Data from the

NATIONAL HEALTH SURVEY

Office Visits for Diseases

of the RespiratorySystem

The National Ambulatory

MedicalCare Survey

United States, 1975-76

Based on data obtaine~ from a national sample of office-based

physicians, statistics are presented which describe ambulatory

medical care during visits for treatment of diseases of the

respiratory system. Utilization patterns of visits which included

diagnoses of acute and chronic respiratory conditions are presented

in terms of demographic and clinical characteristics. Highlighted

diagnoses include acute upper respiratory infections, influenza,

pneumonia, emphysema, asthma, hay fever, and other chronic

respiratory conditions. Data regwding influenza visits for 1974,

1975, and 1976 are also presented.

DHEW Publication No. (PHS) 79-1793

Series 13

Number 42

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Public Health Service

Office of Health Researchr Statistics, and Technology

National Center for Health Statistics

Hyattsville, Md. July 1979
r

/

Library of Congress Cataloging in Publication Data

Cypress, Beulah K.

Office visits for diseases of the respiratory system.

(Vital and health statistics: Series 13, Data from the National Health Survey; No. 42)

(DHEW publication (PHS) 79-1793)

Includes bibliographical references.

1. Respiratory organs–Diseases–United States–Statistics. 2. Physician services utilization–United States–Statistics. 3. Health surveys-united States. I. Title. II. Series:

United States. National Center for Health Statistics. Vital and health statistics: Series 13,

Data from the National Health Survey, Data on health resources utilization; no. 42.

III. Series: United States. Dept. of Health, Education, and Welfare. DHEW publication;

(PHS) 79-1793.

RA407.3.A349 no. 42 [RA645.R4] 362.1’ 1’0973s

ISBN 0-8406 -0160-3 [362.1’9’6200973] 79-11339
NATIONAL CENTER FOR HEALTH STATISTICS

DOROTHY P. RICE, Director

ROBERT A. ISRAEL, Deputy Director

JACOB J. FELDMAN, Ph.D., Assoczizte Director for Analysis

GAIL F. FISHER, Ph.D., Associate Director for the &operative Health Statistics System

ROBERT A. ISRAEL, Acting Associate Director for Data Systems

JAMES T. BAIRD, JR., Ph.D., Associate Director for International Statistics

ROBERT C. HUBER, Associate Director for Management

MONROE G. SIRKEN, Ph.D., Associate Director for Mathematical Statistics

PETER L. HURLEY, Associate Director for Operations

JAMES M. ROBEY, Ph. D., Associate Director for Program Development

PAUL E. LEAVERTON, Ph.D., Associate Director for Research

ALICE HAYWOOD, Information Ofjicer

DIVISION OF HEALTH RESOURCES UTILIZATION STATISTIC!3

SIEGFRIED A. HOERMANN, Director

JAMES E. DELOZIE~ G?ie~ Am” ulatory CizreStatistics Branch

SIEGFRIED A. HOERMANN, Acting 4 ie~ Hospital Care Statistics Branch

MANOOCHEHR K. NOZARY, Chief, Technical Services Branch

STEWART C. RICE, Chie~ Family Planning Statistics Branch

JOAN F. VAN NOSTRAND, C’hie~ Long-Term Gzre Statistics Branch

Vital and Health Statistics-Series 13-No. 42

DHEW Publication No. (PHS) 79-1793

Library of Congress G.@og GzrdNumber 79-11339
CONTENTS

Introduction . ........................................................................................................................................

scope of the fhNf3y ..................................................."............................".....................................

Source and Limitations of the Data ................................................................................................

All Diseases of the Respiratory System .......................................... ............................................... .....

Section I. Acute Diseases of the Respiratory System ............................................................................

Patient Characteristics .....................................................................................................................

Influenza ..................................................................................................................... ....................

ainid Characteristics .................................................................... ................................................

Coexisting Diagnoses .................................................................................................................

Patient Problems, Complaints, or Symptoms ............................................................................

Seriousness and Status of the Problem ................................ ....................................................

D@nostic and Therapeutic Services .........................................................................................

Vkit Deposition and Duration ..................................................................................................

Physician Specialty .................................................................................." ................................

Section II. Chronic Diseases of the Respiratory System .......................................................................

Patient Characteristics ...............................................................................................................a ....

ahkd Characteristics ...................................................................... ..............................................

Coexisting Diagnoses ........................................................................................... .....................

Patient Problems, Complaints, or Symptoms ............................................................................

Seriousness and Status of the Problem .....................................................................................

D@nostican dTherapeuticSe rvices .........................................................................................

Wit Disposition and Duration ..................................................................................................

Physician Specialty ....................................................................................................................

References ................................................... .........................................................................................

List of Detailed Tables ..........................................................................................................................

AKmendlxes . .

I. Technical Notes ........ ............................................................................... ..............................

1.

2.

3.

4.

5.

II. Definition of Certain Terms Used in This Report ...................................................................

III. Survey Instruments ..................................................................................................................

LIST OF TEXT FIGURES

Average annual rate of office visits for acute upper respiratory infections, except influenza

(460-466, 490), by patient age: United States, 1976-76 ..................................................................

Average annual rate of office visits for pneumonia (460466), by patient age: United States,

1975-76 ...........................................................................................................................................

Average rate of office visits for influenza (470-474) for 1974, 1975, and 1976, by patient age:

United States . .................................................................................................................................

Number of office visits for influenza (470-474) by calendar quarter and year: United States,

1974-76 ...........................................................................................................................................

Average annual rate of office visits for hay fever and asthma, by patient age: United States,

1975-76 ...........................................................................................................................................

1

1

2

3

4

4

5

7

7

7

8

9

9

9

10

10

10

10

11

12

12

12

12

14

15

5

5

6

7

10

...

Ill
LIST OF TEXT TABLES

A.

B.

c.

D.

E.

F.

G.

H.

Number and percent of office visits for all diagnostic classes and for dkeases of the respiratory

system, by patient sex, race, and age: United States, 1975-76 .........................................................

Number and percent distribution of office visits for acute and chronic diseases of the respiratory

system, by diagnosis: United States, 1975-76 ..................................................................................

Number of office visits for influenza (470-474) and annual rate of office visit$ by geographic

region and year: United States, 1974-76 ........................................................................................

Number and percent of office visits for acute upper respiratory infections except influenza

(460-466, 490) by most frequent second- or third-listed diagnosis in rank order: United States,

1975-76 ..........................................................................................................................................

Mean contact duration in minutes of office visits and standard error of the mean, by selected

acute dk.eases of the respiratory system: United States, 1975-76 ...................................................

Number of office visits by selected chronic diseases of the respiratory system listed as second or

thkd diagnosis: United States, 1975-76 ........................................................................................

Number and percent of office visits by principsd diagnosis and most frequent second- or

thmd-listed diagnosis: United States, 1976-77 ................................................................................

Mean contact duration in minutes of office visits and standard error of the mean, by selected

chronic diseases of the respiratory system: United States, 1975-76 ................................................

SYMBOLS

Data not available ............................ ............ ---

Category not applicable ............................... . . .

Quantity zero .............................................. -

Quantity more than O but less than 0.05 ... 0.0

Figure does not meet standards of

reliability or precision *

.............................

3

4

6

8

9

11

11

12
OFFICE VISITS FOR DISEASES

OF THE RESPIRATORY SYSTEM

13euIahK. Cypress, Ph.D., Division of Health Resources Utilization Statistics

INTRODUCTION

From January 1975 through December 1976

an estimated 163.4 million visits to office-based

physicians in the conterminous United States

were attributed to diseases of the respiratory

system. These visits comprised 14 percent of all

office visits—duri;g th=t period. Respiratory

conditions led all other morbid conditions in

volume of visits.= This report describes certain

demographic and clinical characteristics associated with these visits and amplifies Advance Data

report No. 41, “Office Vkits for Respiratory

Conditions.’yl It is the second series report with

a focus on diagnoses based on 1975-76 data. An

earlier report published in Series 132 dealt with

characteristics of visits for circulatory diseases.

The data were collected in the National

Ambulatory Medical Care Survey (NAMCS), a

continuous sample survey conducted by the

Division of Health Resources Utilization Statistics of the National Center for Health Statistics.

Detailed information regarding the background

imd methodolob~ of the survey was published in

Vital and Health Statistics, Series 2, No. 61?

aFor this report the data classified as “morbid” apply

to those visits where the principal diagnosis fell in

certain illness categories based on the Eighth Revision

International Classification of Diseases, Adapted for Use

in the United States (ICDA). These categories are

included in ICDA codes 000-279, 290-629, 680-738, and

780-796. Dkeases of the respiratory system are included

in the ICDA group code 460-519.

The scope of the survey and limitations of

the data are described briefly to assist in

interpreting the estimates. A detailed description

of the 1975-76 survey, including technical

details, definitions, and survey instruments,

appears in the appendixes. The 1975 and 1976

surveys were conducted identically using the

same instruments, definitions, and procedures.

The two years of data were combined to provide

greater reliability of estimates. Therefore, estimates of numbers of visits in this report are for a

2-year period, but ratios and rates represent

average annual estimates.

SCOPE OF THE SURVEY

The basic sampling unit for NAMCS

physician-patient encounter or visit.

is the

“En-

. . .

counter” and “visit” are used interchangeably in

this report.b Only visits in the conterminous

United States in the offices of nonfederally

employed physicians classified by the American

Medical Association (AMA) or the American

Osteopathic Association (AOA) as “office-baseda

patient care” were included in the 1975-76

NAMCS. In addition, physicians in the spe<ies of anesthesiology, pathology, and radiology

were excluded from the physician universe.

bThe term “contact” applies only to that part of the

visit or encounter that involved a face-to-face interchange between physicisn and patient.

1
Major types of ambulatory encounters not

included in the 1975-76 NAMCS were those

made by telephone, those made outside of the

physician’s office, and those made in hospital or

institutional settings. It is planned to extend the

NAMCS to include these encounters in the

future as resources permit.

The definitions of “office,” “physician,”

“patient,” and “visit” as they determine eligibility for NAMCS are presented in appendix II.

SOURCE AND LIMITATIONS

OF THE DATA

The data presented in this report were

derived from information provided by a national

probability sample of office-based physicians. A

sample of 6,529 physicians was contacted during

1975-76. Of the 5,604 physicians who were

eligible for the study, 4,476 (79.9 percent)

participated, providing data on a random sample

of some 114,000 patient visits.

Specially trained interviewers visited the

physicians prior to a designated reporting week,

provided survey materials, and informed each

physician and staff member of the methods and

definitions to be used. During a randomly

assigned 7-day reporting period, the sample

physician maintained a listing of all office visits.

For a systematic random sample of those visits,

data were recorded on an encounter form

provided for that purpose (see appendix III).

The three appendixes to this report provide

information necessary for proper understanding

and interpretation of the statistics presented.

Appendix I contains a general description of the

survey methods, the sample design, and the data

collection and processing procedures. Imputation methods, estimation techniques, and estimates of sampling variation are also presented.

Since the statistics in this report are based on a

sample of ambulatory visits rather than on all

visits, the y are subject to sampling errors.

ThereforE, particular attention should be paid to

the section in appendix I entitled “Reliability of

Estimates. ” Examples of relative standard errors

and instructions for their use are also given in

appendix I.

Definitions of the terms used in this report

and in the survey operations are presented in

appendix II. Facsimiles of survey materials,

including letters, Patient Record forms, and

Induction Interview forms, are in appendix ‘fiL

Data on the utilization of physicians’ services are also collected for the Health Interview

Survey (HIS), another program of NCHS, but

from a different universe. Estimates provided by

HIS may differ from those in NAMCS because

of differences in definitions, populations

sampled, and collection procedures. Data from

HIS are published in Series 10 of JZital and

Health Statistics.

hformation about a maximum of three

diagnoses for each sampled visit was collected

during the survey. Each participating physician

was requested to list on the data collection form

the principal diagnosis which was his evaluation

of the patient’s condition related to the chief

complaint or other reason for visit. Up) to two

additional significant diagnoses known to exist

for the patient at that time could also ble listed,

but these were not necessarily related to the

current visit. Diagnoses were classified and

coded according to the Eighth Revision International Classification of Diseases, Adapted for

Use in the United States (ICDA)$ The principal,

or first-listed, diagnosis is the primary emphasis

of this report. However, patterns of coexisting

diagnoses are often revealing, and additional

data regarding second- and third-listed diagnoses

are given when the y are relevant.

The data used” in this report encompass the

major ICDA category diseases of the respiratory

system (code 460-5 19). This report provides

detailed information about characteristics of

visits for selected most frequent, well-defined

diseases within the category, e.g., influenza

(ICDA code 470-474) and asthma (ICDA code

493).

‘This report is divided into two sections.

Section I describes visits for selected acute

diseases of the respiratory system; section H

includes selected chronic diseases of the respiratory system.

In NAMCS an “acute” condition is defined

as a condition or illness having a relatively

sudden or recent onset, i.e., within 3 months of
the visit. A “chronic” condition is a preexisting .

condition that began 3 months or more before

the visit (see appendix II). However, the acutechronic dichotomy used in this report is based

on the tradition that certain diseases, such as

asthma, are always considered chronic regardless

of the time of onset.

Since this report is an expansion of “a prior

report, 1 the basic estimates of numbers of visits

are the same. However, one change from the

earlier report should be noted. When the physician enters a diagnosis on the Patient Record as

%-onchitis” (without a qualification of “acute”

or “chronic”), it is coded in the survey as

“bronchitis, unqualified” (ICDA code 490).

Since the description of code 490 in the ICDA

reads in part “excludes acute bronchitis” (italics

added), this group of visits was added to the

group of visits for “chronic bronchitis” (code

491) in the first report. Later, when the data were

explored further for the current report, it was

observed that almost all of the visits in the

“bronchitis, unqualified” group were described

as “acute” in item 8 of the Patient Record (see

appendix H1).C Therefore, it was assumed that

when the physician did not precede “bronchitis”

with a descriptive term, he meant “acute bronchitis. ” Because of this change in interpretation,

the numbers of visits used in this report for the

two diseases, “acute bronchitis” and “chronic

bronchitis,” are different from those shown in

Advance Data No. 41.1

Prevalence of a disease cannot be deduced

from the number of physician visits. These visits

do not necessarily reflect the degree to which a

condition is present in the population even

though visits to the physician’s office may be

motivated by a pathological condition or the

visit may result in the detection of the condition. NAMCS was designed to provide information about the provision and use of certain

ambulatory medical care services and is therefore a rich source of data concerning utilization

of physicians’ services when visits are characterized by specific diseases. Prevalence data may be

cItem 8, major reason(s) for visit, was not used as a

source of data for the less detailed advance report.

obtained from other surveys conducted by

NCHS.d

ALL DISEASES OF THE RESPIRATORY

SYSTEM

Visits for respiratory conditions were more

common among patients less than 15 years old

than among older patients. Table A shows that

about 28 percent of all office visits by patients

Table A. Number and percent of office visits for all diagnostic

classes and for diseases of the respiratory system, by patient

sex, race, and age: United States, 1975-76

Sex, race, and age

All visits ...

Sax and race

Female ... ......

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

Black and all

other races ..... .....

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

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

Black and all

other races ..........

Aoe

Under 15 years . .. .... .

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

26-34 yaars .... .... .....

3544 years ....... .. .. ..

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

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

65 years and over ....

All ICDA

diagnostic classasl

Number of

visits in

thousends

1,155,800

697,727

625,201

72,525

458,174

413,320

44,853

208,005

174,974

171,827

122,805

147,082

143,060

187,148

Percent

of

visits

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

Diseases of the

respiratory systeml

Number o

visits in

thousand!

163,401

87,464

76,850

10,614

75,937

67,947

7,990

58,036

21,833

20,532

15,001

16,552

16,362

15,086

Percent

of

visits

14.1

12.5

12.3

14.6

16.6

16.4

17.8

27.8

12.5

12.0

12.2

11.3

11.4

8.1

1Based on the E&hth Revision International~f?.?Sijkat7k7nOf

Diseases, Adapted for Use in the United States (ICDA).

‘For example, see publications of MS (Series 10) and

the Health and Nutrition Examination Survey (Series 11).

3
Table B. Number and percant distribution of office visits for acute and chronic diseases of the respiratory system, by diagnosis:

United States, 1975-76

Diagnosis and ICDA Codel

All respiratory disease diagnoses ......... ........ .............. ........ ...... ........ ...... .............. ........ .... ........ 460-519

Acute upper respiratory infections, axcept influenza ............................ ........ ...... ........ .............. .... .. 460466,490

Acute nasopharyngitis (common cold) ....... ........ .. .... .......... ...... ............ ........ ...... ........ .. ............ .......... ..... 460

Acute sinusitis .. .................... .. ...... .............. .. .. .......... ........ ...... .. ...... ...... .... .... .. .. .... ...... ........ ..................... 461

Acute pharyngitis .......... .. .......... .... ...... .. ...... .. .... .. .... .... ........ ...... .... .... ...... ...... ...... ...... ........ ...... .. .............. 462

Acute tonsillitis ... .... ...... ........ ...... ........ ...... ........ .. ............ ........ ...... .............. .. ...... .............. ...................... 463

Acute laryngitis and tracheitis ...... .................... .. ...................................... ............ .............. ...... ........ ....... 464

Acute upper respiratory infection of multiple or unpacified sites ......... .............. ...... ................ ...... ....... 465

Acute bronchitis and bronchiolitis, and bronchitis unqualified ..... .. .... .................. .. ........ ........ ...... .. 466,490

Influenza ...... ...... ........ ...... .. ...... .............. .... ...... ........ ........ ...... ...... .. ...... .............. ........ ............................ 470-474

pneumonia .......... ........................ .................................... .............. .............. ............ .......... ..................... 480-486

Chronic diseasas of tha respiratory system ..... .. ...... ........ ...... .............. ........ ...... .. ...... ...... . 491493, 502-503, 507

Chronic bronchitis ...... .. ............ .. ...... .......... ........ .... .. ...... .. .... .......... ............ .. ............ .. ...... .. .... .... ............. 491

Emphysema ......... .. .. .... .. .... ........ .. ...... .. ........ .. .. .. ............ .. .. ...... .... .. ........ .... .... .... .. ........ ............................ 492

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

Chronic pharyngitis and nasopharyngitis ................................. .................. ........ .............. ........ .............. .. 502

Chronic sinusitis ... ...... .. .... .... ...... ........ .............. ........ ...... .. .. .... ...... ........ ...... .. .. .... ...... ................ ............... 503

Hay fever ........................... ........ ........ ...... ...... .. .............. ............................ .............. ................................ 507

Other acute and chronic disaases of the respiratory system .. ...................... .... .. 500-501, 504-506, 5138, 510-519

dumber of

visits in

thousands

163,401

92,705

4,445

2,598

17,414

12,573

2,982

33,248

19,446

10,312

5,194

45,602

1,646

5,223

10,591

2,486

8,284

17,012

9,589

Percent

distribution

100.0

56.7

2.7

1.6

10.7

7.7

1.8

20.3

11.9

6.3

3.2

27.9

1.0

3.2

6,7

1.5

5.1

10.4

5.9

~Basedon the Eighth Revision Intemational Classificationof Diseases, Adapted for Use in the United States (~C~A).

less than 15 years old were for treatment of a

respiratory disease, but only from 8 to 13

percent of visits by patients 15 years or older

were for similar conditions. The respiratory

disease category comprised the highest proportion of visits by patients under 15 years old of

all ICDA groups. There was some variation in

the age distribution of visits, however, when

specific acute and chronic diseases were considered separately. Age statistics for specific

diseases are presented in Sections I and II and in

the detailed tables associated with each section.

Table B shows that more than half of the

patients in the respiratory disease group who

visited physicians had acute upper respiratory

infections; Approximately 10 percent of the

visits were made for influenza and pneumonia,

and 28 percent of the office visits were made for

six chronic respiratory problems.

Section 1 of this report presents estimates of

visits for specific acute respiratory diseases in

terms of physician specialty, patient characteristics, and clinical characteristics-presenting

symptoms, associated diagnoses, and patient

management. A similar description is provided for

chronic respiratory diseases in Section 11. Section I also includes a discussion of influenza

visits for the 3-year period 1974-76.

SECTION 1. ACUTE DISEASES OF THE RESPIRATORY SYSTEM

PATlENT CHARACTERISTICS comprise the acute upper respiratory infections

group, as well as for influenza and pneumonia,

Estimates of visits for the six diseases which are detailed by patient sex, race, and age in table
1. The median visit age for these conditions

varied from 10.7 years for acute tonsillitis to

39.9 years for acute sinusitis.e

As a basis of comparison for the median visit

ages shown in table 1, it should be noted that the

median age of the civilhn population of the

United States in 1976 was 29.1 years,5 and the

median visit age for all NAMCS visits in 1976

was about 37 years.

Figure 1 illustrates average annual visit rates

for acute upper respiratory infections (acute

URI’S). The plot hig~lghts the large difference

between the visit rate of patients less than 15

years old and those of older age groups. The visit

rate curve for pneumonia, shown in figure 2, is

flatter than the URI curve in figure 1, and the

differences in pneumonia rates among the age

groups are not statistically significant.

‘Median visit age should not be confused with

median patient age. The calculation of median visit age

includes all visits and the same patient may be counted

more than once.

+

~

>

100 -

50-

I I I 1 I I 1

0 Under 15.24 2S.34 35.44 45-54 55-64

15

65 and

over

AGE IN YEARS

..—_ .— ----

Figure 1. Average annual rate of office visits for acute upper

respiratory infections, except influenza (460-466, 490), by

patient age: United Statas, 1976-76

,~

Urder 15-24 25-34 3544 45.54 55.64 S5 and

15 over

AGE IN YEARS

Figure 2. Average annual rate of office visits for pneumonia

(460-466), by Patientage:United States, 1975-76

INFLUENZA

There has been heightened interest in influenza data in recent years due to outbreaks of

various strains of influenza virus throughout the

country. Influenza surveillance data, collected

and published by the Center for Disease Control

(CDC),’Y 7 provide information on influenza

gathered from, among, other sources, State epidemiologists reporting on emergency room visits

and from about 191 “physician reporting units.’”f

A series of special weekly reports on flu-like

illnesses, issued by NCHS, was based on information collected from a national sample of households queried in HIS. 8 However, NAMCS is the

only source of national data on the utilization of

office-based medical care as a result of an illness

diagnosed by the physician as influenza. Therefore, this report includes separate influenza

estimates for 1974, 1975, and 1976 {rather than

estimates for combined years 1975 and 1976 as

with other diagnoses described in WIS report).

Table C shows the number and annual rate

of influenza visits and visit rates by four

geographic regions for each of the three years.

The year 1975 ranked first in visit volume and

rate, with 1976 second and 1974 last. Visit rates

fCDC Report No. 91“ describes “physician reporting

units” as “sentinel physiciau reporters or routine coumty

or State morbidity reporting. ”

5
Table C, Number of office visits for influenza (470-474) and

annual rate of office visits, by geographic region and year:

Unitad States, 1974-76

Geographic region

All visits ................. ....

All regions .................

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

North Central .............................

South .........................................

West ...................... ...... .......... .....

Year

EIEIIE

Number in thousands

3,755 I 6,123 I 4,189

Visit rate per 1,000 in

population

n

18.2 29.4 20.0

9.7 16.3 14.7

19.8 58.6 15.2

22.4 17.1 23.3

19.8 25.0 28.4

were adjusted for changing yearly regional populations and are, therefore, comparable across

years and regions. For example, the Northeast

Region rate in 1974 of 9.7 visits per thousand

persons is the lowest rate shown in the table. In

contrast, the North Central Region rate in 1975 of

58.6 exceeds all others.

Influenza rates by patient age for 1974,

1975, and 1976 are plotted separately in figure

3. Visit rates in 1975 for patients 25-54 years

old were higher than they were for that age span

in the other two years. For patients aged 55

years and older, 1975 rates exceeded those of

1974 but were not statistically different from

those of 1976. Differences in visit rates for

patients less than 25 years old were also not

statistically significant. Therefore, most of the

increased visit rate in 1975 may be attributed to

visits by patients 25-54 years old. Furthermore,

other NAMCS data indicate that the number of

influenza visits in 1975 by patients in that age

group in the North Central Region were more

than double the 1974 and 1976 volume in the

same area.

The data seem to indicate a high concentration of influenza visits by patients 25-54 years

of age in the North Central Region during 1975.

However, it is difficult to be certain, from

NAMCS data alone, that this was not a statistical

I I I I I I I I

o Under 15.24 2534 3a.44 4554 55.64 6!5and

15 over

AGE IN YEARS

Figure 3. Average rate of office visits for influenza (470-474) for

1974, 1975, and 1976, by patient age: United States

quirk. There is no precise way to validate these

data. Furthermore, office visits may or may not

be a real index of increased incidence of dhease

because of the many other factors which affect

office visits. On the other hand, there is some

evidence reported by CDC of “high influenza

activity” in 1975 which affected some of the

States in the North Central Region.G This

outbreak was less related to older persons than

the 1976 outbreak was.g Figure 3 shows that in

1975 the highest visit rate was in the age group

35-44 years, while in 1976 patients 55-64 years

old made office visits more frequently. To some

degree these findings support CDC data.

However, it should be. noted that many

factors motivate physician visits. For example,

the outbreak of swine flu in early 19757 might

have precipitated the upsurge in office visits by

—

gPersonal communication with CDC representative.

6
patients with febrile upper respiratory illnesses

during the balance of the year.

Reports from CDC and HIS indicate that

influenza epidemics typically occur in the fourth

calendar quarter of a year and in the first

quarter of the succeeding year.6’8 It is instructive, therefore, to examine office visit data

during the four quarters of each of the three

years of interest for their degree of consistency

with HIS and CDC data. The NAMCS quarterly

visit estimates for 1974-76, charted in figure 4,

appear to support these epidemiological findings

since the highest proportions of visits for each

year are in the first and fourth quarters. The

beginning of 1975 appears to have had the most

influenza visit activity.

CLINICAL CHARACTERISTICS

Coexisting Diagnoses

Over 92 million visits in 1975-76 were due

primarily to an acute upper respiratory infection

other than influenza. Since patients who suffer

from acute respiratory problems often also have

other acute and chronic conditions, data on

second- or third-listed diagnoses should be

examined. The most frequent second or third

diagnoses noted by physicians when patients

visited for acute UIU are shown in table D. Since

all but three of the diagnoses listed are among

the top 25 ranking conditions seen by physicians

in 1975-76, it is not unusual to find them

associated with the over 92 million visits for

acute URI. However, visits for chronic sinusitis,

diarrheal disease, and other diseases of the blood

and blood-forming organs (chiefly lymphadenitis), which are not as highly represented in the

total NAMCS visit count, appeared frequently

with acute UIU.

Patient Problems, Complaints, or Symptoms

Patients’ principal problems, complaints, or

symptoms—the reasons for visit-have been identified and coded according to a taxonomy

developed for NAMCS.9 The reason for visit as

expressed by the patient that the physician

5,0m

[

4,000

3,W0

2,DO0

[

1,Ooa

80+)

eoo

4C0

202

0

quartel

— IL,’

:,.,,,, ,,,:,,.,

md Th!rd Fourrh

quarter quartet

Q1974

~1975

@1976

—

q.”aner

1974 1975 1976

CALENDAR CIUARTE R AND YEAR

Figure 4. Number of office visits for influenza (470474) by calendar quarter and year: United States, 1974-76

7
Table D. Number and percent of office visits for acute upp,er

respiratory infections except influenza (460466, 490) by

most frequent second- or third-listed diagnosis in rank order:

United States, 1975-76

Rank

1

2

3

4

5

6

7

8

9

10

11

Second- or third-1 isted

diagnosis

and ICDA code 2

All visits ............460466.490

Otitis media ........ .. ............ ..... 381

Essential benign hypertension ....... ...... ........ ............ 401

Heart disease ............. ..... 410429

Chronic sinusitis ..... .............. . 503

Hay fever ............................... 507

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

Other diseases of blood and bloodforming organs4 ... .. .... ........289

Obesity, not specifiad as of

endocrine origin .......... .. ...... 277

Diabetes mellitus ... ................250

Diarrheal disease .... .. .... .. ...... .. 009

,Other eczema and

dermatitis . ......................... 692

Wsmber of

visits in

thousands

92,705

2,768

1,298

1,044

912

849

808

780

773

760

679

635

Percen t3

100.0

3.0

1.4

1.1

1.0

0.9

0.9

0.9

0.8

0.8

0.7

0.7

INumber of “iSits for different second or third diammsesare

not additive since more than one diseaw may have been

diagnosed during the same visit.

2Based onthe Eighth Revim”on International ~m@CatiOnOf

L&eases, Adapted for Use in the United States (lCDA).

3F’ercents will not add to 100.0 because only the mOSt

frequent second or third diagnoses are listed in the table.

41n~ludes lymphadenitis, unspecified, except meSenteriC.

s[n~hrdes allergy or allergic reaction, not elsewhere classified.

judged most responsible for the patient making

the visit was entered on the Patient Record. In

NAMCS this is considered the principal problem,

complaint, symptom, or reason for Visit.h The

physician may also list other significant problems in order of their importance at that visit.

Patients with respiratory illnesses rarely

present a solitary symptom; a complex of

symptoms, or syndrome, is more likely to be

present during a visit. Therefore, the problems

listed in rank order of number of visits (table 2)

should be interpreted from this perspective. In

this table each acute respiratory disease diagnosis is listed with its most frequently associated

reasons for visit. These latter are presented in

‘The terms “problem, “ “complaint,” or “symptom”

and “reason for visit” are used interchangeable y in this

report.

the table as principal and secondary or tertiary

symptoms. Since order may not be a distinguishing Characteristic of symptomatology, it is

logical to add the number of visits fcw a given

principaI problem to the number of visits Iisted

second or third. The extent of pervasiveness of a

problem in a given diagnosis may then be

gauged. For example, “cough” was the principal

symptom causing about 8.4 million visits for

acute bronchitis, but there were an aldditiond

2.7 million visits for acute bronchitis in which

cough was listed second or third, making a total

of about 11.1 million visits in which cough was

part of the bronchitis syndrome.

Cough, cold, sore throat, and fever were

symptoms commonly presented during visits for

most acute respiratory conditions. The problem

of chest pain was prominent only with a

diagnosis of bronchitis.

Seriousness and Status of the Problem

Physicians were requested to judge ~the

seriousness of the patients’ problem based on

the extent of impairment that might result if no

care were available. A four-point scale ranging

from “not serious” to “very serious” was used in

the survey. Although a definition of “seriousness” was provided to all participants, it is

difficult to estimate the degree of adherence to

it. Such evaluation is often highly subjective.

The data should be viewed in this context.

Additionally, “not serious” cannot be equated

with “unnecessary. ” For example, while the

physician may consider a mild sore throat “not

serious, ” the physician’s clinical judlgment is

needed to make that decision.

Table 3 shows the results of evaluating the

severity of principal problems associated with

acute respiratory diseases. Except for pneumonia, most diagnosed problems for w’hich visits

were made were judged “not serious” or

“slightly serious. ” Table 3 also provides information on problem status, i.e., whether the

problem was presented by a patient far the first

time or whether the problem was presented for

continuing care. Patients making an office visit

to their physician for acute respiratory

diseases except Pneumonia were ‘likely to

present new r~the~

Since most acute

than continuing problems.

respiratory probdems are

8
usually short-duration, self-limiting conditions,

these outcomes were not unexpected.

Diagnostic and Therapeutic Services

Table 4 shows data on the number of types

of diagnostic and therapeutic services rendered

during visits for various acute respiratory

diseases. Table 5 presents proportions of visits

which included selected diagnostic and therapeutic services. Tables 6, 7, and 8 show data on

selected services rendered when patients visited

for acute URI, influenza, and pneumonia in

terms of patient age and sex and problem status.

Two or more services were provided for

ahnost all visits (table 4), and these services were

most likely to be a limited examination and/or

history and drug therapy. For all diagnoses listed

in table 5, except bronchitis and pneumonia, the

proportion of visits including X-rays was lower

than the average for all NA.MCS visits. Like visits

for most conditions other than circulatory,

proportions of visits in which blood pressure was

measured were lower than average.

Visit Disposition and Duration

Other aspects of patient management included in NAMCS concern the disposition and

duration of the visit.

For most of the acute respiratory conditions

shown in table 9, patients were told to “return if

needed” more often than they were given other

instructions. When pneumonia was diagnosed,

however, patients were more likely to be instructed to return at a specified time. The visit

disposition selected by the physician appears to

reflect the seriousness he attached to the problem. Only in the case of visits for pneumonia,

which was more likely than other diagnoses to

be judged serious or very serious, was the

“return at a specified time” instruction given

more frequently than other instructions. Physicians were more likely to plan no followup when

respiratory diseases were diagnosed than when

visits were due to other morbidity-related ~

disease categories. This reflects the many visits

for self-limiting conditions. “

Visit duration is the physician’s estimate of

the amount of time spent in direct encounter

with the patient. Contact duration when only

staff personnel see tne patient is included in the

survey but excluded from the calculation of

mean contact duration. Table E shows the

average number of minutes per visit for visits

that included a contact with the physician. The

mean contact duration of all NAMCS visits was

about 15.3 minutes. The mean duration of

bronchitis, influenza, and pneumonia visits did

not differ significantly from this average, but

visits for other acute conditions lasted less than

the average time. Proportions of visits are

categorized by time intervals in table 9.

‘ These statistics do not reflect the time

physicians spend in patient care which is not

necessarily in the presence of the patient, such

as evaluating test results, reviewing histories, and

reading X-rays.

Table E. Mean contact duration in minutes of office visits and

standard error of the mean, by selected acute diseases of the

respiratory system: United States, 1975-76

Diagnosis and ICDA codel

Acute nasopharyngitis and acute upper

respiratory infection of multiple or

unqmcif ied sites ..................460. 46!5

Acute sinusitis .... .............................. 461

Acute pheryngitis ........... .. ................ 462

Acute tonsillitis ................................ 463

Acuta laryngitis and tracheitis ..........464

Acute bronchitis and bronchiolitis and

bronchitis unqualified .........466.490

Influenza ........ ........ .......... ......... 470-474

Pneumonia ............ .... .. .............. 48046

Contact duration in

minutes

Standard

Mean2 error of

the mean

i

10.9

10.3

10.8

10.4

12.0

12.5

14.0

13.4

0.27

2.10

0.26

0.32

0.69

0.27

1.68

0.47

I I

lB~ed on the Eighth Revision htenrrZtfOrrd ~SsiyiCatiOtr Of

Diseases, Adapted for Uk? in the United States (ICDA).

2Tirne spentti face-to-face encounter between patient and

physician.

Physician Specialty

Table 10 shows the distribution of visits for

selected acute respiratory conditions according

to physician specialty. The highest proportions

of visits for these respiratory diagnoses, except

9
for acute laryngitis and tracheitis, were to the

offices of general and family practitioners

(GFP’s). This was not an unexpected result since

GFP’s constitute the highest proportion of

office-based physicians in the United States. *”

Tables 11 and 12 show the proportions of

visits to various specialists for acute URI, influSECTION Il. CHRONIC DISEASES

The six chronic diseases highlighted in this

section are listed in table B. These conditions

accounted for about 28 percent of the visits in

the respiratory disease category; the greater

share of this number were due to hay fever (10

percent) and asthma (7 percent).

PATlENT CHARACTERISTICS

Patients visiting physicians for these six

chronic conditions were generally older than

those visiting for the acute conditions described

in Section I. Table 14 shows that the median

visit age ranged from 27.3 years for hay fever to

64.7 years for emphysema. (Almost all visits for

emphysema were by patients 45 years of age and

older.)

Figure 5 illustrates the visit rates for hay

fever and asthma. The asthma curve has a drop

in visit rate at age group 15-24 years, with a

subsequent rise until age 64 years. According to

a recent report from the National Institutes of

Health’s NationaJ Heart, Lung, and Blood Institute (NHLBI), asthmatic children may go

through a disease-free period durin puberty but

may P have recurrences later in life. 1 The NHLBI

can offer no reason for this phenomenon which

appears to be reflected in the office visit rates

illustrated in figure 5. There is a drop in the rate

of hay fever visits after age 34 years which may

be related to the fact that immunotherapy over

time is known to reduce the severity of the

problem. (Data on the major reason for visit

obtained from item 8 of the Patient Record

indicate that the purpose of 23 percent of all

visits by patients with hay fever was immunization or desensitization.)

enza, and pneumonia by patient age, problem

status, and selected services.

The large proportions of visits to pediatricians reflect the young age which is characteristic of visits for respiratory problems. A further

age breakdown of visits to pediatrician is

p~ovided in table 13.

OF THE RESPIRATORY SYSTEM

60 r

10

t

urger 15.24 25.34 35-!4 45.54 55.64 65 and

over

AGE IN YEARS

Figure 5. Average annual rate of office visits for hey fever and

asthma, by patient age: United States, 1976-76

As with most NAMCS visits, proportions of

female,s visiting for most respiratory illnesses

exceeded those of males. However, male visits

clearly exceeded female visits when the diagnosis

was emphysema.

CLINICAL ClCoexisting DiagnosesARACTERISTICS

Patients with chronic respiratory diseases are

known to have frequent episodes of acute

respiratory and other infections, When such

episodes occur, the current problem is usually

indicated on the Patient Record as the principal

10
.

diagnosis. Section I showed that many patients

visiting physicians for treatment of acute UR.I

also had chronic sinusitis, hay fever, and asthma

(table D).” Therefore, two factors should be

examined—the number of visits in which the

chronic problems were listed as second or third

diagnoses (as an aid to estimating their total visit

incidence) and the frequency of other types of

diagnoses when the chronic respiratory conditions were the principal diagnoses. Principal

diagnoses alone tend to underrepresent the

number of times a given diagnosis is a recognized

condition of the patient.

By adding the number of visits for each

disease shown in table F to the number of visits

in which each was a principal diagnosis (table B),

more realistic estimates of visit incidence may be

obtained for these diagnoses. For example,

asthma was the principal diagnosis in about 10.6

million visits but was also a listed diagnosis in an

Table F. Number of office visits by selected chronic diseases of

the respirato~ system listed as second or third diagnosis:

United States, 1975-76

Number of

Diagnosis and ICDA codel visits in

thousands

Emphysema ............ .............. .................. ....... 492 4,592

Asthma ..... ...................... ............ ...... ........ ..... 493 4,503

Chronic pharyngitis and nasopharyngitis .......502 1,367

Chronic sinusitis ............ ........ ...... ...... ........ .... 503 4,599

Hay fever ................................. ...................... 507 5,919

1Bssed on the Eighth Revi.yt”onIntemati”onal~aSSs.fiCatiOnOf

Diseases,Adapted for Use in the United States (lCDA).

additional 4.5 miIIion visits, making a total of

approximately 15.1 milIion visits in which the

patient was identified as having the condition.

Similarly, 22.9 million visits included hay fever

patients.

Diseases that most frequently coexisted with

the principal diagnoses of emphysema, asthma,

and hay fever are shown in table G. Asthma and

hay fever were highly concomitant. Heart disease was the most frequent second or tl+rd

diagnosis when emphysema patients visited, not

a surprising finding in view of the similar age

range for both conditions. Another NCHS report

on diseases of the circulatory system also

pointed out the frequent coincidence of emphysema with coronary heart disease during physician visits.2

Patient Problems, Complaints, or Symptoms

Table 15 lists the symptoms most frequently

associated with visits for chronic respiratory

diseases. Proportions of visits in which patients

presented certain symptoms are listed according

to the symptoms’ assignment to primary status

and to that of lesser importance at that visit in

the physician’s judgment. The order of given

symptoms may not be realistic for respiratory

illnesses because of accompanying multiple

symptoms.

The reason “visit for medication” was given

in 12 percent of asthma visits and 17 percent of

hay fever visits. This reason category includes

therapeutic measures such as allergy shots and

immunizations.

Table G. Numoer and percent of office viks by principal diagnosis and most frequent second- or third-listed diagnosis:

United States, 1976-77

Principal diagnosis and Number of Second- or third-listed Number of

ICDA codel visits in Total diagnosis and ICDA codel~2 visits in Percent

thousands thousands

Emphysema .......... .... .... .. .................. ..... 492 6,223 100.0 Heart disease ..................... ...... .... .. 41 O-429

Asthma

814 15.6

......... ............ .................. ........... 493 10,951 100.0 Hay fever ............. .................. ............. 507 1,361

Hay fever ........................ ....................... 507

12.4

17,012 100.0 Asthma ............................ ................... 493 1,330 7.8

.?Based on the E@hth Revision InternationalCZasss-jicationof Disea.ws,Adapted for U&?in the United States (ICDA).

2Nuber of ~i~it~ for diff’’rent ~eCond- or third-listed diagnoses are not additive since more than one disease maY have been

diagnosed during the same visit.

11
Shortness of breath was cited as the principal problem during 13 percent of asthma visits

and about 42 percent of emphysema visits.

Seriousness and Status of the Problem

By their nature, chronic respiratory diseases

were more often continuing problems than they

were new problems. Of those diseases shown in

table 16, visits for emphysema were proportionately more often judged serious or very

serious than were the other diagnoses. While

more than half of the visits for pharyngitis,

sinusitis, and hay fever were evaluated as “not

serious, ” this does not preclude the necessity for

care and surveillance of these conditions.

Diagnostic and Therapeutic Services

Tables 17 and 18 provide information on the

number and types of diagnostic and therapeutic

services rendered. Typical of most visits, the

limited examination and/or history and drug

therapy were widely used. The percents of visits

which included blood pressure checks were

higher than average for visits including diagnoses

of chronic bronchitis and emphysema. It has

been shown that blood pressure measurement

during physician visits is more related to patient

age than to the presentation of problems associated with hypertension, with use of the

procedure increasing as patients age. 12 The

frequent use of the sphygmomanometer during

bronchitis and emphysema visits may be due to

the nature of the problem or to the older

median visit age related to these two diseases.

A high degree of immunotherapy was used

during visits for asthma (41 percent) and hay

fever (53 percent).

Table 19 gives additional data on services by

patient age and sex and problem status for

asthma visits, and table 20 gives the same

information for hay fever visits.

Visit Disposition and Duration

Table 21 shows that the most frequent

instruction given patients with chronic respiratory dkeases (except sinusitis) was to return at a

specified time. No followup was planned in only

a small proportion of visits. The findings are in

contrast to those for acute respiratory dkease

visits, at which physicians more often made no

plans for follow-up or told the patient to return

if needed.

Table H shows that there was little variation

in mean contact duration among the chronic

respiratory diseases. Visits for chronic problems

lasted longer than did those for acute URI (table

E), reflecting the more intensive care required in

treating chronic illness. However, the mean

duration of these visits was” close to the average

for all NAMCS visits.

Table H. Mean contsct duration in minutes of office visits and

standard error of. the mean, by selected chronic diseases of

the respiratory system: Unitad Statas, 1975-76

Diagnosis and ICDA Codel

Chronic bronchitis ...... .............. ............... 491

Emphysama ....................... .............. ........ 492

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

Chronic pharyngitis and

nasopharyngitis .......... ..... .................... 502

Chronic sinusitis ....................................... 503

Hay fever .... .................. ........ .. ............. .... 507

:ontact duration

in minutesz

Standard

Mean error of

the maan

7

17.6 1.22

17.1 .71

15.2 .76

1- 13.1 1.30

13.1 .93

13.7 .75

1Based on the EighthRevision InternationalCISSSijiCatiOnOf

Disease&Adapted for Use in the United States (ICDA).

2 Time spent in face-to-face encounter between pafiek and

physician.

Additional details on proportions of visits by

time intervals may be found in table 21.

Physican Specialty

Table 22 shows that the majority of visits

for chronic bronchitis, emphysema, and chronic

sinusitis were to GFP’s.

Internists treated a higher proportion of

patients visiting for emphysema than they did

those with other respiratory diseases and were

responsible for the second highest proportion of

visits to all physicians for that problem. Since

about two-thirds of all visits to internists were

by patients 45 years of age and older, internists

12
saw more respkatory problems related to the

elderly, such as ‘emphysema, than those related

to the young, such as acute URI.13

The highest proportions of asthma (32 percent) and hay fever (31 percent) visits were to

allergists and to general and family practitioners,

who treated 30 percent and 26 percent, respectively. Pediatricians saw about 22 percent of all

patients visiting for asthma and 18 percent of

those visiting for hay fever. The pediatrician’s

caseload accounted for 58 percent of asthma

visits to specialists by patients under 15 years

old and 49 percent of all hay fever visits. Table

23 shows the number and percent of office visits

to pediatricians for asthma and hay fever by

patient’s age group.

Data are listed in table 24 on the dktribution of asthma and hay fever visits to various

specialties according to patient age, problem

status and diagnostic and therapeutic services.

000
REFERENCES

1National Center for Health Statistics: Office visits

for respiratory conditions: National Ambulatory Medical

Care Survey, United States, 1975-76, by B. K. Cypress.

Advance Data From Vital and Health Statistics, No. 41.

DHEW Pub. No. (PHS) 79-1250. Public Health Service.

Hyattsville, Md. Oct. 30, 1978.

2Nation~ Center for He~th s~ti~tics: Office ~sits

for diseases of the circulatory system: National Ambulatory Medical Care Survey, United States, 1975-76, by

B. K. Cypress. Vital and Health Statistics. Series 13-No.

40. DHEW Pub. No. (PHS) 79-1791. Public Health

Service. Washington. U.S. Government Printing Office,

Jan. 1979.

3National Center for Health Statistics: National

Ambulatory Medical Care Survey: Background and

methodology, United States, 1967-72, by J. B.Tenney et

al. Vital and Health Statistics. Series 2-No. 61. DHEW

Pub. No. (HRA) 741335. Health Resources Administration. Washington. U.S. Government Printing Office, Apr.

1974.

4National Center for Health Statistics: Eighth Revision International Classijicatz”on of Diseases, Adapted for

Use in the United States. PHS Pub. No. 1693. Public

Health Service. Washington. U.S. Government Printing

Office, 1967.

5U.S. Bureau of the Gmsus: Estimates of the population

of the United States by age. Current Popula tion Reports.

Series P-25, No. 643, Washington. U.S. Government

Printing Office, Jan. 1977, Table 3, p. 13.

6Center for Diseme Control: Injluen.za surveillance.

Report No. 90. DHEW Pub. No. (CDC) 748207. Center

for Disease Control. Atlanta, Ga., Feb. 1976.

7Center for ~~sease Control: Influenza s~~eillance.

Report No. 91. DHEW Pub. No. (CDC) 77-8295. Center

for Disease Control. Atlanta, Ga., July 1977.

8 National Center for Health Statistics: Final weekly

report, Esti”mates of flu-like illnesses from the National

Center for Health Statistics for Week Ending April 17,

1977. Report No. 28. Public Health Service. Rockville, Md.

9National Center for Health Statistics: The National

Ambulatory Medical Care Survey, Symptom classification, by S. Meads and T. McLemore. Vital and Health

Statistics. Series 2-No. 63. DHEW Pub. No. (HRA)

74-1337. Health Resources Administration. Washington.

U.S. Government Printing Office, May 1974.

10 Center for Health Services Research and Development: Phyn”cian Distribution and Medical Licensure in

the U.S., 1975, by L.J. Goodman and H. R, Mason.

Op-464. American Medical Association. Chicago, Ill.,

1976.

11National Heart, Lung, and Blood Institute: Respiratory diseases, Task Force on Prevention, Control,

Education, March 1977. DHEW Pub. No. (NIH)

77-1248. National Institutes of Health. Washington. U.S.

Government Printing Office, 1977.

12Cypress, B. K.: The role of ambulatory medical

care in hypertension screening. Am. J. Public Health.

69 (l): 19-24, Jan. 1979.

13Nation~ Center for He~th Smtistics: Offic{> ~sits

to internists: National Ambulatory Medical Care Survey,

United States, 1975, by B. K. Cypress. Vital and HeaUh

Statistics. Series 13-No. 36. DHEW Pub. No. (PHS)

79-1787. Public Health Service. Washington. U.S.

Government Printing Office, Dec. 1978.

14National Center for Health Statistics: Replication,

AU approach to the analysis of data from complex

surveys, by P. J. McCarthy. Vital and Health Statistics.

Series 2-No. 14. DHEW Pub. No. (HSM) 73-1269. Health

Services and Mental Health Adminishation. Washington.

U.S. Government Printing Office, Apr. 1966.

15National Center for Health Statistics: Pseudoreplication, Further evaluation and application of the

balanced half-sample technique, by P. J. McCarthy. Vital

and Health Statistks. Series 2-No. 31. DHEW Pub. No.

(HSM) 73-1270. Health Services and Mental Health

Administration. Washington. U.S. Government Printing

Office, Jan. 1969.

14
LIST OF DETAILED TABLES

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

Number, percent distribution, and average annual rate of office visits for selected acute diseases of the respiratory system

and percent distribution for all other morbidity-related groups, by selected patient characteristics: United States, 1975-76 .. ..

Number and parcents of office visits for selected acute diseases of the respiratory system by principal diagnosis and by

patient principal and second- or third-listed problem: United States, 1975-76 .. ....... ........... ....... ...............................................

Number of office visits for selected acute diseases of tha respiratory system and percent distribution of visits by problem

status and by problem seriousness, according to diagnosis: United States, 197S76 .... .. .................................. ............ ...... ........

Number of office visits for selected acute diseases of the respirato~ system and percent distribution of visits by number of

types of diagnostic and therapeutic services ordered or provided, according to diagnosis: United States, 1975-76 ... ...... ...... .. ..

Number of office visits for selected acute diseases of the respirato~ system and for all other morbidity-related groups by

diagnostic or therapeutic services ordered or provided, by diagnosis: United States, 1975-76 .................................. .................

Number and percent of office visits for acute upper respiratory inf actions except influenza (460466, 480) by selected

diagnostic or therapeutic sewices orderad or provided, by patient age, sex, and problem status: United States, 197576 ..... ....

Number of office visits for influenza (470-474) and percent of visits by diagnostic or therapeutic sewices ordered or

provided, by patient age, sex, and problem status: United States, 1975-76 .. ........ ...... ...... ............................... ........................ .

Number of office visits for pneumonia (480486) and percent of visits by diagnostic or therapeutic sewices ordered or

provided, by patient age, sex, and problem status: United States, 1975-76 ...................... ...... ...... .................................... ........

Number of office visits for selected acute diseases of the respiretory system and for all other morbidity-related groups and

percent distribution by duration and disposition of visits, by diagnosis: United States, 1975-76 .. ...... ............ .......... ...... ..........

Number of office visits for selected acute diseases of the rezpiretory system and percent distribution of visits by physician

specialty, according to diagnosis: United States, 1975-76 .... ............ ...... .............................................................................. .....

Percent distribution of office visits for sate upper respiratory infections except influenza (460-466, 490) by patient age,

problem status, and selected sewices, according to physician specialty: United States, 1975-76 ........... ....................................

Percent distribution of office visits for influenza (470-474) and pneumonia (480-486) by patient age, problem status, and

selected services ordered or provided, according to physician specialty: United States, 1975-76 ............................ ........ ..........

Number of office visits to pediatricians and percents of visits made by patients under 15 years of age for sdected acute

diseases of the respiratory system and percent of visits by age of patient: United States, 1975-76 ....................... .................. ..

Number, pement distribution, and average annual rate of office visits for selected chronic diseases of the respiratory system

and percent distribution for al I other morbidity-related groups, by selected patient characteristics: United States, 1975-76 ....

Number and percents of office visits for selected chronic diseases of the respiratory system by principal diagnosis and by

patient principal and second- or third-listed problem: United States, 1975-76 .......................... ........................................ ........

Number of office visits for selected chronic diseases of the respirator system and percent distribution of visits by problem

status and by problem seriousness, according to diagnosis: United States, 1975-76 ..................................................................

Number of office visits for selected chronic diseases of the respiratory system and percent distribution of visits by number of

types of diagnostic and ther+eutic sewices ordered or providad, according to diagnosis: United States, 1975-76 ...................

Number of office visits for selected chronic diseases of the respiratory system and for all other morbidity-related groups by

diagnostic or ther~eutic sewices ordered or provided, by diagnosis: United States, 1975-76 .................. .................................

.

17

18

19

19

20

20

21

21

22

22

23

24

24

25

27

28

28

28

15
19. Number and parcent of office visits for asthma (493) by patient age, sex, and problem status and percent of visits, by

diagnostic or therapeutic services orderad or provided: United States, 1975-76 ........................................................................ 30

20. Number and percent of office visits for hay fever (507) by patient age, sex, and problem status and percent of visits, by

diagnostic or therapeutic services ordered or provided: United States, 1975-76 ......................... ............................................... 30

21. Number of offica visits for selected chronic diseases of the respiratory system and for all other morbidity-related groups and

percent distribution by duration and disposition of visits, by diagnosis: United States, 1975-76 ................................... ........... 31

22. Number of office visits for selected chronic diseases of the respiratory system and percent distribution of visits by physician

specialty, according to diagnosis: United States, 1975-76 ............... .......................... ...... .............. ................................. ........... 32

23. Number of of fica visits to pediatricians for asthma and hay fever made by patients under 15 years of age and parcent of visits

by age of patient: United Statas, 1975-76 ................................. .......................... ....................................................................... 32

24. Percent distribution of office visits for asthma and hay fever by patient age, problem status, and selectad sarvices ordered or

provided, according to physician specialty: Unitad Statas, 1975-76 ................................. ............................. ..................... ....... 33

16
Tabla 1. Numbar, percent distribution, and avarege annual rate of office visits for selacted acute disaasas of tha rawiratory system and

percent distribution for all other morbidity-related groups, by selected patient characteristics: Unitad States, 1975-76

Diagnosis and I CDA codel

Acute

sinusitis

(461 )

Acute naso.

pharyngitis

and acute

upper respiratory infection

of multiple or

unspecified

sites

(460, 465)

Acute

Acute bronchitis

laryngitis and

and bronchiol itis,

tracheitis and bronchitis

(464) unqualified

(466, 490)

All other

morbidity.

related

ICDA2

groups

[000456,

520-628,

68G738,

780-786)

Patient sex, race, and age Am te

pharyngitis

(462)

Acute

tonsillitis

M63)

Influenza

(470.474) (460468)

I I

Number of visits in thwsands

All visits ...... ............... .......... ...... .... 37,693 2,598 17,414 12,573 2,982 19,446 10,312 5,1a4 667,261

Percent distribution

100,0 1OQ.o 100.0 100.0 100.0 100.0 I 100.0I 100.0 100.0

61.5

38.5

90.3

9.7

11.7

12,1

24.4

30.2

21.7

. . .

. . .

. . .

. . .

. . .

. . .

. . .

%;

82.9

17,1

45.0

13.3

19.3

15.4

7.0

18.6

1.3

90.3

57.3

42.7

74.4

25.6

“11.2

“16.6

28.9

35.9

“6.6

39.9

5.1

55.2

44.6

90.4

9.6

45.2

16.9

21.6

12.1

4.2

17.8

2.6

52.3

-47.7

87.8

12.2

61.5

17.1

12.4

7.6

●1.3

10.7

1.1

58.3

41.7

93.6

●6.4

54.0

“4.9

●16.O

21.5

‘3.7

11.1

4.8

57.0

43.0

66.0

12.0

35.2

9.8

19.8

23.6

11.8

28.9

2.7

47.0 50.8

53.0 49.2

—Race

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

Sl=k and all other .......... .... ............................

94.0 89.2

6.0 10.8

Age —

Under 15 years ...............................................

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

26.44 years ... .... .... ..........................................

4564 yews ..... ...... ......................... .... ...... .......

65 years and cuer .... ............... ................ ...... ...

18.1 I 37.7

14.3 12.4

31.7 17.1

25.9 2Q.3

10.0 12.5

35.3 24.9

1.8 4.7

Median visit ags ..............................................

Standard error of median visit age ... .... ...........

Visit rate per 1,000 in population

t

6.2 41.7

6,9 44.5

5.5 38.7

All visits .......... .......................... ......

—sex

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

46.6

51.4

41.5

30.1 24.7 \ 12.4

30.5

29.fl

30.4

28.1

73.3

27.8

14.8

11.1

“3.9

7.1

8.0

6.2

7.7

●3.5

15.3

●1.9

+4.5

7.5

●2.6

22.5

27.1

94.5

85.8

86.2

117.7

160.7

64.8

68.9

67.7

61.4

12.2

12.7

—Race

5.3 43.4

12.2 30.5

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

Slack and all other .......... ........ .. ......................

47.2

42.6

26.7

11.3

12.8

10.3

—AW

“2.7 74.6

“5.6 38.0

7.4 35.7

10.8 24.6

●4,0 17.0

Under 15 years ........ ............................... ........

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

2544 yeal’S .................... .................................

4564 years ........ ........ ................... .... .. .. ..........

65 years and over .......................... .... ..............

64.8

24.6

36.4

53.3

53.2

17.7

19.0

31.0

31.1

24.1

18.6

8.3

8.4

12.3

15.1

. ..

.. .

. ..

...

lBased on the E&hth RevWon Intematfond CL2.@7catfon of Diseases, Adapted for Use in the United States (lCDA).

‘For this report excludes categories relating to special conditions and examinations without sickness; complications of presnancy, childbirth, and the puerperium;

congenital anomaIie& certain causes of perirmtal morbidity and mortality; accidents, PoisOnins& and violence; diagnosi~ “none” and “unkno~.”

17
Table 2. Number and percents of office visits for selected acute diseases of the respiratory system by m-incioal diaanosis and Ibv Datient

principal and second- or third-listed problem: Unikd States; 1975-76’

Principal diagnosis and patient’s problem, complaint,

or symptom, and NAMCS codel

Acute nasopharyngitis and acute upper respiratory infection of

multiple or unspecified sites ............. .. .................... .. ...... ...... .. .... .. .............. .....

Cold ..... ........ .... .... ...... ...... .. .... .. ...... .. ...... ........ .... .... .... .. .... .... .... ........ ...3l2

Cough ......... .. ...... .................... ........ .............. .............. .............. ........ .. 311

Throat soreness ......................... ........................ .............. .... .......... ...... 520

Fever ........ ...... ........ ...... .. ...... ........ .............. ........ .. ............ .... .............. 002

Nasal congestion ................... .. ........ ...... .............. ...... .. .............. ...... .... 301

Earache ............... .. .... .. .......... .. .. ...... .............. .. ............ ........ ..... ....... .... 735

Headache ..... .. ........ ...... ...... .... .. .. ...... .. ...... ...... .. ............ .. ............ ...... ... 056

Acute sinusitis ............. .............. .......................................... ........ .........................

Sinus problems ........ .............. ........ .............. .............. ........ ...... .. .... ..... 304

Acuta pharyngitis .................... .................... .............................. .. .... ...... ........ .......

Throat soreness .............. .............. .............. ........ ...... ............ .. ............. 520

Fever .... .......................................... .............. ...... ...... .. .... .... ................ 002

Cold ...................................................................... .............. .............. .. 312

Cough ..... .... .......... ...... .. .... .... .... .. ........ .... ........ ............................ ........ 311

Acute tonsillitis ................... ............ .. .............. .............. ...... .. .......... .....................

Throat soreness .... .............. ...... .................................. ...................... ... 520

Fever ..... ...... .......... ............ ........ ...... ...... .. ...... .. ...... ........ ...... ............... 002

Symptoms referable to tonsils ..... ........ ...... ............ .............. .. .... .... ..... 527

Acute laryngitis and trecheitis .......... .. ...... ................ .... ........ ...... ........ ...... ...... ......

Cough .. .......... .... ........ ...... ........ ...... ................ ...... ...... ........ .. .. .. ........ ... 311

Disorders of voice .. ...... ........ ...... ............................ ................ .... .. ....... 325

Acute bronchitis and bronchiolitis, and

bronchitis, unqualified ................ ................ ...... .............. .......... ......................

Cough ..... ...... ........ ........ ...... ........ .................... ...... .. ........ ...... .............. 311

Cold .. .... .......... ........ ...... ........ .................... ................ .................... ...... 312

Other symptoms raferable to the respiratory system ............ .... ...... .... 330

Fever ......... .. ............ ........ ...... .. ...................... .............. .................... ... 002

Throat soreness ...... .............. .... ........ .. .... ........ .. .... ...................... ...... ... 520

Pain in chest ... ........ ...... ........ .... .. .. .... .. .. .......... .............. .. ...... ...... ...... .. 322

Influenza .......... .................... ........ .... .. ........ .... .............. .............. ............. .............

F kl . . . . . . . . . . . .. .. . . .. . . . . . . .. . . . . . . . . . . .. . . . . .. .. . . .. . . . . . . .. . . . . . . . . . . . . . . . . .. .. .. . . . . .. . . . . . . . . . . .. .. . 313

Cough .............. .......................... .................................. .................... ... 311

Fever .............. .................................................................................... 002

Cold .... .............. .............. ........ ...... .............................................. ........ 312

Pneumonia ........................................ ................ ...................... .... ............ .. ...........

Cough ........... .. .................... ...... .. ........ .... ........ ...... .. ........ .... ........ .... .... 311

Fever ....... ...... .. ...... .. .... .. ...... .. ...... ...... .. ...... ...... ...... .. ...... ...... .. .. .. .. ...... . 002

Principal diagnosis

and principal problemz

Qumber of

visits in

thousands

37,693

10,646

6,318

5,268

3,173

1,904

691

*326

2,598

1,208

17,414

10,509

1,782

1,057

839

12,573

6,665

1,969

1,411

2,982

917

590

19,446

8,408

2,653

1,381

1,005

718

632

10312

3,133

1,201

1,172

690

5,194

1,437

’450

Percent of

visits3

100.0

28.3

16.8

14.0

8.4

5.1

1.8

*0.9

100.0

46.5

100.0

60.4

10.2

6.1

4.8

100.0

53.0

15.7

11.2

100.0

30.8

19.8

100.0

43.2

13.6

7.1

5.2

3.7

3.3

100.0

30.4

11.6

11.4

6.7

100.0

27.7

*8.7

Principal diagnosis and

second- or

third-1 isted problam

Uumber of

visits in

thousands

37,693

1,735

5,531

2,268

2,2.44

1,833

716

580

2,598

*

17,414

1,273

1,179

*287

1,045

12,573

1,060

1,253

’206

2,982

*380

*

19,446

2,747

*434

●558

1,669

605

719

10,312

●268

652

1,086

●21 5

5,194

833

750

Percent of

visits

100.0

2.3

7.3

3.0

3.0

2.4

1.0

0.8

100.0

●

100.0

3.4

*0.8

3.0

100.0

4.2

5.0

●0.8

100.0

*6.4

*

100.0

7.1

1.1

1.4

4.3

1.6

1.9

100.0

1.3

3.2

5.3

*1.O

100.0

8,0

7,2

——

lproblems areidentified andcoded according toasymptOm cl~sification developed fOrusein N~CS (see reference 9).

Zwlthiti a given diagno~i~, vi~its fordifferent p~cjpdproblems areadditive; visits fordifferent pn"ncipd problemS maYnOt be added

to viaits for different second or’ thitti problems since they may have been presented during the same visit.

3percents ~llnOt add to 100.ob~cause dlproblems related toeachdiawosis are not-listed.
Table 3. Number of office visits for selected acute diseases of the respiratory system and percent distribution of visits by problem status

and by problem seriousness, according to diagnosis: United States, 1975-76

Diagnosis end ICDA codel

Acute nesopharyngitis and acute upper

respiratory infection of multiple or

unspecified sites .... ..... ...... ............ 460,465

Acute sinusitis ............ .................... .... ...... . 461

Acute pharyngitis ....... ...... ................ ......... 462

Acute tonsillitis .................... ..................... 463

Acute laryngitis and tracheitis ...................464

Acute bronchitis and bronchiolitis, and

bronchitis, unqualified .... ....... ......466. 490

Influenza ... ......... ............ .................... 470474

Pneumonia .............. ........... ................ 480-486

Number of

visits in

37,693

2,598

17,414

12,573

2,982

19,446

10,312

5,194

II Problem status I

Problem seriousness

Total

r

New

problem

11

100.0 59.4

100.0 59.7

100.0 63.9

100.0 61.1

100.0 57.6

100.0 51.8

100.0 73.8

100.0 41.5

Continuing Not Slightly Serious or

problem serious serious very serious

Percent distribution

40.6

40.3

36.1

38.9

42.4

48.2

26.2

58.5

57.9

29.7

51.7

34.9

46.3

35.1

33.2

13.2

36.4

60.5

40.6

51.2

43.7

53.0

56.6

38.9

5.7

*9.8

7.7

14.0

●1O.I

11.9

10.2

48.0

lBased on the Eighth Revision International C7as.sificatiors of Diseases, Adapted for Use in the United States (ICDA).

Table 4. Number of office visits for selected acute diseases of the respiratory systam and percent distribution of visits by number of

types of diagnostic and therapeutic sewices orderad or prwided, according to diagnosis: United States, 1975-76

Diagnosis and ICDA code]

Acute nasopharyngitis and acute upper respiratory infection of

multiple or unspecified sites . ................. ........ .......................... 460,465

Acuta sinusitis ............. ........................................................ ...... ........... 461

Acute pharyngitis ......... .. ...................... ............ .............................. ...... 462

Acute tonsillitis .............. ............................. ..... .................................... 463

Acute laryngitis and trecheitis ........ ........................................... ........... 464

Acute bronchitis and bronchiolitis, and bronchitis

unqualified .................................... .......................................... 466,490

Influenza ............. .. ..... ..................................... ........................ ...... 470474

Pneumonia .......................................... ....... ................................... 480486

Number of

visits in

37,693

2,598

17,414

12,573

2,982

19,446

10,312

5,184

Number of types of service

Total II None

I

Percent distribution

L

100.0 1.1

100.0 -

10Q.O 0.8

100.0 0.5

100.0 1.0

100.0 1.0

100.0 0.3

100.0 1.1

17.0

4.2

15.3

18.8

21.1

14.5

15.7

17.3

40.3

44.7

41.1

40.8

39.7

36.3

40.6

27.8

41.7

51.2

42.8

39.9

38.3

48.1

43.4

53.8

I ~~ed on the Eighth Revision Intemtjond Ckzs.@cation of Diseases, Adapted for use in the united States OC~A).

19
Table 5. Number of office visits for salected acute disaases of the respiratory system and for all other morbidity-related groups by

diagnostic or therapeutic services ordered or provided, by diagnosis: United States, 1975-76

Diagnosis and ICDA codel

Acute

tonsillitis

(483 )r

Acute

Acute bronchitis

laryngitis and

and bronchiolitis,

tracheitis and bronchitis

(484) unqualified

(486, 490}

Influenza

(470474)

Pneumonia

(4804S6)

Acute naso.

pharyngitis

and acute

upper respiratory infection

of multiple or

unspecified

sites

(460, 465)

Acute

sinusitis

(461 1

Acute

pharyngitis

(4621

All other

morbidityrelated

ICDA2

groups

(000458,

520-629,

680-738,

780.796)

Diagnostic or therapeutic service

Number of visits in thousands

All visits ........ .. ...... ......................... 37,693 2,598 17,414 12,573 2,982 19,446 10,312 5,194 667,261

Percent3

68.8 I

66.2

*1 0.4 13.1

54.5

9.9

L!mited history andlor examination ..............

General history andlor examination ..............

Clinical laboratory test ............ .... .............. .. ..

X-ray .... .........................................................

Blood pressure check ...... ........................ .......

Drug prescribed ........................... .... .. .... ......

Injection ..... ...... ................................. ...... ......

Medical counseling ........ .. ...... ... .. ............. .....

Other diagnostic and therapeutic

services5 ............ .... . ... ................ ........... .

66.0

12.8

14.3

3.0

25.1

81,8

26.7

7.8

B2.2

“6.8

“9.4

●7.4

20.6

90.5

34,0

‘3.4

65.4

11.5

24.9

“1.3

67.7

18.8

27.0

8.0

42.4

65.5

19.1

16.6

36.0

68.8

9.7

30.8

‘1.3

18.8

77.4

24.9

5.6

3.5

84.7

17.8

19.3

34.8

27.2

63.6

“14,8

I

13.9

“2.1 12.6

14.0

●4.7

10.0

79.0

31.5

7.9

16.3 I 30.5 I 26.3

77.0 76.9 79.8

25.2 29.2 45.0

‘8.9 9.3 7.-1

21.9

“1 0.3

4.9 ●13.2 ●2.8 “3.8 I 8.21 ●4.9 ●6. 1

1Based on the Eighth Rev&ion In temdtional C’Sawi$icaffonof Diseases, Adapted for Use in iha United Stotes ([CD A).

2For this report excludes categories relating to special conditions and examinations without sickness, complications of pregnancy, childbirth, and the puerperium;

con enitd anomalies; certain causes of perinatd morbtdity and mortality; accidents, poisonings, and violence; diagnosis “none” and “unknown.”

3 Percents will not add to 100.0 because more than one service may have been provided.

41ncludes prescription and nonprescription drugs.

‘Includes electrocardiogram, hearins test, vision test, endoscopy, immunization, office surgery, physiotherapy, psychotherapy and therapeutic listening, and other

diagnostic or therapeutic services.

Table 6. Number and percent of office visits for acute upper respiratory infections except influenza (460-466, 490) by selected

diagnostic or therapeutic services ordered or provided, by patient age, sex, and problem status: United States, 1975-76

Limitad history General history Clinical Blood

andlor andlor laboratory X-ray

Drug Injection Medical

pressure

examination examination test check

prescribed cwnseling

Number of

wsits in

thousands

Pat!ent age, sex, and problem statvs

Percentz

“1.8 “1.5

“1.8 “3.3

●2.9 “4.7

‘2.4 12.0

“4.3 28.5

6.3 34.6

7.7 42.2

“a.6 50.1

14,566

10,332

10,082

a,298

12,595

17,689

15,036

6,106

50,926

41,777

54,548

38,157

59.3

65.1

67.5

65.1

69.5

68.5

70.a

71.6

67.7

66.3

6a.o

65.7

1a.4

11.7

12.3

11.a

10.7

9.4

10.4

‘6.9

15.1

21.9

25.7

29.5

20.2

16.7

14.0

, 12,1

19.4

17.6

19.0

18.1

77.6 21.9

79.2 21.6

77,5 20.3

77.5 22.0

83.3 31.2

82,4 29.1

78.7 38.2

77.6 32.4

8.5

7.9

8.8

●7.7

5.6

7,2

7.8

“8,6

8.2

7.0

7.6

7.7

11.1

12.8

4.7 25.3

4.4 19.3

80.1 27.1

79.0 28.4

4.9 22.9

4.0 22.1

83.1 26.4

74.6 29.6

13.5

9.5

1Includes prescription and nonprescription drugs.

2Percents will not add to 100.0 because more than one service may have been provided.

20
Table 7. Number of office visits for influenza (470474) and percent of visits by diagnostic or therapeutic services ordered or provided,

by patient age, sex, and problem status: United States, 1975-76

Diagnostic or therapeutic service

Patient age, sex, and problem status

—Age

Under 6 years ......... ....................... .... .......

6-14 years .. .... .. .. .. .. .. .... .... ........................

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

25-?4 years .... .. .... .... .... .... ........................

45.64 years .......... .. .. .... .... .... ....................

65 years and over ............................ .... .... .

—89x

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

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

Problem status

Naw problem ......... .... ........ .. .... ................

Continuing problem ............ .................. .. .

Percen#

J

‘14.4

“12.5 ●2.8

“1O.1 .

‘12.0 “4.2

“14.0 ●1O.4

‘27.1 ‘4.0

16.2 ●6.4

12.1 ‘3.2

15.8 “3.8

8.9 “7.1

971 59.6 ]

893 51.4 i

1,472 67.5

3,267 45.9

2,674 55.2

1,034 58.9

4,849 56.6

5,463 52.6

7,607 55.7

2,705 51.1

*1 2.7

“30.0

●42

“6.6

“5.4

‘20.7

‘20.9

●8.9

●6.4

‘4. 1

“4.1

“16.5

‘5.5

●9.6

7.8

+7.4

●1 .6

“52.3

76.2

‘50.9

“28.8

42.8

49.1

44.0

●45.5

39.3

50.1

43.6

48.9

*27.2

29.1

36.1

‘36.8

85.4

64.0

84.2

76.5

29.9 79.7

23.1 79.9

12.0

“8.1

11.1

“6.8

26.9

24.6

82.7

71.7

llncludes prescription and nonprescription drugs.

‘Percents will not add to 100.0 because more than one service may have been provided,

‘ Table 8. Number of office visits for pneumonia (480-486) and percent of visits by diagnostic or therapeutic services ordered or provided,

by patient age, sex, and problem status: United States, 1975-76

—

Number of

visits in

thousands

Diagnostic w therapeutic service

X.ray

Patient age, sex, and problem status Blood

pressure

Medical

counseling

Age Percent2

—

Under 6 years ........ ................... ........... .. ..

6-14 years .................... .. ...................... ....

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

2544 years ........................... .. .. ...............

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

65 years and over ..... ................................

—sex

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

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

Problem status

New problem ....... ........ .... .. .. .. .. ........ ........

Ccmtinuing problem .............................. ...

1,260

676

643

890

1,058

649

2,640

2,554

2,156

3,037

5a.3

“51 .6

“79.1

67.5

62.0

●77.5

86.2

63.2

56.0

71.0

‘28.3

●16.4

*5.O

●22.O

●10.7

*20.9

*25.1

“25.9

“20.7

●11.5

‘14.7

● 10.4

“11.7

“5.5

“11.6

●13.7

“6.2

‘7.9

“1 2.9

●12.1

“9.0

“30.3

“30.9

“33.6

“29.0

“38.6

●50.8

26.5

33.1

44.7

27.9

●6.3

‘7.2

“ 14.8

“45.4

“42.1

*52.6

24.7

30.0

31.4

24.3

60.4 ●16.1

●59.3 ●7.1

“60.2 *4 0.0

64.6 “16.4

70.4 ●25.7

●17.4 “65.6 ●32.3

‘14.4

●21 .4

‘19.2

‘19.4

62.6 26.3

84.7 “ 17.4

‘23.4

‘16.3

70.7 “24.3

58.6 20.3

28.8

10.0

lIncludes prescriptic.n and nonprescription drum.

2Percents will not add to 100.0 because more than one service may have been provided.

21
Table 9. Number of office visits for selected acute diseases of the respiratory system and for all other morbidity-related groups and

percent distribution by duration and disposition of visits, by diagnosis: United States, 1975-76

,,

Diagnosis and ICDA codel

Acute naso.

pharyngitts

and acute

upper respir3t0ry infection

of multiple or

unspecified

sites

(460, 466)

Acute

sinusitis

(461 )

Acute

pharyngitis

(462)

-—

All other

morbidityrelatad

ICDA’3

groups

(000.458,

520.629,

1660-738,

780-796)

.—

Acute Acute

Acute laryngitis bronchitis

tonsillitis and bronchiolitis,

and

M63 ) trache itis and bronchitis

{454) unqualified

(466, 4901

Duration and disposition of office visit Influenza

(47@474)

Pneumonie

(480AIB8)

I I

Number of wsits in thousands

All visits ................................... . ... 37,693 2,598 17,414 12,573 2,982 19,446 10,312 5,194 667,261

—

Percent distributmn

It

100.0 100.0 100.0

21.5 23.8 15.9

45.5 44.8 42.2

24.0 25.1 25.7

8.4 5.7 15.6

‘0.6 “0.6 “0.6

100,0 100.0 100.0 100.0 1Oo.c 100.0

Duration3

20.1

46.3

23.7

9.4

“0.5

23.0

26.2

46.4

5.1

37.2

37.2

15.1

9.3

“1.1

13.7

21.2

61.6

4.4

13.7

46.0

26.0

13.2

*1.2

11.2

36.9

20.9

29.6

“1.3

20.0

21.5

53.0

5.5

9.8

36,8

36.1

16.3

‘1,0

11.1

64.1

16.2

5.4

13.4

38.5

27.5

21,9

7,5

8.2

63.7

24.9,

3.6

Disposition

No followup .. . ... ... ... ................. ... . ... . ....

Return at specified time .. ........ . ..... .. ...........

Return if needed ............ ....... .. ....... . .. ..... .. .

Telephone followup ... . . ............ ... . . ... . ....

22.6 16.9 12.0

22.2 29.0 27.0

42.7 44.0 52.4

14.3 9.6 10.2

13.7

42.0

38.6

6.0

lBasedon the Eighth Revition International Clmification of D&ws, Ad~tedfor Uwtn the United States (lCDA).

2For this report excludes categcmies relatins to special conditions and examinations without sickness; complications of pregnancy, childbirth and the p,uerperium;

con enital anomalies; certain causes of perinatal morbidity and mortality; accidents, poisonings, and violence: diagnosis ‘<none” and “unknown. ”

~Face.to.face emounter between physician and Patient.

4Percents will not add to 100.Obeca"se more than onedisposition mayhave been possible.

Table 10. Number of office visits forselected acute diseases of the respiratory system andpercent distribution of visits by physician

specialty, according to diagnosis: United States, 1975-76

Physician specialty

Number of

visits in

thousands

37,693

2,59a

17,414

12,573

2,982

19,445

10,312

5,194

General and

Total

Internal

family Pediatrics

Gmaral

medicine

prastica

surgery

Diagnosis and ICDA code]

II I I ! *’E Percent distribution

3.5

“1.0

“2.6

● 2.4

●2.3

●2.8

“2.0

‘3.3

Acute nasophary ngitls and acute upper re~iratory

mfectionof multiple orunspeci fled sttes ............460.465

Acute sinusitis . .............. ............... ................................... 4f31

Acute pharyng!tis .. .... .... .. ........................................ .. .. .... 462

Acuta tonsillitis ........... ... . . ........ . ... ............................ 463

Acute Iaryng!tis and tracheitis ...... ... . . . . .................... .464

Acute bronchitis and bronchlol itis, and

tvonchms unqualified .. ........ ... . .................... 466,490

Influenza . .. . ............... . .. ... .......... . ....................... 470-474

Pneumonia ...... . ... . . . ... . ...... . . . . .................... .. 460-466

2.0 4.5

“7.5 “6.6

100.0 53.6 7.4

100.0 57.2 ‘2.4

100.0 36.3 “6.2

26.4

28.2

40.9

3.9 4.1

“4.0 5.8

●9.1 ‘5.2

‘0.3 5.7

●3.1

●4.3

100.0 57.3 13,6 20.3

100.0 76.5 7.3 8.8

100.0 50.5 14,9 27.0

●0.3

“0.0

lBasedon the E&hth Revition International Clmdfication of D&emas, Adap*dfor Usein the United States (ICDA).

22
Table 11. Percent distribution of office visits for acute upper respiratory infections excePt influenza (460-466,490) bypetientage,

problem status, and selected services, according to physician specialty: United States, 1975-76

Patient age, problem status, and selected services

Total .......... .................... ...... ................ .............................. ........ .

Patient age

Under 15yaars ........................... ............ ........ ...... .... .............. .... ........ ...... ...

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

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

45-64 yeare ...... .... ............................................... .......... .................. .............

65years and over ............. .............. ....... .... .................. .................... ...... ......

Problem status

New problem ............................................................ .................. .................

Continuing problem ............ ....... .............. .............................. .... .................

Diagnostic or therapeutic servicel

Limited history and/or examination ...... .... ........ .................. ...... ............ ......

Generel history and/or examination .................................... .... ....................

Clinical laboratory test .... ........... ................................. ........... .................. ...

X-ray .... .. ....................................................... ........ ............ .................. ........

Blood pressure check .................................................. ........... .......... ............

Drugprescribed2 .................................................. .......... .. .......... .................

Injection ............ .................. ..................................... ...... ........ .... .................

Medical counseling ........ ...... ............................. ...... ........................ .............

Physician specialty

General and

family

Internal

Pediatrics medicine Otolaryngology

practice

100.0

32.5

17.1

23.4

19.6

7.4

59.9

40.1

70.5

10.2

15.1

3.7

27.3

82.3

33.9

6.1

100.0

11.6

14.3

31.0

27.9

15.3

65.5

34.5

71.3

14.2

22.3

13.6

46.5

75.4

15.3

10.2

100.0

94.7

4.2

“0.6

*0.5

66.5

43.5

58.9

16.4

28.4

*2.3

3.7

77.3

15.5

9.7

100.0

*1 5.0

*13.3

42.8

*21 .7

*7.2

48.7

51.3

65.3

*1 0.4

● 6.5

*5.5

*1.3

74.3

●14.8

*1 0.2

Ipercents witl not add to 100.o because more than one service may have been protided.

21nchldes prescription and nonprescription drugs.

23
Table 12. Percent distribution of office visits for influenze (470-474) and pneumonia (480-486) by patient age, problem status, and

selected services ordered or provided, according to physician specialty: United States, 1975-78

Patient age, problem status,

and selected services

Total ......... .......... .............. .............. ....

Patient age

Under 15 years ..................... ...... ...... .. .............. ...

15-24 yaars ........... .................... ........ ...... .. ...... ....

2544 years .. .... .... ...... .... ...... ........ ........ ...... .........

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

65 years and over .. ...... .......... ........ ...... ........ ...... ..

Problem status

New problem ....... .. .. ...... .............. ........ .............. .

Continuing problem ................. ...... .....................

Diagnostic or therapeutic servicel

Limited history and/or examination ...................

General history and/or examination ....................

Clinical laboratory tast .............. ...................... ....

X-ray ... .................. .... .......... ...... ........ ........ .... ......

Blood pressure check ......... .. .... ................ ...... .....

Drug prescribed .. ........ .............. .........................

injection ........ ...................... ...... .............. ........ ...

Medical counseling ... ............ ...... .............. ...... .. .. .

=

Inf Iuenza I Pneumonia

General and Internal General and

family Pediatrics family

Internal

medicine Pediatrics

practice mactice

medicine

100.0

11.8

16.2

33.8

28.3

9.9

72.7

27.3

53.7

●6.4

11.5

‘3.6

25.7

83.0

50.0

*5.3

100.0

*3.O

*11.9

*29.9

*29.8

*25.4

76.4

23.6

68.6

*17.5

*33.4

*14.8

*54.1

*6 I .2

*20.8

*11.5

Percent distribution

100.0

93.4

‘4.0

*2.5

73.8

26.2

*4 I .0

*36.1

*2 I .5

*2.O

*0.6

65.0

*24.1

*25.5

100.0

*20.1

“16.4

23.5

29.8

*1 0.1

38.0

62.1

65.3

*14.7

* 16.4

27.8

30.1

69.6

31.8

*7.6

100.0

*2.7

‘16.2

●22.4

*18.2

*40.6

49.5

50.5

80.2

*14.8

*1 9.8

*57.3

*53.5

●5I .4

*7.O

*1 5.5

100.0

97.2

●1.9

‘0.8

43.1

‘56.9

51.7

●:27.3

*:25.9

*:29.6

*0.4

160.0

‘*10.6

*I 3.3

——

lPercents will not add to 100.0 since more than one service may have been provided.

21nclude5 prescription and ncmpreSCriptiOn drugsTable 13. Numbar of office visits to pediatricians and percents of visits made by patients under 15,years of age for selected acute diseases

of the respiratory systam and percent of visits by aga of patient: United States, 197!$76

Diagnosis and ICDA codel

Acute nasopharyngitis and acute upper respiratory

infection of multiple or unspecified sites ......................... ...... 460, 465

Acute pharyngitis .......... .............. .... .... ...... ............ .. ............ ............... 462

Acute tonsillitis ......... ........................................ .... ............................ . 463

Acute laryngitis and trecheitis ............................................................ 464

Acute bronchitis and bronchiolitis, and bronchitis

unqualified ......... .............. .... .... ...... ........ .... ........ .. .... ...... ........ 466,490

Inf Iuenza .............................................. .............. .................. ....... 470-474

pneumonia ................................ ....................................... ....... ..... 480-486

Number of

visits in

thousands

8,149

4,945

3,551

1,220

3,938

904

1,400

-

Age

Under 3 3-5 6-10 11-=

years years years yaws

Percent2

51.7

25.5

25.5

*43.5

36.6

*27.5

*39.4

22.1

20.7

35.3

*29.9

28.3

*1 8.3

*28.5

14.2

29.1

25.3

*2 I .2

20.7

*30.4

*19.4

7.2

17.7

*11.3

*3.7

*7.8

‘“l 7.3

*9.9

——

1Based on the Eighth Reviss”onInterrrationalC7assifi%ationof Disemw, Adapted for Use in the United States (ICDA).

2percents ~11 not add to 100.o because percents of age groups 15 Years and over are not shown.

24
Table 14. Numbar, percent distribution, and average annual rata of office visits for salectad chronic diseases of the respiratory system

and percent distribution for alI other morbidity-related groups, by selected patiant characteristics: United States, 1975-76

selected patient characteristics

All visits ............................................

—Sax

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

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

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

Black and all other ............................................

—Age

Under 15 years ..................................................

15-24 yaars .......................................................

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

45.64 years .......................................................

65 years and over ..............................................

Median visit aga in years ....................................

Standard error of median visit age

In years ........................................................

All visits ............................................

—Sex

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

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

Race

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

Black and all other ............................................

Chronic

bronchitis

(491 )

Diagnosis and ICDA codel

I I I

Chronic

Emphysema Asthma pharyngitis Ch[onic

(492) (493) and naso- sinusitis

pharyngitis (503)

(502)

Hay

fever

(507)

All other

morbidityrelated

ICDA2

groups

(000-458,

520-629,

680-738,

780-796)

Number of visits in thousands

1,646 I 5,223 I 10,951 ] 2,486 I 8,284117,012 I 667,261

100.0

50.6

49.4

92.4

●7.7

*1 .5

*6.3

*19.3

45.3

*27.7

57.4

3.0

4.0

3.9

4.0

4.2

●2.3

100.0

29.6

70.4

91.9

*8.1

●1.1

●0.1

●4.8

44.9

49.0

64.7

2.2

12.5

7.2

18.3

13.2

●7.7

100.0

54.9

45.1

87.3

12.7

32.9

10.9

18.1

28.1

10.1

32.0

4.4

58.2

41.9

84.8

●5.2

25.5

●13.1

30.8

*18.8

●11.9

33.0

5.8

Visit rate per 1,000 population

26.2

27.8

24.6

26.4

25.4

6.0

6.7

5.2

6.5

●2.4

58.8

41.2

89.9

10.1

10.3

14.8

35.7

27.4

11.7

37.8

2.7

19.9

22.6

17.0

20.5

15.3

100.0

!56.3

43.7

94.4

5.6

29.2

16.6

30.9

17.7

5.6

27.3

2.2

40.8

44.4

36.9

44.3

17.3

100.0

61.5

38.5

90.3

9.7

11.7

12.1

24.4

30.2

21.7

...

. ..

...

. ..

...

. ..

...

25
Table 14. Number, percent distribution, and average annual rate of office visits for selected chronic diseases of tha respiratory system

and parcent distribution for all othar morbidity-related groups, by selected patient characteristics: United States, 1975-76--Con.

Selected patient characteristics

Age

Under 15 years ...... .... .... ........ ...... ...... .............. ..

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

2544 years ... .. ...... .. .. .... ...... ...... .. ........ ...... ... ....

45-64 yaars .................................. ...... ........ .......

65 years and cwer ............ ............ ...... .............. ..

Chronic

bronchitis

(491 )

*0.2

●1.4

*3.O

8.7

*1 0.6

Emphysema

(492)

——

Diagnosis and ICDA codel

Asthma

(493)

Chronic

pharyngitis

and nasopharyngitis

(502)

Chronic

sinusitis

(503)

*0.1

*0. I

“2.4

27.3

60.3

Visit rate per 1,000 population

Hay

fever

(507)

47.1

36.4

49.9

35.0

22.3

—

All other

morbidityra Iated

ICDA2

groups

(0100-458,

520-629,

680-738,

780-796)

. ..

...

...

---

...

1Based on the Eighth Reviss”onInternationalCkrsss”ficationof Dieeases,Adapted for Use in the United States (ICDA).

2For this ~epofi excludes categories relating to special conditions and (?.XmnirNitiOrIS without SkkM3SS; complications ‘f pxe~ancy?

childbirth, and the puerrserium; congenital anomalies; certain causes of uerinatal morbidity and mortality: accidents. uoisonisms. and

violence; diagnosis %one”” and %nh-own .“

-.

26
Table 15. Number and percents of ofFice visits for selected chronic diseases of the respiratory system by principal diagnosis and by

patient principal and sacond- or thiFd-listed problem: United States, 1975-76

Principal diagnosis and patient’s problem, complaint,

or symptom and NAMCS codel

Chronic bronchitis ................................................................................................

Cough .................................. ...... .... .......................................................... 311

Emphysema .......... .......................... ...... .............. .... ..............................................

Shortness of breath ........... .. ...... .... .. ...... ...... .. .... ........ .... .. .... .. .... ...... ......... 306

Cough ..... ...... .. ...... .... .. .. .... .. .. .... ...... ........................ .. ...... .......... ........ ...... . 311

Asthma .. ...... ...... ........ .... .. ...... .. .... .. ...... ...... ............ ............ .. .... ...... ...... ...... .. .... .. ...

Asthma ............... ........ .......... .. .... .............. ... ......... ................................... 328

Other disorders of respiratory rhythm and sound ............... ..................... 307

Shortness of breath .... .... ........ ..... ....................... ..... .................. ............... 306

Cough ......... ...... ........ ....... ................. ... ..... ......................... ...... ...... ...... .... 311

Visit for medication ...............................................................................9lo

Hay fevers ............................ ........ ........ .......... ................................ .... ..... 329

Chronic pharyngitis and nasopharyngitis ........................... ...................................

Nasal congestion ..... .. ............ ...... ...... ............ ...... ........ ...... ............ ...... ..... 301

Chronic sinusitis .... ........ .................. .............................................. .......................

Sinus problems ................ ...... ..... ......... ..................................................... 304

Headache .......... .......................... .. .................. .... ..................................... 056

Nasal congestion ............. ................ .. .............. ................ ... ..... ...... ........... 301

Throat soreness .................... ..................... ..... ...... .......................... ...... .... 520

Cough .................... .................... ............ .................................................. 311

Cold ...................... ............... .................. .............. .................................... 312

Hay fever . .. ........................................................... ...................... ..........................

Nasal congestion ................................................ ...................................... 301

Hay fever .......... ................. ........................................................ .. ...... .... .. 329

Visit for medication ................................................. .............................. 910

Sneezing .......... ...... ...... .. .................. .............. ........................................... 310

Cough ...................................................................................................... 311

Principal diagnosis and

principal problem2

Number of

visits in

1,646

*499

5,223

2,210

*378

10,951

2,973

1,832

1,421

1,401

1,337

*267

2,486

615

8,284

1,741

1,653

1,156

608

598

●557

17,012

4,791

3,409

2,903

649

●551

PerCant of

visits3

100.0

●30.3

100.0

42.3

*7.2

100.0

27.2

16.7

13.0

12.8

12.2

*2.4

100.0

24.7

100.0

21.0

20.0

14.0

7.3

7.2

●6.7

100.0

28.2

20.0

17.1

3.8

●3.2

Principal diagnosis and

second- or

third-listed problem

Number of

visits in

thousands

1,646

*277

5,223

*295

●431

10,591

●288

*539

’260

639

*

562

2,486

*219

8,284

●365

*442

603

●329

*384

*265

17,012

992

* 545

*2 I 6

*2 I o

*281

Percent of

visits

00.0

*8.4

00.0

*2.8

*4.1

00.0

*1.3

*2.5

+1.2

2.9

*

2.6

100.0

*4.4

IOQ.O

*2.2

*2.7

3.6

*2.O

*2.3

*1.6

100.0

2.9

*1.6

*0.6

‘0.6

*0.8

lproblems are identified and coded according to a symptom classification developed for use in NAMCS (see reference 9)-

2Witiin ~ ~ven diagnosis, ~lt~ for different pn-n~-pal problems are additive, but vkdts for different Pn%cr.Pal problems maY not be

added to visits for different second or ?hir’dproblems since they may have been presented during the same visit.

3percents MI not add to I o().Obecause all problems related to each diagnosis are not listed.

41ncludes allergy shots, immunizations, routine inoculations, injections of vitamins and hormones; new and renewal prescriptions.

51ncludes allergy and pollinosis.

27
Table 16. Number of office visits for selected chronic diseases of the respiratory system and percent distribution of visits by problam

status and by problem seriousness, according to diagnosis: United States, 1975-76

Diagnosis and ICDA codel

Chronic bronchitis .. .... .. ...... .. ...... ...... .. . 491

Emphysama ..... ...... ........ ........ ...... .... .... 492

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

Chronic pharyngitis and nasopharyngitis ... .... .. ........ .. .... .. .... .. ...... 502

Chronic sinusitis .... .. .. ...... ........ .... .. ...... 503

Hay fever ... ...................................... .... 507

Number of

visits in

thousands

1,646

5,223

10,951

2,486

8,284

17,012

Total

100.0

100.0

100.0

100.0

100.0

100.0

percent distribution

‘27.0

13.1

9.5

38.7

50.7

16.7

73.0 I

39.6

86.9 10.0

90.6 21.6

61.3

49.3

83.3

57.3

54.6

57.0

40.6

31.8

46.3

33.7

36.3

36.8

*19.7

58.2

32.1

9.0

9.0

6.2

1Based on the Eighth Rewkion In tematiorral Classification of Diseases, Adapted for Use in the United States (ICDA).

Table 17. Number of office visits for selected chronic diseases of the respiratory system and percent distribution of visits by number of

types of diagnostic and therapeutic services ordered or provided, according to diagnosis: United States, 1975-76

Diagnosis and ICDA code]

Chronic bronchitis ............. ...... .. .... ........ .. ...... ........ ........ ...... .... .... .... 491

Emphysema .. ...... .. ...... ...... ...... .. ...... .. ...... .............. .. .... ........ ...... .. ..... 492

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

Chronic pharyngitis and nasopharyngitis ... .... .. ...... .. .... ................ ..... 502

Chronic sinusitis ... ...... ........ .. ...... ...... ........ ...... .............. ........ ........ .... 503

Hay fever ............. .............. ........ ...... ........ .............. .............. ............ 507

Numbar of

visits in

thousends

J__L *12.5 *22.3 65.2

●0. I 10.9 21.0

+0.5 32.5 27.5

*2.2 19.7 43.8

“0.7 15.9 32.6

*0.3 45.7 28.1

1 Baaed on the Eighth Revitdon International C&e~”f7cation of Diseases, Adapted for Use in the United Statss (ICDA).

1,646

5,223

10,951

2,486

8,284

17,012

Number of typas of service

Total None One Two

Three or

more

II I I I

Percent distribution

100.0

100.0

100.0

100.0

100.0

100.0

68.1

39.5

34.4

50.9

25.9

.—

28
Table 18. Number of office visits for selected chronic diseases of the respiratory system and for all other morbidity-related woups by

diagnostic or therapeutic services ordered or provided, by diagnosis: United States, 1975-76

Diagnostic or therapeutic service

Al I visits ............................................

Limited history and/or examination .................

Ganeral history and/or examination ..................

Clinical laboratory test ......................................

x-ray .................................................................

Blood pressure check ........................................

Electrocardiogram .............................................

Drug prescribed ...............................................

Injection ...........................................................

Immunization ...................................................

Medical counseling ............................................

Other diagnostic and therapeutic

services5 ......................................................

Chronic

bronchitis

(491 )

Emphysema

(492)

Diagnosis and ICDA codel

Asthma

(493)

Chronic

pharyngitis

and nasopharyngitis

(502)

Chronic

sinusitis

(503)

Hay

faver

(507)

All other

morbidityralated

ICDA2

groups

(000-458,

520-629,

680-738,

780-796)

Number of visits in thousands

1,646 I 5,223 I 10,951 I 2,486 I 8,284117,012 I 667,261

53.6

●25.8

*32.3

●24.1

53.3

V 4.9

59.4

*27.5

●3.2

●17.8

●8.6

71.7

12.5

17.2

13.4

62.7

●9.7

63.1

22.8

●4.2

16.7

11.4

Percent of visits3

53.0

10.1

6.0

5.8

19.9

*1 .3

49.4

26.4

40.7

11.5

7.7

57.2

● 14.9

*7.6

*5.7

20.0

‘0.0

67.6

● 14.9

●I 4.5

*8.4

11.6

68.5 38.2

7.0 6.9

10.3 4.8

*6.7 *2.1

35.9 9.2

*1.2 ●0.7

79.0 31.9

29.5 22.6

*1.1 52.7

9.5 10.3

16.1 10.7

lBased on the E@hth Revision ‘In temational Classification of Diseases, Adapted for We in the United States (ICDA).

67.7

18.8

27.0

8.0

42.4

4.6

65.5

19.1

1.6

16.6

29.9

‘For this report excludes categories relating to special conditions and examinations without sickness; complications of pregnancy,

chitdbtih and the puerperium; congenital anomalies; certain causes of perinatal morbldit y and mortality; accidents, poisoninga, and

violence; diagnosis “none” end “unknown.”

Spercen& will not add to 100.0 because more than one service may have been provided.

g~clude~ prescription and nOnpreSCIiPtiOn drugs.

5~cludes heafing test, ~ion test, endosCopy, office surgery, physiotherapy, psychotherapy or therapeutic listening, and other

diagnostic or therapeutic services.

29
Table 19. Number and percent of office visits for asthma {493) by patient age, sex, and problem status and percent of visits, by

diagnostic or therapeutic services ordered or provided: United States, 1975.76

Patient age, sex, and

problem status

Patient age

Under 6 years ... .. .. .. ....... .......

6-14 years .. .. .. .. .... ........ .........

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

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

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

65 years and over

Patient sex

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

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

Problem status

Newprobiem . ... ... . ....... .. ...

Continuing problem ..............

Wmber of

visits in

thousands

Diagnostic or therapeutic service

.Im]ted history

andlor

examination

45,7

46.4

‘47,1

52,7

62,1

56,7

53.8

51.9

50,0

53.3

Blood Drug Immunization

pressure Injection I

Medical

prescribed andtor

check desensitization

counseling

“3.3 55,2

●4. 1 39.9

‘1 3.9 ‘45.8

“26.5 46.9

31.4 54.7

“35.0 52.2

1,552

2,049

1,195

1,977

3,077

1,101

6,007

4,944

1,034

9,917

“1O,9

“8.4

“9.3

“11,6

‘9,9

●1O.6

110

“9.0

●37.5

7.2

“7.0

‘5.1

‘7.4

●4.8

“5.7

‘7,9

“5.8

“6.2

●19.7

●4.5

“7,4

‘4,4

●3,8

●6.2

“6.6

“5.9

“4.9

“7.0

‘20.8

“4.3

36.2

26.9

‘16.1

‘20.7

27.8

●29.2

25.2

27.9

26.5

26.4

“32.0

46.9

52.2

46.5

35.4

“33.5

42.9

38.1

●9.5

“44.0

●12.8

●6.1

●1 2.1

●18.6

‘9.5

●12.1

13.8

‘8.8

“15.7

11.1

23.1 I 50.9

15.6 47.4

‘35.3 78.3

18.3 46.3

llncIudes prescription and nonprescrlpti.m dru~s.

2Percents w#llnot add to 100. Obecause nmrethmt oneswvice mayhnve been provided.

Table 20. Numbar and percent of office visits for hay fever (507) by patient age, sex, and problem status and percent of visits, by

diagnostic or therapeutic services ordered or provided: United States, 1975-76

Diagnostic or therapeutic sewice

Number of

visits m

thousands

Lim!ted history General history Blood Drug Immunization

andlor andlor Injection

Medical

pressure prescribed andlor

examl nat don examination check desensitization

counseling

Patient age, sex, and problem status

Percent2

“1 5.0

“9.1

“9.0

11.5

“1 0.6

●5.6

10.1

10.7

‘17.8

8.8

1,323

3,642

2,823

5,263

3,004

957

9,579

7,434

2,848

14,164

“13.0

“5.8

“9.6

● 5.0

“5.7

“9.4

6.4

‘7.6

24,1

43,5

“0.8

“1.3

“?2.3

“ 10.4

‘14.7

● 18.0

10.5

“7.6

22.4

6.6

“40.6

22.7

35.7

33.4

32.8

●32.4

34.2

29.0

73.0

23.6

●12.0

1B.O

24.9

27.0

23.3

’21.8

22.3

23.0

‘14.0

24.3

54.2

59.8

46.9

51.8

50.3

● 53.0

52.5

53.0

11,5

61.0

“33.3

32.6

38.6

39.5

46.5

’31.3

40.3

354

54,8

34.8

llncludes prescnpti(]n and mmprescrtptmn drugs.

2Percents wdl not add to 1000 bemuse rnme tba” one serv,ce may have been prowded.

30
Table 21. Number of office visits for selected chronic diseases of the respiratory system and for all other morbidity-related groups and

percent distribution by duration and disposition of visits, by diagnosis: United States, 1975-76

Diagnosis and ICDA codel

Chronic

bronchitis

(491 )

Emphysema

(492)

Asthma

(493)

Chronic

pharyngitis

and nasopharyngitis

(502)

Chronic

sinusitis

(503)

All other

morbidityrelatad

I CDA2

groups

(000.458,

520-629,

680-738, ~

780-796)

Hay

fever

(507)

Duration and disposition

Number of visits in thousands

All visits ... .. ...................................... 1,646 I 5,223 [ 10~51 [ 2,486 I 8,284] 17,012 I 667,261

Percent distribution

100.0 100.0 100.0 -1- 100.0 100.0 100.0 100.0

Duration3

O-5 minutes ....... ............ ........ .............. ..............

6-10 minutes ............................... .............. ........

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

16-30 minutes ... .............. ...... ...... .................... ..

31 minutes or longer ............. .............. ...... ........

Dis~osition4

*9.7

●29 .7

37.1

●I 6.8

●6.7

6.9

28.0

31.8

26.6

6.7

22.6

31.9

24.6

14.8

6.2

*2.9

77.3

17.2

●3.7

20.0

40.7

23.3

13.2

2.9

●16.5

48.1

32.8

●2.9

20.1

36.1

25.7

16.0

2.1

40.1

28.0

16.5

10.4

5.1

13.4

38.5

27.5

21.9

7.5

I

No followup .............. .... ............................ ........

Return at specified time ....... ...... ........ ...... ...... ...

Return if needed .......................... .................. ...

Telephone followup ............ .. ...... .................. ....

●5.5

58.6

●32.9

●3 .6

*4.5

74.9

16.2

●2.5

13.4

38.4

42.7

*6.4

4.7

74.5

19.6

●1.8

8.2

63.7

24.9

3.6

lBased on the Eighth Revrkion International Ckrssz”Jication of Diwaaq Adapted for Use in the United States (ICDA).

ZFCW this ~ePort e~cl~des categories relating to special conditions and examinations without SiCkIMS; COmmiCdiOsIS Of PrWISSICY,

childbirth and the puerperium; congenitrd anomalies; certain causes of perinatal morbidlt y and mortality; accidents, poisoninga, and

violence; diagnosia “none” and “unknown.”

3Face.to.face encounter between physician and patient.

4Percent5 W-II not add to 100.0 because more than one disposition may have been possible.

31
Table 22. Number of office visits for selected chronic diseases of the respiratory system and percent distribution of visits by physician

specialty, according to diagnosis: United States, 1975-76

Physician specialty

Number of

D!agnosis and ICDA codel vtslts in General and Internal All other

thousands Total family ~edici”e Pediatrics Otolaryngology Allergy specialties

practice [residual)

Chron!c bronchitis ...................................... ........ .... . 491

Emphysema ...................................... .... .............. ..... 492

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

Chronic pharyngitis and nasopharyngms .................502

Chron!c sinusitis ... .......................................... ......... 503

Hay fever ................. .......................................... ....507

I

1,646

5,223

10,951

2,486

a#284

17>012

Percent distributim

100.0 52.9 “25.8 “0.3 ●1.2 “0.6 “19.2

100.0 52.4 30.3 ●0.6 ‘0.0 ●3.1 13.6

100.0 29.5 10.6 21.9 ‘0.7 32.3 5.0

100.0 30.3 ‘4.2 ‘14.9 34.3 ‘11.9 4.4

100.0 60.5 10.2 ● 5.6 ●13.5 ‘0.8 9.4

100.0 26.3 9.9 17.8 9.a 30.6 5.8

1Based on the Eighth Revision In tenrariond Clamificatfon of Diseases, A dapted for Use in the United States (ICDA).

Table 23. Number of office visits to pediatricians for asthma and hay fever made by patients under 15 years of aga and percent of visits

by age of patient: United States, 1975-76

I Diagnosis and lCIMcodal

Patient aga

Asthma Hay fever

(493) (507)

Number in thowands

All visits ......... .. ...... .. ...... ...... .. .............. ...... .. ...... ........ ...... .. .... .. ...... .. ...... .... .. .. ...... .. .. .. .. ........ ....... 2,399 3,034

Percent2

Under 3 yaars ... .............. .. ............ ........ .......... ............................ ............ ...... ........ ...... ........ ...............~......... *I 5.8 ‘9.0

3-15 years ..... .... ...... ...... .. ...... ...) .. .. .. .... ........ .. ........ ....i . .... ...<...... .... .... ...... ........ .... .. ...... .................4.............. 24.0

6-10 years

18.4

......... ........ ...................... .... ........ .. ...... ........ ........ .................. .. .... ........ .......... ........... ................... 31.5 32.9

11-14 vears .................... .............. ........ ...... .......... ............ .............. .............. ........ ...... ........ ......................... *1 5.1 19.4

1Based on the Eighth Reviss”on In temational Clm”fication of Diseases, Adapted for Use in the United states (lCDA).

2percent~ will not add to 100.o because percents of age groups 15 Years and over are not sho~. ”

32
Table 24. Percent distribution of office visits for asthma and hay fever by patient age, problem status, and selected services ordered or

provided, according to physician specialty: United States, 1975-76

Patient age, problem status, and selected services

Total ................................................... ...............

Patiant age

Under 15 years ............................ ................... ...................

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

25A14 years ................ .................. ................. .. ...................

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

65 years and over ............................................ .. ... .............

Problem status

New problem ............................................................... ......

Continuing problem .............. ........ ........................... .... .... ..

Diagnostic or therapeutic sarvicesl

Limited history andlor examination ............ ......................

General history andlor examination ..................................

Clinical laboratory test .......................... ............................

x-ray .......................... ............................. ..........................

Blood pressure check ........ .. ...............................................

Drug prescribed .. .. ....................... ....................... .............

Iniection ..... ................................... ....................................

Immunization .............................. .... .... ........................ ......

Medicel counseling .. .... ............................................ ...........

Asthma Hay fever

Physician specialty Physician specialty

General and Internal Pediatrics Allergy General and Internal

family practice medicine family practice

Pediatrics Allergy

medicine

Percent distribution

100.0

21.5

“1O.3

18.7

39.4

“1O.1

“9.0

91.0

64.2

“6.B

“5.5

‘4.6

31.9

62.4

42.9

‘14.0

‘4.0

100.0

●4.9

“3.7

“24.3

‘47.1

“20.0

“1 0.6

89.4

60.3

“13.8

“1 1.9

“6.7

●46.4

55.0

“22.1

● 14.0

‘24.2

100.0

86.3

“5.8

●4.6

“2.7

“0.6

“13.3

86.7

44.7

“1O.8

●5.4

“4.3

●2.8

41.2

26.9

43.8

●8.9

100.0

17.8

17.1

24.6

29.1

“11.5

●6.1

93.9

45.5

“1 0.9

“4.1

‘6.2

●9.8

39.8

“1 2.7

76.1

16.2

100.0

21.7

17.0

35.5

19.8

“6.0

26.3

73.7

39.2

●3.3

“5.9

“1.B

16.5

37.4

37.4

3B.1

“B.4

100.0

‘1 3.0

“25.0

“32.6

“16.6

●12.8

“18.0

82.0

36.5

●9.8

“11.8

●5.1

‘27.0

26.5

●14.5

62.2

‘9.1

100.0

79.8

“8.8

“7.7

“2.7

“1.0

“11.3

88.7

25.6

●9.4

‘5.5

“0.9

‘0.9

26.5

+14.5

62.2

“9.1

1Cc).o

17.4

19.6

36.2

21.5

“5.3

●6.1

93.9

42.2

●7.3

●2.2

“0.1

●5.1

21.6

16.2

74.1

12.4

lPercents will notaddt.a 100.Obecause mwcthan onesemice mayhave been pr'Jvided.

21ncludes prescription and nonprescription drugs.

33
APPENDIXES

CONTENTS

I. Technicaf Notes ...............................................................................................................................

Statistical Design ........................................................................................................................

Data Collection and Processing ..................................................................................................

Estimation Procedures ...............................................................................................................

Reliability of Estimates ..............................................................................................................

Tests of Significance ..................................................................................................................

Population F@resandR ateComputation ................................................................................

Systematic Bias ..........................................................................................................................

II. Definition of Certain Terms Used in Tbis Report ............................................................................

Terms Relating to the Survey .....................................................................................................

Terms Relating tothe Patient Record Form ..............................................................................

III. Survev Instruments .........................................................................................................................

In&oductory Letter From Director, National Center for Health Statistics .................................

I.

IL

I.

II.

Patient Record and Patient Log ....~............................................................................................

Induction Interview Form ..........................................................................................................

LIST OF APPENDIX FIGURES

Approximate relative standard errors for estimated numbers of office visits, 1975-76 Nationaf

Ambulatory Medical Care Survey ....................................................................................................

Approximate relative standard errors for percentages of estimated numbers of office visits,

1975-76 National Ambulatory Medical Care Survey ........................................................................

LIST OF APPENDIX TABLES

Distribution of physicians in the 1975-76 National Ambulatory Medical Care Survey sample and

response rates, by physician’s specialty ...........................................................................................

Estimated number of persons in the civilkm noninstitutionalized population of the United States

used in computing average annual rates in this publication, by race and sex: United States,

1975-76 ...........................................................................................................................................

35

35

36

38

38

41

41

42

43

43

44

47

47

48

49

39

40

36

41

34
APPENDIX I

TECHNICAL NOTESi

This report is based on data collected in the

NationaI Ambulatory Medical Care Survey

(NAMCS). The NAMCS is an annual sample

survey of office-based physicians conducted by

the Division of Health Resources Utilization

Statistics of the National Center for HeaIth

Statistics. The present report is based on information collect ed during 1975 and 1976.

Statistical Design

Scope of the swuey. –The target population

of NAMCS encompasses office visits within the

conterminous United States made 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.

Sample desi@z.-The NAMCS utilizes a multistage probability design that involves probability samples of primary sampling units (PSU’s),

physician practices within PSU’S, and patient

visits within practices. The first-stage sample of

87 PSU’S was selected by the National Opinion

Research Center (NORC), the organization responsible for NAMCS field and data processing

operations and under contract to the National

Center for Health Statistics (NCHS). A PSU is

a county, a group of adjacent counties, or a

standard metropolitan statistical area (SMSA).

A modified probability-proportional-to-size procedure using separate sampling frames for

SMSA’S and for nonmetropolitan counties was

empIoyed. After sorting and stratifying by size,

region, and demographic characteristics, each

‘Prepared by Thomas McLemore, M.S.P.H., Division of Health Resources Utilization Statistics.

frame was divided into sequential zones of 1

million residents, and a random number was

drawn to determine which PSU came into the

sample from each zone.

The second stage consisted of a probability

sample of practicing physicians selected from

the master fiIes maintained by the American

Medical Association (AMA) and American Osteopathic Association (AOA) who met the folIowing criteria:

Office-based, as defined by AMA and AOA.

Principally engaged in patient care activities.

NonfederalIy employed.

Not in the specialties of anesthesiology,

pathology, clinical pathology, forensic pathology, radiology, diagnostic radiology,

pediatric radioIogy, or therapeutic radiology.

Within each PSU, all eligible physicians were

arranged by nine specialty groups; general and

family medicine, internal medicine, pediatrics,

other medical specialties, general surgery, obstetrics and gynecology, other surgicaI specialties, psychiatry, and alI other specialties. Then,

within each PSU, a systematic random sample of

physicians was selected in such a way that the

overalI probability of selecting any physician

in the United States was approximately constant.

During 1975-76 the total NAMCS sample

included 6,529 physicians. Sample physicians

were screened at the time of the survey to assure

that they met the aforementioned criteria; 925

physicians did not meet all of the criteria and

were, therefore, ruled out of scope (ineligible)

35
for the study. The most frequent reasons for

being out of scope were that the physician was

retired, deceased, or employed in teaching,

research, or administration. Of the 5,604 inscope (eligible) physicians, 4,476’ (79.9 percent)

participated in the study. Of the participating

physicians, 679 physicians saw no patients during their assigned reporting period because of

vacations, illness, or other reasons for being

temporarily not in practice. The physician sample size and response rates by physician specialty

are shown in table I.

The final stage was the selection of patient visits within the annual practices of the

sample physicians. This involved two steps.

First, the total physician sample was divided

into 52 random subsamples of approximately

equal size, and each subsample was randomly

assigned to 1 of the 52 weeks in the survey year.

Second, a systematic random sample of visits

was selected by the physician during the assigned week. The sampling rate varied for this

final step from a 100-percent sample for very

smalI practices to a 20-percent sample for very

large practices, as determined in a presurvey

interview. The method by which the sampling

rate was determined is described later in the

Technical Notes and in the Induction Interview

form displayed in appendix III. During 1975-76

information was coIlected on 113,921 patient

visits by means of NAMCS.

Data Collection and Processing

Field procedures. –Both mail and telephone

contacts were used to enlist sample physicians

into NAMCS. Physicians received introductory

letters from NCHS (see appendix III) and AMA

or AOA. When appropriate, a letter from the

physician’s specialty organization, endorsing the

survey and urging his participation, was enclosed

with the NCHS letter. A few days later, a field

representative from NORC telephoned the sample physician to explain the study briefly and

to arrange an appointment for a personal interview. An initially nonresponding physici;n was

generally recontacted via a telephone call or

special explanatory letter and requested to reconsider participation in the study.

During the personal interview, the field

Table 1. Dwtributlon of physicians In the 1975-76 Nat(onal Ambulatory Medical Care Survey sample and resPonse rates, by physician

specialty

PhysicIan’s specialty

6,529

1,687

1,765

938

435

392

2,316

679

558

1,079

761

468

293

Number of physicians

925 5,604 1,128

260 1,427 333

245 1,520 337

124 814 202

74 361 53

47 345 82

189 2,127 381

54 625 113

48 510 94

87 992 174

231 530 77

79 389 45

152 141 32

4,476

1,094

1,183

612

308

263

1,746

512

416

818

453

344

109

——

Response

rate

79.9

76.7

77.8

75.2

85.3

76.2

82.1

81.9

81.6

82.5

85.5

88.4

77.3

36
representative determined the sample physician’s

eligibility, ascertained his cooperation, delivered

survey mat erials with verbal and printed instructions, and assigned a predetermined Mondaythrough-Sunday reporting period. A short interview concerning basic practice characteristics,

such as type of practice and expected number of

office visits, was administered. Office staff who

were to assist with data collection were invited

to attend the instruction session or were offered

separate instruction sessions.

Before the beginning of and again during the

week assibmed for data collection, the NORC

interviewer telephoned the sample physician to

answer possible questions and to insure that

procedures were going smoothly. At the end of

the survey week, the participating physician

mailed finished survey materials to the interviewer who edited the forms for completeness

before transmitting them for central data processing. Problems or missing data at this stage

were resolved by interviewer telephone followup

to the sample physician; if there were no problems, field procedures were complete with respect to the sample physician’s participation in

NAMCS. After the end of the survey year each

sample physician was sent a thank-you letter,

from NCHS along with one of the survey’s

statistical reports.

Data collection. –The actual data collection

for the NAMCS was carried out by the physician

aided by his office staff when possible. Two data

collection forms were employed by the physician: the Patient Log and the Patient Record

(appendix III). The Patient Log is a sequential

Iisting of patients seen in the physician’s office

during his assigned reporting week. This list

served as the sampling frame to indicate the

visits for which data were to be recorded. A

perforation between the patient names and

patient visit characteristics permitted the physician to remove patient names thus protecting

the confidentiality of the patient.

Based on the physician’s estimate of the expected number of office visits and expected

number of days in practice, each physician was

assigned a patient sampling ratio. These ratios

were designed so that about 30 Patient Records

were completed during the assigned reporting

week. Physicians expecting 10 or fewer visits

each day recorded data for all of them; those

expecting more than 10 visits per day recorded

data for every second, third, or fifth visit, based

on the predetermined sampling interval. These

procedures minimized the data collection workload and maintained approximate equal reporting levels among sample physicians regardless of

practice size. For physicians assigned a patient

sampling ratio, a random start was provided on

the first page of the log, so that predesignated

sample visits on each succeeding page of the

log provided a systematic random sample of patient visits during the reporting period.

Data processing. -In addition to completeness checks made by the NORG field staff, clerical edits were performed upon receipt of the

data for central processing. These procedures

proved quite efficient, reducing item nonresponse rates to a negligible amount-2 percent

or less for each data item.

Information contained in items 5 and 9 of

the Patient Record were coded in a separate

medical coding operation. This coding was performed by the American MedicaI Records Association, under subcontract to NORC. The data

in item 5, the patient’s reason for visit, were

coded according to a special classification system developed for that purpose.g The diagnostic

information, item 9 of the Patient Record, was

coded according to the Eighth Revision International Classification of Dkeases, Adapted for

Use in the United States (ICDA).4 A maximum

of three entries was coded from each of these

items. A two-way independent verification procedure with 100-percent verification was used to

control the medical coding operation. Differences between coders were adjudicated at

NCHS.

Information from the Induction Interview

and Patient Record was keypunched, with 100-

percent verification, and converted to computer

tape. At this time, extensive computer consistency and edit checks were performed. Data

items stiIl unanswered at this point were imputed

by assigning a value from a Patient Record with

similar characteristics; imputations were based

on physician specialty, major reason for visit,

and broad diagnostic categories.

NOTE: A list of references follows the text.

37
Estimation Procedures

Statistics produced from NAMCS were derived by a multistage estimating procedure.

The procedure produces essentially unbiased

national estimates and has basically three components: (1) inflation by reciprocals of the probabilities of selection, (2) adjustment for nonresponse, and (3) a ratio adjustment to fixed

totals. Each of these components is described

briefly in the material that follows.

Injl’ation by reciprocals of sampling pro babilities. –Because the survey utilized a threestage sample design, there were three probabilities: (1) the probability of selecting the PSU,

(2) the probability of seIecting a physician

within the PSU, and (3) the probability of selecting a patient visit within the physician’s practice.

The last probability was defined to be the exact

number of office visits during the physician’s

specified reporting week divided by the number

of Patient Records completed. All weekly estimates were inflated by a factor of 52 to derive

annual estimates.

Adjustment for nonresPonse.–Estimates

from NAMCS data were adjusted to account for

sample physicians who refused to participate in

the study. This was done in such a manner as to

minimize the impact of nonresponse on final

estimates by imputing to nonresponding physicians the practice characteristics of similar responding physicians. For this purpose, similar

physicians were judged to be physicians having

the same specialty designation and practicing in

the same PSU.

Ratio adjustment. –A poststratification adjustment was made within each of nine physician specialty groups. The ratio adjustment was

a multiplication factor that had as its numerator

the number of physicians in the universe in each

physician specialty group, and as its denominator, the estimated number of physicians in that

particular specialty group. The numerator was

based on fipres obtained from the AMA-AOA

master files, and the denominator was based on

data from the NAMCS sample.

Reliability of Estimates

Since the statistics presented in this report

are based on a sample, they will differ somewhat

from the figures that would be obtained if. a

complete census had been taken using the same

forms, instructions, and procedures. However,

the probability design of NAMCS permits the

calculation of sampling errors. The stamdard

error is primarily a measure of sampling variability that occurs by chance because only a sample

rather than the entire population is surveyed. As

calculated in this report, the standard error also

reflects part of the variation which arises in the

measurement process. It does not include estimates of any systematic biases that may be in

the data. The chances are about 68 out of 100

that an estimate from the sample would differ

from a complete census by less than the standard error. The chances are about 95 out of 100

that the difference would be less than twice the

standard error and about 99 out of 100 that it

would be less than 21/2 times as large.

The relative standard error of an estimate

is obtained by dividing the standard error by the

estimate itself and is expressed as a percentage of

the estimate. For this report, asterisks (*) are

presented along with the estimate for any esti-.

mate with more than a 30-percent relative standard error.

Estimates of sampling variability were calculated using the method of half-sample replication. This method yields overall variability

through observation of variabilityy among random subsamples of the total sample. A description of the development and evaluation of the

replication technique for error estimation has

been previously published.14’15

Approximate relative standard errors for

aggregates and percentages are presented in figures I and II. In order to derive error estimates

that would be applicable to a wide variety of

statistics and could be prepared at moderate

cost, several approximations were required. As a

result, the relative standard errors shown in figures I and II should be interpreted as approximate rather than exact for any specific estimate.

Directions for determining approximate relative

standard errors from the figures follow.

1. Estimates of aggregates: Approximate

relative standard errors (in percent) for

aggregate statistics, such as the number

of office visits with a given characteristic, -
are obtained from the curve in figure I, This calculation has been made for sever calculated by the following formula: eral percentages and bases and is presented in figure II. Alternatively, the

RSE (x) = 0.0009113499 + 54”14306.100 formula

.-.x

54.14306 (1 -~) .100 RSE@)=~ ~.x

where x is the aggregate of interest in

thousands.

2. Estimates of percentages: Approximate

relative standard errors (in percent) for 3.

estimates of this type can be calculated

from the curve in figure I as follows. Obtain the relative standard error of the

numerator and denominator. Square

each of the relative standard errors, subtract the resulting value for the denominator from the resulting value for the

numerator, and extract the square root.

can be used to calculate RSE for any

percentage (p) and base (x, in thousands).

Estimates of rates where the numerator

is not a subclass of the denominator: Approximate relative standard errors for

rates where the denominator is the total

U.S. population or one or more of the

age-sex-race groups of the total population are equivalent to the relative standard error of the numerator that can be

obtained from figure I.

Figure 1. Approximate relative standard errors for estimated numbers of office visits, 1975-76 National Ambulatory Medical Survey

1“ 0

100 1,000 10,000 100:000 1,006,000 “

SIZE OF ESTIMATE (IN THOUSANDS)

Example of use of this graph: An estimate of 10 million office visits (read from scale at bottom of

graph) has a relative standard error of 8.0 percent (read from scale at left of graph) or a standard error

of 800,000 office visits (8.0 percent of 10 million visits).

39
Figure II. Approximate relative standard errors for percentages of estimated numbars of office visits, 1975-76 National Ambulatory

n

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[ Base of percentage shown on curves in millions]

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ESTIMATED PERCENTAGE

Example of use of this graph: An estimate of 20 percent (read from scale at bottom of graph)

based on ‘an es-timate of 10 rni~ion visits has a relative s;andard error of 14.7 percent (read from scale

at left of graph) or a standard error of 2.9 percentage points (14.7 percent of 20 percent).

4. Estimates of differences between two

statistics: The relative standard errors

shown in this appendix are not directly

applicable to differences between two

sample estimates. The standard error of a

difference is approximately the square

root of the sum of the squares of each

standard error considered separately.

This formula will represent the standard

error quite accurately for the difference

between separate and uncorrelated characteristics, although it is only a rough

approximation in most other cases.

The half-sample replication procedure was

also used to calculate standard errors for the

specific estimates of mean contact duration of

visit presented in this report; these standard

errors are presented in tables E and H along

with the estimates.

In addition to sampling error, survey results

are ‘subject to reporting and processing ‘errors

and biases due to nonresponse or incomplete

response. There is no way to compute the magnitude of these errors. However, these types of

errors were kept to a minimum by methods

built into the survey procedures. Extensive

pretesting and careful attention was given to

phasing of the questions and the terms employed and their definitions in order to eliminate

ambiguities and encourage uniformity. Steps

taken to reduce nonresponse bias were discussed

40
in the sections on field procedures and data

collection. Errors in coding and processing were

reduced by verification and consistency checks.

Tests of Significance

In this report, the determination of statistical inference for single comparisons is based on

the t-test with a critical value of 1.96 (0.05

Ievel of significance). The Bonferroni technique

is used for simultaneous testing of multiple

comparisons. Terms relating to differences, such

as “higher,” “less,” and so forth, indicate that

the differences are statistically significant.

Terms such as “similar,” “no difference,” and

so forth, mean that the difference between the

statistics being compared is not statistically

significant. Lack of comment regarding the

difference between any two statistics does not

mean the difference was tested and found to be

not significant.

Population Figures and

Rate Computation

The population figures used in computing

average annual visit rates are presented in table

II. These figures are based on an average of the

July 1, 1975 and July 1, 1976, provisional estimates of the civilian noninstitutionalized population of the United States obtained from the

U.S. Bureau of the Census. Because NAMCS

includes data for only the conterminous United

States, the original Census estimates were modified to account for the exclusion of Alaska and

Hawaii from the study. For this reason the population estimates should not be considered as

official population estimates and are presented

Table 11. Estimated number of persons in the civilian noninstitutionalized population of the United Statesz usad in computing averaga

annual rates in this publication, by race and sex: United States, 197576

Age

Race and sex

All ages

Under 15 15-24 25-34 35-44 4554 55-54 65 years

yaars years years years years years and over

Number in thousands

AH races................. 208,610 52,723 38,729 30,369 22,353 23,349 19,608 21,479

Male.................................. 100,639 26,884 18,977 14,714 10,737 11,242 9,240 8,845

Female .............................. 107,971 25,839 19,752 15,655 11,616 12,107 10,368 12,634

White ........................... 181,265 43,988 33,147 26,567 19,571 20,780 17,727 19,496

Male.................................. 87,823 22,491 16,356 13,034 9,513 10,063 8,376 7,991

Female .............................. 93,462 21 #497 16,791 13,533 10,058 10,727 9,352 11,505

All other races............. 27,324 8,736 5,582 3,603 2,782 2,558 1,881 1,983

Male.................................. 12,816 4,393 2,621 1,681 1,224 1,179 864 854

Female,...,.,,..., .................. 14,509 4*343 2,961 2,122 1,558 1,379 1,016 1,129

1Excludes Alaska and I%wdi.

41
here solely for the purpose of providing denominators for rate computations.

Average annual visit rates in this report were

calculated as follows. The numerator was obtained by dividing the estimated number of office visits for 1975-76 by 2, to obtain an average

annual number of office visits. This number was

then divided by the appropriate population

figure to obtain an average annual visit rate.

As previously discussed, reliability estimates for

average annual visit rates can be calculated from

figure I.

Systematic Bias

There have been no attempts to determine

systematic bias in the data reported here or to

measure the impact of any biases. There are several factors, however, that the user of these

data should understand, all of which indicate

that these data underrepresent the total number

of office visits to office-based physicians. Some

of those factclrs are:

1. The sampling frame for the 1975 and

1976 NAMCS included all nonfederally

employed, “office-based, patient care”

physicians on the AMA-AOA master

files. There are certainly physicians not

so classified who, at the time of the survey, would have met the criteria for that

classification. Visits to these physicians

are not represented in these data.

2. Physicians who participated in NAMCS

did a thorough and conscientious job in

keeping the Patient Log; however, the

probability that a patient was accidentally omitted from the survey is much

greater than the probability that a

patient was included who did not make

a visit. This factor could also introduce

a bias into the data.

000
APPENDIX II

DEFINITIONS OF CERTAIN TERMS USED IN THIS REPORT

Terms Relating to the Survey

O~~ice(s). –Premises that the physician identifies as locations for his ambulatory practice.

Responsibility over time for patient care and

professional services rendered there generally

resides with the individuzd physician rather than

with any institution.

Ambulatory patient. –An individual presenting for personaI health services, neither bedridden nor currentIy admitted to any health care

institution on the premises.

Physician. –Can be classified as either:

In-scope: AU duIy licensed doctors of medicine and doctors of osteopathy currently in

practice who spend some time in caring for

ambulatory patients at an office location.

Out-of-scope: Those physicians who treat

patients onIy indirectly, incIuding specialists

in anesthesiology, pathology, forensic pathology, radiology, therapeutic radiology,

and diagnostic radiology, and the following

physicians:

●

●

●

●

physicians in military service

physicians who treat patients only in

institutional setting (e.g., patients

nursing homes and hospitals)

physicians employed fuIl time by

an

in

an

industry or institution and having no

private practice (e.g., physicians who

work for the Veterans Administration,

the Ford Motor Company, etc.)

physicians who spend no time seeing ambulatory patients (e.g., physicians who

ordy teach, are engaged in research, or

are retired).

Patients. –Can be classified as either:

In-scope: All patients seen by the physician

or member of his staff in his office(s).

Out-of-scope: Patients seen by the physician

in a hospital, nursing home, or other extended care institution, or the patient’s

home. [Note: If the doctor has a private

office (which fits definition of “office”)

located in a hospital, the ambulatory patients seen there would be considered “inscope.”] The following types of patients are

also considered out of scope:

● patients seen by the physician in any

institution (including outpatient clinics

of hospitals) for which the institution

has the primary responsibility for the

care of the patient over time

● patients who telephone and receive advice from the physician

. patients who come to the office only to

leave a specimen, pick up insurance

forms, or pay their bills

● patients who come to the office only to

pick up medications previously prescribed by the physician.

Visit. –A direct, personal exchange between

ambulatory patient and the physician (or members of his staff) for the purpose of seeking care

and rendering health services.

Physician specialty. –Principal specialty (including general practice) as designated by the

physician at the time of the survey. Those

physicians for whom a specialty was not obtained were assigned the principal specialty

43
recorded in the Master Physician files maintained by AMA or AOA.

Region of practice Location. –The four geographic regions, excluding Alaska and Hawaii,

which correspond to those used by the U.S.

Bureau of the Census, are as follows:

Region

Northeast . . . . . .

North Central . . .

South . . . . . . . . .

West . . . . . . . . . .

States included

Connecticut, Maine, Massachusetts, New Hampshire,

New Jersey, New York,

Pennsylvania, Rhode Island,

Vermont

Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota,

Missouri, Nebraska, North

Dakota, Ohio, South Dakota, Wisconsin

Alabama, Arkansas, Delaware, District of Columbia,

Florida, Georgia, Kentucky,

Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West

Virginia

Arizona, California, Colorado, Idaho, Montana, Nevada, New Mexico, Oregon,

Utah, Washington, Wyoming

Metropolitan status of practice location. –

Physician’s practice is classified by its location in

metropolitan or nonmetropolitan areas. Metropolitan areas are standard metropolitan statistical areas (SMSA’S) as defined by the U.S.

Office of Management and Budget.

The definition of an individual SMSA involves two considerations: first, a city or cities

of specified population that constitute the

central city and identify the county in which it

is located as the central county; second, economic and sociaI relationships with “contiguous” counties that are metropolitan in

character, so that the periphery of the specific

metropolitan area may be determined. SMSA’S

may cross State lines. In New England, SMSA’S

consist of cities and towns, rather than counties.

Terms Relating to the

Patient Record Form

Age. –The age calculated from date of birth

was the age at last birthday on the date of visit.

Color or race. –On the Patient Record, color

or race includes four categories: white, Negro/

black, other, and unknown. The physician was

instructed to mark the category which in the

physician’s judgment was most appropriate for

the patient based upon observation and/or prior

knowledge of the patient. “Other” was restricted

to Orientals, American Indians, and other races

neither Negro nor white.

Patient’s principal problem(s), complaint(s),

or symptom(s) (in patient’s own words). —The

patient’s principal problem, complaint, symptom, or reason for the visit as expressed by the

patient. Physicians were instructed to record key

words or phrases verbatim to the extltnt possible, listing that problem first which in the

physician’s judgment was most responsible for

the patient’s visit.

Seriousness of problem in item 5a. –This

item includes four categories: very serious,

serious, slightly serious, and not serious. The

physician was instructed to check one of the

four categories according to his or her own evaluation of the seriousness of the patient’s problem causing this visit. Seriousness refers to physician’s clinical judgment as to the extent of

the patient’s impairment that might result if no

care were given.

Major reason(s) for this visit. –The patient’s

major reason(s) for the visit were classified by

the physician into one or more of the following

categories:

Acute problem: A condition or illness having

a relatively sudden or recent onset (i.e.,

within 3 months of the visit).

Acute problem, followup: A retu~m visit

primarily for continued medical care of a

previously treated acute problem.

Chronic problem, routine: A visit primarily

to receive regular care or examination for a

preexisting chronic condition or illness (onset of condition was 3 months or more

before this visit).

44
Chronic problem, ji!areup: A visit primarily

due to a sudden exacerbation of a preexisting chronic condition.

Prenatal care: Routine obstetrical, care provided prior to delivery.

Postnatal care: Routine obstetrical care or

examination provided following delivery or

termination of pregnancy.

Postoperative care: A visit primarily for care

required following surgical treatment. Includes changing dressing, removing sutures

or cast, advising on restriction of activities or

routine aftersurgery checkup.

Well adult/child exam: General health maintenance examinations and routine maintenance examinations and routine periodic

examinations of presumably healthy persons, both children and adults. Includes

annual physical examinations, well-child

checkups, schooI, camp, and insurance examinations.

Family planning: Services or advice that

enable patients to determine the number and

spacing of their children. Includes both

contraception and infertility services.

Counseling/advice: Information of a health

nature that would enable the patient to

maintain or improve his physical or mental

well-being. Included would be advice regarding diet, changing habits or behavior, and

general information regarding a specific

probIem.

~nzrnunization: Administration of any inoculation of specific substances to produce a

desired immunity; this includes oral vaccines. (Allergy shots are not included in this

category, but are entered under “other.”)

Referred by another physician~agency: Medical attention prompted by advice or referral

for consultation or treatment from another,

physician, hospital, clinic, heaIth center,

school nurse, minister, pharmacist, and so

fofih. Does not include self-referral or referral by family or friends.

Administrative purpose: Reasons such as

completing insurance forms, school forms,

work permits, or discussion of patient’s bill.

Other: The reason for this visit is not covered

in the preceding Iist.

Principal diagnosis. –The physician’s diagnosis of the patient’s principal problem or complaint. In the event of multiple diagnoses, the

physician was instructed to list them in order of

decreasing importance; “principal” refers to the

first-listed diagnosis. The diagnosis represents

the physician’s best jud~ent at the time of the

visit and may be tentative, provisional, or

definitive.

Other significant current diagnosis. –The diagnosis of any other condition known to exist

for the patient at the time of the visit. Other

diagnoses may or may not be related to the

reason for that visit.

Treatments and services ordered or provided. —These include the following:

Limited history/exam: History and/or physical examination that is limited to a specific

body site or system , or that is concerned

primarily with the patient’s chief complaint,

for exampIe, pelvic exam or eye exam.

General history/exam: History and/or physical examination of a comprehensive nature,

including all or most body systems.

Clinical lab test: One or more laboratory

procedures or tests including examination of

blood, urine, sputum, smears, exudates,

transudates, feces, and gastric content, and

including chemistry, serology, bacteriology,

and pregnancy test.

Blood pressure check: SeIf-explanatory.

EKG: Electrocardioqam.

Hean”ng test: Auditory acuity test.

Vision test: Visual acuity test.

Endoscopy: Examination of the interior of

any body cavity, except ear, nose, and

throat, by means of an endoscope.

Office surgery: Any surgical procedure performed in the office this. visit, including

suture of wounds, reduction of fractures,

application/removal of casts, incision and

draining of abscesses, application of supportive materials for fractures and sprains, and

45
all irrigations, aspirations, dilatations, and

excisions.

Drug prescribed: Drugs, vitamins, hormones,

ointments, suppositories, or other medications ordered or provided, except injections

and immunizations.

X-ray: Any single or multiple X-ray examination for diagnostic or screening purposes.

Radiation therapy is not included in this

cat egory.

Injection: Administration of any substance

by syringe and needle subcutaneously, intravenously, or intramuscuhu-ly. This category

does not include immunizations, enemas, or

douches.

Immunization/desensitization: Administration of any immunizing, vaccinating, or desensitizing agent or substance by any route,

for example, syringe, needle, orally, gun, or

scarification.

Physiotherapy: Any form of physical therapy ordered or provided, including any

treatment using heat, light, sound, or physical pressure or movement, for example,

ultrasonic, ultraviolet, infrared, whirlpool,

diathermy, cold therapy, and manipulative

therapy.

Medical counseling: Instructions and recommendations regarding any health problem,

including advice or counsel about diet,

change of habit, or behavior. Physicians are

instructed to check this category only if the

medical counseling is a significant part of the

treatment.

Psychotherapy/therapeutic listening: All

treatments designed to produce a mental or

emotional response through suggestion, persuasion, reeducation, reassurance, or support,

including psychological counseling, hypnosis,

psychoanalysis, and transactional therapy.

Other: Treatments or services rendered

which w-e not listed in the preceding categories.

Disposition. –Eight categories to describe the

physician’s disposition of the case are provided as follows:

JVO followup planned: No return visit or

telephone contact was scheduled for the

patient’s probIem on this visit.

Return at specified time: The patient was

told to schedule an appointment or was

instruct ed to return at a particular time.

Return if needed, P.R.N.: No future appointment was made, but the patient was

instructed to make an appointment with the

physician if the patient considers it necessary.

Telephone followup planned: The patient

was instructed to telephone the physician on

a particular day to report on his progress, or

if the need arises.

Referred to other physician/agency: The patient was instructed to consult or seek care

from another physician or agency. The patient may or may not return to this physician at a later date.

Returned to referring physician: Patient was

referred to this physician and was now instructed to consult again with the physician

or agency which referred him.

Admit to hospital: Patient was instructed

that further care or treatment wilI be provided in a hospitaI. No further office visits

were expected prior to that admission.

Other: Any other disposition of the case not

included in the above categories.

Duration of visit. –Time the physician spent

with the patient, but does not include the time

patient spent waiting to see the physician, time

patient spent receiving care from someone other

than the doctor without the presence of the

physician, and time spent reviewing records,

tests results, and so forth. In the event a patient

was provided care by a member of physician’s

staff but did not see the physician during thle

visit, “duration of visit” was recorded as zero

minutes.
APPENDIX Ill

SURVEY INSTRUMENTS

INTRODUCTORY LETTER FROM DIRECTOR,

NATIONAL CENTER FOR HEALTH STATISTICS

@

*,..*.m+,

:

;

: DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE

z. ...

% “,, .*”’ PUBLIC HEALTH SERVICE

HEALTH RESOURCES ADMINISTRATE.W

RoCMVILLE. MARVLAND -

NAT’1ONALCEN7ER FcX

HSALTH STATISTICS

flm,rlc,” MUIC41 Amor.latlon

Jmn9i H.s.smmons, M.O.

Enuutlv. W.. PruldwM

N. Ue”.8 MWIC.I &SOChuO*

Alf,ed F. Fisher

Exuutl”. Dl,utor

Amnrlc.” Ar.a~.Fwd D8C13’I.tOa*SY

John M. SllaW, M.D.

Eurat, w .T,.Mu I*I

Amwk.” AUdWIWOf hWI!tY

?hyllclans

Roqsr Tusk..

Exocutlv9 Olroctor

AuI.IIc,” Ac.d.lfiY .f NwrOl*SY

stanlay A. Ndson

Exocutlvo Dl,utor

fis~,$:;,a”aa mY st OtthO#uUC

Chartm V. Nuk, M.D.

Exocutln Dlroctor

Am.rlG,” Aud9mYat ?8tilatrlRo80rt G. Frazlu, M.D.

Ex9CUtlv9 Dlr0ct07

AIMII.2,” C.IIW Of OMt*tIkhml

●nd Qmmol.tists

Wm.n H. mar=, Mm.

Dk.ctor

Arimrl.,” C@l.W Of WiYlkh.8

EOward C. Roi9now, Jr.vM.D.

Exuutwti VICOPr-M911t

Arn.rlcan CU19SS Of FnWnttW

M.dlcl”.

WaId a.ntl.y

Exccutlvo Dlrutor

Arn#,lca” COII09001 SUIS-IW

c. R.allln%hanlon. M.D.

EXOCUIWODwQctof

Amwlem 0st9eDathk AssoalnM~n

Edward P. CIOWO!I, D. 0.

ExWutlVO OI1OCtOf

A.n.rlo.n PrOctalOslcs=l*tY

Nblandro F. CMtrO, M.D.

Socr*talv

Am.,lca” ●,Ych88ttiCfiSS0*18tt0.

M81vln Sabshln, M.O.

-d#Cal Olr-tor

A:::~;sOcl.tY al Intar-1

Wlltlam R. R.mnY

Ex.CUtlvm OlrutOI

Am.!tem SOCIOtYOf m@k #.d

R,co”,trucuv85urs901w, Inc.

D.llm F. WhJl*Y

ExuutlvCVIC* Pf-ld.111

Dear Dr.

The National Center for Health Statistics, as part of its

continuing program to provide information on the health

status of the American people, is conducting a National

Ambulatory Xedical Care Survey (NA’ICS).

The purpose of this survey is to collect information

about ambulatory patients, their problems, and the

resources used for their care. The resulting published

statistics will help your profession plan for more

effective health services, determine health manpower

requirements, and improve medical education.

Since practicing physicians are the only reliable source

of this information, we need your a.~istance in the NAMCS.

As one of the physicians selected in our national sample,

your participation is essential to the success of the

survey. Of course, all information that you provide is

held in strict confidence.

?lanyorganizations and leaders in the medical profession

have expressed their support for this survey, including

those shown to the left. They join me in urging your

cooperation in this important research.

Within a few days, a survey representative will telephone

you for an appointment to discuss the details of your

participation. We greatly appreciate your cooperation.

Sincerely yours,

Dorothy P. Rice

Director

Arn.,lcs” U..1.,ICAS*OCI.UO.

WI B, J.nntngh JI.. M.D.

Ex.cutlve Dl,OCtOI

A, S. CI.U.. otArn.rlcmM.dial

Coil.,.s himA, D. Co PP.r,M.O.. WI.D.

Pr”ta*nt

47
PATl ENT LOG

As e.ch Dmml awes. mm,d nmne and lrm.

of “,s,, o“ !h, I.g b,l.W F., ,he Pwent en.

lered O. lb”, $3, al,. COmplele the p.l,ent

,em,d m the ,,gh,.

PATIENT’S NAME I

TIME OF

VISIT

=----F= m

+----l= Record Items 1.12 for this Dadent I m I

CONTINUE LISTING PATIENTS

ON NEYT P,&~C

1975-76

PATIENT RECORD AND PATl ENT LOG

ASSURANCE OF CONFIDENTIALIW-- All -fc,r,nmon /,h,c. n..,d p,.,m,, (JL.n,,,,c,,,.n .f an ,n,j,v,dU.,

. pr..llc+. m m eslabhshment WIII be held co. fwlmr! al. m !11w .s?,! ..1, h, Der,o.s engaged m and fc,

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1. DATE OF VISIT PATl ENT RECORD

/ /

/

NATIONAL AMBULATORY MEDICAL CARE SURVEY

.M“....-. .9.”,,./ v,,

2. OATE OF BIRTH 4. COLOR OR 5. PATIEN~S PRINCIPAL PROBLEM(S) 6. SERIOUSNESS OF

RACE

‘ 7. HAVE YOU EVERSEEN

COMPLAINT(S), OR SYMPTOM(S) ~ VISIT PROBLEM IN ITEM 5a THIS PATlENT LIEFORE~

.=+=+ ‘–

[In pafimf’s awn word.) (C},eck one)

, @ WHITE YES : NO

‘: VERY SERIOUS

3. SEX ‘ ❑ ‘EfT~~K ] i&i%NT_

t

‘ sFRIOUS II YES. for the problen,

, ~ FEMALE , ❑ OTHER - SLIGHTLY SERIOUS ,

md!ca ted m ITEM 5a J

z 3 MALE !4 G UNKNOWN I b OTHER_. I ~ : NOT SERIOUS ! YES ., NO

1 t

8. MAJOR REASON(S) FOR THIS VISIT (Chck a//m,/o, ,.sasom}

—

, ❑ ACUTE PROBLEM . ~ WELL AD IJLTICHILO EX4M

o, II ACUTE PROBLEM, FOLLOW-UP I u FAMILY PLANNING

., ❑ CHRONIC PROBLEM, ROUTINE Z COUNSELING, ADVICE

w @ CHRONIC PROBLEM, FLARE-UP :: lMMUiNILATION

., ~ PRENATAL CARE :. REFERRED BY OTHER PHYS;AGENCY

,, ❑ POSTNATAL CARE . C ADMINISTRATIVE PURPOSE

]. O POSTOPERATIVE CARE

7

. r OTHER (Spec,fy)

(Operadve procedure)

10. DIAGNOSTIC/THERAPEUTIC SERVICES OROEREO/PROVIDELl THIS VISIT (Chmka// that J@y/

01 tl NONE

D2 ❑ LIMITED HWFORY/EXAM

03 0 GENERAL HISTORYIEXAM

M ❑ CLINICAL LAS. TEST

05 D BLOOD PRESSURECHECK

G6 ❑ EKG

07 n HEARING TEST

00 ❑ VISION TEST

09 D ENDOSCOPY

10 D OFFICE SURGERY

11 ❑ DRuG PRESCRIBE

12 ❑ X-RAY

13 ❑ INJECTION

14 ❑ IMMUNIZATIONIDESENSITIZATION

1S ❑ PHYSIOTHERAPY

16 ❑ MEDICAL COUNSELING

17 ❑ RSYCHOTHERAPYfTHERAPEUTIC

LISTENING

18 ❑ OTHER (Spwifyl

RA-34-4 DEPARTMENT OF HEALTH, EDUCATIO

EV. 8.75 pUBLIC HEALTH SERV

HEALTH REsOu RcEs ADMINIf

NATIONAL CENTER FOR HEALTF

9. PHYSICIAN’S PRINCIPAL OIAGNOSIS ~ VISIT

a OIAGNOSIS ASSOCIATE WITH ITEM 5a ENTRY ..— _

,

b. OTHER sIGNIFICANT CURRENT OIAGNOSES

(in order of importance)

11. OISPOSITiON THIS VISIT ~ 2. DURATILWIOF

(Check all rhat Z

~ VISIT [Time

actuallyspenrwith

, ❑ NO FOLLOW.UP PLANNED

physicim)

z ~ RETURN AT SPECIFIEO TIME

, •l RETuRN IF NEEOEO. P RN.

. a TELEpHoNE FOLLOW-UP PLANNED

* ❑ REFERREo TO OTHER —.—----MINUTES

PHYsIcIANIAGENCY

, ❑ RETURNEO TO REFERRING

PHYSICIAN

, ❑ AoMIT TO HOSPITAL

8 0 OTHER (SLIeCdy)

&ND WELFARE O.M.B. #S8-S72106

iATION

rATISTICS
CONFIDENTIAL*

NoRC-4233

FORM

Form Approved.

OM8 No. 68RL498 1

NATIONALAMBULATORYMEDICAL CARE SURVEY

INDUCTIONINTERVIEW 11111

(Phys.ID Number)

BEFOIU3STARTINGINTERVIEW

1. ENTER PHYSICIANI.D. NUMBER IN BOX TO RIGHT, ABOVE

2. ENTER DATES OF ASSIGNED REPORTINGWEEK IN Q. 2, P.2

Doctor, before I begin, let me take a minute to give you a little backgroundabout

this survey.

Although ambulatorymedical care accountsfor nearly 90 per cent,of all medical care

receivedin the United States,there is no systematicinformationabout the characteristicsand problemsof people who consultphysiciansin their offices. ~is kind

of informationhas been badly needed by medical educatorsand others concernedwith

the medicalmanpower situation.

In responseto increasingdemands for this kind of information,the National Center

for Health Statisticsjin close consultationwith representativesof the medical

profession,has developedthe NationalAmbulatoryMedical Care Survey.

Your own task in the survey is simple,carefullydesigned,and should not take much

of your time. Essentially,it consistsof your participationduring a specifiec!

7-day period, During this period, you simply check off a minimal amount of infotniation concerningsome of the patientsyou see.

Now, before we get into the actual procedures,I have a few questionsto ask about

your practice. The answersyou give me will be used only for classificationand *

analysis,and of course—all informationyou provide is held in strict confidence.

1. First, you are a

(ENTERSPECIALTYFROM CODE ON FACE SHEET LABEL.)*

Yes . . . . . . . . .

No. . . . (ASKA) . .

A. IF NO: What is your specialty (includinggeneralpractice)?

Is that right?

. . 1

. . 2

(Name of Specialty)

*

All informationwhich would permit identificationof an individual,a

practice,or an establishmentwill be held confidential, will be used only by persons

engaged in and for the purpose of the survey, and will not be disclosed or released

to other persons or used for any other purpose.

49
2. :<cw,doctor, this study will be concerned with the ambulatory patients you will

see in your office during the week of (READ REPORTING DATES ENTERED BELOW).

(that’s a (that’s a

r Monday) through / Sunday)

month date month date

Are you likely to see ~ ambulatory patients in your office during that week?

Yes. . . . . .(GOTOQ.3) ..1

No . . . . . . (ASK A). . . .2

A. IF NO: why is that? RECORD VERBATIM, THEN READ PARAGRAPH BELOW

Since it’s very important, doctor, that we include any ambulatory patients

that YOU ~ happen to see in your office during that week, I’d like to

leave these forms with YOU anyway--just in case your plans change. 1’11

plan to check back with your office just before (STARTING DATE) to make

sure, and I can explain them in detail then, if necessary.

GIVE DOCTOR THE+J PATIENT RECORD FORMS AND GO TO Q. 9, P. 6.

50
3. A.

B.

c.

At what office location gill yotibe seeing ambulatory patients duririgthat

7-day period? RICORD UNDER A BEL~ AND ASK B WHEN INDICATED.

IF HOSPITAL EMERGENCY ROOM”OR HOSPITAL OUTPATIENT DEPARTMENT, OR OTHER

INSTITUTIONAL LOCATION IN A: Thinking about the ambulatory patients you see

-PLACE IN A), do you, yourself, have principal responsibility for their

care over time, or does (INSTITUTION IN A) have primary responsibility for

their care over time? CODE UNDER B BELW.

IS that all of the office locations at which you expect to

patients=ring that week?

Yes. . . . . .

No . . . . . .

see ambulatory

. . . . 1

. . . . 2

IF NO: OBTAIN ADDITIONAL OFFICE LOCATION(S), ENTER IN “A” BELOW, AND REPEAT.

A. I

B.

Principal

Office Location Reaponaib~lity?

Insti- Physician tution

(1) 1 2

(2) 1 2

(3) 1 2

(4) 1 2

34D.

~n Scope?

!es No

1 2

1 2

1 2

1 2

D. FOR EACH OFFICE LOCATION ENTERED IN A, CODE YES OR NO TO “IN SCOPE” ABOVE.

IN SCOPE (Yes) [OUT OF SCOPE (No) [

Private offices Hospital emergency rooms

Free-standing clinics Hospital outpatient departments

(non-hospital based) College or university infirmaries

Groups, partnerships Industrial outpatient facilities

Kaiser, HIP, Mayo Clinic Family planning clinics

Neighborhood Health Centers Government-operated clinics

Privately operated clinics (VD, maternal & child health, etc.)

(except family planning)

IN CASE OF DOUBT, ASK: Is that (clinic/facility/institution) hospital based?

Is that (clinic/facility/institution) government

operated?

IF ALL LOCATIONS ARE OUT OF SCOPE, THANK THE DOCTOR AND LEAVE.

PATIENT RECORDS MUST BE COLLECTEDFROM ALL IN-SCOPELOCATIONS

1REGARDLESSOF ANWER TO B -- PRINCIPALREsF’oNs131LiTy.

● 51
4. A. During that week (REPEAT DATES), how nlanyambulatory patients do you expect

to see in your office practice? (DO NOT COUNT PATIENTS SEEN AT [OUT-OF-SCOPE

LOCATIONS] CODED IN 3-B.)

ENTER TOTAL UNDER “A” BELOW AI@ CIRCLE ON APPROPRIATE LINE.

B. And during those seven days (REPEAT DATES IF NECESSARY), on how many ~ do

you expect to see any ambulatory patients? COUNT EACH DAY IN WHICH DOCTOR

EXPECTS TO SEE ANY PATIENTS AT AN IN-SCOPE OFFICE LOCATION.

ENTER TOTAL UNDER “B” BELOW AND CIRCLE NUMBER IN APPROPRIATE COLUMN.

DETERMINE PROPER PATIENT LOG FORM FROM CHART BELOW. READ ACROSS

ON “TOTAL PATIENTS” LINE UNDER “A” AND CIRCLE LETTER IN APPROPRIATE

“DAYS” COLUMN UNDER “B.”

THIS LETTER TELLS YOU WHICH OF THE FOUR PATIENT LOG FORMS (A, B, C, D)

SHOULD BE USED BY THIS DOCTOR.

LOG FORM DESCRIPTION Expected total

patients during

survey week.

~[ w

A--Patient Record is to be

completed for ALL

patients Iiste=n Log.

B--Patient Record is to be

completed for every

SECOND patient listed

on Log.

C--Patient Record is to

conmleted for every

THIb patient listed

on Log.

*D--Patient Record is to

comuleted for every

FIF& patient list;d

on Log.

be

be

Q. 4-A.

1 2 3 4 5 6 7

1- 12 PATIENTS AAAAAAA

13- 25 “ B AAAAAA

26- 39 “ CBAAAAA

40- 52 “ CBBAAAA

53- 65 “ I DCBBAAA

66- 79 “ DCBBBAA

80-92 “ “ID D C B B B B

93-105 “ DDCBBBB

106-118 “ DDCCBBB

119-131 “ DDCCBBB

132-145 “ DDDCCBB

146-158 “ DDDCCBB

159-171 “ DDDCCCC

172-184 “ DDDCCCC

185-197 “ DDDDDDD

198-210 “ DDDDDDD

I 211+ II DDDDDDD

*

In the rare instance the physician will see more than 500 patients during his

assigned reporting week, give him two D Patient Log F~s and instruct him to complete a patient record form for only every tenth patient. Then you are to draw an X

or line on line 5 on every other page of the two folio pads, starting with page 1 of

the pad.

52

●
5. FIND PATIENT LOG FOLIO WITH APPROPRIATELETTERAND ENTER LETTERAND NUMBER

OF THIS FORM HERE.

(FolioNumber)

6. HAND DOCTOR HIS FOLIO AND EXPLAINHOW FORMS ARE TO BE FILLED OUT. SHOW DOCTOR

THE INSTRUCTIONSON POCKXT OF FOLIO AND ITEM 10 DEFINITIONSON CARD IN FOLIO,

TO WHICH HE CAN REFER AFTER YOU LEAVE.

RECORD VERBATIM BEIJ3WANY CONCERN,PROBLEMSOR QUESTIONSTHE DOCTOR RAISES.

7. IF DOCTOR EXPECTS TO SEE AMBULATORYPATIENTSAT MORE THAN ONE IN-SCOPELOCATION

DURING ASSIGNEDWEEK, TELL HIM YOU WILL DELIVER THE FORMS TO THE OTHER LOCATION(S).

ENTER THE FORM LETTER AND NUMBER(S)FOR THOSE LOCATIONSBEIOW, BEFORE DELIVERING

FORM(S).

IOcation Patient Record Form Letter & Number

8. During the surveyweek (REPEATEXACT DATES),will anyone be availableto help

you in fillingout these records (at each IN-SCOPE location)?

Yes . . . . (ASKA) ...1

No . . . . . . . . . . .2

A. —,IF YES” Who would that be?

RECORD NAME, POSITIONAND LOCATION.

NAME I POSITION IOCATION

B.

*

INTERVIEWER:

wAS PERSON

BRIEF

BY YOU?

Yes I No

1 2

1 2

1 2

1 2

“INTERVIEWERSHOIJLDBRIEF SUCH PERSON IF POSSIBLE.

53
9. DO you have a solo practice, or are you associated with other physicians in a

partnership, in a group practice, or in some other waY?

solo. . , . . . . . . . - . . .1

Partnership . , (ASK A-C) . . . 2

Group . ..(ASKAKC)C) ..,3

<--- Other (SPCIFY AND ASK A-C). . . 4

IF PARTNERSHIP, GROUP, OR OTHER:

A. Is this a prepaid group practice? Yes . . (ASK[l]) . . , 1

No . . . . . . . . . .2

[IO IF YESTOA: What percent

of patients are

prepaid? per cent

B. How many other physicians are

associated with you? NUMBER OF PHYSICIANS:

c. What are the specialties of the other physicians associated with you?

Specialty Number of Physicians

(1)

(2)

(3)

(4)

(5)

10, Now 1 have just one more question about your practice. (NOTE: IF DOCTOR PRACTICES

IN LARGE GROUP, THE FOLLOWING INFORMATION CAN BE OBTAINED FROM SOMEONE ELSE.)

A. What is the total number of full-time (35 hou’rs or more per week) employees of your (partnership/

group) practice? Include persons regularly employed who are now on vacation, temporarily ill,

etc. Do not include other physicians. RECORD ON TOP LINE OF COLUMN A BELOW.

(1) Ho=any O( these full-time employees are a . . , (READ CATEGORIES BEfRW AS NECESSARy AND

RECORD NIMIJEROF EACH IN COLUNN A.)

B. And what is the Lotal number q[ part-time (less than 35 homrs per week) employees of your

(partnership/group)practice? Again, include persons regularly employed who are now on vacation,

ill, etc. Do not include other physicians. RECORD ON TOP LINE OF COLUMN B BELOW.

(1) How many of these part-time employees are a . . . (READ CATEGORIES BELOW AS NECESSARY

AND RECORD NLT4BER OF [AcH IN COLUt-tN B.)

A. B.

Employees Full-time Part-time

(35 or more hourslweek) (Less than 35 hourslweek)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

ToTAL:

Registered Nurse . . . . , . . . . . . . . . .

Licensed Practical Nurse . . . , . . . . . . .

NursingAide. . . ,. , . , , . . , , . , . .

Physician Assistant* , . . , . . . , . . . , .

Technlclan. . , . . . . . . . . . , . . . . .

Secretary or Receptionist . . . . . . . . , .

Other (SPECIFY)

TOTAL:

[

+,

Physician Assistant must hc a p,r.aduateof an accredited training program for Physician Assis Lanes

(Pl>yslcic?:. Ixtcndcrs, :kdcj, etc.) or crrrifled by the NaL1onal Board of Medical Lxamirmrs chrouzh the

CeItlfJLalllunU.am for l,sSIS1ant to !IIcPrimary Care Physician.

54
11. During the past seven (7) days, %hout how many house calls did you make?

NUMBER OF HOUSE CALLS: \

12. During the past seven (7) days, how many times did you provide to patients

advice or consultation by telephone?

None. . . . . . . .1

1-9 . . . . . . . .2

10-24 . . . . . . .3

25-49 . . . . . . .4

50 or more . . . . . 5

BEFORE YOU LEAVE, STRESS THAT ~ AMBULATORY PATIENT SEEN BY TRE DOCTOR DURING

THE 7-DAy PERIOD ATQ IN-SCOPE OFFICE LOCATIONS (REPEAT THEM) IS TO BE INCLUDED IN THE SURVEY, TRAT EACH PATIENT IS TO BE RECORDED ON THE LOG, AM) ONLY

THE APPROPRIATE NUMBER OF PATIENT RECORDS COMPLETED.

Thank you for your time, Dr. . If you have any (more) questions,

please feel free to call me. My phone number is written in the folio. I’ll

call ~ on Monday morning of your survey week just to remind you.

13. TIME INTERVIEW ENDED . . . . . . . . AM

PM

14. DATEOFINTERVIEW . . . . . . . . . . . . . . .

I I I II 11

(Month) (Day) (Year)

COMPLETE ITEMS I AND II ON THE LAST PAGE

IMMEDIATELY AFTER THE INTERVIEW.

55
-8-

i, How much interest do you think the II. How confident are you that the

doctor has in the survey? doctor will complete the forms?

Great interest . . , 1

Some interest , . . , 2

Little interest . . . 3

No interest . . . . . 4

Can’t tell . . , , , 5

I

Definitely will . . 1

Probably will . . . 2

Doubtful . . . . . 3

INTERVIEWER NUMEER

i

INTERVIEWER’S SIGNATURE
Series 1.

Series 2.

Series 3.

Series 4.

Series 10.

SOi~J 11.

Series 12.

Series 13.

Series 14.

VITAL AND HEALTH STATISTICS Series

Programs and Collection Procedrsre~. --Reports which describe the general programs of the National

Center for Heafth Statistics and its offices and divisions and data collection meth:xf< Ilsr-d and include

definitions and other material necessary for understanding the data.

Data Evaluation and Methods Research. - Studies of new’ statistical methmiologv in{ luding experi

mental tests of new survey methods, studies of vital statistics collection methods. new analytical

techniques, objective evaluations of reliability of collected data, and contributions to st~tistiral theory.

Analytical Studies. --Reports presenting analytical or interpretive studies based on vital anti health

statistics, carrying the analysis further than the expository tvpes of rt=ports in the other w=~i~s.

Documents and Committee Reports. --Final reports of ma]or committee< c(,ricern4 \vith ~.ital and

heaith statistics and documents such as recommended model vital refzistr~tion la~vs and re~-ised birth

and death certificates.

Data From the Health Intervieuf Survey. Statistics on illness, .I<c]dental injuries. disability. use of

hospital, medical, dental, and other services, and other health-related topics. all bawd on data collected

in a continuing national household interview survey

Data From the Health Examination Surney and the Health and Nutrition Examirurtton Suruey.-Data

from direct examination, testing, and measurement of national samples of the civilian noninstitu

tionalized population provide the basis fc)r two types of reports: (1) estim>tes .lf the medica]iy defined

prevalence of specific diseases in the United States and the distributions of the pf~pulrrI ion v~th respect

to physicaI, physiological, and psychological characteristics and ( 2) analysis of wl:atit,nshlps among the

various measurements without reference to an explicit finite universe of persons

Data From the Institutionalized Population SuVwy T. Discontinued eff=, [i. e 19-”. FIYIIW reports fr~~m

these surveys will be in Series 1.3.

Data on Health Resource.~ Lhilization. -Statistics on the utilization ,Jf health manpower and fa.cilitics

providing long-term care, ambulatory care, hospital care, and family planning w-vices.

Data on Health Resourcer: .Man#roww and Faci[itics. -Statistics on lhe number<. tzeographic distri

/

bution, and characteristics of health resources including phvsiriai}s, dcntis~s. nl~r~es, other health

occupations, hospitals, nursing homes, and outpatient facilities.

Series 20. Data on Mortality. --Varimrs statistics on mortality other than as included in re~~llar annual or monthly

reports. Special analyses by cause of death, age. and other demographic vari:]ble:. ~r-ogt-aphic and time

series analyses; and statistics on characteristics ,lf deaths not avalla})le fritm tll- vit~i r-cords basecl on

sample surveys of those recnrds,

For a list of titles of reports published in these series, write t:>:

r

S~ientific and f_echnicai ln+ornlation Branch

National Center for Health $tatistics

Puhli( Health Service

rI\2ttsvilllJ. Md, 2078?

-.
I

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