patient Record

Patient characteristics

In 1992, an estimated 89.8 million

visits were made to emergency

departments of non-Federal, short-stay,

anti general hospitals in the United

States-about 35.7 visita per 100

persons. Of these visits, 34.0 million

(37.8 percent) we~ injury related. ThB

results in an annual rate of 13.5 injury

visits per 100 persons to a hospital

emergency department. Injury-related

visits by patient’s age, sex, and race are

shown in table 1. Persons 15–24 years

of age had the highest ED injury visit

rate (20.2 visits per 100 persons) of

the six age categories analyzed. Males

had a higher rate of injury-related

visits than females d@ using both

crude and age-adjusted rates, and they

accounted for 56.4 percent of all ED

injury visits. This differs from ED

visits in general, where there was no

significant difference in the visit rates

for males and females. Fhwre 2 shows

the visit rates by age and<ex. Males

had signilieantly higher rates of

injury-related visits compamd with

females for each age group under

45 years.

White persons made 82.!!percent of

all injurp?lated ED visits, with black

persons, hkinhcfic Islanders, and

American Indians/Eskimos/AJeuts

amounting for 14.7 pereen~ 1.5 pereen~

and 0.8 percen~ respectively. While the
Advance Data No, 261 ● February1,1995 3

Table 1. Number, percent distribution, percent that are injury related, and annual rate of injury-related emergency department visits, by

selected patient and vieit characteristics: United States, 1992

Number of

Number of Percent vklts per

vklts In Percent injury 100 persona

Patient and VISIYchamterktlc thousands dktributlon related’ per yeaP

Patient characteristic

Ailin]ury-related vlslts . . . . . . . . . . . . . . . . . . . . . . . . .

Age

Undsr15yaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 YsMs.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-84 yeats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sexerrdags:

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Under15years . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44ysers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4W54year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6E-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yearserrdover . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Urrder15year3 . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

,25-44years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45+4yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

86-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . .

Raceandaga:

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Undar15yaare . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24ysara . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44yeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64ysars . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yeareandover . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Under15yeare . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24ysars . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-84yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85-74yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yeersarrdover . . . . . . . . . . . . . . . . . . . . . . . . . .

Allotherraces . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AalarrlPaciticlstarrder. .<...... . . . . . . . . . . . . . . .

Americanlndian&ktmo/Aleut... . . . . . . . . . . . . . . .

Emer~ncydepartment chatacterktic

Geographicreglom

Northeast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Midwest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

south . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

west . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33,950 100.0 37.8 13.5

8,714

6,937

11,277

3,959

1,458

1,605

25.7

20.4

33.2

11.7

4.3

4.7

36.7

46.7

41.4

31.6

25.1

23.4

15.4

20.2

13.9

8.2

7.9

13.0

14,812

3,567

2,670

4,714

1,796

940

1,124

31.8

35.0

33.2

33.6

27.1

26.1

25.9

43.6

10.5

7.9

13.9

5.3

2.8

3.3

11.5

12.9

15.4

11.4

7.1

9.2

14.6

19,138

5,147

4,267

6,584

2,163

518

480

44.3

41.8

62.8

49.7

38.8

21.1

19.0

56.4

15.2

12.6

19.3

6.4

1.5

1.4

15.7

17.8

25.0

16.4

9.3

6.3

10.4

28,154

7,227

5,823

8,970

3,331

1,283

1,520

82.3

21.3

17.2

26.4

9.8

3.8

4.5

39.9

42.8

50.2

43.6

32.9

25.6

24.2

13.4

16.1

21.2

13.2

8.0

7.8

13.6

4,987

1,311

972

1,974

524

138

67

14.7

3.9

2.9

5.8

1.5

0.4

0.2

29.1

25.5

33.8

33.8

24.8

20.7

13.3

15.9

14.6

19.1

20.2

10.5

8.4

6.8

808

529

279

2.4

1.5

0.8

37.3

37.8

35.3

7.7

. . .

. . .

6,346

9,268

9,892

6,261

20.1

2e.4

S0.7

19.8

37.4

36.9

32.8

35.7

13.6

16.1

12.4

12.3

‘Permntofallen’wgency departnwntviaitain aachcatego~that areinjurymlebd,

%aadonU.S.Buraauof theCerwsaatirnatesof thedvilian,noninatitutkmalisad populatimoftheUnSad 3tatasasofJulyl, l~2.
4 Advance Data No. 261 ● February 1, 1995

30

r

I

_ Male ~ Female

25

18

Under 15-24 25-44 45-64 65-74

15 years

75 ears

years years years years anJ over

Figure 2. Annual rate of injury-related visits to emergency departments by patient’s age

and sex: United States, 1993

Table 2. Number, percent distribution, and annual rate of vlait to hospital emergency

departments by major reason for visk United States, 1992

Number of

Nurrrbar vfsltsper

of Vlsns Percent 100 persons

Wit chatacteristlc In thousands dfsfrfbuflon per year’

AIIEDvMs2... . . . . . . . . . . . . . . . . . . . . . .

Allinjury-relafedvk.lts. . . . . . . . . . . . . . . . . . . .

lnJury-flretvlalt . . . . . . . . . . . . . . . . . . . . . .

Injury-follow-upvlsif. . . . . . . . . . . . . . . . . . .

Statedcauaaof lnjury3. . . . . . . . . . . . . . . . . .

Illness-flrat visit . . . . . . . . . . . . . . . . . . . .

Illness-follow-upvisit. . . . . . . . . . . . . . . . .

Otherreason’ . . . . . . . . . . . . . . . . . . . . . .

Allothervlsits . . . . . . . . . . . . . . . . . . . . . . . . .

89,796

33,950

28,388

3,178

2,383

1,467

129

787

55,846

100.0

37.8

31.6

3.5

2.7

1.6

0.1

0.9

62.2

35.7

13.5

11.3

1.3

0.9

0.6

0.1

0.3

22.2

persons) than the South and West

(12 visits per 100 persons) did (table 1).

Prior-visit status

The majority of injury-related visits

(87.9 percent) were first-time visits.

While just 5 percent of illness-related

visits to ED’s were classitiedas

follow-up visits, 9.7 percent of the

injury-related visits were follow-up

visits from a previous injury visit. The

majority of ED visits (62.2 percent)

were made for illness and 37.8 percent

were made for injury (table 2).

Urgency of this visit

Almost half of the first-visit injury

cases were classified as urgent by

hospital staif. In comparison, only

15.8 percent of follow-up injury visits

were classified as urgent. Urgency of

visit was defined as those visits in

which the patient requires immediate

attention for an acute illness or injury

that threatens life or function and where

delay would be harmful to the patient.

Hospitals made slightly ditferent

interpretations about how they

determined urgency for the survey. In

some cases, the determination of

urgency was based upon the severity of

the patient’s symptom(s); in other cases,

it was based upon the patient’s

diagnosis or the nature of the lreatment

provided.

‘Based on U.S. Bureau of the Census estimates of the civilian noninstitutionalksd population of the United Statea as of

July 1, 1932.

%D is emergency department.

%d.das vbifs not re.cfdd as injury related but had a cause of injury recorded in tiem 10.

‘lndudas vidls with blank or other majar reasons recc+ded in tiem 9, yet had a cause of injury in item 10.

overall ED visit rate for black persons

was significantly higher than for white

persons, there was no significant

dflerence between the ED injury visit

rates for white and black persons,

whether using crude or age-adjusted

rates. However, black persons between

the ages of 25 and 44 did have a

significantly higher injury-related visit

rate than did white persons in that age

category.

Examining the percent of ED visits

that were injury related for each

population subgroup in table 1 shows

that while overall one-third of the ED

visits were for injuries, almost twothirds of the ED visits for males aged

15–24 years were for injuries. White

persons in all age groups tended to have

a higher proportion of ED visits for

injuries compared with black persons.

Visit characteristics

Geographic region

There were slight regional

differences in the utilization of ED

services for injuries. The Midwest had a

higher injury visit rate (16 visits per 100

Cause of injury

Up to three external causes of

injury wem coded and classified

according to the Mernational

Ckmi$cation of Diseases, 9th Revision,

Clinical Modification (ICD-9-CM) (3).

Table 3 shows the number of annual

injury-related ED visits for the lirstlisted cause of injury, using the major

cause of injury categories spec&xl by

the ICD–9-CM @codes) along with

any subclassification codes that had

reliable estimates. E-code data were

reported for 84 percent of the injuryrelated visits. In visits where the place

of occurrenm was listed as the tirst

cause, the second cause was used for

purposes of this analysis. Almost

one-thiid of the injury-related visits
Advance Data No. 261 ● February1, 1995 5

Table 3. Number and percent distribution of Injury-refated emergency department visits by cause of injury United States, 1992

Nuntw of vW&

CaUaa of injury and E code’

Percent

in thousands dtatrfbufion

Alllnjwy-related visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Olheracoktants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E916-E928

Sfmckbyfaillng object . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E916

strfldng agahrsf orafruckby objects orperaons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E917

Caughthrorbefween obJec@. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E318

Machinery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ES19

Cuffhrgorpiercinginstruments... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E92cI

Flreamrmkaile. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E922

Hotsubsfance,caustioorcorroslve maferiaf. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E924

Overexertio n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E927

Otherandunspecffladmusas.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..E928

Accidentalfals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E880-E888

Fatifromstebs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E880

Fatlfromladdem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,.< E881

Fatlfrombullding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E882

Fatl into hole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..E883

Otherfalifromoneleveltoanother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E834

Fetlonsarneievel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E8a5

Otherandunepactfiedfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E83r3

Motorvehicieacckfenfs,trafficand non-traffic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E81o-E825

Othermotorvehlcle acddentlnvoMng coilieion wlthanother motorvehide. . . . . . . . . . . . . . . . . . . . E812

Motorvehtcta aoddenti nvolvlngcoiltsionwifh othervehkle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E813

Moforvehktecollkdonwifhpadastrian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E814

Oihermotorvehlcle accidant lnvolvhrgcollision on highway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E815

Motorvahtcia acddarrtduetolossofcontrolwithout coilfdononhighway . . . . . . . . . . . . . . . . . . . . E816

Noncoliialon motorvehicieacckfantwhile boarding oralighfing . . . . . . . . . . . . . . . . . . . . . . . . . . . E817

Othernoncollision motorvehlcleacddent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E818

Unspecffledmotorvehkfeacddant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E819

Othermotorvehidenontrafticaccldant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E824

HomldWmdlnju~pupow&inflid@ byotherparaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . E960-E963

Fight,brawi, rape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E960

Aesauitbyoutthr@iardnginstrument. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..Egr36

Unapectfiadassautf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E966

Acckfentsdueto naturalandenvkonmentalfactors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E900-E30s

Venomousanlmalsandptants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..E905

Otherln]urycauaadbysrrlmata.... .’, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..E906

Acckfentscaiaedbysubnrsraion,suffocation, andforelgn bodies . . . . . . . . . . . . . . . . . . . . . . . E910-E915

Foreignbodylrreye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E914

Foreign bodyhrotherortflce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E915

Ofherroadvehideacddenta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E826-EE23

Otherroadacddent,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E826

Acckfenthrvohfinganimelbelngrldden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E828

Surglcalandmedkal proceduresaethe causaofabnormal raacfionofpafient oriafercomplkaflon

withoutmentlon ofmlsadventuraatthetlme ofprocedure. . . . . . . . . . . . . . . . . . . . . . . . . . . E87s-E879

DuetosurgfcaVmedtoalprocedure.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E878

Duetoothermadkslprooadure... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..E87g

Din@, medicind and biological substmces causing aWe~effeda intheqetiicu~ . . . . . . . . . E930-E349

Duetounspeciffeddrugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E947

Accldantatpoisoningby druga,madicinal substances, andblologkata. . . . . . . . . . . . . . . . . . . . E850-ES56

PofaonlngbyanaQasks,a ntipyretka, andantkheumalke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E85Q

Polsonlngbyotherdrugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E856

Accidental polaonlng byothersdldand Ikfukfsubstances, gases,andvapora . . . . . . . . . . . . . . . E860-E8&g

Sukkfeandself-hrftktedinjury... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. E950-E959

Affemptadsulchiabyaolldorlkfuldaubafancas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E950

Accldentscausedbyfireandftames. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...7.... E890-E899

Unspeclfledflres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E833

Ofhe~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unknown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33,950

10,388

639

3,018

670

486

3,077

87

473

1,567

195

7,706

639

201

162

171

9s7

1,289

4,223

4,130

403

62

178

101

114

73

323

2,684

66

1,5=

5a6

173

731

1,374

442

664

1,040

646

324

636

547

73

404

226

178

370

118

333

so

171

192

180

90

127

74

202

5,351

100.0

30.5

1.9

8.9

2.0

1.4

9.1

0.3

1.4

4.7

0.6

22.7

1.9

0.8

0.5

0.5

2.3

0.4

12.4

12.2

1.2

0.2

0.5

0.3

0.3

0.2

1.0

7.9

0.3

4.6

1.7

0.5

2.2

4.0

1.3

2.5

3.1

1.9

1.0

1.9

1.6

0.2

1.2

0.7

0.5

1.1

0.3

1.0

0.3

0.5

0.8

0.5

0.3

0.4

0.2

0.8

15.8

lBasadon the /nWrr#fl.xra/ chssikafbn d D/seases, Sth Revision, clinical Modification (lCD-S-CM) (3).

%cludaa all other msjor E-cede categories where the eatirmte was too low to be raliable.

3includea unoxlable, illegible, and blank E-code$,
6 Advance Data No. 261 ● February 1, 1995

All

others

29%

Violence

related

6Y.

, Note IncludesontythoseInjury-relatedvisitswith codable cause otInjwy.

Accidental

falls

27%

Motor vehicle

accidents

14%

Figure 3. Percent distribution of leading causes of Injury treated at emergency department

visk United States, 1992

were under the general category of

“Other accidents” (E916-E928)

(30.5 percent). “Accidental fritls”

(E880-E888) (22.7 percent) and “motor

vehicle accidents” (E81O-E825)

(12.2 percent) wem the second and third

largest categories. Table 3 also presents

the estimates for individual 3-digit codes

within the larger categories. The codes

listed were those for which the numbs

of visits were large enough to provide a

reliable estimate. The most frequently

occurring 3-digit E-code was

“unspecified fall” (E888) (12.4 percent

of total). The category “other road

vehicle accidents” (E826), which

includes bicycle accidents, accounted for

over half a million ED injury visits.

“Unspecified assault” (E968), “figh~

brawl, rape” (E960), and “assault by

~cutting or piercing instruments” (E966)

have reliable estimates within the

broader category of “homicide and

injury purposely inllicted by other

persons.” Together these 3 codes

accounted for 96 percent of the speehic

causes within the larger category.

Combining various E-code

categories at and above the 3-digit level

yields interesting results for

summarization purposes. The major

groupings in table 3 might be combined

in a better way because some of the

individual E-codes within “other

accidents” have a greater frequency of

occurrence than do some of the major

categories. Figure 3 presents the top five

causes of injury if E-codes are

categorized in a slightly different

manner. Sdll, “accidental falls” and

“motor vehicle accidents,” as delined

above, accounted for 41 percent of the

injury-related visits with E-codes.

However, combining “accidentally

struck by persons or objects” (E916)

with “struck by falling objects” (E917)

places this category, labeled “struck

accidentally” in figure 3, among the

leading causes. “Accidents caused by

cutting or piercing instruments or

objects” (E920) alone accounted for

11 percent of the causes of injury-related

visits. Combining “homicide and injury

purposely inflicted” (E960-E969) with

“suicide and self-inflicted injury”

(E950-E959), as a measure of injury

caused by violence, places it among the

top five causes of injury in visits to

emergency departments. These five

causes accounted for over 70 percent of

injury-related visits in 1992 where a

cause was specified. It should be noted

that although the E-co& classification of

injury causes includes the terms

“homicide” and “suicide,” very few

visits with these causes ended in death

in the emergency department. In facti

there were so few cases observed in the

sample that reliable population estimates

could not be made. The term

“intentional injury” (either by self or

others) is perhaps abetter label when

using the classification for morbidity

purposes.

Table 4 shows the annual visit rates

and percent distribution of these top five

injury causes by selected patient

characteristics. The data show that

persons in the age categories under 15

years and 65 years and over had higher

rates of visits for accidental falls than

the other age categories. Not

surprisingly, persons between 15 and 24

years had the highest rate of visits for

motor vehicle accidents. The rates of

visits related to intentional injuries were

highest among persons between 15 and

44 years. The data also show that black

persons were more likely than white

persons to make an ED visit because of

violence (3:1) and motor vehicle

accidents (5:3). On the other lhand,

white persons wem more likely to make

a visit due to accidental falls than were

black persons (3:2). Figure 4 displays

ED injury-related visit rates by race for

the top five causes of injury.

Using the E-code data at the fourth

digit level, the estimates may be

combined to provide reliable estimates

of certain categories of injuries. For

example, table 5 shows the number of

visits to ED’s related to tirearms, pedal

cyclists, pedestrians, and motorcyclists.

Place of occurrence information was

provided for less than 15 percent of the

injury-related visits with appropfite

causes of injury (e.g., E850-E869 or

E880-E928) and is therefore not

discussed in further detail. A separate

itim for place of occurrence was added

to the 1993–94 Patient Record form to

improve reporting of this information.

Alcohol- or drug-related

problem

The proportion of visits that were

alcohol related was higher for injuryrelated ED visits (3.6 percent) compared

with noninjury related visits

(2.3 percent). Nelson and Stussman (4)

examined E-code data for different

responses to item 14, “Is problem

alcohol or drug related?”, on the ED

Patient Record and found that an injury

was three times as likely to L’@classified

as “homicide and injury purposely
Advance Data No. 261 ● February1, 1995. 7

Table 4. Number, annual rate, and percent distribution of injury-ratatad emergency department visits by selected pattent characteristics,

according to the top five causes of injury: United States, 1992

Cause of injury’

Motor Cut by

Arxidentaf vehicle struck

Selecled characteristic Total fails acokfsnts aocfdarrfal(y Obysxts violence OfheF

Alllnjury-relafed vkdts.. . . . . . . . . . . . . . . . . . . . .

AlllnJuty-related visits . . . . . . . . . . . . . . . . . . . . . .

Age

Undsr15ye8rs . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X+4yeara. . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 yearn . . . . . . . . . . . . . . . . . . . . . . . . . . .

65yeareendover . . . . . . . . . . . . . . . . . . . . . . . .

Sex

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Race

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allinjury-relatedvleits . . . . . . . . . . . . . . . . . . . . . .

Age

Under15years . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44years . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-84yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65yearsarrdover . . . . . . . . . . . . . . . . . . . . . . . .

Sex

Ferrrafe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Race

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33,950

135.0

154.4

201.7

138.7

81.6

99.5

114.6

156.6

134.4

158.5

78.8

100.0

25.7

20.4

X32

11.7

9.0

43.8

56.4

82.9

14.7

2.4

7,706

30.6

44.8

27.4

21.5

20.5

46.6

30.8

30.5

32.2

24.7

17.5

100.0

32.8

12.2

22.7

12.9

79.4

51.7

48.3

87.5

10.1

2.4

Number of visifs in thousands

4,130 3,657

Rate per 1,000 personss

16.4 14.5

9.4 20.0

36.1 26.0

19.1 13.4

10.2 7.6

10.1 5.8

15.3 102

17.8 19.1

15.2 14.8

25.5 15.5

13.1 5.9

Percent distrbuflon

100.0 100.0

12.8 30.8

30.1 24.4

37.6 23.9

11.9 10.1

7.5 4.9

48.0 36.1

52.0 83.8

77.2 85.0

19.4 13.3

3.3 1.7

3,077

12.2

12.7

19.3

14.3

8.1

4.6

8.1

16.6

12.1

13.5

10.8

100.0

23.2

21.6

37.6

12.8

4.6

WI

85.9

82.6

13.8

3.6

1,714

6.8

2.9

15.9

10.4

2.9

“0.6

5.3

8.4

5.3

17.7

“4.1

100.0

9.5

32.0

49.3

8.1

“1.1

40.3

59.7

65.0

32.5

“2.5

13,666

54.3

64.7

77.0

59.9

32.4

29.7

44.7

64.5

54.7

61.6

25.6

100.0

26.7

19.4

35.7

11.5

6.7

42.3

57.7

63.8

14.2

2.0

‘Basedonthe/ntemat&a/ ChssiriafiwofDkeases, SthRevision,ClinicalMcdif?esfiin(3),Accidanralfalls(EW3-ESS8); Mdorvehdeawdents (E810-ES25~Sfrwk sccidentelly(E318-E9 17);

Sharp obpcts (E320~ Vibnce (E950-E3S9).

%ther includes visits for causq other than Iho$e Iiited in table plus unmdabls causes and blank causss of injuty.

3Bassd on U.S. Bureau of Cerws sethnstes of the civilian noninsfiiufiinalized popufsfion of the Unfisd States as of July 1, 1332.

inflicted” in an alcohol- and drug-related

visit in comparison with all other visits.

Alcohol and drug use wasdetemnined

by thehospitalstalf ifthepatient

indkatedorstdl suspectedthataleohol

or drugs played apart intheinj ury,

whetherby the patientoranother

person. Patient’s use ofalcohol ordrugs

wa8notnecessarily veritiedbyblood or

urinetests.1’hese data undoubtedly

underestimate the roleofakoholand

drugs inEDinjury visits.

Notwithstanding,visits classifiedas

related to alcohol and/or drugs had a

greaterlikelihood (61)ofbeingeaused

by violence than were visits not so

classhied.

Reason forvisit

Initemllofthe EDPatient

Recor&thepatient’s (orpatient

surrogate’s) ’’compltint(s), symptom(s),

orotherreason(s) forthisvisitin the

patient’s own words” isrecorded. Upto

three reasons forvisit are classiiedand

coded aecordmgto AReasonfor Wsit

ClassijcationforAmbulatory Care

0WC)(5).Thepficipal reasonisthe

problem, compkdng or reason listedin

item llaoftheEDPatientRecord.

The RVC is divided into the eight

modules or groups of reasons displayed

in table 6. Half of all injury-related

visits were made for reasons ckssitied

in the injuries and adverse effects

module. About 43.2 percent were in the

symptoms module with the largest

being symptoms referable to the
8 Advance Data No. 261 ● February 1, 1995

Aooidental

falls

Motor vehicle

acoidents

Struck

accidentally

_ White m Black

18

14

12

Shsrp Violenca

objects

Figure 4. Annual rate of injury-related visits to emergency department by patient’s race

and leading sausea of injury United States, 1992

Table 5. Number, peroen~ and rate of visits to emergency departments by selsoted causes

of Injury United Statea, 1992

Number of Peru3nt of Rate per

visits /n injury 1,000

Selected cause’ thousands V/sits personsz

Firearm s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 0.3 0.4

Pedal cyclists. . . . . . . . . . . . . . . . . . . . . . . . . . . 321 0.9 1.3

Pedaatftans. . . . . . . . . . . . . . . . . . . . . . . 74 0.2 0.3

Motorcyclists. . . . . . . . . . . . . . . . . . . . . . . . . . . 62 0.2 0.2

lB*edon the/ntematima/ C/-iFkatbn of Di*=ea WhRewsion. Cllnbal Modifi*ion (3): Firearms [ES’22, E955.O-.4,

(14.0 percent), and “fractures” (800-

829) (11.2 perce-nt).There wemno sex

differences for the principal diagnoses

except that males tended to havea

higher percent of their dmgnoses as

“open wounds” compared to females

(28.2 and 18.7 percent respectively).

There were few mce differences in

diagnoses although white persons tended

to have higher rates of “fractures” and

“crushing injuries” (925–929) than

black persons had. There wem 1.8

million visits that had an injury

d~osis (N-code) that were not

indicated by hospital stall to be injury

related or to have a cause of injury

recorded in item 10 of the Patient

Record. These visits are not included in

this report 83 injury visits.

The we of N-co& most frequently

found for the principal diagnosis

dtiered, as expected by age of patient

and cause of injury. Vkita for lpatients

65 years and over were twice as likely

to have a principal diagnosis of

“fracture” compared to younger

patients. Patienta between the ages of 15

and 44 years were twice as likely to

have a principal diagnosis of “sprains

and strains” compared to other age

groups. Chddren under 15 years were

one and a half times mo~ likely to have

an open wound dimnosis than were

E9S5.O-.4, E970, and E9B5&4] Psdal cyclkts (ESkI-E807(.3), E810-ES25(.6), E82=&9(.1)~ Pedesfris& in rrwtor”vehicle

accidents (E810-E825(.7)); Motorcyclists (E810-E825(.2)). olde; patienta. SM-arly, of the top five

%ased on U.S. Bureau of the Census esthmtes of the civilian noninsfiiuflonahzed popuk,fion of the Untied states as CJJuly 1,

---- causes of injury visits to emergency

musculoskeletrd system, accounting for

27.4 percent of the visits.

The 20 most frequently mentioned

principal reasons for visi6 representing

52.6 percent of all visits, are shown in

table 7. It is important to note that the

rank ordering presented in this and other

tables may not always be Aiable

because near estimates may not differ

from each other due to sampling

variability. “Upper extremity

lacerations” was the most frequently

mentioned specific reason for visit

(6.8 percent).

Principal diagnosis

The principal diagnosis or problem

associated with the patient’s most

important reason for visit and any other

significant current diagnoses are

recorded in item 12. Up to three

dmgnoses are coded and classified

aecordmg to the ICW9-CM (3). As

expected, injury and poisoning

(ICD-9-CM codes 800-999) accounted

for 81 percent of all visits, and diseases

of the musculoskeletal system (710-739)

accounted for 5 percent. Supplementary

classification dmgnoses (those unrelated

to injury or illness such as general

examimtion) were made for 4 percent of

the injury-related visits. The mnainhg

10 percent were distributed over all the

other major categories.

Within the main ICD-9-CM injmy

category (N-codes), most of the

principal diagnoses were “open

wounds” (870-897) (24.1 percent),

“sprains and strains of joints and

adjacent muscles” (840-848)

(14.4 percent), “contusions” (920-924)

departments, visits resulting from

accidental falls were mom likely to

result in a “fracture” diagnosis than

were other causes (21). Visits due to

motor vehicle accidents more lklcely

resulted in a principal diagnosis of

“sprains and strains” compared to other

causes (2:1). “Open wounds” was found

most often for visits caused by cuts

from sharp objects (86.7 percent).

“Open wounds” was also the leading

principal diagnosis for patients struck

accidentally or who were victims of

intentional injuries (about 28 percent

each).

The 20 most frequently reported

principal diagnoses are shown in table 8.

These are categorized at the three-digit

codtng level of the ICD–9-CM and

account for 55.5 percent of all injuryrelated ED visits. The most commonly

recorded diagnosis was “open wound of

head other than eye or ear” (873),
Advance Data No. 261 ● February1,1995 9

Table 6. Numbar and parcsnt distribution of injury-related emergency department vlsita by patient’s principal raaaon for vtaiti

Unitad Stataa, 1992

Number of

Prlnc@l mason for vkt and RVC wds’

P61cent

ftE2x?a dlsfrtwfkm

Allvlslta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33,950 100.0

Syrrpto mmodule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S001+933

General symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . scrol-sow

symptomsreferableto psychobgicaVrnentaldlsordera . . . . . . . . . . . . . . . . Sloo-Slee

symptomsreferableto the nervoussystem(excludingsense organs). . . . . . . S200-S259

symptomsreferableto the cardlovascular~~hatic system. . . . . . . . . . . . . S260-S293

Syrrptomareferabl etotheeyaaan daars . . . . . . . . . . . . . . . . . . . . . . . s300—3sgg

syqtomareferable totheraqdratoryaystem . . . . . . . . . . . . . . . . . . . . . S400-S499

Syr@ornerefersble tothed@etlvesyatem. . . . . . . . . . . . . . . . . . . . . . . S500-SS39

Syn_ptomerafwatrletot he@torrrinaryeystem. . . . . . . . . . . . . . . . . . . . SS4rF382S

Syrr@omsreferabletotheetdn, hair,arrdnalls. . . . . . . . . . . . . . . . . . . . . S630-SS99

Syr’rptornsreferableto the muscutoskalstalsystem . . . . . . . . . . . . . . . . . . s90&3$ree

Dbeaeamoduia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...0001-0999

Dlsgrrostic/aweeningarrdpreventivemodula. . . . . . . . . . . . . . . . . . . . . . . . X1C+X599

Traafrnerrtmodula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. TIoo-T6e9

Injurlasand advereeeffecte module.. . . . . . . . . . . . . . . . . . . . . . . . . . . .. J60%@sre

lnjurybytypa and/orbcatbn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Joo1-J79s

injury,NOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .J800-J633

Polaoningandadversaetfecte. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. J900-J999

Taslrasuits module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. RIoo-fww

Admlnlslratlvemodule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,.. .AIOA1404O

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. UWO—U339

14,663

1,s48

197

1,016

42

704

403

606

120

327

9,268

84

151

1,276

17,061

14,6al

1,s65

405

“24

“24

43.2

5.7

0.6

3.0

0.1

2.1

1.2

1.8

0.4

1.0

27.4

0.2

0.4

3.6

50.3

43.3

5.8

1.2

*0.I

%1

2.0

‘BaaadonARaaaon rbrWsfiClaaafioatkmforAnkwlakvy&ra (RVC)(5).

%cludes problemsand mmpbinta net akwhera classii, entriesof “’None:bhks, and illegibbdries.

Table 7. Number, percent distribution, and cumulative percent of Injury-rehted emergency department viaita by the 20 prlnoipal raaaona

for visit most fraqusntiy mentioned by patient= United States, 1992

Nunbr of

klens h *nf

Prhc@al mason for vIM and RVC cede’

CumulaWe

thousands dsrrbufkw

Alllrrjuryvlstta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33,950 100.0 . . .

UpperextramHylacerstbns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. J225 2,321 6.8 8.6

Facalacaratbns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..J21o 1,463 4.4 11.2

Handandflrrgarsymptome . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . ..sgw 1,225 3.6 74.8

Head,nack,andfacainjury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..J505 1,066 3.1 18.0

Harrdarrdfingarinjury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..J570 993 2.9 20.9

Nacksymptorne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..s900 933 2.7 23.6

Backsymptoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..sg05 913 2.7

ffiWSyfl@OMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S325

26.3

860 2.6

Anklesymptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..sew

2s.9

633 2.5

Footandtoesymptome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..sew

31.4

784t 2.3

Headsndnacklaceratbns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..J205

33.7

728 2.1 36.8

Sutura-ln8ertbn/ramoval. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..T565 693 2.0 37.9

AcckbnlNOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..J81o 687 2.0 33.8

Shouldersymptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..sg40 642 1.9 4*.8

Armsymptome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S945 635 1.9 43.6

Pakr,epacifledsftenotraferabfs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S055 621 1.6

Haadache,palnlnhead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..s210

45.5

621 1.6 47.3

Lagsymptome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..sg~ 801 1.8

Lowbacksymptome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..sgIo

48.1

601 1.8 60.8

Wrisfeyrrptom s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..w~ 591 1.7

Allotherreasons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

52.6

15,634 46.0 86.6

Blank. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466 1.4 100.0

‘BamdonARaason forViitC/aaa,?iitjon forAtiu/atoryCam (WC)(5).
10 Advance Data No. 261 ● February 1, 1995

Table 8. Number, percent distribution, and cumulative percent of injury-related emergency department visits by the 20 principal

diagnoses most frequently rendered by hospital staff United States, 1992

Number of

Wits In Percent

Princ@al dlagnosb and \CD-SLCM code’

Cumulative

thousands dlstrfbuflon percent

Allvisits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X3,950 100.0 . . .

Openwoundof head(otherthan eyeorear) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873

Contusion oflowerlhnbandotherun?pacified sites . . . . . . . . . . . . . . . . . . . . . . . . 924

Openwoundofflngar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...863

Spralnsandafrairrsofunepecitiadparfsof back. . . . . . . . . . . . . . . . . . . . . . . . . . . 647

Sprakrsandstralnsofanklaandfoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...845

Openwoundof olherand un?+x3ctfiadsif%, excaptllmbs. . . . . . . . . . . . . . . . . . . . . 879

Contusion ofupperliti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...923

Contusion offace,acaip,sndnacksxcapt eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . 920

Contus40noftmnk, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...922

Injury, olherandunspecified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...959

Openwoundof hand,excspttinger. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...882

Intracranial injuryof otherarrd un?pecltied nattrra. . . . . . . . . . . . . . . . . . . . . . . . . . 854

Openwoundof knee,lag(exceptthlgh), andsnkla . . . . . . . . . . . . . . . . . . . . . . . . . 691

Encounterforotherand unapeclfisd proceduraeandattercare. . . . . . . . . . . . . . . . V58

Fracfureofradiusanduhta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...813

Sprskrsandetrslnsofwrlstandhand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..W2

8pfatnsandatrainsofkrreeandleg.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..84.4

Ffactureofoneormorephaktngas offhan d . . . . . . . . . . . . . . . . . . . . . . . . . ...818

Superflctal injwyofeyeandadnexa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...918

Unspeclfieddlsordaraofthebacic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...724

Allotherdlagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2,561

1,755

1,604

1,597

1,311

1,257

1,255

883

744

720

675

564

548

540

518

518

509

482

442

392

15,095

7.5

5.2

4.7

4.7

3.9

3.7

3.7

2.5

2.2

2.1

2.0

1.7

1.6

1.6

1.5

1.5

1.5

1.4

1.3

1.2

44.5

7.5

12.7

17.4

22.1

26.0

29.7

33.4

35.0

36.1

40.3

42.2

43.9

45.5

47.1

46.6

50.2

51.7

53.1

54.4

55.5

100.0

lBased on the /rrfernafiorra/ c/8s”fh+orI of Dkeaseq Sth Flevisiin, Clinical Mcdificatiwr (lCD-S-CM) (3).

Table 9. Number and percent distribution of emergency department visits and percent of total visits that are Injury related, by selected

diagnostic andlor screening services: United States, 1992

Number of Percent

viaifs In Percent

Dlagnosfic and/or screening servlca ordered orprvvfded by phyefcfarr’

InJury

thousands diafrfbution ralatec?

Allin]ury-related visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33,950 100.0 07.8

Blood presaure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25,202 74.2 08.1

Extremltyx ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12,091 35.6 819.3

Othardiagnosllclmaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,147 12.2 44.3

Otherbloodtesf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,397 10.0 13.2

Cheatxray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,657 7.8 $7.6

Mentalstatusexam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,044 6.0 38.7

Urinalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,063 6.1 15.1

Etectrocardlogram (EKG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,495 4.4 12.6

CTscan/MR13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 860 2.5 09.8

HlVserology4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 0.3 34.2

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,584 13.5 25.9

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,819 11.2 35.2

‘Total may exceed total number of visits becsuse more than one service may be reported per visii.

%ercant of all enwgency department visits in each cetegory that are injury related.

3CT is computerized tomography. MRI is megnetic reeonanca imaging,

$-W IS human irnrnmxteticiency virus.

occurring at 7.5 percent of all injury

visits.

Diagnostic and screening

services

Statistics onvtious diagnostic and

screening services orderedorprovided

by hospital staffduring an injury-related

ED visit are displayed in table 9.

Approximately 88.8 percent of all

injury-related ED visits included one or

moredhgnostic orscreeningservice.

Themostfrequently mentioned

dmgnosticservice wasbloodpressure

check, recorded at74.2 percent of visits,

Extremityxray(35 .6percent)wasthe

second most frequent diagnostic

procedure. About 9 of every 10 ED

vi8it8 with extremity xrayswereinj ury

related. Half of allinjury-related visits

for accidental falls involvedan

extremity xray. Vkitsduetomotor

vehicle accidents orviolence were more

likely to have blood tests andtninalysis

performed compared toinjuryvisitsfor

othercanses.

Readersshotddnote thatforitems

8,15,16, 18, and19, hospital statYwere

asked to check all ofthe applicable
Advance Data No. 261 ● February 1,1995 11

Table 10. Number ●nd percent distribution of InJury-related emergency department vlelte and percent that we injury related, by selected

procedurw United States, 1992

NunLw of Pemsrrt

vMs In Percent

Prooedureprwk#ad by hoqltal star7’

Irrjuiy

fhouserrds dMfbuffon ralatec#

AIIVMS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33,950 100.0 37.8

Woundcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,757 31.7 93.1

Otihopsdlccara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,706 19.8 34.8

Intrevenousflukts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,075 6.1 18.0

Eyeand/orear,nose,andthroatcare . . . . . . . . . . . . . . . . . . . 1,241 3.7 49.9

Bladdercatheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415 1.2 17.9

Naeogsetrktubeend/orgaetrklavags . . . . . . . . . . . . . . . . . . 372 1.1 42.4

Endotracheatln!ubafkm . . . . . . . . . . . . . . . . . . . . . . . . . . .

CPR3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

110 0.3 27.0

63 0.2 21.6

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,470 7.3 36.9

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13,226 33.2 25.7

‘Ttilrnayexceed totslnumberdvisits becsusemcrethan onepmceduremsy bereportad pervisit

?%wmtotallemwgsmcy departmentviaitsineach categorylhstareirrjwy relatad.

3cp~ is ~a~~pulmnaw rasuscitat”kxt

Table 11. Number and percent distribution of injury-related emergency department visits and percent that are injury related, by number

of medications provided or prescribed: United States, 1932

Number of Percent

vieltsin Percart InJury

Nurnbarofmedications r?rouserrck dktribufion related’

AllirtJu~ralatedvk4fs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . =,950 100.0 37.8

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 12,812 37.7 46.2

One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12,244 36.1 41.8

Two . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,691 16.8 30.2

Three . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,004 5.2 24.8

Four . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 723 2.1 22.4

Fiveormcm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476 1.4 17.9

lpemnt ~ all ~mwency depati~nt visits in each cate90rythat are iniuryMlaad.

Table12.Number, parcentdistrlbution, cumulathrepercen~ andtherapeuttcclaesiflcation ofthe15drugsmost frequaritly provided or

prescribed In injury-related emergency department vleita by entry name of drug: United Statee, 1992

Number of

mentionsIn Percent Cumulative

Enbyrranreofdmg’

77wapaufio

thousenck disfnbufion paroarrf oiaaehYoatkvr2

Alldrugmentions . . . . . . . . . . . . . . . . . . . . . . . . . 34,910 100.0 . . . . . .

Tetanus-relafedbiologioals...... . . . . . . . . . . . . .

Tylenol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Motrtn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tylenolwithoodelne . . . . . . . . . . . . . . . . . . . . . . .

Toradol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oernerol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Anvil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Vkodin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Keflsx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Darvocet-N . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Lkkoaine.. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ibuprofen, . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neosporln . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Flsxerll, , .,.,........,,.. . . . . . . . . . . . . .

Benadryl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allothermentlorm . . . . . . . . . . . . . . . . . . . . . . . .

3,311

2,692

2,216

1,790

1,079

1,017

873

794

701

668

635

627

607

546

507

16,946

9.5

7.4

6.3

5.1

3.1

2.3

2.5

2.3

2.0

i .9

1.8

1.8

1.7

1.6

1.5

48.6

9.5

16.9

23.3

26.4

31.5

34.4

36.9

33.2

41.2

43.1

44.9

46.7

48.4

50,0

51.6

100.0

V8cclneaandantleerums

Gsneralanatgeaks

Ganerelanelgesks

Gensralanafgeska

Generalana)geeks

General anaigeaks

Genera!anaigaaks

Genemlanrdgesks

Cephaksperins

General analgealca

Locafaneathetke

General arselgssks

Antlb8cferial agan18

Muadereiaxants

Antlhkfeminee

. . .

‘Theentrymade bythehos@talaratl cnthapreaoription orothermed!cd racord$.Thbrnay katredananm, genertorwrm,or d+airadtheqsutie sffacl.

z~arapeut~ damnmtlon b bsaad on the IVsfkmd /Jr&gCodeDkwObrM1985 Edition(8),
12 Advance Data No. 261 ● February 1, 1995

Table 13. Number, percent distribution, and cumulative percent of drug mentions for the 15 most frequently usad generic sutmtancss in

inJury-rsiatsd emergency department visits: United Stctes, 1992

Number of

mentions In Percent

Generic substance

Cumulative

thousands’ dlafdbuflon percent

Alldrug rnenllons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45,207 100.0 . . .

Acetemlnophen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,759 15.0 15.0

Ibuprofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,869 8.6 23.5

Tetanustoxoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,793 6.2 29.7

Codeine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,006 4.4 34.1

Diphtherletoxold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,673 4.1 36.3

Lidocslne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,230 2.7 41.0

Bacitrechr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,195 2.6 43.6

Mepeitdine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,086 2.4 46.0

KetorolacTromethamhre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,079 2.4 4s.4

Dlhydrocodelne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 924 2.0 50.5

Polymyxin B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 846 1.9 52.3

Cephsfexlrr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 792 1.6 54.1

Neproxen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741 1.6 55.7

Neomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734 1.6 57.4

Propoxyphene . ~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 715 1.6 58.9

Allothermentions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18,561 41.1 100.0

‘Frequency of mention combines single-ingredient agents with mentioms of theagent esaningredient inacomMnationdrug.

Tabie 14. ‘Number and percent distribution of emergency department visits and percent of total visits that are injury reiatad, by patisnt’a

expected source ofpaymenh Unitsd States, 1992

Number of Percent

vlalta In Percent Injury

fxpectedsourceof payment’ morrsarrda dlatrtbuUon ralatd

Allvkits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33,950 100.0 37.8

Prlvateantiorcommerclel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13,869 40.9 42.9

Medlosid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,072 14.9 24.9

Patient-paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,006 14.7 40.4

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,129 9.2 23.0

HMO ancVorotherprepald . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,701 8.0 41.1

Othergovemmerrl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,759 5.2 43.6

Nocharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 0.6 27.4

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,877 10.8 80.1

Unknown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464 1.4 32.2

‘Total may excead total number c1 visits because more than one pay sourcamay be mded for each vM.

2Parcant of all wnargency depadment visits In each category that are Injuty ralafad.

Table 15. Number and percentdistributfon of emergency department visits and percant oftotsi visits that are injury reiated, bytypeof

provider scat: United States, 1992

Number of Percent

visits in Percent Injury

Typeofprovfder’ thousands dlstrlbutfon relater+

AllvIsits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33,950 100.0 37.6

3faffphyslclan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fmglsterednurse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otherphysician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rsaldentantiorlntem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nuraa’sakle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Llcanssdpractlcslnurae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Physiclen eseiatant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nuraapreofifloner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28,466

28,350

3,799

3,750

3,210

2,039

664

564

83.8

83.5

11.2

11.0

9.5

6.0

2.5

1.6

36.4

36.0

36.1

30.5

37.8

34.9

49.2

31.7

‘Total may exceed total number of visits because more than one provider maybe reported per vi$it.

2Percant of all errwgency department visi!g In each category that are Injury related.
Advance Data No. 261 ● Februarv1.1995 13

Table 16, Number, percent dlstrlbutton of injury-related emergency department visits and percent that are injury related, by disposition

of vlslk Unltad States, 1992

Nurrrbar of Percent

vM% in Percent Irr]wy

Dkpos/tkwr’ thousands dlatribuflon rslateti

Allvisits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33,950 100.0 37.8

Refer toolherphysickm/clinic .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13,54s 39.9 40.8

Retumto emerganoy department aeneeded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,928 26.3 38.8

Retumto referring physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,957 20.5 36.6

Retumto emergency dspatment appolnhnent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,881 8.5 86.9

No followup planned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,325 6.8 43.6

Admittohoaplfaf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,072 6.1 17.1

Translertootherfacility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340 1.0 31.1

Leftagalnstrnedicaladvloe..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 0.9 30.2

Deadonarrkwfordiedinemargancy department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “51 90.2 “18.2

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,650 4.9 36.0

‘Total may exmd total number or visit. because mere than one disposition may be repwted par visii

+ercant of all amargency department visits i. each cetegow that are inj.!y related.

categoriesforthat item, with theresult

thatmultipleresponses couldbecoded

for each visit.

Procedures

I?rocedureswereperformedat

60.8percent of injury-relatedED visits

(table10), which was twice the percent

for illne8s-relatedvisit8.The most

frequentlymentionedprocedurew38

wound carc,recordcd at 31.7percentof

thevisit800rthopedic carewasthe

pmcedurewith the secondhighest

fiequency,ocmrring at one-lifth of the

visits. Roughly94 Percentofall visits

withwoundcare ororthopediccare

wmidentiliedas related to aninjury.

Injury visits were less likely to require

the use of intravenousfluids compamd

with illness-relatedvisits (6.1 and

19.5percentrespectively).

Medication therapy

Medicationwas used at 62.3percent

of the injury-relatedvisits. Hospitalstaff

were instructedto record all new or

continuedmedicationsorderedor

provided at the visi~ including

prescriptionand nonprescription

preparations,and immunizingand

desensitizingagents.As many as five

medicationsor drug mentions could be

coded per visit. Visit8with one or more

drug mentions are termed “drug visits”

for thii report.Table11 showsthe

frequencyand percent of numbers of

medicationsadministeredor prescribed

during the visit. There was amaverage

A145,655 Dsaths

Figure 5. The injury~yramid: United Statas, 1992

of 1.1 drug mentions per injury-related

ED visitor 1.8 mentions per injuryrelakd drug visit. Only one drug

mention was recordedat 36.1percent of

the injury-relatedvisits. Medications

were administeredor prescribedless

f@uently for injury-relatedvisits

comparedwith illness-relatedvisits

(62.3 and 73.3percentrespectively).

The 15 most frequentlymentioned

medicationsin injury-relatedED visits

are presentedin table 12 accordingto

the name written on the ED Patient

Record by the health care provider

regardlessof whetherit is a brand name,

generic name, or therapeuticeffect.

Tetanus-relatedbiological, Tjdenol,and

Motrin were the three drugs or

immuni2iig agents most ti-equently

provided or prescribedduring injuryrelatedED visit8.They 8ccountedfor

about onequruter of all drug mentions.

Of the top drug name8mentionexlmost

are classifiedas general analgesics.This

is W on tie therapeuticcategories

used in the Nm”onal Drug Code

Directory, 1985 edition (NIX!)(0.

The 15 most tlequentiy used

generic substancesfor 1992 injuryrelated ED visits are shown in table 13.

Drug products contrdniig more than one

ingredient(combmationproduct8)are

includedin the data for each ingredent.

For example, acetaminophenwith

codeine is included in both the count for

acetaminophenand the count for
14 Advance Data No. 261 ● February 1, 1995

codeine. Acetaminophen was the generic

ingredient most frequently used in drugs

or&red or provided by hospital staif,

occurring in 15 percent of drug

mentions. The top 15 generic substances

accounted for almost 60 percent of all

drug mentions. As expected, the top

generic substances in injury-related

visits are different from those for

illness-related ED visits. Only

acetaminophen, ibuprofen, and codeine

appear on both lists of top 15 generic

substances.

Expected source of payment

Expected source of payment for

injury-related visits (table 14) was most

often private/commercial insurance

(40.9 percent). “Medicaid” and

“patient-paid” each accounted for about

15 percent of the injury-related visits.

“HMO/other prepaid” and “Medicare”

were each mentioned at about 8 percent

of injury-~lated ED visits. The

patient-paid category includes the

patient’s contribution toward “copayments” and “deductibles.” Whiie

tijuries made up 37.5 percent of the ED

workload, they accounted for 60 percent

of the visits whose payment source was

categorized as “other” on the form. It is

possible that visits paid by worker

compensation were recorded under

“other.” A separate category for worker

compensation was placed on the

1995–96 Patient Record to provide

better information for future analyses.

About 40 percent of the “Other

Government,” “HMO/Other prepaid,”

“Private commercial,” and “Patientpaid” visits are injury related. Only

about 24 percent of the Medicare and

Medkaid visits are injury related.

Providers seen this visit

A registered nurse or staff physiciau

was seen at 84 percent of injury-related

ED visits (table 15). These percents are

not significantly different from those

corresponding to all ED visits.

Disposition of this visit

The most frequent disposition was

to refer the patient to another physician

or clinic (39.9 percent). Only 6.1 percent

of injury-related ED visits resulted in

hospital admission (table 16). This is

lower than the 18 percent of illnessrelated visits that ended in

hospitalization. Roughly one-quarter of

the injury-related visits had a disposition

of “Return to ED as needed.” This

means no followup is planne~ but if the

condition worsens, the patient should

return. Patients in injury-related visits

were more likely to be scheduled for

another ED appointment compared with

illness-related visits (8.5 and 2.6 perceng

respectively). Vkits resulting from

accidental falls and motor vehicle

accidents were more likely to result in a

hospital admission for the patient (9.2

and 11.2 percent respectively) than were

injury visits for other causes

(5.2 percent).

Impact of data

The NHAMCS data present a better

picture of the impact of injuries on

health care utilization. Figure 5 presents

the injury pyramid indicating the

national estimates from which relative

rates of various health care events and

death may be determined. The following

rates are based on 59.6 million reported

injuries that were obtained from the

1992 National Health Interview Survey

(7). For every 100 injuries requiring

medical attention or resulting in the loss

of at least one-half day tkom usual

activities, there were 110 physician

office visits (8); 57 emergency

department visits; 4.5 hospitalizations

(9); and 0.24 deaths (10). Another way

of comparing the relative impact of

injuries is using the number of deaths as

the base. For each death in 1992

resulting from an injury, there were 19

hospitalizations, 233 ED visits, and 450

physician office visits.

The impact of injuries comprises a

significant portion of health care

expenditures in the United States. The

average cost of an ED visit in 1987 was

$166 (11). After adjusting for changes in

the consumer price index between 1987

and 1992, the cost in 1992 dollars

would be $271. Based on this cost, the

annual national cost of visits to ED’s

alone for injury-related purposes is over

9.2 billion dollars. The 1992 NHAMCS

data revealed that the rates of injuries

resulting in ED visits are highest among

males 15-24 years of age. Close to

two-thirds of all ED visits for this

population were for injuries. Continued

reliance on injury prevention programs,

especially targeted to thii population,

should help to reduce resources spent in

health care, loss of productivity, loss of

life, and loss of quality of life as a

result of personal injuries. These data

support the injury prevention programs

that emphasize nonviolent solutions to

conflicts, elimination of alcohol and

drug abuse, and incn?ased education in

home, school, recreational, workplace,

and transportation safety procedures and

practices. The 1992 NHAMCS data

provide the first national data on

nonfatal causes of injury resulting in

emergency medka.1 care. Analysis of

data by E-codes supports the prevention

efforts that promote individual practices

and behaviom that reduce a person’s

risk of injury, such as proper storage of

firearms in the home, avoiding drinking

and driving, using safety restraints while

riding in an automobile, and wearing a

helmet when riding a bicycle or

motorcycle.

Additional reports that utilize the

1992 NHAMCS data will be

published. In addition, a computer

tape containing both the emergency

and outpatient department data is

available at a nominal cost from the

National Technical Information

Service. These data will also be

available on CD-ROM and diskettes.

Questions regarding this report may

be directed to the Ambulatory Care

Statistics Branch by calling

(301) 436-7132.

References

1. McCaigLF. National Hospital

Ambulatory Medical Care Survey

1992 emergency department

summary. Advance data from vital

and health statistics; no 245.

Hyattsville, Maryland: National

Center for Health Statistics. 1994.

2. McCaig LF, McLemore T. Plan and

operation of the National Hospital

Ambulatory Medical Care Survey.

National Center for Health Statistics.

Vital Health Stat 1(34), 1994.
3. Public Health Service and Health

Care Financing Administration.

International classification of

d~eases, 9th revision, clinical

modification. Washington, D.C.:

Public Health Service. 1991.

4. Nelson CR, Stussman BJ. Alcoholand drug-related visits to hospital

emergency departments: 1992

National Hospital Ambulatory

Medical Care Survey. Advance data

from vital and health statistic% no

251. Hyattsvili~ Maryland National

Center for Health Statistics. 1994.

5. Schneider D, Appleton L,

McLemore, T. A reason for visit

classification for ambulatory care.

National Center for Health Statistics.

Vital Health Stat 2(78). 1979.

Advance Data No. 261 ● February1,1995 15

6. Food and Drug Administration.

National Drug Code dwectory, 1985

ed. Washington Public Health

Service. 1985.

7. Benson V, Marano MA. Current

estimates from the National Health

Interview Survey. National Center for

Health Statistics. Vital Health Stat

10(189). 1994.

8. Schappert SM. National Ambulatory

Medical Care Survey 1992

summary. Advance data tiom vital

and health statistics no 253.

Hyattsville, Maryland National

Center for Health Statistics. 1994.

9. Graves EJ. 1992 Summary National

Hospital Dkcharge Survey. Advance

data from vital and health statistic$

no 249. Hyattsvill% Maryland

National Center for Health Statistics.

1994.

10. Kochanek KD, Hndson BL. Advance

report of final mortality statistics,

1992. Monthly vital statistics repoti,

vol. 43, no. 6. suppl. Hyattsville,

Maryland National Center for Health

statistics. 1994.

11.1987 National Medical Expenditure

Snrvey Public Use Tape 14.5;

Household Survefi Ambulatory

MedicaI Visit Dataj Calendar Year

1987.

12. Shah BV, Barnwell BG, Hnnt PN,

LaVange LM. SUDAAN user’s

manual release 5.50. Research

Triangle Park, North Camlinrc

Research Triangle Institute. 1991-
16 Advance Data No. 261 cFebruarv 1, 1995

Technical notes

Source of data and

sample design

The information presented in this

report is based on data collected in the

1992 National Hospital Ambulatory

Medical Care Survey (NHAMCS) from

December 2, 1991 through December

27, 1992. The data were adjusted to

produce annual estimates. The target

universe of NHAMCS includes visits

made in the United States by patients to

emergency departments (ED’s) and

outpatient departments (OPD’S) of

non-Federal, shofi-stay, and general

hospitals. Telephone contacts are

excluded.

A fore-stage probability sample

design is used in NHAMCS. It involves

samples of primary sampling unit8

(PSU’S), hospitals with ED’s and/or

OPD’S within PSU’S, EDs within

hospitals and/or clinics within OPD’S,

and patient visits within EDs andh

clinics. For 1992, a sample of 524

non-Federal, short-stay, and general

hospitals was selected from the SMG

Hospital Market Database. Of this

group, 474 hospitals we~ in scope, or

eligible to participate in the survey. The

hospital response rate for the NHAMCS

during this period was 93 percent.

Hospital staff were asked to complete a

Patient Record (figure 1) for a

systematic random sample of patient

visits occurring during a randomly

assigned 4-week reporting period. The

number of Patient Record forms

completed for ED’s was 36,271.

Characteristics of the hospital, such

as ownership and expected number of

ED visits, were obtained from the

hospital administrator during an

induction interview. The U.S. Bureau of

the Census, Housing Surveys Branch,

was responsible for the survey’s data

collection. Data processing operations

snd medlcd coding were performed by

the National Center for Health Statistics,

Health Care Surveys Section, Research

Triangle Parkr North Carolina.

Sampling errors

The standard error is primarily a

measure of the sampling variability that

occurs by chance when only a sample,

rather than an entire universe, is

surveyed. The standard error also

reflect3 part of the measurement error,

but does not measure any systematic

biases in the data. The chances are 95

out of 100 that an estimate horn the

sample differs from the value that would

be obtained from a complete census by

less than twice the standard error.

The standard errors that were used

in tests of significance for thi3 report

were calculated using generalized linear

models for predicting the relative

standard error for estimates based on the

linear relationship between the actual

standard error, as approximated using

SUDAAN software, and the size of the

estimate. SUDAAN computes standard

errors by using a fimt-order Taylor

approximation of the deviation of

estimates horn their expected values. A

description of the software and the

approach it uses has been published

(12). The relative standard error (RSE)

of an estimate is obtained by dividing

the standard error by the estimate itself.

The result is then expressed as a percent

of the estimate.

Relative standard errors for

emergency department estimates are

shown in tables I and II. Standard errors

for estimates in percents of visits and

drug mentions are shown in tables III

and IV. Multiplying the estimate by the

RSE will provide an estimate of the

standard error for the estimate.

Alternatively, relative standard

errors for aggregate estimates may be

calculated using the following general

formulz where x is the aggregate of

interest in thousands, and A and B are

the appropriate coefficients flom table V.

RSE (x) =

d

A+:v1OO

Similarly, relative standard errors

for an estimate of a percent maybe

calculated using the following general

formulz

‘s’(’)=Ev’oo

where p is the percent of interest

expressed as a proportion, and x is the

denominator of the percent in thousands,

Table L Approximate relative standard

errors for estimated numbers of emergency

department visk National Hoepltal

Ambulatory Medioal Care Survey, 1992

Relative

Estimated number of standard

emergency department efror in

visits in thousands percent

lo . . . . . . . . . . . . . . . . .

20 . . . . . . . . . . . . . . . . .

50 . . . . . . . . . . . . . . . . .

58 . . . . . . . . . . . . . . . . .

100 . . . . . . . . . . . . . . . .

200 . . . . . . . . . . . . . . . .

500 . . . . . . . . . . . . . . . .

1,000 . . . . . . . . . . . . . . .

2,000 . . . . . . . . . . . . . . .

5,000 . . . . . . . . . . . . . . .

10,000 . . . . . . . . . . . . . .

20,000 . . . . . . . . . . . . . .

50,000 . . . . . . . . . . . . . .

100,000 . . . . . . . . . . . . .

71.1

50.4

32.0

29.7

22.8

16.4

10.8

8.1

6.4

5.1

4.6

4.3

4.1

4.0

NOTE The smallest reliible estimate for visits to hospital

emergency depertmenfs is 58,0C0. Estimates below thB figure

have a relefive sfendard error greater than 30 peroent and are

deemed unreliable by by NCHS stendards.

Exemple of use of table An aggregate estimata of 20 million

visk has a relafiwe afendard error of 4.3 pert.ant or a

standard error of 880,000 visits (4.3 percent of 20 Mien).

Table Il.Approximate relative standard

errors for estimated numbers of drug

mentions at emergency department visik

National Hospital Ambulatory Medical Care

Survey, 1992

Relative

Estimated number standsrd

of drug mentions error in

in thousends percent

lo . . . . . . . . . . . . . . . . . 71.9

20 . . . . . . . . . . . . . . . . . 50.9

50 . . . . . . . . . . . . . . . . . 32.4

59 . . . . . . . . . . . . . . . . . 29.9

100 . . . . . . . . . . . . . . . . 23.1

200 . . . . . . . . . . . . . . . . 16.6

500 . . . . . . . . . . . . . . . . 11.1

1,000 . . . . . . . . . . . . . . . 6.5

2,000 . . . . . . . . . . . . . . . 6.8

5,000 . . . . . . . . . . . . . . . 5.5

10,000 . . . . . . . . . . . . . . 5.0

20,000 . . . . . . . . . . . . . . 4.8

50,000 . . . . . . . . . . . . . . 4.6

100,000 . . . . . . . . . . . . . 4.5

200,000 . . . . . . . . . . . . . 4.5

NOTE The smallest ml!able estimate of drug mentions at

visits to hoepifal amergency departments is 59 millimn.

Estimates below this figure have a re!afive standard error

greater than 30 parcent and are deenmd unreliable by NCHS

standards.

Exemple of uee of table: An aggregate estimate of 10 million

drug mentions hes a relafiie standard error of .55 peraant or

a sfendard error G4S50,000 drug mentions (.5.5 percent of 10

million).

using the appropriate coefficients from

table V.

Adjustments for hospital

nonresponse

Estimates horn NHAMCS data

were adjusted to account for sample
Advance Data No. 261 ● February 1, 1995 17

Table Ill.Approximate standard errors of percents of estimated numbers of emergency department visik National Hospital Ambulatory

Medical Care Survey, 1992

Eetknatedparcant

Base ofpercent

@7itS h thousands) 1 or 99 5 or 95 10 or90 20 or 80 30 or 70 40 or 60 50

lo . . . . . . . . . . . . . . . . . . . . . . 7.1

20 . . . . . . . . . . . . . . . . . . . . . . 5.0

50 . . . . . . . . . . . . . . . . . . . . . . 3.2

100 . . . . . . . . . . . . . . . . . . . . . 2.2

200 . . . . . . . . . . . . . . . . . . . . . 1.6

500 . . . . . . . . . . . . . . . . . . . . . 1.0

1,000 . . . . . . . . . . . . . . . . . . . . 0.7

2,000 . . . . . . . . . . . . . . . . . . . . 0.5

5,000 . . . . . . . . . . . . . . . . . . . . 0.3

10,000 . . . . . . . . . . . . . . . . . . . 0.2

20,000 . . . . . . . . . . . . . . . . . . . 0.2

60,000 . . . . . . . . . . . . . . . . . . . 0.1

100,000 . . . . . . . . . . . . . . . . . . 0.1

15.5

10.9

6.9

4.9

3.5

22

1.5

1.1

0.7

0.5

0.3

0.2

0.2

Standard ermrinperoentaga points

21.3

15.1

9.5

6.7

4.8

3.0

2.1

1.5

1.0

0.7

0.5

0.3

0.2

2&4

20.1

12.7

9.0

6.4

4.0

2.8

2.0

1.3

0.9

0.6

0.4

0.3

32.5

23.0

14.6

10.3

7.3

4.6

3.3

2.3

1.5

1.0

0.7

0.5

0.3

&l.8

24.6

15.6

11.0

7.8

5.9

3.5

2.5

1.6

1.1

0.8

0.5

0.3

35.5

25.1

15.9

11.2

7.8

5.0

3.6

2.5

1.6

1.1

0.8

0.5

0.4

Examp!aofuseofiabkAnestirnateof40 Pwc%ntbasedonanaggregateestimate oflOmNionvisitshasasfandarderrord 1.1 percantorarelafive sfandarderrorof2.8percant(l.l percent

dwided by 40 percent),

Table IV.Approximate standard errors of percents of estimated numbers of drug mentions at emergency department visi&KNational

Hospital Ambulatory Medical Care Survey, 1992

EWnatedpercent

Base ofpercwrt

(dregmentionsin thousands) 1 or 99 5 or 95 10 or90 20 or 80 30 or 70 40 or 60 50

lo ............ ...... ....

20 . . . . . . . . . . . . . . . . . . . . . .

50 . . . . . . . . . . . . . . . . . . . . . .

100 . . . . . . . . . . . . . . . . . . . . .

200 . . . . . . . . . . . . . . . . . . . . .

500 . . . . . . . . . . . . . . . . . . . . .

1,000 . . . . . . . . . . . . . . . . . . . .

2,000 . . . . . . . . . . . . . . . . . . . .

5,000 . . . . . . . . . . . . . . . . . . . .

10,000 . . . . . . . . . . . . . . . . . . .

20,000 . . . . . . . . . . . . . . . . . . .

50,000 . . . . . . . . . . . . . . . . . . .

Ioo,ooo . . . . . . . . . . . . . . . . . .

200,000 . . . . . . . . . . . . . . . . . .

7.1

5.0

3.2

2.3

1.6

1.0

0.7

0,5

0.3

0.2

0.2

0.1

0.1

0.1

15.6

11.1

7.0

4.9

3.5

2.2

1.6

1.1

0.7

0.5

0.3

0.2

0.2

0.1

.%mfardermrinpercentaga points

21.5

15.2

9.6

6.8

4.8

3.0

2.2

1.5

1.0

0.7

0.5

0.3

0.2

0.2

28.7

20.3

12.8

9.1

6.4

4.1

2.9

2.0

1.3

0.9

0.6

0.4

0.3

02

32.9

23.2

14.7

fo.4

7.4

4.6

3.3

2.3

1.5

7.0

0.7

0.5

0.3

0.2

35.1

24.8

15.7

11.1

7.9

5.0

3.5

2.5

1.6

1.1

0.8

0.5

0.3

0.2

35.9

25.4

16.0

11.3

8.0

5.1

3.6

2.5

1.6

1.1

0.8

0.5

0.4

0.3

Exampleofuseof tabbAnestirrmte ofEOpsrcentbased onanaggregateestimate oflOmillionvi$if$has astandmderrord 1.1 Percentorarelative sfand8rdwrorof2,2 percent(l.lpercunt

dwided by 50 percent).

hospitals that were in scope butdld not

participate in the study. This adjustment

wascaIculated to minimize the impact

of response on final estimates by

imputing to nonresponding hospitals

data from visita to similar hospitals. For

this purpose, hospitals were judged

similar if they were in the same region,

ownership control group, and

metropolitan statistical area control

group.

Adjustments for ED and/or

clinic nonresponse

Estimates ftom NHAMCS data

were adjusted to account for ED’s and

sample clinics that were in scope but

did not participate in the study. TM

adjustment was calculated to minii

the impact of response on final estimates

by imputing to nonrespondmg ED’s or

clinics’ data from visits to similar EDs

or clinics. For this purpose, ED’s or

clinics were judged similar if they were

in the same ED or clinic group.

Test of significance and

rounding

The determimtion of statistical

infenmce is based on the t-test. The

Bonfemoni inequality was used to

establish the critical value for

statistically significant dhlerences

(0.05 level of significance over all

analyses performed on estimates in a

table). Txms relating to dtierences such

as “higher than” indicate that the

difference is statistically significant. A

lack of comment regarding the

d~erence between any two estimates

does not mean that the diKereme was

tested and found to be not significant.

In the tables, estimates of ED visits

have been rounded to the nearest

thousand. Consequently, estimates will

not always add to totals. Rates and

percents were calculated from original

unrounded figures and do not
18 Advance Data No. 261 ● February 1, 1995

necessarily agree with percents

calculated from rounded data.

Definition of terms

F’atienl-h individual seeking

personal health services who is not

currently admitted to any health care

institution on the premises.

Hospital-All hospitals with an

average length of stay for all patients of

less than 30 days (shofi-stay) or hospital

whose specialty is general (medical or

surgical) or children’s general Federal

hospitals, hospital units of institutions,

and hospitals with fewer than six beds

stalTed for patient use are excluded.

Emergency department-Hospital

facility for the provision of unscheduled

outpatient services to patients whose

conditions require immdlate care and

which is st.atfed 24 hours a day. If an

ED provided emergency services in

different areas of the hospital, then all

these areas were selected with certainty

into the sample. Off-site emergency

Table V. Coeffiolants appropriate for determining relative standard error by type of

estimate for hospital emergency departments: National Hospital Ambulatory Medical Care

Survey, 1992

Coefficient with use for

esthetes In thousands

Type of estimate A B

Vlslts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.00158 5.04053

Drug mentions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.00235 5.14293

departments open less than 24 hours are

included if staffed by the hospital’s

emergency department.

Wsit—A direct personal exchange

between a patient and a physician or

other health cam provider working

under the physician’s supewision, for

the purpose of seeking care and

receiving personal health services.

Urgendemergent-A visit wherein

the patient requires immediate attention

for an acute illness or injury that

threatens life or function and where

delay would k harmful to the patient.

Non-urgent—A visit wherein the

patient does not require attention

immediately or within a few hours.

Injury-related visit—A visit during

which hospital st.atlindicated that the

visit was a result of any kind of

accident or injury includlng but not

limited to falk, lacerations burns;

intentional injurky unintentional

poisonings by drugs, medicinal

substances, blologicals, gases, or vapors;

adverse reaction to drugs; complications

of surgical and medical procedures; and

insect and animal bites.
Advance Data No. 261 ● February 1, 1995 19

Symbols

--- Data not available

. . . Category not applicable

Quantity zero

0.0 Quantity morethan zero but

lessthan 0.05

z Quant”~ morethan zero but

lessthan 500 where numbers

are roundedto thousands

* Figure does not meet standard

of reliabilityor precision
20 Advance Data No. 261 ● February 1, 1995

Suggested citation

Burt CW. Injury-related visits to hospital

emergency departments: United States, 1992.

Advance data from vital and health statistics;

no 261. Hyattsville, Maryland: National Center

for Health Statistics. 1995.

Trade name dlaclaimer

The use of trade names is for identification

only and does not imply endorsement by the

Public Health Service, U.S. Department of

Health and Human Services.

Natfonal Center for Health Statistioa

Copyright Information

Director

All material appearing in this report is in the Manning Feinleib, M. D., Dr. P.H.

public domain and may be reproduced or

copied without permission; citation as to Deputy Director

source, however, is appreciated. Jack R. Anderson

U.S. DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics m

6525 Belcrest Road

Hyattsville, Maryland 20782

OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

To receive this publication regularly, cxmtact

the National Center for Health Statistics by

calling 301-436-8500

DHHS Publication No. (PHS) 95-1250

5-0411 (2/95)
Number 262 . March 30, 1995

Advance

Data

FromVitaland HealthStatisticsofthe CENTERS FOR DISEASE CONTROL AND PREVENTION/National Centerfor Health Statistics

Office Visits for Glaucoma: United States, 1991-92

by Susan M. Schappert, M.A., Division of Health Care Statistics

Introduction

During the 2-year period 1991–92

there were an estimated 17.5 million

visits made to nonfederally employe~

office-based physicians in the United

States at which the principal, or

first-listed dmgnosis was glaucoma-an

average of 8.7 million visits per year.

An additional 3.2 million visits over this

same period included glaucoma as the

seeond- or third-listed diagnosis.

This report presents national

estimates pertaining to glaucoma-related

office visits. These estimates are based

upon data collected in the National

Ambulatory Medical Care Survey

(NAMCS), a national probability sample

survey conducted by the Division of

Health Care Statistics of the National

Center for Health Statistics, Centers for

Disease Control and Prevention.

Statistics are presented on patient

characteristics, physician praetiee

characteristics, and visit characteristics

for visits with a diagnosis of glaucoma,

The 1991 and 1992 National

Ambulatory Medical Care Surveys

shared identical survey instruments,

definitions, and procethues. The

resulting 2 years of data have been

combined to provide more reliable

estimates. Inmost cases, the estimates,

percent distributions, and rates presented

in this report reflect average annual

estimates based on the combined 1991

and 1992 data. Figures representing

2-year totals rather than averages are

noted as such in the text.

A copy of the Patient Reeord form,

the survey instrument used by

participating physicians to rword

information about their patients’ office

visits, is shown in figure 1. In item 11

of the form, physicms are requested to

record a principal diagnosis (the

dmgnosis most closely associated with

the patient’s most important reason for

visit) as well as any other current

diagnoses. Up to three diagnoses are

coded and classified aeeording to the

International Classijicatwn of Diseases,

9th Revisioq Clinical A40dijicatwn

(ICD-9-CM) (1) for each visit. This

report focuses primmily on office visits

at which the patient’s principal

diagnosis was reeorded as glaucoma

(K!D--9-CM COdOS 365.0-365.9). Such

visits are termed “glaucoma visits”

throughout this report.

It is necessary to keep in mind that

the estimates presented in this report are

based on a sample, rather than on the

entire universe of office visits, and as

such, they are subject to sampling

variability. The technical notes at the

end of this report include a brief

discussion of the sample design,

sampling errors, and guidelines for use

in evaluating the precision of NAMCS

estimates. Additional reports

summarizing general findings from the

1991 and 1992 NAMCS have been

published (24).

Patient characteristics

visits with a principal diagnosis of

glaucoma are deseribed in terms of the

patient’s age, sex, and race, and

geographic region of the visit in table L

The overwhelming majority of glaucoma

visits were made by persons 45 years of

age and over (92.8 percent), and more

than half (61.3 percent) were made by

females. About nine-tenths

(88.3 percent) of the visits were made

by white persons.

‘fhe ovemll rate of office visits with

a principal dmgnosis of glaucoma was

3.5 viMs per 100 persons per year. Visit

rates rose with age, and significant

increases were noted in eaeh age group

after the age of 44, that is, among

persons 45-54 years, 55-64 years,

65–74 years, and 75 years and over.

(Wsit estimatesfor persons under the

age of 25 years were not statistically

reliable and have been omitted tlom the

age analysis.) ‘IEe visit rate was highest

for persons 75 years of age and

over-an average of 26.8 visits per 100

persons per year (figure 2).

The glaucoma visit rate was higher

for females than for males overall, with

swlc&.

~@ %

4

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

f

Public Heaith Service

Centers for Disease Control and Prevention

*%% National Center for Health Statistics CIX

ma

CENTERS FOR DIsEAsE CONTROL

AND PREVENTON
9 -“.”,.”” AAmnee W“. IlataW ,.”. Nn -“-9R9 a- .March ..”. “.. ““,Ml 1. QQR ““”

Anmntua 01 Oontld..llalify-All [.1.m.tlon wh(eh would JI.nnlt Id.ntlfloall.n .1..

Indlvldu.1, . P,aclio., o, .“ .stabll,hmmf will b. h,ld Co”fld.”tld, UIIII b. we My by

O.partm.m of H.shh ●nd Hunan Barvlm.

W130nb Ongsg.d in .nd for th. PUIPOSM of th3 SUN*Y and W no: b. dl.clo.od or

Cmtars for D133**e Cmlrol

m!+amd to c.thw fmr..ns w UIti f.r .ny othu p.rpo..,

Publk H8alth 33wk.

Nti!+n.1 C+m.r (or H9dlh St.tlsuaa ID

1. DAT2 OFVISIT

~

PATlENT RECORD OMB No. 0920-0234

NATiONAL AMBUIJXTORY MEDICAL CARE SURVEY Expires 4-30-93

CDC S4.21D

2. DATEOF WITH 4. COLOR OR RACE 5. ~NICITY S. EXPECTEDSOURCE(B)OF 7. WAS PATIENT 8. 18TNISVISIT

~

PAYMENT[Check all that or)p;y]

1 ~ white

REFERREDFOR INJURYRELATED?

Hhpanlc I ❑ HMO/othw prepaid 6 ❑ ~~’lclal THIS VIBJTBY 1❑ Y*S 20N0

i •l c+lgln 2 ❑ ❑lack

ANOTNER

z❑ Medicare 6 n PatIen2 paid PNYBICIAN?

3. SEX Asian / Pacific Not 9. DOES PATlENT

s❑ Istandw 2 D Hispanic 3 ❑ Modlc2id 7 ❑ No ch6r06 1 m Yes 8MOKE CIGARET’TEB?

1❑ Female z ❑ Malo Amcrhn Indlnn I

4❑ Eskimo/ Aleut

*QM 11JY63

4 ❑ OWr govwnmml 8 ❑ Othw s ❑ Unknown

2UN0

10.PATIENT’SCOMPLAINTS),SYMPTOM S),

4{

11. PHYSICIAN’S OIAGNOSES 12. HAVEYOU OR

OR OTHERREASON(S) OR THISVISI

13,~fiS&Av~&M

[Inpatitnres own wor&]

ANYONE INYOUR .

PRACTICESEEN {Check all fhat apply

. P&y= PATlENTBEFORE? regardless of any enby

in itcm 1 IJ

& Mm knptiti Wllhwe-n1Oa 1UY2$ 2i-JNo 1❑ None of below

.2 ~ Odpressbm

b. Olhac b. Cihm tt p% for the condition

In itam 118? 3.2 NypdfWtu2an

4 ❑ Hypcrcho16stordtenria

c.Omw cm

1❑ Yes 2DN0

5 ❑ obesity

14.AMBULATORY8URQICAL 1S. DIAGNOSTIC/ BCREENINQSERVICE8

PROCEDURE(S) (Check all ordered or prm,ldedl

16. THERAPEUTICSERVICES

[Check all ordered mprovided. ficludc mcdicorion]

lRecord any oufpallcvdd!u~,wwic or I ❑ None 11❑ Pap test

fhera utlc procedure. For rhrfirst,

chccr appropriaw bores.] 2❑ Blood pmsure !2 ❑ strep 2hm7!ttezt I ❑ None 6❑ Drug abu66 OTHER THERAPY:

3❑ Urinalysis 13❑ HIV serology

4❑ EKG - resting

7 Q Alcohot nbusa

14❑ ch01e3tu01 rn.sslxa &XJOU;;;G 1 m ~ Psychotherapy

a

6❑ EKG - MWCiS8 15❑ Other lab test BD Srrwklng cessation 14❑ CW?OGthJOhll~~

I ❑ Schwuw s ❑ Local m68thesld 6❑ Mammogram 16❑ H@zringtest 2 l_JOlet Isn t16dring aid

2 ❑ Performed 4 C Rribnzl an-theda

9 ❑ Fzmlly/ COC131

‘rI_J Chest x-ray 17❑ VilU22 a2uitY 9 ❑ Exmise 16❑ ph@0thW2W

5 ~ Ganerd nnzmthesia e❑ Other radblogy 18❑ Montzt tiatus exam

10 ~ Growth / Avdopfn.nt

4 I-J Cfwktwol rwductien 17❑ otiW7 til,mpy [.fP2c{fij

100 Othu {Specfil II ❑ F.zmltyplannlng

o❑ AUargy ta8tlng 6 ❑ Walght reckmtlon

tz ❑ Othzr oounssling

b. 20 I_J Sp4mm0by

17.MEDICATION Ifnone, chsck hsm a Z. NW m~j~ti~? 18. DISPOSITIONTHISVISIT 19. ~~RATION

{Rrcord all new Yel No

[ChrckalI fha2nppiyi

or cunfimed

THIS VISIT

tmdiraltom i. I ❑ No follow-up planned [rime &flwIty

ordered or In 20

provided ar

SPCIUwith

2❑ Return at speciflad tlmc physiciun]

fhw vim, U$<

the SOM< brand 2. ~u 20 3 ❑ Return if need6d, P.R.N.

nameor generic

nameMer#d o)t 4 U Telephone fdllow-up plrmrwd

any I/x or oflce 9. In 2U

medicolrecord,

6❑ Rstomed to other @ly8i0i61fl

Include iinmuni22n*

and dcsensihzing

e ❑ Roturrmd to relting plrysloian

4.

agents]

ID 20 7❑ Admit to tmspltil

s. ~D 20 8 rJ other [Spec(f)j MInfne6

Figure 1. Patient Record form

females making an avemge of 4.2 visits

per 100 for each year compared with 2.8

visits per 100 males. While increasing

rates by age were observed for both

females and males, age-specific rates

were not found to k significantly

dfierent by sex in any age category.

The rate of visits with a principal

diagnosis of glaucoma waa not

significantly difkrent for white persons

than for black persons. White Wrsons

made an average of 3.7 visits per 100

persons per year compared with 3.0

visits per 100 black persons. For persons

ages 45 years and over, the rates for

white persons and black persons were

10.6 and 10.9 visits per 100,

respectively. Further analysis of noteworthy because it has been found

age-specific visit rates by race was that black persons tend to have higher

hampered by the fact that visit estimates intraocular pressure, the main

for black persons in several of the age determinant and risk factor for

groups were too low to ensure statistical glaucomrt than white persons (5), that

reliib~Ity. Aggregation of the estimates

into broader categories (for example, 65

years and over and 75 years and over)

showed rates for black persons that

appeared to be substantially larger than

for white persons in these age groups,

but none of the apparent dilYemux

were statistically significant because of

the high standard errors assm+it.ed with

the low estimates.

The lack of difference in racespecilic visit rates for glaucoma is

glaucoma is the most common cause of

irreversible b~mdness among black

Americans(6), and that black Americans

are at a higher risk of primary openangle glaucoma than are their white

counterparts (7). Javitt et al. have noted

that glaucoma is six to eight times more

prevalent among black persons in this

country, but that black persons are not

receiving care for open-angle glaucoma

at the same rate as older white

Americans (8).
Advance Data No. 262 ● March 30,1995 3

Table 1. Number, percent dlstrlbution, and annual rate of office vislta with a principal

dlagnoals of glaucoma by patient’s age, sex, race, and geographic region of the visit

averaged over a 2-year period: United States, 1991-92

Wit

Number fate

Selectedpafknt and of vkits in Percent per 100

visitcharacterkika thousands distribution persons’

Allvisits . . . . . . . . . . . . . . . . . . . . . . .

Age

Under 25yeare . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . .

45-54 years . . . . . . . . . . . . . . . . . . . . .

55-64 yeafs . . . . . . . . . . . . . . . . . . . . .

65-74 yearn . . . . . . . . . . . . . . . . . . . .

75yeers andover . . . . . . . . . . . . . . . . .

Sex

Female . . . . . . . . . . . . . . . . . . . . . . . .

Under 25yeafa . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . .

45-54 yeara . . . . . . . . . . . . . . . . . . .

55-64years . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . .

75yearsarrdover . . . . . . . . . . . . . . .

Mefe . . . . . . . . . . . . . . . . . . . . . . . . .

Undar25yeers . . . . . . . . . . . . . . . . .

25-44years . . . . . . . . . . . . . . . . . . .

45-54yeats . . . . . . . . . . . . . . . . . . .

55-84years . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . .

75yeersarrdover . . . . . . . . . . . . . . .

Race

White . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . .

Geographic region

Northeast . . . . . . . . . . . . . . . . . . . . . .

Midwest. . . . . . . . . . . . . . . . . . . . . . .

south. . . . . . . . . . . . . . . . . . . . . . . . .

west . . . . . . . . . . . . . . . . . . . . . . . . .

8,742

“56

564

720

1,315

2,s31

3,254

5,359

“45

’265

414

897

1,809

2,126

3,382

*I2

“299

Ym8

618

1,021

1,126

7,721

934

*87

1,662

1,724

3,844

1,711

100.0

“0.7

6.5

8.2

15.0

32.4

37.2

61.3

*0.5

93.0

4.7

6.0

20.7

24.3

38.7

*0.I

“3.4

“3.5

7.1

11.7

12.9

88.3

10.7

*1.0

19.0

19.7

41.7

19.6

3.5

“0.1

0.7

2.7

6.2

15.4

26.8

4.2

“0.1

“0.6

3.0

6.3

17.8

27.9

2.8

“0.0

“0.7

“1.6

6.2

12.4

24.6

3.7

3.0

“0.9

3.3

2.8

4.3

2.1

‘BasedonU.S, BureauoftheCensus astimatasoftha oivifiannoninafWtiinalizad populationforJuiy 1, lWl,ardJu~l, 1ss2,

averagedoverthe 2-yearpsricd,

Compamtivedatatim theNational

HospitalAmbulatory MedicalCamSurvey

showthatbktck-ns accountedfm

about one-thkl (36.6 pement) of the

glaucomavisitsmade tohospitaloutpatient

-~t8(@D’s)rn lwcompaKXl

WithWhite- (61.3percent).

However,theestimated numberofOPD

visitswiththispincipal diagnosiswasonly

278,0MoveraU, muUing inestimatesthat

wemtoolowtopennit meaningfnlanalysis

byraceandage.

Office visit rates did not &tier

statistically by geographic region of

thecoun~, exeeptthat the rate was

higher in the South (4.3 visits per 100

persons) than inthe West (2.1 visits

per 100 persons).

Physician practice

characteristics

About three-quarters (76.8 percent)

ofallglaucoma visits during 1991–92

weremade toophthalmologist.s. The

remainder (23.2 percent) were made to

other specialists, including physicians

who deseribed themselves as glaucoma

specialists. (Because the Amexican

Medical Association’s (AMA) master

file, upon which the determination of

physicianspecialtyfor NAMCS

purposes is basr@ did not have a

separate specialty code for physicians

reporting themselves to the AMA as

glaucoma specialists, such physicians

were classified as “other” specialists

both in the AMA mastefie and in the

NAMCS.)

Glaucoma was the second most

ikquently reported principal dmgnosis

at office visits to ophthahnologists after

eatarac~ accounting for 15.3 percent of

the visits to this specialiy (table 2). It

should be noted that the ranked order

presented in this and other tables in this

report may not always be reliable

because some estimates may not be

statistically dtierent from other near

estimates due to sampling variabtihy.

Visit characteristics

Referral status and prior-visit

status

Data pertaining to patient’s referral

status and prior-visit status are shown in

table 3. Only 6.8 percent of all glaucoma

visits during 1991–92 were the result of

a referml by another physician.

However, of all visits made by new

patients (that is, patients who had not

seen the physician previously), about

two-thiids (68.1 percent) were recorded

as referrals fi’om another physician. In

contras4 about one-third (31.6 pereent)

of all nonglaucmua v~lts made by new

patients (that is, visits with a principal

diagnosis other than glaucoma) were the

result of referraIs from other physicians.

The majority (89.1 percent) of

glaucoma visits were made by patients

who were making return visits to the

physician for care of their condition.

Ten percent of the viMs were made by

new patients. However, by age group,

17.3 percent of the visits by persons

45-64 years were made for new

problems, compared with 9.0 percent of

those 65 years of age and over. “New

problem” visits include those made as a

new patient or as a continuing patient.

The chronic natme of glaucoma is

highlighted by the fact that among all

return visits for the care of previously

heated problems, ghtueoma was the fifth

most frequently recorded principal

dmgnosis related to illness or injury.

Among visits with this prineiprd

dmgnosis, there were 4.1 return visits

recorded during the 2-year period for
4 Advance Data No. 262. March 30,1995

30 r

25

20

15

10

5

n

6.2

m

25-44 45-54 55-64 65-74 75 years

years years years years and over

Age of patient

NOTE: Estimates for persons under 25 years of age were statistically unreliable.

Figure 2. Annual rate of office visits with a principal diagnosis of glaucoma by age of

p;tien~ averaged over a 2-year period: United States, 1991-92

Table 2. Annual numbar and percent distribution of office visits to offfce-based

ophthalmologists by the 10 most frequently mentioned principal dlagnoeaa, averaged

over a 2-yasr period: United States, 1991-92

Number of

vklts In Percent Cumulative

Prlncpal dkgnosk and ICB9GM coda’ thousands distribution percent

Allvlslts . . . . . . . . . . . . . . . . . . . . . . . . . 43,884 100.0 ...

Cataract . . . . . . . . . . . . . . . . . . . . . ...366 7,196 16.4 16.4

(?JhJcOInS. . . . . . . . . . . . . . . . . . . . ...365 6,715 15.3 31.7

Disorders of refraction and accommodation ..367 5,871 13.4 45.1

Organ or tissue replaced by other means . . .V43 2,731 6.2 51.3

Other retinal dlsordere. . . . . . . . . . . .362 2,214 5.0 56.3

Other disorders of eye. . . . . . . . . . . . . .379 1,961 4.5 60.8

Spedal investigations and examinations. . . .V72 1,S38 4.2 65.0

Disorders of conjunctival. . . . . . . . . . . ...372 1,805 3.7 68.7

Dlabates mellitus . . . . . . . . . . . . . .....25o 1,335 3.0 71.7

Inflammation of eyelids. . . . . . . . . . . . . .373 1,296 3.0 74.7

Allotherdlagnoses . . . . . . . . . . . . . . . . . . 11,121 25.3 100.0

‘Based on the /ntemationa/C/assifbatimof Diseases,5’thRevision,C/inice/ Modifkatbn (lCD-e-CM) (f).

every visit that was recorded as a new

problem encounter (table 4).

Expected source of payment

In item 6 of the Patient Record

form the physician is asked tcrlist the

expected source of payment for the

visiu more than one source may be

listed by the physician for eaeh visit.

Medieare was the expected source of

payment at 61.9 percent of visits with a

principal diagnosis of glaucou

followed by private insurance

(36.6 percent), payment made by the

patient (18.8 percent), Medicaid (8.0

percent), and HMO/preprrid plan

(7.1 percent) (table 5).

Reason for visit

In item 10a of the Patient Record

form, the physician is asked to record

the patient’s most important complain4

symptom, or other reason for the visit

using the patient’s (or patient

surrogate’s) own words. These responses

have been classified and coded using the

Reason for Wit Classi$catiori for

Ambulatory Care (WC) (9). This

classification is divided into eight

modules, or groups of reasons. These

are shown in table 6. The disease

module accounted for the highest

percent of visits with a first-listed

dngnosis of glaucoma (46.9 percent),

indkating that the majofity of visits

were made by persons whose condition

had been diagnosed previously and was

known to them. Thk finding

corresponds with the high return visit

ratio found among glaucoma visits that

was discussed earlier. The disease

module was followed by the diagnostic,

screening, and preventive module

(27.2 percent), the treatment module

(9.7 percent), and the symptom module

(9.4 percent).

Diagnostic and screening services

The majority (82.3 percent) of

glaucoma visits included a visual acuity

examination ordered or provided by the

physics compared with 4.8 pereent of

all other Om~ visits (that is, visits that

did not liit glaucoma as a principal

diagnosis). Overall, 82.5 million office

visits included a visual acuity exam

during 1991–92, and glaucoma was the

most frequently recorded principal

dmgnosis at these visits, accounting for

17.4 percent of the total.

About one-third (32.7 percent) of

glaucoma visits included one diagnostic

service ordered or provided by the

physic- about half (52.4 percent)

included two diagnostic services. With

the exception of visual acuig~,none of

the specified categories was reported at

frequencies high enough to yield relible

estimates, and 54.2 percent of the visits

reported “other” diagnostic services that

were unspecified as to type. Data on

diagnostic services are shown in table 7.

Principal diagnosis

Glaucoma is classified into more

specific dmgnoses according to the

International Ckmsi$cation of Diseases,

9th Revision, Clinical Modi$cation

(ICD-9-CM) (l). Of the total number of

glaucoma visits made during 1991–92,

the majority (63.2 percent) were coded

as unspecified glaucoma (ICID-9-CM

code 365.9); 20.7 percent were openangle glaucoma (ICD-9-CM code

365.1); and 14.0 percent were coded as
Advance Data No. 262. March30,1995 5

Table 3. Number and percent distribution of offfca visits with a principal diagnosis of

glaucoma by rafarral rttatusand prior-visit status, averaged over a 2-yaar period:

United States, 1991-92

Number of

visitsIn Perc3nt

Witcharacteristic thousands dktribuffon

Allvlsls . . . . . . . . . . . . . . . . . . . . . . . . . 8,742 100.0

Referralstatus

Patlantwasrsferrad byartotherphyskian . . . . 597 6.8

Patfantwae notreferred byanotherphyskian. . 8,144 93.2

Prior-vtsffstatus

Newpatienf . . . . . . . . . . . . . . . . . . . . . . . 877 10.0

Ofdpatlent. . . . . . . . . . . . . . . . . . . . . . . . 7,864 90.0

Newproblem . . . . . . . . . . . . . . . . . . . . . “74 -0.9

Oldproblam . . . . . . . . . . . . . . . . . . . . . 7,790 89.1

Table 4. Number and percent of oftlce visits and return visit ratio for the 10 most

frequent principal diagnoses among return visits for the care of previously treated probIama,averaged over a2-yearperIod: UnitadStataa,1991 -92

Number of

visitsin Return

Ptfnc#?a\d/agnosisandlCD-5=CMcoda’ thousands Percent visitLatiot

Allretumvlslts . . . . . . . . . . . . . . . . . . . . 443,996 100.0 . . .

Essentialhypertension. . . . . . . . . . . . ...401

Norrnafpregnancy . . . . . . . . . . . . . . . ..v22

Heafthsupervfsfonoflnfantorchffd. . . . . . .V20

Suppuratfveandunspecifladotltlsmadia. . ..382

Dfabatesrnaliftus. . . . . . . . . . . . . . . . ..25o

Generalmedkaf examination.. . . . . . . . . ,v70

Acuteupperrespiratory infections. . . . . ...465

GfsUCOMS . . . . . . . . . . . . . . . . . . . . ...365

Asthma . . . . . . . . . . . . . . . . . . . . . ...493

Affar@crhlrsitis . . . . . . . . . . . . . . . . . ...477

23,552

20,655

12,643

12,067

11,810

9,246

8,774

7,730

7,678

8,737

5.3

4.7

2.8

2.7

2.7

2.1

2.0

1.8

1.7

1.5

4.0

2.4

2.1

0.9

3.4

0.5

0.4

4.1

2.4

1.9

lBassd on the /ntomatiwra/ C/assifiition of Diseases, 9th Revision, C/inics/ Modifn8tbn (lCC-9-CM) (1).

%tum vKi ratii is therstii of visils nwda by pfevioustj seem pstients for the care of lxevioustj treatad problems to visk mede

for the treatment of new problems. “New probbm” visii maybe msde by elher new or OH patients.

Table 5. Number and percent distribution of office visits with a principal diagnosis of

glaucoma by expected source(s) of payman~ averaged over a 2-yaar period:

United States, 1991-92

Nurn!mrof

Vklfsh Percent

Expectedsource(s)ofpayment’ thousavro% dlsfrlbufion

Aflvfaffs . . . . . . . . . . . . . . . . . . . . . . . . . 8,742 100.0

Madfcara. . . . . . . . . . . . . . . . . . . . . . . . . 5,409 81.9

Prfvatekommerdafirrsuranca. . . . . . . . . . . . 3,196 36.6

Patfant-pafd. . . . . . . . . . . . . . . . . . . . . . . 1,641 18.8

Madkald . . . . . . . . . . . . . . . . . . . . . . . . . 700 6.0

HMO/otherprepafdpfan2. . . . . . . . . . . . . . . 624 7.1

Othsrgovemment . . . . . . . . . . . . . . . . . . . 412 4.7

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . *249 “2.9

Nocharge . . . . . . . . . . . . . . . . . . . . . . . . “105 “1.2

Unknown. . . . . . . . . . . . . . . . . . . . . . . . . 966 “0.8

‘Numbsrsrrraynot addtototalsbecawre morethsnoneexpected sourceofpayrr-wmt maytmrepotied pervisit.

%fMOkhealth rnsintenanm organizafkm.

borderlineglaucoma (ICD-9-CMeode by older adults isundersco~d bythe

365.0). Wits for glaucoma me tiding that for persons in the age

deseribed by speciiic diagnosis in groups 65-74 and 75 years and over, it

table 8. was the third most fiquently reported

The prominence of glaucoma 28 a principal diagnosis, accounting for

principaldiagnosis among office visit8 3.2 pereent of the diagnosa among

those 65-74 years and 4.4 percent of the

diagnoses among those 75 years and

over. For visits by all age groups,

glaucoma was the 10th most frequently

reported morbidity-related principal

diagnosis and the 13th most frequent

principal diagnosis during 1991-92.

(MorbWy-related diagnoses am defined

here as those classifiable to disease or

injury, in contrast to nonillness- or

noninjury-mlated visits. Examples of

visits with diagnoses that are not

morbidlly related would include visits

for routine pregnaney examination or

general rnedcal examination.)

Concomitant diagnoses

About one-quzu-ter(26.4 percent) of

glaucoma visits had a seeond diagnosis

listed on the Patient Record form, and

9.1 percent included a rhiid diagnosis.

Cataract was the most frequently

reported second- or third-listed

diagnosis, showing up at about

12.5 percent of all visits with a principal

dmgnosis of glaucoma.

Physician’s checklist of selected

conditions

In item 13, which was added to the

Patient Record form for 1991,

physicians were requested to report if

the patient had any of four medkal

condition%hypertension,

hypercholesterolem@ obesity, and

depression-regardless of what was

coded as the tirs~ seeon~ or third

dmgnosis in item 11 of the Patient

Record form. At 11.2 pereent of

glaucoma visits, physicians cheeked

hypertension as an accompanying

condition. However, virtually none of

the glaucoma visits during 1991–92

included a second or third diagnosis of

hypertension in item 11 of the Patient

Record form. This suggests that

physicians tend to underreport existing

chronic conditions as a diagnosis in item

11.

Therapeutic services

Therapeutic services ordered or

provided at glaucoma visits are shown

in tables 9–11. Medication therapy was

the most frequently mentioned

therapeutic serviee at glaucoma visits,
6 Advance Data No. 262. March30,1995

Table 6. Number and percent distribution of oftloe visits with a principal diagnosis of

glaucoma by patient’a principal reason for vlsl~ averaged over a 2-year period:

United States, 1991-92

Number of vlslts Percent

Prfnc@a\ reason for vkff and RVC code’ In thousands diatrfbutton

AllviaHs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,742 100.0

Synptom module . . . . . . . . . . . . . . . . . . . . . ..SOOIA999 825 9.4

Vlaiondysfunctions . . . . . . . . . . . . . . . . . . . . . . ..S305 536 6.1

Another. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “289 *3.3

Disesee moduie . . . . . . . . . . . . . . . . . . . . . ..DOOI-D999 4,096 46.9

Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . ...0415 4,041 46.2

Another . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “55 “0.7

Diagnostic, acreenlng, andpreventlve frrodule. . . . .XIOO-X599 2,380 27.2

Other andunspecffIed diagnostic teafs . . . . . . . . . . .X370 1,972 22.6

Eyeexamination . . . . . . . . . . . . . . . . . . . . . . . . ..X23Q “315 “3.6

Another . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “93 “1.0

Treatment module . . . . . . . . . . . . . . . . . . . . ..TIOO-T699 846 9.7

Progreasviait, not otherwiaespecitied. . . . . . . . . . . ..T800 W2 6.2

Atlolher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -304 “3.5

Tesfresulfsmodule . . . . . . . . . . . . . . . . . . . ..RIQO-R7QQ “84 91.0

Other ?, . . . . . . . . . . . . . . . . . . . . . . . . . ..U99Q-U999 511 5.s

lBaaadon “AReasomforvisit ClsssiffcationforAmbulatoryCare”(RVC)(9).

%cludes problem andcomplaintsnotelsewhereclsasifmd,entriesof “none,”bbmks,and illegib!eentries.Noneofthe visits

hadreasonscoded inthe mjurissandadverseeffsctamoduk (JOOI-J999)orthe adrdnistrattiemodule(AIOO-A140).

Table 7. Number and percent distribution of office visits with a principal diagnosis of

glaucoma by diagnostic and screening services, averaged over a 2-year period:

Unltad States, 1991-92

Diagnostic and screening sefvlme

ordered orperfornred at the vlal~

Nunrber of

vlslts In

thousands

Percent

distribution

Allvlsite . . . . . . . . . . . . . . . . . . . . . . . . . 8,742 100.0

None . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,208 13.8

VIsualacuity . . . . . . . . . . . . . . . . . . . . . . . 7,196 82.3

Ofhe+ . . . . . . . . . . . . . . . . . . . . . . . . . . 5,110 58.5

Number of diagnostic and screening services

ordered or performed at the Welt

None . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,208 13.8

One . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,862 32.7

Two . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,579 52.4

Threeormora . . . . . . . . . . . . . . . . . . . . . “93 “1.1

lNumbersrnaynotadd tototals beosusemorstkm onecatemwyrraybereportedpervicii.

2W.2pr@nt ofglauwm viati$includedunspetifmddiagnostnsewi=$ noneofthespecificdiagnosticserv!ocsliited onthe

PatientRscordform(withthe exceptionofthe visualacuityexamination)were recordedat frequencieslargeenoughto provide

estimatesthatwsrestatiitical~ reliable.

Table 8. Number and percent distribution of offfoe visits with a principal diagnosis of

glauooma bydetailed diagnosis, averaged over a2-yearperiod: UnitedStatas, l 991-32

Nurribar of

vklts In Percanf

Pt7nc@al dkumosta and CD-.9-CM COde’ thousands distribution

Allvians . . . . . . . . . . . . . . . . . . . . . . . . .

Borderflneglaucorna. . . . . . . . . . . . ...365.0

Preglaucoma, unapecifkd . . . . . . . . .365.00

Other borderline glaucoma . . .365.01,365.02

Oculerhypertendon. . . . . . . . . . ...365.04

Open-angleglaucorna. . . . . . . . . . . . . .385.1

Open-angleglaucmna, unapecifed . ...365.10

Prhnaryope n-angfeglaucoma. . . . ...365.11

Otheropen-angle glaucoma . . .365.12.365.13

Prtrnatyangle-dosura glaucoma. . . . . . . .365.2

Unspecified glaumma. . . . . . . . . ...365.9

8,742

1,222

792

“39

391

1,809

808

932

“69

*186

5,525

100.0

14.0

9.1

“0.5

4.5

20.7

9.2

10.7

“0.8

“2.1

63.2

'Basedonthe/nfemafitia/ C/sifcatbn of Di%ases,9th Re@bn, C/iniu/Mtiifkatbn (lCBKM) (l).

recorded at 79.6 pereent of visits

(table9). Thisissignificantiy higher

than the63.3percent ofallother visita

at which mdlcation therapy was

mentioned. Nonmedieation therapy was

mentionedat 12.4pereent ofglaucoma

visits, with counseling (4.9percent),

eorrectivelenses (4.4percent), and other

therapy (5.4percent) recordedbythe

physician as either ordered or provided

at the visit.

As used in the NAMCS, the term

“drug” is interchangeable with the term

“mediation” and includes rr.tl newer

continued medieations ordered or

provided at the visit, including both

prescription and nonprescription

preparations, immunizing agents, and

desensitizing agents. The term “drug

mention” refers to each mention of

medication on the Patient Rexmrdform.

Because doctors ean record lmore than

onedrugpervisi4 thetotalmunberof

drug mentions will generally be higher

than the number of visits. The term

“drug visit” refers to any visit in which

atleast one drug isordered or provided

by the physician. An earlier report is

available that describes the method and

instruments used in collecting and

processing NAMCS drug data (10).

There were about 27.7 million drug

mentions at glaucoma visits during

1991–92, an average of 13.8 million

mentions per year. This yields an

average of 2.0 drug mentions per drug

visit or 1.6 drugs ordered or provided

per vKlt overall.

About one-third of glaucoma visits

included a single mediation

(33.6 percent), while approximately

one-ilfth (21.6 percent) listed two

medications and one-quarter (24.4

percent) listed three or mom

medications.

As expected, most of the drugs

prescribed were classified aa ophthalmic

drugs, specifically agents used to treat

glaucoma (59.6 pereent) and ocular

anti-infective and anti-inflammatory

agents (9.6 percent). Drug mentions at

glaucoma visits am listed in table 10 by

therapeutic classifkation, based on the

National Drug Code Directory, 1985

edition (11).

The m~ority of drugs mentioned at

glaucoma visits were single-ingre&ent

preparations (91.3 percent), were

prescribed as trade names rather than

generies (71.4 percent), and were
Advance Data No. 262 ● March 30,1995 7

Table 9. Numbar and percent dlstrlbutfon of office visits with a principal dlagnosls of

glaucoma by therapeutic servlcee, averaged over a 2-year pericd: United States, 1991-92

Number of

Therapeuticsarvlces vlsltsIn Percent

orderedorprovkiad at the Vlsttt thousands dktrlbuflon

AIIvIsHs. . . . . . . . . . . . . . . . . . . . . . . . . 8,742 100.0

Medlcatlon therapy

New or continuing medication . . . . . . . . . . . . 6,962 79.6

Visits without mention of medication . . . . . . . . 1,779 20.4

Number of new or

continued medications

None . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,779 20.4

One . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,938 33.8

Two . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,869 21.6

Three . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,589 18.2

Fourormom . . . . . . . . . . . . . . . . . . . . . . 545 6.2

Nonmedication therapy

None . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,659 87.6

Othercounsallngz . . . . . . . . . . . . . . . . . . . 425 4.9

Corracflvelensas . . . . . . . . . . . . . . . . . . . . 3s6 4.4

Otherlherapy . . . . . . . . . . . . . . . . . . . . . . 470 5.4

Ambulatory surgary

None . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,125 92.9

Oneormoraprocedures . . . . . . . . . . . . . . . 616 7.1

‘Numbsrsmay notaddto totals because mera ihen ona category may ba reported pa vM.

%ounseling other than the spediad categories of diet, exercke, webht raductiin, alcohol .busa, smoking -sat??., and

femiiykoekd.

Table10.Number and percent distribution ofdrugmentions bytharapeutic claesificaticn

for office visits with a principal diagnosis cf glaucoma, averaged over a 2-year paricd:

United States, 1991-92

Nurriwr of

drugmerrfforrs Percent

Therapeuticciasslfkation’ in thousands dtsfrfbution

Alldrugmantions . . . . . . . . . . . . . . . . . . . . 13,835 100.0

Ophthatmlcdrugs . . . . . . . . . . . . . . . . . . . 10,930 79.0

Agents uesdtotreef glaucoma. , . . . . . . . . 6,241 59.6

Ocular antf-hsfecffve and arstI-lntlsmmstoty

agents . . . . . . . . . . . . . . . . . . . . . . . . 1,330 9.6

Mlscellaneousophthalmic preparations . . . . . 1,199 8.7

Mydrietksandcyclopiegics........ . . . . “160 “1.2

Cardiovascular-renaldrugs. . . . . . . . . . . . . . 1,136 8.2

Diuretics . . . . . . . . . . . . . . . . . . . . . . . . S07 5.6

Other . . . . . . . . . . . . . . . . . . . . . . . . . . “330 *2.4

Other . . . . . . . . . . . . . . . . . . . . . . . . . . 1,767 12.8

Unc18eeiffecVmlscellaneous.... . . . . . . . . . . 9511 *3.7

‘l%erspautimciass isbawrfontlmetandard drugdassificatiorsuaed intheNatioms/Drvg Cod8LXmot~,f9S.5 Eddbrr(ll).

%dudasthefolbwing dssaiitbrwanasthatb drugs,antimicmbialqrents, Psychophsrrnacobgiidrugs, gastrointtimal

agents,matabolk andnufriant qersts, hcmnonesandaganfsafkting honmonal mechanisms, immuriologbagemts, $IWmumus

mambrsne, onco~cs, drugs used for pain relisf, and raspirabxy tract drugs.

available only by prescription was also prominen~ occurring in

(92.8 percent). 16.6 percent of drug mentions at

Drug mentions at glaucoma visits glaucoma visits.

are displayed in table 11 according to

their most frequently occurring generic Ambulatory surgical procsdurss

ingredients. Tmolol was the generic

ingredient that appeared most frequently, The 1991 NAMCS added a new

showing up in 21.4 pment of all item perminiig to whether ambulatory

glaucoma drug mentions. Pilocarpine surgery was scheduled or performed at

the current visit. Physicians were asked

to record up to two ambulatory surgical

procedures per visit. These were coded

according to the International

Classificationof Diseases, 9th Revision,

ClinicalModijkatiotq Volume3

(ED-9-CM) (l).

Ambulatory surgery was recorded at

an estimated 1.2 million glaucoma visits

over the 2-year period (an average of

616,000 visits per year), and a total of

1.3 million procedures wem scheduled

or performed. The proportion of

glaucoma visits wifh mention of

ambulatory surgery (7.1 percent) is not

significantly difTerentthan the

6.0 pereent of visits with principal

dmgnoses other than glaucoma that

included ambulatory surgery in

1991–92.

While no specific ambulatory

procedures were recorded at fiequeneies

large enough to obtain reliable

estimates, all of the surgical procedures

mentioned were related to the eye and

included operations on the iris, diary

body, sclera and anterior chambe~

iridotomy and simple iridectomy,

operations on the lens operations on the

retina choroi~ vitreous, and posterior

chambeq and operations on the orbit

and eyeball (ICD-9-CM, Volume 3,

codes 12-14, 16).

Disposition of visit

Nine of ten glaucoma visits

(93.3 pereent) resulted in a scheduled

return visit. In confras$ 62.0 pereent of

all other visits included a scheduled

retmn visit. The predominance of this

type of d~position among gIaueoma

visks is mirrored in the correspondingly

high return tilt ratio that was discussed

previously. Data on disposition of visit

are shown in table 12.

Duration of visit

The mean duration of physicirtnpatient eontaet for glaucoma vishs was

21.7 minutes, compared with 17.3

minutes for office visits in general.

Mean duration dcxx not include visits in

which no face-to-face contact with the

physician oczuned. Physician-patient

eontaet only includes the time s~nt in

actual face-to-face contact between

physieirrn and patient. Data on duration
8 Advance Data No. 262. March 30,1995

Table 11. Number, percent distribution, and therapeutic classification for the five most

frequently occurring generic ingredients In drug mentions at office visits with a prlncipsl

diagnosis of glaucoma, averaged over a 2-year period: United States, 1991-92

Number of

dmg mentions Percent

Generfc /ngrad/ent’

Therapeutic

In thousands distribution Ckreeifkatior?

Atl mentions . . . . . . . . . . . 13,835 100.0 . . .

Timolol . . . . . . . . . . . . . . 2,957 21.4 Agents used to treat glaucoma

Pkwarplne...... . . . . . . 2,295 16.6 Agents used to treat glaumma

Betexotol hydrochloride. . . . 1,2s4 9.3 Agents used to treat glaumma

Dlpivefrhr. . . . . . . . . . . . . 1,055 7.6 Agents used to treat glaucoma

Levobunolsl hydrochloride . . 911 6.6 Miscellaneous ophthalmic preparations

‘Fruquency of mention combines single-ingredient agents tih rnsmtions of the agent as an ingredient in a corrbination drug.

27herapeufii classiticstion is based on the f’ffffionel DrugCodsDirectoy, f9&5 .Edikm (11). In cases where a generic ingredient

had more than one theraptitc clessitication, it was listed in the cstegory which ocourred with the greatest frequency.

Table 12. Number and percent distribution of office visits with a principal diagnosis of

glaucoma by disposition and dumtion of visig averaged over a 2-year period:

United States, 1991-32

Number of

vis/ts in Percent

VW charsctertetlc thousands dletttbutlon

Allvlstts, . . . . . . . . . . . .

Dlspodtlon of visit’

Return at epedfied time. . . .

Other ? . . . . . . . . . . . . .

Duration of vkdt

0mirrutes3 . . . . . . . . . . . .

l-5mlnutes . . . . . . . . . . .

6-10mkrutes . . . . . . . . . .

11-15 minutes . . . . . . . . .

16-30 mltrutss . . . . . . . . .

More than 30 minutes. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

?3,742

8,164

814

“39

764

1,657

1,936

1,809

2,547

100.0

93.3

9.3

“0.4

6.6

19.0

22.1

20.7

2e.1

‘Numbers rnsy not add to totals because more then one disposition may be reported per visit

$hfleof the other sped. diiposifion categories had frequencies large enough to provide estimstes thst were atstistic?diy

%isita ;t which there was no face-to-fase sontacl between the phywcian and the patient.

8

6

4

2

0 1

8.7

4.3

3.1

2.3

1975-78 1980-81 1985 1989-90 199f-92

Year

NOTE. Based on 2-year averages, except 1985.

Figure 3. Office visits with a principal diagnosis of glaucoma United States, 1975-92

of glaucoma visits are shown in

table 12.

Visits with a second or third

diagnosis of glaucoma

In addhion to the estimated total of

17.5 million office visits with a

first-listed diagnosis of glaucoma during

1991–92, there were 3.2 million office

visits at which a second or third

diagnosis was listed as glaucoma. Visits

in wlich the second or third d~agnosis

was glaucoma were not found to differ

significantly horn visits in which the

principal diagnosis was glaucoma in

terms of the age, sex, or race of

patients.

At office visits in wK1chglaucoma

was the second- or third-listed diagnosis,

the principal diagnosis was listed within

the major ICD-9-CM coding (classof

disorders of the eye and adnexa

(ICD-9-CM COdeS 360-379)

62.9 percent of the time. No specific

dmgnosis was recorded at ilequenckx

high enough to provide reliable

estimates, although the frequency of

visits with a principal diagnosis of

cataract approached statistical reliabWy.

Glaucoma visits between 1975

and 1992

In 1975, glaucoma was the ninth

most frequently mentioned morbldityrelated principal diagnosis among

persons 65 years of age and oldw, by

1992, it was the fifth. Overall, glaucoma

visits were estimated at 4.5 million

during 1975–76, an average of 2.3

million per year. However, the average

for 1991 and 1992 was 8.7 million-an

increase of 284.6 percent (figure 3).

Visits for glaucoma by age and sex of

patients between 1975 and 1992 are

shown in table 13. Race data have been

omitted from the table because

glaucoma visit estimates for the black

population prior to 1989 were

statistically unreliable when using

NAMCS data.

Annual rates of glaucoma visits

between 1975 and 1992 for the U.S.

population in general are shown in

figure 4, using both crude and ageadjusted rates. Both the crude and the

age-adjusted rates for 1991–92 were
Advance Data No. 262. March30,1995 9

Table 13. Number, percent distribution, and annual rate of offtce visits with a principal

diagnosis of glaucoma by patient’s age and sex United States, 1975-S2

Year

Patierrf ctraracferistic 1975-76 1960-S1 1965 1983-90 1991-92

Attvisns . . . . . . . . . . . . . . . . . . . . . . .

Age

Undar25years . . . . . . . . . . . . . . . . . . .

X-44yesla. . . . . . . . . . . . . . . . . . . . .

45-84 yeara . . . . . . . . . . . . . . . . . . . . .

6S-74years . . . . . . . . . . . . . . . . . . . . .

75yemend over . . . . . . . . . . . . . . . . .

Sex

Fenzafe . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

AIIvLsII s . . . . . . . . . . . . . . . . . . . . . .

Age

Undar26yeara, . . . . . . . . . . . . . . . . . .

2G’44yeals . . . . . . . . . . . . . . . . . . . . .

45-64years . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . .

75yeereendover . . . . . . . . . . . . . . . . .

Sex

Fernefe . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Allvistts . . . . . . . . . . . . . . . . . . . . . . .

Age

Undar25ye8rs . . . . . . . . . . . . . . . . . . .

25-44years . . . . . . . . . . . . . . . . . . . . .

46-64ye81s . . . . . . . . . . . . . . . . . . . . .

6%74years . . . . . . . . . . . . . . . . . . . . .

75yeafaandover . . . . . . . . . . . . . . . . .

Sex

Female. . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

2,273

“75

*138

827

706

527

1,398

875

100.0

*3.3

“6.1

36.4

31.0

23.2

61.5

38.5

1.1

“0.1

“0.3

1.9

5.2

6.7

1.3

0.9

Number of vlstts In thousands’

3,080 4,304 6,083

“45 ●62 *27

2s3 ’214 *ZW

934 1,218 1337

897 1,356 1,s81

910 1,464 2,405

1,884 2,610 3,847

1,215 1,895 2,246

Percentdistrbution

100.0 100.0 100.0

*1.5 ●1.4 “0.4

7.6 “5.0 “3.8

?23 26.3 25.2

28.1 31.5 31.0

29.8 33.8 39.5

60.5 60.6 63.1

39.5 33.4 36.9

Visit rate per 100 persorrsz

1.4 1.8 2.5

“0.0 *0.1 “0.0

0.4 “0.3 ‘0.3

2.3 2.7 3.3

5.8 8.2 10.5

10.2 14.1 20.8

1.6 2.2 3.1

1.1 1.5 1.3

8,742

*5S

564

2,035

2,831

3354

5,3s3

3,382

100.0

“0.7

6.5

23.3

32.4

37.2

61.3

38.7

3.5

90.1

0.7

4.3

15.4

28.8

4.2

2.8

%&edonBurawofthe Cerrsus~-imks~the dvifiannoninstitutbnalizedpopulationforJulylof eachsurveyyear. Rateafor

mMMyeam am basdonan averageofthepopulatmnestimtesfor Julyl ofeaAy~r oftie2-year ~rid. Suwey~m

fmm 197S-SSdidnothwiudeAbrslraor Hawaii,

signiticantlyhigher thanthosereported

in 1975-76.

VWratesincreased fortheage

groups4544 years, 65-74 years, and

75yearsandoverbetween 1975and

1992 (figure5).Among persons 65years

ofage and over, the rate ofglaucoma

visit3went from 5.7vi&tsper 100

per80nsin1975to 19.9 vi.Msper100

personsin 1992.Vksitrates increasedfor

both sexesbehveen 1975 and 1992.

Significantdtierences werenotedinthe

overallgkmcoma visitrates formales

comparedwithfemales ineachofthe

years analyze~except for1975-76.

About one-quarter(23.2percent)of

glaucomavisitswem made bypersons

75 years ofageaud overin 1975-76,

but 37.2percent of the total were made

by this age group in 1991-92. Them

was acmrespondingdec reasein the

percent of visits made by persons45-64

years, from 36.4percent of visits in

1975-76, to 23.3percent in 1991-92.

The percent of visits made by persons

65-74 was not found to dtier

significantlybetween 1975 and 1992,

Reasonsfor the substantialincrease

in rates ofglaucoma-related officevisits

during 1975–92are unckar. Data ffom

the NationalHealth InterviewSurvey

(NHIS)show an increasein the overall

rate of personsreporting a glaucoroatous

condition,fkom5.7 conditionsper 1,000

persons in 1977 to 10.4 conditionsper

1,000personsin 1991 (12,13).Agespecificrates for glaucomawere not

available horn the NHIS during the

1970’s,but an increase in glaucomatous

conditionswas noted among persons 65

years of age and over between 1982 and

1991,from 41.8 conditionsper 1,000

persons to 57.0 conditionsper 1,000

persons (14).

In 1991, the NationalEye Institute

of the NationalInstitutes of Health

issued new governmentguidelinesfor

glaucoma testing that advise all

Americansages 60 and older and black

Americansages 40-59 to nxeive

glaucoma screeningtests at least once

every 2 years.This heightened

awarenessof the need for early

detection of glaucomajin combination

with new diagnosticproceduressuch as

laser tomogmphicscanners aud Fourier

ellipsometrythat yield more precise

measurementsthan am possible with

photographyand ophthalmoscopes(15),

may result in even higher visit rates for

glaucoma than are seen in the 1991-92

NAMCS survey data.

References

1.

2.

3.

4.

Public Health Service and Health

Care Finsncing Administration,

Intem8tional Classification of

Diseases, 9th Revision, Clinical

Modification. Wsahingtou Public

Health Service. 1980.

Schappert SM. National Ambrdstory

Medicsl k Survey: 1991

summary. Advance dsta from vital

and health statistics; no. 230.

Hyattsvitl% Msryland: National

Center for Health Statistics. 1993.

Schappert SM. Nationrd Ambulatory

MwEcal Cme Survey: 1991

smmnsry. Nationsl Center for Health

Statistics. Vital aud Health Stat

13(116).

Schappert SM. National Ambulatory

Medical Care Survey 1992

summary. Advsnce data horn vital
10 Advance Data No. 262. March 30,1995

4.0

[

— Crude rata —— Age-adjusted rate

0.5

t

1975-76 1980-81 1985 198+90 199i-92

Year

NOTES Based on 2-year averages, except 1985.

Age-adjusted estimates are based on the 1975-76 U.S. population.

Figure 4. Annual rate of office visits with a principal diagnosis of glaucoma

United States, 1975-92

Patient’s age

_ 65-74 years ~ 75 years and over

26.8

R

1975-76 196Q-81 1985 1989-90 199+92

Year

NOTE Based on 2-year averages, except 1985.

Figure 5. Annual rate of offloe visits with a principal diagnosis of glaucoma by patients

65-74 years and 75 years and OVSKUnited States, 1975-92

5.

and health statistic no. 253.

Hyattsville, Maryland: National

Center for Health Statistics. 1994. 6.

Hosklns HD, Kass MA (eds).

Becker-ShatTer’s Diagnosis and

Therapy of the Glaucomas, 6th ed.

St. Louis C.V. Mosby. 1989.

Danyluk AW, Paton D. Diagnosis and

Management of Glaucoma. Clinical

Symposia. 1991. Vol. 43. No. 4. 2–2.

7.

8.

9.

Tlelsch JM, Sommer A, Katz J,

Royall RM et al. Racial Variations in

the Prevalence of Primary Openangle Glaucoma. Journal of the

American MedicaJ Association. 1991.

226:369-74.

Javitt JC, McBean AM, Nicholson

GA, Babish JD et al. Undertreatment

of Glaucoma among Black

Americans. New England Journal of

Medicine. 1991.325:1418-22.

Schneider D, Appleton L,

McLemore T. A reason for visit

classification for ambulatory care.

National Center for Health Statistics.

Vlkd and Health Stat 2(78). 1979.

10. Koch H, Campbell W. The collection

and processing of drug information.

National Ambulatory Me&al Care

Survey, 1980. National Center for

Health Statistics. Vital and Health

Stat 2(90). 1982.

11. Food and Drug Administration.

National Drug Code Directory, 1985

Edition. Washington Public ‘Health

Service. 1985.

12. Feller, Bmbrua A. Prevalence of

selected impairments, United States,

1977. National Center for Health

Statistics. Vital and Health Stat

10(134). 1981.

13. Adams PF, Benson V. Current

estimates from the National Health

Interview Survey, 1991. National

Center for Health Statistics. Vital and

Health Stat 10(184). 1992.

14. National Center for Health Statistics.

Current estimates from the National

Health Interview Survey United

States, 1982. Vital and Health Stat

10(150). 1985.

15. Cotton P. Glaucoma Detection

before Damage, Fewer Side Effects

May Be Possible. Journal of’the

&nerican Medical Association. 1990.

2641793.
Advance Data No. 262. March 30,1995 11

Technical notes

Source of data and sample

design

The information presented in this

report is based on data collected in the

National Ambulatory Medical Care

Survey (NAMCS) over the 2-year

period from January 1991 through

December 1992. The target universe of

NAMCS includes office vtilts made in

the United States by ambulatory patients

to nonfederally employed physicians

who are principally engaged in office

practice, but not in the specialties of

anesthesiology, pathology, or radiology.

Telephone contacts and nonoffice visits

are excluded.

A multistage probability sample

design is used in NAMCS, involving

samples of primary sampling units

(PSU’S), physician practices witim

PSTJ’S,and patient visits within

physician practices. The PSU’S are

counties, groups of counties, county

equivalents (such as parishes or

independent cities), or towns and

townships (for some PSU’S in New

England). For 1991, a sample of 2,540

nonfederal, office-based physicians was

selected from master files maintained by

the American Medical Association and

American Osteopathic Association.

Physicians were screened at the time of

the survey to ensure that they were

eligible for survey participation. Of

those screenti 1,887 physicians were

eligible (in-scope) to participate in the

survey. l%e remaining 653 physicians

were ineligible (out-of-scope) due to

reasons of being retir@ employed

primarily in teaching, research, or

administration, or other reasons. The

physician response rate for the 1991

NAMCS was 72 percent.

For 1992, a sample of 3,000

nonfe&ral, offi-based physicians was

seIected ilom master files maintained by

the American Medical Association and

herican Osteopathic Association. Of

those screene 858 physicians were

ruled ineligible (out-of-scope); 2,142

were in-scope for the survey. The

physician response rate for the 1992

NAMCS was 71 percent.

Sample physicians were asked to

complete Patient Record forms (figure 1)

for a systematic random sample of office

visits occurring during a randomly

assigned l-week reporting period.

Responding physicians completed

33,795 Patient Record forms in 1991

and 34,606 Patient Record forms in

1992.

Characteristics of the physician’s

practice, such as primary specialty and

type of practice, were obtained horn the

physicians during an induction

interview. The U.S. Bureau of the

Census, Housing Surveys Branch, was

responsible for the survey’s data

collection. Processing operations and

medical coding were performed by the

National Center for Health Statistics,

Health Care Survey Section, Research

Tliangle Park North Carolina.

For 1992, several changes were

made in the sample design of the

NAMCS that should be considered in

the interpretation of the survey results.

In an effort to even the precision of

estimates across each of the physician

specialty strata in the sample design, the

decision was made to increase the

proportion in the sample of specialists in

general surgery, psychiatry, otolaryngology, and neurology. Although this

would result in a conesponding decrease

in the sample of the larger physician

specialties, most notably general and

family practice, internal medicine, and

ptilatrics, the precision of the3e

estimates tended to be much higher

relative to the smaller speciah.ies, and it

was expected that the end result would

bean acceptable balance of precision

levels across all strata.

However, the reduced number of

general practitioners, internists, and

pediatricians sampled in 1992, coupled

with the high percents of sampled

physicians in these specialties who were

determined to be ineligible (out-ofscope) for survey participation, resulted

in low numbers of survey respondents in

these categories and a lowering of the

precision of these estimates Mative to

other survey years, especially when

d~aggregated by other variables such as

race. Because vkits made by black

patients were often found to be cIustered

among the sampled physicians and were

more likely to be made to general and

family practitioners, which were

undersampled in 1992 it is

recommended that caution be exercised

when interpreting differences in race

data and individual physician specialties.

Despite the difference in sample

sizes, the 1991 and 1992 surveys were

identical in terms of survey instruments,

definitions, and procedures. The

resulting 2 years of data have been

combined to provide more reliable

estimates. All estimates, percent

dfitributions, and mtes presented here,

unless otherwise notedj reflect 1991 and

1992 data that were averaged over the

2-year period.

Sampling errors

The standard error is primarily a

measure of the sampling Variti-tilty that

occurs by chance when only ak%mple,

rather than an entire universe, is

surveyed. The relative standard error of

an estimate is obtained by dividing the

standard error by the estimate itselC the

re,sultis then expressed as a percent of

the estimate.

Relative standard errors (RSE’s) for

estimated numbers of office visits,

expressed as 2-year averages for the

period 1991–92, are shown in table I.

Relative standard errors for estimated

numbers of drug mentions, also

expressed as 2-year averages, are

Table L Approximate relative standard

errors for eatfmated numbara of office

visits: NationatAmbulatory Medical Care

Survey, 1991-92

E#matad nurrkr

of officetidfs

(~raseed as

annual avafagas) Relatiw standatd

in Uwuswxls errorh percent

50 . . . . . . . . . . . . . . . . . . . . . 78.4

100 . . . . . . . . . . . . . . . . . . . . 55.5

2?50 . . . . . . . . . . . . . . . . . . . . 35.2

S46 . . . . . . . . . . . . . . . . . . . . 20.0

500 . . . . . . . . . . . . . . . . . . . . 25.0

1,000 . . . . . . . . . . . . . . . . . . . 17.8

2300 . . . . . . . . . . . . . . . . . . . 11.6

5,000 . . . . . . . . . . . . . . . . . . . 8.5

10,000 . . . . . . . . . . . . . . . . . . 6.5

25,000 . . . . . . . . . . . . . . . . . . 4.9

50,000 . . . . . . . . . . . . . . . . . . 4.2

W13,000 . . . . . . . . . . . . . . . . . 3.8

250,000 . . . . . . . . . . . . . . . . . 3.6

500,000 . . . . . . . . . . . . . . . . . 3.5

NOT= The srtdesf refiible estimate for visits to aggrqated

8PM= k *,Coo Visits pa ysar [or a 2-yssr total of

~i,~ Visii). Estimates below ths @urs hsve a rslafive

standard error greater than S0 psroant and are desmsd

unrefiabb by NCHS standards.

Exampls of use 01 &b. An aggragrsta esthmte of 10 nilbn

visitsPef Yom has a rslatii standard error of 6.5 percent or a

standard error of 650,000 visits (6.5 percent of 10 million).
12 Advance Data No. 262. March 30,1995

Table Il. Approximate relative standard

errors for estimated numbers of drug

mentions: National Ambulatory Medical

Cara Survey, 1991-92

Eshated number

of dmg mentions

(expressed as

annual averages) Relative standard

In thousands error In percent

50 . . . . . . . . . . . . . . . . . . . . . 109.0

100 . . . . . . . . . . . . . . . . . . . . 77.2

250 . . . . . . . . . . . . . . . . . . . . 48.9

500 . . . . . . . . . . . . . . . . . . . . w?

674 . . . . . . . . . . . . . . . . . . . . 30.0

1,000 . . . . . . . . . . . . . . . . . . . 24.7

2,500 . . . . . . . . . . . . . . . . . . . 16.0

5,000 . . . . . . . . . . . . . . . . . . . 11.7

10,000 . . . . . . . . . . . . . . . . . . 8.8

25,000 . . . . . . . . . . . . . . . . . . 6.5

50,000 . . . . . . . . . . . . . . . . . . 5.5

100,000 . . . . . . . . . . . . . . . . . 4.9

250,000 . . . . . . . . . . . . . . . . . 4.6

500,000 . . . . . . . . . . . . . . . . . 4.4

Table lV.Approximate standard errorsof percentefor estimated numbers ofdrug

mentions: National Ambulatory Msulical Care Survey, 1991-92

Base of percswf Esthrratadpercwrt

(Vkifs,expreaaedas

annual aversges, 7 or 5 or 10 or 20 or 30 or 40 or

In thousands) 99 95 90 80 70 60 50

50 . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.8

100 . . . . . . . . . . . . . . . . . . . . . . . . . . 7.7

250 . . . . . . . . . . . . . . . . . . . . . . . . . . 4.9

500 . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . 2.4

2,500 . . . . . . . . . . . . . . . . . . . . . . . . . 1.5

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . 1.1

10,000 . . . . . . . . . . . . . . . . . . . . . . . . 0.8

25,000 . . . . . . . . . . . . . . . . . . . . . . . . 0.5

50,000 . . . . . . . . . . . . . . . . . . . . . . . . 0.3

100,000 . . . . . . . . . . . . . . . . . . . . . . . 0.2

250,000 . . . . . . . . . . . . . . . . . . . . . . . 0.2

500,000 . . . . . . . . . . . . . . . . . . . . . . . 0.1

Standard error in percentage points

23.7

16.8

10.8

7.5

5.3

3.4

2.4

1.7

1.1

0.8

0.5

0.3

0.2

32.7

23.1

14.6

10.3

7.3

4.6

3.3

2.3

1.5

1.0

0.7

0.5

0.3

43.6 49.9 53.4

30.8 35.3 37.7

19.5 22.3 23.9

13.8 16.8 18.9

9.7 11.2 11.9

6.2 7.1 7.6

4.4 5.0 5.3

3.1 3.5 3.8

2.0 2.2 2.4

1.4 1.6 1.7

1.0 1.0 1.2

0.6 0.7 0.8

0.4 0.5 0.5

54.5

38.5

24.4

17.2

12.2

7.7

5.5

3.9

2.4

1.7

1.2

0.8

0.6

Examp!e of use of table An estimate of 20 parcant based on an estimate of 10 m![liin drug mentions per year has a standard

error of 3.1 parcent orarelatie stsndard efrorof 15.5 percent (S.l percant divided by20psrcent).

NOTE The smallaat reliable estmnate ot drug mentions to

aggregated speciaftiea is 874,000 drug mentions per year (or

a2-yeartotalof 1,347,000 mentions). Estimates below this

figure have a relatiie standard error greeter tkm 30 percent

andamdeamed unreliable by NCHS standards,

Example of use of table An aggregate estimate of 25 nWon

drug mentkmsperyaar hasara!etiveatstiard errorofS.5

parcent or a standard error of 1,625,000 dmg mantiins (6.5

parcent cd 25 Mien).

presented in table IL Standard emors for

estimated percents of visits and drug

mentions aredisplayed intables III and

Iv.

Alternatively, relative standard

errors for 2-year averages maybe

calculatedusing the following general

formuh where x is the average of

interest inthousrmds multipliedby2 to

obtainrhe2-year total,andAand Bare

theappropriate coefficients fromtableV.

Therelativestandard errorobtainedin

this way applies to both the 2-year total

and the 2-yem average.

RSE(X)= 4 A++ o1OO

Similarly, relative standard errors

forpercentsmaybe calculated using the

following general formul% where p is

thepercent ofinterest andxisthe

denominator of the percent in thousands

(andthe denominator isthe2-year

aggregate estimate rather than the

average), using the appropriate

Table Ill. Approximate standard errors of percents of estimated numbers of offfce visits:

National Ambulatory Medical Care Survey, 1991-82

Base of percent Estimated percent

(idsffs, expressed as

annual averages, 1 or 5 or 10 or 20 or 30 or 40 or

h thousands) 99 95 90 80 70 60 50

Standard error in percentage points

50 . . . . . . . . . . . . . . . . . 7.8 17.1 23.5 31.3 35.9 36.4 33.2

100 . . . . . . . . . . . . . . . . 5.5 12.1 16.6 22.2 25.4 27.1 27.7

250 . . . . . . . . . . . . . . . . 3.5 7.8 10.5 14.0 18.1 17.2 17.5

500 . . . . . . . . . . . . . . . . 2.5 5.4 7.4 9.9 11.4 12.1 12.4

1,000 . . . . . . . . . . . . . . . 1.7 3.8 5.3 7.0 S.o 8.6 8.8

2,500 . . . . . . . . . . . . . . . 1.1 2.4 3.3 4.4 5.1 5.4 5.5

5,000 . . . . . . . . . . . . . . . 0.8 1.7 2.4 3.1 3.8 3.8 3.9

10,000 . . . . . . . . . . . . . . 0.6 1.2 1.7 2.2 2.5 2.7 2.8

25,000 . . . . . . . . . . . . . . 0.4 0.8 1.1 1.4 1.8 1.7 1.8

50,000 . . . . . . . . . . . . . . 0.3 0.5 0.7 1.0 1.1 1.2 1.2

Ioo,ooo . . . . . . . . . . . . . 0.2 0.4 0.5 0.7 0.8 0.9 0.9

250,000 . . . . . . . . . . . . . 0.1 0.2 0.3 0.4 0.5 0.6 0.8

500,000 . . . . . . . . . . . . . 0.1 0.2 0.2 0.3 0.4 0.4 0.4

Exsmpbofuseof tabkAnastimataof 20percentbasadon anest@kof25miliion visbperyearhss astandarderrcfof 1.4

percent or a relafiie a4andard arror of 7.0 percent (1.4 percent divided by 20 percent).

coefficient fiomtable V. (The 3year

aggregate is obtained by multiplying the

average estimate by 2.)

Rm(p) = Ip; (;-P). 100

Adjustments for nonresponse

Estimates from NAMCS data were

adjusted to account for sample

physicians who were in-scope but did

not participate in the study. This

adjustment was calculated to miniiz.e

the impact of reqxmse on final estimates

by imputing to nonrespondiqg

physicians data from visits w similar

physicians. For thk purpose, physicians

were judged similar if they had the

same specialty designation and practiced

in the same PSU.

Test of significance and

rounding

In this repom the detemnination of

statistical inferenee is based on the

two-tailed t-test. The Bonferroni

inequality was used to establish the

critical value for statistically significant

dtierences (0.05 leve~ of significance)

based on the number of possible

comparisons within a particular variable

or (combination of variables) of interest.

Terms relating to differences such as

“greater than” or “less than” indicate

that the dtierenm is statistically
Advance Data No. 262. March30,1995 13

Table V. Coefflcienta appropriate for determining relative standard errors by type of

estimate and physician group= National Ambulatory Medical Care Survey, 1991-92

Coe~clent for use with esfimetes in thousands

TW of esfimate andphyskian speciaffy A B

visits

Overetltotals . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generatand famllypraofice . . . . . . . . . . . . . . . . . .

Osteopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internalmedidne. . . . . . . . . . . . . . . . . . . . . . . . .

Pediahfcs.. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generatsurgery . . . . . . . . . . . . . . . . . . . . . . . . .

Obetetrtceandgynecology. . . . . . . . . . . . . . . . . . .

Orthopedicsurgery. . . . . . . . . . . . . . . . . . . . . . . .

Cardlovesculardieeeees . . . . . . . . . . . . . . . . . . . .

Derrnatotogy. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Urologicalswgery.. . . . . . . . . . . . . . . . . . . . . . .

Psychiatry. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurology. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . .

Ototaryngology. . . . . . . . . . . . . . . . . . . . . . . . . .

Allotherepecialties . . . . . . . . . . . . . . . . . . . . . . .

Drug mentions

Overalltotais . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalendfamllypradlce . . . . . . . . . . . . . . . . . .

Osteopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . .

tntematmedidne. . . . . . . . . . . . . . . . . . . . . . . . .

Pedtatrlcs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalsurgery . . . . . . . . . . . . . . . . . . . . . . . . .

Obefefrfcsendgynecokcgy. . . . . . . . . . . . . . . . . . .

Orthopadicsurgery. . . . . . . . . . . . . . . . . . . . . . . .

Cerdlovsec.ulerdieeases. . . . . . . . . . . . . . . . . . . .

Oarnlefology. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Urotogicaisurgery. . . . . . . . . . . . . . . . . . . . . . . .

Psychiatry. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurology.. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmolqy . . . . . . . . . . . . . . . . . . . . . . . . . .

Otolaryngology. . . . . . . . . . . . . . . . . . . . . . . . . .

Atlotherspeciattiee . . . . . . . . . . . . . . . . . . . . . . .

0.001157131

0.007330504

0.01402452

0.008718567

o.oo79e43e6

0.006665247

0.00919564

0.00s1337

0.01363253

0.01276351

0.008000282

0.009414736

o.01314n4

0.007936146

0.007549396

0.0153701 a

0.001853163

0.009065669

0.01656477

0.01146498

0.01245118

0.03935224

0.01454044

0.01566053

0.01575914

0.01239377

0.0188n19

0.01430555

0.01532433

0.0251486

0.008374063

0.0226223

61.31199989

54.54704362

18.13642054

55.2166744

35.23091766

10.65103125

25.59962011

24.20372144

12.56469271

10.26901649

11.92853664

12.66630675

5.38720816

23.64617495

8.0936265

35.00317779

118,69462

100.36778

23.472S982

103.21367

26.7351n86

8.06W6786

31.24056408

23.3833057

24.23751806

15.34507357

10.66S6669

15.e93744s

6.67244393

25.1361195

12.25916054

57.79950436

significant.Alaek ofcommentregarding

theditFerencebetween any two

estimatesdoesnot meanthatthe

dilfereneewaatested andfoundtobe

nonsignificant.

Inthetables, estimates ofoffice

visitshavebeen roundedtothe nearest

thousand. Consequently, estimates will

nota.lwaysaddto totals.llatesand

percents werecalculated fromoriginal

unrounded figures and donot

nece.wtrilyagree withpercenta

calculatedfromrounded data

Definitionofterms

Ambulatorypatient-An ambulatory

patient is anindividual seeking personal

health serviccs who isnotcurrently

admitted toanyhealth eareinstitution

on the premises.

Drug mention—A drug mention is

the physician’s entry on the Patient

Record form of a pharmaeeutieid agent

—by any route of administration- for

prevention, diagnosis, or lreatment.

Generic as well as brand-name drugs are

includedj as are nonprescription and

prescription drugs. Along with all new

drugs, the physician also records

continued medications if the patient was

specifically instructed during the visit to

continue the medkation. Physicians may

report up to five mediations per visit.

Drug visit-A drug visit is a visit at

which mediation was prescribed or

provided by the physician.

O@ce—An office is the space

identified by a physician as a location

for his or her ambulatory praetiee.

Offices customarily include consultation,

examination, or treatment spaces that

patierm associate with the particular

physician.

Physicizzn-A physician is a duly

Iieensed doctor of medieine (M.D.) or

doctor of osteopathy (DO.) who is

currently in office-based practice and

who spends some time caring for

ambulatory patients. Excluded tlom the

NAMCS are physicians who am hospital

based who speeiake in anesthesiology,

pathology, or radiolog~ who are

federally employe~ who treat only

institutionalized patien~ or who are

employed fidl time by an institution and

spend no time seeing ambulatory

patients.

Wsit—A visit is a direct personal

exchange bt%veen an ambulatory patient

and a physician or a staff member

working under the physieiau’s

supervision, for the purpose of seeking

care and rendering personaI health

services. Excluded horn the NAMCS

are visits where medkal care was not

provide@ such m visits made to drop off

speeimens, pay bills, make

appointments, and walk-outs.
14 Advance Data No. 262 ● March 30,1995

Symbols

. . . Data not available

,.. Category not applicable

Quantity zero

0.0 Quant”~ more than zero but less

than 0.05

z Quantity more than zero but less

than 500 where numbers are

rounded to thousands

*

Figure does not meet standard of

reliability or precision
Number 263 ● April 24, 1995

I

Advance

Data m

FromVkal and Health Statisticsofthe CENTERS FOR DISEASE CONTROL AND PREVENTION/National Centerfor Health Statistics

Relationship Between Cigarette Smoking and Other

Unhealthy Behaviors Among our Nation’s Youth:

United States, 1992

by Jean C. Willard and Charlotte A. Schoenborn, M. P.H., Division of Health Interview Statistics

Introduction

The transitional period between

childhood and adulthood is a time in

which youth experience many physical

changes, as well as a developing sense

of self and increasing emotional

independence (l). During this time,

adolescents often develop behaviors that

extend into adulthood (2). Young people

may experiment with risky health

behaviors, some of which have long

term health consequences (3). Some

adolescents use these behaviors to bond

with peers, improve their social image,

and appear independent and mature (l).

Recently, health risk behaviors of

adolescents have been the foeus of

considerable study (4-13).

Cigarette smoking almost always

begins in the adolescent years (5,14) and

smoking at early ages increases the risk

of beaming ill or dying horn causes

attributable to smoking (l). Reduction in

smoking prevrdenee among adolescents

is one of the objectives established in

the National Health Objectives for the

Year 2000 (2). These objectives

311COIIlpSSS 22 pliOlity WfXiS, including

tobacco, alcohol and other drugs,

>hysical activity and fitness, nutrition,

violent and abusive behavior, and family

Naming. Each priority area contains

numerous specific, measurable health

objectives. Many of the objectives

specifically target health-threatening

behaviors among adolescents and young

adults.

Progress toward achieving the

National Health Objectives for the Year

2000 is monitored closely at the Federal

level. Much research was devoted to

establishing baseline prevalence

estimates of high risk behaviors and

developing objectives based on both the

baseline estimates and a realistic

appraisal of what cah be accomplished

by the end of the decade. While the

objectives set targets for individual

behaviom, a large body of research

suggests that many high risk behaviors

are interrelated. The recent Surgeon

General’s Repot Preventing Tobacco

Use Among Young People (l),

summarized studies that have shown

relationships between smoking and other

health-threatening behaviors such as

drinking alcohol, using illicit drugs,

using smokeless tobacco products,

-g mqms, engaging in physical

fights, ever having had sexual

intercourse, and failure to wear seat

belts. Research has also shown that

adolescents who participated in

interscholastic sports were less likely

than youth who did not participate to be

regular or heavy smokers (6). Much of

this earlier research was based on

samples of youth who were in school,

with data collected in a classroom

setting. This report expands upon earlier

research by delineating the relationship

between cigarette smoking and other

high risk behaviom among adolescents

in the general household population of

the United States, including youth who

have Ieft school either prematurely or by

graduating. Examining the relationships

between smoking and other high risk

behavio~ may provi& CIUWon how to

reduee smoking and other unhealthy

behaviors among adolescents, thereby

furthering progress toward achieving the

National Health Objectives for the Year

2000.

This report uses data horn the 1992

National Health Interview Survey of

Youth Risk Behavior (NHIS-YRBS) and

presents prevalence estimates for

selected unhealthy behaviors among

adolescents in the United States

according to smoking status. These

unhealthy behaviors, consistent with

earlier studies, include drinking alcohol;

consuming more than five aIcoholic

beverages in a row using marijuq

eoeaine, and smokeless tobacco;

S**VJQ. ~6+’$ %

‘4

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Heatth Service

Centers for Disease Controland Prevention

L

National Center for Health Statistics CENTERS CDC FOR DIsEAsE CONTROL

AND PREVENTION
2 Advance Data No, 263 ● April 24, 1995

carrying weapon~ physical fighting;

sexual intercourse; failure to use a seat

belt lack of exercise; and consumption

of fewer than five servings of fruits and

vegetables daily. These behaviors are of

significant public healti concern as

evidenced by thek inclusion in the

National Health Objectives for the Year

2000.

The data presented in this report

provide an overview of unhealthy

behaviom that are recognized as

important for the current future health of

our Nation’s youth. However, these data

do not provide specific tracking

information for the objectives because

of the age specificity of most objectives.

Data and methods

The N131S-YRBSwas developed to

provide estimates of health risk

behaviom for the noninstitutionalized,

household population of youth aged

12-21 years. The NHIS is a continuous,

nationwide, household interview survey

of the civihan noninstitutionalized

population of the United States,

conducted by the National Center for

Health Statistics (NCHS)(15). Interviews

are conducted for NCHS by the

interviewing strollof the U.S. Bureau of

the Census. Information is obtained

about the health and sociodemographic

characteristics of each member of the

household. Each year, special topic

surveys are included in conjunction with

the basic NHIS. These topics change

annually. In 1992, theNHIS-YRBS was

one of the special topics.

Within each NHIS sample family,

one youth who was attending school and

up to two youth who were not in school

or whose in-school status was unknown

were selected for the NHIS-YRBS

interview. Youth in all NHfS sample

families, including emancipated youth

(married youth and/or those not living

with a parent or guardian), were eligible

for selection. The youth were followed

back approximately two months after

the initial household interview. NHISYRBS interviews were conducted in

person from April 1992 through March

1993. NHIS-YRBS interviews were

completed for 10,645 youth,

representing an overall response rate of

73.9 percent.

Rather than using the traditional

face-to-face interview or selfadministered questionnaires, the

NHIS-YRBS used a unique

audiocassette technology, developed in

collaboration with researchers at

University of Michigan’s Survey

Research Center. This technology

zitlowed the youth to listen to the

questions, using a personal headset and

to record answers on an answer sheet

that contained only answer categories.

The answer sheet did not contain any

information that would altow pruents or

others in the household to know what

questions the youth was answering. The

voice on the interview tape matched the

sex of the respondent males heard a

male voice and females heard a female

voice. This data collection method

ensured greater privaq and increased

data quality for youth with poor reading

skills.

Using data tlom the 1992 NHISYRBS, this report presents prevalence

estimates for selected unhealthy

behaviors among male and female

adolescents 12-21 years old and

examines the relationship between

cigarette smoking and each of the other

behaviors, using age-adjusted statistics.

Table 1 contains percents and standard

errors for each of the selected unhealthy

behaviom by smoking status. These

unadjusted statistics (table 1) are used

for discussions of overall prevalence.

Table 2 contains percents, age-adjusted

to the full NHIS-YRBS sample, and the

associated standard errors. For data on

sexual intercourse, age adjustment was

Iiited to the NHIS-YRBS sample aged

14=21 years because only youth 14

years and older were asked the

questions related to sexual experiences.

Age-adjusted statistics are used in all

dkcussions of findings concerning

relationships between smoking and other

unhealthy behaviors. Age-adjusted

statistics control for variations in the age

dktributions of the various smoking

status groups. Statistics for all youth

ages 12–21 years are shown in order to

provide an overall view of the

relationships between smoking and a

variety of other behaviors during the

adolescent and young adult years.

Age-specific analyses (not shown)

revealed that the relationships between

smoking and other unhealthy behaviors

were stronger at the younger ages, but

remained consisten~ if somewhat

attenuated, among youth 18–21 years of

age.

Definition of smoking terms

Definitions for smoking status in the

national health objectives are aimed at

adults. For adults, current smoker is a

person who has ever smoked 100

cigarettes in his or her lifetime and

smokes “now”- “now” being defined

by the respondent. Recent measures of

smoking status assess regularity of

smoking in adults by distinguishing

between “everyday” and “some day”

smokers. These definitions may not be

appropriate for adolescents.

Consistent with other studies of

adolescents, current smokers are defined

as youth who have smoked at least one

cigarette in the past 30 days. Former

smokers are youth who had smoked at

least one cigarette every day for 30 days

at some time in their lives, but had not

smoked cigarettes in the past month.

Experimenters are youth who had

smoked at least one or two puffs of a

cigarett~ but had never smoked

cigarettes every day for 30 daysand had

not used cigarettes in the past 30 days.

“Never smokem” ate youth who had

never had even one or two puffs of a

cigarette. Definitions for other terms

used in thk report are in the technical

notes.

Findings

Figure 1 shows prevalence of

smoking among youth aged 12-21

years. About 29 percent of male youth

and 26 percent of female youth were

current smokers in 1992 and about

3 percent of both sexes were former

smokers. About 28 percent of male

youth and about 30 percent of female

youth had experimented with cigarettes,

but had never smoked regularly. About

40 percent of youth had never taken a

puff of a cigarette.
Advance Data No. 263 ● April 24, 1995 3

- Current smoker EZ9 Former smoker = Experimenter W Never smoker

50 f40.3 40.3 40.4

40 ~

30

20

10

0-

All Maie Female

Figure 1. Percent of youth 12-21 years of age by smoking status and sex United Statea,

1992

Table 1 shows the prevalence of general, the patterns appear similar for

selected unhealthy behaviors among adolescent males and females. For

male and female adolescents by example, among both male and female

smoking status. Figures 2 and 3 display youtkiifailure to eat at least five semings

overall prevalence of these behaviors for of tilts and vegetablm daily had the

males and females, respectively. The highest prevalence of the unhealthy

data in figures 2 and 3 correspond to behaviom examined (86.1 percent and

column 1 of table 1. Together these data 87.9 percen~ respectively), followed by

show the overall pattern of unhealthy failure to always use seat belts

behaviors among U.S. adolescents. In (70.2 percent and 61.4 percent of males

Drank alcohol

Had five of mor;~p~

Used marijuana

Usad cocaine

Used smokelsss tobacoo

Carried a weapon

Physical fiiht

Sexual intercourse1

Did not use seat belt

Exercisedfewer than three

times a week

Ate fewer than five

servings of fruits

and vegetables daily

4s.3

86.1

0 20 40 60 80 100

Percent

IAge8 14.21 years andneverm~rrad.

Figure 2. Prevalence of seiactad unheaithy behaviors among adoieecent maies:

United States, 1992

and females, respectively), and engaging

in sexual intercourse (62.7 percent and

58.7 percent of males and females,

respectively). Prevalence of cocaine use

was only about 1 percent for both

groups.

Although the patterns among the

behaviors appear similar for .ma.Iesand

females, prevalence estimates for some

behaviors dtiered markedly between the

sexes. Among the more noteworthy

dii%erencesare: male youth were more

likely than female youth to have

engaged in a physical fight in the past

year (47.9 percent versus 29.2 percent);

to have carried a weapon in the past

month (23.5 percent versus 5.6 percent);

to have used smokeless tobacco

(13.4 percent versus 1.5 percent); and to

have used marijuana (12.2 percent

versus 9.2 percent). Female youth

(52.7 percent) were more likely than

male youth (39.9 percent) to get

@adequate exercise (deiined as

exercising less than three times per

week). Prevalence of consumption of

any alcohol was about the same for

male (45.3 percent) and female youth

(44.0 percent), although males

(29.1 percent) wem somewhat more

likely than females (22.0 percent) to

have had five or more drinks in a row.

Figures 1-3 and table 1 show

prevalence estimates of unhealthy

behaviom among U.S. adolescents.

Using these estimates and the population

table in the technical notes of this

repor$ the reader can estimate the

numbers of youth who are both smoking

and engaging in other high risk

behaviors. Analysis of interrelationships

between smoking and other unhealthy

behaviors should be restricted to the

data in table 2.

Table 2 presents data on the

relationship between smoking and

selected other unhealthy behaviors

among adolescents, adjusted for

ditTerences in the age composition of the

various smoking status groups.

Generally, youth who had never smoked

were significantly less likely to have

engaged in each unhealthy behavior

studied than were current smokers. With

a few exceptions, “never smokers” were

also less likely than former smokers or

experimenters to participate in unhealthy

behaviors.
4 Advance Data No. 263 ● April 24, 1995

Drank alcohol

five or more drinks

in a row

Used marijuana

Used cocaine

Used smokeless tobacoo

Canied a weapon

Physical fight

Sexual intermurse’

Did not use seat belt

Exercised less than three

times a week

Ate less than five

servings of fruits and

vegetables daily

44.0

87.9

!

, * 1 t 1

0 20 40 60 60 100

Percent

1Ages 14.21 years and never married.

Figure 3. Prevalence of selected unhealthy behavfors among adolescent femafes:

United Staes, 1992

Drinking avoid episodic heavy drinking

(sometimes called binge drinking) if

Alcohol consumption among youth they do drink. Table 2 shows that after

has serious short term and long term controlling for differences in age

healtl consequences. Prevention efforts composition, about three-quarters

are d~ected at encouraging young (74.4 percent) of current smokers aged

people to abstain from alcohol and to 12–21 years old had consumed alcohol

- Current smoker W Former smoker

100

80

60

E

g

~ 40

20

0

73.7

~ Experimenter m Never smoker

75.1

Male Female

Figure 4. Percent of youth who drank alcohol In the past month, by smoking statua and

sex United States, 1992

in the past 30 days, compared with

23.0 percent of “never smokers.”

Figure 4 shows the percent of youth

who drank alcohol in the past month by

smoking status and sex. Among cnrmnt

smokers, prevalence of alcohol

consumption in the past month was

about the same for males and females.

Among those who have never smokez

males were slightly more like~y than

females to have consumed alcohol in the

past month. Table 2 also shows that

current smokers (50.3 percent) wem

considerably more likely than former

smokem (25.5 percent), experimenters

(21.3 percent), and “never smokers”

(9.5 percent) to have had five or more

drinks in a row in the past month. Rates

of episodic heavy drinking were

somewhat lower for females than for

males across all categories of smoking

status, but the pattern remained the

same.

Marijuana and cocaine use

As with alcohol, drug use among

our Nation’s young people is a major

problem and the focus of extensive

prevention efforts. Table 2 shows past

month use of each of two drugs—

marijuana and cocaine-by smoking

status. Among youth 12-21 years of

age, controlling for differences in age

composition, 26.5 percent of tadoleseent

current smokers reported marijuana use

in the previous 30 days compared with

10.3 percent of former smokers,

6.2 percent of experimenters, and only

1.5 percent of youth who had never

smoked. Among both males and

females, current marijurma use was

considerably more prevalent among

current smokers than among youth who

were not currently smoking. Table 2 also

shows that 3.5 percent of current

smokers 1>21 years old had used

cocaine in the previous month. Although

data for former smokers, expmimenters,

and “never smokers” do not meet

reliibdity stanckuds, patterns indicate

that prevalence may be lower in these

groups.

Smokeless tobacco

Smokeless tobacco use among our

Nation’s youth is a serious public health

concern. Like so many other behaviors,

use of smokeless tobacco (chewing
Advance Data No. 263 ● April 24, 1995 5

tobacco and snuff) is frequently taken

up during the adolescent years. Table 2

shows that after controlling for

differences in age composition, male

adolescents who were current smokers

(28.1 percent) and former smokers

(27.5 percent) wem almost seven times

more likely to have used smokeless

tobacco in the past month than were

male youth who had never smoked

(4.1 percent). Although the small

number of female adolescents reporting

use of smokeless tobacco makes

estimates of this behavior unreliable for

most subgroups, the data suggest that

currently smoking females may be more

likely to be users of smokeless tobacco

than other adolescent females.

Carrying weapons and physical

fights

Table 2 also movides imtmtant

insights into the ;xtent to wh;ch youth

engage in two types of violent

behavior+amying weapons and

engaging in physical fights-according

to smoking status. After controlling for

differences in age composition, about

onequarter of youth who were current

smokers reported carrying a weapon

such as a gun, knife, or club during the

previous 30 days, compared with about

one-tenth of youth who had never

smoked. Figure 5 shows that adolescent

male smokers were more &m twice as

likely (39.4 percent) as males who had

never smoked (16.5 percent) to have

carried a weapon. Rates of carrying

weapons among male former smokem

(30.8 percent) and experimenters

(22.1 percent) ranked between the other

two groups. Adolescent female current

smokers were more thau four times as

likely (11.0 percent) as female youth

who had never smoked (2.6 percent) to

have carried a weapon during the

previous month. As with males, female

experimenters (5.8 percent) mnked

between those of current and “never

smokers” on the mte of those who

carried weapons. Due to the small

number of female former smokers who

carried weapons, data for thii group

were unreliable.

Table 2 shows that male cummt

smokers (64.1 percent) were more likely

than males who had experimented with

cigarettes (47.1 percent) and those who

had never smoked (38.4 percent) to have

been involved in a physical fight in the

past year. Among female adolescents,

current smokers (443 percent) were

- Cunent smoker - Former smoker IZZl Experimenter UMIIUiMNever smoker

40

30

10

0

L 39.4

Male Female

1~ta fm female f~w smokersare statisticallynreli~le.

—. — Figure 5. Percent of youth who carried weapons in the past month, by smoking status

and sex: United States, 1992

more than twice as likely as “never

smokers” (19.8 percent) to have engaged

in physical fighting in the past year.

Sexual intercourse

The NHIS-YRBS includes data on

sexual intercourse for adolescents 14-21

years of age. For this repor4 analysis

was restricted to youth who had never

been married.

Prevalence of sexual intercourse

among never married adolescents was

high across all smoking status groups.

Table 1 indicates fhat 6 of 10 never

married adolescents 14 years old and

older (60.8 percent) had engaged in

sexual intercourse at some time in their

lives. There appears to be a relationship

between cigarette smoking and sexual

intercourse. Current smokers

(80.0 percent) and former smokers

(80.4 percent) were most likely to have

engaged in sexual intercourse compared

with 60.6 percent of youth who had only

experimented with cigarettes and

41.4 percent of youth who had riever

smoked at all (table 2).

seatbelts

Injuries are one of the l-mg

causes of death among adolescents and

young adults. Injury deaths among those

15–24 years of age are largely

attributable to motor vehicle accidents

(2). Overall, 65.8 percent of adolescents

did not rdways use seat belts when they

rode in a car (table 1). Table 2 shows

that over three-quarters (76.6 pmmt) of

current smokers did not aIways wear a

seat belt compmd with about one-half

(55.7 percent) of adolescents who had

never smoka with the other two

groups falling in between.

Vigorous exeroise

Regular participation in vigorous

exercise is recognized as having

important health benefits for people of

all ages, including youth. In the

NHIS-YRBS, youth were asked how

often in the past week fhey engaged in

any activities that made them sweat or

breathe hard. The percent of youth who

reported participating in such vigorous

activities 3 or more days in the week

preceding the interview is shown in

table 2, according to smoking status.
6 AdvanceData No. 263 ● April 24, 1995

Overall, prevalence of regular, vigorous

exercise among adolescents was low

(46.2 percent), regardless of smoking

status (table 1). Table 2 shows that

49.6 percent of adolescent current

smokers exercised less than 3 times

during the week preceding the survey;

44.8 percent of “never smokers”

exercised thk infrequently.

Eating habits

Guidelines for healthy eating

generally recommend eating five or

more servings of fruits and vegetables

daily. The National Health Objectives

for the Year 2000 address this issue for

adults, but not for children or youth,

Nevertheless, the NHIS-YRBS asked

youth about tilt and vegetable

consumption during the day preceding

the interview. Overall, 87.0 percent of

all adolescents consumed less than five

servings of fruits and vegetables

(table 1). Table 2 shows that

consumption of fewer than the

recommended miniium quantities of

fruits and vegetabks was somewhat

more common among adolescents who

currently smoked (89.6 percent) than

among those who had never smoked

(83.6 percent).

Discussion and conclusions

This report provides a broad

overview of the links between smoking

and other high risk behaviors. Although

it does not establish causal links, it does

show a consistent association between

smoking and other unhealthy behaviors

among adolescents, further strengthening

the evidence that unhealthy behaviors

among adolescents are interrelated. In

almost all cases, current smokers had

the highest and “never smokers” the

lowest rates of other risk behaviors. The

dtierences were particularly striking for

use of other addictive substances such

as alcohol, marijuan% and smokeless

tobacco current smokers were 3–17

times more likely than adolescents who

had never smoked to have used these

other substances in the past 30 days.

(Data for cocaine were suggestive of a

similar relationship, but were not

statistically reliable due to small

numbers of youth reporting cocaine

use.) Although not quite as dramatic,

differences between smoking and

nonsmoking teenagers were also

noteworthy for carrying weapons,

physical fighting, sexual intercourse, and

failure to use seat belts. For two risk

behaviors+xercising less than three

times per week and eating fewer than

five servings of hits and

vegetables-smokerx simiiarly had

higher prevalence rates than those who

had never smoke~ but the differences

were less striking.

The interrelationships behveen

smoking and other unheatthy behaviors

are undoubtedly complex. Multivariate

analyses are needed to delieate the

nature of these interrelationships. The

data presented here suggest that high

risk behaviors may cluster. That is,

youth who engage in some high risk

behaviors are liely to be engaging in

others. Interventions that target multiple

high risk behaviors may be more

effective in getting youth to adopt

healthy behaviors than programs that

target a single behavior.

References

1.

2.

3.

4.

5.

6.

Centers for Disease Control.

Preventing tobacco use among young

people: a report of the Surgeon

General. Atlrmkx National Center for

Chronic Disease Prevention and

Health Promotion, Office on

Smoking and Health, 1994.

Public Health Service. Healthy

people 2000: national health

promotion and disease prevention

objectives. Washington: U.S.

Department of Health and Human

Services, 1991.

Designing health promotion

approaches to high-risk adolescents

through formative research with

youth and parents. Public Health Rep

108(supp. 1): 68-7.1993.

Marcus SE, Giovino GA, Pierce JP,

Harel Y. Measuring tobacco use

among adolescents. Public Health

Rep 108(l) :2&24. 1993.

Escabedo LG, Marcus SD, Holtzman

D, Giovino GA. Sports participation,

age at smokmg initiation, and the

risk of smoking among US high

school students. JAMA 269(11):

1391-95.1993.

Bachman JG, Wallace JM, O’MaUey

PM, et al. Racial/ethnic dtierences in

smoking, drinking, and illicit drug

use among American high school

7.

8.

9.

seniors, 1976-%9. Am J Public

Health 81(3):372–77. 1991.

Centers for Disease Control.

Tobacco, alcohol, and other drag use

among high school stndents-United

States, 1991. MMWR 41(37):698-03.

1992.

Webster DW, Gainer PS, Champion

HR. Weapon carrying among

inner-city junior high school

students: defensive behavior vs

aggressive delinquency. Am J Public

Her&h 83:1604-8.1993.

Vanderschmidt HF, Lang JM,

Knight-WiUiams V, Vanderschmidt

GF. Risks among inner-city young

teens: the prevalence of sexual

activity, violence, drugs, and

smoking. Journal of Adolescent

Health 14:282-88.1993.

10. Centers for Disease Control. Physical

fighting among high school

students-United States, 1990.

MMWR 41(6):91-94. 1992.

11. Centers for Disease Control. Sexual

behavior among high school

students-United States, 1990.

MMWR 40(51). 1992.

12. Centers for Disease Control.

Vigorous physical activity among

high school students-United States,

1990. MMWR 41(3). 1992.

13. Centers for Disease Control. Selected

tobacco-use behaviors and dietary

patterns among high school

students-United States, 1991.

MMWR 41(24). 1992.

14. Centers for Disease Control.

Reducing the health consequences of

smoking: 25 yeas of progress, a

report of the Surgeon General.

Washington: Public Health Service.

DHHS Publication No (CDC)

89-8411.1989.

15. Benson V, Marano MA. Current

estimates from the National Health

Interview Survey, 1992. National

Center for Health Statistics. Vital

Health Stat 10(189). 1994.

16. Kolbe LJ, Kann L, Collins JL.

Overview of the Youth Risk

Behavior Surveillance System. Public

Health Rep 108(supp. 1): 2-10.1993

17. Centers for Disease Control. Heatth

risk behaviors among adolescents

who do and do not attend school—

United States, 1992. MMWR 43(8).

1994.
Advance Data No. 263 ● April 24, 1995 7

Table 1. Percent of youth ages 12-21 yeare who engaged in seleoted unhealthy behaviors by type of behavior, sex, and smoking statu=

United States, 1992

All snroldng Current Former Never

statuses smoker smoker Expwimerrfer smoker

Standard Sferrdad SkmCfard Standard .5?andSrd

UnheaUiYrybehevio+ and sex Persenf error Percent error Percent error Percent error Percent error

Drank alcohol

Bolheexee . . . . . . . . . . . . . . . . . . . . . .

Mefe . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Had five or more dtfnks in a row

Both eexss . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Femefe . . . . . . . . . . . . . . . . . . . . . . . .

Usedrrrerijusna

Bofheexes . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Fenrafe . . . . . . . . . . . . . . . . . . . . . . . .

Used cocaine

Bothsexes . . . . . . . . . . . . . . . . . . . . . .

Msle . . . . . . . . . . . . . . . . . . . . . . . . .

Fernefe . . . . . . . . . . . . . . . . . . . . . . . .

Used smokeless tobacco

Bothsexes . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Femafe . . . . . . . . . . . . . . . . . . . . . . . .

Csnledaweepon

Bolheexes . . . . . . . . . . . . . . . . . . . . . .

Mafe . . . . . . . . . . . . . . . . . . . . . . . . .

Ferrrale . . . . . . . . . . . . . . . . . . . . . . . .

Engaged In physkal fight in past year

EkNhsexes . . . . . . . . . . . . . . . . . . . . . .

Mefe . . . . . . . . . . . . . . . . . . . . . . . . .

Fenrefe . . . . . . . . . . . . . . . . . . . . . . . .

Ever had sexual Intercourse*

Bothaexes . . . . . . . . . . . . . . . . . . . . . .

Mate . . . . . . . . . . . . . . . . . . . . . . . . .

Fernefe . . . . . . . . . . . . . . . . . . . . . . . .

Did not always use seat half

Bothaexes . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Exercisadvborously fewer

than3tImesinpast weel?

Bothaaxee . . . . . . . . . . . . . . . . . . . . . .

Mate . . . . . . . . . . . . . . . . . . . . . . . . .

Femefe . . . . . . . . . . . . . . . . . . . . . . . .

Ate fewer than five servings of fndta

arrdvegetsblesyesterday

Bothsexes . . . . . . . . . . . . . . . . . . . . . .

Mace . . . . . . . . . . . . . . . . . . . . . . . . .

Female. . . . . . . . . . . . . . . . . . . . . . . .

44.6

45.3

44.0

25.6

22.1

22.0

10.7

12.2

9.2

1.2

1.4

1.0

7.5

13.4

1.5

14.5

23.5

5.6

38.6

47.9

23.2

60.8

62.7

58.7

65.8

70.2

61.4

46.2

389

52.7

67.0

86.1

87.9

0.69

0.88

o.e4

0.58

o.7e

0.75

0.39

0.59

0.46

0.11

0.16

0.15

0.37

0.65

0.20

0.42

0.72

0.39

0.62

0.86

0.78

0.77

1.02

1.07

0.69

0.88

0.94

0.52

0.80

0.85

0.42

0.56

0.57

77.9

78.2

77.7

54.5

5e.5

48.8

2e.1

31.1

26.8

3.9

4.2

3.5

16.1

27.9

2.9

23.2

35.0

10.1

46.7

57.7

38.7

81.7

81.8

81.6

75.5

79.7

70.8

54.4

50.2

59.2

89.8

69.4

90.3

o.e3

1.31

1.29

1.07

1.42

1.57

1.04

1.49

1.35

0.37

0.57

0.55

0.90

1.53

0.91

1.43

0.93

1.09

1.52

1.54

0.98

1.34

1.41

1.05

1.27

1.63

1.06

1.49

1.49

0.71

0.95

0.93

55.5

56.4

54.9

28.8

34.6

24.0

11.7

16.4

7.8

“1.5

“1.6

“1.5

14.2

22.4

“1.4

18.9

29.9

9.s

42.3

49.5

36.4

82.4

*80.8

*84.1

67.2

77.7

53.4

55.3

55.0

55.5

91.3

93.3

69.7

3.40

5.69

4.01

2.80

4.92

3.10

2.13

3.97

I.%r

0.75

1.15

1.00

3.07

5.72

0.84

3.13

5.88

2.79

2.99

5.21

3.98

2.70

4.12

3.20

3.13

4.21

4.13

3.17

5.17

4.01

1.66

2.42

2.25

46.7

48.0

4e.4

23.4

26.7

202

6.8

7.8

5.8

“0.3

“0.4

“0.2

6.2

11.2

1.4

13.3

21.5

5.7

38.2

44.9

28.1

61.8

61.8

61.9

66.9

70.4

63.7

46.1

37.2

54.4

882

87.6

30.8

1.12

1.64

1.57

1.00

1.43

1.23

0.56

0.64

0.70

0.03

0.75

0.11

0.51

0.95

0.38

0.76

i .35

0.66

1.06

1.51

1.37

1.28

1.86

1.76

1.13

1.47

1.80

1.03

1.46

1.40

0.64

1.03

0.77

17.6

18.8

16.5

6.8

8.2

5.4

1.1

1.6

0.6

‘0.1

“0.2

90.1

2.1

3.6

“0.6

9.2

16.2

2.4

33.2

42.9

23.4

37.9

42.5

%3.2

58.4

62.9

53.8

40.1

33.3

46.9

83.1

82.2

64.0

0.79

1.00

i .07

0.51

0.76

0.61

0.18

0.30

0.18

0.06

0.08

0.07

0.25

0.44

0.19

0.64

0.92

0.39

0.89

1.23

1.11

1.28

1.65

1.77

1.00

1.33

1.38

0.94

1.19

1.32

0.73

1.01

0.95

‘Fleferenca period Is past30 days un!a.ss othenvise spacified.

2Ages 14-21 yaars and never maniac!,

%igcfous is dafined as axercise that made the youth sweat and breathe hard.
8 Advance Data No. 263 ● Am’il 24, 1995

Table 2. Age-adjusted percent of youth ages 12-21 years who engaged in selected unhealthy behaviora by type of behavior, sex, and

smoking status: United States, 1992

All smoking Current Former

statuses

Never

smoker smoker Experimenter smoker

.Standsrd .Sfsndard .%indard

Unhealthy behavio~ and sax

Standard

Perc3rrt

Standard

error Percent error Percent error Percent error Percent error

Drank alcohol

Both aexes . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Femafe . . . . . . . . . . . . . . . . . . . . . . . .

Had five or more drfnks In a row

Both aaxea . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Usedmarl]uana

Both saxes . . . . . . . . . . . . . . . . . . . . . .

Mafe . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Usedcmaine

Bothaexes . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Used smokeless tobacco

Bothaexes . . . . . . . . . . . . . . . . . . . . . .

Mace . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Carriedaweapon

Bothsexes . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Engaged in physical fight In paat year

Both saxas . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Ever had sexual intercoursa2

Bothaexes . . . . . . . . . . . . . . . . . . . . . .

Mete . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Did not ahvays use seat beff

Bothsaxas . . . . . . . . . . . . . . . . . . . . . .

Mace . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Exercised vigorously fewer than

3timesinpastweef?

Bofhsexes . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Ate tewer than five servings of fruits and

vegetables yesterday

Both saxes . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

44.3

45.3

43.4

25.4

29.2

21.7

10.7

12.3

9.1

1.2

1.5

1.0

7.5

13.5

1.5

14.5

23.4

5.6

38.6

47.7

29.3

60.8

62.4

59.1

65.8

70.2

61.4

46.2

40.1

52.4

87.0

86.1

87,9

0.61

0.80

0.85

0.53

0.72

0.71

0.38

0.58

0.45

0.11

0.18

0.15

0.37

0.65

0.21

0.41

0.71

0.38

0.59

0.81

0.77

0.72

0.96

1.05

0.68

0.87

0.93

0.56

0.79

0.83

0.42

0.58

0.57

74.4

73.7

75.1

50.3

53.7

46.4

26.5

28.0

24.7

3.5

3.5

3.6

16.1

28.1

3.0

25.6

39.4

11.0

54.7

84.1

44.3

80.0

79.9

80.0

76.6

80.6

72.2

49.6

45.6

54.0

89.6

66.4

90.7

1.11

1.60

1.56

1.22

1.61

1.80

1.02

1.48

1.34

0.48

0.47

0.79

1.02

1.76

0.60

1.12

1.74

1.10

1.09

1.40

1.70

0.99

1.38

1.42

1.03

1.38

1.61

1.17

1.62

1.64

0.80

1.18

1.00

47.0

50.4

41.6

25.5

31.5

18.8

10.3

15.2

5.4

-f .1

‘1.4

“1.0

13.7

27.5

‘1.5

20.2

30.8

“11.3

48.6

53.9

41.8

80.4

77.7

82.9

71.6

79.0

66.3

48.9

51.5

45.6

91.2

92.8

90.1

3.92

6.23

3.25

2.93

4.57

2.89

2.19

3.98

1.30

0.55

0.99

0.82

3.50

6.48

0.92

3.42

6.40

4.29

3.50

5.42

5,20

3.27

5.58

3.43

3.05

4.34

3.81

3.78

6.27

4.44

1.94

2.61

2.91

45.4

45.4

45.4

21.3

24.7

18.2

6.2

7.4

5.2

‘0.3

“0.4

“0.2

6.1

11.1

1.5

13.8

22.1

5.8

38.3

47.1

29.6

60.6

60.0

61.0

67.7

70.9

64.9

44.1

36.1

51.6

89.0

87.5

90.5

1.01

1.49

1.42

0.88

1.27

1.11

0.52

0.79

0.62

0.09

0.14

0.10

0.49

0.92

0.36

0.78

1.37

0.70

1.05

1.39

1.45

1.13

1.61

1.64

1.11

1.44

1.56

1.00

1.42

1.40

0.65

1.04

0.82

23.0

25.2

20.8

9.5

12.0

7.2

1.5

2.3

‘0.8

“0.2

“0.3

“0,2

2.4

4.1

“0.6

9.5

16.5

2.6

29.0

38.4

19.8

41.4

45.9

36.6

55.7

60.3

51.2

44.8

37,7

51.7

83.6

82.7

84.5

1.02

1.s4

1.29

0.69

1.07

0.81

0.25

0.43

0.25

0.10

0.13

0.12

0.28

0.52

0.20

0.59

1.02

0.43

0.86

1.32

0.95

1.40

1.85

1.89

1.11

1.56

1.47

1.00

1.39

1.43

0.74

1.05

1.01

‘t?eferenca period IS psst 30 days unless otherwise speehed.

2Agas14-2f years and never married.

%gorousisdefinedas axercisethat !mdethe youfhsweatand breathe hard.

NOTE Tdalage-adjustd ~r@ntsmy dtiershgMly fromtotal percents shown lntablel duetominor variations lnfiemnonre$ponse among youth inthevarious smoMngtiatus groups.
Advance Data No. 263 ● Ai)t’il 24, 1995 9

Technical notes

Target population

Theestimatespresented in this

report me based on data from the 1992

National Health Interview Survey of

Youth Risk Behavior (NHIS-YRBS).

The National Health Interview Survey

(NHN) is a continuous, nationwide,

household interview survey of the

civilian noninstitutionalized population

of the United States, conducted by the

National Center for Health Statistics

(NCHS), Centers for Disease Control

and Prevention (CDC).

The NHIS-YRBS was a followback

survey of a subsample of youth ages

12–21 years who were identified at the

time of the 1992 NHTShousehold

interviews. Within each NHIS sample

family, one youth attending school and

up to two youth not in school or whose

in-school status was unknown were

randomly selected for the NHLS-YRBS

interview. Youth in all NHIS sample

families, including emancipated youth

(mamied youth and/or those not living

with a parent or guardian), were eligible

for selection. The youth were

interviewed approximately 2 months

after the irdtial NHM interview.

lVHIS-YRBS interviews were conducted

in person from April 1992 though

March 1993. The ages shown in thk

report represent the youths’ ages at the

time of the initial NHIS intemiew,

which may not be the same as their ages

at the time of the IWIIS-YRBS

interview because of the 2-month lag

between the two data collection points.

The questions on sexual intercourse

were asked of all youth who were 14

years old or older by the time of the

NHIS-YRBS interview. However, for

consistency with other data presented in

this repo@ the data on sexual

intercourse shown in tables 1 and 2 am

limited to youth who were 14 years old

at the time of the initial NHIS

household interview.

description of the survey

The NHN-YRBS provides estimates

of health risk behaviors for the

noninstitntionalized household

population of youth ages 12-21 years.

I’epics covered in the YRBS include:

tobacco use including cigarettes,

chewing tobacco, and snufi alcohol

consumption; illegal drug use and

perceptions of risks associated with their

ustz nutrition, including weight control;

physical activi~, injury control,

including hehnet use when riding

bicycles and motorcycles; violence,

including frequency of physical fighting

and carrying weapons; overnight stays

away from home and without

permission sexual history and practices

and AIDS education at home and in

school. This survey is part of the Youth

Risk Behavior Surveillance System

(YR13SS). The YRBSS was developed

by the Division of Adolescent and

School Health of the National Center for

Chronic Disease Prevention and Health

Promotion, Centers for Disease Control

and Prevention (cDC), to monitor the

major health risk behaviors of American

youth. The surveillance system is

described elsewhere (16). The majority

of the YRBSS is school-based and has

been tracking behaviors of in-school

youth since 1990. The 1992 NHISYRBS added a new dimension to the

study of health risk behaviors among

American youth by providing estimates

of risk behaviors for out-of-school youth

(17). Out-of-school youth were

oversampled in the IWHS-YRBS to

achieve reliable estimates for this

hard-to-reach group; a special question

was added to the basic NHIS

questionnaire in 1992 to determine

school status for the YRBS sample.

Data collection methods

Interviews are conducted for NCHS

by statl of the U.S. Bureau of the

Census. The basic health and

demographic questionnaire of the NHIS

is administered in a personal interview,

with telephone follow-up permitted for

hard-to-reach people. Basic health

information is collected for every

member of the family residing in the

household. Based on the roster of family

members listed at the time of interview,

a subsample of youth was selected for

the NHIS-YRBS.

Because the samphng frame was the

1992 NHIS and three-quartm of the

data were collected in 1992, for ease of

reading, findings from the NHIS-YRBS

are referred to as 1992 results although

the &ta were collected from April 1992

through Mamh 1993.

In. collaboration with researchers at

University of Michigan’s Survey

Research Center, extensive

methodological testing was conducted

during the development of the NHISYRBS to determine the optimal mode of

data collection from adolescents. Results

indicated that due to the sensitive

nature of the questions on the NHTSYRBS, privacy and confidentiality

would be of paramount concern to teens

during the interview. Youth indicated

that they would be mom likely to

answer questions honestly if the

questions could not be heard by others

in the household. Further, younger teens

and those with less developed reading

skills found a written questionnaire to

be dficult to complete. For these

reasons, questions were asked of teens

using a portable audio headset. They

recorded their answers on an answer

sheet that included only answer

categorh, not questions. In addition to

providing @vacy and beiig easier for

less advanced readers, this mode of data

collection had the added benefit of

providing standardation in asking

questions that eliminated the normal

variations that occur when an

interviewer asks the questions.

Response rates

Of the13,789persons 12–21 years

of age idendlied as eligible in the basic

NHIS interview, NHIS-YRBS interviews

were completed for 10,645 youths,

representing a response rate of

77.2 percent of eligible respondents and

an overall response rate of 73.9 percent

(the product of the YRBS response rate

(77.2 percent) and the response rate for

the basic NHIS household interview

(95.7 percent)).

School status was ascertained in

two ways. At the time of the initial

NHIS questionnak, 8,062 youth were

currently in school or on vacation tlom

school, 1,886 youth were not in school,

and the school status of the remaining

697 adolescents was unknown. At the

time of the NHIS-YRBS interview,

8,203 were currently in school or on

vacation from school, 2,384 were not in
10 Advance Data No. 263 ● April 24, 1995

school, and the school status of the

remaining 58 youth was not ascertained.

Due to some field difficulties in

rostering eligible youth, the number of

teenagers selected for the NHIS-YRBS

was somewhat smaller than the number

of youth ultimately identified as having

been eligible for interview. Hence, the

response rate for the NHIS-YRBS was

somewhat lower than it might have been

had all eligible youth been given the

opportunity to respond. Another factor

that may have contributed to the YRBS

nonresponse rate was the requirement

that interviews be done in person.

Because of the portable audio headset

method of data collection, telephone

follow-up was not permitted for the

NHIS-YRBS. Comparison of

respondents and nonrespondents

indicated that the two groups were not

substantially dtierent in terms of their

sociodemographlc profiles. Item

nonresponse ranged from 0.15 to

7.86 percent for the questions discussed

in this report.

Sample design and statistical

testing

The NHIS sample is selected so that

a national probabiMy sample of

households is interviewed each week

throughout the year. A detailed

discussion of the sample design is

available in Current Estimutes from the

National Health Interview Survey, 1992

(15). Because the estimates shown in

this report are based on a sample, they

are subject to sampling error. The

standard error is a measure of sampling

error. The standard errors shown in

tables 1 and 2 of this report were

calculated using SUDAAN (SUrvey

DAta ANalysis), developed by the

Research Triangle Institute for analysis

of complex sample surveys. The

unadjusted percents were calculated

using PROC CROSSTABS. The

age-adjusted percents were calculated

using PROC DESCRIPT. The entire

NHIS-YRBS sample (age groups: 12-13

years, 14-17 years, and 18–21 years)

was used as the standard population. For

the data on sexurd intercourse, age

adjustment was limited to the two older

groups because the question was asked

only of youth 14 years and older. Data

for tables 1 and 2 were tabulated using

WOR (without ~placement) design. All

estimates in this report are based on

data that have been weighted to

repre3ent the U.S. population of youth

1>21 years old. Table I shows the

numbers of youth in the total U.S.

population and in each of the four

smoking status subgroups. This table

can be used to estimate numbers of

youth engaging in combinations of

smoking and other health risk behaviom.

Population estimates derived by using

table I maybe slightly different from

those that would be obtained had the

exact denominators for each individual

variable been provided. However, the

dtierences will be small and of no

statistical consequence.

All dtierences cited in this report

are statistically significant at the .05

level. The t-tes~ with a critical value of

1.96, was used to test all comparisons

that are discussed. Lack of comment

regardhg the dtierence between any

two estimates does not mean that the

dtierence was tested and found not to

be statistically significant.

Definition of terms

Current wnokers—Youth who had

smoked at least one cigarette in the past

30 days.

Table L Number of youth by cigarette smoking status and age, United Statee, 1992

Former smokers—Youth who had at

one time smoked at least one cigarette

per day for 30 days, but had not smoked

cigarettes in the past month.

Experimenters-Youth who had

smoked at least one or two puffs of a

cigarette, but had never smoked

cigarettes every day for 30 days and had

not used cigarette3 in the last 30 days.

Never smokers—Youth who had

never had even one or two puffs of a

cigarette.

Drank alcohol<onsumed at least

one alcoholic drink, includlng beer,

wine, wine coolers, and liquor on at

least one of the past 30 days.

Episodic heavy drinking—

Consumed at least 5 drinks within a

couple of hours in the past month.

Smokeless tobacco-snuff such as

Skord, Skoal Bandhs, or Copenhagen, or

chewing tobacco such as Redman, Levi

Garre% or Beechnut.

Marijuana-Marijuana, grass, or

pot.

Cocaine—Any form of cocaine,

including pow&r, craclG or freebase.

Carried a weapon-Gun, kniie, or

club, carried at least once in the past 30

days.

Physical ji@t-Had bn involved

in at least one physical fight in the past

year.

Wgorous exercise—Exercise that

caused sweating andheavy breatMmg.

Fewer than jive servings offiwits

and vegetables—Adolescents were

asked about their consumption of

selected foods the day before the

interview and could respond that they

had consumed the food once, twice or

more, or not at all. The foods were fruit

juice, fn@ green sala~ and cooked

vegetables. The sum of the youth’s tilt

and vegetable intake was obtained by

Ages 12-21 years Ages 14-21 years’

Smoking status Total Males Females Total Males Females

Number In thousanda

Allyoulhz . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33,518 16,816 16,702 23,412 12,152 11,260

Current smokers . . . . . . . . . . . . . . . . . . . . . . . 9,132 4,818 4,314 7,336 4,042 3,295

Former smokem . . . . . . . . . . . . . . . . . . . . . . . 1,033 468 565 739 372 367

Exparimentera . . . . . . . . . . . . . . . . . . . . . . . . 9,835 4,759 5,076 7,478 3,7S4 3,744

Never smokers . . . . . . . . . . . . . . . . . . . . . . . . 13,516 6,771 6,747 7,859 4,005 3,654

lNever married and 14-21 years d age at time of NHIS initial household interview.

‘Excludes youth for whom srwiring status is unknown.
Advance Data No. 263

● April 24, 1995 11

adding1 for each time the youth said

“once” and2 for each time the youth

said “2 or more.” Thus, the prevalence

of fndt and vegetableintake isa

conservativeestimatebecause youth

who had more than2 servingsofa food

were countedas having had only2

servings.

Availability of data and ralated

data sources

The NHIS-YRBSis availableon

data tape from the Division of Health

InterviewStatistics.The NHIS-YRBS

public use data tape includes data for all

questionsincludedin the youth risk

behaviorquestionnaireas well as all

other health and demographic‘

informationgath=d during the initial

householdinterview.For some youth

ages 18-21 years, data tkomthe

NHIS-YRBS can be linked to other

specialtopicsthat were part of the 1992

IWIIS,includingAIDS Knowledgeand

Attitudes,CancerControl, Cancer

Epidemiology,and Family Resources.

The NHIS-YRBSis also availableon

CD-ROMfrom the U.S. Government

Printing Officeand tim the National

TechnicalInformationService.Contact

the NationalCimterfor Health Statistics’

Data DisseminationBranch for ordefig

information.

Symbols . . . Data not available . . . Category not applicable

Quant”w zero

*

Figure does not meet standard of

reliability or precision (more than

30-percent relative standard error

in numerator of percent or rate)

●✍ Figure does not meet standard of

reliability and quantity zero
12 Advance Data No. 263 ● April 24, 1995

Suggested citation

Willard JC, Schoenborn CA. Relationship

between cigarette smoking and other

unhealthy behaviors among our Nation’s

youth: United States, 1992. Advance data

from vital and health statistics; no 263.

Hyattsville, Maryland: National Center for

Health Statistics. 1995.

Copyright information

All material appearing in this report is in the

public domain and may be reproduced or

copied without permission; citation as to

source, however, is appreciated.

National Center for Health Statistics

Acting Director

Jack R. Anderson

Acting Deputy Director

Jennifer H. Madans, Ph.D.

U.S. DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics

6525 Belcrest Road

Hyattsville, Maryland 20782

OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

BULK RATE

POSTAGE & FEES PAID

PHSINCHS

PERMIT NO. G-281

To receive this publication regularly, contact

the National Center for Health Statistics by

calling 301-436-8500

DHHS Publication No. (PHS) 95-1250

5-0740 (4/85)
Number 264 ● May 24, 1995

Advance

Data w

From Vital and Health Statistics of the CENTERS FOR DISWSE CONTROL AND PREVENTION/National Center for Health Statistics

1993

Introduction

Summary: National Hospital Discharge Survey

by Edmund J. Graves, Division of Health Care Statistics

During 1993, there were an

estimated 30.8 million d~charges of

inpatients, excluding newborn infants,

from short-stay non-Federal hospitals in

the United States. These discharges

accounted for 184.6 million days of

inpatient hospital care. The dkcharge

rate was 120.2 per 1,000 population and

the average length of stay was 6.0 days.

These and other statistics presented

in this report are based on data collected

by means of the National Hospital

Discharge Survey (NHDS), a continuous

survey that has been conducted by the

National Center for Health Statistics

(NCHS) since 1965. In 1993, data wem

abstracted from the medical records of

approximately 235,000 discharges from

466 short-stay non-Federal hospitals.

Beginning in 1988, a new three-stage

stratilied sample design was put in

operation. A brief description of the new

design, data collection procedures,

estimation process, and definitions of

terms used in thii report are in the

I

section entitled “Technical notes.” A

description of the development and

design of the original NHDS, which was

in operation from 1965–1987, has been

published (l). DitRrences may exist

between data for 1988–93 and earlier

years because of the redesign of the

survey.

Medical data were coded according

to the International Classijicatwn of

Diseases, 9th Revision, Clinical

Modijkatr-on (ICD-9-CM) (2). Up to

seven diagnoses and four procedures

were coded for each discharge. Although

diagnoses included in the ICD-9-CM

section entitled “Supplementary

classification of external causes of injury

and poisoning” (codes EIKWE999)

were used in the NHDS, these diagnoses

are excluded from this report.

Beginning in 1991, all ICD-9-CM

procedure codes were used in the

NHDS. In previous years, selected codes

were excluded. These were primarily

codes for certain miscellaneous

diagnostic and therapeutic procedures.

Starting in 1985, some hospitals

participating in the IWDS have been

submitting machine-readable data tapes.

In 1993, approximately 32 percent of the

hospitals used this method to submit

data. More detailed analyses of NHDS

data iue published in Series 13 of the

NCHS Etal and Health Statistics

reports.

Data highlights

Utilization by patient and hospital

characteristics

The number, rate, and average

length of shy of discharges tlom

short-stay non-Federal hospitals are

shown by age, geographic region, and

sex in tables 1–3. Of the 30.8 million

d~charges from short-stay hospitals

during 1993, an estimated 12.3 million

were for males and 18.6 million were

for females. The discharge rate per

1,000 population for females was 141,

which was 44 percent higher than the

rate of 98 for males. The number and

rate of discharges were higher for

females than for males lmgely because

women 154.4 years of age were

Acknowledgments

This report was prepared in the Divisionof Health Care Statistics.Jean Kozak of the Hospital Care Statistics Branch providedtechnioal

assistanceindevelopingthe styleand contentof thisreport.Elaine Woodofthe HospitalCare StatisticsBranchverifiedthe data. Maria Owings,

also of the HospitalCare StatisticsBranch,and George Wolfe of the TechnicalServices Branch,producedestimated parameters for relative

standarderrorequations.CharlesAdams and Malcolm Graham of the TeohnicalServices Branchdid tie computerprogrammingforthe report.

This reportwas edited by KlaudiaCox and typesetbyAnnette F. Facemire of the PublicationsBranch, Divisionof Data Services.

c-SU&FOR DIsEAsE CONlllOL

AND PREVENTION

SWlcu.o R+

4

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

<4

c

Public Heaith Service

pn m

d Centers for Disease Control and Prevention

‘k.=

National Center for Health Statistics
2 Advance Data No. 264 ● May 24, 1995

Table 1. Number of discharges from short-stay hospitals by selected characteristics:

United States, 1993

[Discharges of inpatients from non-Federal hospitals. Excludes newborn Infants]

Both

Selected characteristic sexes Male Female

Number In thousands

Total. . . . . . . . . . . . . . . . . . . . . . . . 30,825 12,262 18,563

Age

Under 15years, . . . . . . . . . . . . . . . . . 2,141 1,193 846

15-44 years. . . . . . . . . . . . . . . . . . . . . . 11,200 3,179 8,021

45-64 years . . . . . . . . . . . . . . . 6,283 3,143 3,141

65yeare andover . . . . . . . . . . . . . . . . . 11,201 4,748 6,453

Region

Northeast . . . . . . . . . . . . . . . . . . . . . . 6,965 2,931 4,033

Midwest . . . . . . . . . . . . . . . . . . . . . . . 7,097 2,900 4,197

South . . . . . . . . . . . . . . . . . . . . 11,580 4,448 7,132

West . . . . . . . . . . . . . . . . . . . . . . . . . 5,183 1,963 3,200

Table2. Rateof discharges from short-stay hospitals by selected characteristics:

United States, 1993

[Dischargesof inpatients from non-Federal hospifals. Excludes newborn Infants]

Bofh

Selected charecterlstlc sexes Ma/a Female

Number per 1,000 population

Total. . . . . . . . . . . . . . . . . . . . . . . . . . 120.2 98.4 140.8

Age

Under15yeare . . . . . . . . . . . . . . . . 37.7 41.1 34.2

15-44years . . . . . . . . . . . . . . . . . . . . . 95.4 54.5 136.0

45-64years . . . . . . . . . . . . . . . . . . . . . 126.6 131.5 1Z2.5

65yearsandover . . . . . . . . . . . . . . . . . 341.6 357.2 330.9

Region

Northeast . . . . . . . . . . . . . . . . . . . . . . 135.6 116.6 151.6

Midwest. . . . . . . . . . . . . . . . . . . . . . . 116.4 97.9 13%9

South . . . . . . . . . . . . . . . . . . . . . . . . . 130.6 104.0 155.5

West . . . . . . . . . . . . . . . . . . . . . . . . . 93.3 72.0 114.2

Table 3. Average length of stay for discharges from short-stay hospitals by selected

characteristics: Unltad States, l 993

[Dlszharges of inpatients from non-Federal hospitals. Excludes newborn Infants]

Both

Selected characteristic saxes Male Female

Total. . . . . . . . . . . . . . . . . . . . . . . . . .

Age

Under15yeacs . . . . . . . . . . . . . . .

15-44yeaB . . . . . . . . . . . . . . . . .

45-64yeam . . . . . . . . . . . . . . . . . . . . .

65yearsandover . . . . . . . . . . . . . . . . .

Region

Northeast . . . . . . . . . . . . . . . . . . . . . .

Midwest . . . . . . . . . . . . . . . . . . . . . . .

South, . . . . . . . . . . . . . . . . . . . . . . . .

West . . . . . . . . . . . . . . . . . . . . . . . .

6.0

5.2

4.2

6.2

7.8

7.0

6.1

5.7

5.1

Nutierotdays

6.5

5.0

5.8

6.3

7.5

7.4

6.5

6.3

5.8

5.6

5.4

3.5

6.1

8.1

6.7

5.8

5.4

4.6

fkquentlyh ospitalized for deliveries and

pregnancy-related conditions.

lheaverage length ofstaywas 6.5

days for males and 5.6 days for females

during 1993. Theaverage length ofstay

ofthe4.Omillion womenwhowere

hospitalized for deliveries was2.4 days.

The average length of stay waE5.2 days

for chddren under 15 years ofage,4.2

days for the 15-44 years age group, 6.2

days for those 45-64 years of age, and

7.8 days for the group 65 years of age

and over.

Thenumberofdkcharges from

shom-stayhospitals bygeogrryphic

region during 1993 ranged frolm 11.6

millionintheSouth to5.2millionin

the West. Regional differences in the

numberofdischarges wereaocounted

for in partby variations inthe

population sizes. l%e dkchargemtesper

1,000 population ranged from 136in the

Northeastregionto 93inthe’West.

Average lengthsof stay bygeographic

region wem 5.1 days inthe Wes45.7

days inthe South, 6.1 days in the

MidwesC and 7.0 days in the Northeast.

Utilization by diagnosis

Thenumber and rates of discharges

and average length of stay for each

ICD–9-CM diagnostic chapter and

selected categories within chapters are

shown by sex and age in tables 4-6. In

1993, 5.6 million dkcharges had a

principal or fist-listed diagnosis in the

ICD-9-CM diagnostic chapter of

diseases of the circulatory system. Other

leading ICD–9-CM dmgnostic chapters

were supplementary clmsifications

(including females with &liveries) (4.4

million discharges), diseases of the

respiratory system (3.1 million

dkcharges), and diseases of the

digestive system (3.1 million

dkcharges). Approximately

53 percent of the discharges from

non-Federal short-stay hospitals were

included in these four ICD-9-CM

diagnostic chapters.

Within the chapters, the common

diagnostic categories were deliveries,

heart dkease, malignant neoplasms,

pneumom psychoses, and fmctures.

Excluding deliveries, these last five

dmgnostic categories were leadhg
Advance Data No. 264

● May 24,1995

3

first-listeddiagnosesfor both males and catheterization,and dmgnostic

females. ultrasound and for the group 65 years

Common diagnosesfor children of age and over, arteriographyand

under 15 years of age were acute angiocardiography,diagnostic

respiratoryinfections,pneumonb and ultrasound and computerizedaxial

asthma.For the age group 15-44 years tomography.

of age, frequentdiagnoseswere

deliveries,psychoses, and fractures.For

those 45-64 years of age and References

65 years of age and over, heart disease

and malignantneoplasmsweremajor 1.

causesof hospitalization.Average

lengths of stay ranged from 1.3 days for

chronic diseaseof tonsils and adenoids

to 12.0 for psychosis. 2.

Utilization by procedure

One or more surgicalor nonsurgical

prcxxdureswere performedduring an

estimated20.0 million of the 30.8 3.

million hospitalizationsin 1993.A total

of 41.6 million procedures,or an

averageof 2.1 per dkcharge where at 4.

least one procedurewas performecL

were recordedin 1993.

The number and rate of all-listed 5“

proceduresin 1993 for each ICD-9-CM

procedurechapter and selected

categoriesare shown by sex and age in

tables7 and 8. More than three-fourths

of all the surgicaland nonsurgical

proceduresperformedduring 1993were

in5 of the 16 ICD-9-CM procedure

chapters.These chaptemwere

miscellaneousdiagnosticand therapeutic

procedures(13.6 million), obstetrical

procedures(6.8 million), operationson

the digestive system (5.1 million),

operationson the cardiovascularsystem

(4.4 million), and operationson the

musculoskeletalsystem (3.2 milIion).

Withii the chapters,frequent

proceduresfor males were arteriography

and angiocardiography,cardiac

catheterization,dmgnosticultrasoun~

and compukxizedaxial tomography.

Procedurescommonlyperformedon

femaleswere episiotomy,fetal EKG and

fetal monitoring, cesareansection, and

repair of obstetric laceration.

Commonlyperformedprocedures

for childrenunder 15 years of age were

respiratorytherapyand spinal tam for

the age group 15-44 years, episiotomy,

fetal EKG and fetal monitoring, and

cesamansection;for those 45-64 years

of age, arteriographyand

angiocardiography,cardiac

Simmons WR. Development of the

design of the NCHS Hospital Discharge

Survey. National Center for Health

Statistics. Vital Health Stat 2(39). 1970.

Public Health Service and Health Care

Financing Administration. International

Classidcation of Diseases, 9th Revision,

Clinical Modification. Washington Public

Health Service. 3rd ed. 1980.

SMG Marketing Group, Inc. Hospital

Market Database. Chicago: Healthcare

Information Specialists. 1987.

SMG Marketing Group, Inc. Hospital

Market Database. Chicago: HealthCare

Information Specialists. April 1991.

Shah BV. SESUDN Standard errors

program for computing of standardized

rates from sample survey data. Research

Triangle Park, North Carolina Research

Triangle Jnstitute. 1981.
4 Advance Data No. 264 ● May 24, 1995

Table 4. Number of discharges from short-stay hospitals, by first-llstsd diagnosis, sex, and agcx United Ststea, 1993

[Dlech&ges of inpatients from non-Federal hos itats. Excludes newborn infants. Diagnostic groupings and cods nun’here are beeed on the /nternet/onel Cbeeffkatkm of

Dfseasas, 5ih Revision, Clinical Modifkatlons (1’CC-0-CM)]

sex Age

Under 15 1544 4s-64 65 years

Category of first-lkted diagnosis and ICD-3-CM code Total Male Female years years years and over

Allconditione . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Infectiousandpsrssitl cdiseeees. . . . . . . . . . . . . . . .001-139

Sepflcemla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..038

Neoptaame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...140-289

Malignant neoplesms. . . . . . . . . . . . . . . . . . . . ...140-208.230-234

Malignant neoplssm oflargelntestlne and rectum . . . .153-154,197.5

Matignsrd neoplesm oftrachea, bronchus, sndlung . . .162,197.0,197.3

Malignant neoplaemofbreast . . . . . . . . . . . . . . . . . . .174-175.198.81

Benign neoplasrns and neoplasms of uncertain

behavior andunspecifled nature . . . . . . . . . . . . . . . .210-223,235-239

Endocrine, nutritional and metabolic dkeasas,

andimmunltydisordera . . . . . . . . . . . . . . . . . . . . . . . . . . . ...240-279

D!abeteemelllfus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...250

Volumedepletion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .276.5

Diseaaesoflheblood andblood-forming organe . . . . . . . . . . . . ...280-263

Mentatdlsordere . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .290-319

Psychoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...290-299

Alwhoidependencssyndrome . . . . . . . . . . . . . . . . . . . . . . . . ...303

Diseaeesofthenervoussyetemand eenaeorgans . . . . . . . . . . ...320-389

Dlsassesofthecentral nervous system . . . . . . . . . . ...320-236.340-349

Diseeeesoftheearandmastoldprocess. . . . . . . . . . . . . . . . . .360-369

Dtseasesofthedrculatorysyatem. . . . . . . . . . . . . . . . . . . . . ...390459

Hearfdfsease . . . . . . . . . . .391 -392.0,393-398,402,404,41 0418,420-429

Acutemyocardiet infarction . . . . . . . . . . . . . . . . . . . . . . . . . ...410

Coronaryatherosclerosls . . . . . . . . . . . . . . . . . . . . . . . . . . . . .414.0

Otherischemlcheertdiseasa . . . . . . . . . . . . . . . .411413,414.1-414.9

Cardiacdyerhythmkae. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...427

Congestive hesrffailura . . . . . . . . . . . . . . . . . . . . . . . . . . ...428.0

Cerebrovaeculerdlsease . . . . . . . . . . . . . . . . . . . . . . . . . . ..430-486

Diseaeesoftherespiratorysyetem . . . . . . . . . . . . . . . . . . . .460-519

Acuterespiratoryhrfecflons.... . . . . . . . . . . . . . . . . . . . . . ..460-466

Chronicdisease oftonsllsend adenokfs. . . . . . . . . . . . . . . . . . . ...474

Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...430466

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...493

Dieeeeesofthedlgestlve system . . . . . . . . . . . . . . . . . . . . . . . .520-579

Lflcersofthe stomach andsmelllntestlne. . . . . . . . . . . . . . .531-534

Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...540-543

Ingulnet hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...550

Noninfectlousentetftis andcoltils. . . . . . . . . . . . . . . . . . . . . . .555-558

Cholelithisels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...574

Dlseasesofthegenitourlnarysystem. . . . . . . . . . . . . . . . . ...560-629

Calculusofkidneyendureter.. . . . . . . . . . . . . . . . . . . . . . . . ...592

Hyperpfeslaofprostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...600

Compiicationsofpregnency,chiktbirth, endthepuerperium’. . . .630-676

Abotfions andectopic and molarpregnancies . . . . . . . . . . . . ..630-638

Diseasesoftheskin andsubcutaneoustlesue . . . . . . . . . .860-709

Mellulftisendabacasa. . . . . . . . . . . . . . . . . . . . . . . . . . . ...681-682

Dieeases of themusculoskeletsf system andconnecflve tlSSue. . . . . .710-739

Arthropathieeend relateddleordere. . . . . . . . . . . . . . . . . . . .710-719

Intervertebraidlscdlsordere.... . . . . . . . . . . . . . . . . . . . . . . . ..722

Congenttalanomslles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..740-759

Cetiain condfiione originating intheperinatal period. . . . . . . . . . .760–779

.Symptoms, signs, sndiil-definedcondifIons. . . . . . . . . . . . . . . ...760-799

Injuryendpolsonlng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...800-999

Fractures, allsifes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..800=329

Fractureof neckoffemur . . . . . . . . . . . . . . . . . . . . . . . . . . ...820

Intracreniai injuries (exdudingthose whh skull fracture) . . . . . . ...950-654

Lacetationeandopenwounde... . . . . . . . . . . . . . . . . . . . . ..970-9@t

.Supplementary claseKtcatlons. . . . . . . . . . . . . . . . . . . . .vol-V82

Femaleswithdellvertee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..V27

30,825

797

270

1,855

I ,492

157

104

168

373

1,210

484

347

327

1,827

1,054

252

691

276

118

5,633

3,951

745

4s2

842

549

875

641

3,142

400

37

1,164

466

3,079

216

223

83

350

476

1,915

225

185

594

133

451

304

1,561

541

391

150

139

327

2,718

1,017

307

160

171

4,419

4,015

12,282

390

118

759

690

73

114

*

69

480

212

128

149

959

500

183

312

119

59

2,865

2,078

435

322

447

267

334

365

1,528

204

17

598

191

1,358

114

131

76

139

134

663

143

185

. . .

. . .

214

146

697

215

219

82

81

153

1,395

440

72

102

129

166

. . .

18,563

407

152

1,098

792

64

80

167

304

730

252

216

178

688

564

59

369

159

59

2,747

1,873

310

170

395

262

481

456

1,614

196

20

586

278

1,721

102

92

“6

211

242

1,252

62

. . .

594

133

237

155

874

325

172

89

58

174

1,323

577

235

58

42

4,251

4,015

2,141

169

18

39

31

.

.

.

“8

90

15

57

50

75

30

.

95

29

52

25

13

*

.

“

.

.

*

667

222

26

209

159

206

*

47

‘6

87

.

62

.

*

.

*

37

23

37

11

.

105

134

53

236

77

●

30

20

57

11

11,200

231

28

346

180

“7

“7

36

186

256

120

50

100

1,063

564

175

179

98

17

421

242

47

25

45

42

21

38

468

62

9

142

128

878

34

131

17

107

168

746

104

*

592

132

129

34

461

111

206

28

*

134

i ,007

303

*8

72

107

4,110

4,001

‘The first-listed diagnoses for ferneles wth deliveries is coded V27, shown under “Supplenmntary c!assmcatioM”

6,283

120

44

564

459

46

75

62

125

300

147

50

83

375

237

62

154

61

20

1,599

1,167

250

208

2s9

123

169

172

576

41

.

191

94

610

81

23

19

61

146

446

64

44

.

*

105

76

433

114

131

10

.

87

515

144

20

23

25

105

.

11,201

276

180

865

811

103

111

71

74

564

182

168

113

268

222

13

252

90

29

3,587

2,529

446

256

489

380

681

629

1,430

75

642

87

1,165

120

16

40

95

161

662

36

140

. . .

. . .

180

111

611

305

55

“8

.

53

959

434

276

35

20

147

,..
Advance Data No. 264 ● May 24,1995 5

Table 5. Rate of discharges from short-stay hospitals, by first-listed diagnosis, sex, and age: United States, 1993

her s of inpatients from non-Fedarel ho Itele. Exdrrdee newborn infants. Diagnostic grouphrge end coda numbers era basad on the krtemat/ona/ Ck’aaificatfon of

%&~3th Reviakwr, CllrrkalModh7catlona &J4-CM)J

sax AGIS

Under 15 1544 45-64 65 years

Category of first-lkted diagnosis end ICO-9-CM cods Total Male Female years years yeara and over

Atlcondifkxrs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Infeotlous andparaeitic diaeasae . . . . . . . . . . . . . . . . . . . . . . . ..00I-IW

Septicemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...036

Neeplaems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...140-239

Metignent naopfaams . . . . . . . . . . . . . . . . . . . . . . ...140-208.230-234

Metlgnsnt neoplasm of large Intestine and reotum . . . . ...163-154.197.5

Mstignsnt neoplasm of traohea, bronchus, end lung . . ...162.197.0.197.3

Mslignsrrf neoplasm of breast . . . . . . . . . . . . . . . . . . .174-175.198.81

Benign neopiaams end neoplaarns of uncwrtsfn

behavior end unspedflsd nature . . . . . . . . . . . . . . . . .210-221r,235-233

Endoorfne, nutritional end metsbollc dia8esas,

endimmuntly dfeorders . . . . . . . . . . . . . . . . . . . . . . . . . . . ...240-279

Dlabates rnsllttus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...250

Volumadapletion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...276.5

Disasaes of the blood and bkrod-forming organs. . . . . . . . . . . . ...280-289

Mentetdleordsra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...230-319

Psydrosas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...280-299

Aloohol dependence syndrome . . . . . . . . . . . . . . . . . . . . . . . . ...303

Diesaaee of the nervous system and sense organs . . . . . . . . . . ...320-363

Dlseeees of the centrat nervous system . . . . . . . . . . ...320-336.340-343

Disaeeeeof lheeersnd meatokfprooass. . . . . . . . . . . . . . . . ..380-3S9

Dkmeeasoftheckculetoryey item..... . . . . . . . . . . . . . . . . . ..390-K3

Heertdlseeaa . . . . . . . . . . .391 -382.0,3834S8,402,404,41 0-416,42048

Acute rnyocardiaf infercfion . . . . . . . . . . . . . . . . . . . . . . . . . ...410

Coroneryatheroscfameis . . . . . . . . . . . . . . . . . . . . . . . . . . ...414.0

Otheriachemic heart diea@3 . . . . . . . . . . . . . . . .411-413,414.1-414.9

Canliacdyarhythmlee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...427

Congaatlve traertfalhrm . . . . . . . . . . . . . . . . . . . . . . . . . . ...428.0

Cersbrovsecular cWsass. . . . . . . . . . . . . . . . . . . . . . . . . . ..430—436

DWesasofth ere~ir8forysy etem. . . . . . . . . . . . . . . . . . . . ...460-519

Acute reaplretory hrfaoflons. . . . . . . . . . . . . . . . . . . . . . . . . ..460+66

Chronlcdissaas oftonsllssrrd adenokfe. . . . . . . . . . . . . . . . . . . . . .474

Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..4S0-466

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A83

Diawweaofthe dlgaetlvesydem. . . . . . . . . . . . . . . . . . . . . ...620-579

Utceraofthe stomech arrdsrnsl lintesfhre.. . . . . . . . . . . . . . . . .531-5W

Appendldtis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..540+13

Ingulnal hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...550

Nonhrfecflous enterll!s sndcolitle . . . . . . . . . . . . . . . . . . . . .. S55-55S

Clrolellfhleefs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .574

Diseaaasofthegenltorrrhtsrysyetem. . . . . . . . . . . . . . . . . . . ...560-623

Csfcrrlueofktdneysndureter.... . . . . . . . . . . . . . . . . . . . . . . . .582

Wfmrpkraieofprostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...600

Co~il*lonsofpmgnmq, M#&inh, andthepuerpsrttrmt. ., . . ...630-676

Abortionssndeotoplc errdmolerpmgnenctea ., . . . . . . . . . . ...630-639

Dtaeaassofthestdn endsuboutsmaoustiesue . . . . . . . . . . . . . ...680-706

Cellulltlsandabeoass . . . . . . . . . . . . . . . . . . . . . . . . . . . ...661-662

DLsaasasofthemtrsouloakeletal systemendoonnecfive tissue......7lO-733

Arfhropathlesandrelataddiaordara. . . . . . . . . . . . . . . . . . . ...710-719

hrtervertabratdlecdteordera... . . . . . . . . . . . . . . . . . . . . . . . ...722

Congenlfalarromstles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...740-759

Certehr condttlons originating lntheperinatat period. . . . . . . . . . ...760-779

Syn@ome, signs, sndlffdatlrrad conditions . . . . . . . . . . . . . . . . ..780-798

Injury sndpoisonkrg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...800-898

Fredures,elislfes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...800-629

Fradureofneokoffemur . . . . . . . . . . . . . . . . . . . . . . . . . . . ..620

Intmcmnlel injutfas (sxdudingthoeswllh skuilfrscture) . . . . . . . ..650+51

Laoamtlonserrdopsnwounds . . . . . . . . . . . . . . . . . . . . . . ...870-804

Suppkmtentaryclsssifications...... . . . . . . . . . . . . . . . . . . . ..VO1-V82

Fernslaswith dallverlas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V27

1,202.1

31.1

10.5

72.3

57.8

6.1

7.6

6.6

14.5

47.2

18.1

13.5

12.7

71.3

41.1

9.8

26.5

10.8

4.6

219.6

1!%1

29.0

192

32.8

21.4

34.1

32.8

122.5

15.6

1.4

46.2

18.3

120.1

8.4

8.7

3.3

13.7

18.6

74.7

8.8

7.2

23.2

5.2

17.6

11.8

80.9

21.1

15.3

5.9

5.4

12.7

106.0

39.7

12.0

6.2

6.7

172.3

156.8

964.2

31.3

9.5

60.9

55,3

5.9

9.2

.

5.5

38.5

17.0

10.4

11.9

77.0

40.1

15.5

25.0

9.8

4.7

231.6

166.8

34.9

25.8

35.9

21.5

31.6

30.9

122.8

16.4

1.3

46.0

15.3

109.0

9.1

10.5

8.1

11.1

10.8

53.2

11.5

14.8

. . .

. . .

17.2

11.9

55.1

17.3

17.6

6.5

6.5

12.3

112.0

35.3

5.8

8.2

10.4

13.5

. . .

1,407.9

30.9

11.5

83.2

60.1

6.4

6.1

12.7

23.1

55.4

19.1

16.5

13.5

65.9

42.0

4.5

28.0

12.1

4.5

208.4

142.1

23.5

12.9

29.9

21.4

36.5

34.6

122.4

14.9

1.5

44.5

21.1

130.5

7.7

7.0

*0.6

16.0

25.9

95.0

6.2

. . .

45.1

10.1

18.0

11.8

66.3

24.7

13.0

5.2

4.4

13.2

100.4

43.8

17.8

4.4

3.2

322.4

304.5

377.3

28.6

3.2

7.0

5.5

.

.

*

-t .4

15.9

2.6

10.0

8.9

13.2

5.3

*

16.6

5.2

9.1

4.4

2.4

*

*

.

.

.

.

117.6

38.2

4.5

36.9

28,0

36.3

*

8.3

●I.4

15.3

●

10.9

*

*

*

*

6.5

4.1

6.5

1.9

.

18.5

23.6

9.3

41.9

13.5

*

5.3

3.5

10.1

2.0

845.5

19.7

2.4

29.5

15.4

●0.6

“0.6

3.0

14.2

21.8

10.2

4.3

8.5

92.8

46.1

14.9

15.3

8.3

1.5

35.9

20.6

4.0

2.2

3.8

3.5

1.8

3.2

33.3

5.3

0.8

12.1

fo.9

74.9

2.9

11.2

1.4

9.1

14.3

63.6

8.8

●

50.4

11.3

11.0

8.0

41.0

9.5

17.5

2.3

.

11.4

65.8

25.8

-0.7

6.1

9.1

350.3

S41.o

t ,268.1

24.3

8.9

117.8

92.6

9.3

15.1

12.4

25.2

60.6

28.8

10.1

12.8

75.8

47.9

12.5

31.1

12.3

4.0

322.7

235.4

50.5

42.1

60.3

24.9

34.1

34.7

116.3

82

.

38.5

19.0

163.6

12.4

5.8

3.8

12.3

23.5

89.9

16.9

8.9

.

.

21.3

15.3

87.4

22.9

26.3

2.0

.

17.5

103.9

29.1

4.1

4.6

5.1

21.1

*

3,415.7

64.7

64.9

270.0

247.4

31.5

33.9

21.5

22,7

17f.9

55.4

57.7

34.4

87.7

67,8

4.1

76.9

27.6

9.0

1,093.9

771.3

136.0

78.7

152.0

115.8

207.6

192.0

436.2

2%2.7

195.9

26.6

361.2

36.6

4.8

12.2

29.0

49.0

201.8

11.1

42.7

. . .

. . .

54.8

33.7

166.3

63.0

16.7

“2.4

.

16.3

232.3

150.7

64.1

10.7

5,9

44.8

. ..

I/The first-listeddi~noses forfsmake withdeliveriesis mdsd V27, shovrnunder %upplamntary daa$ifiostions.”
6 Advance Data No. 264 ● May 24,1995

Table 6. Average length of stay for discharges from shoti-stay hospitals, by first-listed diagnosis, sex, and agw United States, 1993

!&ass!, gfhi+.wkkm, Cllnti\ModMmt[om$L=M)]

her es of Inpeflents from non-Fedaral ho Itala. Excludes newborn Infants. Diagnostic groupln~ end coda numbacs are based on the /rrternat/ofra/ C/ass/fket/ofr of

Sex Age

Under 15 15-44 45-64 65 yeais

Category of flfat-listed diagnosis and lCIM&CM mde Total Male Female yeara years years and over

Allcondltlons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

infectious and parasitic diseases. . . . . . . . . . . . . . . . . . . . . . .001–139

Septicemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...038

Neoplaeme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...140-238

Malignant neoptaams . . . . . . . . . . . . . . . . . . . . . . ...140-208.230-234

Metlgnant neopiaem ofisrge intestine end rectum . . . . ...153-154.197.5

Malignant neoplaam oftrachea, bronchus, and lung . . . .162,197.0,197.3

Malignant neopleemofbraaef. . . . . . . . . . . . . . . . .174–175,198.81

Benign neoplasme and neoplasma of uncertain

behavlorand unapeclflednature . . . . . . . . . . . . . . . . .210-229,235-’239

Endocrfne, nutritional and metabolic diseases,

andlmmunify dlaorders . . . . . . . . . . . . . . . . . . . . . . . . . . . ...240-279

Diabetes rnallitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...250

Volume depletion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...276.5

Diseaees of the blood and blood-formlng organs. . . . . . . . . . ...260-289

Menfeidlsordare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...290-319

Psychoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..290-289

Alcoholdependencesyndrome.. . . . . . . . . . . . . . . . . . . . . . . . ..303

Diaeaeesoflhe nefvouseystemand aeneeorgsns . . . . . . . . . ..320-389

Dlseaeesofthecenfral nervous system . . . . . . . . . . . .320+38.340-349

Dleeaaasoftheearandmaafoldproceae. . . . . . . . . . . . . . . .380-389

Diseaeesoftheclrculatoryayetem. . . . . . . . . . . . . . . . . . . . . . . .380-452

Heartdiseaae . . . . . . . . . . .391 -392.0,393-338,402,404,410-41 6,420422

Acute myocardlal inferctton . . . . . . . . . . . . . . . . . . . . . . . . . ...410

Coronary atherosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . ...414.0

Other iechemtc heart dleeaaa . . . . . . . . . . . . . . . .411-t13,414.l-114.9

Cardiac dyerhythmlas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...427

Congaaflveheartfallure . . . . . . . . . . . . . . . . . . . . . . . . . . ...428.0

Cerabrovaaculerdlsaasa . . . . . . . . . . . . . . . . . . . . . . . . . . ..430-436

Dlseaaasoftheraephatoryeyatem . . . . . . . . . . . . . . . . . . . . ...460-519

Acute respiraforyinfections . . . . . . . . . . . . . . . . . . . . . . . . . ..480-4W

Chronlcdlsmaaoftonsilssndadenokfa. . . . . . . . . . . . . . . . . . . ...474

neumonia . . . .’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...43-

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..493

Diaeaaesofthe digestlvesystem . . . . . . . . . . . . . . . . . . . . . . . .520–579

Ulceraofthe stomach andsmallinteatlne. . . . . . . . . . . . . .531-534

Appendlcltls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...540-543

Anguinathernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..550

Noninfectious enteritis sndcoiltls. . . . . . . . . . . . . . . . . . .555-558

Cholellthiaeis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...574

Dieeaaesofthegenttourhrrysystem. . . . . . . . . . . . . . . . . . . ...580-829

Ceiculusofktdneymd ureter... . . . . . . . . . . . . . . . . . . . . . . . ..532

Hyperplaeieofprostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...600

Complicationsofpregnancy,chiidbirth, andthepuerperium’. . . . . . . .630-676

Abortions andectopicand molarpmgnancles . . . . . . . . . . . . ...830-638

Dieeaaesoftheskhr andsubcufaneoustlasue . . . . . . . . . . . . . ...880-703

Cellulitiearrdabscaes . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..881-882

Dteaaeeeofthemueouloekeletel syetemand connective tissue. . . ...710-733

Arthropathtesend relsteddlaordere. . . . . . . . . . . . . . . . . . . . . .710-719

Interverfebretdiacdlaordara..... . . . . . . . . . . . . . . . . . . . . . ...722

Congenitaienomeiiee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .740-759

Certahr condttlons originating lntheperlnatai petiod. . . . . . . . . . ...760-779

symptome, signs, endill-deflnedcondiflons . . . . . . . . . . . . . . . ...780-799

Injuryandpoiaonlng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..800--339

Frectfrres, aiisites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..8~29

Fracfureof neckoffemur . . . . . . . . . . . . . . . . . . . . . . . . . . ...820

Intrecrsnlal lnjurlas (excludlngthosewtih skuiifreoture) . . . . . . ...850-854

Lacerafionsandopenwounds . . . . . . . . . . . . . . . . . . . . . . ...670-904

Supptamantaryctassificattons.... . . . . . . . . . . . . . . . . . . . . . . .VOI-V82

Femeteswlth daliverfes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..v27

6.0

7.9

10.6

7.4

8.1

11.0

8.7

3.7

4.5

6.6

7.5

5.9

5.8

10.3

12.0

8.5

5.4

8.5

3.1

6.7

8.3

7.4

6.0

4.5

4.6

7.5

8.4

6.7

4.0

1.3

7.6

4.4

5.7

6.7

4.5

2.7

4.8

4.2

4.5

2.9

3.8

2.6

2.0

7.6

6.6

5.8

6.8

4.0

6.7

11.3

2.6

6.4

7.5

10.3

7.3

3.7

2.9

2.4

6.5

6.4

10.9

8.3

8.5

10.5

8.4

.

5.9

6.4

7.2

5.5

5.7

9.6

11.6

6.2

5.7

9.1

2.5

6.3

6.0

7.0

5.6

4.5

5.0

7.0

6.1

6.5

3.6

1.2

7.6

3.6

5.6

6.5

4.6

2.6

4.6

4.8

4.7

2.8

3.8

. . .

. . .

7.9

6.7

5.1

6.0

3.6

6.1

11.3

2.7

5.8

6.7

10.5

7.1

3.5

8.3

5.6

7.5

10.3

6.7

7.7

11.4

9.0

3.7

4.1

6.7

7.7

6.2

5.9

10.6

12.3

9.3

5.3

8.1

3.7

7.0

6.6

7.8

6.7

4.6

4.7

7.3

8.7

7.0

4.4

1.3

8.0

4.9

5.7

6.8

4.3

“4.8

5.0

4.1

4.4

3.2

. . .

2.6

2.0

7.3

6.4

6.4

7.4

4.5

7.3

11.3

2.8

6.9

8.0

10.2

7.5

4.2

2.7

2.4

Numberofdays

5.2

4.4

7.7

7.2

7.0

.

.

.

“8.0

4.1

4.5

2.7

4.5

14.5

16.1

.

4.2

6.2

3.4

5.2

5.8

.

.

.

.

.

*

3.8

3.2

1.3

4.6

3.4

4,0

.

5.0

“2.5

2.5

.

4.1

.

.

.

.

3.9

3.8

4.7

4.2

*

7.2

11.5

3.1

4.6

4.3

.

2.9

3.3

6.1

2.6

4.2

7.7

11.7

4.8

6.1

“9.3

“6.5

3.2

3.5

5.2

5.0

6.2

5.3

9.3

10.9

6.4

5.1

6.7

2.0

5.3

4.7

5.5

4.1

3.2

2.7

6.2

9.0

4.9

3.6

1.2

6.6

3.5

4.4

4.9

3.6

1.6

4.0

3.3

3.4

2.8

.

2.6

2.0

6.5

5.8

3.7

3,3

3.5

4.6

.

2.4

4.8

5.6

“10.1

7.5

3.0

2.5

2.4

8.2

9.5

12.1

7.3

8.0

9.8

8.6

3.9

4.5

6.1

7.3

5.2

5.8

10.5

12.4

8.5

5.2

8.1

2.9

5.9

5.5

6.6

5.2

4.1

4.4

6.5

8.3

6.9

4.4

*

7.4

5.4

5.4

6.1

5.1

1.9

5.5

3.2

4.0

2.6

3.3

.

.

7.5

6.8

4.8

6.1

3.9

4.8

“

2.3

6.3

6.4

to.4

7.5

4.5

6.0

.

7.8

9.6

10.3

8.4

8.6

11.7

8.9

3.6

6.1

7.8

9.6

7.0

6.8

12.5

13.7

9.2

6.3

11.5

3.5

7.2

6.8

8.0

6.9

4.9

5.2

7.6

8.4

8.6

6.4

9.2

6.7

7.1

7.5

8.7

3.7

7.8

6.1

6.1

4.0

3,9

. . .

. . .

9.2

7.7

8.2

8.5

5.9

“6.0

.

4.1

8.5

9.4

10.3

10.5

6.3

11.9

. . .

'The fir%t-li8teddiagnoses for fem?Jestithdefiverba baled V27, shown under’’Supplmmtatycf a88Frarfiom”
Advance Data No. 264 ● May 24,1995 7

Table7. Number of all-fistedprocedures for discharges from short-stay hospftafa,by procedure category,se% and age: United States, 1993

~%~f iPti..kfm.mn-FeAA hWti*.=d.&snehlnfm!s. PmmdmgmWIn@mdm nu*aeba~ontie/tiem~n~ ~/~ht/onot

FfeWon, C//rr/ca/IWIW/cefforrs ([CD-3-CM)]

sax ALE

Undsr 15 1544 45-64 65 years

Pmedure category arrd CD-3-CM code Total Male Female y&ars years years errd over

All Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Operelkmsonfhenervouss ysfem. . . . . . . . . . . . . . . . . . . . . . . ...01-05

Splneftep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..CB.31

Operaffons on fheendoufne system.. . . . . . . . . . . . . . . . . . . . . ...0647

Oparetiorrs on fheeye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..C8-16

Operations ontheear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...18-MI

operaffons onthen~, mwfh,sndpherynx... . . . . . . . . . . . . . . ...21-23

Torrsflfecfomywlthorwlfhwt adenokfecfomy . . . . . . . . . . . . . ...28.2-28.3

Operefforrson fhere@reforysystam.. . . . . . . . . . . . . . . . . . . . ...30-34

Bronohoscopywfthorwfthouf bbpsy. . . . . . . . . . . . . . . .33.21-33.24.33.27

Operetfonson thecardbvaswiar system . . . . . . . . . . . . . . . . . . . . ..35-s9

Removslofcoronery artery obstruofon. . . . . . . . . . . . . . . . . . . . ...36.0

Coroneryarfery bypess@t l/......,.. . . . . . . . . . . . . . . . . ...36.1

CerKfiecoefheterfzafbn . . . . . . . . . . . . . . . . . . . . . . . . . . . .37.21-37.23

hrserffon,nspfacement,removat, end revfdon

ofpaoemaker feadeordevice . . . . . . . . . . . . . . . . . . . . . . ...37.7-37.8

Shunt orvescular b~ . . . . . . . . . . . . . . . . . . . . . . . . . ...33.0-39.2

f-femodlelysfs. . . . . . . . . . . . . . . . . . . . . ., . . . . . . ..< . . . ...39.95

Opsratfons onthehemio andlyr@mkey sfem. . . . . . . . . . . . . . . . ..4O+

Opemfionson fhedigesfive system . . . . . . . . . . . . . . . . . . . . . . ...&-=

Endoscopyof small lntsstinewlth orwifhoufbbpsy . . . . . . .45.1145.14$.16

En&+d~lnfeSl~wMorwHhd~~. . . . . . . . . . .45.21 -45.26

Parffafexdsbn of fargeinteeffne . . . . . . . . . . . . . . . . . . . . . . . . ...45.7

Appendectomy, exdudirrgirrddentel . . . . . . . . . . . . . . . . . . . . . . ...47.0

Chotecyalesfomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..51.2

Rapefroflngulnelhemfa . . . . . . . . . . . . . . . . . . . . . . . . . ...53.0-53.1

Lysbofpsrffoneela~esbns . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54.5

Operatforrsonfheurfnerysystem...... . . . . . . . . . . . . . . . . . . ...56-59

CySoacopywffhorwfltroutbk$wy..... . . . . . . . . . . . . . . ..57.31-57.s3

Operallonsonfhemsbgerrkrtorgsrrs... . . . . . . . . . . . . . . . . . . . ..W-64

Prosfatecfomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...60.2-60.6

Operaffonsonfheferrrsbgenffeforgarrs. , . . . . . . . . . . . . . . . . . ...65-71

Oophoractomyands@rgo-oophorectomy . . . . . . . . . . . . . . ...65.3-65.6

Bkderatdestrudbrr orocdusbn offsfbpiarr tubas . . . . . . . . . . . ..66.2W56.3

Hysterectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...66.3-68.7.66.9

DfiatbnandcurWa~ofufwus... . . . . . . . . . . . . . . . . . . . . . . . ..W.O

Ra@frcfoystocebandreckwafs. . . . . . . . . . . . . . . . . . . . . . . . ..70.5

Obsfetrbafprccechrres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..72-75

Epfsfofomywifhor wifhoutforcepsor

vacuumextradfon. . . . . . . . . . . . . . . . . . . . .72.1,72.21,72.31,72.71,73.6

AdKfdafn@ureofmwnbrenes.. . . . . . . . . . . . . . . . . . . . . . . . ...73.0

Ceearesnesctbrr . . . . . . . . . . . . . . . . . . . . . . . . . .74.0-74.2.74.4.74.39

FetatEKG (ecf@)andfetelmorrifodng, nototherwbeapecKled . . . .75.32.75.34

Rspelrofcummtobstetrfole.cerdon . . . . . . . . . . . . . . . . . . ...75.5-75.6

OpemfkmsonthemuacoloskebtafeySem . . . . . . . . . . . . . . . . . . . ..76-S4

Parffafexdsbnofbone . . . . . . . . . . . . . . . . . . . . ...76.2-76.3.77.6-77.6

Openredudbnoffracfurewffhintemeffixstbn . . . . . . . . . . . . . . . ...79.3

ExofdonordeetrucffonofinfervertebmtcW . . . . . . . . . . . . . . . . . ...80.5

Totafhfpre@aoernenf.... ...,. . . . . . . . . . . . . . . . . . . . . . . ..81.51

Tofsffmesmpkwernsnt . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...81.54

@etibwontielnteguwti~sy9m. . . . . . . . . . . . . . . . . . . ...65-86

Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85.4

DeMdementofwound,fnfedlon,orbum . . . . . . . . . . . . . . . . .26.22.66.28

Sfdn@f.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...86.6-66.7

Mbcakmewsdlegrrcetfcandtherspeufloprocedures. . . . . . . . . . . . ...87-39

Compuferfzedsxleltomography . . . . . . . . . . . .87.03.87.41 ,67.71,66.01,66.36

Pyetogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87.73-87.75

Ati~~~wdm@ti~q~u~ng~tut~eW. . . . ...68.4-66.5

Dfagrrcdouffraeound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86.7

CkWM~~nkOfing . . .. . . . . . . . .. . . . . . . . . . . . . . . . . .. . .68.6

Redbkrfopsscan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S2.&92.l

Raspkatorytherapy... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..s3.9

41,606

309

334

90

331

83

390

50

986

301

4,410

~8

465

1,010

281

773

328

377

5,Q96

632

517

207

250

502

109

347

326

466

317

2,197

443

364

562

127

159

6,763

1,!s62

744

917

1,142

860

3=

227

423

S33

125

179

1,364

124

334

120

13s99

1,156

197

1,731

1,420

505

412

676

16,142

448

166

25

166

4s

213

24

554

173

2,619

266

353

613

147

99

168

197

2,106

367

211

93

135

146

96

58

653

211

466

3f7

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

1,6+10

123

175

163

51

62

565

*

764

69

6,455

565

106

1,024

572

239

173

427

25,466

460

166

64

203

35

177

26

432

126

1,791

130

1s3

397

141

74

161

161

2$90

465

306

113

115

354

13

269

610

118

. . .

. . .

2,197

443

364

562

127

153

6,763

1562

744

917

1,142

860

1,623

104

247

150

74

117

799

123

150

51

7,143

534

89

706

646

266

239

449

Nu*frrthousende

1,863

166

140

.

19

40

77

31

46

13

131

.

14

.

.

*

22

169

11

.

.

49

.

10

*

35

.

30

. . .

●6

.

.

.

.

19

.

*

.

.

.

151

.

13

.

*

.

74

.

20

11

654

59

*

19

60

23

12

165

16,021

327

66

30

63

22

163

16

167

56

486

30

21

90

*

19

73

63

1,376

143

74

24

146

162

19

171

317

60

Xl

.

1,464

225

363

326

99

41

6,740

1,555

742

915

1,136

857

1,2W

86

142

175

9

.

475

24

106

46

3,036

272

73

163

354

69

68

117

9,178

163

47

35

81

13

64

.

277

68

150

165

205

420

42

56

117

117

1,342

207

133

60

35

Im

27

84

all

63

96

66

492

164

.

172

19

60

.

*

.

.

.

.

796

76

79

115

31

42

364

43

66

28

3,S91

251

59

663

318

12?

103

165

14j546

211

58

22

206

“8

66

.

475

142

2&4

163

260

465

232

94

137

176

2$210

471

307

120

17

166

54

90

570

161

312

250

245

52

63

“9

56

. . .

. . .

. . .

. . .

. . .

. . .

1,a43

50

183

44

63

131

450

57

118

34

6,3f5

576

6f

6?XJ

666

271

222

409

‘Thenumberofdischargeawithacorontiryartery bypassgraftwas3fW,C00.
8 Advance Data No. 264 ● May 24,1995

Table 8. Rate of all-listed procedures for discharges from short-stay hospitals, by procedure category, sex, and age: United States, 1993

E%aa!, Wrf7evlekm, C/lnlm/Mod#/@t/ons (kDWM)]

her es of inpatients from non-Federsl hos We. Excludes newborn infants. Procedure groupings and coda numbets are baaed on the Interrratlonal C/assif/cat/on of

Sex Age

Under 15 15-44 45-64 65 years

Procedure category and K-XI-9-CM code Total Male Female years years vears and over

Allprocedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Operatlonsonthe nervoussysfem . . . . . . . . . . . . . . . . . . . . . . . ..o1-05

Spinattap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...03.31

Operafionsontheendoctfne syefem . . . . . . . . . . . . . . . . . . . . . . . .06-07

Operefionsontheeye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..06-16

Operationsontheear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..16-20

Operations onthenosa, mouth,and pharynx . . . . . . . . . . . . . . . ...21-29

Tonefllecfomywith orwithout adenoldecfomy. . . . . . . . . . . . ...28.2-28.3

Operationsonthe respiratory system . . . . . . . . . . . . . . . ..30-34

Bronchoscopywllh orwlthoutbiopsy. . . . . . . . . . . . . . .33.21-33.24.33.27

Operstionsonthecardlovaecularayafem . . . . . . . . . . . . . . . . . . . ..3~~

RernovalofcoronaryarfeIyobslructon . . . . . . . . . . . . . . . . . . . ...36.0

Coronaryarterybypaaegraffl/..... . . . . . . . . . . . . . . . . . . . ...36.1

Cerdiaccatheterlzdlon . . . . . . . . . . . . . . . . . . . . . . . . . . .37.21-37.23

InsertIon, replacement, removal, and revision

ofpacemakertaadsordevice.. . . . . . . . . . . . . . . . . . . . . . .37.7-37.8

Shuntorvaecuhvbypaee. . . . . . . . . . . . . . . . . . . . . . . . . ..39.~9.2

Hernodiaiyele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...39.95

Opsratkmsonthe hemicend lymphatlcsystem . . . . . . . . . . . . . ...40-41

Operstkmsonthedlgeetiveeyafem . . . . . . . . . . . . . . . . . . . . . . . .42-U

Endoscopy ofarnall intestine wlthorwllhout biopsy. . .45.11 -45.14,45.16

Endoscmpy oflarge intestine wlfhorwlthout biopsy . . . . . . . . .45.21 -45.25

Parflet exdelon oflarga intestine . . . . . . . . . . . . . . . . . . . . . . . ...45.7

Appendectomy, exdudingincldental . . . . . . . . . . . . . . . . . . . . . ...47.0

Cholecyetecfomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51.2

Repalrofinguinal herni a...... . . . . . . . . . . . . . . . . . . . ..53.~53.l

Lysisofperitonealadheslons.... . . . . . . . . . . . . . . . . . . . . . . ..54.5

Operafionsontheurlnarysyatem. . . . . . . . . . . . . . . . . . . . . . . . ..55-59

Cyatoecopywlth orwithoufblopsy. . . . . . . . . . . . . . . . . . . .57.31-57.33

Operatkmsonthe rnalegenlfalorgans. . . . . . . . . . . . . . . . . . . . . ..6~64

prostatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..60.2+o.6

Operafionsonthefemale genifalorgans . . . . . . . . . . . ..65-71

Oophorectomy endaalpingo-oophorecfomy. . . . . . . . . .65.=5.6

Bilateral deetrudlon orocclusbnof falloplantubes . . . . . . ...66.2-66.3

Hysterectomy. . . . . . . . . . . . . . . . . . . . .. -. - . . . . ..68-~8.7.68.9

Dilationandcureftageofuterus... . . . . . . . . . . . . . . . . . . . . . . ..69.0

Repalrofcystocelaandrecfoceb . . . . . . . . . . . . . . . . . . . . . . . ..70.5

Obsletrtcalprocedurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..72–75

Eplelotomywifhor withoutforcapeor

vacuumexfrsctton . . . . . . . . . . . . . . .72.1,72.21,72.31,72.71,73.6

Artlffciaf ruptureofmembranes. . . . . . . . . . . . . . . . . . . . . . . . . ..73.o

Ceesrean.wdlon . . . . . . . . . . . . . . . . . . . .74.0-74.2,74.4,74.99

Fetaf EKG (sca~)endfetaJ monltorlng, nototherwlse epecffled . .75.32,75.34

Fmpalrofcurmntobetetrklacemtlon . . . . . . . . . . . . . . . . ...75.5-75.6

Operefionsonthe musculoskeletsl system. . . . . . . . . . . . . . . . .76-34

Parflal excieion ofbone . . . . . . . . . . . . . . . . . . .76.2-76.3,77.6-77.8

Open reducflon offracturewlfh interneJWdbn.. . . . . . . . . . . . . ...79.3

Exc!slon ordestmcfion oflntewerfebrd disc . . . . . . . . . . . . . . . . ...80.5

Totathipraplacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...81.51

Totalkneereplacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..81.54

Operaflonson theintegumentary system . . . . . . . . . . . . . . . . ..85-86

Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85.4

Dsbridamantofwound, infedion, orbum . . . . . . . . . . . . . . .86.22.86.28

.Wfngraft . . . . . . . . . . . . . . . . . . . . . .. - . . . . . . . . . . . ..86.~67

Miecallaneousdiagnostlcandtherepeutic procedures . . . . . . . . . ...87-99

Corrqmterizedexls!tomography . . . . . .87.03,87.41,87.71,66.01,66.=

Pyelogmm . . . . . . . . . . . . . . . . . . . . . . . . . . . .. - . . . ..87.7~7.7~

Arteriography andangiocardlography udngcontrasfm aterld. . . . .88.4-68.5

Diagnostlcultraaound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86.7

Circulatoymonltoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .896

Radlolaobpescan. . . . . . . . . . . . . . . . . . . . . . . . . . . . ...92.0-92.1

Res@afoiytherepy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...93.9

16,225.6

354.5

130.1

35.0

152.4

32.5

152.2

19.6

384.4

117.3

1,719.8

155.3

189.3

393.8

109.6

67.5

128.1

147.1

1,987.4

324.5

201.7

80.6

97.5

195.6

42.6

135.5

492.4

128.2

182.6

123.7

856.6

172.6

149.6

219.0

49.6

62.1

2,637.3

606.9

290.3

357.7

445.5

X35.3

1,256.9

88.6

164.8

130.0

48.8

69.7

531.7

48.3

130.2

46.7

5,302.9

451.8

76.8

674.9

553.9

196.9

160.6

341.7

12,955.9

360.7

134.6

20.2

151.1

38.4

171.3

19.1

444.7

138.6

2,102.0

215.2

283.2

491.6

112.8

79.4

134.5

157.7

1,690.7

234.3

169.6

74.8

106.5

118.6

77.3

46.7

524.0

169.2

375.8

254.6

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

1,264.5

98.8

140.8

147.2

41.1

49.8

453.5

.

147.9

55.4

5,181.3

453.3

86.4

822.2

459.3

192.0

139.1

342.6

f9,315.6

348.6

125.8

48.9

153.7

26.8

134.1

20.0

327.4

97.2

1,358.7

98.7

100.5

301.3

106.6

56.2

122.1

137.0

2,267.7

353.0

232.0

86.0

87.1

268.4

9.9

219.3

462.5

69.4

. . .

. . .

1,666.0

335.6

2el .0

426.0

96.4

120.8

5,129.6

1,164.4

564.6

695.8

866.4

652.2

1,230.9

78.9

187.4

113.7

56.1

6s.5

605.7

93.1

113.5

38.4

5,417.9

450.3

67.8

535.7

643.2

201.5

181.0

340.8

3,283.4

330.9

247.0

.

34.1

89.9

135.7

54.3

80.7

23.7

230.0

.

24.9

*

.

.

38.4

298.6

18.9

*

.

87.2

.

18.0

.

61.1

.

53.3

. . .

“10.0

.

“

.

●

33.9

.

.

.

*

.

265.6

.

23.0

.

.

.

129.8

.

35.1

18.9

1,505.4

104.4

.

33.2

105.9

40.3

21.3

326.2

13,653.6

278.5

75.3

25.2

70.4

19.1

136.7

13.6

159.7

49.5

414.2

25.6

17.9

76.7

.

16.4

62.3

53.5

1,172.3

121.8

62.7

20.8

126.4

155.4

16.0

145.3

270.4

51.3

25.4

.

1,238.9

191.7

326.4

278.2

84.6

35.1

5,743.7

1,325.6

631.9

780.0

970.4

730.0

1,049.2

82.1

120.8

148.8

7.8

*

405.2

20.2

91.9

39.6

2,589.2

231.9

62.1

156.0

302.0

75.6

59.0

99.4

18,521.8

369.4

93.8

70.9

163.2

25.9

170.3

.

559.3

176.8

3,148.5

372.9

413.2

648.2

85.0

116.0

235.9

235.6

2,707.5

418.1

268.0

120.6

71.2

302.2

53.7

169.7

668.1

166.8

193.4

133.5

993.0

331.3

*

347.1

38.7

121.5

*

.

*

*

.

.

1,610.2

152.8

159.7

231.5

‘63.4

85.5

735.2

86.8

176.8

57.2

6,843.1

505.9

118.4

1,410.4

641.7

246.7

219.8

333.1

44,360.0

644.6

178.4

65.8

634.5

“25.8

201.6

.

1,449.9

432.2

6,811.7

556.4

791.8

1,479.8

708.2

285.5

419.1

536.2

6,738.7

1,437.1

936.0

367.3

52.0

512.8

163.7

273.6

1,737.3

552.8

952.2

761.3

747.6

159.7

. . .

191.5

“26.1

176.5

. . .

. . .

. . .

. . .

. . .

. . .

3,182.2

153.1

575.0

133.7

252.5

400.0

1,372.7

173.1

361.3

104.0

19,259.2

1,757.9

187.2

2,531.1

2,097.6

626.7

676.1

1,246.2

%te rate per IOO,COO popubtion of dmcharges wfih a mmnary aflery bypass grafl was 120.8.
Advance Data No, 264 ● May 24,1995 9

Technical notes

Survey methodology

Souroe of data

TheNational Hospital Discharge

Survey covers discharges from

noninstitutional hospitals, exclusive of

Federal, military, and Department of

Veterans Affairs hospitals, located in the

50 States and the DMrict of Columbia

Only short-stay hospitals (hospitals with

an average length of stay for all patients

of fewer than 30 days) or those whose

specialty is general (medical or surgical)

or chikhn’s general are included in the

survey. These hospitals must also have

six beds or more statTed for patient use.

From 1988 through 1990, the

NHDS sampling frame consisted of

hospitals that were listed in the April

1987 SMG Hospital Market Database

(3), met the above critefi~ and began

accepting patients by August 1987. In

1991 the sampling fmme was updated to

include hospitals from the 1991 SMG

Hospital Database (4). For 1993, the

sample consisted of 528 hospitals. Of

the 528 hospitals, 15 were found m be

out of scope (ineligible) because they

went out of business or otherwise failed

to meet the criteria for the NHDS

universe. Of the 513 in-scope (eligible)

hospitals, 466 responded to the survey.

Sample design and data collection

TheNCHShas conducted the

NHDS continuously since 1965. The

original sample was selected in 1964

from a frame of short-stay hospitals

listed in the National Master Facilby

Inventory. That sample was updated

periodically with samples of newly

opened hospitals. Sample hospitals were

selected with probabilities ranging horn

certainty for the largest hospitals to 1 in

40 for the smrdlest hospitals. WMin

each sample hospital, a systematic

random sample of discharges was

selected. A report on the design and

development of the original NHDS has

been published (l).

Beginning in 1988, the NHDS

sample includes with certainty all

hospitals with 1,000 beds or more or

40,000 discharges or more annnalIy. The

remaining sample of hospitals is based

on a stratified three-stage design. The

first stage consists of a selection of 112

primary sampling units (PSU’S) that

comprise a probability subsample of

PSU’S to be used in the 1985-94

National Health Interview Survey. The

second stage consists of a selection of

noncertainty hospitals from the sample

PSU’S. At the third stage, a sample of

discharges was selected by a systematic

random sampling tectilque.

Two data collection procedures

were ‘used for the survey. The first was a

manual system of sample selection and

data abstraction. The second was an

automated method used for

approximately 32 percent of the

respondent hospitals in 1993, that

involved the purchase of data tapes from

abstracting service organizations, State

data systems, or hospitals.

In the manual system, the sample

selection and the transcription of

information ffom the hospitrd records to

abstract forms were performed at the

hospitals. The completed forms, along

with sample selection control sheets,

were forwarded to NCHS for coding,

e&ting, and weighting. Of the hospitals

using the manual system in 1993, tibout

55 percent had the work performed by

their own medhl records staff. In the

remaining hospitals using the manual

system, personnel of the U.S. Bureau of

the Census did the work on behalf of

NCHS.

For the automated system, NCHS

purchased tapes containing machinereadable medka.1 record data that were

systematically sampled by NCHS.

The medical abstract form and the

automated data tapes contain items

relating to the personal characteristics of

the patien~ including birth date, sex,

race, and marital status, but not name

and address; administrative information,

including admission and discharge dates,

discharge status, and medical record

numbm and medical information,

including diagnoses and surgical and

nonsurgical operations or procedures.

Since 1977; patient ZIP Code, expected

source of paymen~ and dates of surgery

have also been collected. (The medical

record number and patient ZIP Code are

confidential information and are not

available to the public.)

Presentation of estimates

The relative standard error of the

estimate and the number of sample

records on which the estimate is based

(referred to as the sample size) are used

to identify estimates with relatively low

reliabfity.

Because of the complex sample

design of the NHDS, estimates of less

than 5,000 are not presented; only an

asterisk (*) appears in the tables. These

estimates generally have a relative

standard error of more than 30 percent

or are based on a sample of fewer than

30 cases. Estimates of 5,000 to 9,000

are preceded by an asterisk (*) to

indicate that they should not be assumed

to be reliable. These estimates rue

generally based on fewer tlan 60 cases.

Sampling errors and rounding

of numbers

The standarderroris primarilya

measure of sampling variability that

occurs by chance because only a sample

rather than the entire universe is

surveyed. The relative standard error of

the estimate is obtained by dividing the

standard error by the estimate itself and

is expressed as a percent of the estimate.

The resulting value is multiplied by 100,

so the relative standard error is

expressed as a percent of the estimate.

Estimates of sampling varialMity

were calculated with SESUDAAN

software, which wmputes standard

errors by using a first-order Taylor

approximation of the deviation of

estimates from their expected values. A

description of the software and the

approach it uses has been published (5).

The constants for relative standard

error curves for the 1993 National

Hospital Discharge Survey m presented

in table I. The relative standard error

RSE(X) of an estimate X maybe

estimated horn the formukc

RSE(X) = 100 -X

where X, @ and bare as detied in

table I.
10 Advance Data No. 264 ● May 24, 1995

Table L Estimated parameters for relative standard error equations for National Hospital

Discharge Survey statistics by selected characteristfca: United States, 1993

Number of

discharges or Number of

first-listed diagnoses procedures

Charaderietlc a b a b

Total. . . . . . . . . . . . . . . . . . . . . . . . . . 0.00129 1,082.615 0.00178 483.926

Sex

Male . . . . . . . . . . . . . . . . . . . . . . . . . 0.00425 332.S43 0.00661 273.720

Fernate . . . . . . . . . . . . . . . . . . . . . . . . 0.00304 417.946 0.003s6 636.779

Age

Undar15years . . . . . . . . . . . . . . . . .. . . 0.06552 110.056 0.03770 110.109

15-44 year9 . . . . . . . . . . . . . . . . . . . . . 0.00818 245.201 0.00s63 304.399

45-64years . . . . . . . . . . . . . . . . . . . . . 0.00826 182.876 0.00509 127.555

65yeareandover . . . . . . . . . . . . . . . . . 0.00410 314.867 0.00176 551.656

Region

Northeast . . . . . . . . . . . . . . . . . . . . . . 0.00282 307.085 0.00561 321.543

Midwest . . . . . . . . . . . . . . . . . . . . . . . 0.00686 660.696 0.00648 212.188

South . . . . . . . . . . . . . . . . . . . . . . . . . 0.002s9 543.012 0.00373 418.823

west . . . . . . . . . . . . . . . . . . . . . . . . . -0.00193 1,689.447 0.0065S 1,0s7.077

E&imateshavebeen rounded tothe

nearest thousandth. Forthis reason,

figureswithintables donotalwaysadd

tothetotals.Rates andaveragelengths

ofstay werecalculated from original,

unrounded figures andwillnot

necessarily agree precisely with rates or

average lengths of stay crtlculated from

rounded data.

Testsof significance

In this repro% statistical inferenee is

based on the two-tailed t-test with a

critical value of 1.96 (0.05 level of

significance). Terms such as “higher”

and “less” indicate that dflerences are

statistically significant.. Terms such as

“simiiar” or “no difference” mean that

no statistically significant difference

exists between the estimates being

compared. A lack of comment on the

difference between any two estimates

does not mean that the difference was

tested and found not to be significant.

Terms relating to

hospitalization

Hospitals-AU hospitals with an

average length of stay for all patients of

fewer than 30 days or hospitals whose

specialty is general (medical or surgical)

or children’s general are eligible for

inclusion in the National Hospital

Discharge Survey, except Federal

hospitals, hospitril units of institutions,

and hospitals with fewer than six beds

st.aEed for patients’ use.

Patient—A person who is formally

admitted to the inpatient service of a

short-stay hospital for observation, care,

dmgnosis, or treatment. The terms

“patient” and “inpatient” are used

synonymously.

Newborn infant—A patient admitted

by birth to a hospital.

Discharge—The formal release of a

patient by a hospital that is, the

termination of a period of

hospitrrliiation by death or by

deposition to place of residence, nursing

home, or another hospital. The terms

“discharges” and “patients discharged”

are used synonymously.

Discharge rate—he ratio of the

number of hospital discharges during a

year to the number of persons in the

civilian population on July 1 of that

year.

Days of care—The number of

patient days accumulated by a patient at

time of discharge. A stay of less than 1

day (patient admission and dkchrtrge on

the same day) is counted as 1 day in the

summation of total days of care. For

patients atiltted and discharged on

different days, the number of days of

care is computed by counting all days

from (and including) the date of

rtdmission to (but not including) the date

of discharge.

Average length of stay-The number

of days of care accumulated by patients

discharged during the year divided by

the number of these patients.

Terms relating to diagnoses

Diizgnosis-A disease or injury (or

factor that influences health status and

contact with health services that is not

it8elf a current illness or injury) on the

medical reeord of a patienL

Principal diagnosis—The condition

established after study to be chiefly

responsible for occasioning the

admiision of the patient to the hospital

for care.

First-listed diagnosis-The coded

diagnosis identified as the principal

diagnosis or listed tlrst on the face sheet

or discharge summary of the lmedical

record if the principal diagnosis cannot

be identified. The number of first-listed

dwoses is equivalent to the number of

discharges.

Terms relating to procedures

Procedure—A surgical or

nonsurgical operation, diagnostic

precedure, or special treatment reported

on the medical reeord of a patient.

Beginning with the 1991 data, all

ICD-9-CM procedure codes are used in

the NHDS. Previously selected codes,

primarily codes for miscellaneous

diagnostic and therapeutic procedures,

were not used.

All-1istedprocedures—The number

of procedures on the face sheet of the

medical reeord. In the NHDS a

maximum of four procedures are coded.

Rate of procedures—The ratio of

the number of procedures during a year

to the number of persons in the civilii

population on July 1 of that year

determines the rate of procedures.

Demographic terms

Population—The U.S. resident

population excluding members of the

Armed Forces.

Age—Patient’s age at birthday prior

to admiision to the hospital.
Advance Data No. 264 ● May 24,1995 11

Geographicregion-Hospitals arc

classifiedby location in one of the four

geographicregions of the United States

that correspondto those used by the

U.S. Bureau of the Census.

Regwn Statesincluded

Northeast. . . . Maine,New Hampshire

Vermont4Massachusetts,

Rhode Island

Connecticut New York

New Jersey, and

Pennsylvania

Midwest.. . . . Michigq Ohio, Illinois,

India Wisconsin,

Minneso@Iowa

Missouri,North Dako@

South Dako@ Nebraslq

and Kansas

south . . . . . . . Delawm Marylau&

District of Columbia

Virginia WestViigin@

North Caro~& south

Carolin% Georg@

I?lori@ Kentucky,

Tennmq AlabQ

Mississippi,Arkansas,

Louisian&Oklahomajand

Texas

west........Mona Idaho,

Wyoming,Colorado,New

Mexico,Arizom Utah,

Nev~ Washington,

Oregon,Califomi&

HSWtil, and Alaska

Symbols

---

. . .

0.0

z

●

#

Data not available

Category not applicable

Quant”Ryzero

Quantity more than zero but less

than 0.05

Quantity more than zero but less

than 500 where numbers are

rounded to thousands

Figure does not meet standard of

reliability or precision (more than

30-percent relative standard error

in numerator of percent or rate)

Figure suppreaeed to comply with

confidentiality requirements
12 Advance Data No. 264 ● May 24, 1995

Suggested citation Copyright Information National Center for Healthl Statistics

Graves EJ. 1993 Summary : National Hospital All material appearing in this report is in the Acting Director

Discharge Survey. Advance data from vital public domain and may be reproduced or Jack R. Anderson

and health statistics; no 264. Hyattsville,

Maryland: National Center for Health

copied without permission; citation as to

source, however, is appreciated. Acting Deputy Director

statistics. 1995. Jennifer H. Madans, Ph.D.

U.S. DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics m

6525 Belcrest Road

Hyattsville, Maryland 20782

OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

To receive this publkxdion regularly, cmtact

the National Center for Health Statistics by

calling 301-436-8500

DHHS Publication No. (PHS) 95-1250

5-1237 (5/95)
Number 265 ● July 6, 1995

I

Advance

Data

From Vital and Health Statistics of the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Centerfor HealthStatistics

Underreporting of Race in the

National Hospital Discharge Survey

by Lola Jean Kozak, Ph.D., Division of Health Care Statistics

Introduction

Race data horn the National

Hospital Discharge Survey (NHDS) has

become increasingly incomplete in

recent years. This report examines

factors related to the underreporting of

race and explores the effects of the

un&rreporting on NHDS estimates of

hospital use by race. A major concern is

whether discharges for each racial group

are equally likely to be underestimated.

If underreporting of race is a general

phenomenon, then the NHDS estimates

of hospital use for each racial group are

too low. However, if dficharges for

some mcial groups are more likely to be

underestimated than others in the

NHDS, using the data to make

comparisons across racial groups could

be misleading.

The NHDS has been conducted

continuously by the National Center for

Health Statistics (NCHS) since 1965.

The dam for the survey come Ilom a

sample of inpatient records that are

non-Federsl general and short-stay

specialty hospitals located in the United

States. In 1990, data were abstracted

horn mcdica.1records of 266,000

discharges from 474 hospitals. In 1991,

484 hospitals provi&d data from

274,000 medical records, and 494

hospitals provided data from 274,000

medical records in 1992.

Beginning in 1988, a 3-stage

stratified sample design was put into

operation for the NHDS. For the tit

stage! primary sampling units (Psu’s)

were sample@ in the secon~ hospitals

were sampled from the PSU’S, and the

third stage consisted of sampling

discharges within the selected hospitrds.

In addition, hospitals with 1,000 beds or

more or 40,000 discharges or more per

year were selected with certainfy.

Since 1985, two data collection

procedures have been used for the

NHDS. One is a manual system in

which data are abstracted from the face

sheet or d~charge summary of the

discharge at the hospital, either by

hospital SW or personnel of the U.S.

Bureau of the Census, on behalf of

NCHS. The other, an automated metho~

involves the purchase of data tapes from

abstracting service organizations, State

data systems or hospitals.

Further information about the

survey design, data collection

procedure, sampling errors, and

definition of terms used in this report

can be found in the section entitled

“Technical notes.”

D- from the NHDS have been

used to examine racial d&erences in

patterns of hospital use that may reflect

differences in access to care or in the

distribution of health problems. Recent

studies that have used race data from

the NHDS have investigated a variety of

topics, including hysterectomy (l), HIV

(2), stroke (3), children’s asthma (4),

preechnpsia and eclampsia (5),

appendicitis and appendectomy (6),

coronary arteriography and conmary

bypass surgery (7), hip flWtURX (8), and

obtained from a national sample of medical record for each sampled idiopathic cardiomyopathy (9).

Acknowledgments

This reportwas preparedin the Divisionof Health Care Statistics.Linda Lawrenceand Chuck Dennisonof the HospitalCare StatisticsBranch

providedoperationaldata and assistad with the descriptionof the survey. Michael J. Monsour,formerly of the TeohnioalServices Branch,

producedthe parametersfor relativestandarderrorequations.The reportwas edited by KlaudiaM. Cox and lypeset byAnnetts F. Facemireof

the PublicationsBranch,Divisionof Data Services.

SUWCJ$.O

## %

4

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

!(

Public Health Service

Centers for Disease Control and Prevention

k=

National Center for Health Statistics CENTERS cmFOR DISEASE CONTROL

AND PREVENTKJN
2 Advance Data No. 265 ● July 6, 1995

0 “

1 1 1 1 1 I 1 I 1

1982 1983 1984 1985 1986 1987 1988 1989 1980 1991 1992

Year

Figure 1. Percent of discharges with race not stated: United States, 1982-92

The NHDS race data have never

been 100 percent complete. From 1982

through 1989, discharges with race not

stated ranged from 8.9 to 11.5 percent of

total discharges. Then, in 1990, the

proportion of discharges with race not

stated incma.sed to 15.7 percent. In

1991, 17.8 percent of discharges were

not identified by race, and in 1992,

19.8 pereent of discharges were in the

racenot-stated category (figure 1).

TWOmain factors were found to be

related to the increasing underreporting

of race in the NHDS. FirsL a growing

number of the hospitals that participated

in the NHDS in 199G92 did not report

race for any of their patients. In 1989,

17 hospitals did not report race, but in

1992 the number had increased to 63.

Nonreporting hospitals made up only

12.8 percent of the hospitals

participating in the survey in 1992, but

accounted for 70.7 percent of the

discharges with race not stated. SeCon&

race was not reported for the majority of

patients that were identified as Hispanic.

In 1992, 16.0 percent of the discharges

with race not stated were identified as

Hispanic.

These two main problems will be

discussed further in the following

sections of this report. Approaches to

estimating the racial distribution of

patients not reported by race will also

be examined. To further evaluate the

effects of the underreporting of race, the

NHDS race data will be compared with

data from other sources, including

hospital use data from National Health

Intmview Survey, Medicare data from

the Health Care Fwcing

Administration, and natahty data from

the Division of Vital Statistics. Finally,

adjustment of NHDS race data for

underreporting will be discussed.

Highlights

The number of hospitals in the

NHDS that reported race for less than

3 percent of discharges increased

from 17 in 1989 to 63 in 1992.

Most of the hospitals that did not

report race in the 1990-92 period

used the automated data collection

method.

Based on data from previous years

and county populations, hospitals that

did not report race in 1990-92 were

likely to have a higher proportion of

white discharges than hospitals that

reported race.

A specific race was reported for only

25–35 percent of Hispanic patients in

the 1990-92 perio@ most Hispanic

patients were probably white.

In comparison with the number of

discharges estimated from the

1990-92 National Health Interview

Survey, NHDS estimates of

discharges were signhicantly lower

for white patients, but not

significantly different for black

patients.

Proportional adjustment of NHDS

race data may produce more accurate

estimates of white discharges, but it

does not improve comparisons

between racial groups.

Hospital reporting patterns

The majority of hospitals that

participate in the National Hospital

Discharge Survey (NHDS) report race

for all or ahnost all discharges. In 1992,

for example, 296 hospitals (59.9 percent)

reported race on 97–100 percent of their

sample records (table 1). The discharges

not identified by race come primarily

from a small group of hospitals that do

not report race for any or almost any of

their discharges. In 1992, 63 hospitals

(12.8 percent) reported race cmless than

3 percent of sampled records. These 63

hospitals accounted for 83.4 percent of

the sampled records with race not stated

in the 1992 NHDS, and 70.7 percent of

the estimated number of dischmges with

race not stated.

Nonreporting hospitals, which are

defined in this report as those providing

race data for less than 3 percent of

discharges, have increased in number in

recent years (figure 2). In 1989 there

were only 17 nonreporting hospitals, but

the number jumped to 45 in 1990,

increased to 50 in 1991, and to 63 in

1992. Nonreporting hospitals accounted

for 50 percent of the sampled records

with race not stated in 1989, but for

81-84 percent in 1990-92.

Most of the hospitals that did not

report race in the 1990-92 period used

the automated data collection method.

As described earlier, the automated

method refers to the purchase of

medical record data in electronic form

fkom abstracting service organizations,

State data systems, or hospitals. In

contrast data collected via the manual

method were transcribed fmm the

medical reeord to abstract forms

specifically for the NHDS.

As shown in figure 2, only 5

hospitals that did not report race used

the automated data collection method in

1989, but in 1990, 31 nonreporting

hospitals used the automated method. In

1991, 35 nonreporting hospitals used the

automated data collection method, as did

48 nonreporting hospitals in 1992. The

number of nonreporting hospitals using

the manual method only increased from

12 in 1989 to 15 in 1992.

A concerted effort was made to

improve the NHDS response rate in the

1990’s, which resulted in a substantial
Advance Data No. 265 ● July 6,1995 3

Table 1. Number and percent distribution of hospitals by proportion of sample records

with race reported: United States, 1992

~:~~fi~{$On-Federal hOw~~sthat~~~batd fntheNatbnalHospRd Diecharge~un/eY. Exciudesrww

Hospitals

Proportion of records

with race reporfed Number Percenf

Allremrds . . . . . . . . . . . . . . . . . 494 100.0

0.C-2.9parcant . . . . . . . . . . . . . . 63 12.8

3.0-49.9 percent . . . . . . . . . . . . . 15 3.0

50.0-74.9 persant . . . . . . . . . . . . 21 4.3

75.0-S8.9percent . . . . . . . . . . . . 41 8.3

90.0-96.9 parcent . . . . . . . . . . . . 58 11.7

97.0-100.0 percent , . . . . . . . . . . 296 59.9

10

rl

@ Automated - Manual

1989 1990 1991 1992

Year of survey

Figure 2. Number of hospkais not raportfng race that used the automated and manual

methods of data ooikretfom 1989-92

Tabie 2. Percent dhtrfbutton of discharges by raea, for 26 nonraportfng hospitals based

on previous data and for reporting hospitals: United States, 1882

[Discharges of inpatients fmm non-Fedaral short-stay ho?pitals. Excludes newborn infants]

26 nonreporfkrg

Rata IrospnaIs* E&2$

Percent distrbufion

Aflraces . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0

White . . . . . . . . . . . . . . . . . . . . . . . . . 87.3 75.2

Black . . . . . . . . . . . . . . . . . . . . . . . . . 8.3 13.9

Another races . . . . . . . . . . . . . . . . . . . 2.1 4.2

Racanotsfated . . . . . . . . . . . . . . . . . . . 2.3 6.7

lNOnmP~ng ho$p~akr~oned ram for ISSS than 3 percant of dscharges. Radal ddributionWes~~ onthe * r~nt

de$a mporfed W esch hospital.

%ospifals thsf &ported mce for 2-100 pemant of disohargsa.

increase in the number of hospitals

participating in the survey, horn 408 in

1989 to 474 in 1990,484 in 1991, and

494 in 1992. Many hospitals that had

not participated in previous ye8rs agreed

to participate in the NHDS through the

automated systems. Much of the data

obtained using rhe automated method

were from State data systems or other

systems that used the National Uniform

Billj or UB-82 (and its successor,

UB-92) for data collection. The National

Uniform Bill was established for

processing hospital bills and does not

include race as a required item. ‘IEus,

the race of discharges w83 often not

included in the data horn such systems

purchased for the NHDS.

Race for nonreporting

hospitals

Animportantquestion to investigate

is whether nonreporting hospitals have

the same racial distribution of

dmcharges as reporting hospitals. TWo

approaches were taken to answer this

question. FirsL &ta tim previous years

were reviewed. The NHDS was

redesigned in 1988, and with some

exceptions (some hospitals went out of

business, a few new hospitals were

added to the sample in 1991), the same

hospitals were in the sample from 1988

through 1992. Among the 63 hospitals

that did not report race in 1992 were 26

that had reported race in at least 1 year

from 1988-91. For each of these 26

hospitals, the percent d~tibution of the

weighted number of discharges by race

was obtained for the most recent year in

which race WBSreported. This percent

distribution was multiplied by the

weighted number of discharges from the

hospital in 1992.

The resulting distribution of

discharges by race for the 26 hospitals

combmed is shown in table 2. The

estimated proportion of patients who

were white W8Ssignificantly larger in

the 26 nonreporting hospitals

(87.3 percent) than in hospitals that

reported race in 1992 (75.2 pmxmt).

The reporting hospitals had higher

proportions of patients who were black

all other races, and race not stated.

Because the 26 hospitals that

previously reported race may or may not

be representative of all the hospitals that

did not report race, a second approach

to estimate the racial dktibution of

d~charges from nonreporting hospitals

was used. This involved an examination

of the populations they served. The

1990 Census provided data on the racial

d~tributions of counties (10) that can be

used to approximate service areas of

hospitals despite the fact that some

hospitals may serve only part of a

county or multiple counties.

A prehninary test was conducted to

investigate whether it would be

reasonable to use county population

distributions by race as proxy measures

for the distribution of dficharges by

race. A 20-percent stratified random

sample was taken of the hospitals that
4 Advance Data No. 265 ● July 6, 1995

reported race for 97–100 percent of their

discharges in 1992. The county in which

each sampled hospital was located was

identified and the percent dMribution of

the population of the county by race

was obtained. This percent distribution

was multiplied by the weighted number

of discharges from the hospital in the

county.

The resulting distribution of

dkcharges by race for the sample

hospitals was 76.8 percent white

patients, 17.5 percent black patients, and

5.6 percent patients of other races. In

comparison, the distribution reported for

these sample hospitals was 80.0 percent

white dk.charges, 15.2 percent black

discharges, and 4.1 percent discharges of

other races.

Although not exac~ the population

d~tribution of a county appeared useful

as a general indkator of the racial

distribution of discharges from a

hospital in the county. Thereforq the

procedure used in the test was applied

to the nonreporting hospitals. The

county in which each nonreporting

hospital was located was identified and

the percent d~tribution of the population

of the county by race was obtained. This

percent distribution was multiplied by

the weighted number of discharges from

the nonreporting hospital in the county.

The resulting d~tributions of

discharges by race for nonreporting

hospitals are shown in table 3. For each

year 1990 through 1992, the proportion

of discharges that were white calculated

for nonreporting hospitals was

significantly higher than the proportion

in reporting hospitals. Conversely, the

proportions of discharges that were

black calculated for nonreporting

hospitals were significantly lower than

the proportions in reporting hospitals.

The “all other races” category

accounted for larger proportions of

dischwges for the nonreporting than for

the reporting hospitals, but these

proportions may have been somewhat

overestimated, as in the preliminary test.

These findings afe not definitive,

but along with the data on racial

distributions in previous years, they

suggest that nonreporting hospitals may

have a higher proportion of white

discharges and a lower proportion of

black discharges than reporting

hospitals.

Hispanic patients

Race and ethnicity are separate data

items for the NHDS. On the ethnicity

variable, patients are identified as being

of Hispanic origim non-Hispanic origin,

or not stated. Ethnicity, in general, is not

well reported. For example, in 1992,

only 24.6 percent of all NHDS

dkcharges were identified as Hispanic

or non-Hispanic. Because ethnicity data

are not reliable, these Ma are not

released horn the NHDS.

Data on Hispanic origin are

discussed here &cause patients

identified as Hispanic usually have

missing race data. As shown in table 4,

more than half of Hispanic patients were

in the racenot-stated category in

1990-92. Another 13-17 percent were

reported in the “other” race category, so

only 25-35 percent were identified as a

specific race during thii 3-year period.

The lack of race data for Hispanic

patients is sepamte fkom the problem of

hospitals not reporting race. Hospitals

that do not report race almost never

report ethnicity. However, certain other

hospitals report all or ahnost all patients

identified as Hispanic in the race not

stated category. In 1992, for example,

112 hospitals reported race for less than

3 percent of their Hispanic discharges,

and these hospitals accounted for

two-thirds of the Hispanic discharges

not identified by race.

These 112 hospitals were more

liely to provide data through the

manual data collection system than the

automated system. In the manual

system, NCHS strM are instructed to

code records as “race not stated” when

Hispanic is written in as a race.

Automated system data are not coded by

NCHS staff and do not necessarily

follow this practice. In 1992, a total of

32 NHDS hospitals were found in which

all Hispanic discharges were assigned to

the “other” race category. These were

predominantly hospitats using the

automated data collection system.

Some of the hospitals that have rdl

their Hispanic discharges assigned to the

“mce not stated” or “other” race

categories are known to be using data

collection forms that do not separate

race and ethnicity. Other hospitzds

probably also use combined Megories.

The Federal standards for reporting race

and ethnic statistics (11) allow race and

ethnicity to be collected in a combhwl

format in which Hispanics are not

identified by race.

If identified by race, the evidence

indkates that most Hispanics “inthe

“race not stated” and “other” categories

would be classified as white. Among

Table 3. Percent distribution of discharges by race for nonreportinft hotdtals based on countY population and for rePorting hospitals,

according to year: United States, 199=2 -

.- . . . . .— .

[Dlaohargas of Inpatlenta from non-Fedaral short-stay hospitals. Excludes newborn infants]

1990 1991 1992

Nonreporfirg Report/n

~

Nonrapotiing Repofllnq

Race hoqifals i

Nonreportiyg Repott/n

hospifels hospifels ‘ hospitals hospifals 4

hosplteis

Percent distribution

All races . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0

W/Me. . . . . . . . . . . . . . . . . . . . . . . . . 83.0 77.7 83.8 76.4 83.2 75.2

Black . . . . . . . . . . . . . . . . . . . . . . . . . 11.4 13.1 10.5 13.6 10.6 13.9

All other races . . . . . . . . . . . . . . . . . . . 5.6 3.5 5.7 3.8 6.2 4.2

Race notefated . . . . . . . . . . . . . . . . . . . 5.7 6.2 6.7

‘ NonrepoRing hospifeh rsported race for kes than 3 percent of dkcharges. Rem distribution was based on the papuleticm of the caunly where the hcepifal was located.

%ospitats that repotied race for S-10+ percent of dmcharg.s.
Advance Data No, 265 ● July 6, 1995 5

Table 4. Percent distribution of discharges by race for patients identified as Hispanic,

according to yswm United States, 1990-92

[Discharges of Inpatients fmm non-Federal short-stay hosplfefs. Excludes newborn Infants]

Race 1990 1991 1992

Percent dkdrbution

Allracas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.3 28.0 23.1

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.8 “0.8 0.8

AmerloanlndkinrEsldmo/AleuforAshrrrPaclflc Islander. . 0.9 3.5 1.7

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.3 14.4 17,2

Racenotstated . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.8 53.4 57.3

Hispanic discharges reportedasa

specilicracein 1992, 90.4percentwere

identitiedas white, 3.1percent as black,

and 6.5 percent as American Indd

Eskimo/Aleut or A&m/Pacific Islander.

In addition, the U.S. Bureau of the

Census estimated that in 1990 the

Hispanic population was 91.3 percent

white, 5.4 percent black, and 3.3 ~rcxmt

American Indian/E&imo/Aleut or

A&n/Pacific Islander (12). Thus, the

lack of information on the race of the

majority of discharges identified as

Hispanic is likely to affect NHDS

estimates of white discharges

disproportionately.

Comparisons

National Health Interview Survey

If dischargesof white patients are

underestimated to a greater extent than

discharges of patients of other races in

the NHDS, this should be evident in

comparisons of estimate3 nom the

NHDS to data from other sources. A

comparison was made of NHDS data

with data from the National Health

Interview Survey (NHIS), which also

produces estimates of hospital use by

race (13-15).

The NHIS is based on a different

universe and uses different definitions

and data collection procedures than the

NHDS. The estimates of hospitalizations

are obtained from interview questions

about overnight stays in short-stay

hospitals during the previous 6 months.

Hospitalizations of persons who died or

were institutionalized during the

reference period are excludd as are

hospitalizations of healthy newborn

infants.

Before comparing NHIS estimates

with NHDS estimates of hospital use,

the NHDS estimates were adjusted.

Patients hospitalized for less than 1 day

were excluded kecause the NHIS data

were only for overnight stays. Persons

discharged dead and those transferred to

Iong-term care institutions were

exclud@ although the NHDS data

would probably still include some

persons who died or were

institutionalized during a 6-month

period. All newborn infants were

exclude4 as is usual for NHDS

estimates, although some sick newborn

infants may be included in tie NHR

estimates. The adjustments do not make

the NHDS and NHIS data completely

alike, but they should be more

comparable.

The adjusted NHDS estimates and

the NHIS estimates of discharges from

short-stay hospitals are shown in table 5

for 1990 through 1992. In each of the 3

years, the NHIS estimate of total

dficharges was not significantly ditTerent

ffom the adjusted NHDS estimate.

However, the estimated number of

discharges for white patients tlom the

NHIS was significantly higher than the

adjusted NHDS estimate each year. The

NHIS estimate was 22 percent higher in

1990,26 percent higher in 1991, and

30 percent higher in 1992. The

estimated number of discharges for

black patients from the NHIS was not

significantly dilTerent from the adjusted

NHDS estimate of black discharges in

any of the years. NHIS estimates of

d~charges for other racial groups were

not available.

Medicare

Another source of information on

the race of hospital discharges is the

Health Care Financing Administration

(HCFA), which obtains data on the

hospitalizations of Medicare

beneficiaries. In 1990, HCFA reported

10,522,000 discharges from short-stay

hospitals for Medicare beneficiaries (16).

Of these, 9,037,000 (85.9 percent) were

identified as white, 1,185,000

(11.3 percent) were other than white,

and 300,000 (2.9 percent) wem not

identified by race.

The NHDS estimate of discharges

with Medicare as the pMcipal expected

Table 5. Number of discharges estimated from the National Hospital Discharge Survey

and the National Health Interview Survey, by year and race: United State+ 1990-92

[Discharges of hrpaflents from short-stay hospitals]

Nafbnal Hoq?Ral Natkmd Health

Yearand race DischargeSurvey’ InfervfewSurvey

1990 Number in thousands

Aflraces2 . . . . . . . . . . . . . . . . . . 27,250 27,058

White . . . . . . . . . . . . . . . . . . . . 1s,713 22,821

Black . . . . . . . . . . . . . . . . . . . . 3,300 3,692

1331

Aflracas* . . . . . . . . . . . . . . . . . . 27,275 26,873

white . . . . . . . . . . . . . . . . . . . . 18,084 22,778

Black . . . . . . . . . . . . . . . . . . . . 3,s95 3,420

1992

Aflracas2 . . . . . . . . . . . . . . . . . . 27,283 27,033

White . . . . . . . . . . . . . . . . . . . . 17,423 22,607

Black . . . . . . . . . . . . . . . . . . . . 3,363 3,654

‘Oischargasfrom non-Fedswal hoapitds. Exdudaa nawbm infants, dschargas to Icog-term cars inattutiins, patienfa diaohargsd

dsa~ amf discharges with inpatient stays 04 lass than 1 day.

21ndudes pstiints of all races and patients Wmsa race was no! atatad.
6 Advance Data No. 265 ● July 6, 1995

Table 6. Number of discharges for women with deliveries and number of Ilve births, by

year and race United States, 1990-92

Discharges for

women with Live

Year end race deliveries’ births 2

1990

Allracss . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allolherraces . . . . . . . . . . . . . . . . . . . . . . . .

Race notefated . . . . . . . . . . . . . . . . . . . . . . . .

1991

All races . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allotherracas . . . . . . . . . . . . . . . . . . . . . . . .

Racenotsfated . . . . . . . . . . . . . . . . . . . . . . . .

1992

Allraces . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allotherraces . . . . . . . . . . . . . . . . . . . . . . . .

Racenotstated . . . . . . . . . . . . . . . . . . . . . . . .

Number in thousands

4,025 4,158

2,431 3,290

584 664

262 164

748

3,973 4,111

2,244 3,241

557 683

289 187

883

3,910 4,065

2,148 3,202

511 674

334 190

916

!Dbchargasof inpatienfa from non-Federal short-stay hospitals eafimated from the National Hospital IMcharge Surwy,

%rats from blrlh oartficetes, Rata of mother assigned to child.

6ource ofpayment w6s1O,625,OOO

discharges in1990. 0fthese,8,135,000

(76.6 percent) we~ identified as white,

and 1,037,000 (9.8percent) were black

andorherraces. Theremaining

1,452,000 (13.7 percent) were in the

race-not-stated category.

Theestimatesof totalMedlcare

dkcharges horn these two sources were

notsignificady different. Likewise, the

estimate ofdkcharges for Medhmre

patients ofblack and other races from

HCFA was not significantly different

from the NHDS estimate for this group.

However, theHCFA estirnateofwhlte

Me&aredischarges was significantly

higherthantheNHDS estimate. Thus,

these findings also suggest that white

patients are more likely to be

underesd.matedin the NHDS than

patients of other races.

Birth certificates

Information about race from bti

certificates was atso compared to NHDS

data on the race of women hospitalized

for deliveries. Beginning with 1989, the

data from bti certificates have been

tabulated by the race of the mother. The

number of btis would be expected to

be somewhat higher than the mudwr of

women with deliveries estimated from

the NHDS because not all births take

place in non-Federat short-stay hospitats,

and because one delivery can result in

multiple births. However, the dtierences

in total number of deliveries and births

were not significantly different in the

1990-92 period.

The racial distribution of live births

reported from birth certificates (17) is

compared to the racial distribution of

women with deliveries from the NHDS

in table 6. The number of live births

identified as white was 35 percent higher

than the number of white women with

deliveries in 1990,44 percent higher in

1991, and 49 percent higher in 1992. In

1990, the number of black live btis

was 17 percent higher than the NHDS

estimate of black women with

deliveries; it was 22 percent higher in

1991, and 32 percent higher in 1992.

The number of live btis that were

other races was not sigticantty

dtierent from the estimate of women

with deliveries of other races in 1990.

However, in 1991 and 1992, there were

more women with deliveries in the

“other races” category than live btis.

This was due to a large number of

women with deliveries in the NHDS

who were reported as an unspecific

other race. These data suggest problems

with NHDS estimates for all the racial

categories of women with deliverk, but

also support the thesis that white

patients are markedly underestimated in

the NHDS.

Adjustments for underreporting

Table 7 shows the number and rate

of discharges by race as estimated from

the NHDS in 1990-92. These estimates

are compared with estimates produced

by two types of adjustments. The fist is

proportional adjustmen~ a strategy used

by researchers to compensate for the

underreporting of race in the NHDS (1,

4, 8). In this approach, the discharges in

the race-not-stated category are assigned

to spechic race categories based on the

distribution of the discharges whose race

is known.

For example, in the 1992 NHDS,

24,838,000 of the estimated 30,951,000

discharges were identified by race.

Among the discharges identified by race,

80.6 percent were white, 14.9 percent

were black, and 4.5 percent were other

races. Distributing the 6,113@O0

discharges in the race-not-stated

categofy in the same proportions,

4,927,000 wem added m the white

category, 909,000 to the black category,

and 278,000 to the other races category.

Proportional adjustment would be

appropriate if the evidence suggested

that patients of atl races were equally

underreported. Because white patients

appear to be underreported to a greater

extent than patients of other races in the

NHDS, proportional adjustment would

not be expected to correct accurately for

nonresponse. Using this adjustmen4

white dk.charges woutd still be

underestimated, and discharges of

patients in the other race categories

would be overestimated. The relative

differences in dischtuge rates between

racial groups am not allected by

proportional adjustment. Thus,

comparisons of proportionally adjusted

rates across racial categories are no

different than comparisons of unadjusted

rates.

Numbers and rates of discharges

resulting from a population-based

adjustment are also shown in table 7.

The population-based adjustment used

the populations of the counties in which

nonreporting hospitals were located to

estimate the racial dMribution of
Advance Data No. 265 ● July 6, 1995 7

Table 7. Number and rate of discharges, by year, race, and type of estimate: United States, 1990-92

[Discharges of inpatients from non-Federal short-stay hospitals. Exciudas newborn infants]

Dkcharga rate

Discharges In thousands per 1,000 population

NHDS Proportional

Year and race

Population-based NHDS Pr~offkvrsi

estimate’

Population-baaed

acfiustrnenf2 a@sfment3 estimate’ adjuafmarrt2 adjustment=

1990

White . . . . . . . . . . . . . . . . . . . . . . . . . 21,376 25,366 24,995 102.8 122.0 120.2

Black . . . . . . . . . . . . . . . . . . . . . . . . . 3,611 4,285 4,038 119.2 141.4

Aliotherraces . . . . . . . . . . . . . . . . . . . 958

133.3

1,137 974 89.8 118.5 101.5

Raoa notstated . . . . . . . . . . . . . . . . . . . 4,s43 781 . . . . . . . . .

1991

White . . . . . . . . . . . . . . . . . . . . . . . . . 20,818 25,317 25,078 99.3 120.8 119.8

Black . . . . . . . . . . . . . . . . . . . . . . . . . 3,717 4,521 4,1s4 120.5 148.5

Allothernxas . . . . . . . . . . . . . . . . . . .

135.6

1,036 1,260 1,046 103.0 125.2

Racenotetated . . . . . . . . . . . . . . . . . . .

104.0

5,528 790 . . . . . . . . .

1992

White . . . . . . . . . . . . . . . . . . . . . . . . . 20,018 24,945 24,778 94.6 117.8 117.1

Back. . . . . . . . . . . . . . . . . . . . . . . . . 3,692 4,601 4,219 117.8 146.9

Atiotherraces . . . . . . . . . . . . . . . . . . .

134.7

1,128 1,405 1,142 107.5 1S4.0 108.9

Racenotefated . . . . . . . . . . . . . . . . . . . 8,113 811 . . . . . . . . .

‘Unadjustedrace datafromNationalHospitalDiichargeSurvey(NHDS).

%iHDS race datawth diacharg= in race notstatedcategorydistributedto race categoriesin proportionsof dischargeswtihknownmea,

%HDS racedatawithdischargesfromnonmpding hospitalsdktributedto race categoriesbasedon county. pomdationaand Hisoaniodsohamasnotidenfifkdas spadfiorace dntributedto raw

ca+tegorlasinthe proportionsofthe Hiapank populatkm

discharges in those hospitals. Thk

procedureisdescribed inthesection,

“Race for nonreporting hospitals.” In

addltion,Hispanic dischargesinthe

race-not-stated categoxyandthe “other

race’’category wereassigneda race

usingthemial dktributionofthe

Hispanic population asestimakyibythe

U.S. Bureau of the Census.

Thepopulation-based adjustment

assumes that patients arehospitalized in

the same proportions that they me in the

population, which is probably not the

case (13–15). In addition, the

population-based adjustment does not

result in an assignment of race to all

discharges, only to those horn the

nonreporting hospitals and Hispanic

patients. In 1990-92,781,000 to

811,000 discharges remained in the

race-not-stated category after the

population-based adjustment. Thus, the

numbers and rates of discharges for

specific race categories, while probably

more accurate, remain underestimated.

Using either methor$ adjusted

numbers and rates of discharges for

white patients were significantly higher

than unadjusted estimates. Although

calculated differently, the numbem and

rates of white dkchruges produced by

proportional adjustment and popuMionbased adjustment were similar. It should

be notes however, that both of these

adjustment are expected to

underestimate white discharges to some

extent. The adjusted estimates of black

discharges and discharges of all other

races were not significantly different

from the unadjusted rates.

Discussion

Racedatafrom the NHDS became

increasingly incomplete in recent years

primarily Imause a growing number of

hospitals that participated in the survey

did not provide racial data on any of

their patients, Most of these hospitals

used the automated data collection

method. They submitted tapes of data

that were usurdly collected for other

purpo8es to the NHDS. These data were

often collected using the National

Uniform Bill (UB-82 and UB-92),

which does not inclu& an item on race.

One solution to this problem would

be for the NHDS to stop using

automated data collection. However,

even before 1985, when all data wem

collected manually using NHDS

abstracts, the proportion of discharges

with no race reported was a concern,

ranging from 9-14 percent. In addition,

the automated data collection system ha3

kecome an integral part of the NHDS

survey design. Approximately one W

of the hospitals that participate in the

survey now provide data through the

automated meth@ and msny are

unwilling to participate in a manual

system.

Another solution would be to add

race to the UB-92 form. This could

greatly increase the amount of race data

reported through the automated method.

However, the NHDS is onIy a secondary

user of UB-92 data. The principal users,

insurance companies and the Health

Care Financing Administration, do not

view a bfig form as the best place to

collect race data. They have enrollment

forms that provide information on the

race of beneficiaries (18).

The other main problem with the

NHDS race da~ lack of racial

information for Hispanic patient8, is also

related to data collection forms.

Hospitals and data systems that use a

combmed race/ethnicity item cannot

supply the NHDS with information on

the race of Hispanic patients The

Fe&ral standards for reporting racial

and ethnic statistics have been

undergoing a wide-ranging review (19).

It is uncertain whether one standard

approach to reporting will be
8 Advance Data No. 265 ● July 6, 1995

established, or whether it will continue

to be acceptable to report race and

ethnicity either separately or in a

combhmd format.

In 1990-92, the hospitals that did

not report race to the NHDS apparently

had a larger proportion of white patients

than the reporting hospitals. Estimates

based on racial distributions of

d~chmges in previous years and on

racial distributions of county populations

both suggested that white patients made

up a larger share of discharges in

nonreporting hospitals than in reporting

hospitals. The Hispanic patients not

reported by race were also likely to be

white in larger proportions than all

patients, based on the distribution of

those with a reported race and on the

raciaJ dMribution of the Hispanic

population. Therefore, discharges of

white patients were probably

underestimated to a greater extmt than

discharges of other racial groups.

Comparisons of NHDS data with

data from other sources supported the

hypothesis that white patients were

disproportionately underestimated. The

National Health Interview Survey

estimated significantly larger numbers of

wtilte discharges than the NHDS, but

similar numbers of black dkcharges. A

larger number of Medicare discharges

were white according to data from the

Health Care Financing Administration

than estimated by NHDS. However, the

number of Medicare discharges of other

races reported by these two sources

were not significantly different. The

number of live btis that were white or

black were huger than the NHDS

estimates of white or black women

hospitalized for deliveries, but

differences were greater for the white

category.

Because white patients are probably

underreported to a greater extent than

patients of other races, proportional

adjustment of NHDS data would not be

expected to produce completely accurate

estimates of the number of discharges in

each race group. This adjustment would

probably produce a more accurate

estimate of white dkcharges, but it

would overestimate discharges of other

races and would not affect comparisons

between racial groups. The populationbased adjustment may also produce a

more accurate estimate of white

discharges, but because it is based on

the assumption that all racial groups

have the same discharge rates, the

estimates of racial groups with higher

rates would be underestimated to some

extent, and comparisons between racial

groups could be distorted.

At presen~ no ideal solution exists

to eliminate the problem of

underreporting of race in the NHDS.

Therefore, the NHDS race data need to

be used cautiously and not

overinterpreted. The data can still be

useful for some types of analyses.

General inferences can be drawn if the

dfierences between racial groups are

large. For example, the rate of HIV

hospitalizations for black patients was

so much larger than the rate for white

patients that even if all the patients in

the race-not-stated category were added

to the white category, the difference

would remain highly significant (2).

When white patients have a h@her

rate than other racial groups despite the

underestimate, such as for coronary

artery bypass grafts (20), it is reasonable

to conclude that the rate for white

patients is higher. Research can also be

done on hospital use patterns withk

racial groups, such as investigation of

major diagnostic categories for black

patients or sex differences in discharge

rates for white patients. In all these

areas, though, it must be recognized that

the numbers and rates produced from

the NHDS for specific racird groups will

be underestimated to an unknown

extent.

References

1.

2.

3.

4.

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al. Hysterectomy in the United

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Kozak LJ, McCarthy E, Moien M.

Patterns of hospital use by patients

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571-81.1993.

Modan B, Wagener DK. Some

epidemiological aspects of stroke

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race, socioeconomic status. Stroke

23(9): 1230-36.1992.

Gergen PJ, Weiss KB. Changing

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Saftlas AF, Olson DR, Franks AL, et

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Addiss DG, Shaffer N, Fowler BS,

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Ford E, Cooper R, Castaner A, et al.

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Rodriguez JG, Sattin RW, Waxweiler

RJ. Incidence of hip fractures, United

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statistical pOtiCy and Standards.

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12. U.S. Bureau of the Census. U.S.

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race, and Hispanic origin 19&0to

1991. Current population reports,

series P-25, no. 1095. Washiugtorr

U.S. Department of Commerce.

1993.

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Center for Health Statistics. Wtrd

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14. Adams PF, Benson V. Current

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Interview Survey, 1991. National

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16. Helblng C. Hospital insurance

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Care Finan Rev. 1992 annual

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17. Ventura SJ, Martin JA, Taffel SM, et

al. Advance report of final natality

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Other Special Populations, National

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Statistics. Sept 14. Washington, D.C.

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19. Office of Management and Budget.

Standards for classification of Federal

data on race and ethnicity. No. 59.

Federal Register. 29831.1994.

20. Graves EJ. National Hospital

Discharge Survey annual summary,

1992. National Center for Health

Statistics. Vital Health Stat 13(119).

1994.

21. SMG Marketing Group, Inc. Hospital

Market Database. Chkago, Illinois:

Healthcme Information Specialists.

1987.

22. SMG Marketing Group, Inc. Hospital

Market Database. Chicago, Illinois:

HealthCare Information Specialists.

1991.

23. Simmons WR, Schnack GA.

Development of the design of the

NCHS Hospital Discharge Survey.

National Center for Herdth Statistics.

Vital Health Stat 2(39). 1977.

24. Haupt BJ, Kozak LJ. Estimates from

two survey designs: National

Hospital Discharge Survey. National

Center for Health Statistics. Vital

Health Stat 13(111). 1992.

25. Shah BV. SESUDW Standard

errors program for computing of

standardii rates from sample

survey data. Research Triangle Park,

North Carolina Research Triangle

htitllte. 1981.
10 Advance Data No. 265 ● July 6, 1995

Technical notes

Survey methodology

Source of data

The National Hospital Discharge

Survey covers discharges from

noninstitutional hospitals, except

Federal, military, and Department of

Veterans Affairs hospitals located in the

50 States and the DMrict of Columbki.

Only shofl-stay hospitals (hospitals with

an average length of stay for all patients

of fewer than 30 days) or those whose

specialty is general (medical or surgical)

or children’s general are included in the

survey. These hospitals must also have

six beds or more stied for patient use.

From 1988 through 1990, the

NHDS sampling tie consisted of

hospitals that were listed in the April

1987 SMG Hospital Market Database

(21), met the above criteriaj and began

accepting patients by August 1987. In

1991 the sampling frame was updated to

include hospitals from the 1991 SMG

Hospital Database (22). The sample

consisted of 542 hospitals in 1990 and

528 hospitals in 1991 and 1992. In

1990, 23 of the sample hospitals were

found to be out of scope cmeligible)

because they went out of business or

otherwise failed to meet the criteria for

the NHDS universe. Seven hospitals

were out of scope in 1991, and 14 were

out of scope in 1992. In 1990, 474 of

the 519 in-scope (eligible) hospitals

responded to the survey. In 1991, 484 of

521 in-scope hospitals mspondecl and

494 of 514 in-scope hospitals responded

in 1992.

Sample design and data collection

The NCHS has conducted the

NHDS continuously since 1965. The

original sample was selected in 1964

from a frame of short-stay hospitals

listed in the National Master Facility

Inventory. That sample was updated

periodically with samples of newly

opened hospitals. Sample hospitals were

selected with probabilities ranging from

certainty for the largest hospitrds to 1 in

40 for the smallest hospitals. Within

each sample hospital, a systematic

random sample of dkcharges was

selected. A report on the design and

development of the original NHDS has

been published (23).

Beginning in 1988, the NHDS

sample included with certainty all

hospitals with 1,000 beds or more or

40,000 discharges or more annually. The

remaining sample of hospitals is based

on a stratified three-stage design. The

tirst stage consists of a selection of 112

primary sampling units (PSU’S) that

comprise a probability subsample of

PSU’S used in the 1985–94 National

Health Interview Survey. The second

stage consists of a selection of

noncertainty hospitals from the sample

PSU’S. At the third stage, a sample of

discharges was selected by a systematic

random sampling technique. A detailed

comparison of the old and new survey

designs has been published (24).

No data collection procedures are

used for the survey. The first is a

manual system of sample selection and

data abstmction. The second is an

automated method that involves the

purchase of data tapes from abstracting

service organizations, State data

systems, or hospitals. Approximately

one third of the respondent hospitals

used the automated method in 1990

through 1992.

In the manual system, the sample

selection and the transcription of

information from the hospital records to

abstract forms are performed at the

hospitals. The completed forms, along

with sample selection control sheets, are

forwarded to NCHS for coding, editing,

and weighting. Of the hospitals using

the manual system, about two-thirds had

the work performed by their own

medical records stafTin 1990 and 1991

and 58 percent in 1992. In the remrdning

hospitals using the manual system,

personnel of the U.S. Bureau of the

Census do the work on behalf of NCHS.

For the automated system, NCHS

purchases tapes containing machinereadable medical record data that are

systematically sampled by NCHS.

The medical abstract form and the

automated data tapes contain items

relating to the personal chamcteristics of

the patients, including birth date, sex,

race, and marital status, but not name

and address; adminktrative information,

including admission and discharge dates,

dkcharge status, and me&cal record

numb% and medical information,

including dmgnoses and surgical and

nonsurgical operations or procedures.

Since 1977, patient ZIP Code, expected

source of paymentj and dates of surgery

have also been collected. (The medical

record number, bti date, and patient

ZIP Code are confidential information

and are not available to the public.)

Presentation of estimates

The relative standard error of the

estimate and the number of sample

records on which the estimate is based

(referred to as the simple size) are used

to identify esdmates with relatively low

reliability.

Because of the complex sample

design of the NHDS, estimates of less

than 5,000 are not presentex only an

asterisk (*) appears in the tables. These

estimates generally have a relative

standard error of more than 30 percent

or are based on a sample of fewer than

30 cases. Estimates based on fewer than

60 cases are preceded by an asterisk (*)

to indicate that they should not be

assumed to be reliable. These estima@

are generally 5,000 to 9,000.

Sampling errors and rounding of

numbers

The standard error is primarily a

measure of sampling variability that

occurs by chance because only a sample

rather than the entire universe is

surveyed. The relative standard error of

the estimate is obtained by dividing the

standard error by the estimate itself and

is expressed as a percent of the estimate.

The resulting value is multiplied by 100,

so the relative standard error is

expressed as a percent of the estimate.

Estimates of sampling variability

were calculated with SESUDAAN

software, which computes standard

errors by using a first-order Taylor

approximation of the deviation of

estimates tlom their expected values. A

description of the software and the

approach has been published (25).

The constants for relative standard

error curves for estimates of discharges

by race from the 1990-92 NHDS are

presented in table I. The relative
Advance Data No. 265 ● July 6,1995 11

Table 1.Estimated parameters for relative standard error equations for number of discharges, by race: National Hospital Discharge

Suwey, 1991-S2

1990 1991 1892

Race a b a b a b

AIIracas . . . . . . . . . . . . . . . . . . . . . . . 0.00213 228.S34 0.00101 546.321

White . . . . . . . . . . . . . . . . . . . . . . . . .

o.000e7

0.00212 228.5S4

448.059

0.00234 927.094 0.00241 419.274

Black . . . . . . . . . . . . . . . . . . . . . . . . . 0.00537 264.999 0.005s9 273.3SS

Another races . . . . . . . . . . . . . . . . . . .

0.00740 363.801

0.02899 119.661 o.0288e 280.075 0.02271 182.649

Racenot atated . . . . . . . . . . . . . . . . . . . 0.02252 226-201 0.0166S 427.619 0.01496 301.892

standard emor~SE(X)] of an estimate

X maybe estimated from the formulz

RSE(X) = 100 ~

where x CLand b are detined in table I.

Estimates have been rounded to the

nearest thousand. For this reason, figures

within tables do not always add to the

totals. Rates and percents were

calculated horn original, unrounded

figures and will not necessarily agree

precisely with rates or percents

calculated from rounded data.

T-ts of significance

In general, statistical inference was

based on the two-tailed t-test using the

Bonferroni criticrd values for post-hoc

multiple comparisons (0.05 level of

signilkance). Critical values were

determined for each set of comparisons,

that is within each table. For

comparisons of NHDS estimates with

the Me&care data from the Health Care

Financing Administmtion (HCFA) and

numbers of live births from birth

certificates, confidence intervals at the

95 percent level (plus and minus 1.96

times the standard error) were

constructed around the NHDS estimates.

If the number of HCFA Medicaxe

discharges or live bitths fell outside the

confidence interval, it was reported as

significantly different from the NHDS

estimate.

In this repom terms such as

“higher” and “less” indicate that

dflerences are statistically significant.

Terms such as “similar” or “no

difference” mean that no statistically

significant dtierence exits between the

estimates brimg comprued. A kick of

comment on the difference between any

two estimates does not mean that the

difference was tested and found to not

be significant.

Definitions of terms

Discharge-The formal release of a

patient by a hospital; that is the

termination of a period of

hospitalization by death or by

disposition to place of residence, nursing

home, or another hospital. The terms

“discharges” and “patients discharged”

are used synonymously.

Discharge rate—The ratio of the

number of hospital &charges during a

year to the number of persons in the

civilian population on July 1 of that

year.

Ethnici~In the NHDS, the

ethnicity of d~charges can be reported

in time categories, which are Hispanic

origb non-Hispanic, and not stated.

Hospiral-All hospitals with an

average length of stay for all patients of

less than 30 days or hospitals whose

specialty is general (medical or surgical)

or children’s general are eligible for

inclusion in the National Hospital

Discharge Survey except Federal

hospitals, hospital units of institutions,

and hospitals with fewer than six beds

stafkxl for patients’ use.

●

●

Reporting hospital-In this repofi a

reporting hospital is one that reported

race for 3–100 percent of d~charges.

Nonreportinghospital-In this repofi

a nonreporting hospital is one that

reported race for less than 3 percent

of discharges.

Live bitih-A live birth is the

complete expulsion or extraction from

its mother of a product of cxmceptio%

irrespective of the duration of the

pregnancy, which, after separation,

breathes or shows any evidence of life.

Newborn infm—A newborn infant

is a patient admitted by bti to the

hospital.

Patient-A person who is formally

admitted to the inpatient service of a

short-stay hospital for observation, care,

diagnosis, or treatment is a patient. The

terms “patient” and “inpatient” are

u8ed synonymously.

Population-The U.S. civilian

population, which is the resident

population of the United States,

excluding members of the Armed

Forces, was used to compute rates. The

U.S. resident population was used to

make population-based adjustments in

estimates of discharges by race.

Race—In ,jheNHDS, the race of

discharges can be reported in six

categories, which are white, black

American Indirrn/Eskimo/Aleu~

Askm/Pscific Islander, other, and not

stated.

Symbols

--- Data not available

. . . Category not applicable

Quantity zero

0.0 Quantity more than zero but less

than 0.05

z Quantity more than zero but less

than 500 where numbers are

rounded to thousanda

●

Figure does not meet standard of

reliability or precision (see

Technical notes)

# Figure suppressed to comply with

confidentiality requirements
12 Advance Data No. 265 ● July 6, 1995

Suggested citation

Kozak LJ. Underreporting of raoe in the

National Hospital Discharge Survey. Advance

data from vital and health statistic no 265.

Hyattsville, Maryland: National Center for

Health Statistics. 1995.

Copyright information Natfonal Center for Health SitatfatIca

All material appearing in this” report is in the Acting Director

public domain and may be reproduced or Jack R. Anderson

copied without permission; citation as to

source, however, is appreciated. Acting Deputy Director

Jennifer H. Madans, Ph.D.

DEPARTMENT OF

HEALTH & HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention m

National Center for Health Statistics

6525 Belcrest Road

Hyattsville, Maryland 20782

OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

To receive this publication regularly, contact

the National Center for Health Statistics by

calling 301-436-8500

DHHS Publication No. (PHS) 95-1250

5-1327 (6/95)
Number 266 ● September 19, 1995

i

Advance

Data Ii9i

From Vital and Health Statistics of the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

Urban and Rural Classification of National Health Provider

Inventory Providers: United States, 1991

by Renee Delfosse, M.A., Divisionof Health Care Statistics

Highlights and use of health care. Table 1 compares

the total numbers of providers according

to an urban-rural continuum. Subsequent

tables compare the total numbers of

providers in urban and rural Iocations

within Census DNisions (table 2) and

within States (tables 3–5).

Previous inventories conducted by

the National Center for Health Statistic

(NCHS) included health providers such

as hospitals, homes for the blina &af,

mentally retarde~ and emotionrdly

disturbed in addition to nursing homes

and board and care homes. The 1991

inventory includes nursing homes, board

and care homes, plus two providers,

home health care agencies, and

hospices, the large majority of whom

care for patienta in au outpatient setting,

the home (l).

This report presents information

from the National Health Provider

Inventory (NHPI) on the numbers of

home health cam agencies, hospices,

musing homes, and board and care

homes classified according to their

kxation. These data are provided to aid

in studies of the differential availabiMy

Table 1. Number and percent of home health agencies, hospices, nursing homes, and board and care homes by rural-urban continuum

codes: United States, 1991

Total Home health cars agerwlaa Hoa@cea Nursing homes Board and care homes

RumMban continuum codes for metropolitan and

norrmetfupolltan countlea Number Percent Nunber Perc8nt Nutrber Percent Nurrber Percent Nurrber Percent

United Sfates . . . . . . . . . . . . . . . . . . . . . . . . . . . 41,492 100.0 6,646 16.5 946 2.3

1.8

2.9

1.9

2.9

3.1

4.3

2.5

2.9

0.9

2.3

15,467 37.3 18,213 43.9

Metropolitan counties

Central countkm of 1 million population or more. . . . . .

Frfnge counties of 1 million population or more . . . . . .

Countlas of 250,000 to 1 million population. . . . . . . . .

Countfee of fewer then 250,000 population. . . . . . . . .

14,403

1,503

9,027

3,615

100.0 2,098

100.0 218

100.0 1,409

100.0 813

14.6

14.5

15.6

17.0

253

43

176

106

4,791 33.3

621 41.3

3,071 %.0

i ,374 38.0

7,261

621

4,371

1,522

50.4

41.3

48.4

42.1

Nonmetropolften counties

Urban populeflon of 20,000 or more, adjacent to a

metropolitan aree . . . . . . . . . . . . . . . . . . . . . . .

Jrban population of 20,000 or more, not adfacent to a

rrw’opolitsnarea. . . . . . . . . . . . . . . . . . . . . . .

Jrban popufatlon of 2,5oO 19,000, adjacent to a

rnatropolltan area . . . . . . . . . . . . . . . . . . . . . . .

Jrben population of 2,500 19,000, not adjacent to a

me~ropollten area . . . . . . . . . . . . . . . . . . . . . . .

>ompfetefy rural or fewer than 2,500 urban population,

adjacent to a malropoiftan area. . . . . . . . . . . . . . .

:ornplatefy rural or fewer than 2,500 utban population,

not adjacent to a matropolffan area . . . . . . . . . . . .

1,343

1,%5

4,013

3,663

702

1,278

100.0 315

100.0 245

100.0 719

100.0 781

100.0 139

100.0 309

16.2

18.2

17.9

21.3

19.8

24.2

60

66

100

107

6

29

762 3S,2

5S9 40.1

1,767 44.0

1,620 44.2

%38 46.1

604 47.3

806

495

1,427

t ,155

219

336

41.5

36.6

35.6

31.5

31.2

26.3

NOTES Excludes beard and care homes for the mentdy retarded. Excludmnonrespondingboardand owe homes.A totslof 85 placescouklnotk codedurberirural.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics CENTERS CDC FOR DISEASE CONTROL

ANo PREVENTION
2 Advance Data No. 266 ● September19, 1995

Table 2. Number and percent distribution of home health agencies, hospices, nursing homaa, and board and oare homes in urban and

rural locations by Census Division: United States, 1991

Total Home healthcars agerrcka Hos@ces Nursing homes Board and care homes

Divklon Number Percent dktributlon Number Percent Number Percent Number Percent Number Percent

Allocations. . . . . . . . . . . . . . . .

New England . . . . . . . . . . . . . . .

Middle Atlantic . . . . . . . . . . . . . .

Eaat North Central . . . . . . . . . . . .

West North Central . . . . . . . . . . .

South Atlantic. . . . . . . . . . . . . . .

Eaat South Central . . . . . . . . . . . .

West South Central . . . . . . . . . . .

Mountahr.. . . . . . . . . . . . . . . . .

Paclflc . . . . . . . . . . . . . . . . . . .

Urtmloeations . . . . . . . . . . . . . .

New England . . . . . . . . . . . . . . .

Middle Atkmtlc. . . . . . . . . . . . . .

East North Central . . . . . . . . . . . .

West North Central . . . . . . . . . . .

South Atlantic . . . . . . . . . . . . . . .

Eaet South Central . . . . . . . . . . . .

West South Central . . . . . . . . . . .

Mountain . . . . . . . . . . . . . . . . . .

Paclfk . . . . . . . . . . . . . . . . . . .

Rural locfdkms. . . . . . . . . . . . . .

New Engiartd . . . . . . . . . . . . . . .

MkidleAtlantic. . . . . . . . . . . . . .

Eaat North Central . . . . . . . . . . . .

West North Central . . . . . . . . . . .

South Atlantic . . . . . . . . . . . . . . .

East South Central. . . . . . . . . . . .

West South Central . . . . . . . . . . .

Mountain . . . . . . . . . . . . . . . . . .

Pacific . . . . . . . . . . . . . . . . . . .

44,577

2,666

4,734

7,209

4,469

6,819

2,465

3,369

2,035

7,791

31,836

2,271

4,269

5,437

2,128

5,244

1,430

2,202

1,445

7,410

9,858

382

452

1,766

2,334

1,562

1,027

1,184

587

382

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

IOQ.o

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

6,853

433

638

1,062

902

1,129

617

845

414

513

4,898

390

776

802

377

854

333

637

263

466

1,846

43

62

259

524

273

262

306

151

46

16.5

18.2

17.7

14.7

20.2

16.6

25.0

27.9

20.3

6.6

15.4

17.2

18.2

14.8

17.7

16.3

23.3

28.9

16.2

6.3

20.2

11.3

13.7

14.7

22.5

17.5

27.5

26.0

25.7

12.7

951

75

62

182

111

164

50

77

69

121

704

56

76

126

56

144

35

61

40

108

242

19

6

56

53

37

15

16

29

11

2.3

2.8

1.7

2.5

2.5

2.7

2.0

2.3

3.4

1.6

2.2

2.5

1.8

2.3

2.7

2.7

2.4

2.6

2.8

1.5

2.5

5.0

1.3

3.2

2.3

2.4

1.5

1.4

4.9

3.0

15,511

1,166

1,604

3,147

2,269

1,968

946

1,966

703

1,720

11,158

1,066

1,469

2,364

1,004

1,479

512

1,186

457

1,619

4,328

116

131

762

1,263

467

431

777

244

96

37.3

44.6

33.9

43.7

50.6

26.9

36.4

56.0

34.5

22.1

35.0

47.0

W.4

43.5

47.2

26.2

35.8

53.9

31.6

21.8

44.8

30.4

29.0

44.3

54.1

31.2

42.0

65.6

41.6

27.1

18,262

970

2,210

2,616

1,187

3,536

652

401

649

5,437

15,076

757

1,94s

2,145

689

2,767

550

316

665

6,217

3,137

204

253

669

494

765

299

83

163

207

43.9

36.4

46.7

39.1

26.6

51.9

34.6

11.6

41.7

69.8

47.4

33.3

45.6

39.5

32.4

52.8

38.5

14.4

47.4

70.4

32.5

53.4

56.0

37.9

21.2

48.0

26.1

7.0

27.6

57.2

NOTES Excludesboard and care homaa for the mentally retarded. Excludas nonraqmnding bead and cam honwa. A total of 85 placaaccdd not be coded urbanhursl.

There were 18,262 board and care

homes, 15,511 nursing homes, 6,853

home health care agencies, and 951

hospices in the United States in 1991

(table 2). Of the 31,836 providers in

urban locations, 47 percent were board

and care homes, 35percent were nursing

homes, 15percent wer’ehomehealti

care agencies, and 2 percent were

hospices. In rural locations the

distribution differed: 45 percent of the

9,656 providers were nursing homes,

33 percent were board and care homes,

20 percent were home health care

agencies, and 3 percent were hospices.

The majority of patients served by

the NHPI providers were elderly.

Approximately 75 percent of home

health care agency and hospice clients,

92 percent of nursing home patients, and

68 percent of l-wardand care home

residents were 65 years and over (2,3).

These percentages were found to hold

on the divisional level for all providers

(4), and on the State level for most

nursing homes and board and care

homes (tables 6-7).

References

1.

2.

3.

Delfosse R. Hospice and home health

agency characteristic~ 1991 National

Health Provider Inventory. National

Center for Health Statistics. Vital

Health Stat. In preparation.

Straban G. Overview of home health

and hospice care patients

Preliminary data from the 1992

National Home and Hospice Care

Survey. Advance data from vital and

health statistics; no 235. Hyattsville,

Maryland National Center for Health

Statistics. 1993.

Sirrocco A. Nursing homes and

board and care homes. Advance data

from vital and health statistic no

244. Hyattsvilk Maryland National

Center for Health Statistics. 1994.

4.

5.

6.

7.

National Center for Health Statistics.

National Home Health and Hospice

Care Survey. Hyattsville, Maryland.

1992.

National Center for Health Statistics.

The Agency Reporting System for

maintaining the national inventory of

hospitals and institutions. Vkd

Health Stat 1(6). 1968.

Institute of Medicine. Toward a

national health care survey, a data

system for the 21st century.

Washington: National Academy

Press. 1992.

Urban-rural continuum codes for

metro and nonmetro counties, 1993.

USDA, ERS.
Advance Data No. 266 ● September19, 1995 3

Tsble 3. Number and percent distribution of home heslth csre agencies, hospiq nursing homes, and bosrd snd care homes by Ststw

United Ststes, 1991

Total Home health cam agencies Ho@es Nursing t1017WS Board and OSfehomae

State Number Pement dktributbn Nunlmr Percent Nun’ber Percent Nunber Pemsnt Number Percent

United states . . . . . . . .

Alabama . . . . . . . . . . .

Alaska . . . . . . . . . . . .

Arizona . . . . . . . . . . . .

Arkansaa . . . . . . . . . . .

Callfomia . . . . . . . . . . .

Colorado . . . . . . . . . . .

Connaotbut . . . . . . . . .

Delaware . . . . . . . . . . .

DlsMot at cohilllbh . . . .

Florkia. . . . . . . . . . . .

Georgia . . . . . . . . . . . .

Hawaii . . . . . . . . . . . .

Idaho . . . . . . . . . . . . .

Illlnoie. . . . . . . . . . . . .

Indiana . . . . . . . . . . . .

lowa . . . . . . . . . . . . . .

Kaneaa . . . . . . . . . . . .

Kentucky . . . . . . . . . . .

Louisiana . . . . . . . . . . .

Maine . . . . . . . . . . . . .

M@and... . . . . . . . .

Maaaaohuaat to.......

Mbhlgan.. . . . . . . . . .

Minnesota. . . . . . . . . .

MbslseiIIP1. . . . . . . . . .

Missouri . . . . . . . . . . .

Montana . . . . . . . . . . .

Nebraska. . . . . . . . . . .

Nevada. . . . . . . . . . . .

Naw HarnPehiIB . . . . . .

Nawk’eey. . . . . . . . .

Naw Maxioo . . . . . . . . .

New York . . . . . . . . . . .

Notth Carolina . . . . . . .

North Dakota . . . . . . . .

Ohb. . . . . . . . . . . . . .

Oklahoma . . . . . . . . . .

Oregon. . . . . . . . . . . .

Pennsylvania. . . . . . . .

Rhode lekmd. . . . . . . .

SouthCarolina . . . . . . .

3outh Dakota . . . . . . . .

Tennaseae. . . . . . . . . .

Texan. . . . . . . . . . . . .

Utah. . . . . . . . . . . . . .

Vermont . . . . . . . . . . .

Virglnla, . . . . . . . . . . .

Waehinglo n.,.....,,

We8tVirginia . . . . . . . .

Wboonaln..,..,...

Wyoming, . . . . . . . . . .

41,577

581

46

417

446

5,316

515

462

741

144

2,103

935

360

133

1,267

744

767

636

728

561

403

560

1,063

2,497

1,022

355

1,115

225

335

136

295

762

250

1,304

1,210

200

1,570

532

1,203

2,088

204

506

272

621

1,850

793

219

766

844

4+2

1,131

98

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

8,853

127

10

71

133

333

101

110

19

18

413

70

18

28

309

150

155

153

112

180

35

36

166

196

198

116

173

43

75

28

60

111

45

470

155

70

252

75

71

317

43

101

80

262

557

53

19

188

81

64

155

41

16.5

22.6

20.6

17.0

23.8

6.3

19.6

22.8

13.5

12.5

19.8

7.5

4.7

13.1

24.4

20.2

20.2

21.9

15.4

32.1

8.7

16.6

15.6

7.8

192

32.7

15.5

21.6

19.0

20.3

20.3

14.6

18.0

21.5

12.8

36.0

16.1

14.1

5.9

15.3

21.1

20.0

28.4

31.9

30.1

27.5

8.7

24.5

9,6

15.5

13.7

41.6

951

19

5

9

11

83

19

9

3

3

34

18

8

14

49

13

25

23

19

11

15

25

26

57

33

1

15

12

6

2

13

19

3

35

46

2

3s

13

14

26

5

13

7

11

42

4

7

28

11

12

24

6

2.3

3.4

10.4

2.2

2.5

1.6

3.7

1.9

2.1

2.1

1.6

1.3

2.1

7.0

3.9

1.7

3.3

3.3

2.6

2.0

3.7

4.3

2.4

23

3.2

0.3

1.3

5.3

1.5

1.4

4.4

2.5

1.2

1.8

4.0

1.0

2.5

2.4

1.2

1.4

2.5

26

2.6

1.3

2.3

2.1

3.2

3.6

1.3

2.9

2.1

6.1

15,511

214

18

120

225

1,178

191

244

47

18

552

342

54

71

613

531

458

366

287

319

138

219

580

435

451

160

533

98

229

34

87

319

68

535

309

65

877

’38a

191

630

104

140

124

285

1,033

90

55

227

279

114

431

31

37.3

w.i

37.5

28.8

50.4

22.2

37.1

50.6

33.3

12.5

28.2

36.6

14.2

35.7

64.2

71.4

59.8

55.3

39.4

56.9

34.2

37.8

52.7

19.8

44.1

45.1

48.0

43.6

56.0

24.6

28.5

41.9

27.2

31.3

25.5

42.5

55.3

73.1

15.9

33.4

51.0

27.7

45.6

34.7

55.8

46.6

25.1

26.8

33.1

27.7

36.1

31.6

18,282

201

15

217

77

3,722

204

119

72

105

1,104

505

3Q0

66

96

50

128

136

310

51

215

240

311

1,749

342

78

392

66

65

74

135

313

134

664

886

43

402

55

927

1,033

52

252

61

263

218

46

136

340

473

222

521

20

43.3

35.8

31.3

52.0

17.3

70.0

=.6

24.7

5f.1

72.9

52.5

54.0

78.9

44.2

7.6

6.7

16.7

19.5

42.6

9.1

53.3

41.4

29.3

70.0

33.5

22.0

35.2

28.3

21.5

53.6

46.6

41.1

53.6

45.4

57.7

21.5

25.6

10.3

77.1

50.0

25.5

49.6

22.4

32.0

11.8

23.6

83.0

43.1

56.0

53.9

46.1

20.4

NOTESExcludeabomrdWtdoarotwmsfor thermntd~rdded. Exdudesapmsntage ofnonmqxmdimbcard ardcarekmms,
4 Advance Data No, 266 ● September 19, 1995

Table 4. Numbar and percsnt of home health agencies, hospices, nursing homes, and board and care homsa In urban araas: Unitad

statsa, 1991

Total Home health w’s agencies Hofplces Nurelng homes Board and care homes

State Number Percent dlstrlbutlon Number Percent Number Percent Number Percent Number Percent

United States . . . . . . . .

Alabama . . . . . . . . . . .

Alaska. . . . . . . . . . . . .

Arizona . . . . . . . . . . . .

Arkansas .,,.....,..

California . . . . . . . . . . .

Colorado . . . . . . . . . . .

Connedlcut . . . . . . . . .

Delaware . . . . . . . . . . .

Dlstrlct of Columbia . . . .

Florida . . . . . . . . . . . .

Gsorgla. . . . . . . . . . . .

Hawall . . . . . . . . . . . .

Idaho . . . . . . . . . . . . .

Illinois . . . . . . . . . . . . .

Indiana . . . . . . . . . . . .

Iowa. . . . . . . . . . . . . .

Kansas . . . . . . . . . . . .

Kentucky . . . . . . . . . . .

Louisiana . . . . . . . . . . .

Maine . . . . . . . . . . . . .

Maryland . . . . . . . . . . .

Meeeachusefte . . . . . . .

Michigan . . . . . . . . . . .

Minnesota . . . . . . . . . .

Mississippi . . . . . . . . . .

Miesourl . . . . . . . . . . .

Montana . . . . . . . . . . .

Nebraetwi. . . . . . . . . . .

Nevada . . . . . . . . . . . .

NewHarnpshira . . . . . .

NswJersey . . . . . . . . .

New Mexico . . . . . . . . .

New York. . . . . . . . . . .

NorthCarollna . . . . . . .

Norlh Dakota . . . . . . . .

Ohio . . . . . . . . . . . . . .

Otdahoma . . . . . . . . . .

Oregon . . . . . . . . . . . .

Pennsylvania . . . . . . . .

RhodeIsland . . . . . . . .

SouthCarollna . . .

South Dakota. . . . . . .

Tannee%e . . . . . . . . . .

Texas . . . . . . . . . . . . .

Utah. . . . . . . . . . . . . .

Vermont . . . . . . . . . . .

Vlrglnla . . . . . . . . . . . .

Waehlngton . . . . . . . . .

WestVlrglnia . . . . . . . .

Wisconsin . . . . . . . . . .

Wyoming . . . . . . . . . . .

31,836

366

27

411

200

5,187

374

460

104

144

1,963

562

377

111

962

527

298

351

326

412

275

532

1,053

1,810

576

172

615

66

175

117

217

750

166

1,751

766

48

1,367

277

1,056

1,766

199

377

62

544

1,313

146

47

547

763

209

771

30

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

4,698

72

6

70

39

320

69

110

12

16

377

41

16

15

250

103

56

74

46

124

25

84

164

135

96

42

95

12

31

21

45

111

30

363

95

13

214

43

49

262

43

67

10

171

421

32

3

126

73

2-I

100

14

15.4

16.7

22.2

‘t7.o

19.5

6.2

76.4

22.9

11.5

12.5

19.2

7.0

4.6

13.5

26

19.5

16.8

21.1

14.6

32.5

9.1

15.6

15.6

7.5

17.0

24.4

15.4

13.6

17.7

17.9

20.7

14.8

17.9

21.9

12.1

26.5

15.7

15.5

4.6

16.0

21.6

17.8

16.1

31,4

32.1

21.9

6.4

23.0

9.6

16.3

13.0

46.7

704

14

2

9

6

75

10

9

2

3

33

16

8

6

39

12

9

14

11

9

9

23

24

27

13

1

11

4

5

2

9

19

3

33

28

2

31

11

13

24

5

9

4

9

35

2

11

21

10

9

17

2

2.2

3.6

7.4

2.2

3,0

1.4

2.7

1.9

1.9

2.1

1.7

2.7

2.1

7.2

4,1

2.3

3.0

4.0

3.4

2.2

3.3

4.3

2.3

1.5

2.2

0.6

1.8

4.5

2.9

1.7

4.1

2.5

1.6

1.9

3.6

4.1

2.3

4.0

1.2

1.4

2.5

2.4

6.5

1.7

2.7

1.4

23.4

3.6

1,3

4,3

2.2

6.7

tl,156

141

9

117

104

1,151

129

244

33

16

515

166

a

31

593

373

177

159

125

223

89

199

557

376

242

68

291

30

65

25

66

315

47

555

206

20

750

197

163

539

101

102

30

176

662

70

33

159

242

59

270

8

35.0

36.5

33.3

28.6

52.0

22.2

34.5

50.8

31.7

12.5

26.2

32.0

14.3

27.9

61.6

70.8

59.4

45.3

36.1

E4.1

32.4

37.4

52.9

20.9

41.9

39.5

47.3

34.1

48.6

21.4

30.4

42.0

28.0

31.7

26.5

40.6

54.9

71.1

15.4

33.9

50.6

27.1

46.4

32.7

50.4

47.9

70.2

29.1

31.7

26,2

35.0

26.7

15,076

159

10

215

51

3,641

186

117

57

105

1,036

333

297

57

80

39

56

104

144

46

152

226

308

1,270

225

61

216

42

54

69

97

305

88

780

456

14

372

26

831

863

50

199

18

166

195

42

241

438

107

364

6

47.4

41.2

37.0

52.3

25.5

70.2

44.4

24.4

54.8

72.9

52.9

58.2

76.8

51.4

8.3

7.4

18.8

29.6

43.9

11.2

55.3

42.5

23.2

70.2

38.9

35.5

35.4

47.7

30.9

59.0

44.7

40.7

52.4

44.5

57.9

28.6

27.2

9.4

78.7

46.8

25.1

52.8

29.0

34.2

14.9

28.8

44.1

57.4

51.2

49.6

20.0

NOTES:Excludes bcerd and care homes for the mentally reterded. Excludes nonresponding board and care homes. A total of 85 places coukl not be ooded urbatirural,
Advance Data No. 266 ● September19, 1995 5

Table 5, Number and percent of home health agencies, hospices, nursing home% and board and care homes in rural areas: United

statas,1991

Total Home haa#th care agendas HoqMcas Nurslw tlOMW Board and cam homes

State Number Pement dlsfrlbutlon Nu&r Percent Nurrbar Percent Nurriw Percent Number Percent

Unitad3fates . . . . . . . .

Alabama . . . . . . . . . . .

Alaska . . . . . . . . . . . .

Arizona . . . . . . . . . . . .

Arkansas. . . . . . . . . . .

Calitomla . . . . . . . . . . .

Colorado . . . . . . . . . . .

Connecfiout . . . . . . . . .

Delaware . . . . . . . . . . .

Distriof of Columbla . . . .

Florida . . . . . . . . . . . .

Georgia . . . . . . . . . . . .

Hawsll . . . . . . . . . . . .

Idaho . . . . . . . . . . . . .

Illinois. . . . . . . . . . . . .

Indlena . . . . . . . . . . . .

Iowa . . . . . . . . . . . . . .

Kansas . . . . . . . . . . . .

Kentucky . . . . . . . . . . .

Louisiana. . . . . . . . . . .

Maine . . . . . . . . . . . . .

Maryland. . . . . . . . . . .

Meesechusatts. . . . . . .

MlohlP . . . . . . . . . . .

Minnesota . . . . . . . . . .

MlsskslI@ . . . . . . . . . .

Mlssourt . . . . . . . . . . .

Montana . . . . . . . . . . .

Nebmsks. . . . . . . . . . .

Nevada. . . . . . . . . . . .

New Hen@hs . . . . . .

Naw Jaraey . . . . . . . . .

Naw Mexko . . . . . . . . .

New York . . . . . . . . . . .

North Carolina . . . . . . .

North Dakota . . . . . . . .

Ohio. . . . . . . . . . . . . .

Oklahoma . . . . . . . . . .

Oregon . . . . . . . . . . .

Pennsylvania . . . . . . . .

Rhode lekand. . . . . . . .

South Carolina . . . . . . .

-South Dakota . . . . . . . .

Tennessee . . . . . . . . . .

Texes . . . . . . . . . . . . .

Utah.. . . . . . . . . . . . .

Vermont . . . . . . . . . . .

Virglnie. . . . . . . . . . . .

Washington. . . . . . . . .

WestVkgkria . . . . . . . .

Wisconsin. . . . . . . . . .

Wyoming . . . . . . . . . . .

9,656

167

17

5

246

124

140

. . .

36

. . .

137

351

. . .

88

305

217

466

345

400

149

126

47

. . .

662

444

183

488

137

220

21

78

. . .

82

153

424

151

203

255

144

233

. . .

125

210

277

534

46

172

233

77

203

359

68

100.0

100.0

100.0

100.0

100.0

100.0

100.0

. . .

100.0

. . .

100.0

100.0

. . .

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

. . .

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

. . .

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

. . .

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

1,948

53

3

1

84

13

22

. . .

7

. . .

36

28

. . .

11

59

47

33

78

64

46

10

12

. . .

60

98

74

78

37

44

7

15

. . .

15

27

80

57

38

32

22

35

. . .

33

70

91

136

21

16

67

6

30

55

27

20.2

31.7

17.6

20.0

38.2

10.5

22.9

. . .

19.4

. . .

26.3

8.0

. . .

12.5

19.3

21.7

21.2

22.6

16.0

30.9

7.9

25.5

. . .

e.8

22.1

40.4

15.7

27.0

20.0

33.3

19.2

. . .

18.3

17.6

14.2

37.7

18.7

12.5

15.3

11.7

. . .

26.4

33.3

32.9

25.5

45.7

9.3

28.0

10.4

14.8

15.3

38.7

242

5

1

2

5

8

9

. . .

1

. . .

1

2

. . .

6

10

1

16

9

8

2

6

2

. . .

30

20

92

4

6

1

9

4

. . .

21

2

20

65

8

2

1

4

. . .

3

3

2

7

2

7

5

1

3

7

4

2.5

3.0

5.9

40.0

2.0

6.5

6.4

. . .

2.8

. . .

0.7

0.6

. . .

6.8

3.3

0.5

3.4

2.6

2.0

1.3

4.8

4.3

. . .

4.4

4.5

50.3

0.8

5.8

0.5

42.9

5.1

. . .

25.6

1.3

4.7

43.0

3.9

0.8

0.7

1.3

. . .

2.4

1.4

0.7

1.3

4.3

4.1

2.1

1.3

1.5

1.9

5.9

4,329

70

9

2

121

25

62

. . .

13

. . .

37

155

. . .

40

220

158

281

227

162

96

4e

20

. . .

117

209

17

243

66

144

5

21

. . .

46

40

101

29

127

192

28

91

. . .

38

84

107

366

19

44

68

36

55

160

23

44.8

41.9

52.9

40.0

49.2

20.2

44.3

. . .

36.1

. . .

27.0

44.2

. . .

45.5

72.1

72.6

60.3

65.6

40.5

64.4

36.9

42.6

. . .

17.2

47.1

9.3

48.8

49.6

65.5

23.6

26.9

. . .

58.1

26.1

23.8

192

62.6

75.3

19.4

30.4

. . .

30.4

44.8

38.6

66.9

41.3

25.6

26.5

48.8

27.1

44.6

33.8

3,137

33

4

26

76

37

. . .

15

. . .

63

186

.. .

31

16

11

70

31

166

5

61

13

. . .

475

117

173

24

31

36

. . .

64

243

30

2e

83

169

. . .

51

43

77

23

4

105

es

a

115

137

14

32.5

23.4

23.5

10.6

62.9

26.4

. . .

41.7

. . .

46.0

47.3

. . .

35.2

5.2

5.1

15.0

9.0

41.5

3.4

48.4

27.7

. . .

83.6

26.4

34.7

17.5

14.1

46.7

. . .

54.s

57.3

14.8

71.4

64.6

56.5

. . .

40.6

20.5

27.6

4.3

8.7

61.0

41.4

41.6

56.7

38.2

20.6

NOTES Excludes board andcarehomesfor Ihernentaliy rclarde.d. Exdudesn onreaponding boardandcarehorr&. AtotalotSSpleces couldno+beocded urbarirural,
6 Advance Data No. 266 ● September 19, 1995

Table 6. Number of residenta 65 years of age and over in board and care homes: United States, 1991

Realdents Residents Percent of all resident.4

State Residents with reported age 65 years of age and over 65 years of age and over

Number

United States . . . . . . . . . . . . . . . . . . . . . .

Alabama . . . . . . . . . . . . . . . . . . . . . . . . .

Alaska . . . . . . . . . . . . . . . . . . . . . . . . . .

Arizona . . . . . . . . . . . . . . . . . . . . . . . . . .

Arkansas . . . . . . . . . . . . . . . . . . . . . . . . .

California . . . . . . . . . . . . . . . . . . . . . . . . .

Colorado . . . . . . . . . . . . . . . . . . . . . . . . .

Connedlcut . . . . . . . . . . . . . . . . . . . . . . .

Delaware . . . . . . . . . . . . . . . . . . . . . . . . .

Dlstrlctof Columbia . . . . . . . . . . .

Florida . . . . . . . . . . . . . . . . . . . . .

Georgia . . . . . . . . . . . . . . . . . . . .

Haweil . . . . . . . . . . . . . . . . . . . . . . . . . .

Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . .

Illinois. . . . . . . . . . . . . . . . . . . . . . . . . . .

Indiana . . . . . . . . . . . . . . . . . . . . . . . . . .

lowa . . . . . . . . . . . . . . . . . . . . . . .

Kansas . . . . . . . . . . . . . . . . . . . . . . . .

Kentucky . . . . . . . . . . . . . . . . . . . . . . . . .

Louisiana . . . . . . . . . . . . . . . . . . . . . . . .

Mehre . . . . . . . . . . . . . . . . . . . ... ,,,..

Maryland . . . . . . . . . . . . . . . . . . . . . . . .

Massachusetts . . . . . . . . . . . . . . . . . . . . .

Michigan . . . . . . . . . . . . . . . . . . . . . . . . .

Minnesota . . . . . . . . . . . . . . . . . . . . . . . .

Mississippi . . . . . . . . . . . . . . . . . . . . . . . .

Missouri . . . . . . . . . . . . . . . . . . . . . . .

Montana . . . . . . . . . . . . . . . . . . . . .

Nebraska . . . . . . . . . . . . . . . . . . . . . . . . .

Nevada . . . . . . . . . . . . . . . . . . . . . . . . . .

NewHampehira . . . . . . . . . . . . . . . . . . . .

NawJersey . . . . . . . . . . . . . . . . . . . . . . .

New Mexico . . . . . . . . . . . . . . . . . . . . . . .

New York. . . . . . . . . . . . . . . . . . . . . . . . .

North Carolina . . . . . . . . . . . . .

North Dakota . . . . . . . . . . . . . . . . . . . . .

Ohio. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oklahoma . . . . . . . . . . . . . . . . . . . . . . . .

Oregon . . . . . . . . . . . . . . . . . . . . . . . . . .

Pennsylvania . . . . . . . . . . . . . . . . . . . . . .

RhodeIsland . . . . . . . . . . . . . . . . . . . . . .

South Carolina . . . . . . . . . . . . . . . . . . . . .

South Dakota . . . . . . . . . . . . . . .

Tennessee . . . . . . . . . . . . . . . . . . . . . . . .

Texas . . . . . . . . . . . . . . . . . . . . . . . . . . .

Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Vermont . . . . . . . . . . . . . . . . . . . . . . . . .

Virginia. . . . . . . . . . . . . . . . . . . . . . . . .

Washington . . . . . . . . . . . . . . . . . . . . . . .

WestVlrglnla . . . . . . . . . . . . . . . . . . . . . .

Wleconsln . . . . . . . . . . . . . . . . . . . . . . . .

Wyoming. . . . . . . . . . . . . . . . . . . . . .

302,820

2,545

149

3,692

1,815

54,722

3,698

2,298

500

1,408

27,529

4,532

2,267

1,429

3,084

1,396

4,340

810

3,442

697

2,768

2,373

5,767

18,190

5,017

1,131

7,556

1,101

2,005

812

1,329

8,474

1,501

27,544

15,321

910

4,234

1,435

6,866

23,811

920

4,810

331

3,799

3,899

1,250

1,830

10,296

8,489

1,996

6,464

436

267,514

2,351

146

3,150

1,681

48,446

3,421

1,981

304

1,082

22,617

3,978

1,289

1,135

2,984

1,289

3,861

754

3,018

841

2,541

2,233

5,538

16,331

4,502

930

6,887

961

1,942

612

1,204

6,938

1,412

25,145

13,589

793

3,800

1,349

5,717

21,210

574

4,146

305

3,440

3,425

962

1,679

9,558

7,374

1,819

6,110

382

182,469

1,328

15

2,291

1,051

35,384

2,569

1,330

175

414

17,953

2,728

849

835

1,685

603

1,637

245

1,846

67

1,834

1,318

3,023

10,579

1,178

554

4,237

793

1,349

400

831

4,186

520

16,660

10,099

683

1,908

557

4,814

16,271

306

2,704

175

2,507

2,158

816

1,285

6,810

5,233

1,428

3,913

273

68.2

56.5

10.3

72.7

f.i2.5

73.0

75.1

67.1

57.6

38.3

7’9.4

68.6

65.9

73.6

56.5

46.8

42.4

32.5

61.2

10.5

72.2

59.0

54.6

64.8

26.2

59.6

61.5

82.5

69.5

65.4

74.0

60.3

36.8

66.3

74.3

86.1

50.2

41.3

84.2

76.7

53.7

65.2

57.4

72.9

63.0

#4.8

76.5

71.3

71.0

76.5

64.0

75.4

NOTES:Excludesboardandcare hornmforthe mentaliyretarded.Excludesnonreapondingboardandcare homes.
Advance Data No. 266 ● September19,1995 7

Table 7. Number of residents 65 years of age and over in nursing homes: United Statee, 1991

Raafdants Rasidants Percent of al residents

State Ras/dents Wh reported age 65 years of age and over 65 yearsof age and over

United States............,..

Alabama . . . . . . . . . . . . . . . . . .

Alas . . . . . . . . . . . . . . . . . . .

Artzona . . . . . . . . . . . . . . . . . . .

Arkansas . . . . . . . . . . . . . . . . . .

California . . . . . . . . . . . . . . . . .

Colorado . . . . . . . . . . . . . . . . . .

Connecticut . . . . . . . . . . . . . . . .

Delaware . . . . . . . . . . . . . . . . . .

DIaWc40fColumbia. . . . . . . . . . .

Florfda . . . . . . . . . . . . . . . . . . .

Georgia . . . . . . . . . . . . . . . . . . .

Hawaii . . . . . . . . . . . . . . . . . . .

Idaho. . . . . . . . . . . . . . . . . . . .

Illlnols. . . . . . . . . . . . . . . . . . . .

Indiana . . . . . . . . . . . . . . . . . . .

lowa . . . . . . . . . . . . . . . . . . . . .

Kansas . . . . . . . . . . . . . . . . . . .

Kentuc~ . . . . . . . . . . . . . . . . . .

Louisiana . . . . . . . . . . . . . . . . . .

Mane. . . . . . . . . . . . . . . . . . . .

Maryland . . . . . . . . . . . . . . . . . .

Maasachusatts . . . . . . . . . . . . . .

Midrlgan . . . . . . . . . . . . . . . . . .

Minnesota . . . . . . . . . . . . . . . . .

MisaPsippi . . . . . . . . . . . . . . . . .

Missouri . . . . . . . . . . . . . . . . . .

Montana . . . . . . . . . . . . . . . . . .

Nebraska . . . . . . . . . . . . . . . . . .

Nevada . . . . . . . . . . . . . . . . . . .

NewHampshire . . . . . . . . . . . . .

NewJersey . . . . . . . . . . . . . . . .

New Mexico . . . . . . . . . . . . . . . .

NewYork . . . . . . . . . . . . . . . . . .

NorlhCarolina . . . . . . . . . . . . . .

Nortfr Dakota . . . . . . . . . . . . . . .

Onto. . . . . . . . . . . . . . . . . . . . .

Oklahoma . . . . . . . . . . . . . . . . .

Oregon . . . . . . . . . . . . . . . . . . .

Pennsylvania . . . . . . . . . . . . . . .

Rhodeletend . . . . . . . . . . . . . . .

South Carolina . . . . . . . . . . . . . .

SouIh Dakota . . . . . . . . . . . . . . .

Tennessee . . . . . . . . . . . . . . . . .

Texas . . . . . . . . . . . . . . . . . . . .

Utah.. . . . . . . . . . . . . . . . . . . .

Verrrwnt . . . . . . . . . . . . . . . . . .

Virginia . . . . . . . . . . . . . . . . . . .

Washington . . . . . . . . . . . . . . . .

West Virginia . . . . . . . . . . . . . . .

Wlsoonain . . . . . . . . . . . . . . . . .

Wyoming . . . . . . . . . . . . . . . . . .

Number

1,478,903

21,675

808

12,103

20,298

98,885

15,871

27,921

4,308

2,881

58,878

24,728

2,840

4,871

67,540

46,231

33,214

25,304

24,966

32,367

9,241

25,977

48,276

46,196

43,298

14,819

45,745

6,297

17,779

3,043

7,523

40,068

5,634

99,372

28,546

6,784

77,676

27,456

13,392

83,107

9,440

13,089

8,192

32,304

90,405

5,544

3,591

25,775

24,525

9,809

46,838

2,211

1,287,279

19,435

657

10,806

17,288

89,420

14,316

22,366

3,680

2,408

52,276

31,324

2,721

4,408

74,418

40,765

29,865

22,116

22,020

26,883

8,610

20,745

42,620

40,087

36,095

11,145

38,302

5,822

16,752

2,765

7,202

34,619

5,003

88W

24,827

5,365

68,252

24,984

11,262

71,095

8,524

11,807

7,378

28,277

77,246

5,037

3,137

22,567

20,985

8,236

40,150

2,118

1,188,308

17,972

517

9,931

15,650

79,388

13,017

20,651

3,378

2,246

48,628

28,407

2,504

3,997

66,207

37,140

28,524

20,435

20,283

23,934

8,229

19,081

39,s4s

36,643

34,054

10,355

35,866

5,4s0

15,736

2,434

6,S46

X2,325

4,602

83,060

22,307

5,868

62,560

23a

10,473

66,824

8,226

11,026

7,0&4

26,211

71,875

4,357

2,863

20,852

19,321

7,761

36,772

1,982

92.3

92.5

78.7

91.9

80.5

8S.8

80.9

92.3

92.3

93.3

84.9

90.7

92.0

90.7

69.0

91.1

95.2

92.7

92.1

89.1

95.6

92.0

93.5

91.5

%.3

92.9

93.1

82.5

93.9

88.0

95.1

93.4

92.0

84.1

82.3

95.4

91.7

92.8

93.0

84.0

96.5

92.6

95.7

92.7

83.0

86.5

W.5

92.4

92.1

84.2

91,6

93.8
8 Advance Data No. 266 ● SeDtember 19, 1995

Technical notes

Creating a mailing list

The 1991 NHJ?I was a mail survey

conducted by NCHS. The inventory’s

mailing list of home health me

agencies and hospices contained 14,089

addressev the mailing list of nursing

homes and board and care homes

(iicluding those for the mentally

retarded) contained 73,106. Both the

agency and facility lists were

constructed using NCHS’s Agency

Reporting System, which is an ongoing

system designed to update periodically

the NHPI listings (5).

Mail survey

The Bureau of Census under an

interagency agreement with NCHS

served as the data collection and

data-processing agent. Three

questionnaire mailouts plus a field

followup were used to complete the

inventory. At the end of the mail survey,

refusrds, postmaster returns, and

nonresponses were contacted by

telephone. Also contacted were places

who did not respond to questionnaire

items considered critical for selecting

samples for the Long-Term Care

Component of the National Health Care

Survey (6).

Because of the large number

(17,156) of nonresponding board and

care homes, resource constraints made it

possible to follow up only one-half of

these non.mspondents. As a result,

nonresponding board and care homes

will not be included in the data

presented in this report.

Results of mail survey

Home health care agencies and

hospices

Of the 14,089 agencies to which

questionnaires were mailed, 7,804

responded and classified as home health

agencies or hospices. Of tie remaining

6,285, 116 agencies were

nonrespondents, and 6,169 agencies

were out of scope or not in operation

(questionnaks were returned by the

post office ancl/or field interviewers were

unable to locate by telephone). The

overall agency response rate was

98.5 percent. The numerator is 7,804,

the numkr of responding agencies. The

denominator is 7,920, the number of

responding agencies plus 116 rei%sing

agencies and nonresponding agencies.

Nursing homes and board and

care homes

The facility response rate, excluding

those board and care places not in the

followup, was 99 percent (there were

262 refusals). If the 8,578 were counted

in the calculation as in business and

nonresponses, the response rate for

facilities would be 84 percenh Because

some of these 8,578 agencies were

either out of sco@ or out of business,

the response rate was probably

somewhat higher than 84 percenL

Classification system

Home health care agencies and

hospices

NCHS classified the 7,804 agencies

using the questionmdre item “type of

client.,” The client data were used

because they allowed for the

classification of the largest numbers of

agencies into either the home health

care agency category (6,797) or hospice

category (943), with only 64 agencies

remaining in the category of agencies

providing both home health and hospice

care. Based upon additional information

in an agency’s recorcl 56 of the

agencies providing both home health

and hospice care are included with

home health agencies, and 8 are

included with hospices.

Nursing homes and board and

care homes

Excluding the 8,578 nonrespondmg

board and care homes and the 262

facilities that refused to participate, each

of the remaining facilities was classiikd

as either a nursing home (15,511) or a

boafd and care home (31,431). For

pwposes of this survey, no faciMies for

the mentally retarded were classified as

nursing homes. However, if a facility

was primarily a nursing home and

happened to be certilied as an

intermediate care facility for the

mentally retarded (ICF–MR), it would

have been classified as a musing home.

As a result this tile contains 24 nursing

homes that were also ICF–MR’S, and

11,204 board and care homes that were

not ICF-MR facilities for the mentally

retarded. The classification system used

to separate nursing homes from board

and care homes relied heavily on criteria

such as the respondent’s categorization

of the home, the home’s certification,

the number of beds setup and sta&d

for use, the employment of registered

nurses or licensed practical nurses, the

services provided, and the number of

mentally retarded patients.

Note that a more detailed technical

notes section for the 1991 NHPI is

included in other reports (1,3).

Definitions

Home health care agency-An

agency providing health services to

individuals in their homes for the

purpose of (a) promoting, maintaining,

or restoring healti, or (b) maximizing

the level of independence, while

minimizing the effects of disability and

illness (including terminal illness).

Hospice—An agency providing

specialized services for terminally ill

people and their families, including

medical services, social and emotional

support for patients and families,

volunteer suppxl and bereavement

services for families following the death

of the patient.

Nursing homes— A nursing home is

a facility with three beds or more that is

either licensed as a nursing home,

certified as a nursing facility under

Medicare or Medlcaidj identified as a

nursing care unit of a retirement center,

or determined to provide nursing or

medical care.

Board and care lzomes-This

generic term describes a residentird

setting that provides either routine

general protective oversight or

assistance with activities necessary for

independent living to physically limited

persons (excludes those for the mentally

retarded).

Rural-urban continuum codes for

metropolitan and nonmetropolitan

counties—These codes are based on the

1990 census. Rural counties included

nonmetropolitan counties that had an
Advance Data No. 266 ● September 19, 1995 9

urbanpopulationfewer than 2,500.

Urban countiesincluded countiesnot

consideredrural. Nonmetmpolitan

countiesare those countiesthat are not

consideredmetropolitan.Metropolitan

areas, as definedby the Officeof

Managementand Budget include core

countiescontaininga city of 50,000 or

more people and a total area population

of at least 100,000.Additionrd

contiguouscounties are included in

metropolitanareasif they are

economicallyand sociallyintegrated

with the core county (7).

Geographicdivisions-The U.S.

Bureau of the Census groupsthe 50

States plus the District of Columbia”into

the followingdivisions:

Diviswn

New

England

Mkldle

Atlantic

East North

Central

WestNortlI

Centml

Statesincluded

Connecticut Maine,

Massachusetts,New

Hampshire,Rhode Island

Vermont

New Jersey,New York,

Pennsylvania

Illinois,Indiana

Michiga Ohio,

Wisconsin

Iowa KW=, MiIUleSO@

Missouri, NeNorth Dakott& South

Dakota

south

Atlantic

Eastsouth

Centrrd

west south

central

Mountain

Pacitic

Delaware,District of

ColumbiajFlorim

GeorgiajMarylandjNorth

Carolilq south Carolina

Virgini%WestVirginia

AlabamiLKentucky,

Mississippi,Tennessee

Arkansas,Louisia@

OklahomajTexas

Arizon%Colorado,Idaho,

Mon~ Nevac@New

Mexico, Utah, Wyoming

AlaSk& caIiforn@

Hawaii, Oregon,

Washington
10 Advance Data No. 266 ● September 19, 1995

Symbols

--- Data not available

. . . Category not applicable

Quantity zero

●

Figure does not meet standard of

reliability or precision (more than

30-percent relative standard error

in numerator of percent or rate)

*_ Figure does not meet standard of

reliability and quantity zero
Number 267 ● August 8, 1995

Advance

1

Data

From Vital and Health Statistics of the CENTERS FOR DISEASE CONTROLAND PREVENTION/National Center for Health Statistics

Office Visits to Neurologists: United States, 1991-92

by Susan M. Schappert, M.A., Division of Health Care Statistics

Introduction

During 1991–92 an estimated 14.5

million visits were made in the United

States to nonfederrdly employed

office-bssed physicians speeirdizing in

neurology, the diagnosis and treatment

of disor&rs of the nervous system-an

average of 7.3 million visits per year.

This report summarizes data pertaining

to office vM.s to neurologists in terms

of physician practice characteristics,

patient characteristics, and visit

“characteristics.

The information presented in this

report is based on data collected by the

National Ambulatory Medical Care

Survey (NAMCS), a national probability

sample survey conducted by the

Division of Health Care StatisticS of the

National Center for Health Statistics,

Centers for Dkase Control and

Prevention. This survey was conducted

yearly from 1973 through 1981, again in

1985, and has resumed an annual

schedule with the 1989 survey.

The 1991 and 1992 NAMCS shared

identical survey instruments, definitions,

and proeednres. The resulting 2 years of

data have been combmed to provide

more reliable estimates, and the reader

should note that the estimates, percent

distributions, and rates presented in this

report reflect average annual estimates

based on the combined 1991 and 1992

dam unless otherwise stated. Figure 1

shows the Patient Record form, which is

the sumey instrument used by

participating physicians to nxord

information about their patients’ office

visits.

Only visits to the offices of

nonfederally employed physicians who

were classified by the Ameriean Medical

Association or the American Osteopathic

Association as “office-base~ patient

care” were included in the NAMCS

sample. Viiits to private nonhospitalbased clinks and health maintenance

organizations wem considered to be

within scope of the survey, but those

that took place in government-operated

facilities wem not. Physicians

specializing in anesthesiology,

pathology, or radiology were not

included in the sample, nor were v~lts

to hospital-based physicians or

physicians primarily engaged in training,

resemch, or administration. Telephone

ccmtsets and visits made outside the

physician’s office were also excluded.

The National Hospital Ambulatory

Medical Care Survey (NHAMCS)

collects patient and visit data horn

hospital-based outpatient departments

and emergency departments. Results

horn that survey are available in other

published rOpOrtS(1+.

It is necessary to keep in mind that

the estimates presented in this report are

based on a samplG rather than on the

entire universe of office visits, and as

such, they are subject to sampling

variability. The Technical notes at the ‘

end of this report dkcuss briefly the

sample design, sampling errors, and

guidelines for judging the precision of

NAMCS estimates. Additional

publications summarizing NAMCS data

from 1991 and 1992 are available (5-7).

Physician practice

characteristics

Onaverage, 2.9 visits per 100

persons per year were ma& m

neurologists during 1991 and 1992

(tabIe 1). This specialty reeeived

1.0 pereent of all office visits made to

ambulatory care physicians during the

2-yem period.

Viiit rates did not differ by

gqraphic region, except that the West

had a higher annual vi.4t rate (3.8 visits

per 100 persons) than did the Northeast

(2.4 visits per 100 persons). The

majority of neurology visits

(95.4 pereent) wexe made to doetms of

medlcirq 4.6 percent were made to

doctors of osteopathy (table 2).

Patient characteristics

Visks to neurologists are shown by

patient’s age, sex, and race in table 3.

The visit rate was significantly higher

for pemons 25 years and over compmed

with those under age 25. However, no

-u+/

#+ *

4

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

[

Public Health Service

Centers for Disease Control and Prevention

L=

National Center for Health Statistics CENTERS CDC FOR DISEASE CONTROL

AND PREVENTION
& -“.”,,”” ““.- m.”. -“. - n“~””. “, . ““”

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pwaons●ngageaIn and far tha WP08.8 of Ihe S.W9Y ..6 w not b. dh.1.nd m Publk HeatthSwvlco rblm,.d to Bthw P8r.on ,0, us,d fc+anyathm,P“,Prme. NUIOMI OMtu for Hedkh8Ut18N0S ID

L DATEOF VISIT

._/-&

PATlENT RECORD OMB No. 0920-0234

NATIONAL AMBUIJiTORY MEDICAL CARE SURVEY Explre8 4-30-93

Month Day CDC 64.21 D

2. DATE OF BIRTH 4. COLOR OR RAOE 5. =HNICITY & EXPECTED SOURCE(S) OF 7. WAS PATlENT S. 1STHIS VISIT

~ 1❑ Wlllta

PAYMENT [Check .!! rhar tlpp!y] REFERRED FOR INJURY RELATED?

Hlspanio t ❑ HMO/olhW prepaid $ ❑ ~~=~al THIS VISkT BY

~❑ afgl” ANOTHER laYSa 2UN0

I

2 ❑ Black

2 ❑ Medicara 6 D Patient Pdd PHYSICIAN?

3. 95X *ian I PaoIfiIJ Not 9. DOES PATIENT

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1❑ Y46

4 ❑ Eddmo / Almd ● ❑ Otfmr gowrnmant a ❑ Other 20N0 3 ❑ Unknown

20N0

10. PA71EN7W COMPLAINTS) SYMPrOM S),

4

11. PHYSICIAN’S DkAGNOSES

OR OTHER REASON(S) iOh THIS VfS

12. HAVE YOU OR 13. ::~;:vnEENT

ANYONE IN YOUR

[h parient’s own tuords]

.

PRACTICE SEEN !Check all tkt LW!J

- P$CbmdbCbm&/ PATIENT BEFORE? regardless of any entry

in itcm II]

,, MM1 lm#Oltnlt Wlmbnlos l~Y02 2DN0 i ❑ None of bdow

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14. AMBULATORY SURGICAL 1S. OIA~NOSlfC / SCREENING SERVICES

PROCEDURE(S) [Check .// ordered or prov{dciff

16. THERAPEUTIC SERVICES

[Check all ordered nrprovt&d. Krc!ude tnrdication]

[Record any ou#patic.t diognostm m T❑ None 11 ❑ Pap teat

rherapcudc proccdurc, For tkeprs#,

check appropriate ties.] 2❑ elood pmre 12❑ StreP threat test I ❑ Norm en DruoabIM OTHER THERAPY

3 ❑ Urlm2tyds 13❑ HIV eerology 7❑ Atcohol abusa

4 ❑ EKG - resting 14❑ Chdederd meaeura plmou;;G / 13❑ P6ychetherapy

8. s❑ EKG - exercise {5 ❑ Othdf lob ted 8❑ SmOIdng costion !4 IJ Corractivz 1217263

I ❑ Soheduled 3❑ l-owl anedhszia 0❑ Mamm0gr2m 16❑ Hemkng tsti 2 ❑ ebt is ❑ Hearing aid

9 U Family/ SOdat

2 ❑ Performed 4❑ Regional an+sthosia 7❑ Che6t X-!lly 170 Vi21d 2@ity 3 ❑ E.XWC123 16❑ Phydothe.mpy

10❑ GIuwth / davalopmant

s❑ General anesthem 6❑ Other 7d0bgY I B❑ M3ntal 2katu3 exam 4 ❑ Cholesterol reduction !7 I_J Othm fhzmpy {SPCC(BJ

1S~ Other /Spc@y] t? ❑ Family planning

9 ~ ASWJY tektrng 5 ❑ Wo&M mduoOon

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b

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17. MEDICATION if none, chook here ❑ a. N-w modlastlcm? la. DISPoslnON THIS ~~

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[Re.ord all new Yax M

[Check all that apply]

or cnnfhnwd

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medication 1<

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ordered or In 2CI spcttt wl:h

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thk vim’r. L%*

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nameor generic

name enterzd on

4 a Telephone follow-up plmnod

any R.x or @ice 3. ~El 2C s❑ Referred to afhor phyzician

medtcal record.

Include imnnmtmkr 6 ❑ Rztumed 10 roferfing physician

and desensidzing 4. II--J 2E

agents.] 7 ❑ Mmtt to hospital

5. lo 21-J 8 I-J Othzu[Spccfy] Mlnutek

..-. 4 m-as --• “---.J s-—

significant dtierences were noted among

visit rates for those in the age groups

2444 years, 45-64 years, 65–74 years,

and 75 years and over. In addition, visit

rates for persons under 15 years and

15–24 yesrs of age did not dtier

significantly from eaeh other. Females

had a higher visit rate to neurologists

than did males (3.3 visits per 100

females per year compared with 2.5

visits per 100 males). Significant

differences were cotined to the age

group 25-44 years, with females in that

group making 4.0 visits per 100

compared with 2.3 visits per 100 males.

White persons had a significantly higher

rate of visits to neurologists (3.2 visits

per 100 persons per ye@ than did black

persons (1.6 visits per 100 pemons per

year).

Persons 254 years of age

accounted for more than one-third

(35.3 percent) of all offim visits to

neurologist& those 44 years and over

amounted for slightly less than half of

the visits (46.1 percent). Females made a

higher proportion of visits to

neurologists than did males, 58.0 percent

and 42.0 percenq respectively. White

persons made 91.1 pereent of the visits

to this SpCCidty, and black pkXSOIIS

accounted for 7.0 percent.

Visit characteristics

Referral status and prior-visit

status

Nearly one-third (30.2 percent) of

office visits to neurologists ‘werethe

result of a refenal by another physician

compared with 6.0 percent of the visits

to all other physicians (figure 2). While

60.5 percent of neurology visits were

made by patients returning for care of a

previously treated problem, more than

one-third (35.8 percent) were made by

new patients. In comparison, only

15.5 percent of the visits to all other
Advance Data No. 267 ● August 8, 1995 3

Table 1. Annual number, percent distribution, and rate of office visits by physician

specialty, averaged over a 2-year period United States, 1991-92

Nutrber of

Number of vk/ts per

tisik fn Percent 100 parsons

Phys/ckur speclatly thousands dktdbuf/on per yea+

Allvisifs . . . . . . . . . . . . . . . . . . . . . . . 715,867 100.0 266.3

Genersl and femify pracifoe . . . . . . . . . . . 192,051 26.8 76.8

Internal madidne . . . . . . . . . . . . . . . . . . 101,598 14.2 40.6

Pediattisa . . . . . . . . . . . . . . . . . . . . . . 65,387 11.9 34.1

Obstettfos end gynecology. . . . . . . . . . . . 62,601 8.7 25.0

Ophthalmology . . . . . . . . . . . . . . . . . . . 43,864 6.1 17.5

Orthopedic surgery . . . . . . . . . . . . . . . . . 36,958 5.2 14.8

Dermatology . . . . . . . . . . . . . . . . . . . . . 2e,l 79 4.1 11.7

Generafsurgety . . . . . . . . . . . . . . . . . . 22,797 3.2 9.1

Otoleryngology . . . . . . . . . . . . . . . . . . . 21,007 2.9 a.4

Paychlatry . . . . . . . . . . . . . . . . . . . . . . 17,769 2.5 7.1

Urologicafsurgery . . . . . . . . . . . . . . . . . 13,857 1.9 5.5

Cerdioveecufardiseeees. . . . . . . . . . . . . 13,146 1.8 5.3

Neurology . . . . . . . . . . . . . . . . . . . . . . 7,253 1.0 2.9

Aflotherspecfaftfss . . . . . . . . . . . . . . . . 66,382 9.6 27.3

lBawd on U.S. Bureau of the Census estimates of the civilian, noninstifutimalized populaticm of the Unled States for Jup 1,

1991, and July 1, 1992, averaged over the 2-year period.

Table 2. Annual number, percent distribution, and rate of offfce visits to neurologists by

selected physician praotice characteristics, averaged over a 2-yeer period United States,

1991-92

Physkfan pl%tdke Number of vkffs Percenf Number of Wslfsper

characfetfstkx in thousands dkfribufion 100 persons peryea+

Allvfaifs . . . . . . . . . . . . . . . . . . . . . . . 7,253 100.0 2.9

Geographic region

Northeast . . . . . . . . . . . . . . . . . . . . . . 1,191 16.4 2.4

Midwest . . . . . . . . . . . . . . . . . . . . . . . 1,815 25.0 3.0

South . . . . . . . . . . . . . . . . . . . . . . . . . 2,172 20.0 2.6

west . . . . . . . . . . . . . . . . . . . . . . . . . 2,076 28.6 3.8

Professional fdentlfy

Dooforofmedklne . . . . . . . . . . . . . . . . . 6,921 95.4 2.8

Oostorofoskopathy . . . . . . . . . . . . . . . 332 4.6 0.1

‘Basedon U.S,Bureau oflheCensusestirnates ofthecivilian, noninstitutiinalimd pc.pu!@ionofthe UnitedStatesfor Ju&l,

1S31, arxl July 1, 1SS2, averaged over the 2-year pericd.

physicians were by new patients

(figure 3). Visits by referral statm and

prior-visit status are summarimd in

table 4.

Expected sources of payment

Private insurance was an expected

source of payment at nearly one-half

(44.4 percent) of all visits to

neurologists compared with one-third

(34.1 percent) of visits to all other

specialties. Medicare was an expected

pay soume at one-lifth of all neurology

visits (21.8 pereent). Data on expected

sources of payment are shown in

table 5. It should be noted that more

than one expected source of payment

could be reeorded per visit.

Patient’s principal reason for visit

Table 6 shows the patient’s

principal reason for visiting the

physic@ according to the eight

modules, or groups of reasons, outlined

in A Reasonfor VisitClassi$catwnfor

Ambulatory Care (WC) (8). Principal

reason for visit (item 10s on the Patient

Record form) is the patient’s most

important complaint(s), symptom(s), or

other reason(s) for this visit expressed in

the patient’s (or patient’s

spokesperson’s) own words. Up to three

rea30ns per visit may be coded based

upon the classification system found in

the RVC.

Eight out often visits to this

specialty (81.1 pereent) were due to a

symptomatic problem or complain4 with

the largest proportion of symptoms

being those referable to the nervous

system (excluding sense organs)

(43.3 percent). Musculoskeletal

symptoms were listed at 22.9 percent of

the visits.

Specific reasons for visit are listed

in table 7. The single most frequently

mentioned principal reason for visiting

the neurologist was headaehe or pain in

hea~ amounting for 18.4 percent of the

visits. A higher proportion of visits by

females were for this rea30n

(22.5 percent) compared with males

(12.7 percent). Convulsions, mentioned

at 9.1 percent of visits, was the second

most frequent reason, followed by

disaubances of sensation (5.5 percent).

It should be noted that estimates that

differ in rank order may not be

signiticzmtly dtierent fmm each other.

Diagnostic services

About one-third of all visits to

neurologists included no diagnostic or

sermning seMces; 4 of every 10 visits

(42.2 pereent) included one semice. The

most frequently mentioned speeilic

category was blood pressure check

which was reported at more thsn

one-third of the visits (37.3 percent).

Mental status exams were more

likely to be ordered or provided at visits

to neurologists compared with visits to

all other physicians (8.8 pereent and

1.1 pemen~ respectively), as waa “other

radiology” (radiology other than chest x

ray). Unspecified diagnostic services

were reported at 29.6 percent of all

visits to neurologists. Table 8 displays

vMs by the number and we of

dmgnostic services ordered or provided.

Principal diagnosis

Data on pMeipal diagnoses

rendered at office visits are obtained

from item 1la of the Patient Record

form where physicians are asked to

record the prineipsl dkgnosis asoeiated

with the patient’s most importmt reason

for visit. Dhgnoses are classified and

coded according to the lnternatitmal

Classi$catwn of Diseases, 9th Revisiofi

ClinicalModification(ND-9-CM) (9).
4 Advance Data No. 267 ● August 8, 1995

Table 3. Annual number, percent distribution, and rate of offtoe visits to neurologists by

selected pattent characteristics, averaged over a 2-year period: United States, 1991-92

Number of Weltrate

tidk In Percent

Patient characteristic

per 100

thousands distribution parsons’

AIIvIsIW. . . . . . . . . . . . . . . . . . . . . .

Age

Under 15years . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . .

25-44years . . . . . . . . . . . . . . . . . . . . .

45-64yeare . . . . . . . . . . . . . . . . . . . . .

65-74yeara . . . . . . . . . . . . . . . . . . . . .

75yesrsandover . . . . . . . . . . . . . . . . .

Sex end age

Female . . . . . . . . . . . . . . . . . . . . . . .

Under15years . . . . . . . . . . . . . . . . .

15-24yeafa . . . . . . . . . . . . . . . . . . .

X-44years. . . . . . . . . . . . . . . . . . .

45-64years . . . . . . . . . . . . . . . . . . .

65-74yeare . . . . . . . . . . . . . . . . . . .

75yearaandover . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Under15yeare . . . . . . . . . . . . . . . . .

15-24years . . . . . . . . . . . . . . . . . . .

25+4years . . . . . . . . . . . . . . . . . . .

45-64yeers . . . . . . . . . . . . . . . . . . .

65-74yeaIs . . . . . . . . . . . . . . . . . . .

75yeemandover . . . . . . . . . . . . . . .

Race

While . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . .

Asian/PacificIslander . . . . . . . . . . . . . . .

AmericanlndlaniEsldmo/Aleut. . . . . . . . .

7,253

770

577

2,559

1,663

820

633

4,2i O

329

312

1,647

1,071

441

410

3,044

442

265

912

622

380

224

6,605

508

113

“27

100.0

10.6

8.0

35.3

26.1

11.3

8.7

58.0

4,5

4.3

22.7

14.8

6.1

5.6

42.0

6.1

3.7

12.6

11.3

5.2

3.1

91.1

7.0

1.6

“0.4

2.9

1.4

1.7

3.2

4.0

4.5

5.2

3.3

1.2

1.6

4.0

4.3

4.3

5.4

2.5

1.5

1.5

2,3

3.6

4.6

4.9

3.2

1.6

---

---

‘Visit rates are besed on U.S. Bureau of tha Census esth’nates of the oMlien, noninstilufhalized U.S. population for July 1,

1991, and July 1, 1S32, averaged ovar the 2-year period.

More than one-third (36.1 percent)

of allvisita toneurologktsr esultedina

principal diagnosis that was clmsifiable

toadiseaseofthe nervoussystemand

senseorgans(table 9).Almutone-fifth

of the visits (21.3 percent) were

reeordedas “symptoms, signs, and

ill-defined conditions.” Dkasesofthe

musculoskeletal system andcmmective

tissue accounted for 14.6 percent of the

visits.

The top 20 principal diagnoses at

visits toneurologists areshownin

table 10. The mostfrequently listed

specitic d~gnosis was “generrd

symptoms’’(ICD-9-CM code780),

occurringat13.3 percentofvisits .This

catego~ falls within the larger

classification of ’’symptoms, signs, and

ill-defined conditions” ofthe ICW9–

CM. This classification includes signs

and symptoms for whlchno more

specilic dmgnosis can be made even

after investigation of the facts, transient

symptoms whose causes could not be

determined provisional diagnoses, cases

referred elsewhere before a diagnosis

was made, cases in which a precise

diagnosis was unavailable for any other

reason, and certain symptoms that

represent important problems in medical

care and that might be desired to

classify in addtion to a known cause.

General symptoms (ICD-9-CM code

780) may include any of the following

subcategories coma and stupor,

hallucinations, SytlCOpe (fainting) and

collapse, convulsions, dizziness and

giddiness, sleep disturbances, pyrexia

(fever) of unknown origin, malaise and

fatigue, hyperhidrosis (exeessive

sweating), and other general symptoms.

Among the neurology visits reported

here, convulsions (ICD-9-CM code

780.3) accounted for more than

three-quarters of the “general

symptoms” diagnoses.

The second and thiid most

frequently reported dmgnoses at

neurology visits were migraine

(10.3 percent) and symptoms involving

head and neck (5,7 percent). A higher

proportion of visits by females listed

diagnoses of migraine and symptoms

involving head and neck than did visits

by males. (Among visits with the latter

diagnosis, 97.1 percent were coded to

ICD-9-CM subcategory 784,0,

headache). Parkinson’s dkease, which

accounted for 4.6 percent of the visits

overalL was listed at 6.6 percent of

visita by males compared with

3.1 percent of visits by females. The

most tiquently reported diagnoses by

age group are presented in table 11.

Inttxwtingly, one-fifth (19.8 percent)

of visits to neurologists were reported to

be injury related in item 13 of the

Patient Reeord form eompamd with

about one-tentl (9.1 percent) of visits to

all other physicians. This is not readfly

apparent from an examination of the

reported ICD–9-CM codes, however, as

only 6.7 percent of neurology visits

were classified to the “injury and

poisoning” category of the ICD-9-CM.

Therapeutic services

Table 12 presents data on

therapeutic services ordered or provided

at visits to neurologists. Medication

therapy was mentioned at nearly

two-thirds of the visits (63.7 percent),

and nonmedication therapy was ordered

or provided at more than one-quarter of

the visits (27.9 percent). The most

frequently mentioned types of

nonmedication therapy included “other

counseling” (8.0 percent), exercise

counseling or education (7.1 percent),

physiotherapy (6.4 percent), and diet

counseling or education (5.2 percent).

Ambulatory surgery was scheduled or

performed at 1.3 percent of visits to

neurologists, significantly less than the

corresponding 6.1 percent of visits to all

other physicians.

Tables 13, 14, and 15 p~sent more

detailed drug data relating to neurology

visi@ As used in the NAMCS, the term

“drug” is interchangeable with the term

“medication” and includes all new or

continued medications ordered or

provided at the visit. This includes both

prescription and nonprescription

preparations, immunizing agents, and

desensitizing agents. “Drug mentions”

refer to the total number of medications
Advance Data No. 267 ● August 8, 1995 5

Physician specialty

Neurology 30.2

General surgery

Orthopsdio surgery

Otolaryngology

Urological surgery

Ophthalmology

Dermatology

Oardiovasular

dseaeas

Psychiatry

Obstetrics and

gynecology

Other

I 1 I I I 1 1 I

o 5 10 15 20 25 30 35 40

percent of otica visits

lure 2. Percent of offfce visits that are referrals, according to physician specialty:

Iited States, 1991-32

Physician specialty

Neurology 35.8

Otolafyngology

Orthopwlic surgery

General surgery

Dermatology

Urological surgery

Ophthalmology

Psychiatry

Obstetrics and

gynecology

General and family

cwdo:~$e:

Internal mediane

Pediitriis

Other

I I I I

o 10 20 24) 40

Percent of office visits

Figure 3. Percent of offfce visits made by new patients, according to physician specialty:

United States, 1991-92

Wed in item 17 of the Patient Record

form. Physicians may record more than

one medication per visi~ so that the

total number of drug mentions may

exceed the total number of visits. “Drug

visits” refer to visits with at least one

mention of medkation ordered or

provided by the physician. An earlier

report destibes in detail the method and

instruments used in the collection and

processing of NAMCS drug data (10).

Among visits to neurologists, there

was an average of 8.1 million drug

mentions per year for 1991 and 1992,

yielding 1.8 mentions per drug visit and

1.1 mentions per visit overall. Table 13

shows the number of drug mentions by

therapeutic classification, adapted from

therapeutic categories used in the

N&-onal Drug Code, 1985 edition (11).

In cases where a particular drug was

classifiable to more than one therapeutic

category, it was listed under the

category that ocamed with the greatest

frequency. Necrologic drugs

(25.9 percent), drugs used for pain relief

(22.4 percent), and psychopharmacologic

drugs (20.2 percent) were reported most

fkquently, together accounting for abut

two-thirds (68.5 percent) of the drugs

mentioned at visits to neurologists

The generic substances used most

frequently in medications ordered or

provided at neurology visits are shown

in table 14. Acetaminophen was the

most frequently occurring substance

(8.3 percent of mentions), followed by

carbamazepine (6.0 pement) and

amitriptyline (4.9 percent). It should be

noted that drugs containing more than

one ingredient are listed in the data for

each ingrdlenL For example,

acetaminophen with codeine would be

listed both under the count for

acetaminophen as well as the count for

codeine.

Table 15 displays drug mentions

according to entry name, that is, the

name recorded by the physician in item

17 of the Patient Record form. This

couId be a trade name, generic name, or

simply a desired therapeutic effect.

Tegretol was the specific entry listed

most tkquently (6.0 percent of

mentions), followed by Dikmtin

(4.3 percent) and Sinemet (3.5 percent).

Dispositionof visit

Viits to neurologists were more

likely to include insfruetions to return at
6 Advance Data No. 267 ● August 8,1995

Table 4. Annual number end percent distribution of office visits to neurologists and to all

other physicians by patient’s referral status and prior-visit status, averaged over a 2-yaar

period: United States, 1991-92

visits to neurologkts Vkifs to all other physicians

Number of Nurrbar of

vkffs In Percent vkifs in Percent

WI draracterktlc thousands dkfrfbuflon thousands dktributlon

AIIvMs. . . . . . . . . . . . . . . . . . . . . . . 7,253 100.0 708,614 100.0

Referral status

Referred by another phyaldan. . . . . . . . . 2,189 30.2 42,598 6.0

Not raferred by another physklan. . . . . . . . 5,064 69.8 666,016 94.0

Prior-visit status

New patient . . . . . . . . . . . . . . . . . . 2,597 35.8 109,4e4 15.5

Otdpatient, newprobfem . . . . . . . . . . . . . 269 3.7 159,512 22.5

Oldpatient, old problem . . . . . . . . . . . . 4,386 60.5 439,608 62.0

Table 5. Annual number and percent distribution of office visits to neurologists and to all

other physlchms by patient’s expected source(s) of paymen~ avemged over a 2-yaar

period: United States, 1991-92

Wts to rreut’ologkts Vkits to all other phyakkns

Number of Number of

vkffs in Percent vklts In Percent

E@eded source(s) of payment’ thouean& dkfrfbutlon thousands dktdbutlon

Allvtsits . . . . . . . . . . . . . . . . . . . . . . . 7,253 100.0 708,614 100.0

Private/commerdal lnsuranca . . . . . . . . 3,220 44.4 241,927 34.1

Medkefs . . . . . . . . . . . . . . . . . . . . . . . 1,581 21.8 145,086 20.5

Patient-paid . . . . . . . . . . . . . . . . . . . . . 983 13.5 150,664 21.3

HMO/otherprepaidpten . . . . . . . . . . . . . 827 11.4 122,833 17.3

Medlcakf . . . . . . . . . . . . . . . . . . . . . . . 523 7.2 73,231 10.3

Othergovemment . . . . . . . . . . . . . . . . . 221 3.1 14,795 2.1

Nocharge . . . . . . . . . . . . . . . . . . . . . . 84 0.9 11,381 1.6

Other . . . . . . . . . . . . . . . . . . . . . . . . . 736 10.1 28,123 4.0

Unknown . . . . . . . . . . . . . . . . . . . . . . . 68 0.9 15,732 2.2

‘Tbtalmay excsedtotalnumbercf visitsbecausemomthanone categoryw ba reportedparvisit.

aspecifictime (70.5percent)than were

visit3toallother specialties

(62.3 percent). Also, a higher proportion

of these visits resulted in inslructionsfor

the patient toreturn tothereferring

physician (7.7 percent) compared with

visita to all other physicians

(0.9 percent). Thk is a reflection, to

some degree, of thelargemtmberof

referrakmade to this specialty relative

to other physician specialties. Data on

disposition of visit are displayed in

table 16.

Duration of visit

About three-quarters (73.3 percent)

of visits to neurologists lasted more than

15 minutes, compared with one-thiid

(32.3 percent) of visits to all other

physicians. Average duration of

neurology visita was 30.5 minutes

compared with 17.2 minutes for all

other visits. Average duration is based

on the time spent in direct face-to-face

contact between the physician and the

patient. It does not include visits of

“zero” minutes duration, that is, visits

in which the patient did not meet with

the physician directly. Data on duration

of visits are shown in table 17.

VMs to neurologists between

1975 and 1992

The overall number of visits to

neurologists increased by 283.3 percent

Table 6. Annual number and percent distribution of office visits to neurologists by patient’s principal reason for visitj averaged over a

2-year period: United States, 1991-92

Nutn5er of vklta Percent

Prtnc@al reason for VISHand RVC code’ In thousands dktrfbrftlon

Allvidts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,253 10CLO

synyiommodul e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S001-S999 5,881 81.1

Syrr@cme referable tc the nervcus system (excluding sense organs) . . .S200-S259 3,141 43.3

Syn@ome referable to the musculoskeletal system. . . . . . . . . . . . . . .S800-S999 1,662 22.9

Genarat symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S001-S033 508 7.0

symptoms referable to paytiologkaf and mental dleorders. . . . . . . . . .S100+199 262 3.6

Symptornerefereble totheeyesand aars . . . . . . . . . . . . . . . . . . . ..S300+399 193 ;~,7

symptoms referable to the respiratory system. . . . . . . . . . . . . . . . . .S400-S499 51 ().7

Allothersymptoms2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 ().9

Diaaase module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. DOO1-0999 459 6.3

Dtsgnostlo, screening, end preventive modute . . . . . . . . . . . . . . . . . . .XIBX599 95 “1.3

Treatment module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..TIOO-T899 362 5.3

Injury endadversee ffectsmodule . . . . . . . . . . . . . . . . . . . . . . . . . .. JOO%J993 83 “1.1

Teat resulta module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..RIOO-R700 58 0.8

Admlnktratfvemodule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A1BA140 ●6 “0.1

Other ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..U930-U999 289 4.0

‘Baaed on A ReasonforWit CkssfioatkmforAr?iwktofyCam (WC) (8).

%cludes symptomsreferableto the cardwascular and lymphaticsystem(S260-S299); aymptom$referabletothe d@st??esystem(S500-SS39);symptomsreferabletothe genitounnsrysystem

?%=MMs, woMem,sndco~lain& n@ekeWretisfid, Mtiofmne,”andilkgibleetin-.

S29~ andsymptorrareferableto the skin,hair,and nails(8S30-8SS3).
Advance Data No. 267 ● August 8,1995 7

Table 7. Annual number and percent distribution of office vleits to neurologlets by the 20

most frequently mentioned prlnclpal reasona for VISIL according to patlant’s sax, averaged over a 2-yaar period United States, 1991-82

Patient’ssex

Numberof visits

Prhro@a/masonfor visitand RVG code’ in thousands Total Male Female

Percent dletrbuflorr

Allvisifs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,253 100.0 100.0 100.0

Headache, pahrhshead . . . . . . . . . . . . . ..S210 1,334 18.4 12.7 22.5

Convulsions . . . . . . . . . . . . . . . . . . . . . ..S205 859 9.1 10.1 8.3

D18Wbenoes of .sensslion . . . . . . . . . . . . . .S220 397 5.5 5.5 5.4

Necksymptome . . . . . . . . . . . . . . . . . . ..S900 374 5.2 3.8 6.1

Backsymptoms . . . . . . . . . . . . . . . . . . ..S905 344 4.7 5.2 4.4

Vertigcdlzzinees . . . . . . . . . . . . . . . . . . ..S225 256 3.5 3.9 3.2

Progrees visit, nototherwise spactfied. . . . . . .T800 254 3.5 3.0 3.9

Legsymptome . . . . . . . . . . . . . . . . . . . ..S920 251 3.5 4.0 3.1

Abnormal hsvoluntery movements. . . . . . . . . .S200 239 3.3 4.7 2.3

Low backsymptoms . . . . . . . . . . . . . . . .. S910 198 2.7 3.2 2.4

Dieordersof motor functions. . . . . . . . . . . . .S095 135 1.9 1.6 2.1

Viskrndysfuncfkm s . . . . . . . . . . . . . . . ..S305 131 1.8 1.3 2.2

Hsndandfinger symptome . . . . . . . . . . . ..S960 117 1.6 1.2 1.9

Arrnsyrnptome . . . . . . . . . . . . . . . . . . . ..s945 113 1.6 1.7 1.4

Dtsturbancas of memory . . . . . . . . . . . . . ..S215 105 1.4 1.3 1.6

Migraine headache . . . . . . . . . . . . . . . . ..D385 85 1.2 ‘0.8 1.4

Shoukfersymptoms . . . . . . . . . . . . . . . . ..S940 84 1.2 1.2 1.1

Ganeral weakness . . . . . . . . . . . . . . . . . ..S020 84 1.2 “0.6 1.6

Disturbances ofslaep . . . . . . . . . . . . . . . ..S135 74 1.0 1.3 “0.8

Other diseases ofcantral nervous syetem . . . .D370 89 1.0 “1.1 0.9

Allotherreasons . . . . . . . . . . . . . . . . . . . . . . . 1,951 26.9 31.8 23.4

‘Basad on A Reason for WI Classikatim forArriwfatov Care (WC) (8).

Table 8, Annual number and percent distribution of office visits to neurologists and to all

other physicians by diagnostic services ordered or performed, averaged over a 2-yaar

period: United States, 1991-92

L&Its to S/l

W?Jtsto naurologkfs ofharphyakiens

Nurnbarof Number of

vfslfain Percent visitsin Percent

UlaftctraracterktIc thouaanc% dMribufIon ftrousande d&sfdbufion

Allvisfts . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nurrbar of diagnostic

services ordared or performed

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Two . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Three . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Four. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fiveormcre . . . . . . . . . . . . . . . . . . . . . . . . .

Diagnoatiosetvlces orderedorperformed’

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Blocdpreesurecheck . . . . . . . . . . . . . . . . . . . .

Urlnalysfs . . . . . . .. o....... . . . . . . . . . . .

EKGrestin& . . . . . . . . . . . . . . . . . . . . . . . . .

Olherradkrlogy . . . . . . . . . . . . . . . . . . . . . . . .

Cholesterol measure . . . . . . . . . . . . . . . . . . . . .

Otherlabtest . . . . . . . . . . . . . . . . . . . . . . . . .

Hearingtesl . . . . . . . . . . . . . . . . . . . . . . . . . .

Visrralawify . . . . . . . . . . . . . . . . . . . . . . . . . .

Menfalstsfusexsrw . . . . . . . . . . . . . . . . . . . . .

Otha# . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7,253 100.0 708,614 100.0

2,386 32.9 250,785 35.4

3,061 42.2 246,957 34.9

1,154 15.9 123,726 17.5

450 6.2 52,095 7.4

122 1.7 21,450 3.0

78 1.1 13,621 1.9

2,W8

2,702

130

86

602

42

977

66

165

6S8

2,196

32.9

37.3

1.8

1.2

8.3

0.6

13.5

0.9

2.3

6.8

30.3

250,765

307,770

95565

21,419

36,315

25,360

119,980

10,130

41,088

8,102

143,983

35.4

43.4

13.5

3.0

5.4

3.6

16.8

1.4

5.8

1.1

20.3

~Totalmayexcerrd totalnumberdvisifa baoausernorethan oneoatagoiymay baraporkfparvbit

%KQiselectmoardiimm.

%mf.lbwingdiagnostii serviceoategorbawara notraportadatviaiito naurdogiskalbrgytaeting, spironwt~andpaptaat.

Thefolbwhmdmmmafii senrbcetaowiae wammoorbdatvbita tonaurolookfs.but wifhfrawenoieathat waratoolowto

producerdi;bb&timataa: EKGaxekkm,mamrrw &am, atrapthmattes!c&f xrayandHIV(hunran irnmunodarkbmqvirua)

aarobgy lleseaarvkea havebeaninoludad inthe’’other”osbgory. Unspe%hsddmgnoetic sarvicasacewnted for29,6parcemt

ofallrepxfadservkaa atvbiifoneurolog.bta.

from a 2-year total of 3.8 million in

1975-76 to 14.5 million in 1991-92.

The 1975-76 toml represented

approximately 0.3 percent of all visit8 to

office-based physicians during that time

period. The1991-92 share, l.OpercenL

was signhicantly higher. According to

data tiom the American Medical

Association there were 6,257

nonfederally employedr office-based

neurologiws in the United State3

(excluding possessions) in 1992

compared with l,847in 1975, an

increase of 238.8 percent (12,13).

The rate of visits m neurologists

increawif romanaverageof 0.9 visit3

per 100 persons per year in 1975-76 to

2.9 visits per 100 persons per year in

1991–92. The age-adjusted visit rate for

1991–92 was 2.3 visits per 100 persons,

using the 1975-76 U.S. populations

the standard (figure 4). Wits to

neurologists during 1975–92 are shown

by patient’s age in table 18.

References

1.

2.

3.

4.

5.

McCaig LF. National Hospital

Ambulatory Mdlcal Cme Survey

1992 emergency department

summary. Advance data ffom vital

and health statistics, no. 245.

Hyattsvillq Maryland. National

Center for Health Statistics. 1994.

McCaig LF. National Hospital

Ambulatory Medical Care Survey

1992 outpatient department summary.

Advance data from vital and health

statistics, no. 248. Hyattsville,

Maryland. National Center for Health

statistics. 1994.

NeIson CR, Stussman BJ. AlcohoIand drug-rclsted visits to hospital

emergency departments: 1992

National Hospital Ambulatory

Medical Care Survey. Advance data

tkom vital and health stdistics, no.

251. Hyattsville, Maryland. National

Center for Health Statistics. 1994.

Burt CW. Injury-related visits to

hospital emergency departments:

United States, 1992. Advance data

horn vital and health statistics, no.

261. Hyattsville, Ma@md. National

Center for Health Statistics. 1994.

Schappert SM. National Ambulatory

Medical Care Survey 1991

summary. Advance data from vital

and health statistic no. 230.

Hyattsvilk+ Maryland National

Center for Health Statistics. 1993.
8 Advance Data No. 267 ● August 8, 1995

Table 9. Annual number and percent distribution of office vlslta to neurologkrta by

principal diagnosis, averaged over a 2-year period: Unltad Stataa, 1991-92

Nurnbar of

visits In Perc3rrf

Prlnc@al dlagnosia and ICD-9-CM code~ thousmds dktrfbutfon

AllvMts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Infedlousand parasdtfcdlseaees . . . . . . . . . . . . . . . . . . . . . . . . ...001-139

NeoPfaeme . . . . . . . . . . . . . . . . . . . . . . . ..- . . . . . . . . . . . . ..14~=9

Endocrfrre, nufritlonal andmatabollc dlaeaeas, SndlmmunifYdlmr*m. . ..240-279

Mentetdieorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...290-319

Dieeaeesof thenervous system and=msorgans . . . . . . . . . . . . ...320-339

Dleeaeeeof thecircufatory eyatem . . . . . . . . . . . . . . . . . . . . . . . ..-~9

Dieaaeesof thereeplmtory system... . . . . . . . . . . . . . . . . . . . . ...460-519

D!seaees of themuscufoekeletal system andconnectfVe tleeue . . . . . . . .710-738

symptome, signs, andiil-deflned conditions . . . . . . . . . . . . . . . . . . . .780-7~

Injury andpoleoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...800-999

Suppkmwntaryc faeetficeticm. . . . . . . . . . . . . . . . . . . . . . . . . . . ..VOI-V82

Allotherdlagnosesz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unknowns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7,253

65

60

75

602

2,616

344

41

1,060

1,544

464

169

71

132

100.0

0.9

0.8

1.0

8.3

36.1

4.7

0.6

14.6

21.3

6.7

2.2

1.0

1.8

lBasadon the htternatimal C/a.sMicatim of Diaa8ses, Gfh Revisbn, C/inioal Mcd/fkatbn (lCD-%CM) (9).

%dudss diseasesofthe bkmdand blind-formingorgans(280-263~ diaa.ms of the digastiiesyafam (520-S79); diaaassaof

the geniourinary system (SS&5291 complicationsof pragnan~, ohildbitih,andthe puerparium(6S0-876h diaassaaofthe skin

andsubcutaneoustissue(630-709); mngenifalanomalies(740-75S); and carfainmndiins ofiginafinginMa pwinatalperiod

(#~~)blmkdiwnosas, unmdabkdagwes,andllleglbledmgnosm

Table 10. Annual number and percent distribution of oftlce visits to naurologlsta by tlm 20

moat frequently mentioned principal dlagnosaa, according to patient’s 8.x, ●voragad over

a 2-vear mwlock Unltad Stataa, 1991-92

Nrr&r of Patlent3 sex

vlalfs in

Prfnc#Ml dlsgnosfa and ICD-9-CM Codai thousands Totsf Mafe Fernak

Percent dletrbtrtfon

Aflvtsits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Genaref symptoms . . . . . . . . . . . . . . . . . . . . . . . . ...--...760

Convukfons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...780.3

Corns and stupor, helluclnatfons, eyncopa and collapse, dlzzfneee and

gkktlnees, steep dkWtmncae, matatse and latlgue, other general

symptoms . . . . . . . . . . . . 780.0-780.2,760.4-780.5, 780.7,760.9

Migretne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...346

.symptomelnvolvin gheadandnec k...... . . . . . . . . . . . . ...764

Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...734.0

~heefa, other speech disturbance, other symbolic dyefunctfon,

Spisfexis . . . . . . . . . . . . . . . . . . . . . . . ..784.3.734.5-734.7

Parkfnson’s dleease . . . . . . . . . . . . . . . . . . . ...-........332

Other and unepectfted dfeordere of back . . . . . . . . . . . . . . . . . .724

Mononeurifle of uppar limb and mononeurttls multlpkx . . . . . . ...354

Mutfiple ecteroefs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...340

Spmfns and etrafns of other and unspecified parfe of back. . . . ...647

Other dtsordersof adtlfsaues . . . . . . . . . . . . . . . . . ...-...728

Other dfsordereof oervlcafreglon . . . . . . . . . . . . . . . . . . . ...723

Spedet eyn@orne or syndromes, not eleawhere cfaasMed . . . . ...307

EPIIsPSY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...345

Acute, butilldeflned, carabrovaWdmdke= . . . . . . . . . . . . . .436

Hyperldnatic eyndroma ofchlldhood . . . . . . . . . . . . . . . . . . ...314

Spondyfoefe andaflleddfsordara . . . . . . . . . . . . . . . . . . . . ...721

Intervertebral dlecdlaorcfefs . . . . . . . . . . . . . . . . . . . . . . . ...722

Other exfmpymrnklef diseSwad Anotimovemant dborrfef'e. ..333

Haredftery arfdldfopafhlc pa@hemfnauroPathy. . . . . . . . . . . ...356

Mononeuritfe oflowerllmb . . . . . . . . . . . . . . . . . . . . . . . . ...355

Naurotlcdieordare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...300

Atlotherdiagnoeae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7,253

965

769

195

746

414

402

*12

331

274

268

244

231

198

197

152

150

131

121

119

115

114

106

30

79

633

100.0 100.0

13.3 15.8

10.6 +3.1

2.7 2.7

10.3 5.7

5.7 3.4

5.5 3.3

“0.2 “0.1

4.6 6.6

3.8 4.2

3.7 2.5

3.4 “0.6

3.2 3.2

2.7 3.6

2.7 3.1

2.1 1.3

2.1 1.9

1.8 2.2

1.7 3.0

1.6 1.5

1.6 *1.1

1.6 1.6

1.5 1.6

1.2 1.9

1.1 “0.6

11.6 15.3

100.0

11.5

8.8

2.7

13.6

7.4

7.2

“0.2

3.1

3.5

4.6

5.2

3.5

2.1

2.5

2.7

2.2

1.5

●0.7

1.8

2.0

1.6

1.4

‘0.7

1.5

8.4

6.

7.

8.

9.

Schappert SM. National Ambulatory

Medical Care Survey: 1991

summary. National Center for Healti

Statistics. Vital and Healfh Stat

13(116). 1994.

Schappert SM. National Ambulatmy

Medical Care Survey: 1992

summary. Advance data from vital

andhealth statistic~ no. 253.

Hyattsville, Maryland: National

Center for Health Statistics. 1994.

Schneider D, Appleton L, McLemore

T. A reason for visit classificsition for

ambulatory care. National Center for

Health Statistics. Vital and Health

Stat 2(78). 1979.

Public Health Service and Health

Care Financing Administration.

International Classification of

Diseases, 9th Revision, clMcal

modification. Washington: Public

Health Service. 1980.

10. Koch H, Campbell W. The collection

and processing of drug infonuation.

National Ambulatory Medkil Care

Survey, 1980. National Center for

Health Statistics. Vital and Health

Stat 2(90). 1982.

11. Food aid Drug Administration.

National Drug Code Directory, 1985

Edition. Washington Public Health

Service, 1985.

12. Goodman LJ, Mason HR. Physician

distribution and medical licensure in

the United States, 1975. American

Medical Association, Center for

Health Services Research and

Development. Chicago, Illinois.

1976.

13. Roback G, Randolph L, Seidman B.

Physician characteristics and

distribution in the United States.

American Medical Association,

Department of Physician Data

Services. Chicago, Illinoix 1993.

‘Basedonthe /ntemafiofIa/Cksifiitkm of LMasfses,f3h Revisiw, Cfinioa/ Afcufifiitbn (lCO-SCM) (9).
Advance Data No. 267 ● August 8, 1995 9

Table 11. Annual number and percent distribution of offioe visits to neuroiogista by the most frequently mentioned principai diagnoses,

acwrding to patient’s age, averaged over a 2-year period: United States, 1991-92

Nuniw of vklfs Percent

Prfrro@aldhgnosls and ICD-9-CM code’

Cumulative

h thousands diatiibuflon percent

Under 15 years

Allvisits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generafsymptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...780

~erMnetlc~ndmm ofchlldhood . . . . . . . . . . . . . . . . . . . . . ..3l4

Migralrre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...346

Symptomsinvohdngheadandneck . . . . . . . . . . . . . . . . . . . . ...764

Allolherdlagrroses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years

Atlvtdfs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generatsymp!oms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...780

Mlgralne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..846

.Symptomslnvofvlngheadandneck . . . . . . . . . . . . . . . . . . . . ...764

Spralnsandsfrainsof othersndunspeclfisd partsofback . . . . . . ...647

Aliotherdiagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years

Aflvishs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...346

Generatsymptoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...780

.Syrnplomsinvoh4ngheadandneck... . . . . . . . . . . . . . . . . . ...764

Multiplesderosls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...340

3prainsandslrahrsofothererrdunspecIfisdperfsofback . . . . . . ...847

Otherand unspsolfteddleordarsofbsck. . . . . . . . . . . . . . . . . . ...724

Mononeuritts ofupper lbnband mononeurttis multiptax. . . . . . . . . . ..S54

Otherdlsordersofsofttissues... . . . . . . . . . . . . . . . . . . . . . . ..729

Otherdlsordarsofc=ervicalreglon. . . . . . . . . . . . . . . . . . . . . . . ..728

Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...345

Allofherdlagnosas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 yeare

Allvidts.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalsympfoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..76o

Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..W6

Otherandunepeclfteddlsordareof back. . . . . . . . . . . . . . . . . . . ..724

Syrr@omshrvofvIrrgheadandnaok... . . . . . . . . . . . . . . . . . ...764

Mulfiplasdemds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...340

MononeurltieofupperIlmbandmononeuritlsmutfiplex. . . . . . . . . ...364

Parkineon’sdisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..332

Otherdlsordaraofsofttisaues. . . . . . . . . . . . . . . . . . . . . . . . ...723

Olherdleordarsofcarvicalregion. . . . . . . . . . . . . . . . . . . . . . . ..723

Spondyloslsandallieddisordara.... . . . . . . . . . . . . . . . . . . ...721

Allotherdiegnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65 years and over

Alivlaits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Paddnson’sdisaase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...332

Generatsympfoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..76o

Acute,butill-deflnsd,carebrovasoulardk@saa.. . . . . . . . . . . . . ...436

MononeudtisofuppsrIlmband mononeurltismultiplex . . . . . . . . . ...354

Heradifaiyand ldlopefhic peripheral neuropathy . . . . . . . . . . . . . ...356

>thereM~ymMddwawad¬imwmentdhr~m . . ...333

Otherandunspeclfieddisordarsof back. . . . . . . . . . . . . . . . . . ...724

Wotherdlagnoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

770

287

102

53

41

287

577

120

w

57

56

281

2359

421

256

198

133

126

120

100

95

95

79

930

1,893

134

163

97

96

94

66

83

63

69

56

887

1,454

246

106

88

78

56

53

53

772

100.0

37.3

13.3

6.8

5.4

37.2

100.0

20.6

11.1

9.8

9.7

46.7

100.0

16.4

10.0

7.8

5.4

4.9

4.7

3.3

3.7

3.7

3.1

36.4

100.0

10.2

9.6

5.1

5.1

5.0

4.5

4.4

3.6

3.8

3.0

45.8

100.0

16.9

7.4

5.8

5.4

4.0

3.7

3.6

53.1

. . .

37.3

50.6

57.4

62.8

100.0

. . .

20.8

31.9

4+.7

51.3

100.0

. . .

16.4

26.4

WI

38.6

44.5

49.2

53.1

56.8

80.5

63.6

100.0

. . .

10.2

19.8

25.0

30.1

35.0

S9.6

44.0

47.6

51.2

54.2

100.0

. . .

16.9

24.3

30.2

35.6

39.6

43.2

46.8

100.0

‘Basedonihe/r?tematima/ C/aasifiiationof/Xsaases,Wri?eviskwr,C/inlsa/A4cdifntkm(lC0-9-CM) (9).

NOT= A maximumof 10 diagnosesware listedperege group.Onkrerible eatirmteswreindudud inthe table,sos~mf~r~s~havef~rthm 10dmgnosea.
10 Advance Data No. 267 ● August 8, 1995

Table 12. Annual number and percent distribution of office visits to neurologists and to all other physicians by therapeutic services

ordered or provided, averaged over a 2-year period: United States, 1991-92

Vk/ts to neuro/og/sts VMa to all other physlsfans

Number of Number of

visits Percent visits Percent

Therapeutic service ordered or provided’ In thousands dkttibuflon in thousands dlstrfbutlon

Allvkils . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,253 100.0 708,614 100.0

Medlcatlon therapy

Neworcontinued medication . . . . . . . . . . . . . . . . . . . . 4,624 63.7 450,237 63.5

Nomedlcation reported . . . . . . . . . . . . . . . . . . . . . . . . 2,629 36.3 256,377 36.5

Counseling, education, and other nonmedication therapy

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diet . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Exerciaa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cholesterolreduction . . . . . . . . . . . . . . . . . . . . . . . . .

Weightreduction . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Drugabuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AtcoholsJ)uae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Smoktngceasation . . . . . . . . . . . . . . . . . . . . . . . . . . .

Famllykodal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gruwttddevelopment . . . . . . . . . . . . . . . . . . . . . . . . . .

Familyptennlng . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Othercounsaiing . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Correctlvelenses . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hearingald . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Physiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5,230

379

513

73

174

37

-17

49

152

90

“14

579

163

465

178

72.1

5.2

7.1

1.0

2.4

0.5

“0.2

0.7

2.1

1.2

“0.2

8.0

2.2

6.4

2.5

481,938

82,639

54,426

21,567

27,773

1,767

3,157

15,621

13,574

17,145

6,220

58,119

18,970

7,763

432

14,629

20,163

68.0

11.7

7.7

3.0

3.9

0.3

0.4

2.2

1.9

2.4

0.9

6.2

2.7

1.1

0.1

2.1

2.6

Ambulatorysurgery echeduledorpetforrned

Noprocadures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,159 98.7 665,389 93.9

Oneormoreprocedures . . . . . . . . . . . . . . . . . . . . . . . 94 1.3 43,225 6.1

'Total my M*dtotil number &visits because momthan onemtego~may berepotied psrvisit
Advance Data No. 267 ● August 8, 1995 11

Table 13. Annual number and percent distribution of drug mentions at office visits to

neurologists by therapeutic classification, averaged over a 2-year period: United States,

1991-92

7herapeufic claaaiffoation’

Atlmentions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurologlcdruge. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Antlconvutsants. . . . . . . . . . . . . . . . . . . . . . . . . . .

Drugs used to treat skeletalmusclehyperacltitly. . . . . . .

Drugs used in extrapyremkfal movement disorders . . . . .

Drugeused inmyaathenlagrevis . . . . . . . . . . . . . . . .

Drugeusedfor reliefofpein . . . . . . . . . . . . . . . . . . . . .

Generafenstgaab. . . . . . . . . . . . . . . . . . . . . . . . .

Antterthritke . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Drugsusedto treat migraineand otherheadaches . . . . .

Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychopharmacologic digs . . . . . . . . . . . . . . . . . . . . .

Antkieprsssants. . . . . . . . . . . . . . . . . . . . . . . . . . .

Antianxietydrugs . . . . . . . . . . . . . .. . . . . . . . . . . . .

Sedafiveeand hypnotice. . . . . . . . . . . . . . . . . . . . . .

Antipsychoticdruge. . . . . . . . . . . . . . . . . . . . . . . . .

CNSstlmukmts,anorexiants . . . . . . . . . . . . . . . . . . .

Cardlovaecular-renaJdrugs..... . . . . . . . . . . . . . . . . .

Arrflhypertensiveegents. . . . . . . . . . . . . . . . . . . . . .

Antlarrhythmlcagents . . . . . . . . . . . . . . . . . . . . . . .

Dkrratka.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

HormonesarrdagentsaffecMnghormonsl machardeme. . . .

Raef)iratorytraotdnrgs . . . . . . . . . . . . . . . . . . . . . . . .

Anflmlorob[aldruga. . . . . . . . . . . . . . . . . . . . . . . . . . .

Geatrolnteatirretdruge. . . . . . . . . . . . . . . . . . . . . . . . .

Mefaboltoandnutrfentagents.... . . . . . . . . . . . . . . . .

Hernstologicdrugs. . . . . . . . . . . . . . . . . . . . . . . . . . .

Ototogkdnrgs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SkIn/mucousmembrance

Ofhe? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unc!aeeltlad, mlscelkmeous. . . . . . . . . . . . . . . . . . . . .

Number of

dmgmentiona

in thousands

Percerrf

disfrfbufion

8,143

2,109

1,284

419

375

●2O

1,825

910

612

280

“23

1,642

820

269

2?24

116

113

929

435

166

137

191

310

164

176

145

127

79

70

55

66

423

100.0

25.9

15.8

5.1

4.6

“0.2

22.4

11.2

7.5

3.4

‘0.3

20.2

11.3

3.3

2.7

1.4

1.4

fl.4

5.3

2.0

1.7

2.3

3.6

2.3

2.2

1.8

1.6

1.0

0.9

0.7

0.8

5.2

l-rhempe~cda=fi~on &bawdonthesta@ard drugclaasikdbn usedintheNatiorM DrWCO&DiIWtOLM 19850d~cxI

g:) (w

desanesthetii, mdmphammticaWmntraS mda, onm~~, immunologicagants,ophthalmicdrugs,andantiparssifii

agents.
12 Advance Data No. 267 ● August 8, 1995

Teble 14. Number and percent of drug mentions at office visits to neurologists by the 20

most frequently used generic substsncas, averaged over a 2-yaar period: United States,

1991-92

Number of

occurrerws In Percent of

Generic substance thousands’ ail dmg mention~

Allmantlons. . . . . . . . . . . . . . . . . . . . . . . . . .

Acetaminophen. . . . . . . . . . . . . . . . . . . . . . . .

Cerbernszeplne. . . . . . . . . . . . . . . . . . . . . . . .

AfnMptyline . . . . . . . . . . . . . . . . . . . . . . . . . .

Phenyloin . . . . . . . . . . . . . . . . . . . . . . . . . . .

Aspktn. . . . . . . . . . . . . . . . . . . . . . . . . .

Csffelne . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Levodopa . . . . . . . . . . . . . . . . . . . . . . . . . . .

Csrbidopa. . . . . . . . . . . . . . . . . . . . . . . . . . .

Butsfbifsf. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neproxen . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dhrefproexsodium . . . . . . . . . . . . . . . . . . . . . .

Proprenolol . . . . . . . . . . . . . . . . . . . . . . . . . .

Verapamil . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dkhlorslantipyrfne . . . . . . . . . . . . . . . . . . . . . .

Isornathaptenemucaf e........ . . . . . . . . . . .

Noftrfpfyllne . . . . . . . . . . . . . . . . . . . . . . . . . .

Phenobarbital . . . . . . . . . . . . . . . . . . . . . . . . .

Codeine . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ibuprofen . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cydobenzeprhre . . . . . . . . . . . . . . . . . . . . . . .

10,186

673

491

3S6

352

345

263

281

281

241

230

216

213

175

162

162

159

147

139

139

125

. . .

8.3

6.0

4.9

4.3

4.2

3.5

3.5

3.5

3.0

2.6

2.7

2.6

2.1

2.0

2.0

2.0

1.6

1.7

1.7

1.5

‘Frequencyofnmtiin combinessingla-ingredient agentswthmentmms oftheagentasan ingredientinacotination dreg.

%sed on an average d 8,143,000 drug mentiins per year at otfIce VMS to neurobgbts during t 991-S2.

Table 15.Annual number, percent distribution, and therapeutic classification ofthe20drugs most frequently

prescribed at office vislta to neurologists by entry name, averaged over a 2-year period: United States, 1991-92

Number of

dNgNIWrf\OIrS Percent

Entrynameofdmg’ in thousends dkttfbutlon Therapeutic ciaaelfi’catior+

Aflmanilons . . . . . . . . .

Tegretol . . . . . . . . . . . .

Dilsntln . . . . . . . . . . . .

Sinemat . . . . . . . . . . .

ElavI1 . . . . . . . . . . . . .

Dapakote . . . . . . . . . . .

Indarsl . . . . . . . . . . . .

Midrib . . . . . . . . . . . . .

Pamakrr . . . . . . . . . . .

Anaprox . . . . . . . . . . .

Phenobarbltaf . . . . . . . .

Arnffrfpfyline. . . . . . . . .

Flexertl . . . . . . . . . . . .

Cefen. . . . . . . . . . . . .

Prozac . . . . . . . . . . . .

Naprosyn . . . . . . . . . . .

Mysoline . . . . . . . . . . .

Aspirin . . . . . . . . . . . .

Rifafin. . . . . . . . . . . . .

Darvocet-N . . . . . . . . .

FIoricat . . . . . . . . . . . .

Another. . . . . . . . . . .

8,143

481

352

281

251

216

211

162

145

131

126

125

125

113

109

98

95

92

92

90

85

4,754

100.0

6.0

4.3

3.5

3.1

2.7

2.6

2.0

1.8

1.6

1.5

1.5

1.5

1.4

1.3

1.2

1.2

1.1

1.1

1.1

1.0

56.4

. ..

Neurologlc drugs (entlconvulsante)

Neurologlc drugs (entlconvufsarts)

Neurologlcdrugs (drugs usedinexfrapyrafnidal movement disorders)

Psychopharmacologic drugs (entklapreseants)

Neurologlc druge(anticonvufeatrts)

Cardiovaecutar-renal drugs (antihypertensive agents)

Drugausedforrellef ofpaln(drugsused totreatmigrelneend otherhasdaches)

Psychopharmamlogic drugs (antldepreasants)

Drugs usad for relief of psln (antiarfhritics)

Psychophsrmecotoglc dmgs(sedstlvasand hypnotfca)

Psychophermecologfc drugs(antfdepreseants)

Neurologicdnrgs(drugs usadtofreatskelefal muadehyperscfivity)

Cerdlovsecular-renal druge(antiarrhylhmic agents)

Psydwpharrnacologic drugs (antWprassante)

Drugsusedforrellef ofpsin(sntlsrthrlfl=)

Necrologic drugs (anflconvulaants)

Drugsusedforrelief ofpefn(ganeraf anafgaah)

Psychopharmacotoglc dregs (CNS stimulants, anorexiants)

Drugs used for relief of pain (general anafgeske)

Drugsusedforrellef ofpafn(genemtsnafgesi=)

. . .

‘The trade or generic name used by the physician on the prescription or other medical records.

%herepeutic .Ie$sificetmn is based on the standard drug olassficatkm used in the Nafionel Drug Cccl+ Dkeotow t985 edtion (NDC) (11).
Advance Data No. 267 ● August 8,1995 13

Table 16. Annual numbar and parcant distribution of offfco vfslts to nsurologista and to sfl

other physicians by disposition of visit avsragad ovar a 2-yaar period: United Ststaa,

1991-32

Vleifsto nsumbglsts Visitsto all ofherphysMns

Number of Nuni)er of

vfelfein Percent vislfein Peroerrt

Dkipoelfkmof visit’ thormerro3 distifbuflon Ulormarrds dkfrfbuflon

Allvleit e . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,253 100.0 708,814 100.0

Retumatapeoifla dtlrne. . . . . . . . . . . . . . . . . . 5,117 70.5 441,353 62.3

Retumtf needad . . . . . . . . . . . . . . . . . . . . . . . 627 11.4 163,582 23.1

Retumto referrirrgphyddan... . . . . . . . . . . . . . 560 7.7 6,285 0.9

No folbwupplenned. . . . . . . . . . . . . . . . . . . . . 490 8.6 67,719 9.6

Telephonefolbwupplanned . . . . . . . . . . . . . . . . 433 8.0 21,675 3.0

Refertootherphysfdsn . . . . . . . . . . . . . . . . . . 276 3.8 21,838 3.1

Admttto hospite l . . . . . . . . . . . . . . . . . . . . . . 50 0.7 5,s70 0.6

Otherdleposition. . . . . . . . . . . . . . . . . . . . . . . 47 0.6 7,115 1.0

‘Total may axceed total number d viaifa bscauae rnora than ona categoiy may ba raported for aach visii.

Table 17. Annual numbar and parcent distribution of offfce visits to naurologlsta and to sfl

othsr physicians by duration of visl~ avaragsd over a 2-yaar parlod: United Statae,

1991-62

Weltsto rreumlogkfs VWtsto afl otherphysldens

Nutir of Nrrn’barof

VisttsIn PerOwt Vletlsin Percent

Dwaffonof VM thouserrde dfsfrfbufion thousands Lwrfbuflon

Allots. . . . . . .. . . . . . . . . . . . . . . . . 7,253 100.0 708,614 100.0

Omlnufes’ . . . . . . . . . . . . . . . . . . . . . . “9 *0.1 8,502 1.2

l-6minutes . . . . . . . . . . . . . . . . . . . . . *2O “0.3 57,600 8.2

6-10minutes . . . . . . . . . . . . . . . . . . . . 369 5.5 166,473 26.3

11-15 minutes . . . . . . . . . . . . . . . . . . . 1,502 20.7 227,145 32.1

16-30 minutas . . . . . . . . . . . . . . . . . . . 2,384 40.9 179,206 25.3

31-60 mtnuf8e . . . . . . . . . . . . . . . . . . . 2,066 26.8 45,710 6.5

Morethen 60mkwfss. . . . . . . . . . . . . . . 271 3.7 3,777 0.5

‘WJitain MM there was no fam-tefaoa wntact Imtwaan tha physician and ttw pdiant.

3.0 r

2.5 -

2.0 -

1.5 -

1.0 -

0.5 -

— Cruds rats — — /Qe-adjustsd rate

2.9

2.5

2.3

0.9

0.9

1975-76 1980-81 1985 1989-901991-82

Year

NOTES:Sesadon2-year averages,excspt19S5.Aga-ac@stadestimatesare basedonthe 197576

U..%population.

Figure 4. Annual rata of office visits to neurologist Unitad States, 1975-92
14 Advance Data No. 267 ● August 8, 1995

Table 18. Number, percent distribution, and rate of office visits to neurologists, by

patient’s age United States, 1975-82

Pat/errf’s age 1975-76 1980-81 1985 1988-.90 1991-92

Aflvisik . . . . . . . . . . . . . . . . . . . . . . .

Under 15years . . . . . . . . . . . . . . . . . . .

15-24years . . . . . . . . . . . . . . . . . . . . .

26-44years . . . . . . . . . . . . . . . . . . . .

45-64years . . . . . . . . . . . . . . . . . . . . .

66-74years . . . . . . . . . . . . . . . . . . . . .

75yearesrrdover . . . . . . . . . . . . . . . .

Allvfsifs . . . . . . . . . . . . . . . . . . . . . . .

Under15yeare . . . . . . . . . . . . . . . . . . .

15-24yeafs . . . . . . . . . . . . . . . . . . . . .

25-44yeafe . . . . . . . . . . . . . . . . . . . . .

46-64yeare . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . .

75yeereerrdover . . . . . . . . . . . . . . . . .

Allvlelt s . . . . . . . . . . . . . . . . . . . . . .

Under15yesm . . . . . . . . . . . . . . . . . . .

15-24years . . . . . . . . . . . . . . . . . . . . .

25-44yeafs . . . . . . . . . . . . . . . . . . . . .

4%64yeafs . . . . . . . . . . . . . . . . . . . . .

65-74yeara . . . . . . . . . . . . . . . . . . . . .

75yemandover . . . . . . . . . . . . . . . . .

1,892

-147

24s

663

577

173

78

100.0

7.8

13.1

35.4

30.5

9.1

“4.1

0.9

‘0.3

0.6

1.3

1.3

1.3

“1.0

Number of Welts in thousands’

3,013 4,992 6,167

338 403 311

311 500 542

991 1,567 2,341

1,029 1,454 1,812

M5 626 839

“176 422 521

Percent dlelrbuflon

100.0 100.0 100.0

11.2 8.1 5.0

10.3 10.0 8.8

32.9 31.8 36.0

34.1 29.1 26.1

11.4 12.5 13.6

“5.5 8.5 8.4

Vish rate per 100 personsz

1.4 2.3 2.5

0.7 0.6 0.6

0,8 1.3 1.5

1.6 2.7 2.9

2.4 3.3 3.5

2.2 3.8 4.7

“2.0 4.1 4.5

7,253

770

577

2,659

1,883

820

633

100.0

10.6

8.0

35.3

28.1

11.3

8.7

2.9

1.4

1.7

3.2

4.0

4.5

5.2

‘Numbersare shownas 2-yesr aversgesexceptfor 1985.

%ased on Bureau of the Census esfknales of the civilian noninsfifufiinalked pmpulafion for July 1 of each survey year. Rates for

wmtimdyeaB are bmedonan average of thepopulafmn etimtesfor Julyl of each yeerofthe 2-year period. Suweyyears

from1975-1985did notincludeAlssks orHswaii.
Advance Data No. 267 ● August 8, 1995 15

Technical notes

Source of data and sample design

Theinformation presented in this

report is based on data collected in the

National Ambulatory Medical Care

Smvey (NAMCS) over the 2-year

pericdfrom January 1991 through

December 1992. The target universe of

NAMCS includes office visits made in

the United States by ambulatory patients

to nonfederally employed physicians

who are principally engaged in office

practice, but not in the specialties of

anesthesiology, pathology, or tilology.

Telephone contacts and nonoffice visits

are excluded.

A multistage probability sample

design is used in NAMCS, involving

samples of primary sampling units

(PSU’S), physician practices within

PSU’S, and patient visits within

physician practices. The PSU’S am

counties, groups of counties, county

equivalents (such as parishes or

independent cities), or towns and

townships (for some PSU’S in New

England). For 1991, a sample of 2,540

nonfe&ral, office-based physicians was

selected from master files maintained by

the American Medical Association and

American Osteopathic Association.

Physicians were screened at the time of

the survey to ensure that they were

eligible for survey participation. Of

those screened, 1,887 physicians were

eligible (in-scope) to participate in the

survey. The remaining 653 physicians

were ineligible .(out-of-scope) due to

reasons of being retiredj employed

primarily in teaching, research, or

administration or other reasons. The

physician response rate for the 1991

NAMCS was 72 percent.

For 1992, a sample of 3,000

nonfe&ral, office-based physicians was

selected from master files maintained by

the American Medical Association and

American Osteopathic Association. Of

those screenedj 858 physicians were

ruled ineligible (out-of-scope); 2,142

were in-scope for the survey. The

physician response rate for the 1992

NAMCS was 71 percent.

Sample physicians were asked to

complete Patient Record forms (figure 1)

for a systematic random sample of office

visits occurring during a randomly

assigned l-week reporting period.

Responding physicians completed

33,795 Patient Record forms in 1991

and 34,606 Patient Record forms in

1992.

Charactefitics of the physician’s

practice, such as primary specialty and

type of practice, were obtained from the

physicians during an induction

interview. The U.S. Bunizm of the

Census, Housing Surveys Branch, was

responsible for the survey’s data

collection. Processing operations and

medical coding were performed by the

National Center for Health Statistics,

Health Care Survey %ctiom Research

Triangle Parkj North Carolina.

For 1992, several changes were

made in the sample design of the

NAMCS that should be considered in

the interpretation of the survey results.

In an effort to even the precision of

estimates across each of the physician

specialty strata in the sample design, the

decision was made to increase the

proportion in the sample of specialists in

general surge~, psychiatry,

otolaryngology, and neurology. Although

this would result in a corresponding

decrease in the sample of the larger

physician specialties, most notably

general and family practice, internal

medicine, and pedntrics, the precision

of these estimates tended to be much

higher relative @ the smaller specialties,

and it was expected that the end result

would be an acceptable balance of

precK1on levels across all stxata

However, the reduced numbers of

general practitioners, internists, and

p~]atricians sampled in 1992, coupled

with the high percents of sampled

physicians in these specialties who were

determined to be ineligible (out-ofscope) for survey participation, resulted

in low numbers of survey respondents in

these categories and a lowering of the

precision of these estimates relative to

other survey years, especially when

duaggregated by other variables such as

race. Because vMs made by black

patients were often found to be clustered

among the sampled physicians and were

more likely to be made to general and

family practitioners, which were

undersampled in 1992, it is

recommended that caution be exemised

when interpreting diifenmces in race

data and individual physician specialties.

Despite the difference in sample

sizes, the 1991 and 1992 surveys were

identical in terms of survey instruments,

definitions, and procedures. The

resulting 2 years of data have been

combined to provide more reliable

estimates. All estimates, percent

distributions, and rates prqented here

unless otherwise notedj reflect 1991 and

1992 data that were averaged over the

2-year period.

Sampling errors

The standard error is primarily a

measure of the sampling variability that

occurs by chance when only a sample,

rather than an entire universe, is

surveyed. The relative standard error of

an estimate is obtained by dividing the

standard error by the estimate itse~ the

result is then expressed as a percent of

the estimate.

Relative standard emors (RSE’s) for

estimated numbers of office visits,

expressed as 2-year averages for the

period 1991-92, are shown in table I.

Relative standad errors for estimated

numbers of drug mentions, also

expressed as 2-year averages, are

presented in hWe II. Standard errors for

estimated percents of visits and drug

mentions are displayed in tables III-VI.

Alternatively, relative standard

errom for 2-year averages may be

calculated using the following general

formuh where x is the average of

interest in thousands multiplied by 2 to

obtain the 2-year total, and A and B are

the appropriate coefficients from

table VII. The relative standard error

obtained in this way applies to both the

2-year total and the 2-year average.

RSE(X) = d A+: .100

Similarly, relative standard errors

for percents may be calculated using the

following general formula where p is

the percent of interest and x is the

denominator of the percent in thousands

(and the denominator is the 2-year

aggregate estimate rather than the

average itself), using the apprcyxiate

coefficient from table VII. (The 2-year
16 Advance Data No. 267 ● August 8, 1995

Table L Approximate relative standard errors for estimated numbers of office visits by

selected physician specialties: National Ambulatory Medical Care Survey, 1991-92

Estimated number of oflca visiis Physic/an qecial(y

(expressed as annual average)

in thousands All’ Naurolog~

25 . . . . . . . . . . . . . . . . . . . . . . . .

35 . . . . . . . . . . . . . . . . . . . . . . . .

50 . . . . . . . . . . . . . . . . . . . . . .

100 . . . . . . . . . . . . . . . . . . . . .

250 . . . . . . . . . . . . . . . . . . . . . .

346 . . . . . . . . . . . . . . . . . . . . . . . .

500 . . . . . . . . . . . . . . . . . . . . . . . .

1,000 . . . . . . . . . . . . . . . . . . . . . . .

2,500 . . . . . . . . . . . . . . . . . . . . .

5,000. . . . . . . . . . . . . . . . . . . . . . .

10,000 . . . . . . . . . . . . . . . . . . . . . .

25,000 . . . . . . . . . . . . . . . . . . . . . .

50,000. . . . . . . . . . . . . . . . . . . . . .

100,000 . . . . . . . . . . . . . . . . . . . . .

250,000 . . . . . . . . . . . . . . . . . . . .

500,000. . . . . . . . . . . . . . . . . . . . .

Relatlve standard error in percent

110.8

93.7

78.4

55.5

35.2

30.0

25.0

17.8

11.6

8.5

6.5

4.9

4.2

3.6

3.6

3.5

34.7

30.0

25.9

20.0

15.5

14.5

13.6

12.6

11.9

11.7

11.6

11.5

11.5

11.5

11.5

11.5

‘The smallest reliable estimate for visits to aggregated s~oialfias B 246,000 tisifs per year (or a 2-year total of 691 ,OCOvisits).

Esfirnatas be!ew this figure have a relatMe standard emor greater than 30 percent and are d~med unreliable by NCHS

standards.

%he mkilast rallable estirnete for vkifs to neurdoglsts is 35,000 visits per year (or a 2-year total of 70,000 visk+. Eetimatas

be!-awfhis fkmm have a relative standard error greater than 30 percent and are deemsd unreliable by NCHS standards.

Grampb of use of table For visfis to neurok.gisfs, an estimate of 10 million vl=sik per year has a mlattie standard error of 11.6

percent or a standard error of 1,160,000 visits (11.6 percent of 10 mullion).

Table ll.Approximate relative standard errora for aatimated numbers ofdrugmentlons by

selected physician specialty=: National Ambulatory Mdical Care Suwey, 1991-92

Estirrratadnunrber ofoffic%visits Phys/c/an specialty

(expressad as annual average)

in thousands Alil Netrro/og~

RelalWe standard emor in percent

25 . . . . . . . . . . . . . . . . . . . . . . . . . 154.1 38.7

46 . . . . . . . . . . . . . . . . . . . . . . . . . 114.3 30.0

100 . . . . . . . . . . . . . . . . . . . . . . . 77.2 22.2

250 . . . . . . . . . . . . . . . . . . . . . . . 48.9 17.1

500 . . . . . . . . . . . . . . . . . . . . . . . . 34.7 15.0

674 . . . . . . . . . . . . . . . . . . . . . . . . 30.0 14.5

1,000 . . . . . . . . . . . . . . . . . . . . . . . 24.7 13.9

2,500 . . . . . . . . . . . . . . . . . . . . . . . 16.0 13.1

5,000 . . . . . . . . . . . . . . . . . . . . . . . 11.7 12.9

10,000 . . . . . . . . . . . . . . . . . . . . . . 6.6 12.8

25,000 . . . . . . . . . . . . . . . . . . . . . . 6.5 12.7

50,000 . . . . . . . . . . . . . . . . . . . 5.5 12.6

100,000 . . . . . . . . . . . . . . . . . . . . . 4.9 12.6

250,000 . . . . . . . . . . . . . . . . . . 4.6 12.6

500,000 . . . . . . . . . . . . . . . . . . . . . 4.4 12.6

‘The smallest reliable esfirnste of drug mentions at visks to aggregated speciatlies is 674,000 dmg merstiins per year (or a

2-year total of 1,S47,000 mantions). Estimstas below this figure have a ralative standard error greater than 30 percent and are

desmed unreliable by NCHS standards.

‘Thesmallestreliable asfmwteofdrugn wntions atvisiisio neurologists ~4S,CsJOdrug rr_mntmnspmyear(ora2-yaar totalof

91,000 mentions), Estimatss be!ew this figure have a relative standard erm greater than 30 percent and are deermd unreliable

by NCHS standards.

Example of use of tab~ For neuro!agists, an esfimata of 25 tillicm drug mantions per year has a relatie standard error of 12.7

percsnt or a standard error of ~1 75,000 drug mentions (12.7 percent of 25 millkm).

aggregate is obtained by multiplying the Adjustments for nonresponse

average estimate by 2.)

EstimatesfiomNAMCS data were

RSE(p) = d MH).lOO adjusted to account for sample

n.x physicians who were in-scope but did

r

--

notparticipate in the study. lhk

adjustmentwasealculated tominimim

the impact of response on final estimates

by imputing to nonrespondi.ng

physicians data from visits to similar

physicians. For this purpose, physicians

werejudgedsimiku iftheyhadthe

same specialty desigmtion and practiced

inthesamePSU.

Testof significance and rounding

Inthisrepo%thedetermination of

statistica.linference isbasedonthe

two-tailedt-test. TheBonferrcfni

inequalitywasused toestablishthe

critic-rdvaluefor statisticrdl ysignifica.nt

differences (0.05 level of significance)

based on the number of possible

comparisons within aparticula.r variable

or(combination ofvariables) ofinterest.

Terms relatingto dlfferencessuc has

“greatert han’’or’ ’less than’’indicate

thatthedii7erenceis statistically

significant. Alack ofcommentregadng

the difference between anyfsvo

estimatesdoesnot meanthatthe

dflerencewastested andfoundtobe

nonsignificant.

In the tables, estimates of office

visits have been rounded to the nearest

thousand. Consequently, estimates will

not always add to tota18.Rates and

percents were calculated from original

unrounded figures and do not

necessarily agree with percents

calculated from rounded data.

Definition of terms

Ambulatory patient—An ambulatory

patient is an individual seeking personal

health services who is not cumently

admitted to any health care institution

on the premises.

Drug mention—A drug mention is

the physician’s entry on the Patient

Record form of a pharmaceutical

agent—by any route of admini8tmtion-for prevention, diagnosis, or

treatment. Generic as well as brandname drugs are included, as are

nonprestiption and prescription drugs.

Along with all new drugs, the physician

also records continued medications if

the patient was specifically instructed

during the visit to continue the
Advance Data No. 267 ● August 8, 1995 17

Table Ill. Approximate standard errors of percents of estimated numbers of office visits to

aggregated specia[tfe= Natfonal Ambulatory Medical Care Survey, 1991-92

Base ofpercarrt(visits, Estimatedparsent

ex$maaedas annual

average,In thousands) 10r99 5or95 100r30 200r80 300r70 400r60 50

Standard error In percentage points

50 . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.8 17.1 23.5 31.3 35.3 38.4 39.2

100 . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 12.1 16.6 22.2 25.4 27.1 27.7

250 . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5 7.6 10.5 14.0 16.1 17.2 17.5

500 . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5 5.4 7.4 9.9 11.4 12.1 +2.4

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . 1.7 3.8 5.3 7.0 8.0 8.6 8.8

2,500 . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 2.4 3.3 4.4 5.1 5.4 5.5

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . 0.8 1.7 2.4 3.1 3.6 3.8 3.9

10,000 . . . . . . . . . . . . . . . . . . . . . . . . 0.6 1.2 1.7 2.2 2.5 2.7 2.8

25,000 . . . . . . . . . . . . . . . . . . . . . . . . 0.4 0.8 1.1 1.4 1.6 1.7 1.8

50,000 . . . . . . . . . . . . . . . . . . . . . . . . 0.3 0.5 0.7 1.0 1.1 1.2 1.2

Ioo,ooo . . . . . . . . . . . . . . . . . . . . . . . 0.2 0.4 0.5 0.7 0.8 0.9 0.9

250,000 . . . . . . . . . . . . . . . . . . . . . . . 0.1 0.2 0.3 0.4 0.5 0.6 0.6

500,000 . . . . . . . . . . . . . . . . . . . . . . . 0.1 0.2 0.2 0.3 0.4 0.4 0.4

NOTE Emnple of use C4tabl.s An estimate of 20 percent bcsed cman mfimate d 25 rnllion vkiis per yam has a atendard

error of 1.4 permnt or a rahtiie standard error of 7.0 percent (1.4 permnf dwkJedby 20 percent).

Table IV. Approximate standard errore of percents of estimated numbers of offfce visits to

neurologlste: National Ambulatory Medical Care Sunrey, 1991-92

Basa ofpercerrt(visits, Esthatedpercwrt

qmsaad as annual

average, In thousands) lor99 5or95 100r90 200r80 300r70 400r60 50

50 . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3

100 . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6

250 . . . . . . . . . . . . . . . . . . . . . . . . . . 1.0

500 . . . . . . . . . . . . . . . . . . . . . . . . . . 0.7

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . 0.5

2,500 . . . . . . . . . . . . . . . . . . . . . . . . . 0.3

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . 0.2

7,250 . . . . . . . . . . . . . . . . . . . . . . . . . 0.2

10,000 . . . . . . . . . . . . . . . . . . . . . . . . 0.2

Standarderrorlnparcentaga points

5.1 7.0 9.3 10.6 11.4 11.6

3.6 4.9 6.6 7.5 8.0 8.2

2.3 3.1 4.1 4.8 5.1 5.2

1.6 2.2 2.9 3.4 3.6 3.7

1.1 1.6 2.1 2.4 2.5 2.6

0.7 1.0 1.3 1.5 1.6 1.6

0.5 0.7 0.3 1.1 1.1 1.2

0.4 0.6 0.8 0.9 0.9 1.0

0.4 0.5 0.7 0.8 0.8 0.8

NOTEExarrpleot uaadtabloAneafiite of20percentbaaed onanmtimded 7,250,0Wneurokgy viskapxyaarhas a

atandardermrof0.8 peroantoraralafiie standarderrorof4.O parmnt(O.8pwoant dwkfadby20parcent).

Table V. Approximate standard errors of percente of estimated numbers of drug mentions

atvlslta toaggregated spacialtiee: National Ambulatory Medicaf Care Survey, 1991-92

B6seofpersent(tislts, Estirnatadparcmt

expressedas annual

average, In thousmds) 10r99 50r95 100r90 200r60 300r70 400r60 50

50 . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.8

100, . . . . . . . . . . . . . . . . . . . . . . . . . 7.7

250 . . . . . . . . . . . . . . . . . . . . . . . . . . 4.9

500 . . . . . . . . . . . . . . . . . . . . . . . . . . 3,4

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . 2.4

2,500, .,..,..........,,, . . . . . . 1.5

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . 1.1

10,000 . . . . . . . . . . . . . . . . . . . . . . . . 0.8

25,000 . . . . . . . . . . . . . . . . . . . . . . . . 0.5

50,000 . . . . . . . . . . . . . . . . . . . . . . . . 0.3

100,000 . . . . . . . . . . . . ...<.. . . . . . 0.2

250,000 . . . . . . . . . . . . . . . . . . . . . . . 0.2

500,000 . . . . . . . . . . . . . . . . . . . . . . . 0,1

Standard errorlnperoentaga points

23.7 32.7 43.6 49.9 53.4 54.5

16.8 23.1 30.6 35.3 37.7 38.5

10.6 14.6 19.5 22.3 23.9 24.4

7.5 10.3 13.6 15.8 16.9 17,2

5.3 7.3 9,7 11.2 11.9 12.2

3.4 4.6 6.2 7.1 7.6 7.7

2.4 3.3 4.4 5.0 5.3 5.5

1.7 2.3 3.1 3.5 3.8 3.9

1.1 1.5 2.0 2.2 2,4 2.4

0.8 1.0 1.4 1.6 1.7 1.7

0.5 0.7 1.0 1.0 1.2 1.2

0.3 0.5 0.6 0.7 0.8 0.8

0.2 0.3 0.4 0.5 0.5 0.6

NOTE Example of uaa c1table: An eslimata cd20 percent based on an intimate & 10 rdliim drug mwrfions has a standard

error of3,1 pwoantc+aralatFFeafandarde rrorof15.5p arcent(3.t percent dMdedby20permnt).

medication.Physicians mayreportupto

fivemedications per viWt.

Drugvisit-Adrug visitisavisitat

which medication wasprescrilxxi or

provided by thephysiciau.

Neumlogist—As defined inthe

NAMCS, a neurologist is a physician

whohas self-designated the practice

specialty ofneurology orchild

neurologyonthe American Medical

Association’s Physicians’ Professional

Activities Questionnaire. The

physician’sspecialty isalsoverified

duringtheNAMCS interview.l%e

pmcticespecirdty ofneurologyis

delinedin the category of’’other

specialties’ ’bythe American Medical

Association (additional categories

includefamily/generrd practke,medical

specialties, andsurgkal specialties),and

theAmericanBoard ofPsychiatryand

Neurology cmiks physicians inthat

specialty.

Oflce-Anofficeis thespace

identiiiedbya physician asa location

forhisorherambukitory practice.

Offices customarily include consultation,

examination,ortreatment spaces that

patients associate with theparticular

physician.

Physiciun-A physician is a duly

licensed doctor of medicine (M.D.) or

doctor of osteopathy @.O.) who is

currently in office-based practice and

who spends some time caring for

ambulatory patients. Excluded fmm the

NAMCS are physicians who are hospital

base~ who specialize in anesthesiology,

pathology, or radiolog~ who are

federally employed; who treat only

institutionalized patients; or who are

employed full time by an institution and

spend no time seeing ambulatory

patients.

Wsit—A visit is a direct personal

exchange between an ambulatory patient

and a physician or a staff member

working under the physician’s

supervision, for the purpose of seeking

care and rendering personal health

semices. Excluded from the NAMCS

are visits where medical care was not

provided, such as visits made to drop off

specimens, pay bilk, make

appointments, and wak-outs.
18 Advance Data No. 267 ● August 8, 1995

Table W. Approximate standard errors of percents of estimated numbers of drug mentions

at office visits to neurologists: National Ambulatory Medical Care Survey, 1991-92

Base of percent (vMs, Esflmated percent

expressed as annual

average, In thousands) lor99 5or95 100r90 200r80 300r70 400r60 50

Standard error In percentage points

50 . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6 5.6 7.6 10.3 11.8 12.7 12.9

100 . . . . . . . . . . . . . . . . . . . . . . . . . 1.6 4.0 5.5 7.3 6.4 9.0 9.1

250 . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 2.5 3.5 4.6 5.3 5.7 5.8

500 . . . . . . . . . . . . . . . . . . . . . . . . . . 0.6 1.8 2.5 3.3 3.7 4.0 4.1

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . 0.6 1.3 1.7 2.3 2.7 2.8 2.9

2,600 . . . . . . . . . . . . . . . . . . . . . . . . . 0.4 0.8 1.1 1.5 1.7 1.8 1.8

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . 0.3 0.6 0.6 1.0 1.2 1.3 1.3

8,000 . . . . . . . . . . . . . . . . . . . . . . . . . 0.2 0.5 0.6 0.8 0.9 1.0 1.0

10,000........................ 0.2 0.4 0.6 0.7 0.8 0.9 0.9

25,000 . . . . . . . . . . . . . . . . . . . . . . . . 0.1 0.3 0.4 0.5 0.5 0.6 0.6

NOTE ExanyYleof useoftableAn estimate of20percentbssed onanestlmateofS million drugmentk.ns peryearat

neurologyvisitshes astsrwlarderrorof 0.8percentorarelstive stsndarderrorof 4.0peroent (O.8percent dividedby20

percent).

Table VII. Coefficients appropriate for determining relative standard errors by type of

estimate and physician speolalt~ National Ambulatory Medical Care Survey, 1991-92

Coa~c/ent for usa with esthrratas In thousands

T~e of ast/mate and physician spec/ai7y A B

VMS

Overalltokds. . . . . . . . . . . . . . . . . . . . 0.001157131 61.31199983

Generaf sndfamilypractice . . . . . . . . . . . 0.007330504 54.54704362

Osteopathy . . . . . . . . . . . . . . . . . . . . . 0.01402452 18.13642054

Intemalmedicine . . . . . . . . . . . . . . . . . . 0.006716567 55.2168744

Pediatrics . . . . . . . . . . . . . . . . . . . . . . 0.007994388 35.33091768

Generafsurgery . . . . . . . . . . . . . . . . . . 0.006685247 10.65103125

Ob~etrksandg ynecology. . . . . . . 0.00919684 25.59982011

Orfhopedlcsurgery . . . . . . . . . . . . . . . . . 0.005641337 24.20372144

Csrdlovssculardisaasas . . . . . . . . 0.01383253 12.5W.89271

Dermatology . . . . . . . . . . . . . . . . . . . . . 0.01275351 10.28301649

Urologkalsurgery . . . . . . . . . . . . . . . . . 0.008000282 11.92653664

Psychiatry . . . . . . . . . . . . . . . . . . . . . . 0.008414736 12.86530675

Neurology . . . . . . . . . . . . . . . . . . . . . . 0.01314774 5.36720616

Ophthafomology . . . . . . . . . . . . . . . . . . 0.007938146 23.64517495

Ototaryngology . . . . . . . . . . . . . . . . . . . 0.007543396 8.0936265

Allotherspecle.ltles . . . . . . . . . . . . . . . . 0.01537018 35.00317779

Drugmentlons

Overalltotals . . . . . . . . . . . . . . . . . . . .

Generslandfamilypractice . . . . . . . . . . .

Osteopathy . . . . . . . . . . . . . . . . . . . . .

Intemalmedlclne . . . . . . . . . . . . . . . . . .

Pedlafrtos . . . . . . . . . . . . . . . . . . . . . .

Generslsurgary . . . . . . . . . . . . . . . . . .

Obstetftcs andgynecology. . . . . . . . . . . .

Orfhopedlcsurgety . . . . . . . . . . . . . . . . .

Cardlovasculardlseases . . . . . . . . . . . . .

Dermatology . . . . . . . . . . . . . . . . . . . .

Urologicalsurgefy . . . . . . . . . . . . . . . . .

Psychiatry . . . . . . . . . . . . . . . . . . . . . .

Neurology . . . . . . . . . . . . . . . . . . . . .

Ophthalmology. . . . . . . . . . . . . . . . . .

Otolaryngology . . . . . . . . . . . . . . . . . . .

Allotherspecislties . . . . . . . . . . . . . .

0.001863163

0.009085669

0.01658477

0.01148498

0.01245118

0.03935224

0.01454044

0.01566053

0.01575914

0.01299377

0.01867719

0.01430555

0.01593433

0.0251486

0.008374063

0.0226229

118.69462

100.96778

23.4733982

103.21387

26.73517786

6.06606796

31.24058408

23.3838057

24.23751806

15.94507357

10.6886669

15.99374434

6.67244993

25.1381195

12.25916054

57.79950436
Advance Data No. 267 ● August 8,1995 19

Symbols

.-. Data not available

. . . Category not applicable

Quantity zero

0.0 Quantity more than zero but less

than 0.05

z Quantity more than zero but less

than 500 where numbers are

rounded to thousands

*

Figure does not meet standard of

reliabilii or precision (see

Technical notes)

# Figure suppressed to comply with

confidentiality requirements
20 Advance Data No. 267 ● August 8, 1995

Copyright Information

All material appearing in this report is in the

public domain and may be reproduced or

copied without permiasio~ citation aa to

source, however, is appreciated.

Suggested citation Trade name disclaimer National Center for Health Statistics

Schappert SM. Office visita to neurologists: The usa of trade names is for identification Acting Director

Unitad Statas, 1991-92. Advance data from only and does not imply endorsement by the Jack R. Andarson

vital and health statistic; no 267. Hyatt.swille, Public Health Service, U.S. Department of

Maryland National Cantar for Health Health and Human Services. Acting Deputy Director

Statistic. 1995. Jennifer H. Madans, Ph.D.

U.S. DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Public Health Service

Centers for Disease Ccntrcl and Prevention

National Center for Health Statistics m

6525 Belcrest Road

Hyattaville, Maryland 20782

OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

To receive this publication regularly, contact

the National Center for Health Statistics by

calling 301-436-6500

E-mailmchsquery@nchl Oa.em.cdc.gov

lntarnethttp:/iwww. cdc.gov/nchswww/nc4rshome.htm

DHHS Publication No. (PHS) 95-1250

5-1394 (6/95)
Number 268 . October 6, 1995

i

Advance

Data m

FromVitaland HealthStatisticsofthe CENTERS FOR DISEASE CONTROLAND PREVENTION/National Centerfor Health Statistics

National Hospital Ambulatory Medical Care Survey: 1993

Outpatient Department Summary

Karen L. Lipkind, M.Ed., Division of Health Care Statistics

Introduction

During the 12-month period

January-December 1993, an estimated

62.5 million visits were made to

outpatient departments (OPD’S) of

non-Federal, shofi-stay, and general

hospitals in the United States-24.6

visits pm 100 persons. This was not

signitlcantly different from the 1992 rate

of 22.5 visits per 100 persons.

This report presents data on OPD

visits from the 1993 National Hospital

Ambulatory Medical Care Survey

(NHAMCS), a national probability

survey conducted by the Division of

Health Care Statistics, National Center

for Healrh Statistics, Centers for Dkase

Control and Prevention. The survey was

inaugurated in December 1991 to gather

and d~seminate information about the

health care provided by hospital

emergency and outpatient departments

to the population of the United States. It

is endorsed by the American Hospital

Association, the Emergency Nurses

Association, and the American College

of Emergency Physicians.

This report presents data on OPD

patient characteristics and visit

characteristics. Data from the 1992

NHAMCS have been published (l-4),

and a report on 1993 NHAMCS

emergency department visits is

forthcoming (5).

Because the estimates presented in

this report are based on a sample rather

than on the entire universe of hospital

OPD visits, they are subject to sampling

variability. The Twhricsl notes at the

end of this report include a brief

overview of the sample design used in

the 1993 NHAMCS and an explanation

of sampling errors. A detailed

description of the NHAMCS sample

design and survey methodology has

been published (6).

The OPD Patient Record form is

used by hospitals participating in the

NHAMCS to record information about

patient visits. This form (figure 1) is

intended to serve as a reference for

readers as they review the survey

findings presented in this document.

Patient characteristics

OPD visits by patient’s age, sez

and race are shown in table 1. There

were no significant differences in OPD

visit rates among any of the age groups.

Females made 62.3 percent of all OPD

visits and had a higher vKlt rate (29.8

visits per 100 persons) than males (19.1

visits per 100 persons) did.

WMte persons made 74.1 percent of

all OPD visits, with black persons and

Man/Pacific IslandeIs accounting for

22.4 percent and 3.2 percen~

respectively. The visit rate for black

persons was signhicantly higher than for

white persons overall and in all age

categories (figure 2).

Outpatient department visit

characteristics

Geographic region

By region, the largest proportion of

OPD visits was made in the Northeast

(34.6 percent). Visit rates in the

Northeast (43.3 visits per 100 persons)

and the Midwest (31. 1 visits per 100

persons) were higher than those in the

West (10.3 visits per 100 persons).

Clinic type

A clinic was defined as an

administrative unit of the OPD where

ambulatory medical care is provided

under the supervision of a physician.

Clinics where only ancillary services,

such as radiology, renal dialysis, and

pharmacy, were provided or other

settings in which physician services

were not typically provid~ were out of

scope for the survey. In addition,

ambulatory surgery centers were out of

scope since they are included in the

National Survey of Ambulatmy Surgery.

Sun*. ~&’ %

4

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

~<

Public Health Service

Centers for Disease Controland Prevention

L.=

National Center for Health Statistics CENTERS cmFOR DIsEAsE CONTROL

AND PREVENTKIN
2 Advance Data No. 268. October 6, 1995

Department of Health and Human Services

Publk Health .servke, Centers for Disease Oontrol

OMB No. 0920-027S

E@#&#S4

National Center for Health Statfetics

NDTtCE - Information contained on thbformwhich would permit idontiflcatbn of any individual or eafabllahmmtt hac bean coflected witha guaranteethatitwillbe held

fnatdotcordidenoa, willbeuaadonlyforpurpoaeaatatadforthisstudy,andwillnotbediaofoaadorrefaaeadtootherawithoutthesorwentoftheindividualortheeatabllahmrrm

inaccordancewith aacfbn WE@) of the Publlc Haafth $ervica &x (42 USC S42m). Pubtk reponing burdemfor thle phaaa of the survey la eetlmatad to average 3 mfrtutae

per raaporw. If you have any oommenta regardingthe burden aatimata or any other aepad of this auway, Including suggestions for reducing this burden, sand them to

fha PHS Reporte Cfaaramm - Ann: PRA HHH Bulfdfn~ Rm. ?$?t~ 200 lndepandanca Ave., S.W., Washington, DC 20S01,●nd to the Office of Management ●nd

= paDwwork RaduoUonProieofOIWO-027StiWaah[noton.DC 2ftaOS.

NATIONAL HOSPITAL AMBULATORY 1. PATlENT NAME

MEDICAL CARE SURVEY I

OUTPATIENT DEPARTMENT

PATIENT RECORD 2. PATlENT RECORD NO.

1993-94 =

3. DATE OF ViStT 5. SEX 6. RAOE

-i

~ , ❑ ~emale

* ❑ white

2 ❑ Black

L DATE OF BIRTH 2 ❑ MeJe A6ian I Pacific

30 l~~r

-

Amancan Indiirr

40 Gf&no / Aleut

tO. PATtENT’S COMPLAINT(S), SYMPTOM(S), OR

OTHER REASON(S) FOR THIS VISIT

(In porie.t’2 own werdr)

B. Matirmpatam

b. Orher:

L Olhec:

7. ~HNICiTY 8. EXPECTED SOURCE(S) OF “ 9. WAS PATIENT

PAYMENT (checkelf tit wpfy) REFSRRED FOR

10 Hbpamc THIS VISIT BY

origin 1❑ Private/ wmmwcial s ❑ ~$e~~pfepdd ANOTHER

PHYSICIAN?

No1 2❑ Medicare 6 ❑ PatiSntpaid

2❑ Hispanic I ❑ Yes

3 ❑ Medicaid 7 ❑ No oharge

11. PHYSICIAN’S DfAGNOSES 12. HAS PAWENT BSEI

SEEN IN THIS

8. Prind@ disgnceb /

CLfNIC BEFORE

Pr&ema$eodated

Wth km loa JDYea 2DN0

1

b. 0Pt6n

I

[f yes, for the sondition

h item 11a?

Gomar 11-JY66 2gNo

13. TESTS, SURGICAL AND NONSURGICAL’ PROCEDURES, AND THERAPIES Nona❑

a. SELECTED b. ALL OTHER SERVICES

SERVICES Inciudm Perfc6med Ordered

(Cfrec%all erdered ● Teera ● knegings

or prddedJ ● Surgerie8 and other 1 In *D

procedure.

t ❑ Bfood pressure ● OIhar therapies 2 10 20 (stdr as contact lenses,

2❑ Urmalyss P**w! 3

or phye”otherepy) In 2U

3 ❑ Spiromatry Exclude 4

● Services in item 13a ~n 20

4 a Allergy testing ● Cwn2eling / education

● Madiifions 6 In ,D

s n HIV serology (R220rdone on cod line

. ❑ Clher bfood test %%-$~j%~ 0’ 6

10 20

15. MEDICATIONS / INJECTIONS None O

lndwle ● Rx and OTC ● Mealsordered, ● New reeds

. Immunkafiom auppfrad,or ● Continuingreads

● Alt*arrote administered (vdh 0, tillmul

● Anaameks new orders)

I

2

3

4

5

16. DISPOSITION THIS VISIT

{rmechau 112U2apply)

1 ❑ No iObV-Up phflllad

z D Return to dinio PRN

14. COUNSELINGEDUCATION

(CheIAafl or&red or prevkid)

t ❑ None

2 a Exercle.e

a ❑ Chobeterd raductton

. ❑ Weight reduction

5 ❑ Emrokingcessation

6 ❑ Grcwth / davefopment

7 ❑ injury preventkxr

s ❑ HIV transmission

9 ❑ Cthaf Hofrwb51’nlSSorl

,0 ❑ C6har

3 ❑ Return to cfinic- appointment

4 ❑ Telephone follow-up ptanned

6 ❑ Return to referrfngphyddan

s ❑ Refer to other @@iarrlolinio

7 ❑ Admit to howitai

e.o-fSpe@J

-

17. PROVIDERS SEEN

THtS VISIT

(Gerk all #rat apply)

I ❑ Rasidentrlntwn

2 Q Sfeff phyaidan

s uOlher phye!cian

Phyeicienaaeisfanf/

4 ❑ Nurse practitioner

s ❑ Registered nuree

60

Licenseclpractical

nurea

7 ❑ Nurse’s aids

8 ❑ Orner *ifl)

ptre 1. National Hospital Ambulatory Medioal Care Survey Outpatient Department Patient Record,
Advance Data No. 268 ● October 6, 1995 3

Table 1. Numbar, parcent dlstrlbution, and annuai rate of outpatient department visits with corresponding standard errors by saiaotad

patient and outpatient department characteristics: Unitad Stataa, Ist93

Number of

Number of standard standard VISRSper standard

visits In error In Percent error of

Patient and outpatient department ctwacterlstlcs

100persons error

thousanda Urousarrda dktrtbution percent w veari of rate

Allvisits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Patient characterletic

Age

Under 15yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 yea fs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.5-44 yeats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64yeafa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yearaandover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sexandage:

Femate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Undar15yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

W5-24yeara. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yearaandover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Under15yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X-44years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-84yeafa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yeareandover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Raceandagw

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Under15yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24yeaE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2E-44yeafs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-84yeam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yeareandover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Undar15yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44yeam . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .

45-e4yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85-74year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All other rams

Aeian/Pactticlslander . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AmeficanindianEskimo/Aleut.. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Outpatient department characteristic

Geographic region:

Northeast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Midwest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

62,534

12,927

8,512

18,299

12,365

5,865

4,567

38,935

8,420

6,696

12,081

7,386

3,440

2,908

23,600

6,507

1,814

6,218

4,977

2,426

1,659

9,026

6,257

13,449

9,156

4,676

3,772

14,015

3,398

1,970

4,159

2,751

1,006

731

2,006

177

21,666

17,684

14,389

8,783

7,330

1,930

1,248

2,24a

1,371

ee3

888

4,646

1,018

1,020

1S76

804

484

565

2,783

991

282

749

805

424

321

6,519

1,576

1,109

1,939

1,191

827

644

1,320

534

242

429

328

130

115

321

534

4,155

5,140

2,328

2,150

100.0

20.7

13.6

28.3

19.8

9.4

7.3

62.3

10.3

10.7

19.3

11.8

5.5

4.7

37.7

10.4

2.9

9.9

8.0

3.9

2.7

74.1

14.4

10.0

21.5

14.6

7.5

6.0

22.4

5.4

3.2

6.7

4.4

1.6

1.2

3.2

0.3

34.7

28.3

23.0

14.0

. . .

2.0

0.9

1.0

0.8

0.7

0.9

0.9

1.0

0.9

0.6

0.5

0.4

0.6

O.e

1.0

0.2

0.5

0.4

0.4

0.3

2.2

1.5

0s

1.0

0.7

0.7

0.9

2.1

0.8

0.4

0.7

0.5

0.2

0.2

0.4

0.1

5.1

5.8

3.6

3.1

lB-don U.S. Bureauofthe Cewus=timtes dthedvitian, nonintittimnaimd popuhtim ofthe Uni~SMt-as@Ju&l, 1%.

24.6

22.6

24.8

22.4

24.8

31.5

26.1

29.6

23.0

38.9

29.2

28.6

23.5

36.9

19.1

22.2

10.6

15.5

20.6

2S.0

34.8

21.9

19.3

22.8

19.9

21.4

28.3

33.0

43.8

37.2

S8.3

41.9

53.6

80.1

73.2

. . .

. . .

43.3

28.5

16.2

15.5

2.9

3.5

3.6

2.8

2.8

4.8

6.9

3.6

3.6

5.9

3.8

3.1

4.8

7.2

2.2

3.4

1.6

1.9

2.5

5.1

6.7

3.1

3.5

4.0

2.9

2.8

5.0

7.4

4.1

5.8

4.7

4.3

6.4

7.8

11.5

. . .

. . .

8.3

8.3

2.7

3.8

Clinicswereclassified into five care clinics. Pedatric, obstetricsand included such clinics aapsychiatqr and

typeaaa presentedintable2. About half gynecology,and surgery clinics neurology,accountedfor 6.8percentof

ofaUOPD visits (47.1percent)were accountedfor18.OpercenJ 14.7percen~ visit3.

made to generalmedicine clinicsthat and13.4percent ofvisits, respectively.

includedinternalmedicine and primary The ’’other’’cliniccategory,whlch
4 Advance Data No. 268. October 6.1995

Expected sources of payment

Expected sources of payment were

most often Medkaid (31.1 percent),

privatekommercial insurance

(27.0 percent), and Medicare

(16.9 percent) (table 3). “Patient paid”

and “HMO/Other prepaid” were

indicated at 12.1 and 8.8 percent of

OPD visits, respectively. The patientpaid category includes the patient’s

contribution toward “copayments” and

“deductibles.”

Referral status and prior visit

status

Approximately one-fifth

(19.7 percent) of OPD visits were made

as the result of a referral from another

physician (table 4). About three-quarters

(79.5 percent) of OPD visits were made

by patients who had been seen in the

clinic on a previous occasion, and more

than half (63.7 percent) of all visits were

made by persons who were returning to

the cliiic for cafe of a previously

treated problem. One-fifth (20.5 percent)

of visits were made by new patients,

that is, patients who had not been seen

in that clinic before.

Reason for visit

In item 10 of the Patient Record

form, the patient’s (or patient

surrogate’s) “complaint(s), symptom(s),

or other reason(s) for this visit in the

patient’s own words” is recorded. Up to

three reasons for visit are classified and

coded according to A Reasonfor VW

Classijicdionfor Ambulatoq Care

(WC) (7). The principal reason is the

problem, complain~ or reason listed in

item 10a of the OPD Patient Record

fonrl.

The RVC is divided into the eight

modules or groups of reasons dkplayed

in table 5. About 4 of every 10 visits

were made for reasons classified 8s

symptoms, with the diagnostic/screening

and preventive module &d the treatment

module each accounting for about one

fifth of the visits (19.5 and 18.7 percent

respectively). The 20 most frequently

mentioned principal reasons.for visi~

representing 42.6 percent of all visits,

are shown in table 6. It is important to

note that estimates differing in ranked

I - White ~ Black

I w 73.2

Total Under 15 15-24 25-44 45-64 65-74 75 years

years years years years years end over

Patient’s age

I loPcrisold patientdepartment.

Figure 2. Annual rate of outpatient department visits by pattent’s age and racw

United States, 1993

Table 2. Number and percent distribution of outpatient department visits with corresponding standard errors by type of ollnk United States, 1993

Number of Standard Standard

v!sits In error in Percent error of

TW of C/lnlc thousands thousands distribution percent

Allvlstts . . . . . . . . . . . . . . . . . . 62,5S4 7,330 100,0 . . .

Generslmedlclne . . . . . . . . . . . . 2e,443 4,265 47.1 2.9

surgery . . . . . . . . . . . . . . . . . . . 8,382 1,517 13.4 1.9

Pedlatrlcs . . . . . . . . . . . . . . . . . 11,274 1,728 16.0 1.6

Obstetrics and gynecology. . . . . . . 9,169 1,722 14.7 1.8

Other . . . . . . . . . . . . . . . . . . . . 4,266 608 6.8 i .2

Table 3. Number and percent of outpatient department vislte with corresponding standard

errors by patient’s expected source of paymenh United States, 1993

Number of Stendatd Standard

vlslts In error /n error of

Expected source of payment thousands+ thousands Percent percent

Allvist is...,...........,.. 62,534 7,330 . . . ,,.

Medicaid . . . . . . . . . . . . . . . . . . 19,442 2,124 31.1 2.3

Private/commercial. . . . . . . . . . . . 16,906 3,390 27.0 2.6

Medicare . . . . . . . . . . . . . . . . . . 10,542 1,693 16.9 1.4

Pallent-paid . . . . . . . . . . . . . . . . 7,692 966 12.1 1.1

HMO/other prepaid=. . . . . . . . . . . 5,496 1,216 8.6 1.5

Other . . . . . . . . . . . . . . . . . . . . 2,835 605 4.5 0.7

Other govemmenl . . . . . . . . . . . . 2,755 557 4.4 0.7

No charge . . . . . . . . . . . . . . . . . 1,392 431 2.2 0.6

Unspeclfled . . . . . . . . . . . . . . . . 2,243 749 3.6 1.1

lNumbers may axcead total numkw of visitsbecsusemorethanone sourca of payment may be coded for each visit

2HM0 b health maintenaneaorganization,
Advance Data No. 268. October 6,1995 5

order may not be significantly W&ent

from each other. “Progress visit” was

the most frequently mentioned visit

(10.5 percent), reflecting the large

number of return visits for a pmriously

treated problem. Five of the top 20

reasons for visigwhich accounted for

15 percent of all OPD visits, were

classified in the diagnostic screening and

preventive module. The reasons were

“Routine prenatal examination,”

“General medical examination,” “Well

baby examination,” “Other and

unspecified diagnostic tests,” and

“Prophylactic inoculations.” “Stomach

and abdominal pain, cramps and

spasms,” and “Cough” were the most

frequently mentioned reasons for visit in

the symptom module each accounting

for 1.8 percent of the visits.

Principal diagnosis

Theprincipal diagnosis or problem

associated with the patient’s most

important reason for visit and any other

significant current diagnoses are

recoded in item 11. Up to three

diagnoses are coded and classified

according to the International

Classificatwn of Diseases, 9th Reviswn.j

Clinical Modi@m”on (ICD-9-CM3 (8).

Displayed in table 7 are OPD visits by

principal diagnosis using the major

Table 4. Numbw and percent distribution of outpatient deparhent visits with corresponding

standard errors by referral status and prior visit status: Unikf States, 1393

Nurrtrarof SWndard

vktla in WrWkr Partwnf WW of

W charadedsfic flrorlsands thorwands dsmuffm percd

Allvisits . . . . . . . . . . . . . . . . . . . . . . . . 62,534 7,330 100.0 . . .

Retanal status

Nc4rafermd byanotherphys#err . . . . . . . . 50,1s5 6,261 80.3 1.6

Raferradby anotharphyaioian . . . . . . . . . . 12,350 1,566 19.7 1.6

Prfor Waltstatus

Olctpafierlt . . . . . . . . . . . . . . . . . . . . . . 48,727 6,061 79.5 1.1

OIdprMam . . . . . . . . . . . . . . . . . . . . 39,823 4,s5s 63.7 1.3

Newproblem . . . . . . . . . . . . . . . . . . . 9M 1,473 15.6 12

Newpatiant. . . . . . . . . . . . . . . . . . . . . 12,s07 1,510 20.5 1.1

diseasecategoriesspeciliedby the

ICD-9-CM. The supplementary

classification is provided to deal with

situations in which circumstances other

than a disease or injury are recorded as

diagnoses. It accounted for 22.6 percent

of all OPD visits, and was followed by

d~ears of the respirator system

(8.7 percent).

The 20 most frequently reported

pMcipal diagnoses are shown in table 8.

These an? categorized at the three-digit

coding level of the ICD-9-CM and

accounted for more than one third

(35.2 percent) of all OPD vish,s. The

most commonly recorded diagnosis was

“Normal ~gn311Cy,” occurring at

7.9 pement of all visits.

Tests, surgical and nonsurgical

procedures, and therapies

Statistic3on various diagnostic

tests, surgical and nonsurgical

prwedures, and therapies performed or

ordered by hospital strollduring an OPD

visit are shown in table 9.

Approximately three quarters of all OPD

visits included one or more diagnostic

or screening service. The most

hequently mentioned checkbox category

(itim 13a) was blood pressure check,

recoded at 54.4 pement of visits. Other

frequently mentioned services included

Table 5. Number and percent distribution of outpatient defwtmant visits with corresponding standard errors by Patient’s txindmd

rea80nfor vleit: Unitid States, 1993

. . . .

Nunber of Sfarrdsrd SfSrrdard

Vianein errorin Peroenf errorof

Prlrrcpalreasonfor visitand RVC wdei urorwand2 fmmanda diafrbofforr per(wrrf

Allvisifs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Syrnptommodule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. S001-S893

Generaf symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S001-S033

symptoms referable to psychobgicaUmental disorders . . . . . . . . . . . . . . S103-S133

Symptoms referable to the nervous system (excluding sense organs). . . . . S200-S253

symptoms referable to the cardfovaeorrlarflytrphatlc syetem. . . . . . . . . . . S260-.S233

Syrr@ornsreferable totheeyesand ears . . . . . . . . . . . . . . . . . . . . . . S300-.S333

.symptomerefersbl etotherespirafor ysystem . . . . . . . . . . . . . . . . ...3400-3492

symptoms referable to the dlgeetlve system. , , . . . . . . . . . . . . . . . . . . .S500-S633

.Symptorns referable to the gankourfnmy system . . . . . . . . . . . . . . . . . . S640-S82S

symptoms referable fo the skin, hair, and nails, ., . . . . . . . . . . . . . ...3830-3899

Synptome referable to the musculoskeletsl system . . . . . . . . . . . . . . . . Sr30&S389

Diaease module, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. DW1-D383

Dlagno8tlo/8creenkrg and preventive module. . . . . . . . . . . . . . . . . . . . . . X1 OO-X5S8

Traatmsnt module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. TIoo-T899

Irrjurlasand adverae effeotsrrmdule . . . . . . . . . . . . . . . . . . . . . . . . . . .. JOOld933

Test resutts module . . . . . . . . . . . . . ... ,,, ,.. .,, . . . . . . . . . . .. R1OO-R7OO

Admlnlsttatlve module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AI WA140

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. U960-U9B3

24,S46

3,419

2,191

1,565

187

2,167

3,273

2,707

2,837

2,318

4,102

8,078

12,223

11,676

2,374

777

431

4,06s

7,330

3,275

420

42S

201

43

340

642

3s1

629

522

686

825

1,785

1,64s

337

127

13$

654

100.0

33.7

5.5

3.5

2.5

0.3

3.5

5.2

4.3

4.5

3.7

6.7

9.7

19.5

18.7

3.8

1.2

0.8

6.5

. . .

1.7

0.5

0.6

0.2

0.1

0.3

0.6

0.3

0.7

0.5

0.7

0.8

1.4

1.7

0.4

0.1

0.2

1.0

lBawd onA Rewon forVisitCbwfhtbn forAtiu/dory Care (FPJC)(T).

%cludes problermand complakrtanotelsewhereclassitkd,entrfesof “none”,blanks,and ilbgibb entries.
6 Advance Data No. 268. October 6, 1995

other blood tests (20.5 percent) and

urinalysis (13.9 percent). Readers should

note that for items 8, 13, 14, 16, and 17

on the OPD Patient Record form,

hospital staff were asked to check all of

the applicable categories for that item.

Therefoce, multiple responses could be

coded for each visit.,

Up to six entries for tests, surgical

and nonsurgical procedures, and

therapies not listed in the checkbox

categories were made in item 13b.

Results of the open-ended responses

were coded according to volume 3 of

the ICD-9-CM (8). There were an

estimated 33 miKlon procedures of this

type reported. Approximately two-thirds

of the procedures were reported as being

performed (not just ordered) during the

visit. The 20 most frequently reported

procedures are shown in table 10. Other

individual psychotherapy, eye

examinations, and Pap smears were

among the most frequently mentioned

procedures

Counseling/education

Ahnost half (46.6 percent) of all

OPD visits included some form of

counseling or education eifher ordered

or provided (table 11). “Other”

counseling was recorded at one-third of

visits (36.9 percent), followed by

counseling on growth/development

(5.3 percent of visits).

Medications/injections

Hospital staff were instructed to

record all new or continued medications

ordered, suppli@ or administered at the

visi6 including prescription and

nonprescription preparations, and

immunizations and desensitizing agents.

Up to five medications or drug mentions

were coded for each visit. As used in

the NHAMCS, the term “drug” is

interchangeable with the term

“medication”. The NHAMCS drug data

base permits classification by a wide

range of variables, including specitic

drug entry name, trade name, generic

class, therapeutic category, prescription

or nonprescription status, federally

controlled substance status, and

composition status (that is, whether the

drug is a single- or multiple-ingredient

product). A report describing the method

Table 6. Number and percent distribution of outpatient department visits with corresponding standard errors by the 20 principal raaaons for visit moat frequently mentioned

by patientw United States, 1993

Number of Standard Standatd

vklts In eiror In Percent error of

Reason for vklf and RVC Codei thousands thousands dlstffbutlon percent

Allvlsits . . . . . . . . . . . . . . . . . . . . . . . . . . . 62,534 7,330 100.0 . . .

Progress visit . . . . . . . . . . . . . . . . . . . .. T800

Routine prenatal examination . . . . . . . . . X2O5

General medical examination . . . . . . . . . . . Xl 00

Postoperative visit..........,.. . . . .. T205

Well baby examination . . . . . . . . . . . . . .. XI05

Stomach and abdominal pain, cramps and

spasms . . . . . . . . . . . . . . . . . . . ... .. S545

Cough . . . . . . . . . . . . . . . . . . . . . . . .. S440

Skirrraah . . . . . . . . . . . . . . . . . . . . . . .. S660

Fever . . . . . . . . . . . . . . . . . . . . . . . . .. S010

Earache or ear Infection . . . . . . . . . . . . . . s355

Backsymptoms . . . . . . . . . . . . . . . . . . ..s905

Medication, othar and unspecified ., . . . . . . .TI15

Headceld . . . . . . . . . . . . . . . . . . . . . . .. S445

Headache, pairrin haad . . . . . . . . . . . . .. S210

Depression . . . . . . . . . . . . . . . . . . . . . ..S110

Counsal[ng, not otherwisa stated . . . . . . . . . .T605

Other and unspacitied diagnostic teats . . . . . X370

Prophylactic inoculations . . . . . . . . . . . . . . x400

Hyperfensiorr . . . . . . . . . . . . . . . . . . . .. D510

Knee symptoms . . . . . . . . . . . . . . . . . ..s925

6,593

3,900

3,140

1,394

1.384

1,254

818

506

278

270

10.5

6.2

5.0

2.2

2.2

1.8

1.0

0.5

0.3

0.4

1,121

1,119

808

795

726

716

655

622

620

606

510

500

432

480

479

178

264

143

201

131

147

122

155

93

f43

152

215

133

65

85

1.6

1.6

1.3

1.3

1.2

1.1

1.0

1.0

1.0

1.0

0.6

0.6

0.8

0.8

0.6

0.2

0.3

0.1

0.3

0.1

0.2

0.1

0.2

0.1

0.2

0.2

0.3

0.2

0.1

0.1

All other reasons . . . . . . . . . . . . . . . . . . . . . . . 35,692 1,701 57.4 0.6

lBased on A Reason for Visil C/assificsfbn forArrk5u/story Care (RVC)(7).

Table 7. Number and percent distribution of outpatient department viaite with corresponding standard errors by principai diagnosi!x United States, 1993

Number of Standard Standard

visits in error in Percent error of

Principal diagnosk and lCD-&CM Codaq thousands thousands dktrfbutfon percent

All visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62,534

1,696

3,760

2,275

4,489

3,761

3,595

5,461

2,091

3,678

2,411

3,401

3,590

3,498

14,166

“1,530

2,902

7,330 100.0

Infectious and parasitic diseases . . . . . . . 001-139

Neoplasm . . . . . . . . . . . . . . . . . . . ..140-239

Endocrtne, nutritional and metabolic diseases

and immunity disorders . . . . . . . . . . . . 240-279

Mental dlsordere . . . . . . . . . . . . . . ...290-319

Diseases of the nervous system and sense

organs . . . . . . . . . . . . . . . . . . . . ...320-389

Diseases of the circulatory system . . . . . . 390-459

Diseases of the respiratory syslem. . . . . . 460-519

Diseases of the dlgastive system. . . . . .. 520-579

Diseases of the genifourinary system . . . . 580-829

Diseases of the skin and subcutaneous

tiasua . . . . . . . . . . . . . . . . . . . . . ..680-709

Diseases of the musculoskeletal system and

connectlvetksue . . . . . . . . . . . . . , 710-739

syn’ptoms, signs, and Illdeffned

conditions . . . . . . . . . . . . . . . . . ...780-799

Injury and poisoning. . . . . . . . . . . . . . . 600-999

Supplementary classtiication. . . . . . . . . . VOI-V62

Another dlagnoses2 . . . . . . . . . . . . . . . . . . . . .

Unknowns . . . . . . . . . . . . . . . . . . . . . . . . . . .

236

813

3.0

6.0

0.3

1.0

362 3.6

7.2

0.4

795 1.1

542

531

6.0

5.7

8.7

3.3

5.9

0.5

0.5

0.9

0.4

0.7

993

239

727

680 3.9 0.6

569 5.4 0.6

386 5.7

5.6

22.6

2.4

4.6

0.3

0.5

1.5

0.4

0.5

537

1,784

563

373

1Based on the htemaficrrd C/assificatiorr of Diseases, Wh Revision, C/inios/ kfdifioatbrr (ICD-9-CM) (8).

‘Includes dlsesses Ofthe bloodandblocd-f.ardngorgans(280-289); mmplicatiinsof pregnancy,childbirth,andthe

(630-S7S); mngentil anomahes (740-758); and certain mndflons originating in the perinetal period (760-779).

31ncludes blank diagnoges, uncodable diagrwaea, and illegible diagnoses.
Advance Data No. 268 ● October 6,1995 7

and instruments used tn collect and

process drug information has been

published (9).

Medication was used at

57.1 percent of the outpatient

department visits (table 12). Hospital

staff were instructed to record all new

or continued medications ordered or

provided at the visit including

prescription and nonprescription

preparations, and immunizing and

desensittilng agents. As many as five

medications or drug mentions could be

coded per visit.

There was a total of 75.7 million

drug mentions, or an average of 1.2

drug mentions, per OPD visit. The 20

medications most frequently prescribed

at OPD visits are shown in table 13 by

drug entry name and therapeutic

classification. The therapeutic

classification is based on the therapeutic

categories used in the National Drug

Code Dmtory, 1985 edition (10). The

top 20 medications account for

23 percent of all drug mentions. Tylenol

was the medication most frequently

prescrib@ with 2.2 million mentions, or

2.9 pement of the total. It was followed

by prenatal vitamins (2.5 percent) and

amoxicillin (1.7 percent).

Disposition of this visit

Apprmimately tWO-thiidS of OPD

visits (65.6 percent) resulted in an

appointment being made to return to the

clinic. This and the previously

mentioned finding that most OPD

patients had been seen in the clinic

before are indications of the continuous

nature of care provided in the OPD

setting. For 17.9 percent of visits, the

disposition was “Return to c~micPRN”

(as needed) (table 14). Only 1.5 percent

of OPD visits resulted in hospital

admission.

Providers seen this visit

A stalYphysician was seen at

two-thirds of OPD visits (66.8 percent).

Conversely, one-thiid of the visits had

patients who were NOT seen by a stalf

physician. Registered nurses were seen

at 41.8 percent of visits and residents/

interns were seen at one-quarter

(24.3 percent) of visits (table 15).

Table 8. Number and percent distribution of outpatient department visits by the 20 principai diagnoses most frequently renderad by hospital staff United Statea, 1993

Number of standard S&rafSrd

wits h error h Percerrf error of

Prirrc@sl disgnos/s and ICD-9-CM Codst fholrssnds thousands disiiftwfion percent

Allvisifs . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nonnsfpregnancy . . . . . . . . . . . . . . . . . ..V22

Hesfth supervision of infant or child . . . . . . . . V20

Essentlai hyparfenslon . . . . . . . . . . . . . . ..4oI

General rnadbl examination . . . . . . . . . . . . V70

Suppurstive and unspedilad otifis media . . . . . 382

Acute upper respiratory infeef!ars of mulfipfe or

urrspsciffed sites . . . . . . . . . . . . . . . . ...465

Disbetes memfus. . . . . . . . . . . . . . . . . ...250

Asthma. . . . . . . . . . . . . . . . . . . . . . . ...493

Neuroflc disorders . . . . . . . . . . . . . . . . ...300

Other posfsurglcal stafes. . . . . . . . . . . . . . . v45

Affedive psydroses . . . . . . . . . . . . . . . ...296

Malfgnsrrt neoplasm of fernefe breast . . . . . . . 174

General syrnptorns . . . . . . . . . . . . . . . . ...760

Other and urrspeolffsd disorders of back . . . . . 724

Acufepharyngftis . . . . . . . . . . . . . . . . . ...462

Alcohol dapendenee syndrome . . . . . . . . . . . 303

Follow-up examination . . . . . . . . . . . . . . ..V67

Chronic sinusitis . . . . . . . . . . . . . . . . . ...473

Other disorders of urethra and urfrraryW@. . . . 593

Bronchltls, not spsdffed se acute or chronio . . . 490

Allofherdlagnosss . . . . . . . . . . . . . . . . . . . . .

62,534

4,923

1,676

1,732

1,286

1,242

la

1,103

1,022

914

800

603

&t6

631

572

572

“565

525

503

494

492

40,497

7.s30

913

345

2=

242

220

308

191

267

219

219

201

190

97

155

127

233

109

127

112

106

4,762

100.0 . . .

7.3 1.1

3.0 0.5

2.8 0.3

2.1 0.3

2.0 0.3

2.0 “ 0.3

1.8 0.2

1.6 0.3

1.5 0.3

1.4 0.3

1.3 0.3

1.0 0.3

1.0 0.1

0.9 0.2

0.9 0.2

0.9 0.3

0.8 0.2

0.6 0.1

0.8 0.2

0.8 0.1

64.8 1.5

lBaaad onthe IntamaticfrafClaaaifkstkmof DisazsasjSthRwisbtr, ClinicalAfcdh%atbn(lCO-Q-CM) (8).

Tabie 9. Number and percent of outpatient department visits with eorreaponding standard

errors by sefeotad diagrtoaticservfcea performed or ordered: United Statea, 1393.

Nurrber of Sterrded StSrrdani

Selected dlsgrrosfic servicss performed or VIslta in etror h

ordered by troeplta! stti ftrouesndsj thousands Pemnt p-d

Allvfsifs . . . . . . . . . . . . . . . . . . . . . . . 62,534 7,330 . . . . . .

Blood pressure . . . . . . . . . . . . . . . . . . . 34,013 4,012 54.4 1.9

Other bkmftest . . . . . . . . . . . . . . . . . . 12,s43 1,515 20.5 1.0

Urirrafysis. . . . . . . . . . . . . . . . . . . . . . 8,719 1,23s 13.9 1.2

HIVserofo@ . . . . . . . . . . . . . . . . . . . . 4ss 133 0.8 0.2

Spirometry . . . . . . . . . . . . . . . . . . . . . . *375 122 0.6 0.2

Alfargytesting . . . . . . . . . . . . . . . . . . . . “182 75 0.3 0.1

None . . . . . . . . . . . . . . . . . . . . . . . . . 14,627 1,821 23.4 1.3

lNumbars may aced tdal number of visii bacausa more Ihan one servka may ba raported par viaii,

‘HIV is human immunocfdciency virus.

Additional reports utilizing

NHAMCS data are forthcoming

in the Advance Data Jrom Etal and

Health Statistics series. In addition,

survey data will be available on

computer tape and CD-Rem horn the

National Technical Information Service in

early 1996. Questions regarding this

repo@ future reports, or the NHAMCS

may be directed to the Ambulatory

Care Statistics Branch by caUing

(301)436-7132.

References

1. McCsig LF. National Hospital

Arnbulatmy MtiIcal Care Survey:

1992 emergency department

summary. Advance data from vital

and health statistic no. 245.

HyattsvilIe, Maryland National

Center for Health Statistics. 1994.

2. McCaig LF. National Hospital

Ambulatory Medical Care Survey

1992 outpatient department summary.

Advance data from vital and health

statistics; no. 24S. Hyattsvillq
8 Advance Data No. 268 @ October 6,1995 

Table IO. Number and percent of outpatient department visits by the top write-in diagnostic tests, surgical and non-surgical procedures, 

or therapies most often performed or ordered in hospital outpatient departments: United States, 1993 

Tests, surgical and non-surgical procedures 

and therapies and ED-9-CM code1 

Number of 

visits in 

thousands2 

Standard 

emor in 

thousands 

Standard Percent dis ttibution 

emor of 

Percent percent Total Performed Ordered Unknown3 

All visits a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62,534 7,330 . . . . . . . . . . . . 

All vlslts with procedures wrltten In . . . . . . . . . . . . . . 33,023 1,570 52.8 0.9 100.0 69.4 22.2 8.5 

2,045 563 3.3 5.3 100.0 89.2 0.9 9.9 

1,793 608 2.9 5.7 100.0 90.0 1.6 8.4 

1,744 379 2.8 5.7 100.0 83.0 9.1 7.9 

Other Individual psychotherapy ............ 94.39 

Eye examination not otherwise specified ...... .95.09 

Pap smear. ........................ .91.46 

Other nonoperative measurements and 

examinations ...................... .89.39 

Routine chest x ray ................... .87.44 

Microscopic examination of specimen 

from female genital tract--culture .......... .91.42 

Other mammography .................. .87.37 

Electrocardiogram .................... .89.52 

Diagnostic ultrasound of gravld uterus. ....... .88.78 

Microscopic examination of specimen 

from ear, nose, throat and larynx-culture. ..... .90.32 

Other diagnostic ultrasound .............. .88.79 

Fetal monttortng, not otherwise specified ...... .75.34 

Other physical therapy ................. .93.39 

Skeletal x ray of anMe and foot ............ .88.28 

Skeletal x ray of thigh, knee and lower leg ..... .88.27 

Skeletal x ray of wrist and hand. ........... .88.23 

Gynecological examination. .............. .89.26 

X ray, other and unspecified .............. .88.39 

Tonometry ......................... .89.11 

Other local excision or destruction of lesion 

or tissue of skin and subcutaneous tissue ..... 86.3 

1,548 526 2.5 6.1 100.0 93.3 2.2 4.5 

1,386 216 2.2 6.5 100.0 55.3 34.5 10.2 

1,074 209 1.7 7.4 100.0 87.1 7.4 5.6 

1,024 213 1.6 7.5 100.0 29.8 64.3 6.0 

948 123 1.5 7.8 100.0 65.2 25.7 9.1 

825 185 1.3 8.4 100.0 52.6 43.5 3.9 

574 130 0.9 10.1 100.0 85.9 10.8 3.3 

557 185 0.9 10.3 100.0 55.5 39.3 5.2 

531 267 0.8 10.5 100.0 94.9 2.1 3.0 

463 102 0.7 11.3 100.0 28.5 53.3 18.1 

375 71 0.6 12.5 100.0 73.3 19.2 7.5 

357 93 0.6 12.8 100.0 74.5 19.0 6.4 

353 115 0.6 12.9 100.0 89.0 8.5 2.5 

321 89 0.5 13.6 100.0 85.0 10.6 4.4 

310 60 0.5 13.8 100.0 73.9 19.7 6.5 

307 201 0.5 13.9 100.0 97.4 0.0 2.6 

306 63 0.5 13.9 100.0 88.6 6.5 4.9 

‘Based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) (8). 

*Numbers may exceed total number of visits because more than one procedure may be reported per visit. 

3Not known whether ordered or pefformed. 

Maryland: National Center for Health 

Statistics. 1994. 

Nelson CR, Stussman BJ. Alcoholand drug-related visits to hospital 

emergency departments: 1992 

National Hospital Ambulatory 

Medical Care Survey. Advance data 

from vital and health statis tics; no. 

25 1. Hyattsville, Maryland: National 

Center for Health Statistics. 1994. 

Burt CW. Injury-related visits to 

hospital emergency departments: 

United States 1992. Advance data 

from vital and health statistics; no. 

26 1 e Hyattsville, Maryland: 

National Center for Health 

Statistics. 1995. 

Stussman BJ. National Hospital 

Ambulatory Medical Care Survey: 

1993 emergency department 

summary. Advance data from vital 

and health statistics. HyattsvilIe, 

Maryland: National Center for Health 

Statistics. 1995. To be published. 

McCaig LF, McLemore T. Plan and 

operation of the National Hospital 

Ambulatory Medical Care Survey. 

National Center for Health Statistics. 

Vital Health Stat l(34). 1994, 

Table 11. Number and percent of outpatient department visits with corresponding standard errors by counseiing~education services: United States, 1993 3. 

4. 

5. 

6. 

Counseling/education ordered or 

provided by hospital staff 

Number of 

visits in 

thousands’ 

Standard 

error in 

thousands Percent 

Standard 

emor of 

percent 

All visits . . . . . . . . . . . . . . . . . . 62,534 7,330 . . a D . . 

Growth/development. . . . . . a . . a . 3,29 4 777 5.3 1.1 

Exercise . . . . . . . . e . . . . . . . D . 2,954 521 4.7 0.5 

Injury prevention 0 D 0 a . . . . 0 e D m D "1,594 489 2.5 0.6 

Weight reduction . . . 0 . . D . . . . a D 1,487 227 2.4 2.0 

Smoking cessation. e D . 0 D D e D 0 . D 1,112 186 1.8 0.2 

Cholesterol reduction 0 n . D . . . U . D 790 136 1.3 0.2 

Other STD transmission o . . . . . . . 761 157 1.2 0.2 

HIV transmission. D q . e . . D . . q . D 722 166 1.2 0.2 

Other . . . . . . . . . . . . . . . . . . . . 23,051 3,121 36.9 1.7 

None . . . . . . . . . . . . . . . . . . . . 33,397 3,937 53.4 2.0 

‘Numbers may exceed total number of visits because more than one service may be reported per visit. 

modification, Washington: Public 

Health Service. 1980, 

9. Koch H, Campbell W. The collection 

and processing of drug information. 

National Ambulatory Medical Care 

Survey, 1980. National Center for 

Health Statistics. Vital Health Stat 

2(90). 1982. 

7. Schneider D, Appleton L, McLemore 

T. A reason for visit classification for 

ambulatory care. National Center for 

Health Statistics. Vital and Health 

Stat 2(78). 1979. 

8. Public Health Service and Health 

Care Financing Administration. 

International Classification of 

Diseases, 9th Revision, clinical 
Advance Data No. 268. October 6, 1995 9

Table 12. Number and percent distribution of outpatient department visits with corresponding standard errors by number of medication codas this vfsib United States, 1993

Number of Standard standard

Number of vfatfain error in Percent error of

medication sodes thousands thousands distribution percent

Allvidls. . . . . . . . . . . . . . . . . . . . . . . 62,534 7330 100.0 . . .

None . . . . . . . . . . . . . . . . . . . . . . . . . 26,812 3716

1

42.9 i .9

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 16,002 19s3

2

25.6 1.0

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 9,118 1080

3

14.6 0.7

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,456 530

4

7.1 0.4

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,628 318 4.2 0.4

5 ormore . . . . . . . . . . . . . . . . . . . . . . 3,518 466 5.6 0.6

10. Food and Drug Administration.

National Drug Code Dhe-ctory, 1985

Edition. Washington Public Health

Servicq 1985.

11. Shah BV, Barnwell BG, Hunt PN, La

Vange LM. SUDAAN user’s manual

release 5.50. Research Triangle Pink,

North Carolinz Research Triangle

rnstitute. 1991.

Tabie 13. Number and percent distribution for the 20 drugs most frequantty prescribed at outpatient department visits with corresponding standard errors, by entry name of drug: United States, 1993

Number of Standard standard

druge mentions error in Percent error of

Entry name of drugt h thoussnda thousands disbfbutIon parcwt Therapeutic classlficatlorr2

Alldrug menWms..... . . . . . . . . . . . . .

Tylenol . . . . . . . . . . . . . . . . . . . . . . . .

Pranakdvttamirss . . . . . . . . . . . . . . . . . .

Amoxldllin . . . . . . . . . . . . . . . . . . . . . .

Dlphiher&a& tetanus toxoids

wlthpertusdav acdne. . . . . . . . . . . . . .

Motrin. . . . . . . . . . . . . . . . . . . . . . . . .

Poliomyelitis vacdne. . . . . . . . . . . . . . . .

Leak. . . . . . . . . . . . . . . . . . . . . . . . .

Prednisone . . . . . . . . . . . . . . . . . . . . .

Zantac . . . . . . . . . . . . . . . . . . . . . . . .

Bacfrtm . . . . . . . . . . . . . . . . . . . . . . . .

Procardia. . . . . . . . . . . . . . . . . . . . . . .

Ironpraparaflon . . . . . . . . . . . . . . . . . .

Ventolin. . . . . . . . . . . . . . . . . . . . . . . .

Proventil . . . . . . . . . . . . . . . . . . . . . . .

Hepatitis B. . . . . . . . . . . . . . . . . . . . . .

i-faemophllus Bcorrjugatevacdne . . . . . . .

Vssotec. . . . . . . . . . . . . . . . . . . . . . . .

Influenza vlrusvacclne . . . . . . . . . . . . . .

Bynthroid . . . . . . . . . . . . . . . . . . . . . . .

vitamins. . . . . . . . . . . . . . . . . . . . . . .

Another . . . . . . . . . . . . . . . . . . . . . . .

75.710

2,191

1,879

1,307

934

879

873

795

743

739

721

698

685

682

657

657

656

616

567

555

550

58,296

3,781

326

566

227

173

148

170

126

119

109

163

84

211

129

141

127

139

85

161

92

229

2,930

100.0

2.9

2.5

1.7

1.2

1.2

1.2

1.1

1.0

1.0

1.0

0.9

0.9

0.9

0.9

0.9

0.9

0.8

0.8

0.7

0.7

77.0

.. .

0.4

0.8

0.3

0.3

0.2

0.3

0.1

0.2

0.1

0.2

0.1

0.3

0.2

0.2

0.2

0.2

0.1

0.2

0.1

0.3

0.6

Ganeralanalgaaks

VWmins,mirrerals

Persidttlrrs

Vacdnes and anllsarums

Antiarthrttice

Vaodnas and antiserums

Diuretics

AdrerreJcorticosteroids

Agents used in dtsorders of upper GI tract

Antimlcrobiale

Aot!-snginalagents

Agents used to treat darldency anemias

Bronchmtllators, anllasthmatks

Bronchodkdore, antlasthmatics

vaccines and antiserums

Vaccines and antiserums

Anthypertenslve agents

Vaccines and antlsarums

Agents used to treat thyroid disease

Vitamins, minerafs

‘The entry made by the hospital staff on the prescription or other madiial remrds. This maybe a trade name, generic name, or desired thwapautic effect

%serapeutii dassikation is based on the NatiorrafDrug COC4IYiredoM 1985 Edtiorr (10). [n cases where a drug had mere than one thempeutii use, rt was listed in the category that omurred

withthegreatest fraquen~,
10 Advance Data No. 268. October 6, 1995

Table 14. Number and percent of outpatient department visits with corresponding standard errors by disposition of visik United States,

1993

Number of Standard Standatrl

viaftaIn error in error of

D@osltlon thousands thousands Percent percent

Allvlsifs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62,534 7,330 . . . . .

Retumto clinic - appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Retumto cl[nlc PRN2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Refer toother physlcian/clinlc . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nolollow-up pkmned. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ralurnto referringphyslcian . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Telephonefollow-upplanned..... . . . . . . . . . . . . . . . . . . . . . . . . .

Admltto hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41,017

11,163

4,625

2,805

2,463

2,079

921

2,058

4,746

1,933

595

483

559

564

179

334

65.6

17.9

7.4

4.5

3.9

3.3

1.5

3.3

1.9

1.4

0.8

0.5

0.8

0.8

0.2

0.4

lNumbers may exceed total number of visits because more than one disposition may be reported per visit.

2PRN is as needed.

Table 15. Number and percent of outpatient department visits with corresponding standard errors by type of provider seen:

UnitsdStatas,1993

Number of Standatd Standard

vlslts In error In error of

Type of provider thousandai thousands Percent percent

Allvleits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62,534 7,330 . . . . . .

Ststfphysician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Reglsterednurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Resldent/lntern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Llcansedpracflcalnuree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nurse’saide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Phyelcisn aesietsnWNuree

practitioner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otherphysician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41,786

26,155

15,223

“6,770

5,254

4,547

2,145

11,053

5,720

2,567

2,363

2,186

998

892

555

2106

66.6

41.8

24.3

10.8

8.4

7.3

3.4

17.7

2.4

3.3

2.2

2.6

1.3

1.0

0.6

2.2

lNumbers may exceed total numbsr of visits because more than one provider may be reporfad per visfi.

Symbols

--- Data notavailable

. . . Category notapplioable

Quantityzero

0.0 Quantity morethan zero but

lessthan O.05

z Quantity morethan zero but

less than 500 where numbers

are roundedto thousands

* Figure does not meet standard

of reliabilityor precision
Advance Data No. 268. October 6, 1995 11

Technical notes

Souroeof dataand sampledesign

The information presented in this

report is based on data collected in the

1993National Hospital Ambulatory

Medkal Care Survey (NHAMCS) ftom

December 28, 1992 through December

26, 1993. The data were adjusted to

produce annual estimates.

The @get universe of NHAMCS

includes in-person visits made in the

United States by patients to emergency

departments (EDs) and outpatient

departments (OPD’S) of non-Federal,

short-stay hospitrds (hospitals with

average length of stays for all patients

of fewer than 30 days) or those whose

specialty is general (medcsl or surgical)

or childnm’s general. The NHAIWS

sampling flame consists of hospitals

listed in the April 1991 SMG Hospital

Database.

A four-stage probability sample

design is used in NHAMCS. The design

includes Sillll@S of primary Samphlg

Units (ps~s), hospitals within PSU’S,

ED’s within hospitals and/or clinics

within outpatient departments (OPD’S),

and patient visits within ED’s and/or

cIinics. The PSU sample consists of 112

PSU’S comprising a probability

subsample of the PSU’S used in the

1985–94 National Health Interview

Survey. The hospital sample for 1993

consisted of 489 hospitals. Of this

group, 445 hospitals had either an ED or

OPD in 1993 to make them in scope or

eligible for the survey. During thii

perid 94 percent of the in-scope

hospitals participated. Based on the

induction intmview, 228 of the sample

hospitals had OPD’S. Hospital staff were

asked to complete Patient Record forms

(figure 1) for a systematic random

sample of patient visits occurring during

a randomly assigned 4-week reporting

period. The number of Patient Record

forms completed for OPD’S was 2&357.

Characteristics of the hospital, such

as owierahip and expected number of

OPD visits, were obtained from the

hospital administrator during an

induction interview. The U.S. Buteau of

the Census, Housing Surveys Branch,

was responsible for the survey’s data

collection. Data processing operations

and medical coding were performed by

Analytical Sciences Inc., Durham, North

Carolina.

Samplingerrors

The standard error is primarily a

measure of the sampling variability that

occurs by chance when only a sample,

rather than an entire universe, is

surveyed. The standard error also

reflects part of the measurement emor,

but does not measure any systematic

b-in the data. The chances are 95

out of 100 that an estimate fi-om the

sample differs from the value that would

be obtained from a complete census by

less than twice the standard error.

The standard errors used in this

report (including tests of significance)

were approximated using SUDAAN

software. SUDA4N computes standard

errors by using a first-order Taylor

approximation of the deviation of

estimates from their eqected values. A

description of the software and the

approach it uses has been published

(11). Standard errors for all estimates

are presented in each table. The relative

standard error (RSE) of an estimate is

obtained by dividing the standard error

by the estimate itself. The result is then

expressed as a percent of the estimate.

Appmtimate relative standard errors

for aggregate estimates may be

calculated using the following general

formuk+ where x is the aggregate of

interest in thousands, and A and B are

the appropriate coefficients tkom table I.

RSE (x) =

r

A+:*IOO

Similarly, relative standard emors for an

estimate of a percent maybe calculated

using the following general formuk

where p is the percent of interes~

expressed as a proportion, and x is the

denominator of the percent in thousands,

using the appropriate coefficients from

table I.

‘SE(X)=e.’”

The standard error for a rate maybe

obtained by multiplying the relative

standard error of the total estimate by

the rate.

Table L Coefflciante appropriate for detarmlnlng relative standards errors: National

Hospital Ambulatory Medical Care Survey,

1993

Coe~oient for use

withestfmstee

In thouesnds

TW of estlmste A B

VMls. . . . . . . . . 0.02082 5.924262

Dmg mentions . . . 0.02287 8.12S418

Adjustmentsfor hospital

nonrssponse

Estimatesfrom NHAMCS data

were adjusted to account for sample

hospitals that were in scope but dld not

participate in the study. This adjustment

was calculated to minimim the impact

of response on final estimates by

imputing to nonrespondmg hospitals

data from visk to similar hospitals. For

this purpose, hospitals were judged

similar if they were in the same region,

ownership control group, and

metropolitan statistical area control

group.

Adjustmentsfor ED/clinic

nonrssponse

E8dmam8from NHAMCS data

were adjusted to account for ED’s and

sample clinics that were in scope but

did not participate in the study. ‘His

adjustment was calculated to mhdmize

the impact of nonresponse on final

estimates by imputing to nonrespondmg

ED’s or clinics data flom visks to

similar ED’s or clinics. For this purpose,

ED’s or clinics were judged similar if

they were in the same ED or clinic

group.

Testof significanceand rounding

Thedetermination of statistical

inference is based on the l-test. The

Bonfemoni inequality was used to

establish the critical value for

statistically significant dtierences (0.05

level of significance over all analyses

performed on estimates contained in a

table). Terms relating to dtierences such

as “higher than” indicate that the

difference is statistically signhicant. A

lack of comment regarding the
12 Advance Data No. 268 ● October 6, 1995

difference between any two estimates

does not mean that the difference was

tested and found to be not significant.

In the tables, estimates of OPD

visits have been rounded to the nearest

thousand. Consequently, estimates will

not always add to totals. Rates and

percents were calculated from original

unrounded figures and do not

necessarily agree with percents

calculated from rounded data.

Definition of terms

Patient—An individual seeking

personal herdth services who is not

currently tiltted to any health care

institution on the premises.

Hospital-All hospitrds with an

average length of stay for all patients of

Suggested citation

Lipkind KL, National hospital ambulatory

medical care survey 1993 outpatient

department summary. Advance data from vital

and health statistics; no 268. Hyattsville,

Maryland: National Center for Health

Statistics. 1995.

less than 30 days (short-stay) or hospital

whose specialty is general (medical or

surgical) or children’s general. Federal

hospitals, hospital units of institutions,

and hospitals with less than six beds

staffed for patient use are excluded.

Emergency depa~ent—Hospital

facility for the provision of unscheduled

outpatient services to patients whose

conditions require irnmedate care and

that is staffed 24 hours a day. If an ED

provided emergency servkes in dtierent

areas of the hospital, then all these areas

were selected with certainty into the

sample. Off-site emergency departments

open less than 24 hours are inclu&d if

staffed by the hospital’s emergency

department.

Outpatieti department-Hospital

facility where nonurgent ambulatory

medical care is provided under the

supervision of a physician.

Clim.c—An administrative unit of

the outpatientdepartmentwhere

ambulatory medical me is provided

under the supervision of a physician.

The following are examples of the types

of clinics excluded fmm the NHAMCS:

ambulatory surgical centers,

chemotherapy, employee health servke,

renal dialysis, methadone maintenance,

and radiology.

Wsit—A direct.jpersonal exchange

between a patient and a physician or

other health cam provi&r working

qnder the physician’s supervision, for

the purpose of seeking care and

receiving personal health services.

Copyright information National Center for Health Statfstlca

All material appearing in this report is in the Acting Director

Dublic domain and mav be reproduced or Jack R. Anderson

&opied without permis~on; oi&ion as to

source, however, is appreciated.

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The use of trade names is for identification

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DHHS Publication No. (PHS) 95-1250

5-1596 (10/95)
Advance Data No. 268 Errata Sheet

Please insert t.hk sheet in your copy of National Hospital Ambulatory Medical Care Survey: 1993 outpatient department

summary.

Page Correction

2 Delete items 1 and 2 fkom the Patient Record form.

3 Table 1:

Americau Indian/E&imo/AleuL Standard error in thousands: 53 [not 534]

9 Table 13:

Vitamins, Number of drug mentions in thousamk “550 [not 550]

11 Paragraph 3 under “Source of data. . .“:

Change “Based on the induction interview, [228] of the sample hospitals . . .“ to “Based on the induction

interview, 255 of the sample hospitals . . .“

Suggested citation

LipkindKL. National HospitalAmbulatory

Medical Care Survey 1993 outpatient

departmentsummery.Advancedate from vital

and healthstatistioqno 266. Hyattsville,

Maryland NationalCenterfor Health

statistics. 1395.

Copyright information

All materialappearingin this reportis in the

public&main and may be reproduced or NationaI Center for Health Statistics

copiedwithoutpermiseiorqdtation as to

sourcxa,however,is apprsoiated. ActingDirector

Jack R. Andarson

Tmde name discl~mar Acting Deputy Director

The use of trade names is for identification

only and does not implyendorsementby the

PublicHealth Service, U.S. Departmentof

Health and Human SeM”oas.

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U.S. DEPARTMENT OF HEALTHAND

HUMAN SERVICES

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DHHS PublicationNo. (PHS) 95-1250-E

6-0020 (10/95)
Number 269 . November 30, 1995

Advance

Data

FromVitaland HealthStatisticsofthe CENTERS FOR DISEASE CONTROLAND PREVENTION/National Centerfor Health Statistics

Characteristics of Prepaid Plan Visits to Office-Based

Physicians: United States, 1991

David A. Woodwell, Division of Heafth Care Statistics

Introduction

This report presents data iiom the

National Ambulatory Medical Care

Survey (NAMCS) on visits to private

office-based physicians at which the

expected source of payment was a

health maintenance organization or other

prepaid health care plan. The NAMCS

is a national probability sample survey

of visits to nonfederally employet%

office-based physicians conducted by the

Division of Health Care Statistics,

National Center for Health Statistics,

Centers for Disease Control and

Prevention. l%ii survey is used to

collect da~ on the demographic

characteristics, the medical problem(s),

and the medical treatment of patients

making visits to private office-based

physicians. The NAMCS was conducted

annually ftom 1973 through 1981, again

in 1985, and resumed as an annual

survey in 1989.

Health maintenance organizations

@MO) were first developed in the early

1970’s with the passage of the HMO

Act of 1973. This new initiative

provided grants and loans to enable the

development of HMO’s in an attempt to

halt increasing health care costs. Since

then, HMO’s and other more recent

prepaid plans have attracted younger

and healthier enrollees than traditional

fee-for-service plans, which may result

in inherently lower costs and atlects

compruisons between plans (l–5). Much

of the current literature compares

prepaid plans and tmditional fee-forservice plans in regards to health

outcomes and quality of care (6-10).

This report provides data on health care

delivery by private office-based

physicians involved with patients

seeking care under prepaid health

insurance plans.

Because the estimates presented in

this report am based on a sample rather

than on the entire universe of office

visits, they are subject to sampling

vaxiabilhy. The Technical notes at the

end of this report include au ovemiew

of the sample design used in the 1991

NAMCS, an explanation of sampling

errors, and guidelines for judging the

precK1on of the estimates.

The Patient Record form is

reproduced in figure 1 and is iutended to

serve as a reference for readers as they

review the survey findings. For purposes

of this repo% visits made by patients 65

years of age and older were excluded

from analysis due to their high

utilization and type of medical cam

received as compared with visits made

by patients younger than 65 years of

age. Since a much larger proportion of

nonprepaid than prepaid plan visits were

for patients over 65 years of age (16.2

and 9.1 percen~ respectively), inclusion

of visits by the elderly would bias

comparisons. Prepaidplan visitsare

defined as those at which “HMO/other

prepaid” was checked on the Patient

Record form, regardless of whether

another expected pay source was

checked as weIL NonPrepaidvisitsare

defined as vi,shs for which “HMO/other

prepaid” was not checked as an

expected source of payment. An

expected source of payment was

unspecified in 2.1 percent of the visits.

These records are also excluded tlom

this report. Visits by expected sources of

payment are shown in table 1. The

expected sources of payment for

nonprepaid vishs include patient-ptid

(31.4 percent), privatdcommercial

insurance (46.7 percent), Me@caid

(12.1 percent), and Medicare

(3.7 percent).

To understand the usefulness and

limitations of these da@ two

chamcteristics of the NAMCS should be

noted. FirsG expected sources of

payment are not mutually exclusive.

Because of co-payments, participation in

governmental medical care programs,

and attiliations with other health

insurance organizations, more than one

/+’’’’Q””’

4

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

{<

Public Health Service

Centers for Disease Control and Prevention

%=

National Center for Health Statistics CENTERS cmFOR DtSEASE CONTROL

AND PREVENTION
: nuwuo, usi? UUW.4 o-w. --w - ----------- --, -=--

Asmurance 01 Con f1d9ntloli2y-All Informmlo. wl!kh would permit Idmtlfiaat Ion of m

lndlwldual,. pm.1,.., M.. .atabll.lun.nt Ml! be h.kl wnfldwwlu, ‘#Ill 60 ua.d only by D.PUWUM Of Health ●nd Hum.. ZWV1...

C*nurs for 01.u*. Control

pwons angq.d In m.d for tlw pnpoaae of the auf.ay ●nd will .01 be dlmloaed or Put.!k H“IUI Serti. ,,!.,,Mtoth.r Pm.”, m““d 63, ..Y OtMC PUT..”. Nmlo.al C..tw for H.zltlI Stmktlm ID

1. DATE OF VISIT

____+&&

PATlENTRECORD OMB No. 0920.0234

NATIONALAMBUIJXTORYMEDICAL CARE SURVEY ExPires 4-30-S3

cDC 64.21 D

L DATE OF BIRTH 4. COLOR OR RACE 5. sTHNIC17Y & EXPECTED SOURCE(S) OF 7. WAS PATIENT S, IS THIS VISIT

~

PAYMENT (Check afl that apply[

I ❑ Whit=

REFERRED FOR INJURY RELATED?

Hispanic * ❑ HMO/OIfW prepaid 5 m ~~$=f=ia,

-rHIs Vlsrr BY ?l-JYas 2DN0

1 •l .nfgln ANOTHER

2 ❑ Black

z ❑ Medlczrz 6 ❑ Path-it paid PHYSICIAN?

3. SEX Adnn I pacific Not 9. DOSS PA’rlENT

3D Islander 2❑ HIsPmiG 8 ❑ Mediwdd 7 ❑ No charge t r-J Y*E SMOKE kXQARE77SS?

I ❑ Fomz!4 2 ❑ Male

~ n ‘G:?;?%!” 1 .

t ❑ Other government a U Other 2~N0 ~ ~ :0* $ ❑ Lknkndwn

10. PATIENT’S COMPLAINT S), SYMPTOM S),

ill

11. PHYSICIAN’S DIAGNOSES 12. HAVE YOU OR 13. ~~SHPf#ENT

OR OTHER REASON(S) OR THIS VIS ANYONE IN YOUR

[In patient’s own wor&/ PRACTICE SEEN [Cl[eck .// dlOl:pp{y

. Pmg -Tdl PA71EN7 BEFORE? regardless of any enmy

in Item J!]

L 6!0s1,mpmmnl. WImUOmOk 1DY2B 2UN0 1❑ None of below

2 I_J Depression

, O!Jw: b. Othm If yes, tor the condlhon

In Item 1la? s❑ Hyp6zt6rMon

4 I_J Hyparsholesterolemla

:. cum ., Cxbc

t ❑ Yes 2DN0

5 ❑ Obzziiy

T4. AMBULATORY SURGICAL is. Dm2r40amc I SCREENING sERMcE5

[Check all ordcrcdorprovided]

16.THERAPSU71C SERVICES

PROCEDURE(B) [Check all ordered or provided. ExcIude mzdicatimt]

[Record my 0U1fMli<i7: dfqno.wic m t ❑ Non. 11❑ Pap tast

thero uticprocedure, For dwflr$l,

chmr oppropv;aleburrs.] z ❑ Blood pmssum 12❑ strap throat tozt I ~ None 6 ❑ Drug 2W22 OTHER TNERAPY:

s ❑ LMnalyzk IS o Hfv serology

4 ❑ EK13- mstlng

7 ❑ AfCOflOl abuse

M ❑ Cholesfcrol measwe COlkNSELfNG /

EOfJCATfON

13❑ Psycholharapy

L

6 u EKG - exercise IS u Other lab t-t n❑ Smoking cessation 14 ❑ Corrective Ienzes

, D .Sch4ulerj 3 ❑ Local srmsthzziz 6 ❑ Mammogram 16 n Homing teat

2 I-J D16t 16 ❑ Hearing afd

2 ❑ P4rf0rmdd

0 ❑ Family/ aocizd

4 C Rqional nnesthesla 7 ❑ Chest X+Oy 17 n Visual asuity 3 ❑ Exe7ci2D 16❑ PhyslothWaW

IO L Growth / develqzment

6 ~[ t3ener6f .zneathesla 6 H Olhw radiology 10❑ ManW status ●x4m 4 I_J Cholesterol reducfiin 17❑ Other thWapy (SPeClfY]

10 a 0fh6r I$pecilvl I! C FamllY planning

s l_J Al127gy taztlng 6 ❑ Wzight mducf!on

b

12 ❑ Other oounaefing

10 ❑ SpImmztry

17. MEDICATION If nc+w, chzck hare ❑ a. Now nwdicaflon? la. DISposmON THIS vlsrr 19. ll#RA7iON

[Record all new Yea No

[Check a!! that appiy]

or conn”nutd

-rHIs Visrr

indications 1.

t ❑ No follow-uP plumed Irllne Uctu.lly

ordered or in 20

spzni wldt

prorided at 2 ❑ Raturn at 8pesMied time phyxickm]

IIIITvisit, Ust

the mm? brand 2. 10 20 3 ❑ IIatwm If nz+ackad,P.R.N.

nameor Reneric

name zmertd on

4❑ Telephone fallow-up planned

any RX or Ofice 3. lo 21-J 5❑ Refwred to other physician

medicalrecord.

lnrlud~ Imnmnir,ng e n Returned to Feforring physfclan

awddesenzftiring 4. lo 20

agent.,.] 7 ❑ Admft tohospitsl

s. in 20 8❑ Oth-2r[Specfi] Minuf6s

t

. . . . . . .

Figure 1. Pauemtrecora lorm

expected source of payment is possible. by persons under 65 years of age that ● A higher proportion of pre]paid than

In addition, a patient who has insurance had an expected source of payment of nonprepaid visits by new patients

may have a visit with “patient ptid”

designated as the expcxXedsource of

payment because of copayments or

deductibles. For these reasons all

nonprepaid visits have been combined ●

into one category. Second, the prepaid

plan visits that are the subject of this

report cannot be analyzed aecordlng to

the type of prepaid plan because all

preptid plans were grouped together

into a single C-ategowon the survey

instrument, ●

Highlights

● Between 1985 and 1991 the

proportion of physician office visits

“prepaid plan” almost doubled (10 were referrals (39 and 27 pereenc

and 18 percen~ respectively) with a respectively).

higher tmmortion of 1991 VMS to ● The West represented 33 percent of -..

nonprirnary care specialties.

A higher proportion of prepaid than

nonprepaid visits were to office-based

physicians in the primary care

specialties of general and knily

practice, internal medicine, pediatics,

and obstetrics and gynecology (70

and 62 percen~ respectively).

A higher proportion of prepaid visits

than nonprepaid visits to nonprhnary

care specialties were referrals from

another physician (19 and 12 percen~

respectively).

all prepaid plan visits and 21 percent

of nonpmpaid visits. Less lhan

18 percent of prepaid visits were

made in the South compared with

31 percent of nonprepaid visits.

. Prepaid and nonprepaid visits were

similar with respect to the principal

reason for visi~ physicians’ principal

diagnosis, and medications

prescribed.

● Excluding visits in which there was

no face-to-face contact between

patient and physician, the average
Advance Data No. 269. November30, 1995 3

●

●

duration of prepaid plan visits was

similar to that of nonprepaid visits

(16 minutes vs. 17 minutes,

respectively).

After the exclusion of patients 65

years of age and older, the average

age of patients making prepaid plan

visits was 29.2 years compared with

31.4 years for patients making

nonprepaid visits.

A significantly higher proportion of

prepaid plan visits had at least one

dmgnostic or screening test ordered

or performed (76 percent) compared

with nonprepaid visits (70 percent)

for patients 4544 years of age.

Physician characteristics

In 1991, there were an estimated

91.8 million visits to nonfederally

employed office-based physicians at

which a prepaid plan was an expected

source of payment not includlng visit8

made by patients 65 years of age and

older. This is a significant increase from

1985 in which there were an estimated

51.4 million visits with an expected

source of payment of a pepaid plan. In

1991, about 18 percent of the vi&s by

pemonsunder 65yearsofagehada

-d Pkmas an expectedsourceof

payment compared with 10 percent in

1985.

Of the 91.8 million prepaid plan

office visits in 1991, about 70 percent

were to primary care physiciansincluding general and family

practitioners, intmnists, pediiticians,

and obstetricians and gynecologists

(table 2). The percent of prepaid visits

to primary care physicians was down

tlom 77 Wment in 1985; the first year

data wem collected on an expected

source of payment. The decrease in the

proportion of prepaid visits to primary

care physicians was due to a decline in

the percent of visits to general and

family practitioners fkom 35 percent in

1985 to 26 percent in 1991. The

proportion of prepaid visits to

obstetricians and gynecologists increased

from 7.6 percent in 1985 to 11.0 percent

in 1991. Among nonprepaid visits,

geneml and family practitioners also

dropped as a percent of visit8, tiom

30 percent in 1985 to 25 percent in

1991. Internist8 incmawd as a percent of

Table 1. Number and percent of visits by expected sources of paymenfi

United States, 1991

Number of

visitsIn

@ratted sourcesofpaymenf thousands Percent

Allvisitsz . . . . . . . . . . . . . . . . . . . . . . . 513,819 100.0

Prepaid plans . . . . . . . . . . . . . . . . . . . . 91,824 17.3

Nonprepaid plans . . . . . . . . . . . . . . . . . 421,335 82.1

Allnonprapakt ptenvisdts . . . . . . . . . . . . . 421,995 100.0

Medicare . . . . . . . . . . . . . . . . . . . . . 15,736 3.7

Medicaid . . . . . . . . . . . . . . . . . . . . . 51,055 12.1

Oihergovemment . . . . . . . . . . . . . . . . 12,078 2.7

Privste/commardal insurance . . . . . . . . 197,046 46.7

Patiantpakf . . . . . . . . . . . . . . . . . . . 132,453 31.4

Nodrarge . . . . . . . . . . . . . . . . . . . . 8,635 2.0

Other . . . . . . . . . . . . . . . . . . . . . . . 22,742 5.4

‘Numbersdo mat add to totsls because mare than one source of payment mey be repoitad par visit.

2An addiinal 155,870,0C0 visits wara for patients 65 yaars of aga and over and 10,384,000 VMS had no axpected sourca of

payment indicatad. These V!MS have been axcluded from this report.

Table 2. Number and percent distribution of prepaid plan visits and percent distribution of

nonprepaid visits by physician speciatty United States, 1991

Prepaidptan vkr?s Notprspakl visits

Nrrm5arof

vMts in Peroent Percent

PhysicianWasialw thousands dkfdbution diatrtbution

Allvldts . . . . . . . . . . . . . . . . . .

Pltmary care:

General and femlly practice . . . . . .

Infernal nwdldne . . . . . . . . . . . . .

Ped?atrtcs . . . . . . . . . . . . . . . . .

Obsfetrb and gynecology. . . . . . .

Other than primery care

Orfhopedlc surgery . . . . . . . . . . . .

Dermatology . . . . . . . . . . . . . . . .

Oto!aryngology . . . . . . . . . . . . . .

General surgary . . . . . . . . . . . . .

Urologkal suqery . . . . . . . . . . . .

Csrdlovaecular diesaaaa . . . . . . . .

Ophthalmology . . . . . . . . . . . . . .

Psyohlarr)r . . . . . . . . . . . . . . . . .

Neurology . . . . . . . . . . . . . . . . .

Allolherapaciaitlea . . . . . . . . . . .

91,824

24,204

14,335

15,247

10,095

5,331

3,081

2,774

1,875

1$33

1,282

1,087

1,340

481

8,540

100.0

26.4

15.7

-r6.6

11.0

6.5

3.3

3.0

2.0

1.7

1.4

1.2

1.5

“0.5

9.3

100.0

25.1

11.9

14.4

10.6

5.6

4.2

3.1

3.0

1.2

0.3

4.1

3.2

i .2

11.6

nonprepaid visits horn 8 percent in 1985

to 12 percent in 1991. Sixty-two percent

of the nonprepaid visits were to primary

care physicians.

One possible explanation for the

increasing percent of prepaid plan visits

to nonprimary care specialties is the

increased use of network models and

point-of-senricdopen-ended plans in

1991 as compared with traditional

HMO’s, which dominated the p~paid

plan market in 1985 (11,12). Traditional

HMO’s limit visita to specialists by

requiring the patient to obtain a referml

by their primary care specialist whereas

the requirements for a patient enrolled

in an open-ended plan are not as

stringent.

Table 3 shows that the geographical

d~fribution of prepaid plan visits and

nonprepaid visits differ. The West

accounted for the largest proportion of

prepaid plan visita (33.0 percent) while

the South accounted for the smalleat

proportion (17.9 pement). The

distribution of nonprepaid visks was the
4 Advance Data No. 269 ● November 30, 1995

Table 3. Number and percent distribution of prepaid plan visits and percent distribution of

nonprepaid visits by geographioai region: United States, 1991

Prepaldplan visfts Norprepaid VLsits

Number of

visits In Percent

Region

Percent

thousands dktribution dkfdbut/on

Allvisns . . . . . . . . . . . . . 91,824 100.0 100.0

Northeast . . . . . . . . . . . . 19,199 20.9 24.2

Midwest . . . . . . . . . . . . . 25,930 28.2 24.0

South . . . . . . . . . . . . . . . 16,420 17.9 31.1

Wee . . . . . . . . . . . . . . . 30~76 33.0 20.6

35

[

■ 1985 ❑ 1991

30 v//zi

c.-

“.

south Northeast Midwest West

Figure 2. Number of prepaid pian visits, by geographical region: United States, 1985 and

1991

Tabie 4. Number and percent distribution of prepaid pian visits and percent distribution of

nonprepaid visits by patient’s age and sex United States, 1991

Prepaid plan vktta Nonprepakf vfaffs

Number of

vklts In Percent Persant

A@ and sex thousands dktdbution dkttibution

AIII.Hs . . . . . . . . . . . . . . . . . . . . . 91,624 100.0 100.0

Under 15years . . . . . . . . . . . . . . . . . 24,058 26.2 24.4

15-24 yeaB . . . . . . . . . . . . . . . . . . . 11,009 12.0 12.1

25-44 yesls . . . . . . . . . . . . . . . . . . . 36,65e 39.9 35.4

45-84 yaals . . . . . . . . . . . . . . . . . 20,09e 21.9 26.1

Male . . . . . . . . . . . . . . . . . . . . . . . . . 37,226 40.5 40.2

Undar15ysam . . . . . . . . . . . . . . . . . 12,984 14.1 12.5

15-24 ysars . . . . . . . . . . . . . . . . . . . 3,588 3.9 4.2

25-44 years . . . . . . . . . . . . . . . . . . . 12,235 13.3 12.0

4S84yeare . . . . . . . . . . . . . . . . . . . 8,439 9.2 11.5

Female. . . . . . . . . . . . . . . . . . . . . . . . 54,5ee 59.5 59.6

Under 15years . . . . . . . . . . . . . . . . . 11,094 12.1 11.9

15-24 years . . . . . . . . . . . . . . . . . . . 7,421 S.1 8.0

25-44yeam . . . . . . . . . . . . . . . . . . . 24,424 26.6 23.3

45-64yeam . . . . . . . . . . . . . . . . . . . 11,660 12.7 16.6

reverse, with3 I.l percent occurring in

theSouthand20.8 percentintheWest.

Comparing thegeographical distribution

ofprepaid plan visits overtime,

NAMCSdatashow thatin1985 the

Westhadthelargest munberofprepaid

plan visits (20.1 million visits) and the

Northeast had the smallest number of

prepaid plan visits (7.4 million visits)

(figure 2).

Patient characteristics

Approximately two-fifths

(39.9 percent) of prepaid plan visits

were made by patients 2544 years of

age, and about one-quarter

(26.2 percent) were made by patients

under 15 yearn of age. This pattern

holds true for visits for nonprepaid

sources of payment as well (table 4).

However, patients 2544 years of age

made up a relatively larger portion of

prepaid plan visits compared with

nonprepaid viAts (39.9 vs. 35.4 percent).

Correspondingly, patients 45--@ years of

age made up a relatively smaller portion

of prepaid plan visits compared with

nonprepaid visits (21.9 vs. 28.1 percent).

The majority of visits by persons with

both prepaid and nonprepaid sources of

payment were made by females, who

accounted for a higher percent of visits

than males in all age categories except

under 15 years.

As shown in table 5, the majority

of prepaid plan visits were made by

white persons (80.2 percent). Black

persons made 15.7 percent of these

visits, with all other races a~counting

for the remaining 4.0 percent. In all

race categories, females made a higher

percent of visits than dld males. A

greater proportion of office-based

prepaid plan visits were made by

black persons (15.7 percent) compared

with office-based nonprepaid visits

(8.5 percent). However, data from

1992 show that the percent of

office-based visits by black persons

were stillar for prepaid and

nonprepaid visits based on that year

(see Discussion section).

Visit characteristics

Item 7 on the Patient Rword form

asks if the patient was referred by

another physician for this visit. In
Advance Data No. 269. November 30, 1995 5

Table 5. Number and percent distribution of prepaid plan visits and percent distribution of

nonprepald visits by patient’s race and sex: United States, 1991

Prepafdplan vkifs Nor!prapaid vkits

Number of

viaks in Percent Percent

Race and sax thousands distifbution distribution

Tohfvfetts. . . . . . . . . . . . . . . . . . . . . . 91,824 100.0 100.0

Black . . . . . . . . . . . . . . . . . . . . . . . . . 14,462 15.7 8.5

Male . . . . . . . . . . . . . . . . . . . . . . . . 5,176 5.6 3.1

Female . . . . . . . . . . . . . . . . . . . . . . 9,286 10.1 5.4

White . . . . . . . . . . . . . . . . . . . . . . . . . 73,687 80.2 87.7

Male . . . . . . . . . . . . . . . . . . . . . . . . 30,596 33.3 35.5

Female. . . . . . . . . . . . . . . . . . . . . . 43,091 46.9 52.2

Other’ i . . . . . . . . . . . . . . . . . . . . . . . 3,675 4.0 3.8

Male . . . . . . . . . . . . . . . . . . . . . . . . 1,454 1.6 1.6

Female, . . . . . . . . . . . . . . . . . . . . . 2,222 2.4 2.2

hludes Asiin/Pacific Islander and American lndian/Eskim&Ueuf.

8.2 percent of prepaid plan visits the

patienthadbeenreferred compared with

6.0pement ofthe nonprepaid visits

(table 6). There was a significant

difference in the refemal rate for primary

care physicians compared with olher

specialists. Patients werereferredin

3.4 percent of the prepaid plan visits for

primary care physicians but were

referred in 19.2percent ofvisits for

other specialists. Notethatonly

11.5 percent of the nonprepaid visits to

other specialists were referrals.

‘l?hemajori tyofpreptid plan visits

were madeby patients whohadseen the

physician previously for the same

problem (54.9 percent). In addition, over

oneqnarter of the prepaid plan visits

were made by “old patients” with a

new problem (28.6 percent). New

patients made up less than one-tifth of

the visits (16.5 percent). These patterns

were also observed for nonprepaid

visits. However, a higher proportion of

prepaid than nonprepaid visits by new

persons were referrals (38.8 and

26.5 percent respectively).

Patients that had au expected source

of payment of a prepaid plan were less

likely to smoke cigarettes compared

with those patienta that had another

expected source of payment. As shown

in table 7, about two-thirds of the visits

with a prepaid plan source were made

by patients who did not smoke

cigarettes (68.5 percent), 8.4 percent

were by patients who did smoke. In

comparison, one-tenth of nonprepaid

visits were made by patients who smoke

(11.7 percent) and three-fifths were

made by patients who dld not smoke

(62.1 percent). Smoking status of the

patient was not spechied for about

one-quarter of the visits.

Prepaid plan visits were less likely

to be associated with injuries compared

with nonprepaid visits (table 7). Over all

age groups, about 9 out of every 100

prepaid plan visits were injury related

(9.4 percent) compared with 12 out of

every 100 for nonprepaid visits

(12.2 percent). The only age group to

show a statistically significant

dtierence, however, was for persons

25-44-years-okL For persons in this age

group, nonprepaid visits were 50 percent

more likely to be injury related

compared with prepaid plan visits.

Item 10 of the Patient Record form

aska for the patient’s (or patient’s

surrogate) “complaint(s), symptom(s),

or other reason(s) for this visit (In

patient’s own words).” Up to three

reasons for visit are coded and classified

according to A Reasonfor Wit

Ckmi$cation for Ambula.to~ Care

(WC) (13). The principal reason is the

problem, complain~ or reason listed on

item loa of the Patient Record form.

Approximately 61.0 percent of

prepaid plan visits were classified in the

symptom module of the RVC, one of

the eight modules that makes up the

classification (table 8). Of these

symptoms, 14.0 pment were classifiable

to the respiratory system and

11.2 percent were classifiable to the

muaculoskeletal system. Nonprepaid

visits followed the same pattern.

Table 9 shows the 20 most

frequently mentioned principrd reasons

for visi~ accounting for almost

47 percent of the prepaid plan visits.

Note that estimates that differ in rauked

or&r may not be significantly different

Table 6. Number, percent distribution, and percent of visits referred by another physician by physioan specialty and vfsit status for

prepaid plan and nonprepaid visits, Unitad-States, 1991

Prapaidplan visks NotwvwW V&tfS

Nudw

Nurnbar Percent of Visns Percent Percent

lfl.sltcharacteffatics

Percent

of vktts dkmbouon tsferrad fsferred ct%ttfbtion referred

Allvisits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91,824 100.0 7,505 8.2 100.0 6.0

Primafy cara’ . . . . . . . . . . . . . . . . . . . . . . . . . . . 63,941 69.8 2,151 3.4 61.7 2.5

Other apecialtles . . . . . . . . . . . . . . . . . . . . . . . . . 27,864 30.4 5,354 19.2 36.3 11.5

Nawpaflent, . . . . . . . . . . . . . . . . . . . . . . . . . . . 15,111 16.5 5,660 36.8 18.8 26.5

Okfpatlent-new problem . . . . . . . . . . . . . . . . . . . . 26,277 28.6 1,644 6.3 22.5 4.5

Oldpatlent-old prcblemz . . . . . . . . . . . . . . . . . . . . 50,436 54.9 0.0 0.0 56.7 0.0

lPrimafy ewe spackdtias include geneml and family practice, infernal madicine, pediatrics, and cbatetrix/gynecology.

%urvey odil spacificefions did not allow refemab for old patiint-old problam cases.
6 Advance Data No. 269. November 30, 1995

Table 7. Number and percent distribution of prepaid plan visits and percent distribution of

nonprepald visits by patient’s cigarette-smoking status and whether visit is injury reiated:

United States, 1991

Prepaid pfan vfafts Norprapakt vlslta

Number of

vfslts In Percent Percent

Visit chatacterfatics thousands dfstdbution distribution

AIIvMs. . . . . . . . . . . . . . . . . . . . . . . 91,824 100.0 100.0

Doss patient smoke cigarettes?

Yes . . . . . . . . . . . . . . . . . . . . . . . . . 7,709 8.4 11.7

No . . . . . . . . . . . . . . . . . . . . . . . . . . . 62,878 68.5 62.1

Unknown . . . . . . . . . . . . . . . . . . . . . 21,238 23.1 26.2

Is Walt Injury related?

Yes . . . . . . . . . . . . . . . . . . . . . . . . . . 8,613 9.4 12.2

No . . . . . . . . . . . . . . . . . . . . . . . . . . . 83,212 90.6 87.8

fromeachother.A general medical

exam,accounting forabout5.2million

visit8, 0r5.7percen4 was most

,frequently mentioned atpreptidplan

visits. Cough (4.5 percent), symptoms

referable to throat (3.7 percent), and

prenatal examination (3.3 percent)

followed, all similar to the top principal

reasons for visits from other expected

payment sources.

Data on rhe principal dmgnoses

rendered by physicians are shown in

tables 10 and 11. The principal

diagnosis is the tirst-recorded diagnosis

in item 11 of the Patient Record form

and is associated with the principal

reason for visit as recorded in item 10a.

The principal diagnosis was coded and

classified according to rhe Intem.ational

Classification of Di3eases, 9th Revision,

ClinicaZModification (ICD-9-CM) (14).

The ICD-9<M is organized into

broad categories, most relating to the

major systems of fhe body as shown in

table 10. Diseases of the respiratory

system and the supplementary

classification (for dmgnoses that am not

illness or injury related), each accounted

for about 18.5 percent of prepaid plan

visits, followed by injury and poisoning

and diseases of the nervous system and

sense organs each representing about

8.0 percent of the visits. Nonpmpaid

visits followed the same pattern.

Table 11 lists the 20 most tiequently

mentioned principal dmgnoses rendered

by the physician at the three-digit

coding level of the ICD-9-CM.

Approximately 40 pment of the visits

are accounted for by the top 20

principal diagnoses. Health supervision

of infant or child was the most frequent

principal diagnosis, accounting for

4.9 percent of the prepaid plan visits.

Health supervision of infant or child

was followed by normal pregnancy and

acute upper respirato~ infections of

multiple or unspecified sites, accounting

for 4.5 and 3.4 percent respectively.

Comparing the principal diagnoses of

the hvo types of visits, there is a

difference in the percent of visits for

health supervision of infant or child (4.9

vs. 3.0 percent). This diagnosis

represented 18.8 percent of the prepaid

plan visits for children under age 15,

which was significantly higher than the

corresponding 12.5 percent of

nonprepaid vish. However, this

difference was not found in the 1992

NAMCS data (see Discussion section).

On item 13 of the Patient Record

form, the physician was asked to

Tabie B. Number and percent distribution of prepaid pian visits and percent distribution of nonprepaid visits by patient’s rxincifIai

reason for visit Unit&f Statas, 1991

. .

Prapafd pkm vlaits NonprepaId visits

Number of

visits In Percent Percent

Prtnc@al reason for viatf modute and RVC coda+ thousands dlstrfbuflon dlsfdbtrtlon

Allvisifs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91,824 100.0 100.0

Synptommodulfr . . . . . . . . . . . . . . . . . . . . ..’ . . . . . . . . . . . . . . .. Sl~999 55,980 61.0 59.4

General symplome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Sool~099 6,358 6.9 6.9

symptoms referable to paychobglcal and mental dlaordera . . . . . . . . . . . S1OO-.S199 1,796 2.0 3.3

Symptoms referable to the nervous system (excluding sense organs). . . . . S200-S259 2,923 3.2 3.1

symptoms referable to the csrrllovascular and lymphatic system. . . . . . . . S260-S289 “487 “0.5 0.4

~~tomrefer*le totheeyesmd earn . . . . . . . . . . . . . . . . . . . . . S300-3399 6,046 6,6 6,5

symptoms referable to the respiratory system . . . . . . . . . . . . . . . . . . . .WXX3499 12,666 14.0 12.4

syr@oms referable to the dlgesfive syetem. . . . . . . . . . . . . . . . . . . . . S5-639 3,500 3.8 4.0

synptoma referable to the genitourfnary system . . . . . . . . . . . . . . . . . . SIMW8M 5,340 5.8 4.6

Systemereferable tolhealdn, nails, and hair . . . . . . . . . . . . . . . . . . . . ~3rJ+899 6,337 6.9 6.6

symptoms referable to the muscutoskeletal system . . . . . . . . . . . . . . . . 3900-S999 10,328 11.2 11.7

Dfeaase rnodula . . . . . . . . . . . . . . . . . . . . . . . . . . ..-- . . . . . . . .. D1301-D999 7,314 8.0 7.5

Diagnostic, acraenlng, and preventive module. . . . . . . . . . . . . . . . . . . . . Xl ~X599 15,593 17.0 16.0

Tmatmant module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TIOO-T899 7,102 7.7 8.8

Injury andadvems effecfs rnocfula . . . . . . . . . . . . . . . . . . . . . . . . . . .. JOO14999 3,041 3.3 3.6

Allothermodufas2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,795 3.0 4.9

1Ba8ed on A Raason for WitC/ant7ioatbn forAmbuMofy Care (IWC) (13).

%dudrn test results meduh admini$treiiwe mcdule, unocdable and b!ank entries.
Advance Data No. 269. November30, 1995 7

Table 9. Number, and percent distribution of prepaid plan visits and percent distribution

of nonprapald visits by the 20 principal reasons for visit most frequently mentioned by

pattentrx United States, 1991

Prapaldplan VLSIYS NoryJriwak/ VtSffS

Nurnbar of vialts Percent Percent

Prhc@Il fsason for Waltand RVC code’ In thousands disbfbofion dlstrfbuffon

Allvtafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91,824 100.0 100.0

General nradbal examination . . . . . . . . . . . X1OO

Cough . . . . . . . . . . . . . . . . . . . . . . . .. S440

symptoms referable to throsf . . . . . . . . . . . S455

Prenatal examination, routine . . . . . . . . . . . X205

Well-baby examination . . . . . . . . . . . . . .. XlO5

Prograssvisif . . . . . . . . . . . . . . . . . . . . ..T800

Earache ore8rinfec&m. . . . . . . . . . . . .. S365

Skin rash . . . . . . . . . . . . . . . . . . . . . . .. S860

Kneesymptoms . . . . . . . . . . . . . . . . . .. S925

Postopetatlve vlslt . . . . . . . . . . . . . . . . . ..T205

Stomach pahr, cr~s, and spasms. . . . . . . S545

Fever . . . . . . . . . . . . . . . . . . . . . . . . .. S010

Headache, pain lnhead . . . . . . . . . . . . . . S210

Nasslcongastlon . . . . . . . . . . . . . . . . . ..3400

Head cofd, upper msphatoty infection. . . . . . S445

AIIww. . . . . . . . . . . . . . . . . . . . . . . .. S090

Backsymptoms . . . . . . . . . . . . . . . . . . .. S905

Asthma. . . . . . . . . . . . . . . . . . . . . . . .. D625

Shouktersymptoms . . . . . . . . . . . . . . . .. S840

Slnuspmbtems . . . . . . . . . . . . . . . . . . .. S410

5,247

4,158

3,377

3;064

2,966

2,528

2,511

2,175

1,833

1,777

1,776

1,726

1,703

1,514

1,263

1,277

1,223

1,000

992

933

5.7

4.5

3.7

3.3

3.2

2.8

2.7

2.4

2.0

1.9

1.9

1.9

1.9

1.6

1.4

1.4

1.3

1.1

1.1

1.0

4.3

3.9

3.2

3.9

2.4

2.8

2.4

1.3

1.2

2.0

1.6

2.0

1.7

1.5

1.3

0.8

2.0

0.4

1.0

0.7

Afiotherreasons . . . . . . . . . . . . . . . . . . . . . . . 46,755 53.2 59.0

lBamed on A Rasson for Wit C/sss#iosYbn forA*/atoy Cm (WC) (13).

indkate if the patien~ at tie time of was reported as the patient dmguosis in

visit was aftlicted with any of tbe item 11. Obesity and hypertension were

chronic conditions liste~ despite what checked most frequently, at 7.8 and

6.5 percent of prepaid plan visits,

respectively. In contrastj nonprepaid

visits recorded a signidcantly higher

percent of visits by patients suffering

from depression 6.3 percenL as

comprrred with 4.7P¢ for prepaid

plans (table 12). However, when

examining the differences at various age

groups, only the patients between tbe

ages of 15 and 24 yearn were more

likely to have depression in the

nonprepaid vWs (3.5 percent) compared

with prepaid plan visits (1.0 percent).

Past analysis of this question has shown

that physicians seem to un&rreport

chronic conditions as diagnoses on item

11 of the Patient Record form (15). The

same would hold true for visits to

prepaid and nonprepaid sources of

payment

Diagnostic services performed or

or&rcd at the time of visit are shown in

table 13. The most common service

recorded at prepaid plan visits was a

blood pressure testj 43.0 percenL A

urinalysis was performed or ordered in

13.9 percent while “all other diagnostic

services” accounted for 34.7 percent.

Diagnostic serviees utilization rates in

nonprepaid visits folIowed the same

pattern (table 14). Looking at age

Table 10. Number and percant distribution of prepaid plan visits and percent distribution of nonprepaid visits by principal diagnoshx

Unitsd States, 1991

Prqafdplarr viaks Norpr.spati W&

Nurrirer of w“aifs Percent Percent

Pffnc#Jsl diagnosk and ICL?-9-CM coda’ in thousands dfstrkxrffon distrhdfon

Allvwts.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .’. . . . . . . . . . . . . . . . . . . . .

Infecflous arrdparasitio df.seases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 001-139

Ner@asms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...140-238

Endocrfne, nufrifbnal, and metabolic.

dbessessndimmunltydi borders. . . . . . . . . . . . . . . . . . . . . . . . . . . . ...240-279

Mental diwrrders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 23+319

Dbeaaesoftfre nervous ayetemsrrd eansaorgans. . . . . . . . . . . . . . . . . . ..%?0-363

Dlseasssof thecfrculstory system . . . . . . . . . . . . . . . . . . . . . . . . . . . ...390-459

Disaaaesof thereapbatorys ysfem.. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 480-519

Dtseeaeaof fhedigastlve sysfam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 520-579

Diseaaesof thegenltourinary system. . . . . . . . . . . . . . . . . . . . . . . . . . .. 560-628

D-esofthe Mnmdsu&timmus tisue . . . . . . . . . . . . . . . . . . . . . ..*7m

Diseases of the muaculoakelatal system and mnnective tissue . . . . . . . . . . . . 710-733

~@om, s@ns, ~dll14flned mndklons . . . . . . . . . . . . . . . . . . . . . . ..7w7W

Injury endpcisonlng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...600-339

Supplarnsnfery clawdffcafiorr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VO1-V82

Aflofherdiagnosea2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unknown diagnoses3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

91,824

4,476

2,438

2,664

2,660

7,445

3,577

16,977

2,673

5,486

5,320

6,606

3,2SS

7,870

16,838

1,700

1,639

100.0

4.9

2.7

2.9

3.1

8.1

3.8

18.5

2.9

8.0

5.6

7.2

3.5

8.6

18.3

1.9

1.8

100.0

4.2

2.5

3.3

4.8

10.7

4.3

74.9

3.3

6.0

6.0

6.5

3.7

9.3

17.5

1.4

1.7

‘Based on the Internstimd Clmafioatbn of Dksses, tlth Rwiskm, Clinicsl Mcdikatbn (ICD-9-OM) (14).

%dud- rfisesses of the bbod-forming organs (28J-288); complba!bns of pregnancy, chiklbirth, and the puerparium (6sO+’8~ ccmgenitsl anomslbs (740-759); and mm-n conditbns

origimstiig in the pe!indd Pried (7S4)-779).

%duden blank d~noses, urscodabb diqpwms, and ih’egible dmgnoses.
8 Advance Data No. 269 ● November 30, 1995

Table 11. Number and percent of prepaid plan visits by 20 principal dlagnoaaa most frequently randarad by physicians: United SMaa, 1991

Prqraldplan vlsts Nonprepa\dvislte

Nurrber of

vklts In Percent Percent

Pr/nc/pa/dlagrrds and IGD-9-CM codet iflolreerrds cHrfbuf/on dlstrbutlon

Allvkifs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91,824 100.0 100.0

HeaRheupewlsion ofinfantor child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V20

Normal pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .V22

Acute upper respiratory infections of mulfple or unspecified sites. . . . . . . . . . . 465

Suppuretlve endunspeclfled otkismedla. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .382

Allerglc rhlnitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...477

Chronlcsinusifis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...473

Generelmedbalexarnlnetlon.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..V71J

Essantlalhypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...401

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...-.......433

Acutepharyngifls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...462

Dbeasesofsabaceousglands... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..7IJ6

Bronchifis,note+ecitiedasaculeorchronic . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~0

Contec4dennefitisandothereczema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...692

Dlsbetesmelllttrs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...-....250

Otherdlsordersofsynovlum,tendon, endbursa . . . . . . . . . . . . . . . . . . . . . . . ...727

Actrfetonsillitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...483

Certeinadverseeffecfsnotelsawhere classified. . . . . . . . . . . . . . . . . . . . . . . . . . 995

Perfpheralanthesqathlesandallledsyndrofnas. . . . . . . . . . . . . . . . 728

Sprafnsendsfralnsofother.andunspeMedpSftS ofback. . . . . . . . . . . . . S47

Petsonethisforyofcertelnotherdkaasee . . . . . . . . . . . . . . . . . . . . . . . . . . . ..V12

Allofherdiagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4,s31

4,091

3,160

2,917

2,670

2,659

2,404

2,150

1,983

1,602

1,496

1,392

1,221

1,098

989

S40

930

907

848

782

52,858

4.9

4.5

3.4

3.2

2.9

29

2.6

2.3

22

2.0

1.6

1.5

1.3

1.2

1.1

1.0

1.0

1.0

0.9

0.9

57.6

3.0

3.9

3.0

3.0

1.5

1.9

3.5

2.3

1.3

2.1

1.7

1.6

1.1

1.2

0.6

0.7

0.5

0.8

1.1

0.6

84.6

lBasedon the/ntematima/ C/assifbatbn of Di=ases, 9fh Rsvistin, C/fni=/Mtiifkatbn (lCWM) (14).

differences, children under15yearsof

age were less likely to receive

diagnostic tests compared with older age

groups in both types ofvisits(40 vs.

72percentforprepaid planvisitsand37

vs.65 percentin nonpreptid visits).

Persons 454 years ofage were more

likely to receive diagnostic testsin

prepaid plan visits compared with

nonprepaid visits (76 vs.70percenC

respectively).

Viiitsatwhiehat leastone

nonmedieation therapeutic service was

orderedorprovided represented

on~thirdofthe totalprepaidplan visits,

as shown in table 15. The most

frequently checked therapeutic serviee

was diet cotmseling/education, reported

at 10.7 percent of the visits. Exercise

and growth development counseling/

education followed with percents of 8.6

and3.8, re.spectively. “Another

therapeutic services” ordered or

provided accounted for 14.8 pereent of

tie visits. No significant differences

were found between prepaid and

nonprepaid visits.

The majority of both types of visits

were drug visits in which the patient

was given, prescribed and/or continued

on at least one medication (table 16).

Table 12. Number and percent of prepaid plan visits and percent of nonprepald visits by

selected medical conditiorw United States, 1991

Prepaid plan vlsfts Nonprepaid visits

Number of

vkits in

Medical condition’,2 thousands Percent Percent

Allvlsite . . . . . . . . . . . . . . . . . . . . . . . 91,824 . . . . . .

Depression . . . . . . . . . . . . . . . . . . . . . 4,298 4.7 6.3

Hypertension . . . . . . . . . . . . . . . . . . . . 5,987 6.5 7.0

Hypercholesterolemla. . . . . . . . . . . . . . . 3,791 4.1 3.4

Obesity . . . . . . . . . . . . . . . . . . . . . . . . 7,194 7.6 7.5

1Refers to question IS cm the Palient Record form

2Numbers do not sdd to totals because more than one medicsl condifkm msy be reported per visit and not aft wdegoriee are

Physicians were asked to record all new

or continued me&cations provided at the

visi$ including prescription and

nonprescription p~parations and

immunizing and desensitizing agents.

About one-third of both prepaid

and nonprepaid visits included only

one drug mention (35.4 and

34.6 percenti respectively). The drugs

entered on item 17 of the Patient

Record form are classified based on

the therapeutic categories used in the

National Drug Code Directo~, 1985

edition (16). The reader should

understand that some drugs have more

than one therapeutic application and in

these cases, each drug was assigned to

the category that occurred with the

greatest frequency.

As shown in table 17, antimierobd

agents represented the largest share of

the 95.1 million drug mentions in

prepaid plan visits, 21.2 percent. Of

these, penicillins were the largest group

(7.9 percent). Of the drug mentions,

14.7 percent were respiratory tract drugs,

and drugs used for relief of pain

amounted for 12 percent. Two

significant differences were found

between the prepaid and nonpmpaid
Advance Data No. 269. November 30, 1995 9

visits in the distribution of drug

mentions by therapeutic class.

Psychopharmacologic drugs represented

a larger percent of drug mentions at

nonprepaid vkks compared with prepaid

plan visits (7.0 percent and 4.5 percen~

respectively). This strengthened the

earlier finding that physicians involved

in nonprepaid visits recorded a higher

percent of visits with a diagnosis of

depression than did those involved

with prepaid plan visits (item 13).

The only age group to show a

significant difference, however, was

the 2544 years group. On the other

hand respiratory tract drugs

represented a larger portion of drug

mentions at prepaid plan visits

compared with nonprepaid visits for

persons in this same age group (15.2

vs. 9.9 percent).

Table 18 shows the most tlequently

occurring generic ingredients of the drug

mentions at prepaid plans visits during

1991. Note that drug products

containing more than one ingrtilent are

included in the data for each ingredient.

For example, acetaminophen with

codeine is included in both the count for

acetaminopben and the count for

codeine. Amoxicillin was the most

frequently occurring generic ingredien~

with 7.1 miWon mentiony it

represented 7.4 percent of the total.

The second and third listed generic

ingredients were aceta.tninophen and

erythromycin representing 4.3 and

2.7 percent, respectively. A report

describing the method and instructions

used to collect and process drug

information for the NAMCS is

available (17).

More than one-half (57.7 percent) of

prepaid plan visits resulted in

instructions for the patient to return at a

specific time (table 19), and about

one-quarter of the visits resulted in

instructions to return if needed

(27.0 percent). These percents am not

significantly dilTerent hem the 1985

estimates for prepaid plan visits

(55.3 percent and 26.6 percenq

respectively) and follow the same

pattern as the nonprepaid visits.

Tale 19 also shows the duration of

visit. Of the prepaid plan visits,

61.7 percent lasted between 6 and 15

minutes, 21.6 percent lasted 16 to 30

Table 13. Number and percent of prepaid plan visits and percent of nonprepaid visits by

diagnostic and screening services ordered or provided: United States, 1991

Prapefdplerr VMS Notprspald visits

Nurrbsr of

Diagnostic end screening visits in

eervims ordered orprwided thouearr& Percent Percent

Total vistts~ . . . . . . . . . . . . . . . . . . . . . 91,824 . . . . . .

Blood preeaure . . . . . . . . . . . . . . . . . . . 33,4s5 43.0 39.9

Urinalysk . . . . . . . . . . . . . . . . . . . . . . 12,771 13.9 13.3

EKGresling . . . . . . . . . . . . . . . . . . . . . 1,s07 2.0 1.9

EKGexerdse . . . . . . . . . . . . . . . . . . . . -197 “0.2 0.4

Mammogram. . . . . . . . . . . . . . . . . . . . 1,636 1.s 1.7

Chest xray . . . . . . . . . . . . . . . . . . . . . 1,740 1.9 1.8

Paptest . . . . . . . . . . . . . . . . . . . . . . . 4,737 5.2 5.0

6trepthroat teet . . . . . . . . . . . . . . . . . . 2,710 3.0 2.5

Cholesterol measure . . . . . . . . . . . . . . . . 3,389 3.7 3.2

Hearlngtest . . . . . . . . . . . . . . . . . . . . . 1,723 1.9 1.8

Vkwdacuily .. . . . . . . . . . . . . . . . . . . . 2,030 2.2 4.8

Mental status exam . . . . . . . . . . . . . . . . 1,254 ~.4 1.6

All other diagnostic sarvicae2 . . . . . . . . . . 31,832 34.7 30.1

None . . . . . . . . . . . . . . . . . . . . . . . . . 33,350 38.3 39.6

‘Numbers do not edd to totals bemuse more than one service mey h reported per visii.

‘Includee other radiology, allergy tading, spiromsiry, HIV serob~, other Ieb tasfe, and dher.

Table 14. Number and percent distribution of prepaid plan visits and percent distribution

of nonprapafd visits by number of diagnostic seNicea orderad or provided: United States,

1991

Prspeidplen visRs Norprepahf visks

Nurrber of

Number of d.kagnoeticsenrfces Wts h Percent Percent

ordered orprovidsd thousands dwwltion distribution

Atlvfdte. . . . . . . . . . . . . . . . . . . . . . . 91,824 100.0 100.0

None . . . . . . . . . . . . . . . . . . . . . . . . . 33,350 36.3 33.6

1 . . . . . . . . . . . . . . . . . . . . . . . . . . . 31,754 34.6 32.1

2 . . . . . . . . . . . . . . . . . . . . . . . . . . . 14,7s9 16.1 16.4

3 . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,142 7.8 7.5

4 ormore . . . . . . . . . . . . . . . . . . . . . . 4,&39 5.3 4.5

Table 15. Number and percent of prepaid plan visits and percent of nonprepald visits by

nonmedication therapy ordered or provided: United Statee, 1991

Prspaidplsn v&b Norprepaid vis#s

Number of

visits in

Nonmsdicetion therapy thousands Percent Pefcent

.wwdtsj. . . . . . . . . . . . . . . . . . . . . . . 91,824 . . . . . .

Blat . . . . . . . . . . . . . . . . . . . . . . . . . . 9,655 10.7 11.2

Exerdse . . . . . . . . . . . . . . . . . . . . . . . 7,SS8 6.6 8.1

Cholesterol reduction . . . . . . . . . . . . . . . 2,620 2.9 2.5

Welghtreductbn . . . . . . . . . . . . . . . . . . 3,(KIO 3.4 3.9

Atcohol abuee . . . . . . . . . . . . . . . . . . . . “424 “0.5 0.8

Smotdng cessation . . . . . . . . . . . . . . . . . 1,406 1.5 2.3

Family/sodaI . . . . . . . . . . . . . . . . . . . . 1,944 2.1 2.3

Growth devekpment . . . . . . . . . . . . . . . . 3,450 3.6 4.2

Farrrilypkuming.. . . . . . . . . . . . . . . . . . 677 1.0 1.1

Psychotherapy . . . . . . . . . . . . . . . . . . . 1,644 1.8 3.4

Physiotherapy . . . . . . . . . . . . . . . . . . . . 1,913 2.1 3.0

All other therepeuk servkes2. . . . . . . . . . 13,574 14.8 13.0

None . . . . . . . . . . . . . . . . . . . . . . . . . 61,495 67.0 65.2

lNumbera do not edd to tofala bmeuae mora than one type of rmmwdketion therapy msy ba raported per visit.

‘Includes dmg abuse, dher munsalingl mrrective bnsaa, hearing sid, and other therapy
10 Advance Data No. 269. November 30, 1995

Table 16. Number and percent distribution of prepaid plan visits and percent distribution

of nonprepald visits by number of medications provided or preacrlbed: United States,

1991

Prepaid plan visfls Nonprepa/d vkffs

Number of

vk=lts In Percent Percent

Medketlon therapy’ thousands dktrtbution dktrfbution

Allvldts. . . . . . . . . . . . . . . . . . . . . 91,824 100.0 100.0

Type of visit

Nondrug vleit(O medications) . . . . . . . . . . 35,176 38,3 38.3

DmgvieiF . . . . . . . . . . . . . . . . . . . . . . 56,648 61.7 61.7

Nurnberof medications

1 . . . . . . . . . . . . . . . . . . . . . . . . . . . 32,514 35.4 34.6

2 . . . . . . . . . . . . . . . . . . . . . . . . . . . 14,890 16.2 18.3

3ormore . . . . . . . . . . . . . . . . . . . . . . 9,244 10.1 10.9

llnclud- prescription drugs, omr-th*munter preparations, immunmng agents, anddesenstizinga gents,

%sits at which one or more drugs were provided or prescribed by the physician.

Table 17. Number and percent distribution of prepaid plan visits and percent distribution

ofnonprepaid vlsikfor drug mentions bytherapwtic classification: Unitd Sh~, 1991

PrspaldpLarr visits Noryxepald vklts

Number of

dN&? MeIIt\OtE Percwrt Percent

Theiapeutfc classlfkatloni brthorreands disttfbutlon dktribuflon

Alldrugmentlons . . . . . . . . . . . . . . . . . . 95,104 100.0

Antlmlcroblal agents . . . . . . . . . . . . . . . .

Penicillins . . . . . . . . . . . . . . . . . . . . .

Cephatoeporlns . . . . . . . . . . . . . . . . .

Erythromydnsand linccsarnldes. . . . . . .

Cardlovaecutar-renatdmge. . . . . . . . .

Psychopharmacotogicdruga . . . . . . . . . . .

Radiopharmaceuticatskontraat media

Gaetrointesllnal agents. . . . . . . . . . . . .

Metebolicarrd nutrlantagents. . . . . . . . .

Hormones and agents affecting

honnonetmechantsms . . . . . . . . . . . . . .

Immunologlcagents . . . . . . . . . . . . . . . .

Skin/mucousmembrane . . . . . . . . . . . . .

Neurologlcdrugs . . . . . . . . . . . . . . . . . .

Ophthalmlcs . . . . . . . . . . . . . . . . . . . . .

Drugausedforrellefofpaln . . . . . . . . . . .

Genera!anafgeeics . . . . . . . . . . . . . . .

Antiarthritica . . . . . . . . . . . . . . . . . . .

Reeplraforytmtdrugs . . . . . . . . . . . . . .

Naeatdecongeslants . . . . . . . . . . . . . .

Arrtihk?tamine s . . . . . . . . . . . . . . . . .

Unctaeaified andmiacellaneous. . . . . .

Allothers2 . . . . . . . . . . . . . . . . . . . . . .

20,191

7,546

3,645

3,126

7,181

4,242

2,371

2,912

3,796

7,942

5,390

6,024

1,716

1,750

11,187

5,364

5,448

13,956

3,823

3,600

3,797

2,479

21.2

7.9

3.8

3.3

7.6

4.5

2.5

3.1

4.0

6.4

5.7

6.3

1.8

1.8

11.8

5.7

5.7

14.7

4.0

3.8

4.0

2.6

lBasedon thestsndard drug classification used in the National DrWC4DimctoV, 1985 edtion (16).

%dudes anesthetic drugs, antidotes, hematolcgic agents, c.ncolytics, otologic dregs, and antiparadk agents.

100.0

16.8

6.1

3.8

3.2

8.8

7.0

1.4

3.9

4.3

9.5

4.5

6.7

2.5

2.6

10.9

5.5

5.1

11.3

3.1

2.4

4.5

2.7

minutes. Visits with a durationof nonprepaid visits (16minutes vs. 17

“zero” minutes are those in which there minutes, respectively).

wasnoface-to-face contact between the

patient andphysician. In1991, Discussion

1.7percent of the visits hadaduration

ofzerominutes. Nonsignificant Indeseribingthepatient andvisit

ditTerence was found between the characteristicsof HMO/otkrprepaid

average durations ofprepaidand plan visits foundin the1991NAMCS,

it appears that such visits aregenerally

similar to nonprepaid visits for patients

under 65years ofage with respect to

the principal reason for visitj physicians’

diagnosis, medications prescrib@ and

duration of visit. This report focused

only on visits made by patients under

the age of 65 to reduce the confounding

effects of age and health conditions on

the characteristics examined. Fkepaid

visits were found to differ from

nonprepaid visits as follows

relative to nonprepaid visits, a higher

proportion of prepaid visits wete to

physicians in the primary care

specialties

HMO/other prepaid plans tend to

have a higher proportion of visits

with diagnostic tests performed or

ordered but especially for persons

between the ages of 45 and 64 years

a hQher proportion of prepaid plan

visits to nonprimruy care specialties

were referrals

a lower proportion of prepaid plan

visits were for patients over 65 years

of age

a higher proportion of prepaid plan

visits were in the West

The comparisons of visit and patient

characteristics between prepaid plan and

nonprepaid visk based on the 1991

NAMCS must be interpreted “with

caution. This report focused on

describing characteristics of prepaid plan

visits. For comparison purposes, the

eorreqmnding statistics for visits from

other expeeted sourcee of payment were

presented. However, nonprepaid visits

are for a very diverse set of people with

respect to expected sources of payment.

For example, 12 percent of the

nonprepaid vkits had an expected

source of payment identified as

“Mdlcaid.” Thirty-one percent were

identified as “patient paid.” Only

47 percent were identified as “private/

commercial.” In comparing tie statistics

presented in thii repo~ one must

consider how the dhrsity of coverage

in the nonprepaid group may ifiuence

prepsid and nonprepaid visit

comparisons. The results should not be

interpreted as a straight comparison

between HMO/other prepaid plans and

fee-for-service plans. The reader must

also consider that this report focuses on
Advance Data No. 269. November30, 1995 11

describing patient and visit

characteristics of prepaid plan visits to

office-based physicians and does not

represent characteristics of all visits by

persons who are insured with a prepaid

health plan. The variable that

differentiates the two comparison groups

in this report is an expected source of

payment for the visit. Persons insured in

an HMO may pay out-of-pocket

expenses to seek health care from a

provider other than the HMO to obtain

either noncovered health care or care

horn a provider that is not associated

with the prepaid plan.

TMs report does not include all

possible providers of physician services.

Physicians in hospital-based practices

are not in-scope for the NAMCS,

therefore, hospital-based managed care

offices may not be included if the

physician indicated that helshe was

employed by a hospital. Similarly, vW1ts

to hospital outpatient clinics are not

included in fhis repofi For example,

women seeking mammograms may use

mobde unit3 associated with radiology

clinics of hospitals. Such sources would

not be included in the NAMCS. Data

from population-based surveys may

obtain cWferent estimates of health care

resource use compared with event-based

surveys. The reader is encouraged to

examine data horn the National Health

Interview Survey for population-based

estimates of use of cancer screening by

women insured by an HMO or other

prepaid health insurance plans (18).

Examining data from the 1992

NAMCS for cross-validation purposes

we found that some dtierences between

the 1991 prepaid plan and nonpmpaid

plan visits were not significant. These

differences were noted where applicable.

All of the findings presented in the

Highlights section were replicated using

results horn the 1992 NAMCS.

Examining 1992 data also allows us

to look at visits to hospital outpatients

and emergency departments, which

make up approximately 17 percent of

the ambulatory care visits for persons

un&r the age of 65. The National

Hospital Ambulatory Medical Care

Survey (NHAMCS) tit collected data

in 1992 from hospital providers to help

round out the description of ambulatory

care visits (19). Considering all three

Table 18. Number and percent of drug mentions for prepaid plan visits and percent of

drug mentions for nonprepaid visits for the 20 moat frquentty used generic substance=

United Statea, 1991

Prq)afd@sn Vbu.s NorPrtwsW VfSffS

Wnber of Percenf of Peroenf of

drug nrenf/ons # O?ug S/l drug

Generic subs fsrsce h ftroussndsj rnenfions mersfions

Alldmgrnantions . . . . . . . . . . . . . . . . . . 95,104 . . . . . .

AmoxidUl n . . . . . . . . . . . . . . . . . . . . . 7,085 7.4 5.4

Acatsmhmphen . . . . . . . . . . . . . . . . . . . 4,099 4.3 4.2

Erythromydn . . . . . . . . . . . . . . . . . . . . 2,566 2.7 2.7

Phenylaphrfne . . . . . . . . . . . . . . . . . . . . 2,469 2.6 1.9

Ibuprofen . . . . . . . . . . . . . . . . . . . . . . . 2,325 2.4 1.9

Pheny@ro@nofamIrse. . . . . . . . . . . . . . . 2,110 2.2 1.9

Pseudoaphadrhse. . . . . . . . . . . . . . . . . . 2,056, 2.2 1.0

Guaifenssin . . . . . . . . . . . . . . . . . . . . . 1,834 2.0 1.5

Afbufeml . . . . . . . . . . . . . . . . . . . . . . . 1,640 1.9 1.5

Akohol. . . . . . . . . . . . . . . . . . . . . . . . 1,827 1.9 1.2

Codeine . . . . . . . . . . . . . . . . . . . . . . . 1,722 1.8 2.0

Diph pertussls tetanus vaooine . . . . . . . . . 1,716 1.8 1.2

Vitamin A. . . . . . . . . . . . . . . . . . . . . . . 1,685 1.6 1.7

Trhnathoprim. . . . . . . . . . . . . . . . . . . . 1,666 1.8 1.4

Srslfamethoxszola . . . . . . . . . . . . . . . . . 1,885 1.7 1.4

Ergocsldferol . . . . . . . . . . . . . . . . . . ..’ 1,614 1.7 t .5

Naproxen . . . . . . . . . . . . . . . . . . . . . . 1,597 1.7 1.5

Terfenadlne . . . . . . . . . . . . . . . . . . . . . 1,442 1.5 0.8

Rboffavin . . . . . . . . . . . . . . . . . . . . . . 1,3s0 1.5 1.5

Cofactor . . . . . . . . . . . . . . . . . . . . . . . 1,338 1.5 1.5

1Frequency or msntb oombines single-ingradieti a~nta wih msntkms of the agent as an ktgmdiint in a combination dreg.

Table 19. Number and persent of prepaid pfan viaite and percsmtof nonprepaid vislta by

disposition and duration: United States, 1991

Prty?afd@sn VkS& NorpqssW Vkl?S

Nurriw of

VISM h

Wsif chwacferktic ftrouSerx&s Perusnf p8tW??f

Atlvlsifs . . . . . . . . . . . . . . . . . . . . . . . 91,824 . . . . . .

Dtspoafllont

No followup piannad . . . . . . . . . . . . . . . .

Retumaf spedffctime . . . . . . . . . . . . . .

Retumit neadad . . . . . . . . . . . . . . . . . .

Tefaphona foliowup planned. . . . . . . . . . .

Referred toofherphyafdan . . . . . . . . . . .

Referred to referring phyaidan . . . . . . . . .

Admit tohospifaf . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . .

7,797

53,001

24,791

3,S37

4,208

633

835

306

8.5

57.7

27.0

3.7

4.7

0.8

0.7

1.0

11.4

53.5

23.8

3.6

2.6

0.7

0.8

1.2

Duration

Omfnufesz . . . . . . . . . . . . . . . . . . . . . . 1,595 1.7 1.1

l-5mhwfes... . . . . . . . . . . . . . . . . . . 8,943 9.7 9.4

6-10mkudes . . . . . . . . . . . . . . . . . . . . 27,766 30.3 27.4

11-15 minutas . . . . . . . . . . . . . . . . . . . 28,815 3+.4 a.9

18-30 rninutas . . . . . . . . . . . . . . . . . . . 19,853 21.6 23.7

31-60 minufas . . . . . . . . . . . . . . . . . . . 4,865 5.1 7.0

80minrrtes andover . . . . . . . . . . . . . . . . “161 “0.2 0.5

lNumbaremay notaddto totsk bacsussnwra thanone dispositkmmaybe Iupted par visit

%sits inwhichtharawss nofaoe-to-faoaOo+Maof bahvaanpstii and @yeic&m.

types of ambulatory care providers of pqxiid and nonprepaid visits (11.6

(physician offices, hospital outpatients, vs. 135 percents respectively) (20,21).

and emergency departments), black Figure 3 shows the 1992 distributions of

persons comprisedthe same proportion both prepaid plan and nonpn@d visits
12 Advance Data No. 269. November 30, 1995

■Physicians ~ Ho.spitalo.tpatient ~ Ernergencydapmtrne.t

I

White patients

Prepaid plan

Nonprepaid

Black patients

Prepaid plan

Nonprepaid

I I I i I I

o 20 40 60 80 100

Percent of visits

NOTE Excludesvisitsfor patients 65 years of age and over.

Figure 3. Percent distribution of visits to various providers for prepaid plan and

nonprepald visits by patient’s racexUnited States, 1992

to various providers. More of the

prepaid plan visits were to officebased physicians rather than hospital

settings. Approximately 9 out of 10

prepaid plan visits made by black

patients were to office-based

physicians whereas the corresponding

number for nonprepaid visits is 7 out

of 10. For both races, the proportion

of total prepaid plan visits to

emergency departments are lower than

for nonprepaid visits. The proportion

of visits to emergency departments are

approximately three times higher for

nonprepaid visits compared with

prepaid plan visits. The reader should

note that the nonprepaid visits include

visits made by people who have no

health insurance and it has been

shown that such populations receive

more primary care from emergency

settings (22–2.4.

In summary, results from this study

indicate that after controlling for age

dtierences between prepaid plan and

nonprepaid visits, prepaid plan visits

dtier horn nonprepaid visits on referral

status, physicirm specialty, and regional

distribution. The visits are similar with

respect tQreason for visit+diagnosis,

treatments ordered or provided, and

duration. The proportion of office-based

physicians’ visits that has an expected

source of payment as “prepaid plan”

has increased since 1985.

References:

1. Roghrnann KJ, Gavett JW, Sorensen

AA, Wells S, Wersinger R. Who

chooses prepaid rnedcal care Survey

results from two marketing of three

new prepayment plans. Public Health

Rep 90:516-27.1975.

2. Nycz GR, Wenz.el FJ, Lohrenz FN,

Mitchell JH. Composition of the

subscribers in a rural prepaid group

practice plan. Public Health Rep

91:50L7. 1976.

3. Jackson-Beeck M, Kleinman JH.

Evidence for self-selection among

health maintenance organization

enrollees. J Am Med Assoc

250:282629.1983.

4. Lairson DR, Herd JA. The role of

health practices, health status, and

prior health care claims in HMO

seleztion bias. Inquiry 24:276-84.

1987.

5. Llchtenstein R, Thomas JW, Watkins

B, Puto C, Lepkowski J, fhiamsWatson J, Simone B, Vest D. HMO

marketing and selection bias. Med

Care 30:32945.1992.

6. Ware Jr, JE, Rogers WH, Davies AR,

Goldberg GA, et al. Comparison of

health outcomes at a health

maintenance organization with those

of fe~for-service care. Lancet

1017–22. 1986.

7. Stern RS, Juhn PI, Gertler PJ,

Epstein AMA comparison of length

of stay and costs for health

maintenance organization and

fee-for-service patients. Arch Intern

Med 149:1185-8.1989.

8. Young GJ, Cohen BB. Inequities in

hospital care, the Massachusetts

experience. Inquiry 28:255+2. 1991.

9. Carlisle DM, Siu AL, Keeler EB,

McGlynn EA, KahrI KL, Rubenstein

LV, Brook RH. HMO vs fe&fmservice care of older persons with

acute myocardial infarction. Am J

Public Health 82:1626-30.1992.

10. Greenwald HP, Henke CJ. HMO

membership, treatment and nnortalily

risk among prostatic cancer patients.

Am J Public Health 82 1099–1 104.

1992.

11. Szilagyi PG, Roghrrraan KJ, Foye

HR, Parks C, et al. Increased

ambulatory utilization in IPA plans

among children receiving

hyposensitization therapy. Inquiry

29:467-75.1992.

12. Gemson DH, Freudenheim E, Senie

RT, Elinson J, Fink R. Health

promotion and dkease prevention in

HMOS: A survey of newly

established JPAs in New York City.

Am J Prev Med 6333-8.1990.

13. Schneider D, Appleton L, McLemore

T. A reason for visit classification for

ambulatory care. National Center for

Health Statistics. Vital and Health

Stat 2(78). 1979.

14. Public Health Service and Health

Care Financing Administration.

International Classification of

Diseases, 9th Revision, clirical

modification. Washington Public

Health Service. 1980.

15. Scbappert SM. National Ambulatory

Medical Care Survey 1991

Summary. Advance data from vital

and health statistics no 230.

Hyattsville, Maryland: National

Center for Health Statistics. 1993.

16. Food aod Dmg Administration.

National Drug Code Directory, 1985

Edition. Washington Public IHealth

Service. 1985.

17. Koch H, Campbell W. The collection

and processing of drug information.

National Ambulatory Medkal Care

Survey, 1980. National Center for

Health Statistics. Vital Health Stat

2(90). 1982.

18. Makuc D, Freid VIM, Parsons PE.

Health insurance and cancer

screening among women. Advance

data from vital and health statistic

no 254. Hyattsville, Maryland

National Center for Health Statistics.

1994.
Advance Data No. 269. November30,1995 13

19.McCaig LF, McLemoxe T. Plan and

operation of the National Hospital

Ambulatory Medical Care Survey.

National Center for Health Statistics.

Vital Health Stat 1(34). 1994.

20. Unpublished data horn the National

Ambulatory Me@cal C= Survey,

1992.

21. Unpublished data from the National

Hospital Ambulatory Medical Care

Survey, 1992.

22 Grumbach K, Keane D, Bindman A.

Primary care and public emergency

overcrowding. Am J Public Health

83(3):3724. 1993.

23. Kellerman AL. Nonurgent emergency

department visits: Meeting an unmet

need. J Am Med Assoc

271(M): 19534.1994.

24. Schappert S. Race differences in

hospital emergency department use.

Stat Bull VO176 No 3.1995.

25. Shah BV, Barnwell BG, Hunt PN,

LaVknge LM. SUDAAN user’s

manual, release 5.50. Research

Triangle Park, North Carolina

Research Triangle Institute. 1991.
14 Advance Data No. 269. November 30, 1995

Technical notes

Source of data and

sample design

The information presented in this

report is based on data collected by

means of the National Ambulatory

Medkal Care Survey (NAMCS) from

January 1991 through December 1991.

The target universe of NAMCS includes

office visits made in the United States

by ambulatory patienta to nonfederally

employed physicians who are principally

engaged in office practice, but not in the

specialties of anesthesiology, pathology,

or radiology. Telephone contacts and

nonoffice visits are excluded.

A multistage probability sample

design is used in NAMCS, involving

samples of primary sampling units

(PSU’S), physician practices within

PSU’S, and patient visits within

physician practices. The PST-J’Sare

counties, groups of counties, county

equivalents (such as parishes or

independent cities), or towns and

townships (for PSU’S in New England).

For 1991, a sample of 2,540 nonfederal,

office-based physicians was selected

from the master files maintained by the

American Medical Association and

American Osteopathic Association.

Physicians were screened at the time of

the survey to ensure that they were

eligible for survey participation. Of

those screened, 653 physicians were

ruled ineligible (out-of-scope). The

remaining 1,887 physicians were

in-scope or eligible to participate in the

survey. The physician response rate for

the 1991 NAMCS was 72 percent.

Sample physicians were asked to

complete Patient Records (see figure 1)

for a systematic random sample of office

visits occurring during a randomly

assigned l-week reporting period.

Responding physicians completed

33,795 patient records.

Characteristics of the physician’s

practice, such as primary specialty and

type of practice, were obtained from the

physicians during an induction

interview. The U.S. Bureau of the

Census, Housing Surveys Branch, was

responsible for the survey’s data

collection. Processing operations and

medicrd coding were performed by the

National Center for Health Statistics,

Herdth Care Survey Section, Research

Triangle ParlG North Carolina.

Sampling errors

The standard error is primarily a

measure of the sampling variability that

occurs by chance when only a sample,

rather than an entire universe, is

surveyed. The standard error also

reflects part of the measurement error

but does not measure any systematic

biases in the data. The chances are 95

out of 100 that an estimate from the

sample differs from the value that would

be obtained from a complete census by

less than twice the standard error.

The standard errors that were used

in tests of significance for this report

were calculated using generalized linear

models for predicting the relative

standard error for estimates based on the

linear relationship between the actual

standard error, as approximated using

SUDAAN software, and the size of the

estimate. SUDAAN computes standard

errors by using a ficst-orkr Taylor

approximation of the deviation of

estimates from their expected values. A

description of the software and the

approach it uses has been published

(25). The relative standard error (RSE)

of an estimate is obtained by dividing

the standard error by the estimate itself.

The result is then expressed as a percent

of the estimate.

Relative standard errors for

emergency department estimates are

shown in tables I and II. Standard errors

for estimates in percents of visits and

drug mentions are shown in tables III

and IV. MuMplying the estimate by the

RSE will provide an estimate of the

standard error for the estimate.

Alternatively, relative standard

errors for aggregate estimates may be

calculated using the following general

formulaj where x is the aggregate of

interest in thousands, and A and B are

the appropriate coefficients from table V.

RSE(X) =

T

A+:*IOO

Similarly, relative standard errors

for an estimate of a percent maybe

calculated using the following general

formub where p is the percent of

Table 1.Approximate relative standard

errors for estimated numbers of ofttce

visit= National Ambulatory Medical Care

Suwey, 1991

Estimated number of Relative standard

office vla/ts in thousands error In percent

100 . . . . . . . . . . . . . . . . 72.1

200 . . . . . . . . . . . . . . . . 51.1

500 . . . . . . . . . . . . . . . . 32.5

588 . . . . . . . . . . . . . . . . 30.0

1,000 . . . . . . . . . . . . . . . 23.1

2,000 . . . . . . . . . . . . . . . 16.6

5,000 . . . . . . . . . . . . . . . 11.0

10,000 . . . . . . . . . . . . . . 8.3

20,000 . . . . . . . . . . . . . . 6.6

50,000 . . . . . . . . . . . . . . 5.3

100,000 . . . . . . . . . ...! 4.8

200,000 . . . . . . . . . . . . . 4.5

500,000. . . . . . . . . . . . . 4.3

700,000 . . . . . . . . . . . . . 4.3

NOTES The smallest refiable estimate for visits to

aggregated speclattias is 568,000 visits. Estimates bslow this

figure have a relatiie standard error greater than 30 parcant

and are deemsd unrehable by NCHS standards.

Exampb of use of table: An aggregate estimate of 50 million

visits has a refstiwe standard error of 5.3 parcant or a

etamdard error of 2,653,000 visits (5.3 perormt of 50 million).

Table Il. Approximate relative standard

errors for aatlmated numbers of drug

mentfone: National Ambulatory Medical

Care Survey, 1991

.Est/mated nurnbar of Relative skmdard

dmg M8nt10nS in thOUSSndS error /n percent

100 . . . . . . . . . . . . . . . . 78.1

200 . . . . . . . . . . . . . . . . 66.8

500 . . . . . . . . . . . . . . . . 43.7

1,000 . . . . . . . . . . . . . . . 31.2

1,063 . . . . . . . . . . . . . . . 30.0

2,000 . . . . . . . . . . . . . . . 22.4

5,000 . . . . . . . . . . . . . . . 14.8

10,000 . . . . . . . . . . . . . . 11.2

20,000 . . . . . . . . . . . . . . 8.9

50,000 . . . . . . . . . . . . . . 7.f

100,000.. . . . . . . . . . . . 6.5

200,000 . . . . . . . . . . . . . 6.1

600,000 . . . . . . . . . . . . . 5.8

800,000 . . . . . . . . . . . . . 5.8

NOTES The smalleat refiable estimate for drug mantions is

1,0S3,000 mentions. Estimates balow this figure have a

relatiie etandard error greater than 30 percent and are

deenwd unreliable by NCHS standards.

Exampla of use of tsb!ei An aggregete aafimate of 50 milfkkn

drug rrw.ntiins has a refafiie standard error of 7.1 percent or

a standard error of 3,550,000 mantions (7.1 peroant of 50

milhon).

interest expressed as a proportion, and x

is the denominator of the percent in

thousands, using the appropriate

coefficients from table V.

r

~.(l-pjolm

RSE (X) =

p*x
Advance Data No. 269. November 30, 1995 15

Table Ill.Approximate standard errors for percents of estimated number of offloe visits: National Ambulatory Medical Csre Survey

United States, 1991

Etiirrratedperoant

Base of peroent

(vkfk In thousands) 1 or 99 5 or 95 10 or 90 20 or 80 30 or 70 40 or 60 50

100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

200 . . . . . . . . . . . . . . . . . . . . . . . ! . . . . . . . . .

500 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ioo,ooo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

200,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Soo,ooo . . . . . . . . . . . ...<< . . . . . . . . . . . . . .

1,060,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7.2

5.1

3.2

2.3

1.6

1.0

0.7

0.5

0.3

0.2

0.2

0.1

0.1

15.7

11.1

7.0

5.0

3.5

2.2

1.6

1.1

0.7

0.5

0.4

0.2

0.2

Standard errorhrpercentaga points

21.6

15.3

9.7

6.6

4.8

3.1

2.2

1.5

1.0

0.7

0.5

0.3

0.2

28.8

20.4

12.9

9.1

6.4

4.1

2.9

2.0

1.3

0.9

0.6

0.4

0.3

23.0

23.3

14.8

10.4

7.4

4.7

3.3

2.3

1.5

1.0

0.7

0.5

0.3

35.3

24.9

‘15.8

11.2

7.9

5.0

3.5

2.5

1.6

1.1

0.8

0.5

0.4

36.0

25.5

16.1

11.4

6.1

5.1

3.6

2.6

1.6

1.1

0.8

0.6

0.4

Exampkrotuseot table:Anestimate of20perce.ntbassd onanaggragateestirrwe oflOmillionvisits hasastarrdard.wror d3.3parcentora relafiistandardermr ofll.Opercent(S.3 percant

dwklad by 30).

Table IV.Approximate standard errors of percents of estimated numbers of drug mentions: National Ambulatory Medical Care Survey

United States, 1991

Estirnatedpercent

Base of percent

(drugnrentlons In thousands) i or 99 5 or 95 10 or 90 20 or 80 30 or 70 40 or 80 50

Standard error In percentage points

100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.6 21.1 29.1 38.8 44.4 47.5 48.5

200 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.8 14.9 20.6 27.4 31.4 33.6 3.3

500 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 9.5 13.0 17.3 19.9 21.2 21.7

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 6.7 9.2 12.3 14.0 15.0 15.3

2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 4.7 6.5 8.7 9.9 10.6 10.8

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4 3.0 4.1 5.5 6.3 6.7 6.9

10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.0 2.1 2.9 3.9 4.4 4.8 4.9

20,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.7 1.5 2.1 2.7 3.1 3.4 3.4

50,0CS3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.4 0.9 1.3 1.7 2.0 2.1 2.2

Ioo,ooo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.3 0.7 0.9 1.2 1.4 1.5 1.5

200,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.2 0.5 0.7 0.9 1.0 1.1 1.1

500,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.1 0.3 0.4 0.6 0.6 0.7 0.7

1,000,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.1 0.2 0.3 0.4 0.4 0.5 0.5

Exsmpb of usa of tabb An estimate of 20 parcant basad on an aggragata eafimate of 10 million Waii has a sfandani error d 3,9 pwcamt or a relative standard arror of 19.5 parcant (3,9 psrcant

dhiiad by 20 parcant).

Adjustments for nonresponse

lMimatesfromNAMCS datawere

adjustedtoaecount forsample

physicianswho were in-scopebut did

not participatein the study.This

adjustmentwas c.alculatedtominimize

theimpactofresponse onfinalestimatm

by imputing to nonresponding

physiciansdatafrom visits to similar

physicians.Forthis purpose, physicians

werejudgcdsimiiar iftheyhadthe

samespecialty designationandpraeticed

inthesatnePSU.

Test ofsignificance and

rounding

Inthisrepofi the determinationof

statisticalinferenceisbasedonthe

t-test.TheBonferroni inequalitywas

used to establish the critical value for

statisticalsignificantdflerences (0.05

level of confidence).Termsrelating to

d~erences such as “greaterthan”or

“less than” indicate that the diEerence

is statisticallysignificant

In the tables, estimatesof office

visits have been rounded to the nearest

thousand.Consequently,estimateswilI

not always add to totals.A lack of

commentregardingany two estimates

does not mean that the diffemce was

tested and found not to be significant.

Rates and percents were calculatedfrom

originrdunroundedfiguresand do not

necessarilyagree with percents

calculatedfrom rounded data.

Definition of terms

Ambulatory patient-An ambuMory

patient is an individualseekingpersonal

health serviceswho is not currently

admitted to any health care institution

on the premises.

Physician-A physician is a duly

licensed doctor of medkine (MD) or

doctor of osteopathy(DO)who is

currentlyin office-basedpractice and

who spendssome time earing for

ambulatorypatients. Excluded from the

NAMCS are physicianswho me hospital

based; who specializein anesthesiology,

pathology,or radiology;who are

federallyemploye@who treat only

institutionalizedpatien@ or who are
16 Advance Data No. 269 ● November 30, 1995

Table V. Coefflclsnts appropriate for dotarmining relative standard errors by type of (HMO’s), independent practice

sstfmate and physloian spsoialty National Ambulatory Msdlcal Cars Survey, 1991 organizations (IPA’s), and all other

Coeffldent for use tn?heatlmataa In thowamk prepaid health care plans.

7Jpe of estimate andphyalclan epeclat/y A B Nonprepaid visit—A nonprepaid

visit is a visit for wlich any expected

VMS:

Overall total . . . . . . . . . . . . . . . . . . . . . . . . . .

General mdfamiIypracfioe . . . . . . . . . . . . . . . .

Osteopathy . . . . . . . . . . . . . . . . . . . . . . . . . .

Internal medicine . . . . . . . . . . . . . . . . . . . . . . .

Pediatrtca . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generafsurgary . . . . . . . . . . . . . . . . . . . . . . .

Obstettfcaandgynecotogy . . . . . . . . . . . . . . . .

Orthopedicsurgery . . . . . . . . . . . . . . . . . . . . . .

Cardlovaeoulardisaaees . . . . . . . . . . . . . . . . . .

Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . .

Urotogtcatsurgery . . . . . . . . . . . . . . . . . . . . . .

Psychlatty . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . .

Otofsryngology . . . . . . . . . . . . . . . . . . . . . . . .

Allotherepectaltles . . . . . . . . . . . . . . . . . . . . .

Drug mentions

Overatltotal . . . . . . . . . . . . . . . . . . . . . . . . . .

Generetandfamilypracfice . . . . . . . . . . . . . . . .

Osteopathy . . . . . . . . . . . . . . . . . . . . . . . . . .

Intemalmedidne . . . . . . . . . . . . . . . . . . . . . . .

Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generatsurgary . . . . . . . . . . . . . . . . . . . . . . .

Obetetkssndgynecology . . . . . . . . . . . . . . . . .

Orthopedicsurgery . . . . . . . . . . . . . . . . . . . . . .

Cardlovaaculardlaeases . . . . . . . . . . . . . . . . . .

Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . .

Urofogicalsurgety . . . . . . . . . . . . . . . . . . . . . .

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . .

Otolaryngology . . . . . . . . . . . . . . . . . . . . . . . .

Allotherspecialtie s........ . . . . . . . . . . . . .

0.001744264

0.006617364

0.0163602

0.01573396

0.0163602

0.0163602

0.0163602

0.0163602

0.0163602

0.0163602

0.0163602

0.0163602

0.0163602

0.0163602

0.0163602

0.03340709

0.003224617

0.0122564

0.02764109

0.0122564

0.0122564

0.0122W4

0.0122584

0.0122664

0.0122564

0.0122564

0.0122564

0.01225s4

0.0122564

0.0122564

0.0122564

0.0463562

source ofpayment with theexception of

51.82697927 “HMO/otherprepaid” waschwlcedon

item 60fthe Patient Record Mm.

33.29640705

10.90230266

45.10067385

10.90230286

10.90230266

10.90230266

10S0230266

10.90230286

10.60230286

10,60230286

10.90230266

10.90230266

10.90230266

10.90230286

29.631108

93.92631667

57.64543271

11.55212504

57.64543271

57.64543271

57.64543271

57.64543271

57.64543271

57.64543271

57.64643271

57.64543271

57.64543271

57.64543271

57.64543271

57.64543271

46.53697479

employedfr. dltimeby an institution and

spend no time seeing ambulatory

patients.

Ojlce-Offices are the premises

physicians identi@ as locations fortheir

ambulatory practicq these customarily

include consultation, examination, or

treatmentspaees thatpatients associate

with thepartictdar physician.

Wsit—A visit is a direct personrd

exchange between an ambtdatory patient

andaphysician (orastaffmember

working under thephysician’s

supervision), for the purpose ofstx%ng

care and rendering personal health

serviees.

Drug mention—A drug mentionis

the physician’s entry ofa

pharmaceutical agent-by any routeof

administration-for prevention,

diagnosis, or treatment. Genericas well

asbrand-name drugsareincluda as are

nonprescription and prescription drugs.

Along with all new drugs, thephysician

alsorecordscondnued medieationsif

the patient was specifically instructed

during the visit to continue the

medication.

Drug visit—A drug visit is a visit in

which medication wasprestibedor

provided by the physician.

Prepaid plan visit—A prepaid plan

visit is one for which “HMO/other

prepaid plan” was checked as an

expected source of payment in item6 of

the Patient Record form. Instructions for

completing this item on the 1991 Patient

Rex.mrdfonndefines “HMO/other

prepaid” as including visits covered

under heath maintenance associations
Advance Data No. 269 ● November 30, 1995 17

Symbols

. . . Data not available

. . . Categoty notapplicable

Quantity zero

0.0 Quantity morethan zero but

less than 0.05

z Quant”~ morethan zero but

lessthan 500 where numbers

are roundedto thousands

* Figure does not meet standard

of reliabilityor preoision
20 Advance Data No. 269 ● November 30.1995

Suggested cltatfon

WoodWell DA. Characteristics of prepaid plan

visita to office-baaed physicians Unitad

States, 1991. Advance data from vital and

health statisti~ no. 269. Hyattaville,

Maryland: National Center for Health

statistics. 1995.

Trade name disclaimer

The use of trade names is for identification

only and dces not imply endorsement by the

Public Health Servica, U.S. Department of

Health and Human Services.

Copyright information National Center for Health Statistics

All material appearing in this report is in the Acting Director

public domain and may be reproduced or Jack R. Anderson

copied without permission; citation as to

source, however, is appreciated. Acting Deputy Director

Jennifer H. Madans, Ph.D.

U.S. DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Center for Health Statistics m

6525 Belcrest Road

Hyattsville, Maryland 20782

OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

To recaive this pubiidion regularly, contact

the National Center for Health Statistics by

calling 301-436-8500

E-mail: nchsquery@nchl Oa.em.cdc.gov

Internet http:/Avww.cdc.gov/nchswww/nchshome. htm

DHHS Publication No. (PHS) 96-1250

5-1604 (11/95)
Number 270 . December 7, 1995

Advance

Data m

From Vital and Health Statistics of the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

National Ambulatory Medical Care Survey: 1993 Summary

by David A. Woodwell and Susan M. Schappert, M.A., Division of Health Care Statistics

Introduction

During the 12-month period from

January 1993 through December 1993,

an estimated 717.2 million visits were

made to nonfederally employ@

offiebased physicians in the United

States, or 2.8 visits per person. This mte

is not signilieantly dtierent from office

visit rates observed since 1975 (l–5).

‘Ilk report presents data highlights

from the 1993 National Ambulatory

Medical Care Survey (NAMCS), a

national probability sample survey

conducted by the Division of Health

Care Statistics of the National Center

for Health Statistics, Centers for Disease

Control and Prevention. Statistics are

presented on physician, patien~ and visit

characteristics.

Only visits to the offices of

nonfederally employed physicians

(excluding those in the specialties of

anesthesiology, rdlology, and

pathology) who were classiikd by the

American Medieal Association or the

American Osteopathic Association as

“officwbas@ patient care” were

included in the NAMCS. Visits to

private, nonhospital-based clinks and

health maintenance organizations were

within the scope of he survey, but those

oeeurringin government-operated

facilities and hospital-based outpatient

departments we~ not. Telephone

contacts and vish.s made outside the

physician’s office were also excluded.

Because the estimates presented in

this report am based on a sample rather

than on the entire universe of office

visits, they are subject to sampling

variability. The Technical notes at the

end of this report include an overview

of the sample design used in the 1993

NAMCS, an explanation of sampling

errors, and guidelines for judging the

precision of the estimates.

The Patient Record form is used by

physicians partieipating in the NAMCS

to record information about their

patients’ office visits. This form is

reproduced in figure 1 and is intended to

serve as a reference for readers as they

review the survey Iindmgs presented in

this document.

The physician sample for the

NAMCS was selected with the

cooperation of the Ameriean Medical

Association and the Ameriean

Osteopathic Association. Their

contribution to this effort is gratefully

acknowledged.

Physician characteristics

The distribution of office visits

according to physician specialty is

presented in table 1. The largest share of

visits was made to physicians in general

and family practice (27.6 percent). Visit

rates to each of the physician specialty

groups did not dtier significantly fkom

1992 visit rates with the exception of

otolafyngologists. The rate of visits to

this specialty deereased fkom 9.1 visits

per 100 persons in 1992 to 6.0 visits per

100 persons in 1993. However, the 1993

figure is not significantly dfienmt from

the corresponding rate of 7.7 visits per

100 in 1991. In fac~ the visit rate to

otohuyngologists has ranged between

6.5 and 7.0 visits per 100 persons

between 1975 and 1990, so the 1992

figure appears to be an anomaly.

Doctors of osteopathy received 44.9

million visits during 1993, or

6.3 pereent of all office visits. Visits to

this specialty occurred at a rate of 17.7

per 100 persons, which was not

significantly dtierent from the 1992

visit rate.

Visits according to geograpldc

chsxaeteristics of the physieiau’s

practice are also displayed in table 1.

Visit rates by region-NortheasL

hfidwes~ South, and West<Id not

dfier horn eaeh other in 1993, exeept

that the Northeast rate was higher than

the South and Midwest. Regional rates

were not significantly dflerent than the

corresponding 1992 rates.

Patient characteristics

Office visits by patient’s age, sex,

and race are shown in table 2. Females

made 60.0 percent of all oftiee visits

Smvlw, $N %

4

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

[

<

Public Health Service

Centers for Disease Control and Prevention

%%ma National Center for Health Statistics CENTERS CKFOR DIsEAsE CONTROL

AND PREVE~N
2 Advance Data No. 270. December 7, 1995

. . .

1 I

1. DAYS OF VISIT

+-#+

NATIONAL AMBULATORY MEDICAL CARE SURVEY OMB NO. 092302S4

1993-94 PATlENT RECORD Ewkg4sf~:

--- . . ..

2. DA7E OF SIRTN 4. COLOR OR RACE S. ETHNICITY 0. Expuxm SOUROE(S) OF

PAYMENT lad dI AM w/y)

7. WAS PATIEN7 8. Is THls VISIT

~. , Dvlmt.

RIWERRED FOR INJURY RSLATED?

MonU’I Doy Yew , •~l$ 1❑ Privm ~ so~y- / ccmmdr THls VISIT BY * a Yes

2rJekk

ANOTHER ZONO

2 a M8dkam *lg Palimtpaid PHYSICIAN?

3. Ssx

~❑g#k9.

a.t& *nYfm I-S:AINWN=,

anlhdkaid ?❑ No C3W@

IuFmele tahUb Anwicm In&n/

4 •EA~I~ tnNo ?IJ **8

4(3cu12fwdnmwn2 Snomu

20 No

a ❑ Unknonr

10. PATIENTW COMPLAINT

OR OTHER REASON(S) t%t%t%i’$fs)’

1i. PHYSICIAN% DIAGNOSES f..t $JUC@C~ PLUSibkJ 12. HAVE YOU OR 1% DOES PAmNY HAVE

/r* ptidnt’s owl Wwds]

ANYONE IN YOUR

PRAOTICE SEEN

[addntha6#yny@dkId

PATIENT ❑EFORE?

qlq.tiry inUrn 11]

a.um

3. Fll~ 1a Abihm2J

hloe+lut . * Inm 104. I ❑ Yes 2DN0 2❑ ciatuc2

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s•1 cMaq20fc4i3

e.02w ! com2r I

,DY” ,Otdo I smNonsdlho@lwv8 –

14. TSSVS, SURGICAL AND NONSURGICAL PROCEDURES, AND THERAPISS Nomn

3. SELEOTEDSERVICES b. AU. OTHER SERWE3

tc32tkd101dcmf 0rfimiridl -:: %LL%%%Lk aaiuaa hm k.

● SmJJtrfts●d @k??proc?dnru iitdda ● S2n@$ i~ itdm I&

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!aelood Fm2aJm

PweImad DIdwed

2n Wind*

to *!-J

3❑ .qxrolmby ——

Figure 1. Patient Record form

Pwkmmdordered

to an

——

an ID to

16. MEDICATIONS / INJECTIONS 17. apsFJitiiTloNJJs VISIT

NOM ❑

m*: amhleio!b?+tianmd

●xx MdOm ,

● rmwamkdiau 2a Rdum3t2wdliedb3e

● .ui## M*S

● Alld23iu 2

J ~ Mum II needed, P.RN.

● MdJ odcrd,

S@34 or 4 ❑ Toio@molokww Pkmed

odlhim?d ~

.Nmmd J I-J Fldlbrr4d20Ollw physicial

● cilnl!/ll@d$

(wiho?wilhow ,

a❑ Rdurmd b rzkring phyxick

mu O?dem)] 713 Admi1201wpi291

5 a ❑ OGwr frprcrJ)y

during 1993 and accounted for a higher

percent of visits than males in atl age

categories except the youngest (under 15

years). Females also had significantly

higher visit rates than males in each age

category with the exception of the

youngest group (under 15 years) and the

two oldest groups (65–74 years and 75

years and over). These patterns were

also observed in the 1990-92 National

Ambulatory Medical Care Surveys.

Visit rates were found to increase

with age after the age of 24. Persons

aged 75 years and over had the highest

visit rate of the six age categories

18. :IRATN)N

THIS VISIT

i7iie ObYUdly

$f%%;

—~

analyzed, at 6.1 visits per person. The

pattern, however, was found to be

slightly different for males and females.

Among males, the visit rate for the age

group 15–24 years was significantly

lower than for those under 15 years. But

males in the age group 25-44 years had

a higher rate than those 15–24 years.

The rate increased with each successive

age group, with males aged 75 years

and over having the highest rate of 6.2

visits per person.

There was no significant dtierence

in the visit rates for females under 15

years and those 15–24 years. However,

the rate was higher for females 25-44

years than for those 15–24, and

increased again for those 45-64 years

and 65–74 years of age. There was no

significant dtierenee in visit rates

between females in the two oldest age

groups, 65–74 years and 75 years and

over.

The visit rate for the white

population was sigdkantly higher (3.0

visits per person) than the rate for the

black population (1.8 visits per person)

in 1993. Wit rates were higher for

white persons in each age group

compared with black persons, with the
Advance Data No. 270 ● December 7, 1995 3

exception of those 75 years and over.

White persons made 88.2 percent of all

office visits, with black persons and

Asians/Pachic Islan&rs accounting for

8.1 percent and 3.3 percent respectively.

The visit rate for the black

population in 1993 was significantly

lower than the 1992 rate (2.6 visits per

person), but was not si@cantly

different from the 1991 mte (L9 visits

per person). The higher rates in 1992

may be the result of sampling variability

rather than a true increase, as discussed

in a previous report (5).

Visit characteristics

Referral status and prior-visit

status

Table 3 shows data on office visits

categorized by patient’s referral status

and prior-visit status. The distribution

of visits by referral status and

prior-visit status according to

physician specialty is shown in

table 4. It is important to note tha~ in

previous years, several data items

were used to determine referral status.

Return visits made for treatment of an

“old” problem were not considered

referral visits even if the referral item

on the Patient Record form had been

checked “yes” by the physician. This

edit procedure was instituted on the

assumption that if the physician had

seen the patient previously for

treatment of the same problem

(defined as the current episode of

care), that patient could not have been

referred for the current visit.

However, in recent years, increasing

numbers of physicians in the NAMCS

sample have characterized visits as

referrals an~ at the same time, as being

made by “old” patients for “old”

problems. This apparent inconsistency

may have a number of possible

expkmationx some physicians may be

reporting refereed patients as referred

visi~ changes in referral patterns may

have occurred dated to changes in

insurance coveragq or physicians may

be including patients seen before for

past episodes of care, rather than current

episodes of care.

Beginning with the 1993 survey

year, only data from the referral status

Table 1. Annual number, parcant dlstrlbutlon, and rate of office vlalts by salaotad

physlclsn practice characterlstks: Unltad States, 1993

Nwn!rerof

Number of vMs per

vfdtsin Perc8nt 100parwma

Phyalolanpracticecharacteriatk thousands distribution per yeari

Allvlslfs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Phyddan SpSCkffY

General and famllypraotioe . . . . . . . . . . . . . . . . . .

Irrtemafmadidne. . . . . . . . . . . . . . . . . . . . . . . . .

Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricsarrdgynecology. . . . . . . . . . . . . . . . . . .

Ophthalmology. . . . . . . . . . . . . . . . . . . . . . . . . .

Orthopedicsurgery. . . . . . . . . . . . . . . . . . . . . . . .

Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . . . .

General surgery . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatry. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Urology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otolaryngology. . . . . . . . . . . . . . . . . . . . . . . . . .

Cardlovaa@ardlee aces. . . . . . . . . . . . . . . . . . . .

Allergyandimmunolo~. . . . . . . . . . . . . . . . . . . .

Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pulmonarydlseases3 . . . . . . . . . . . . . . . . . . . . . .

Allotherspec!altles . . . . . . . . . . . . . . . . . . . . . . .

Profesdonalidentity

Dootorof medklne. . . . . . . . . . . . . . . . . . . . . . . .

Doctorof osteopathy . . . . . . . . . . . . . . . . . . . . . .

Geographicregion

Northeast . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Midwest.. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

South. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

717,191 100.0 282.0

197,605

102,436

76,982

64,030

38,373

33,636

31,469

21,703

20,469

15,690

15,380

12,178

10,605

8,S93

4,251

82,991

27.6

14.3

10.7

6.9

5.5

4.7

4.4

3.0

2.9

2.2

2.1

1.7

1.5

1.2

0.8

8.8

77.7

40.3

30.3

?27.2

15.5

13.2

12.4

8.5

8.0

6.2

6.0

4.8

4.2

3.3

1.7

24.8

672,306 83.7 264.4

44,865 8.3 17.7

168,436 23.5 336.6

169,035 23.6 272.5

213,356 2S.7 250.0

1s6,363 23.2 292.7

1B3sed on U.S. Bureau of the Census estimates of the civikan noninsfikrtiinalized pepulafion of the United Stetes as or

July i, lS$@.

2The Vtit rate i3 4S.5 per 100 ferreks.

3These 3peciatties were sampled separately in 1993 onfy as part of a suppbnerrta[ date cdectiin project

item on the Patient Record form will

be used to determine referral status.

The definition of a referred visit

consistent with past usage can be

recreated using information available

on the public use data file. Recent

changes in the health care system may

have altered the way referral status is

conceptualized and interpreted.

Research is under way to improve the

collection of this information in the

NAMCS.

When refened visits are restricted

to those made by new patients and those

made by old patients for new problems,

their share of total visits is 6.6 percen~

not signidcantly difFerent than the 1992

NAMCS figure of 6.2 percent. Using the

number of referred visits reported by

physicians (which includes visits made

by old patients for old problems), the

percent of referred visits is 13.7

(table 3).

Also shown in table 3 are office

visits by prior-v~lt status. Eight out of

ten office visits (84.4 percent) were

made by patients who had seen the

physician on a previous occasion, and

more than half of all visits

(63.1 percent) wem made by persons

returning to the physician for care of a

previously treated problem.

As e= the percent of referred

visits reported by primary care

specialties wa3 relatively low, 10 percent

or less of the total visits to general and

family practitioners, internists,

pe&atricians, and obsteticiansgynec010gist8. In contras6 about half of

all visits to neurologists (50.7 percent)

were reported to be referrals (table 4).

Expected sources of payment

Data on expected sources of

payment are shown in table 5.
4 Advance Data No. 270 ● December 7, 1995

Table 2. Annual number, percent distribution, and rate of office visits by patient’s age,

sex, and race United States, 1993

Number of

Number of vlslts per

visits in Percent pereons

Patient’s age, sex, and rsce thousands d/atfibut/on per yeeri

Allvisb . . . . . . . . . . . . . . . . . . . . .

Age

Under 15yeare . . . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . .

45-84 years . . . . . . . . . . . . . . . . . . . . . . .

65-74 yaais . . . . . . . . . . . . . . . . . .

75yeera andover . . . . . . . . . . . . . . . . . . .

Sex and age

Female . . . . . . . . . . . . . . . . . .

Under15yeers . . . . . . . . . . . . . . . . . . .

15-24yeara . . . . . . . . . . . . . . . . . . . . .

25-44years . . . . . . . . . . . . . . . . . . . . .

45-64years . . . . . . . . . . . . . . . . . . . . .

65-74yeafs . . . . . . . . . . . . . . . . . . . . .

75yesrsandover . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . .

Undar15yesrs . . . . . . . . . . . . . . . . . . .

15-24years . . . . . . . . . . . . . . . . . . . . .

25-44yeats . . . . . . . . . . . . . .

45-E4years . . . . . . . . . . . . . . . . . . . . .

65-74yeara . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . .

Race and age

White . . . . . . . . . . . . . . . . . . . . . . . . . . .

Under15years . . . . . . . . . . . . . . . . . . .

15-24years . . . . . . . . . . . . . . . . . . . . .

25-44yeafa . . . . . . . . . . . . . . . . . . . . .

45-84years . . . . . . . . . . . . . . . . . . . . .

65-74yeats . . . . . . . . . . . . . . . .

75yaaraandover . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . .

Under15yeers . . . . . . . . . . . . . . . . . .

15-24years . . . . . . . . . . . . . . . . . . . . .

25-44yeat3 . . . . . . . . . . . . . . . . . . . . .

45-64yeara . . . . . . . . . . . . . . . . . . . . .

65-74yaars . . . . . . . . . . . . . . . . . . . . .

75yearsandovar . . . . . . . . . . . . . . . . .

All other races

AslanPaclficlslander . . . . . . . . . . . . . . . . .

AmerbnlndlanrEsldmo/Alaut. . . . .

717,191

129,279

62,346

193,914

160,146

93,673

77,633

430,170

60,664

41,406

128,654

96,011

55,215

46,017

287,021

66,615

20,936

65,060

84,135

36,656

29,616

632,500

113,506

53,650

167,026

140,231

86,204

71,884

58,154

10,328

6,308

16,946

14,399

5,381

4,793

23,377

3,160

100.0 2.8

18.0 2.3

8.7 1.8

27.0 2.4

22.3 3.2

13.1 5.0

10.8 6.1

60.0 3.3

8.5 2.2

5.8 2.4

16.0 3.1

13.4 3.7

7.7 5.4

6.7 6.1

40.0 2.3

9.6 2.3

2.9 1.2

9.1 1.6

8.9 2.7

5.4 4.6

4.1 6.2

88.2 3.0

15.8 2.5

7.5 2.0

23.3 2.5

19.6 3,3

12.0 5.2

10.0 6.3

8.1 1.6

1.4 1.1

0.9 1.2

2.4 1.7

2.0 2.8

0.8 3.2

0.7 4.8

3,3 . . .

0.4 . . .

‘BasedonU.S. BureauoftheCensusestimatesoftheciviliannoninstrtulionalkedpopulationofthe UnhedSfeteaas ofJuiy1, 1963.

Physicians were asked tocheck allof

the applicable payment categories for

this survey item, with theresultthat

multiple payment sources could be

coded for each visit. The patient-paid

category includes thepatient’s

contribution toward “co-payments’’and

“deductibles.”

Expected sourcesof payment were

most often private/commercial insurance

(38.7 percent of visits), Medicare

(22.1 percent of visits), HMO/other

prepaid (19.3 percent), and patient-paid

(15.0 percent). Medicaid was listed aa au

expected source ofpaymentat

10.4percent ofvisits.

Injury-related visits

Injury-relatedoffice visits are

presented in terms of patient’s age, sex,

andraceintable 6.Basedondata

collectedinitem 8ofthePatient Record

form, there were an estimated 84.0

million injury-related office visits in

1993, representing 11.7 percent of all

offic.evisits. Corresponding figures for

1992 were 65.6million and8.6percent

of visits, nxpectively. About half of the

injury visits (51.0 percent) were made

by males, and38.8percent weremade

by persons 2544 years old.

The injury visit rate for males was

not significantly higher than the rate for

females in 1993 (34.6 visits per 100

males compared with 31.5 visits per 100

females), nor were there any diierences

noted between males and females by

age.

Among females, injury visit rates

were not significantly different for

women in the age groups 2544,

45–64, 65–74, and75 years andover.

However, the rates for these groups

were significantly higher than for

females under 15 years and 15–24

years of age. Males inthe age group

25-44 years had an injury visit rate

higher than those aged under 15 years

and 15-24 years. However, the rate

was not statistically difTerent for males

in the 25-44, 45–64, 65–74, and 75

years and over groups.

The injury visit rate for black

persons was 19.1 VMS per 100 persons

in 1993, significantly lower than the rate

of 35.6 injury visits per 100 white

persons. Rates were not significantly

dtierent between white males (36.8 per

100) and white females (34.3 per 100),

or between black males (20.9 per 100)

and black femates (17.5 per 100) (data

not shown).

Patient’s cigarette-smoking

status

Results from the 1993 survey

showed that 67.7 million office visits, or

9.4 percent of he total, were made by

patients who smoke cigarettes. However,

patient’s smoking status wa8 not

reported for 27.0 percent of office visits.

Data on visits according to patient’s

cigarett&smoking status are presented in

tables 7 and 8.

Patient’s principal reason

for visit

Item 10 of the Patient Record form

asks the physician to reccrrd the patient’s

(or patient surrogate’s) “complaint(s),
Advance Data No. 270 ● December7, 1995 5

Table 3. Number and percent distribution of office visits by patient’s referral status, according to prior-visit status: United Statss, 1993

Prtor-vtsifstatus

New tlrdpatfent,

Refenal status

Oldpetlenf,

All visits pstk?nt newpmbiem oldproblem

Number of vlsite in thousands

Allvielfs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717,191 111,922 152,698 452,372

ReferradforthisvlQt . . . . . . . . . . . . . . . . . . . . . . 98,159 37,066 10,063 51,028

Notrefemdforthlsvislt. . . . . . . . . . . . . . . . . . . . 619,022 74,854 142,635 401,344

Percantdfsfrbufion

Allvtsits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0

Referradforthisvblt . . . . . . . . . . . . . . . . . . . . . . 13.7 33.1 6.6 11.3

Notrefenedforthlsvtsit . . . . . . . . . . . . . . . . . . . . 66.3 66.9 83.4 88.7

NOTE Numbers may not add to totals bwause ot rounding.

Table 4. Number and percent distribution of oMce visits by physician spaciaity, according to referral status imd prior-visit status: United

states,1993

Referredfor thisV/Sk Not rafarmdfor this vistt

Nurr&r of

Vidfain New OIdpat&rrt, Oldpatkti Naw Oidpatisrrt, Oldpaflanf,

Physlciarrq)edaffy fhouaand$ Tofaf patlant nawpmblsm okfptilem pafkmf new pmbbm oidpr@Iam

Allvisit s . . . . . . . . . . . . . . . . . . . . . .

General and famllypractloe . . . . . . . . . . .

Intemai medldne . . . . . . . . . . . . . . . . . .

Pediatttce . . . . . . . . . . . . . . . . . . . . . .

Obsfehfcs andgynecobgy . . . . . . . . . . . .

Ophthslmol~ . . . . . . . . . . . . . . . . . . .

Orthopadlc surgery . . . . . . . . . . . . . . . . .

osrmatololJj . . . . . . . . . . . . . . . . . . . . .

General surgery . . . . . . . . . . . . . . . . . .

Psychlatty . . . . . . . . . . . . . . . . . . . . . .

Urology . . . . . . . . . . . . . . . . . . . . . . . .

Otokynfplogy.. . . . . . . . . . . . . . . . . .

Cardlovaeculardlsaases . . . . . . . . . . . . .

Alfargyandimmunologyi . . . . . . . . . . . . .

Neurology . . . . . . . . . . . . . . . . . . . . . .

Putmonarydbeaeaet . . . . . . . . . . . . . . .

Allotherapacbitias . . . . . . . . . . . . . . . .

717,191

197,605

102,436

76,962

64,030

38,373

33,636

31,463

21,703

20,463

15,880

i5,3eo

12,17e

10,605

8,393

4,251

62,991

Pamentdistrbutbn

100.0 5.2 1.4 7.1 10.4 19.9 56.0

100.0 0.9

100.0 2.2

100.0 0.9

100.0 3.0

100.0 5.3

100.0 15.3

100.0 6.1

100.0 16.3

100.0 5.0

100.0 14.6

100.0 16.0

100.0 10.2

100.0 6.7

100.0 28.3

100.0 9.e

100.0 11.5

1.1

2.0

1.0

1.5

1.5

2.6

1.4

3.0

“0.2

1.8

2.1

-1.4

“0.3

2.1

1.1

“0.8

1.9

3.4

1.5

5.9

5.7

16,6

8.5

18.7

15.4

17.4

14.2

16.8

13.6

19.7

9.1

16.8

11.3

7.1

5.1

13.1

12.1

12.1

17.3

9.9

10.7

6.5

17.6

6.4

8.3

7.6

11.2

12.6

30.3

24.9

55.8

15.0

7.6

7.3

12.1

9.1

●0.2

3.4

5.3

4.7

2.8

3.5

6.3

9.7

54.6

60.4

55.7

81.5

67.8

46.2

54.5

42.9

66.6

58.2

44.7

60.4

6s.3

36.2

62.4

46.4

lThaaespacMies waremmpkiseptwataly in19330ntyaspart cfasuppbmardsl datacolbctiinprojad.

symptom(s),or other mason(s)for thi8

vKlt in the patient’s own words.” Up to

three reasonsfor visit are classifiedand

coded from the survey accordingto the

Reasonfor VisitClassificationfor

AmbulatoryCare (WC) (6). The

principalmason for visit is the problem,

eomplain~or reason listed in item 10a.

The RVC is divided into the eight

modules or groups of reasons displayed

in table 9. More than half of all visits

weremade for reasons classifiedas

symptoms(57.7pereent).Respiratory

symptoms accountedfor 11.6pereent of

all visits, and musculoskeletalsymptoms

accountedfor 10.7percent,

The 20 most frequentlymentioned

principalmasonsfor Visit representing

42.2 percent of all visits, are shown in

table 10. Gener81medical examination

w33the most frequentlymentioned

reason for visit (5.3pement of the total),

while cough w33the most frequently

mentionedreason related to illness or

injury (3.4percent).Nineteenof the top

20 reasonsfor officevisks in 1993 were

also listed among the 20 most frequently

mentionedreasonsin 1992, al~lt in

slightly differentorder.It should be

noted that estimatesthat difki in ranked

order may not be significantlydiEerent

from each Other.

T-ts, procedures, and therapies

Statistic8on tests, procedure%and

thempiesscheduledor performedby the

physiei.anduring the officeviAt are

d~played in tables 11-13. The 1993

NAMCS PatientRecord form combined

tests, surgical and nonsurgical

procedures,and therapies(except

eounselingkdueationand medication

therapy)into a single item, with six

checkboxesfor commonlyperformed

services aud space to recod up to eight

additionalservices.Results of the

open-endedpart of the item were coded

accordingto the International
6 Advance Data No. 270. December 7, 1995

7ablo 6. Number and percent of oftlco vialte by patient’a expected ●ourco(a) of paymatrk

United States, 1993

Number of Percent

vfslts In of all

Eipected source(s) ofpayrnent’ thousands Vlslts

Allvlstls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717,191 . . .

Private/cx3mmercial insurance . . . . . . . . . . . . . . . . . 277,596 38.7

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15s,804 22.1

HMO/other prepal& . . . . . . . . . . . . . . . . . . . . . . . 138,3s7 19.3

Patisnlpaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107,623 15.0

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74,712 10.4

Othergovemment .,.....,.. . . . . . . . . . . . . . . 11,946 1.7

Nocharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9,623 1.3

Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25,616 3.6

Unknown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14,0!X 2.0

INumbarsrrwrynot addtotda!dbacause rnorathanoneaxpactad aourceofpaymant rnaybareportad pervtait,

‘HMO Is health maintenance organizatbn.

Table 6. Number, percent dlstrlbution, and annual rate of Injury-related office visits by

pattent’s age, sex, and racw United States, 1993

Number of

Number of vtaltspar

visits In Percent 100 persons

PaUent%~, sax, andrace thousan~ distribution per yawl

Allln]ury-related visits . . . . . . . . . . . . . . . . .

Age

Under 15years . . . . . . . . . . . . . . . . . . . . .

15-24 yeara . . . . . . . . . .. . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . .

45-64years . . . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . . . .

75yearaandover . . . . . . . . . . . . . . . . . . .

Sex and age

Femete . . . . . . . . . . . . . . . . . . . . . . . . .

Under15years . . . . . . . . . . . . . . . . . . .

15-24years . . . . . . . . . . . . . . . . . . . . .

X-44years. . . . . . . . . . . . . . . . . . . . .

45-64years . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . .

Mate . . . . . . . . . . . . . . . . . . . . . . . . . . .

Under15years . . . . . . . . . . . . . . . . . . .

16-24yeara . . . . . . . . . . . . . . . . . . . . .

25-44years . . . . . . . . . . . . . . . . . . . . .

45-64yeara . . . . . . . . . . . . . . . . . . . . .

65-74years . . . . . . . . . . . . . . . . . . . . .

75yearsandover . . . . . . . . . . . . . . . . .

Race

White . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . .

Asianpaclfic islander . . . . . . . . . . . . . . . . .

~edcanlndlmEsMm/AleM. . . . . . . . . . . .

83,980 100.0

11,018 13.1

8,489 10.1

32,552 3S.8

18,148 21.6

7,297 8.7

6,476 7.7

41,156 49.0

4,798 5.7

3,667 4.4

14,979 17.8

8,982 10.7

4,078 4.9

4,653 5.5

42,824 51.0

6,220 7.4

4,822 5.7

17,573 20.9

8,166 10.9

3,219 3.8

1,623 2.2

75,140 89.5

6,102 7.3

2,299 2.7

“439 ‘0.5

33.0

19.2

24.7

39.9

36.5

39.2

51.2

31.5

17.2

21.3

36.2

34.8

39.8

59.0

34.6

21.2

26.2

43.7

38.3

38.5

38.2

35.6

19.1

.-.

. . .

lBasedon U.S. Bureau dthe Cemus Mmt~ofthe civilian nonin3titionatized popubtionof the United States as of

Julyl, 19s3.

Classi$cation of Diseases, 9th revision, wouldresultin greater specificity of

Clinical Modi$catioq Volume3, responses, thereby clarifying the large

Procedures Classijicatiotz (ICD-9-CM) numberofservices generally recorded in

(7). It was hoped that allowing the ’’other’’checkbox categoryin

physicians to record services in this way previous versions of thesumey. Data are

shown separately forthecheckbox items

(part a of item 14) and the open-en&d

response categories (partb)inlkeeping

with the format used on the Patient

Record form.

Slightly less than three-quarters

(73.0pereent) ofall officevisit3

includedoneor more tests, procedures

or therapies (excluding counseling/

education and medication therapy that

are collected in separate data items)

(table 11). Blood pressure check was the

most tkquently mentioned checkbox

category, recorded at half (49.8 percent)

of the visits. Blood pressure checks

were ordered or provided at a

significantly higher proportion of visits

by females (54.3 percent) than at visits

by males (43.1 percent).

Other frequently mentioned services

were “other’’bloodtest (16.Opercentof

visits) and urinalysis (13.5 percent). HIV

serology was ordered orpmvidedat

0.3 percent of office vi8its.

The top 25 diagnostic and

therapeutic services (other than those

reported in the checkbox categories on

the Patient Record form) are shown in

table 12. Pap smear, electrocardiogram,

eye examinations, and routine chest x

rays were among the most frequently

mentioned procedures. Table 13 presents

data on additional procedures that while

not among the top 25, were also of

interest.

Physician’s principal diagnosis

Item 11 of the Patient Record form

asks the physician to record the

principal diagnosis or problem

associated with the patient’s most

important mason for the current visit as

well as any other significant current

diagnoses. Up to three diagnoses are

coded and claasitied according to the

ICD–9-CM (7). Displayed in table 14

are office visits by principal diagnosis

using the major dlsea,se categories

specified by the ICD–9-CM. The

supplementary classification, used for

diagnoses that are not classifiable to

injury or illness (for example, general

medical examination, routine prenatal

examination, and health supervision of

an infant or child), accounted for

15.6 percent of all office visits. Diseases

of the respiratory system (13.8 percent)

and diseases of the nervous system and
Advance Data No. 270. December7, 1995 7

Table 7. Number and parcant dldrlbutfon of office visits made by patients who smoke

clgarattes by patient’s age, sexj and mew United Statea, 1993

Nunimr of

vfsik h Percent

Patient’s age, sex, and race thousands dIstrfbutfon

All VLMSby patients who smoke dgereftes. . . . . . . . . 67,720 100.0

Age

Under 15yesrs . . . . . . . . . . . . . . . . . . . . . . . . . . “117 “0.2

VS-24years.. . . . . . . . . . . . . . . . . . . . . . . . . . . 6,121 9.0

25-44 year3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27,692 40.9

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22,541 33.3

S5-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,357 12.3

75yeersand over . . . . . . . . . . . . . . . . . . . . . . . . 2,831 4.3

38X

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38,928 59.0

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27,792 47.0

Race

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59,262 87.5

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,369 9.4

Asian/Pactilclslander . . . . . . . . . . . . . . . . . . . . . . 1,488 2.2

Amerbanlndlen/Eskhno/Aleut.... . . . . . . . . . . . . . “551 “0.8

sense organs (10.8 percent) were also

prominent onthe list.

The 20mostfrequently reported

principaldiagnosm for1993areshown

intable15.These arecategorizedat the

threedigitcodiiglevel oftheICD–9–

CM,andaccmmted for35.5percentof

allofficevisMmade duringtheyear.

The most frequent diagnosis rendered by

physicians at office visits in 1993 was

essential hypertension, occurring at

3.9 percent of all visifs. Essential

hypertension has been the most

frequently reported morbidity-related

diagnosis in every survey year since the

NAMCS began in 1973. (Morbidityrelated dmgnoses are those classifiable

to illness or injury. NonmorbIdity related

diagnoses include routine prenatal

examination, health supervision of an

infantor child and general medical

examination, among others.) Of the 20

diagnoses shown in table 15, 18 also

appeared on the li3t of the 20 most

frequent diagnoses for 1992.

Physician’s cheoldist of msdical

conditions

In addition to the diagnostic data

reported in item 11 of the Patient

Record form, selected information on

the patient’s current health status was

collected in item 13. Physicians wem

given a list of common conditions and

asked to record whether the patient now

has any of them, regardless of what was

recorded as the cument diagnosis in item

11. The list of conditions was modtied

for the 1993 NAMCS and will be

expanded in the 1995 NAMCS. Results

from item 13 are shown in table 16.

Slightly less than one-fifth

(18.9 percent) of the visits were made

by patients who wem reported to have

one or more of the five conditions listed

on the survey form. Obes@ was

checked at 8.7 percent of the total, or

62.7 milIion office visits. Diabetes

(5.6 percent), asthma (4.9 percent), and

osteoporosis (2.5 percent) were all

recorded at a greater proportion of visits

in this item than as a diagnosis in item

Table 8. Number and parcsnt disfributfon of oftlca visits by physician specialty, according to patient’s cigaretta-amofdng status:

United States, 1993

Nuniw of Does pathmf smoke dgeretles?

Visfts in

Phya/dan q?edeh’y thousands Totaf Yes No Urrknownq

Percent dlstrbutbn

Allvieits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Genarel end ferrdlypractk e....... . . . . . . . . . . .

Internal medidne . . . . . . . . . . . . . . . . . . . ...’...

Pedietrks. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obsletrfoe endgynecobgy . . . . . . . . . . . . . . . . . . .

Ophthelmolq . . . . . . . . . . . . . . . . . . . . . . . . . .

Orthopedic surgery . . . . . . . . . . . . . . . . . . . . . . . .

Dermetobgy . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generelsurgery . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Urobgy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otokuyrrgology. . . . . . . . . . . . . ...<. . . . . . . . .

Csrdlovascu!ar diseeess . . . . . . . . . . . . . . . . . . . .

Allsrgy andimmunolo@ . . . . . . . . . . . . . . . . . . . .

Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pulmonary dtseeaes2 . . . . . . . . . . . . . . . . . . . . . .

Allotherspaoleltbs . . . . . . . . . . . . . . . . . . . . . . .

717,191

197,605

102,436

76,962

64,030

33,373

33,636

31,469

21,703

20,469

15,680

15,380

12,178

10,605

6,383

4,251

62,991

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

9.4

10.4

13.6

“0.6

10.7

3.4

11.7

4.7

11.7

19.3

9.4

8.3

9.1

4.6

10.8

12.7

11.3

63.5

61.2

70.9

84.1

65.3

40.5

40.0

41.2

51.3

60.1

48.3

71.9

66.3

73.5

59.6

69.1

62.7

27.0

28.5

15.3

5.3

24.7

56.1

43.4

54.1

36.9

20.5

42.4

19.8

24.6

22.0

28.6

18.3

26.0

%dudea entries01“unknown”and b!ank entries.

%heae spda!lias ware sampled sapwataly in 1863 on~ as parl of a suppbrrwrrtd data collactiin projed
8 Advance Data No. 270. December 7, 1995

Table 9. Number and percent diatributfon of offfce visits by patient’s principal reason for visit United States, 1993

Number of

viaii%h Percent

f%lnc@alreason for visit and RVC Codeq thoueands dlsfrfbuflon

Allvisfts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717,191 100.0

symplom module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..sooI~999

Generaf symploma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..sooI%099

Syrr@ome referable topsychologlceVmentef dkordere. . . . . . . . . . . . . . . . S100-S199

~~tomrefetile tothenewous system (excluding senworgms) . . . . . . . S200-S259

SyMptOMS referable to the cardioveeculevlymphatic system. ., . . . . . . . . . . S260-S299

Symptoma referable totheeyesandears. . . . . . . . . . . . . . . . . . . . . . . . S300-S399

symptoms refersble to the respiratory system . . . . . . . . . . . . . . . . . . . . . S400-S499

SyMptoms referebleto thedlgestivesystem . . . . . . . . . . . . . . . . . . . . . . S50W639

Syn@oms referable tothegenitourinety ayetem. . . . . . . . . . . . . . . . . . . . S640-S829

syrnptoma referable tothesfdn, hafr, endnails . . . . . . . . . . . . . . . . . . . . . S830-S899

symptome referable tothemusculoskeletef syafem. . . . . . . . . . . . . . . . . . S900-S999

Diseeae modufe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. DooI-D999

Dlagnoatlc/screening andprevantive module. . . . . . . . . . . . . . . . . X1OO-X599

Treatment module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. TIoo-T899

Injurlas andadversa effecte module . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Jo01A999

Teslresulte module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. RIoo-R700

Adminlstraffve module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. AIcwA140

Othe~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. U990-U999

414,163

46,990

22,266

22,556

3,748

51,514

63,4s2

32,454

31,370

43,130

76,664

83,981

115,728

67,537

23,248

9,141

7,93S

15,455

57.7

6.6

3.1

3.1

0.5

7.2

11.6

4.5

4.4

6.0

10.7

8.9

16.1

9.4

3.2

1.3

1.1

2.2

~Basedon,4 Reason for VW C/assificefbn for Afrbu/ab’y Care (WC) (6).

%wludesproblem and somplamts not ekewhere olaesified, entries of “none,” b!anks, and illegible entnes.

Table 10. Number and percent distribution of office visits by the 20 principal reasons for visit most frequently mentioned by patients,

according topatient’saex: United States, 1993

Number of Pat/errt’s aax

vlelfs In

Princ@ai reason for vlstt and RVG code~ thouaan& Total Female Male

Percent dietrbution

Atlvkite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717,191 100.0 100.0 100.0

General medicef examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .X1OO

Routine prenatal exeminaflon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .x205

Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S440

Prograaa vieft, nototherwke specified. . . . . . . . . . . . . . . . . . . . . . . . . T800

Postoperative visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. T205

Symptomaraferebletothroat...... . . . . . . . . . . . . . . . . . . . . . . ..s455

Earacheorearinfectlon .,... . . . . . . . . . . . . . . . . . . . . . . . . . . ..s355

Wellbabyexaminatbn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..XI05

Stomachpain,cramps,endspasms . . . . . . . . . . . . . . . . . . . . . . . . ..S545

Backsymptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S805

Vlslondysfuncflons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..s305

Sklnraah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S660

Headacha,pafn lnhead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S210

Headcold, upperraeplratory infection (coryza) . . . . . . . . . . . . . . . . . . . S445

Fever, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..so1o

Naeelcongestlon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..s400

Chaetpalnandretetadsympfoms. . . . . . . . . . . . . . . . . . . . . . . . . ..s050

Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..D510

Kneeaymptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S925

Dapresslon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..S110

Allotherreeaons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38,185

25,S93

24,842

20,836

18,129

17,283

16,130

14,023

13,027

12,78S

12,416

12,138

10,736

10,160

10,006

9,872

9,535

9,503

S,824

8,758

414,347

5.3

3.8

3.4

2.9

2.5

2.4

2.2

2.0

1.8

1.8

1.7

1.7

1.5

1.4

1.4

1.4

1.3

1.3

1.2

1.2

57.8

5.7

6.0

2.9

2.5

2.4

2.5

2.0

i .7

2.0

1.5

1.9

1.5

1.8

1.3

1.2

1.3

1.2

1.2

1.1

1.3

57.0

4.7

. . .

4.3

3.6

2.7

2.3

2.8

2.3

1.6

2.2

1.4

1.9

1.0

1.5

1.7

1.5

1.5

1.5

1.5

1.0

59.2

lBasedon AH=sonfor Msil C/ass#imtbn forAtiu/afoy Care (RVC) (6).

11. It should be noted that in item 11, item 13thanby itemllmayindieate medlcationsordere~ supplied, or

physicians are instructed to reeord up to thatchronic conditions are administeredatthe visit,including

two additional diagnoses, if any (in underreported in item 11. prescription andnonprescription

addition to the principal diagnosis),

Medication therapy

preparations, immunization and

whetherornotthey areofdirect desensitizing agents, andanesthetics. As

concern tothecumentvisit. l“hefact In item 16, physicians were used inthe NAMCS,theterm “drug”is

that higher estimates were producedby instructedtorecordall neworeontinued interchangeable withthetenn
Advance Data No. 270. December 7.1995

Table 11. Number and percent distribution of office visits by tests, surgical and nonsurgical procedures, and therapies ordered or

provided, according to patient’s sex: United Statea, 1993

Number of Patient’s sex

visits in

WJt characteristic fhoussnds Total Female Male

Percent dlsfrbutlon

Allvfafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Number of aervlces ordered or provided

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6ormore . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

717,191

191 ,s91

265,463

154,344

64,331

25,400

<0,956

4,787

100.0

26.8

37.0

21.5

9.0

3.5

1.5

0.7

100.0

;4.0

36.4

22.7

10.1

4.2

1.8

0.8

Percent of Waits

100.0

30.9

37.9

19.8

7.2

2.6

1.1

0.4

Sefecfed semrices2

Blood presstrre . . . . . . . . . . . . . . . . . . . . . . . . . . 357,065 49.8 54.3 43.1

Urfnafysls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96,674 13.5 15.8 10.0

spirometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,577 0.6 0.6 0.7

Afferyytesting . . . . . . . . . . . . . . . . . . . . . . . . . . 2,140 0.3 0.3

HlVserobgy3 . . . . . . . . . . . . . . . . . . . . . . . . . .

0.3

1,825 0.3 0.3 “0.2

O!herbksodteef . . . . . . . . . . . . . . . . . . . . . . . . . 114,904 16.0 16.5 15.3

‘Includeaihesix checkboxcategorias forselsotsdservhs anduptoeightothar sarvkesrecordsd ~thephysiciinin ihespscas~ovidsd onfhePatiantRemrd form.llm.saindude kssfs,

imaging%, surgarks and other procedures, andtherap’es with fheexmpfion c4aducatiin/counesling and medicafiin.

%dumbers may not add to totals because rn-ora than one service maybe reported per visit.

%IIV is human irnmuncdeficierwy virus.

Tabie 12. Number and percent of office visits by the 25 write-in diagnostic and therapeutic

procedures most often ordered or performed: United States, 1993

Number of Percent

Diagnostic and therapeutic procedures vials in of all

ofdered orperfonrred and ICD-9-CM Codef thousands Visns

Allvisits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13,881

Papsrnear . . . . . . . . . . . . . . . . . . . . . . . . . . ...91.46

Elecfrocardlogrsm . . . . . . . . . . . . . . . . . . . . . . . .. W.52

other nOnOp8rStiVe measurements and examlnatkms . . . 89.39

Eye examination, not otherwise specitfed . . . . . . . . . . 95.o9

Rouline chest bray . . . . . . . . . . . . . . . . . . . . . ...67.44

Other local exdsion or destruction of Iesfon or tissue of

skkrand suboufaneous tissue... . . . . . . . . . . . . ...86.3

Mlcrossopic examination of specimen from ear, nose,

throat, andlarynx-cuflure . . . . . . . . . . . . . . . . . . . 30.32

Other Individual psychotherapy . . . . . . . . . . . . . . . . . 94.39

Tonometry . . . . . . . . . . . . . . . . . . . . . . . . . . . ...89.11

Llmttedeye exarninatlon . . . . . . . . . . . . . . . . . . . ..95.oI

Other mammography. . . . . . . . . . . . . . . . . . . . ...87.37

Other phydcaltherepy . . . . . . . . . . . . . . . . . . . ...93.39

General phydoaiexamhsatlon.. . . . . . . . . . . . . . . ...69.7

Gynecological WSISSinatiOn . . . . . . . . . . . . . . . . . . . 89.26

Other dlegnosflc ultrasound . . . . . . . . . . . . . . . . . . . 88.79

Audiometry . . . . . . . . . . . . . . . . . . . . . . . . . . ...95.41

Diagnostic utlreeound of gravid uterus . . . . . . . . . . . . 86.78

Skeletal xrayofwttefand hand . . . . . . . . . . . . . . . . 88.23

Skeletal x ray of thigh, knee, and lower leg . . . . . . . . . 68.27

Skeletal xrayofankfeandfoot . . . . . . . . . . . . . . . . 88.28

Removal of other therapeutic device . . . . . . . . . . . . . 97.89

Fundusphotography . . . . . . . . . . . . . . . . . . . . ...95.11

Manual examination of breasl . . . . . . . . . . . . . . . . . 63.36

Fetal monitoring, not otherwise specified . . . . . . . . . . . 75.34

Xray, other andunepecifled . . . . . . . . . . . . . . . . . . 88.39

lBased on the hbmationd C/assWcatiofrof Dksases, 9fh RevL$brr,C/inks/ Mcdifiiatbn (ICD-3-CM) (7).

12,392

11,570

10,267

9,659

9,363

7,313

6,562

5,6SJJ

4,506

4~f8

4,198

4,149

3,976

3,881

3,355

3,331

2,964

2,943

2,873

717,191

19,613

18,539

18,268

17,179

14,015

. . .

2.7

2.6

2,5

2.4

2.0

1.9

1.7

1.6

1.4

1.3

1.3

1.0

1.0

0.8

0.6

0.6

0.6

0.6

0.6

0.5

0.5

0.5

0.4

0.4

0.4

“rnedkation,” and the term

“prescribing” is used broadly to mean

ordering or providing any medkation,

whether prescription or over-the-counter.

Visits with one or more drug mentions

are termed “drug visits” in the

NAMCS. Up to five medications, or

drug mentions, were coded per drug

visit.

The NAMCS drug data base

permits classification by a wide range of

variables, including speeific product

name, generic class, entry form chosen

by the physician (that is, brand name,

generic name, or the desinxl thera~utic

effect), pre,seription status (that is,

whether the product is prescription or

nonprescription), fedemlly controlled

substance status, composition status (that

is, single or multiple ingredient

product), and therapeutic category. A

report describing the method and

insbnunents used to colleet and process

drug infotition for the NAMCS is

available (8).

Data on mediation therapy are

shown in tables 17-21 and figure 2.

Medkation therapy was the most

commonly mentioned therapeutic service
10 Advance Data No. 270. December 7, 1995

Table 13. Number and percent of office visits by selected diagnostic and therapeutic

procedures: United States, 1993

Number of Percent

Selected prucadures and viaifs in of all

ICD-9-CM codei thousands wt.?!

All visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717,191 . . .

Ophthalmoscopy . . . . . . . . . . . . . . . . . . . . . . . ...16.21

Other endoscapy ofsmalllnlestine . . . . . . . . . . 45.13

Colonosmpy, . . . . . . . . . . . . . . . . . . . . . . . . ...45.23

Flexible slgmoldoecopy . . . . . . . . . . . . . . . . . . ...45.24

Othercystoscopy . . . . . . . . . . . . . . . . . . . . . . ...57.32

Clozsdblopsyof uterus . . . . . . . . . . . . . . . . . . ...68.16

Vaglnoscopy . . . . . . . . . . . . . . . . . . . . . . . . . ...70.21

Injecffon of therapeuflc substance into joint or

ligament . . . . . . . . . . . . . . . . . . . . . . . . . . . ...81.92

Othsr Inclslon with drainage of skin and subcutaneous

tkSUe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...86.04

Biopayof sldnand subcutaneous tksue . . . . . . . . . . 86.11

Appllcatlonofothercast . . . . . . . . . . . . . . . . . . ...93.53

Applicatlonofsplint . . . . . . . . . . . . . . . . . . . . . ...93.54

Irrfgatlonofear . . . . . . . . . . . . . . . . . . . . . . . . ..96.52

1,690

1,709

955

1,446

1,730

1,259

1,057

1,368

1,340

2,687

1,323

1,514

2,745

0.2

0.2

0.1

0.2

0.2

0.2

0.1

0.2

0.2

0.4

0.2

0.2

0.4

lBasedon the/nfemsfiona/ C/asiftitbn of Di*ases, 9th Revisbn, Cflnimf Mdifmatbn (lC&WM) (~.

Table 14. Number and percent distribution of office visits by physician’s principai

diagnosis: United States, 1993

Number of

Prlncpal dlagnosls and visits In Percent

ICD-5LCM codei thouaarr& diatdbufIon

Allvklts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

lnfectlousandparaslllc dfeeaaea. . . . . . . . . . . . . . 001-138

Neoplasm. . . . . . . . . . . . . . . . . . . . . . . . ...140-239

Endocttne, nutrklonal andmetabolicdkeases and

Immunltydlaordera . . . . . . . . . . . . . . . . . . ...240-279

Mentaldkorders. . . . . . . . . . . . . . . . . . . . . ...290-319

Diseasesotthe newous syatemandsensa

organs . . . . . . . . . . . . . . . . . . . . . . . . . . ...320-389

Dlseasssofthecirculatorysystem . . . . . . . . . . . 390-459

Dkeaaeeoftherespirsfory system . . . . . . . . . . . . 460-519

Dkeasesofthedigestive system . . . . . . . . . . 520-579

Diseases of thegenttourinary system . . . . . . . . . . . 580-829

Dkeases of the skin and subcutaneous

tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . ...680-709

Dkeases of the musculoskeletal system and

connectivetksue . . . . . . . . . . . . . . . . . . . ...710-739

symptoms, signs, andill-defined conditions . . . . 780-799

Injuryandpoiscming . . . . . . . . . . . . . . . . . . . ..800–999

Supplementary classification . . . . . . . . . . . . . . VOI-V82

Allotherdiagnosesz . . . . . . . . . . . . . . . . . . . . . . . . . .

Unknown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

717,191

21,828

21,878

25,428

33,613

77,737

57,584

99,114

27,851

41,281

51,910

32,503

46,161

112,087

8,554

17,112

100.0

3.0

3.1

3.5

4.7

10.8

8.0

13.8

3.9

5.8

6.0

7.2

4.5

6.4

15.6

1.2

2.4

lBasedon the/ntemafiona/ C/&ifhatbn of Diseases, 9fh Revisbn, C/inim/MMifkatbn (lC~M) (~.

21ncludm dis=ses of the blood and blod-forfing organs (28&289) mmplicatkms ofpregnancy, childbirth, andthepuerperrum

(630-67S); congenital anomalies (740-759); and oertain conditions originating m ttw perinatsl period (780-779).

31ncludes bknkdisgnoses, unmdable diagnoses, and illegible diagnoses,

in 1993, reported at467.3 million office

visits or 65.2 percent of the totat

(table17).

Therewere913.5miUion drug

mentionsatvisits toofiiee-based

physiciansduting 1993.This yieldsan

average ofl.3 drug mentions per oftice

visi40r2.Odmg mentions per drug visit.

Data on numberof drug visits and

drug mentions byphysician specialty are

shown intable 18. Nine ofevery 10

visits to allergists and immunologists

included atleastonedmg mention, as

did80fevery10 visits to internists.

Drug mentions are displayed by

therapeutic class in figure2 and table 19.

This classification is based on the

therapeutic categories used in the

National Drug Code Directory, 1985

edition (NDC) (9). It should be noted

thatsome chugs have more than one

therapeutic application. In these cases,

the drug was listed under the NDC

classification that occurred with the

greatest frequency.

Cardiovascular-renal drugs

(14.0 percent), antimicrobial agents

(13.9 percent), and drugs used for pain

relief (11.0 pereent) were listed most

frequently.. About onethird (31.6

pereent) of all mentions of antimicrobial

agents wem at visits made by persons

unkr 15 years, and about two-thirds

(69.4 percent) of the mentions of

immunologic agents were at visits by

this age group. Four of every 10

necrologic drug mentions (41.1 percent)

occurred at visits by persons 2544

y-s.

The 20 most frequently used

generic substances for 1993 are shown

in table 20. Drug products containing

more than one ingredient (combination

products) are included in the data for

each ingredient. For example,

acetaminophen with codeine is included

in both the count for amtaminophen and

the count for codeine. Amoxicillin was

the generic ingredient most frequently

used in drugs ordered or provided by

the physician at office visits in 1993 (as

well as in 1990-92), occurring in 3.9

percent of drug mentions.

Table 21 presents the 20

medications most ti’equently mentioned

by physicians in the NAMCS, aceordmg

to the enuy name of drug. Entry name

refers to the actual designation used by

the physician on the Patient Record

form and may be a trade name, generic

name, or simply a desired therapeutic

effect. Amoxicillin was the medication

most frequently reported by physicians,

with 19.2 million mentions (2.1 percent

of the total). It was followed by ~lenol,

Premarin, Lasix, Amoxil, and

Prednisone, each amounting for

1.2 percent of the total. All of these

were among the top 10 drug entry

names mentioned in 1992.

Counseling and education

Data on counseling and education

services ordered or provided at

physicians’ office visits were collected
Advance Data No. 270. December 7, 1995 11

Tabl@ 15. Number and porcant distribution of office visite by the 20 principal diagnoaoc most fraquontiy randared by physician,

aocording to patfant’a smc United Statec, 1993

Number of Patient’ssex

vialtsin

Prlncpal diagnoslaand ICD-9-CM Codei thrxLsan& Total Female Male

Percent dbtrbufton

AflvIslts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ibo.o 100.0 100.0

3.9

. . .

3.7

3.0

3.2

2.8

2.0

1.3

1.5

1.5

1.3

1.3

1.3

1.3

1.0

0.9

0.3

1.2

0.9

0.8

66.6

Eeaerrtlal hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Normalpregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Suppuratfveandunspedtbd otifiemedla . . . . . . . . . . . . . . . . . . . . . . . .

Generafmsdbstexamlnatfon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Healfheupsrvbfonofinfantorc held..... . . . . . . . . . . . . . . . . . . . . . .

Acute upparrespiratoryhrfectbnsof mulllpteor unspedfbd sites . . . . . . . .

Diabeteemellltus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chronlcslrrusftb. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bronchitis,notspedfbd asacuteorchronlo . . . . . . . . . . . . . . . . . . . . . .

Altergicrtdnltls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Acutepharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dlseaaeeofssbaceousglands.. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neuroticdleorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otherpoatsurgbafstates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Aftecthfepsychosss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3psctallnvestigatlonsertdexsmlrrstions. . . . . . . . . . . . . . . . . . . . . . . .

Contaddarmatltlsendothereczeme . . . . . . . . . . . . . . . . . . . . . . . . . .

Oefsoarthrwbendailbddisordara . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allotherdiagnosss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

401

V22

26,124

26,4S8

19,309

19,066

18,50S

17,557

12,997

11,594

17,%0

10,093

9,637

9,576

9,193

8,532

7,ss0

7,351

7,111

6,919

6,890

6,739

462,287

3.9

3.7

2.7

2.7

2.6

2.4

1.8

1.6

1.6

1.4

1.3

1.3

1.3

1.2

1.1

1.0

1.0

1.0

1.0

0.9

64.5

3.9

6.2

2.0

2.4

2.2

2.2

1.7

1.8

1.6

1.3

1.4

1.3

1.3

1.1

1.2

1.1

1.5

0.8

1.0

1.0

63.0

382

V70

V20

465

250

473

433

430

477

462

706

300

V45

236

V72

692

715

366

. . .

%asedonthelntematicml C/mifmtionofDisasses, 9thRevi$br, Ciisioal hfodifik4vr(lCD-3-CM) (7).

Tabie16.Number and percantofoffice vlsitsbyselected medical conditions, according topatient’s ageandsex:United Statea,1993

Patient’s age Patferrf’ssav

All ages, Under 15-24 25-44 45-64 65-74 75 years

Madksf condftfon’ bothS8X8S 15yests years yews years years and over Female Mafe

Nurnberofvtdtaln thousands

193,914 160,146

16,S96 23,50s

4,632 14,366

6,946 7,214

*593 2,3SS

933 ●21 2

164,9s6 120,028

Percent of Wefts

. . . . . .

6.7 14.7

2.4 9.0

4.6 4.5

“0.2 1.5

0.5 “0.1

85.1 74.9

Allvfsfts . . . . . . . . . . . . . . . . . . . . . . . 33,873 77,633

Obaany. . . . . . . . . . . . . . . . . . . . . .

Diabetes . . . . . . . . . . . . . . . . . . . . . . .

Asthma . . . . . . . . . . . . . . . . . . . . . . .

Osteoporosla. . . . . . . . . . . . . . . . . . . .

Hl~ . . . . . . . . . . . . . . . . . . . . . . . . .

Noneofthesbove . . . . . . . . . . . . . . . .

717,191 129,279 62,346

3,580

“765

2,771

●6

“120

55,416

. . .

5.7

“1.2

4.4

“0.0

“0.2

6s.9

430,170

43,171

22,382

20,634

15,043

“503

267,021

19,536

17,366

14,520

2,703

S40

23s,407

. . .

6.8

6.1

5.1

0.3

0.3

63.1

62,707

40,35s

35,154

17,752

1,343

561,632

2,2s6

“223

9,098

*262

11,145

12,496

4,258

5,331

73

67,012

5,231

7,610

2,665

8,766

. ..

117,672

.. .

56gm3

Allvtslts . . . . . . . . . . . . . . . . . . . . . . .

Obsslfy. . . . . . . . . . . . . . . . . . . . . . .

Diabetes . . . . . . . . . . . . . . . . . . . . . . .

Asthma . . . . . . . . . . . . . . . . . . . . . . .

Osteoporosis . . . . . . . . . . . . . . . . . . . .

Hl~ . . . . . . . . . . . . . . . . . . . . . . . . .

Noneoftheabove . . . . . . . . . . . . . . . .

. . . . . . .. . . . .

10.0

5.3

4.8

3.5

“0.1

79.8

6.7

5.6

4.9

2.5

0.2

61.1

1.6

“0.2

7.0

*0.2

11.e

13.3

4.5

6.3

“0.1

71.4

6.8

10.1

3.7

11.3

.. .

91.0

. . .

72.8

‘Numbers may not add to totals because more than one condtiin rmaybe reported per visit

%IIV is human immuncdeficiencyvirus.

initem 15 of the Patient Record form. (9.0 percent), weight reduction notincludedin oneofthenine

Asshownintable 2Zeounselingand (5,7 percent), and growth/development checkbox categories.

education services wererecordedat (4.2percent) werementioned most ‘llecounselingand education

abouthalf(48.5pereent) ofalIoffiee frequently. One-third ofvisits (34.2 eategoriee ofinjury prevention, HIV

visits during 1993. Exereise percent) included “other” counseling transmission, and other STD
12 Advance Data No. 270. December 7.1995

Table 17. Number and percent distribution of office visits by medication therapy and number of medications provided or prescribed,

according to patient’s sex: United States, 1993

Number of Patient’s sax

vkits In

W/t chamcterktlc thousends Total FemsJe Male

Percent distrhdfon

Medlcaflon therspyi

Aflvkdts.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717,191 100.0 100.0 100.0

Dmgvlslts2 . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Vfdts without mention of medication . . . . . . . . . . . . .

467,301

249,890

85.2

34.8

65.0

35.0

65.5

34.5

Number of medications

provided or prescribed by physlclarr

Allvisifs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717,191 100.0 100.0 100.0

249,890

226,541

124,624

56,803

28,328

28,984

34.8

31.6

~7.4

7.9

4.1

4.2

35.0

30.6

17.4

7.9

4.5

4.4

34.5

32.8

17.4

7.9

3.5

3.9

‘Indudee preswiptkm drugs, over-lhe-oxmter preparations, imrrunizing agents, and desensitizing agents.

%lts at which one or mom drugs were provided or prescribed by the physiciin.

Table 18. Number and percent distribution of drug visits and drug mentions by physician spaclal~. United States, 1993

Number of Nurr@erof Percent

dmg VISIW Percent dmg merrtfons Percent of dtug

Physlclan qeclaHy in thousendsl dfstrfbutlon In thousands dlefrfbutfon Vlaw

Alispedallles . . . . . . . . . . . . . . . . . . . . . . . . . . 467,301 100.0 913,503 100.0 65.2

Generaf and family practice, .,....,. . . . . . . . . .

Internal medicine..........,.. . . . . . . . . . . .

Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obetetrtcs. endgynecofogy . . . . . . . . . . . . . . . . . .

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmology. . . . . . . . . . . . . . . . . . . . . . . . . .

psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Orthopedlcsurgery . . . . . . . . . . . . . . . . . . . . . . .

Allergyandimmunology3 . . . . . . . . . . . . . . . . . . . .

Cerd[ovasculardlseases . . . . . . . . . . . . . . . . . . . .

Otola~ngology . . . . . . . . . . . . . . . . . . . . . . . . . .

Generafsurgery . . . . . . . . . . . . . . . . . . . . . . . . .

Urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pulmonarydlseases3 . . . . . . . . . . . . . . . . . . . . . .

Allotherspeciaftfes . . . . . . . . . . . . . . . . . . . . . . .

147,257

81,874

64,773

28,736

21,255

19,230

15,161

11,783

9,861

8,614

7,949

7,189

6,350

4,953

3,312

38,006

31.5

17.5

11.7

6.4

4.5

4.1

3.2

2.5

2.1

1.6

1.7

1.5

1,4

1.1

0.7

6.1

296,201

187,379

88,594

44,818

36,635

33,686

30,379

17,656

20,738

24,800

12#345

12$08

8,611

9,356

9,743

76,054

32.4

20.5

9.6

4.9

4.2

3.7

3.3

1.9

2.3

2.7

1.4

1.4

0.9

1.0

1.1

8.3

74.5

79.9

71.2

46.4

67.5

48.8

74.7

35.0

93.0

70.7

51.7

33.1

40.5

59.0

77.9

60.3

lVisits at which one or more drugs were provided or prescribed by the physician.

2Number ofdrugvMsd Midedbyn umberofo fficev!sttsrm uitlplied by 100.

%hese speoiatties were ssmpled separately in 1993 on~ as pati of a aupplemeniai data mlhmiion projecl.

Wtnsmissionwem addedtothe1993

Patient Record form. Such services were

orderedorprovided at2.6percentj

1.3percent, and 1.4percent of visits,

respectively.

Disposition of visit

Two-thirds of ofice visits

(66.7 percent) included a scheduled

f’ollowup visitor telephone call in1993.

One-quarter (23.3 percent) ofoffice

visits included instructions to returnif

needed.Lessthan lpercentofvisits

resulted in a hospital admission.

Table 23 displays data on disposition of

office visits.

Duration of visit

Data on the duration of office visits

is presented in table 24. Duration of

visit refers m the amount of time spent

in face-to-face contact between the

physician and the patient. This time is

estimated and recorded by tk physician

and does not include time spent waiting

to see the physician, time spent

receiving care from someone other than

the physician without the presence of

the physician, or time spent by the

physician in reviewing patient records
Advance Data No. 270. December7, 1995 13

Table 19. Number and percent distribution of drug mentions by patient’s age, according to therapeutic classification: United States, 1993

Patient’s age

Number of

dmg mentions Under 15 15=24 25-44 45-64 65-74

7tretapeuf\c ofaseelficetkmq

75 years

in ftrouewrds Total years years yeare yeara years and over

Alldrug rnardions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cardiovaaculsr-rsnsl drugs . . . . . . . . . . . . . . . . . . . . . . . . .

Antlmlcroblal agente . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Drugs used forreliefofpaln . . . . . . . . . . . . . . . . . . . . . . . .

Reef)lratorytracfdrugs . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Horrrwnesendagenfssffeoflnghonnonal mechanisms . . . . . . . .

Peychophartnecobgiodrugs . . . . . . . . . . . . . . . . . . . . . . . .

Skin/mucousmerWane. . . . . . . . . . . . . . . . . . . . . . . . . . .

Metebolicsndnufrfentagenta . . . . . . . . . . . . . . . . . . . . . . .

Immunologicagenfe . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gaatrointestinalagents . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmicdruge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NeurologIcdruge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hernstoiogfcagente . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otherand unckrseMe& . . . . . . . . . . . . . . . . . . . . . . . . . . .

913,503

127,549

127,130

100,838

87,751

S5,421

62,532

54,551

43,427

39,732

38,658

31,320

20,418

16,219

77,777

Percantdiefribtrfion

100.0 15.1 6.7 22.8

100.0 “0.7 “0.7 7.7

100.0 31.6 10.6 25.7

100.0 9.0 52 28.9

100.0 26.3 8.7 26.6

100.0 4.2 5.2 21.3

100.0 5.6 4.9 33.1

100.0 14.5 16.5 23.7

100.0 8.3 11.2 25.8

100.0 69.4 2.3 6.2

100.0 4.3 4.3 23.5

100.0 8.9 “3.6 13.9

100.0 “3.5 “5.0 41.1

100.0 “3.2 . 12.2 16.6

100.0 16.6 7.6 23.8

24.7

28.3

18.6

26.6

21.2

36.6

31.0

20.9

19.5

6.8

28.4

19.0

27.5

18.6

28.2

15.9 14.9

28.2 33.4

8.0 5.6

15.7 13.6

10.1 7.2

20.1 12.7

14.5 10.9

10.1 8.2

17.1 18.2

7.6 7.7

21.4 18.1

23.9 30.6

10.9 12.0

20.6 26.7

13.7 12.0

%sedonthestandwd drugcbdfkatiin usedintheAfationa/ DrugCodaDimctory#1985edtion(NDC) (9).

%dudesanesthestim, atid@-, mdnphamwtimaWmntM rmdia,oncotylii, ot.logica, anti~~ti=, andund-fitimkwlknwus drugs.

and/or test results. In cases where the

patient received care from a member

of thephysician’s staff but dld not

actually see the physician during the

visit, duration was recorded as “O”

minutes.

Nearly two-thirds (63.5 percent) of

physicians’ office tilts had a duration

of 15 minutes or less in 1993. The mean

duration time for all visits was 18.4

minute8. Corresponding numbers for

1992 were 66.6 pereent and 17.6

minutes, respectively.

Additional reports utilizing 1993

NAMCS data are forthcoming in the

Advance data horn Vhal and Health

Statistics series. Data from the 1993

NAMCS will be available on computer

tape and CD-ROM from the National

Technical Information Service in

early 1996. Questions regarding this

repcu%future reports, or the NAMCS

may be directed to the Ambulatmy

Care Statistics Branch by calling

(301) 436-7132.

References

1. Nelson C, McLemore T. The

National Ambulatory Medkal Care

Survey. United States, 1975-81 and

1985 trends. National Center for

Health Statistics. vital Health Stat

13(93). 1988.

2. Schapper$ SM. National Ambulatory

Medical Care Survey: 1989

Table 20. The 20 most frequently occurring generic substances in drug mentions at office

visits by number of occurrences and percent of all drug mentions: Unitwt States, 1993

Nunhw of Percent of

Occurrancas aif drug

Generic substance in #ousarrds* Merltlonaz

Allgenerfc substances . . . . . . . . . . . . . . . . . . . . . 1,0s0,98s .. .

Arnoxidllkr . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Acetarnlnophen . . . . . . . . . . . . . . . . . . . . . . . . .

Hydmchlorothiszkfe. . . . . . . . . . . . . . . . . . . . . . .

Albuterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ibuprofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mulfivitamhw+feneral . . . . . . . . . . . . . . . . . . . . .

Eryfhrornydn . . . . . . . . . . . . . . . . . . . . . . . . . . .

Aaplrtn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Phenyiqhrine . . . . . . . . . . . . . . . . . . . . . . . . . .

Guelfenesln . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Estrogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Furoeemkla . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Predrrisone . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Codeine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Digoxln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trimathoprlm . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dlillszem . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hydrwortlsone. . . . . . . . . . . . . . . . . . . . . . . . . .

Pheny~ropanolernine . . . . . . . . . . . . . . . . . . . . . .

Ranitkfine . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35,2W

34,277

15,217

14,343

14,405

14,064

13,459

13,233

12,588

11,727

11,ss0

11,212

10,833

10,153

9,9s4

9,886

9,541

9,516

9,435

9,325

3.9

3.8

1.7

1.6

1.6

1.5

1.5

1.5

1.4

1.3

1.3

1.2

1.2

1.1

1.1

1.1

1.0

1.0

1.0

1.0

1Fraquency or mentkm conbines single-ingredient agents with nmnticws or the agent as an ingredient in a mmbination dreg.

2Bssed on an estimated 913,508,cYXl drug rmrdions in 13$3.

Summary. National Center for Health

Statistics. Vital and Health Stat

13(110). 1992.

3. Schapper~ SM. National Ambulatory

Medical Care Survey: 1990

Summary. Advance data from vital

and health statistics no. 213.

Hyattsville, Maryland National

Center for Health Statistics. 1992.

4. Schappe~ SM, National Ambulatory

Medicsl Care Survey: 1991

Summary. National Center for Health

Statistics. ~lti snd Health Stat

13(116). 1994.
14 Advance Data No. 270. December 7, 1995

Table 21. Number, percent distribution, and thempeutfc classlffcatfon for tfte 20 druge most fmquentiy prescribed at office vlslta, by

entry name of drug: United States, 1993

Number of

dmg mentions Perc4vrt

Entry name of dNg7i In thousands dlstrfbutlon Therzpeuf/c clasalfkathm2

Alldfug mentions . . . . . . . . . . . . . . . . . . . . . . . . 913,503 100.0 . . .

Amoxfdllln . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19,212 2.1 Penicillins

Tylenol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i 1,225 1.2 General analgealoa

Premartn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,675 1.2 Estrogens and progestins

Leak. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,578 1.2 Dluretlca

Amoxfl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,569 1.2 Penicillins

Prednfsone . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,562 1.2 Adrenaf wrtioosterokfe

Zanlac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9,303 1.0 Agantsusadindisordera ofupparGltrac4

Cardizem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,977 1.0 Antianginaf agenta

Allergy ralleforshots . . . . . . . . . . . . . . . . . . . . . . 8,029 0.9 DlagnoafIcs, nonradioacftve and radiopaque

Influenzavirusvaccine . . . . . . . . . . . . . . . . . . . . . 7,685 0.8 Vaccines and antiserums

Procardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,575 0.8 Antlanglnafagents

Lanoxfn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,177 0.8 Cardfacglyoosfdes

SynthroId . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,169 0.8 Agents used to treat thyroid dfsaaae

Vasotec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,032 0.8 Antihypertenefve agents

DlphtheriWTetanusToxoida/Perfusais . . . . . . . . . . . . 6,994 0.8 Vacdresandan tfaerums

Ventolhf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,940 0.8 Bronchodffatom,antfasthmatfca

Prenatelforrmrla(vltamlns) . . . . . . . . . . . . . . . . . . 6,902 0.8 Vitamins, mlnerafs

Naprosyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,769 0.7 Anfiafthrtlfce

Proventll . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,626 0.7 Bronchodllatora,antfasthmallcs

Prozac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,462 0.7 Antldapreaaants

Another. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737,042 80.7 . . .

%eentrymade bythephysiekn onthe.prescription orothermadical reoords.l%isrnsy beatrsdenama, ganericnsme,or desiradtherapautic effac+.

2Basedon the Nafiond Dr~MD/~to~, 1985 Ediimn(NDC) (9). Incases where adrug had morathan onetherapeutic use, it was MedundertheN DCeategc+yt hatocewredwkhthe

hghest frequency,

5. Schappefi SM. National Ambulatory

MedicalCareSurvey 1992

Summary.Advance datafromvital

andhealtb statistics no. 253.

Hyattaville, Marykmd National

Center for Health Statistics. 1994.

6. Schneider D, Appleton L, McLemore

T. A reason for visit classification for

ambulatory care. National Center for

Health Statistics.Vital endHeakh

Stat 2(78).1979.

7.Public Health Service and Heelth

Care Financing Administration.

International Classification of

Diseases, 9thRevision, clinical

modltication. Washington: Public

Health Service. 1980.

S.Koch H, Campbell W. The collection

and processing of drug information.

Nationrd Ambulatory Medical Care

Survey, 1980. National Center for

Health Statistics. Wal Health Stat

2(90). 1982.

9. Food and Drug Administration.

National Drug Code Directory, 1985

Edition. Washingtorx Public Herrlth

Service. 1985.

10. Shah BV, Barnwell BG, Hunt PN, La

Vange LM. SUDAAN User’s

Manual, Release 5.50. Research

Triangle Institute. Research Triangle

Psrk, NC. 1991.

Cardiovascular-renal b

Antimicrobial

Pain relie!

Respiratory trad

Hormones and rale

agentt

Peychopharmacologit

Skitimusous membrerw

g Gastrointestma

E Ophthalmh

Neurologi,

Hematologil

Other

_:

and utiassifiid 8,5

14.0

13.9

1 1 1 1 1 I 1 1 I

o 2 4 8 a 10 12 14 16

Percent of mentiins

SOURCE Ssmd on the standarddrugdasdfkatbn usedintha)4atkm/D~Co&a Directory 196Sedkvr (NDC)(9).

Figure 2. Peroant distribution of drug mentions at offioe visits by therapeutic

classification: United States, 1993
Advance Data No. 270. December 7, 1995 15

Table 22. Number and percent of office visits by counselingkfucation ordered or provided: United States, 1993

Number of Pat/erft’s sex

fdeifs in

CounseIin~education ordered orprovid.d thouaamds Total Female Male

Atlvldts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Exerdsa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Welghtreduotkrn . . . . . . . . . . . . . . . . . . . . . . . .

Growth/development . . . . . . . . . . . . . . . . . . . . .

Cholesterolreducfkrn . . . . . . . . . . . . . . . . . . . . . .

Smotrkrgcessetion . . . . . . . . . . . . . . . . . . . . . . .

Injurypreventlon . . . . . . . . . . . . . . . . . . . . . . . . .

STDtransmiaeion (exceptHlV)z3 . . . . . . . . . . . . . .

HlVWutsmisaion3. . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

717,191

369,4e4

64$?57

40,715

30,255

27,063

22,674

21,786

10,216

9,114

245,281

Percent of vkiis

. .. . . . . . .

51.5

9.0

5.7

4.2

3.8

3.2

3.0

1.4

1.3

34.2

50.4

8.9

5.9

4.2

3.7

3.1

2.6

1.8

1.5

35.4

53.2

9.0

5.3

4.3

3.9

3.3

3.8

0s

1.0

32.5

lNumbemmaynot addtototelsbacsuse morethanonefype ofmunsalingred ucatiorr rrmybempctfed perviaif.

2STD is Saxualp tmnsmilted diseases.

%-N/is human immunodafrcierwy virus.

Table 23. Number and percent of oftlce visits by disposition of vlsib United States, 1993

Number of Percent

Vwfs in of an

D!-spoaltfonl fhouaarrde VMts

Allvrsits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717,191 . . .

Retumatspecifiedtime . . . . . . . . . . . . . . . . . . . .

Retumifneedsd . . . . . . . . . . . . . . . . . . . . . . . . .

Nofolknvupptersned . . . . . . . . . . . . . . . . . . . . . .

Tele+shonefollowuppkmned. . . . . . . . . . . . . . . . . .

Referredtootherphyetdan . . . . . . . . . . . . . . . . . .

Admittohos@tef. . . . . . . . . . . . . . . . . . . . . . . . .

Refumedto refefrlngphyelcien . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

447,169

168,947

61,687

30,937

26,411

6,022

8,360

13,954

62.4

23.3

8.6

4.3

3.7

0.8

1.2

1.9

lNumberamsynot addtototabbecauae momthanonedlspoaifiin tswybemported pervisif.

Table 24. Number and percent distribution of office visits by duration of visik United

states, 1993

Nurrber of

Vfattsfrf Percerrf

Duraflon ftrouaarr& dkfribufion

Allviatte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717,191 100.0

Omlnufesi . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17,4s4 2.4

l-5mkrutes . . . . . . . . . . . . . . . . . . . . . . . . . . . 40,611 5.7

6-10mtmutaa . . . . . . . . . . . . . . . . . . . . . . . . . . . 177,641 24.8

11-15mlnutas . . . . . . . . . . . . . . . . . . . . . . . . . . 219,418 30.6

16-30minutes . . . . . . . . . . . . . . . . . . . . . . . . . . 204286 28.5

31 mInutesandover . . . . . . . . . . . . . . . . . . . . . . 57,540 8.0

lVisita in which there was no faetefsce ccmtasf batwaan patient and ptsysidan.
16 Advance Data No. 270. December 7, 1995

Technical notes

Source of data and sample

design

The information presented in this

report is based on data collected by

means of the National Ambulatory

Medical Care Survey (NAMCS) from

January 4, 1993, through kmuary 2,

1994. The target universe of NAMCS

includes office visits made in the United

States by ambulatory patients to

nonfederrdly employed physicians who

are principally engaged in office

practice, but not in the specialties of

anesthesiology, pathology, or radiology.

Telephone contacts and nonoffice visits

are excluded.

A multistage probability sample

design is used in NAMCS, involving

samples of primary sampling units

(PSU’S), physician practices within

PSU’S, and patient visita within

physician practices. The PSU’S are

counties, groups of counties, county

equivalents (such as parishes or

independent cities), or towns and

townships (for some PSU’S in New

England). For 1993, a sample of 3,400

nonfederal, office-based physicians

was selected from master files

maintained by the American Medkzd

Association and American Osteopathic

Association. Physicians were screened

at the time of the survey to ensure that

they were eligible for survey

participation. Of those screened, 936

physicians were ruled ineligible

(out-of-scope) due to reasons of being

retired, employed primarily in

teaching, research, or administration,

or other reasons. The remaining 2,464

physicians were in-scope, or eligible

to participate in the survey. The

physician response rate for the 1993

NAMCS was 73.0 percent.

Sample physicians were asked to

complete Patient Record forms (figure 1)

for a systematic random sample of office

visits occurring during a randomly

assigned l-week reporting period.

Responding physicians completed

35,978 Patient Record forms.

Characteristics of the physician’s

practice, such as primary specialty and

type of practice, were obtained from the

physicians during an induction

interview. The U.S. Bureau of the

Census, Housing Surveys Bmnch, was

responsible for the survey’s data

collection. Processing operations and

medical coding were performed by the

National Center for Health Statistics,

Health Care Survey Section, Research

Triangle Park North Carolina.

Sampling errors

The standard emor is primarily a

measure of the sampling variabiMy that

occurs by chance when only a sample,

rather than an entire universe, is

surveyed. The standard error also

reflects part of the measurement error,

but does not measure any systematic

biases in the data. The chances are 95

out of 100 that an estimate from the

sample diflers from the value that would

be obtained from a complete census by

less than twice the standard error.

The standard errors used in tests of

significance for this report were

calculated using generalized Iinem

models for prWlcting the relative

standard error for estimates based on the

linear relationship between the actual

standard error, as approximated using

SUDAAN sofhvare, and the size of the

estimate. SUDAAN computes standard

errors by using a first-order Taylor

approximation of the deviation of

estimates from their expected values. A

description of the software and the

approach it uses has been published

(10). The relative standard error (RSE)

of an estimate is obtained by dividing

the standard error by the estimate itself.

The result is then expressed as a percent

of the estimate.

Relative standard errors (RSES) for

estimated numbers of office visits in

1993 are shown in table L relative

standard errors for estimated numbers of

drug mentions are presented in table II.

Standard errors for estimated percents of

visits and drug mentions are displayed

in tables III and IV. MuMplying the

estimate by the RSE will provide an

approximation of the standard error for

the estimate.

Alternatively, relative stzmdard

errors for agfyegate estimates may be

calculated using the following general

formu~ where x is the aggregate of

Table L Approximate relative standard

errors for estimated numbers of ofttce

visits: National Ambulatory Medical Care

Suwey, 1993

Estimated Relatlve

number of standard

office visits error in

In thousands penxrt

100 . . . . . . . . . . . . . . . . . . . . . 83.2

200 . . . . . . . . . . . . . . . . . . . . . 58.9

500 . . . . . . . . . . . . . . . . . . . . . 37.4

787 . . . . . . . . . . . . . . . . . . . . . 30.0

1,000 . . . . . . . . . . . . . . . . . . . . 26.6

2,000 . . . . . . . . . . . . . . . . . . . . 19.0

5,000 . . . . . . . . . . . . . . . . . . . . 12.3

10,000 . . . . . . . . . . . . . . . . . . . 9.1

20,000 ...,............,.. 7.0

50,000 . . . . . . . . . . . . . . . . . . . 5.3

100,000 . . . . . . . . . . . . . . . . . . 4.6

200,000 . . . . . . . . . . . . . . . . . . 4.2

500,000 . . . . . . . . . . . . . . . . . . 3.9

1,000,000 . . . . . . . . . . . . . . . . . 3.8

NOTE The smallest reliable estimate for visfis to aggregated

specislt”es s 781,030 visis. Estimates below this figure have

a relattie standard error greater than 30 percent and are

deenmd unrafiabla by NCHS efandards.

Example of use of tabkx An aggregate estlmtde of 10 million

visits has a re!afiie standard error of 9.1 parcent or a

standard error of 910,000 visits (9.1 peroent of 10 million).

Table IL Approximate relative standard

errors for estimated numbers of drug

mentions: National Ambulatory Madioal

Care Survey, 1993

Estimated Re/at/ve

number of standard

dNg M8f7t10nS etror In

In thousands percent

100 . . . . . . . . . . . . . . . . . . . . .

200 . . . . . . . . . . . . . . . . . . . . .

500 . . . . . . . . . . . . . . . . . . . . .

1,000 . . . . . . . . . . . . . . . . . . . .

1,496 . . . . . . . . . . . . . . . . . . . .

2,000 . . . . . . . . . . . . . . . . . . . .

5,000 . . . . . . . . . . . . . . . . . . . .

10,000 . . . . . . . . . . . . . . . . . . .

20,000 . . . . . . . . . . . . . . .. . . . .

50,000 . . . . . . . . . ! . . . . . . . . .

100,000 . . . . . . . . . . . . . . . . . .

200,000 . . . . . . . . . . . . . . . . . .

500,000 . . . . . . . . . . . . . . . . . .

1,000,000 . . . . . . . . . . . . . . . . .

114.4

81.0

51.4

36.5

30.0

26.1

17.0

12.5

9.6

7.3

6.3

5.6

5.4

5.3

NOTE The smallest refiible estimate of drug mentions for

899re9ated speoiailks is 1,46S,000 mentions Estimates

below this figure have a relative standard error greater than

30 percard arrd are deemed unreliable by NCHS standards.

Example of use of table An aggragsfe estimate of 100 million

drug mentions haa a relafiie standard -error of 8.3 perosnt or

a standard arror C46,300,000 mentions (6.3 percent of 100

million).

interest in thousands, and A and B are

the appropriate coefficients from table V.

RSE (X) =

r

A+:*1OO

Similarly, relative standard errors

for percents may be calculated using the
Advance Data No. 270. December 7, 1995 17

Table Ill.Approximate standard errors of percents of estimated numbers of office visik Nationai Ambulatory Medical Care Survey, 1993

EWnatadpercent

Baaa of pemnt

(b4Ms In thousands) 1 or 99 5 or 95 10 or90 20 or 80 30 or 70 40 or 60 50

100.....................

200 . . . . . . . . . . . . . . . . . . . . .

500 . . . . . . . . . . . . . . . . . . . . .

1,000 . . . . . . . . . . . . . . . . . . . .

2,000 . . . . . . . . . . . . . . . . . . . .

5,000 . . . . . . . . . . . . . . . . . . . .

10,000 . . . . . . . . . . . . . . . . . . .

20,000 . . . . . . . . . . . . . . . . . . .

50,000 . . . . . . . . . . . . . . . . . . .

Ioo,ooo . . . . . . . . . . . . . . . . . .

200,000 . . . . . . . . . . . . . . . . . .

500,000 . . . . . . . . . . . . . . . . . .

1,000,000 . . . . . . . . . . . . . . . . .

8.3

5.9

3.7

2.6

1.9

1.2

0.8

0.6

0.4

0.3

0.2

0.1

0.1

18.1

12.8

8.1

5.7

4.1

2.6

1.8

1.3

0.8

0.6

0.4

0.3

0.2

25.0

17.6

11.2

7.9

5.6

3.5

2.5

1.8

1.1

0.8

0.6

0.4

0.3

33.3

23.5

14.9

10.5

7.4

4.7

3.3

2.4

1.5

1.1

0.7

0.5

0.3

36.1

27.0

17.0

12.1

8.5

5.4

“ 3.8

2.7

1.7

1.2

0.9

0.5

0.4

40.7

28.8

18.2

12.9

9.1

5.6

4.1

2.9

1.8

1.3

0.9

0.6

0.4

41.6

29.4

16.6

13.2

9.3

5.9

4.2

2.9

1.9

i .3

0.9

0.6

0.4

NOTE Example of use of table An estimate of SOpercent baaed on an aggragata estimate of 10 miliiin viaita has a standard errcf of 3.5 percent or a refstiie standard error of 11.7 parcent (3.5

percent divided by 30 parcant),

TabielV. Approximate standard errore ofpercentaof estimated numbers ofdrugmentions: Nationai Ambulatory Medical Care Survey,

1993

Eatirnetedparcant

Base ofpercent

@#fslnthousands) 1 or 99 5 or 95 10 or90 20 or 80 30 or 70 40 or 60 50

100 . . . . . . . . . . . . . . . . . . . . .

200 . . . . . . . . . . . . . . . . . . . . .

500 . . . . . . . . . . . . . . . . . . . . .

1,000 . . . . . . . . . . . . . . . . . . . .

2,000 . . . . . . . . . . . . . . . . . . . .

5,000 . . . . . . . . . . . . . . . . . . . .

10,000 . . . . . . . . . . . . . . . . . . .

20,000 . . . . . . . . . . . . . . . . . . .

50,000 . . . . . . . . . . . . . . . . . . .

Ioo,ooo . . . . . . . . . . . . . . . . . .

200,000 . . . . . . . . . . . . . . . . . .

500,000 . . . . . . . . . . . . . . . . . .

I,ooo,ooo . . . . . . . . . . . . . . . . .

11.4

8.0

5.1

3.6

2.5

1.8

1.1

0.8

0.5

0.4

0.3

0.2

0.1

24.9

17.6

11.1

7.9

5.6

3.5

2.5

1.8

1.1

0.8

0.6

0.4

0.3

Sktrrdarderrorht parcantagepoints

34.3 45.7 52.4

24.2 32.3 37.0

15.3 20.4 23.4

10.6 14.5 16.6

7.7 10.2 11.7

4.9 6.5 7.4

3.4 4.6 5.2

2.4 3.2 3.7

1.5 2.0 2.3

1.1 1.5 1.7

0.8 i .0 1.2

0.5 0.7 0.7

0.3 0.5 0.5

56.0

S9.6

25.0

17.7

12.5

7.9

5.6

4.0

2.5

1.6

1.3

0.8

0.6

57.1

40.4

25.6

18.1

12.8

8.1

5.7

4.0

2.6

1.8

1.3

0.8

0.6

NOTEExarr@eof usecitableAn estiite of30parcentbasad onanaggregataaetirnate of100milfiindrug manfiins hasaatandard errwofl.7p.wc.ant waralafiiastandard errorof5.7

pe-t (1.7 percant dtidad ty 30 parcent),

following general formul~wherep is

thepercent ofinterest expressedasa

proportion, andxis the denominatorof

thepereentin thousands, using the

appro@atecoefficient flomtableV.

‘SE(’)=c“’”

Adjustments for nonresponse

Estimates horn NAMCS data were

adjusted to account for sample

physicians who were in-scope but did

not participate in the study. This

adjustment was calculated to minimize

the impact of response on iinal estimates

by imputing to nonrespondmg

physicirtns data from visits to similar

physicians. For this propose, physicians

were judged similar if they had tie

same specialty designation and practiced

in the same PSU.

Test of significance and

rounding

In thi8repofi the determination of

statistical inferenee is based on the

two-tailed t-test. The Bonferroni

inequality was used to establish the

critical value for statistically significant

differences (0.05 level of significance)

based on the number of possible

comparisons within a particular variable

(or combination of variables) of interest.

Terms relating to differences such as

“greater than” or “kxs than” indicate

that the difference is statistically

significant. A lack of comment regarding

the difference between any two

estimates does not mean that the

dtierence was tested and found to be

not significant.

In the tables, estimates of office

visits have been rounded to the nearest

thousand. Consequently, estimates will

not always add to totals. Rates and

percents were calculiwed from original

unrounded figures and do not

necesmrily agree with percents

calculated from rounded data
18 Advance Data No. 270. December 7, 1995

Table V. Coefficients appropriate for determining relative standard errora by type of

estimateand physician spasialt~ National Ambulatory Medical Care Survey, 1993

Coefficient for use wlfh estimates In thousands

Type of estimate and

phyaiclan apec/a/iy A B

W#rs

Overall total . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generel andlamily practice . . . . . . . . . . . . . . . . . .

Osteopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intemai medicine . . . . . . . . . . . . . . . . . . . . . . . . .

Pedlatrica . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ganeral surgary . . . . . . . . . . . . . . . . . . . . . . . . .

ObsteUfoaendgynecology. . . . . . . . . . . . . . . . . . .

Orthopedic surgery . . . . . . . . . . . . . . . . . . . . . . . .

Cerdiovescukar dlseeaaa . . . . . . . . . . . . . . . . . . . .

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthelomology . . . . . . . . . . . . . . . . . . .

Otolsryngology . . . . . . . . . . . . . . . . . . . . . . . . . .

Allargysndlmmunologyt . . . . . . . . . . . . . . . . . . . .

Pulmonerydiaaaaaa’ . . . . . . . . . . . . . . . . . . . . . .

Aliotherapecialties . . . . . . . . . . . . . . . . . . . . . . .

Drug mentions

Overelltotel . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalsndfsmllypracfice . . . . . . . . . . . . . . . . . .

Osteopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intemalmadiclne . . . . . . . . . . . . . . . . . . . . . . . . .

Pedistrfcs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generelsurgery . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetrfcaandgynecology . . . . . . . . . . . . . . . . . . .

Orthopedlcsurgery . . . . . . . . . . . . . . . . . . . . . . . .

Cerdiovseculardiaeaaes . . . . . . . . . . . . . . . . . . . .

Dermatology . . . . . . . . . . . . . . . . . . . . .

Urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalomolcqy . . . . . . . . . . . . . . . . . . . . . . . . .

Otokwyn@ogy. . . . . . . . . . . . . . . . . . . . . . . . . .

Allergyandlmmunology’ . . . . . . . . . . . . . . . . . . . .

Pulrnonerydlaeeaeal . . . . . . . . . . . . . . . . . . . . . .

AllotherspecfeltIee . . . . . . . . . . . . . . . . . . . . . . .

0.001402906

0.00967743

0.009634146

0.009613634

0.01497736

0.004562476

0.01215806

0.01 S47372

0.01842725

0.01300847

0.01462425

0.011116SS

0.01062749

0.01360671

0.01584593

0.02015721

0.01604307

0.0118534s

0.002655818

0.01454036

0.014s2355

0.01501777

0.0212S038

0.02674708

0.0283S093

0.03130595

0.02412645

0.020s4168

0.03026505

0.02554631

0.01978151

0.02642952

0.03147744

0.02579986

0.02283235

0.02135922

63.14391s63

82.86427569

21.982533

66.930512SS

43.04423824

6.1S923111

45.17522836

30.1373659

13.330613S4

14.22174725

10.21006093

6.36650241

4.46207203

23.79903861

7.10113491

3.3591506s

2.76807823

45.14667567

130.60816

153.42208

34.91826215

127.67927

29.86328192

6.25933055

47.78~72168

31 .2701S391

26.653378

14.43471796

10.123550s

11.76240189

5.29S00076

39.03224336

6.66505135

6.30451913

5.93S3W04

59.19073373

~Physicianstrataaddedas a supplemento the 1993 NAMCSoniy.

Definition ofterms

Ambulatorypatient-An ambulatory

patient isanindividurd seeking personal

hcalthsemiceswho isnotcurrently

admittedto anyhealth care institution

onthepremises.

Drug mention—Adrug mentionis

the physieian’s entry on the Patient

Recordfon.nofa pharmaceutical

agent-by any route ofadministration—

forprevention, diagnosis, or treatment.

Genericaswellas brand-namedrugs are

includ~ as are nonpnxcription and

pre3eription drugs. Along with allnew

drugs, thephysician also records

continued medications ifthepatientwas’

specificallyinsawted duringthevisit to

eontinuethemedkation. Physicians may

report up to five medications per visiL

Drug visit—Adrug visit is a visit at

which medication was prescribed or

provided by the physician.

Ojice-An office is the space

identified by a physician as a location

for his or her ambulatory practice.

Offices customarily include consultation,

examimtion, ortreafment spaces that

patients associate with the particular

physician.

Physician—Aphysician is a duly

licensed doctor of medkine (M.D.) or

doctor of osteopathy @.O.) who is

currently in office-based practice and

who spends sometime earing for

ambulatory patients. Excluded from the

NAMCS are physicians who am hospital

basal, who specialize in anesthesiology,

pathology, or radiology; who are

federally employ~ who treat only

institutionalized patients; or who are

employed full time by an institution and

spend no time seeing ambulatory

patients.

Wsit—Avisit is a direct personal

exchange between an ambulatory patient

and a physician or a staff member

working under the physician’s

supervision, for the purpose of seeking

care and rendering personal health

services. Excluded from the NAMCS

are visits where medkal care was not

providd such as visits made to drop off

specimens, pay bills, make

appointments, and walk-outs.
Advance Data No. 270. December 7, 1995 19

Symbols

--- Data not available

. . . Category not applicable

Quantity zero

0.0 Quantity morethan zero but

lessthan 0.05

z Quantii morethan zero but

less than 500 where numbers

are roundedto thousands

* Figure does not meet standard

of reliabilityor precision
20 Advance Data No. 270. December 7, 1995

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The use of trade names is for identification

only and does not imply endorsement by the

Public Health Servica, U.S. Department of

Health and Human Services.

Suggested citation Copyright Information National Center for Health Statfatfce

Wcodwell DA, Schappert SM. National All material appearing in this report is in the Acting Director

Ambulatory Medical Care Survey: 1993 public domain and may be reproduced or Jack R. Anderson

summary. Advance data from vital and health copied without permission; citation as to

statistics; no. 270. Hyattsville, Maryland: source, however, is appreciated. Acting Depu~ Director

National Center for Health Statistics. 1995. Jennifer H. Madsns, Ph.D.

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not included in regular, annual, or monthly reports. Special

analyses by health and demographic variables and

geographic and trend analyses are included.

Data From the Natfonal Mortality and Natality SurveyaOiscontinued in 1975. Reports from these sample surveys,

based on vital records, are now publishad in Series 20 or 21.

Data From the National Survey of Family Growth—

These reports contain statistics on factors that affect birth

rates, including contraception, infertility, cohabitation,

marriage, dworce, and remarriage adoption; usa of medical

care for family planning and infertility and related maternal

and infant health topics. These statistics are based on

national surveys of childbearing age.

Compilations of Data on Natality, Mortality, Marriage,

Divorce, and Induced Terminations of Pregnancy—

These include advance reports of births, deaths, marriages,

and divorces based on final data from the National Vital

Statistics System that ware published as supplements to the

Monthly Vi Ststisi7csRqwrt (MVSR). These reports provide

highlights and summaries of detailed data subsequently

published in Vita/ Statistics of the United States. Other

supplements to the MVSR published here provide selected

findings based on final data from the National Vial StstLW”ca

System and may be followed by detailed reports in Series 20

or 21.

For answers to questions about this report or for a list of reports published

in these series, contact

Data Dissemination Branch

National Center for Health statistics

Centers for Disease Control and Prevention

Public Health Servka

6!525 Belcrest Road, Room 1064

Hyattsville, MD 20762

(301) 436-6500

E-mail: nchsquery@nchlOa. em.cdc.gov

Internet http://www.crk..gonchswsnchshmemMmMm
DEPARTMENT OF

HEALTH & HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

National Canter for Health Statistics

6525 Belcrest Road

Hyattaville,Maryland 20782

OFFICIAL BUSINESS

PENALTV FOR PRIVATE USE, $3OO

PRESORTED SPECIAL

FOURTH CLASS RATE

POSTAGE & FEES PAID

PHS/NCHS

PERMIT NO,,G-281

DHHS Publication No. (PHS) 96-1866, Series 16, No. 27

6-0231 (4/96)