Data from the

NATIONAL HEALTH SURVEY

Office Visits for Diseases

of the Circulatory System

The National Ambulatory

Medical Care Survey

United States, 1975-1976

Based on data obtained from a national sampIe of office-based

physicians, statistics are presented which describe ambulatory medicaI care during visits for treatment of diseases of the circulatory

system. Physician utilization patterns are described in terms of

patient characteristics, patient condition and management, and

practice characteristics. Highlighted diagnoses include essential

benign hypertension, coronary heart disease, symptomatic heart

disease, cerebrovascular disease, arteriosclerosis, and selected

diseases of veins.

DHEW Publication No. (PHS) 79-1791

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

Public Health Service

Office of the Assistant Secretary for Health

National Center for Health Statistics

Hyattsville, Md. January 1979

Series 13

Number 40
,-— . .. .. - . ..... -.

1

/’

r’
—-.--—- ..”

NATIONAL CENTER FOR HEALTH STATISTICS

DOROTHY P. RICE, Director

ROBERT A. ISRAEL, Deputy Director

JACOB J. FELDMAN, Ph.D., Associate Directorfor Amdysis

GAIL F. FISHER, Ph.D., Associate Director for the Cooperative Health Stati.sties System

ELIJAH L. WHITE, 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 Deve~opment

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

ALICE HAYWOOD, Information Officer

DIVISION OF HEALTH RESOURCES UTILIZATION STATISTICS

SIEGFRIED A. HOERMANN, Director

JAMES E. DELOZIER, Chiej Ambukztory Care Statistics Branch

MANOOCHEHR K. NOZARY, Chiej Technical Services &-anch

STEWART C. RICE, ChieJ Family Phzning Statistics &mch

JOAN F. VAN NOSTRAND, Chiej Long-Term Care Statistics Branch

Vital and Health Statistics-Series 13-No. 40

DHEW Publication No. (PHS) 7!3-1791

Library of Congress Catalog Card Number 78-31501
CONTENTS

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

Background .......................................................................................................................................

Scope of the Survey ..........................................................................................................................

Source and Limitation of the Data ....................................................................................................

Major ICDA Group–Dkeases of the Circulatory System ........................................................................

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

Patient Condition and Management ..................................................................................................

Practice Characteristics .....................................................................................................................

Selected Dkeases of the Circulatory System ..........................................................................................

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

Practice Characteristics ....................................................................................................................

Patient Condition and Management ..................................................................................................

Diseases of fie Circtiatory System As Second- or Third-Listed Dia@oses ..................................

Diagnostic Concomitance ............................................................................................................

Patients’ Principal Problem, Complain~ or Symptom .................................................................

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

Duration of Visit ........................................................................................................................

Disposition of Visit .....................................................................................................................

Referrsd ......................................................................................................................................

Diagnostic-Therapeutic Services ..................................................................................................

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

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

Appendixes

L Technicaf Notes ........................................................................................................................

IL Definition of Certain Terms Used in This Repoti .....................................................................

IIL Survey Instruments ..................................................................................................................

1.

2.

3.

4.

5.

6.

LIST OF TEXT FIGURES

Percent distribution of office visits for diseases of the circulato~ system, by specialty visited:

United States, 1975-76 ................................................................................................................

Average annuaf rate of office visits for selected diseases of the circulatory system by sex of

patient: United States, 1975-76 ..................................................................................................

Average annuaf rate of office visits for selected diseases of the circulatory system, by race of

patient: United States, 1975-76 .................................................................................................

Average annual rate of office visits for essential benign hypertensio~ by race, sex, and age of

patient: United States, 1975-76 .................................................................................................

Average annual rate of office visits for coronary heart disease, by sex and age of patient: United

States, 1975-76 ...........................................................................................................................

Average annual rate of office visits by females for essential benign hypertension and coronary

heart disease, by age of patient: United States, 1975-76 .............................................................

1

:

2

3

3

4

4

5

5

6

10

11

12

13

14

16

18

19

20

20

28

30

39

47

51

5

7

8

9

9

10

,..

ill
7. Average annual rate of office visits by males for essentiel benign hypertension and coronary heart

disease, by age of patient: United States, 1975-76 ............................. .........................................

8. Percent of office visits that included blood pressure measurement in the presence and absence of

hypertension, by visit age: United States, 1975-76 ....................... ...............................................

A.

B.

c.

D.

E.

F.

G.

H.

J.

K.

L

M.

N.

o.

P.

Q.

R.

LIST OF TEXT TABLES

Number and percent of office visits for all diagnostic classes and number and percent for dkeases

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

Number and percent dk.tribution of office visits for diseases of the circulatory system and for

selected principal diagnoses: United States, 1975-76 ............ ...................... .................................

Number, percent distribution, and average annual rate of office visits for essential benign hypertension (40 1), by most frequently visited specirdties and sex and age of patient: United States,

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

Number, percent distribution, and average annual rate of office visits for coronary heart dkease

(410-4 13), by most frequently visited specialties and sex and age of patient: United States,

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

Number and percent of office visits for selected diseases of the circulatory system listed as second

or third diagnoses: United States, 1975-76 ................. ............................. ....... .............................

Number and percent of ot%ce visits for essentird benign hypertension (401) listed as first, second,

or third diagnosis, by other most frequent diagnoses: United States, 1975-76 ...... ............... .......

Number and percent of office visits for coronary heart disease (41 O-413) listed as first, second, or

third diagnosis, by other most frequent diagnoses: United States, 1975-76 .......... .......................

Number and percent distribution of office visits for essential benign hypertension (401) by visit

status, seriousness of problem, and deposition of visit, according to sex and age of patient:

United States, 1975-76 ................ ................................................................................................

Number and percent distribution of office visits for coronary heart disease (410-413) by visit

status, seriousness of problem, and disposition of visit, according to sex and age of patient:

United States, 1975-76 ................................... ................................................ ...... ......................

Number and percent distribution of office visits for essential benign hypertension (401) by

seriousness of problem, according to visit status: United States, 1975-76 ..................................

Number and percent distribution of office visits for coronary heart disease (410-413) by seriousness of problem, according to visit status: United States, 1975-76 ............................................

Percent of office visits for essential benign hypertension (401) and coronary heart disease (410-

41 3), by disposition of visit and seriousness of problem: United States, 1975-76 ........................

Percent distribution of office visits for diseases of the circulatory system by number of types of

diagnostic and therapeutic services ordered or provided, according to selected principal diagnoses: United States, 1975-76 ..... .............................. ..................................................................

Number and percent of office visits for selected dkeases of the circulatory system, by diagr.ostic

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

Number and percent of office visits for selected diseases of the circulatory syste~ by most frequent diagnostic and therapeutic services ordered or provided: United States, 1975-76 ... ...........

Number and percent of office visits for essential benign hypertension (401), by visit status,

seriousness of problem, and diagnostic and therapeutic services ordered or provided: United

States, 1975-76 ........................................ ........................................... .........................................

Number and percent of office visits for coronary heart dkease (410-413) by visit status, seriousness of problem, and diagnostic and therapeutic services ordered or provided: United States,

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

4

6

11

11

12

13

14

16

17

18

18

20

21

22

22

23

24

iv
s. Number and percent of office visits for essential benign hypertension (401), by sex and age of

patient and diagnostic snd therapeutic semices ordered or provided: United States, 1975-76 ..... 24

T. Number and percent of off]ce visits for coronary heart disease (410-413), by sex and age of

patient and diagnostic and therapeutic services ordered or provided: United States, 1975-76 ...-. 25

U. Percent of office visits by selected diagnostic and therapeutic services ordered or provided in the

presence and absence of selected principal di~,oses: United States, 1975-76 ............................. 25

v
SYMBOLS

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

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

Quantity zero --------------------------------------- -

Quantity more than Obut less than 0.05--–- 0.0

Figure does not meet standards of

reliability or precision–— ------------------- *
OFFICE VISITS FOR DISEASES

OF THE CIRCULATORY SYSTEM

Beulah K. Cypress, Ph.D., Division of Health Resources Utilization Statistics

INTRODUCTION

This report presents national estimates of

1975 and 1976 visits to office-based physicians

in the conterminous United States, in which

physicians rendered diagnoses in the category

“diseases of the circulatory system.”

HIGHLIGHTS

In 1975-76 patients made 110.6 million

visits to office-based physicians for treatment of

diseases of the circulatory system. A principal

diagnosis of essential benign hypertension was

assigned to 42 percent of such visits. Chronic

ischemic heart disease caused 24 percent; symptomatic heart disease, 6 percent; cerebrovascular

disease, 4 percent; diseases of arteries, arterioles,

and capillaries, 4 percent; diseases of veins and

Iymphatics, 8 percent.

Seven of eight visits for essential benign

hypertension were made by white persons. In

5 of 8 visits the problem was presented by a

female. The median visit age for females was

62.0 years; for males, 57.6 years. When chronic

ischemic heart disease was the diagnosis, the

median visit age for femzdes was 70.5 years; that

of males was 64.1 years. Males aged 35 to 74

years visited physicians at a higher rate than

females did for care of ischemic heart disease.

However, visit rates of females exceeded those

of males for essential benign hypertension.

Seven in ten visits for cerebrovascular

disease were made by patients 65 years and over.

Patients 75 years and older represented the highest proportion (39 percent) of visits for that

condition, but visits by patients 45 years and

under were rare (3 percent). Arteriosclerosis was

also more common during visits by the elderly

with a median visit age of 75.1 years.

Essential benign hypertension was frequently

concomitant with diabetes mellitus and obesity.

When hypertension was the principal diagnosis,

diabetes mellitus was also listed in about 5 percent of those visits. When diabetes mellitus was

the principzd diagnosis, hypertension was the

second- or third-listed diagnosis during 14 percent of such visits. Obesity was an additional

diagnosis in 10 percent of hypertension visits;

hypertension was second- or third-listed in 5

percent of all visits for a principal diagnosis of

obesity. Diabetes mellitus and obesity were rdso

commonly coincident with ischemic heart disease. However, ischemic heart disease and hypertension were not frequently diagnosed during

the same visits.

Physicians used electrocardiograms (EKG’s),

X-rays, and laboratory tests more often during

initial patient visits than when the patient presented an “old” problem. Blood pressure was

measured about 80 percent of the time when

hypertension was present, but ordy about 30

percent of visits included blood pressure measurement when hypertension was absent. Nonhy -

pertensive females were more Iikely to have

their blood pressure taken than were nonhypertensive males. When hypertension was not

present, the rate of blood pressure measurement

increased with age.

1
BACKGRO(JND

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

and methodology of the survey were published

in Vital and Health Statistics, Series 2, No. 61.1

Separate data for 1975 and 1976 were reported

in Series 13, No. 33 and in Advance Data Report No. 30.z~s

This is the first series report based on

NAMCS data for combined calendar years 1975

and 1976, and the first series report from that

survey with a focus on diagnoses. Statistics

representing 1975-76 visits for essential benign

hypertension, a member of the diagnostic group

of circulatory system diseases, were summarized

in an advance report.A Other brief reports based

on data from 1975, 1976, or combined years

featured physician specialty profiles and visits

by persons aged 65 years and over. s-l A

Information 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, the physician ‘S 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 be

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 (ICl)A). 15 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 where they are relevant and meaningful.

The data used in this report encompass the

major ICDA category, diseases of the circulatory

system, code 390-458. In addition to a general

description of the utilization pattern of ambulatory care for the class of circulatory diseases,

this report provides detailed information about

patient, clinical, and practice characteristics of

visits for selected most frequent, well-defined

diseases within the class, for example,, essential

beni~ hypertension, ICDA code 401.

For clarity, categories of diseases, such as

“diseases of the circulatory system” or “diseases

of the respiratory system, ” are referred to in this

report as “major ICDA group. ” Specific diseases

within the groups are identified by their threedigit codes and designated as “principal,”

“second,” or “third” diagnosis depending on the

priority given by the physician.

Prior to data presentation, the scope of the

survey and limitations of the data are described

briefly to assist the reader in interpreting the

estimates. A detailed description of the 1975-76

survey, including technical details, definitions,

and survey instruments, appears in the appendixes to this report. The 1975 and 1976 surveys

were conducted in identical fashion using the

same instruments, definitions, and procedures.

The 2 years of data were combined to provide

greater reliability of estimates. Therefore, the

reader shouId note that estimates of numbers of

visits contained 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 is the

physician-patient encounter or visit. “Encounter” and “visit” are used interchangeably in this

report.’ 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 as “office-based, patient care” were

included in the 1975-76 NAMCS. In addition,

physicians in the specialties of anesthesiology,

pathology, and radiology were excluded from

the physician universe. Major types of ambulatory encounters not included in the 1975-76

NAMCS were those made by telephone, those

‘The term “contact” is reserved to apply only to that

part of the visit or encounter that involved a face-to-face

interchange between physician and patient.
made outside of the physician’s office, and those

made in hospital or institutional settings. It is

planned to extend the survey 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 H.

SOURCE AND LIMITATION

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

eli@ble for the study, 4,476 (79.9 percent)

participanted in the study, providing data concerning a random sample of some 114,000 patient

visits.

SpeciaIly trained interviewers visited the

physicians prior to a designated reporting week,

provided survey materials, and informed each

physician and staff member about 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).

Readers are urged to review the three appendixes to this report. These appendixes 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.

Because the statistics in this report are based on

a sampIe of ambulatory visits rather than on all

visits, they are subject to sampling errors. Therefore, particular attention should be paid to the

section in appendix I entitIed “Reliability of

Estimates.” Examples of relative standard errors

and instructions for their use are given in appendix L

Definitions of the terms used in this report

and in the survey operations are presented in

appendix II. Facsimiles of survey materials,

including Ietters, Patient Record forms, and Induction Interview forms are reproduced in appendix III.

By means of another program of NCHS, the

HeaIth Interview Survey (HIS), data are collected on the utilization of physician services

but from a different universe. Estimates provided

by HIS may differ from those in NAMCS because of differences in collection procedures,

populations sampled, and definitions. Data from

HIS are published in Series 10 of Vital and

Health Statistics.

The distinction between prevalence of a

disease and physician visits for a disease should

be kept in mind when interpreting the data. For

obvious reasons, physician 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. The N.4NICS

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 obtained from

other surveys conducted by NCHS.b

bFor example, see publications of HIS (Series 10)

and the Health and Nutrition Examination Survey

(HANEs) (Series I 1).

MAJOR ICDA GROUP– DISEASES OF THE CIRCULATORY SYSTEM

Patients’ problems, compkints, or symptoms visits to office-based physicians in 1975-76.

were diagnosed as caused by diseases of the cir- These visits accounted for about 10 percent of

culatory system in an estimated 110.6 million visits for dl dia~oses, and comprised the second

3
leading morbidity-related diagnostic group (diseases of the respiratory system was first with

14 percent).

PATl ENT CHARACTERISTICS

Visits for diseases of the circulatory system

ranked first among major ICDA groups when

patients visiting were 45 years of age or older.

The number of office visits for all diagnoses

according to age groups and the proportions of

visits for each age group visiting for diseases of

the circulatory system are listed in table A. Proportions of visits increased with advancing age.

For visits by patients under 45 years of age, only

2 percent included a circulatory problem; 16

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

classes, and number and percent for diseases of the circulatory system, by sex, race, and age of patient: United States,

1975-76

All diagnostic

classes

Sex, race, and age

All visits..

Sex and race

Female .........

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

Black and other . ....

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

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

Black and other . ....

Age

Under 35 years ........

35444 years .............

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

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

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

75 years and over ....

Number

of visits

in thousands

1,155,900

697,727

625,201

72,525

458,174

413,320

44,853

555,806

122,805

147,082

143,060

120,317

66,831

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

Diseases of the

circulatory system

Number

of visits

in thousands

110,617

—

62,656

55,789

6,866

47,961

44,044

3,916

7,499

7,796

19,217

27,605

29,674

18,B24

Percent

of

visits

9.6

9.0

8.9

9.5

10.5

10.7

8.7

1.3

6,3

13.1

19.3

24.7

28.2

lAbout 84 nercent were visits bv members Of the black race.

2About 72 ~ercent were wsits b; members of the black ra~epercent of visits by patients between 45 and 64

were similarly diagnosed; and 26 percent of all

office visits by patients 65 years or older were

for this major ICDA group. Additional distributions and rates of visits by sex and age are provided in table 1.

For those persons who visited physicians,

proportions of visits for diseases of the circulatory system did not significantly differ by race

(table A). Although the visit rate shown in table

1 was higher for white persons than for members of black and other races, the same was

true of all NAMCS visits regardless of the

diagnosis. That white persons tended to visit

office-based physicians at a higher rate than did

members of all other races was shown in HIS .16

Although there were, on the average, more

visits per person in the population by females

than by males for circulatory problems, a higher

proportion of visits by males than visits by females included a circulatory problem,. Of the

458.1 million visits by males estimated in

NAMCS, 11 percent were for circulatory system

diseases; of the 697.7 million visits by females,

9 percent included this disease group (table A),

PATIENT CC)NDiTION AND

MANAGEMENT

Most visits for circulatory disorders were for

regular care of a preexisting condition or for a

sudden exacerbation of a preexisting chronic

condition (74 percent total). Acute conditions,

defined as those having a relatively sudclen or recent onset, initiated about 14 percent of these

visits, and an additional 12 percent represented

followup care of a previously treated acute condition. (Here as elsewhere in this report data

are used which are taken from source data and

are not shown in tables or charts. )

The high degree of chronically ill patients

among those visiting for diseases of the circulatory system and the tendency of these patients

to seek continuous medical care were reflected

by the ratio of 5.4 visits by returning patients

with continuing problems to each new-problem

encounter. New-problem encounters included

new patients and patients the physician had seen
before but not for the current problem. Continuous rather than episodic care was more likely

when visits were diagnosed as diseases of the circulatory system than when other systems were

involved since there were proportionally fewer

new-problem encounters in this disease group

than in any other major ICDA group.

Ongoing patient management was demonstrated by physicians’ instructions to return at a

specified time or to return if needed, given during 93 percent of visits. In only 3 percent of

visits was no followup planned. When a disease

of the circulatory system was diagnosed, physicians relied on telephone followup for only 2

percent of visits, less often than when other

morbidity-reIated major ICDA groups were invoIved. About 3 percent of these visits resulted

in admittance to a hospital.

PRACTICE CHARACTERISTICS

Figure 1 illustrates the division of visits for

diseases of the circulatory system by physician

speciahy. Most visits made were to offices of

general and family practitioners and internists,

specialists whose combined practices comprised

about 35 percent of office-based physicians in

the United States in 1975 according to the

AMA.lT

All ot

Spec

Figure 1. Percent distribution of office visits for diseases of the

circu Iatory system, by specialty visited: United States, 1975-76

Table 2 shows the minimum amount of variation in proportions of visits by geographic location. Differences between proportions of visits

to physicians’ offices in metropolitan and nonmetropolitan areas, and between SO1Oand other

practice arrangements tend to reflect the distribution of physicians in the United States.

SELECTED DISEASES OF THE CIRCULATORY SYSTEM

In the ICDA, related diagnoses within the visits in 1975 -76.= Chronic ischemic heart discategory of diseases of the circulatory system ease, the third leading morbidity-related condiare grouped by sequences of three-digit rubrics tion, accounted for 2 percent of the total.

(e.g., ischemic heart disease includes codes 410 The balance of this report presents patterns

through 414). The number and percent of visits of office-based medical care for these and other

for each sequence are listed in table B. Percents selected diseases of the circulatory system.

of visits for the most frequent specific principal

diagnoses within each sequence are also shown.

Essential benign hypertension accounted for the

largest number of visits among the diseases of

CThe data classified as “morbidity related” apply to

the circulatory system (42 percent) followed by

visits where the principal diagnosis fell in any of the 17

major ICDA groups (codes 000-999). The two highest

chronic ischemic heart disease (24 percent). proportions of NAMCS visits in 1975-76 were in the

Essential benign hypertension also ranked first ICDA supplementary classifications, “Medical or special

among a.11visits for morbidity-related pnncipaI

examinations” (code YOO), and “Medical and surgical

diagnoses (at the 3-digit ICDA level), comprisaft ercare” (code Y1O). “Prenatal care” (code Y06) was

the fourth leading diagnosis. See Advance Data Report

ing 4 percent of the over 1.1 billion estimated No. 30 for additional information on ranks of diagnoses.

5
Table B. Number and percent distribution of office vis!ts for diseases of the circulatory system and for selected principal diagnoses:

United States, 1975-76

Diagnosis and ICDA codel

Active rheumatic fever and chronic rheumatic heart disease ......................................................................39 O.398

Hypertensive disease ......................................... ............................................... ..........................................4OO4O4

Essential benign hypertension .....................................................................................................................4Ol

Ischemic heart disease ................. ...............................................................................................................4lO.4l3

Acute myocardlal infarction and othar acute and subacute forms of ischemic heart disease .................410-41 1

Chronic ischemlc heart disease ........................................................................................... .........................4l2

Angina pectoris ...........................................................................................................................................4I3

Other forms of heart d!sease ....................................................................................... ..................... ..........42O429

Symptomatic heart disease ......................................... .. .......................... .............. .......................................427

Cerebrovascular disease .................................................... .. ............. ..................... ......................................43O.438

Diseases of arteries, arterioles, and capillaries ............................................................................................44O.448

Arteriosclerosis ............................... .............................................................................................................44O

Diseases of veins and Iymphatics and other diseases of the circulatory system . ..... .....................................45 O.458

Phlebitis and thrombophlebitis .. ........................................................................................... .......................45l

Varicose veins of lower extremities ...................... .......................................................................................454

Hemorrhoids ............. ............................................ ......................................................................................455

Number

of visits

in thousands

110,617

1,867

47,120

46,128

31,314

2,319

26,020

2,975

9,161

7,052

4,505

4,441

2,019

12,210

2,930

2,428

3,686

Parcent

distribution

of

visits

100.0

1.7

42.6

41.7

28.3

2.1

23.5

2.7

8.3

6.4

4.1

4.0

1.8

11.0

2.6

2.2

3.3

1 Diagnostic groupings and code inclusions are based cm the Eighth Revision Interns tional Classs”ficationOfDiseases. Adarwd fof’ use

in the United States, 1965.

PATl ENT CHARACTERISTICS

Essential benign hypertension (401).–Visit

rates for essential benign ~y~ertension, coronary

heart disease,d and other selected diseases of the

circulatory system are plotted in figure 2 by sex

and in figure 3 by race. Demographic data are

also detailed in tables 3 and 4.

Seven of eight office visits for care of essential benign hypertension were made by white

persons. In 5 of 8 visits the probIem was presented by a female. The highest proportion of

visits was in the age group 55-64 years. Visit

dThe term “coronary heart disease” is used interchangeably with the ICDA terminology “ischemic heart

disease” in this report. Both terms refer to the group

of heart ailments, acute and subacute ischemic heart

disease (410-41 1), chronic ischemic heart disease (412),

and angina pectoris (41 3).

rates increased with advancing age up to age

group 65-74 years. Females visiting were, on the

average, older than males, since the median visit

age for females was 62.0 years and for males it

was 57.6 years.e

There was a marked difference in visit rates

by sex beginning at about age 44, with the female rate peaking at age group 65-74 years,

about 10 years later than the male rate peaked

(figure 4). The advanced female age at visits

for hypertension as opposed to the younger

male age at such visits may be related to greater

susceptibility of males to other cardiovascular

diseases that preempt essential benign h ypertension as primary diagnosis. The Framingham

‘Median visit age should not be confused with median

patient age. The median visit age is based on initial and

return visits some of which may be by the same patient.

6
““”” m

Male &ggj

Essential benign Coronw Symptomatic CerebrwawJlar Arterio. Phlebitis Varicose

h) pertension heart heart disease

Hemorrhoids

sclerosis and

(407) dmease

veins of

disease (430438) (4401

(4s5)

thrombo. Ioww

{410.413) (427) phlebitis extremities

[451) (4W

PRINCIPAL DIAGNOSIS AND ICDA CODE

Figure 2. Average annual rate of office visits for selected diseases of the circulatory system, by sex of patient: Unitad States, 1975-76

Study demonstrated that for persons with definite hypertension the incidence rates of diseases

such as coronary heart disease and congestive

heart failure were substantially higher for males

than for females of the same age. 18 Therefore,

while the diagnosis may remain essential benign

hypertension as females age, a principal diagnosis of this disorder for visits made by males may

have been supplanted earlier by other diagnoses.

Coronary heart disease (410-413). –Visit

rates for patients with coronary heart disease

differed from those for patients with essential

benign hypertension. Beginning with age group

35-44 years and up to age 74 years, visit rates

for males who had coronary heart disease exceeded rates for females (figure 5). This is not

surprising in view of the foregoing discussion

suggesting that

hypertension is

a dia~osis of ‘essential benign

often supplanted by its cardiovascular sequelae at an earlier age among males

than among females. Unlike essential benign

hypertension, there was no drop in visit rate for

the oldest age groups.

In figure 6, visit rates for essential benign

hypertension and coronary heart disease are contrasted for visits by females only. Figure 7 illustrates visit rates among males for the same two

diseases.

The changing relationship of visit rates for

these two diseases, depending on the sex of the

visiting patient, can be observed in figures 6

and 7. For office visits by females, rates were

higher for essential benign hypertension than for

coronary heart disease from age 35 years to age

group 65-74 years (figure 6). The hypertension

rate dropped at age 75 years and over and the

coronary heart disease rate continued to rise. Visit

rates for these two conditions were different

7
120

r

I

100

80 -

60 –

40 -

20 –

oWwerlyion

Coronaw

heart

dis?a$e

(410.413)

Sym::pt,c Cerebrovascular Arterio. PhlebKis Varicose Hemorrhoids

disease sclerosis and veinsof (455)

disease (430438) (440) thrombo. lower

(427) phlebitis extremities

(451) (454)

PRINCIPAL DIAGNOSIS AND ICOA COOE

Figure 3. Average annual rate of office visits for selected diseases of the circulatory system, by race of patient: United States, 1975-76

when male patients visited. For males, hypertension rates exceeded those of coronary heart

disease up to age ‘group 55-64 years, after which

the hypertension rate dropped and the other

rate continued to rise (figure 7). For males aged

65-74 years the coronary heart disease rate was

half again as large as the rate for essential benign

hypertension; for visits by mzdes 75 years and

older the rate for the first disease more than

doubled that of the second.

Males visiting for chronic ischemic heart

disease were younger than females with the same

diagnosis. The median visit age for males was

64.1 years in contrast to a median visit age of

70.5 years for females (table 4). One explanation for the older median visit age for females

may be found in the mortality statistics of the

United States.lg In 1975, male deaths from

coronary heart disease exceeded female deaths

‘from the same cause in every age group up to 80

years.

Differences in median visit age between

the two sexes for acute ischemic heart disease

(which included acute myocardiaI infarction)

and angina pectoris were not statistically significant.

Symptomatic heart disease (42 7). –Patients

presenting symptomatic heart disease were

younger than those presenting so’me other

forms of heart disease. About 16 percent of

these visits were made by patients under 45

years old, compared with about 5 percent in the

same age group for chronic ischemic heart

disease.

Cerebrovascular disease (430-438). –Cerebrovascular disease visits more often included elderly

patients than did hypertension or heart disease.

Seven in ten visits for this disease were made by

patients 65 years and over. Patients 75 years

and older contributed to the highest proportion

of visits made for cerebrovascular disorders

(39 percent); such visits by patients under 45

years were rare (3 percent). Of all circulatory

problem visits , cerebrovascuk.r disease had the

lowest proportion of visits by patients under

45 years. As a result, the median visit age of

8
550 r

500 -

450 -

400 -

Female

z

g 350 -

~

8

0.

z 303 -

j.

5

: 250 -

?

$

;

\

> 200 - Male

150 -

lcil -

50 -

0, I I I I I 1

Under 35-44 4554 55.64 6574 75 and

35 over

AGE IN YEARS

Figure 4. Average annual rate of office visits for essential benign

hypertension, by sex and age of patient: United States,

1975-76

71.2 years for this disease was relatively high

compared to other circulatory diseases.

The relationship of hypertension to heart

dkease and to cerebrovascular disease, particularly as a precursor of stroke, has been established. Research findings also suggest that

cerebrovascular disease resulting from hypertension prowesses at a slower rate than does heart

disease resulting from hypertension.zo If this

is true, then the later age of the onset of cerebrovascular disease may welI be reflected in the

older median visit age estimated in NAMCS.

Visits for cerebrovascular disease were about

equally divided between men and women.

Arten-osclerosis (440]. –The median visit

age for patients afflicted with arteriosclerosis

‘% I

150 !-

100

50

I_

. .

n

/

/

/“

,/’

I

i

i

i

/’

Male I

i

:

i’ I

Female

i

/’

/“

/’

/’

/=

/“

i

i

i

/’

/’

/’

i

i

./’

Under 3544 45-54 55.64 65-74 75 and

35 Over

AGE IN YEARS

Figure 5. Average annual rate of office visits for coronary heart

disease, by sex and age of patient: United States, 1975-76

was the highest of all circulatory problems,

75.1 years. According to vital statistics reports,

death rates due to arteriosclerosis did not attain

any significant proportions until the age of at

least 65 years. For example, the 1975 death

rate due to arteriosclerosis for persons 65-74

years old was 26.6 per 100,000 population

compared with 303.1 for cerebrovascular dkease and 132.37 for heart disease. At ages

75-84 years, the rate of death due to arteriosclerosis was 159.4.21 Thus, either arteriosclerosis was not diagnosed untiI later years or patients

with arteriosclerosis who had greater longevity

continued to visit physicians (thus raising the

median visit age).

There was no significant difference in” visit

rate nor in median visit age between femaIe and

male patients.

9
550 ~

500 –

450 –

400 -

z

G 350 —

~

3

;

z 300 –

z

s.

a

& 250 -

K

<

Hwene.slon

,x

~

: 200-

,’ Coroniw heart disease

150-

100-

50-

0

I

Under 35.44 45.54 55.64 65.74 75 and

35 over

AGE IN YEARS

Figure & Average annual rate of office visits by females for

essential benign hypertension and coronary heart dieease,

by age of patient: United States, 1975-76

Phlebitis and thrombophlebitis (451), varicose veins of the lower extremities (454),

hemorrhoids (455). –In contrast to visits for

arterial disease, visits for diseases of veins were

made by younger patients. About half of the

visits for phIebitis and thrombophlebitis as weIl

as for varicose veins of the lower extremities

included patients under 55 years, as reflected

by the median visit ages of 53.9 years and 55.1

years, respectively. Of all circulatory diseases,

the lowest median visit age was reported for

hemorrhoids, 45.6 years. Visits for hemorrhoids

were rarer for persons 65 years and older than

were any other visits made for diseases of the

circulatory system. OnIy 14 percent of the

500

450

400

350

z

g

k

<

$ 300

%.

z

~; “260 -

E

.

: \

200

a

1-

~

>

150 I Coronary hearsdiseasf’ ,

100 ,,

50

0 J

Under 35-44 45.54 55.64 65.74 75 and

35 over AGE IN YEARS

Figure 7. Average annual rate of office visits by males for essential benign hypertension and coronary heart disease, by age

of patient: United States, 1975-76

visits made because of hemorrhoids were made

by persons in that age group, and only 3 percent

were made by persons 75 years and older.

Visits for phlebitis and thrombophlebitis

as well as for varicose veins of the lower extremities were more likely to include a female than

were visits for heart disease or cerebrovascular

disease; the reverse was true for males. However,

proportions of visits made because of hemorrhoids did not differ significantly by patient sex.

PRACTICE CHARACTERISTICS

With minor exceptions, estimates of characteristics of physicians’ practices related to visits

for

did

most specific circulatory disease diagnoses

not vary appreciably from the findings in the

10
Table C. Number, percent distribution, and average annual rate of office visits for essential benign hypertension (401), by most

frequently visited specialties and sex and age of patient: United States, 1975-76

Specialty

General and family practice ......... .................... ........................................

Internal medicine ....................................................................................

Ganeral surgery .................................................... ...................................

Obstetrics and gynecology .......................................................................

Cardiovascular diseases ............................................................................

General”and family practice .............................. ...... .................................

Internal medicine .............. .................... ........................ ..........................

General surgery ................. .............. .................. ......................................

Obstetrics and gynecology .......................................................................

Cardiovascular diseases ............................................................................

Number

of visits

in thousands

27,179

12,779

2,190

727

1,461

. . .

. . .

. . .

. . .

. . .

Percent distribution

100.0 64.4 35.6 62.0 38.1

100.0 60.5 39.5 68.8 31.2

100.0 63.1 36.9 63.4 36.6

100.0 86.2 * 71.2 28.8

100.0 54.1 45.9 64.2 35.8

Visit rate per 1,000 in population

65.1 81.0 48.1 45,0 240.7

30.6 35.8 25.1 23.5 92.9

5.2 6.4 4.0 3.7 18.7

1.7 2.9 * *1.4 ●4 .9

3.5 3.7 3.3 2.5 * 12.2

Table D. Number. . Dercent distribution .andaveraae annual rate of office visits forcoronarv heart disease (41 0-413), bymostfreauently

visited specialtie; andsexand age of patient: United States, 1975-76

Number Sex Age

Specialty of visits Total in thouFemale Male

Under 65 years

sands 65 years and over

Percent distribution

General and family practice ....................... ............... .............................. . 14,920 100.0 50.7

I

49.3 42.9 57.1

Internal medicine ............................ ............................................ ........... . 11,722 100.0 45.6 54.4 46.7 53.3

Cardiovascular diseases ....................... ........................................ ............. 3,089 100.0 39.9 60.2 48.2 51.8

I I

Visit rate per 1,000 inpopulatlon

General and family practice ............................................................. ........ . . .

Internal medicine ................................... ................................................. . . .

Cardiovascular diseases ............................................................................ . . .

35,8 35.0 36.5 17.1 198.4

28.1 24.7 31.7 14.6 145.4

7.4 5.7 9.2 4.0 37.2

major group (diseases of the circulatory system) ease. TabIes 6 and 7 relate type and area locadetailed in an earlier section. Distributions of tion of practice to specialties visited because of

visits for the specific diseases according to geo- hypertension and coronary heart disease.

graphic region, metropolitan and nonmetropolitan areas, and type of practice are shown in

table 5. PATl ENT CONDITION

Table C shows the extent to which hyper- AND MANAGEMENT

tension visits varied bv age and sex of Patient

when the most

were considered.

table D for visits

freq;en;ly visited specialties Most statistics presented in this report reSimilar details are given in Iate to principal or first-listed diagnoses. The

made for coronary heart dis- cIinical picture of patients who utilize physician

11
resources would be incomplete, however, without information regarding the frequency of care

given patients troubled by circulatory problems

not necessarily related to the patient’s principal

complaint.f Visits in which circulatory system

diseases were second- or third-listed diagnoses

provide additional data about the number of

times a disease was a recognized and diagnosed

condition, although it may not have been the

primary diagnosis at the visit.

Furthermore, it was shown earlier that most

visits in which the principal diagnosis was listed

in the diseases of the circulatory system group

included visits by middle-aged and elderly

patients who are generally acknowledged to suffer from multiple maladies, many of which are

classified in other major ICDA groups. These

ailments are also listed on the Patient Record

as “other significant diagnoses. ” All conditions

the physician finds germane to the visiting

patient, therefore, reflect patterns of disease

concomitance.

Diseases of the Circulatory System

As Second- or Third-Listed Diagnoses

Table E shows the number of visits in which

diseases of the circulatory system were identified as additional diagnoses. The volume of

estimated visits which included each specific

disease increased considerably when a maximum

of three known patient conditions were considered. As an example of the use of this table,

there were 46.1 million visits with a principal

diagnosis of essential benign hypertension (table

B). Adding this number to the 28.6 million visits

shown in table E for essential benign hypertension vields / a total of 74.7 million visits in which

essential benign

known to exist

Using the data

hypertension was a condition

for the patient at that time.

in tables- B and E similarly,

‘Although most diseases are characterized by syndromes or configurations of complaints, an attempt is

made in NAMCS to relate the principal diagnosis to the

most important complaint presented by the patient.

A discussion of patients’ principal complaints or symptoms follows in a later section of this report.

Table E. Number and percent of office visits for selected

diseases of the clrculatorv svstem listed as second or third

diagnoses: United States, 1975-76

Diagnosis and ICDA codel

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

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

Coronary heart disease ..............410-413

Symptomatic heart disease ...............427

Cerebrovascular disease .............430-438

Arteriosclerosis .................................44O

Phlebitis and thrombophlebitis .........45l

Varicose veins of lower extremities...454

Hemorrhoids ....................................455

-1- Number Perof visits cent

In thou- Of

sands visits

1,156,900 100.0

28,590

L

2.5

20,887 1.8

7,830 0.7

2,771 0.2

4,119 0.4

904 0.1

1,559 0.1

1,297 0.1

lDiag~ostic groupings and code inclusions are based on the

Eighth Revision In ternati”onal Classification of Diseases, Adapted

for Use in the United States, 1965.

coronary heart disease was a listed diagnosis

during 52.2 million visits.g

Recent hypertension prevalence data are

available from HANES.ZZ These data in conjunction with NAMCS visit data wherein essential benign hypertension was a principal, second-,

or third-listed diagnosis provide some insight

into the utilization of office-based ambulatory

medical care resources by those in need of treatment. According to the findings of HANES,

an estimated 23.2 million adults aged 18-74

years had definite hypertension, 23.4 million

had borderline hypertension, and 81.4 million

were normotensive. However, HANES also

showed that of the borderline and normotensive groups, 8.9 percent and 2.0 percent, respectively, took re~lar medication for high blood

pressure, leading to an assumption in HANES

that an additional 3.7 miIIion adults had controlled hypertension, or a total essential benign

hypertension prevalence of 26.9 million. If 37.3

million, the average yearIy visits (one-half of

the 74.7 million visits in which essential benign

hypertension was a listed diagnosis), is divided

gwhen first., second., ~d third-listed diagnoses are

considered, total visits for two or more diseases are not

additive since it is possible that the two or more diseases

were diagnosed during the same visit.

12
Table F. Number and percent of office visits for essential benign hypertension (401) listed as first, second, or third diagnosis, by other

most frequent diagnoses: United States, 1975-76

Hypertension I

Hypertension

Iisted as first listed as second

diagnosis or third diagnosis

Diagnosis and lCDAcodel

Number Per- Number Perof visits cent of visits cent

in thou- Of in thou- Of

sands visits sands visits

All visits ...................................................... ................................ .....................r........ 46,128 100.0 28,590 100.0

Diabetes mellitus .................................. ...... ......................................................... .. ..............25O

Obesity

2,054 4.5 4,038 14.1

.............................. .............. ........... .........................................................................277 4,674 10.1

Neuroses ......

1,425 5.0

. . . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..3oo 1,380 3.0

Arteriosclerosis..

1,125 3.9

..................................................................... ......................................... ....440 649 1.4 * 340 1.2

Bronchitis, emphysema, asthma.. ............................... ..................................................490-493 ’575 1.3 948

Arthritis and rheumatism, except rheumatic fever

3.3

.................................. ......................71 O.7l8 2,038 4.4 2,957 10.3

lDi~gnosti~ groupings and code inclusions are basedon the Eighth l?evision International Clastificati-on of Diseases, Adapted foi- use

in the United States, 1965.

by the HANES essentiaI benign hypertension

prevalence of 26.9 million, there was an estimated average minimum visit rate of 1.4 visits

to office-based physicians per year for each person aged 18-74 years in the population who

had hypertension. This utilization rat e provides

a benchmark for future estimation and evaluation of the utilization of physician resources by

the segment of the population needing treatment for essential benign hypertension. One

reason for the low rate of utilization may well

be due to the fact, shown in HANES, that 55

percent of the population estimated to have

definite hypertension were never diagnosed as

hypertensive.h As consumer education reduces

this number, the rate of utilization may increase.

Diagnostic Concomitance

The pattern of coexistence of hypertension

with other diaamoses not necessarily in the

group “diseases of the circulatory system” is

described in table F. The same type of analysis

for coronary heart dkease is shown in table G.

The first item of note (which is evident by its

‘Data in HANES were collected from 1971 to 1974.

There is reason to believe that the percent of neverdia~osed hypertensives was slightly less in 1975-76.

absence) is that hypertension and coronary heart

disease were not assigned to first, second, or

third diagnoses interchangeably, to any great

degree. That is, when hypertension was the principal diagnosis, coronary heart disease rarely

was included as a second or third condition.

When essential benign hypertension was a

second- or third-listed diagnosis, coronary heart

disease was not the principal diagnosis. The same

situation prevailed for coronary heart disease

as shown in table G. These data lend support to

the idea offered earlier that its cardiovascular

consequences eventually supplanted essential

benign hypertension as a diagnosis during visits

to physicians.

The diagnoses Iisted in tabIe F were most

frequently observed during visits when hypertension was present. For exampIe, when hypertension was the principal diagnosis, diabetes

mellitus was the second or third diagnosis in

about 5 percent of the 46.1 million visits. When

essential benign hypertension was the secondor third-listed diagnosis, a striking 14 percent of

those 28.6 million visits were diagnosed primarily as diabetes mellitus. Simiku-ly, obesity was

an additional diagnosis ii 10 percent of visits

made for essential benign hypertension, and was

principal dia~osis for 5 percent of visits when

essential benign hypertension was listed as

13
Table G. Number and percent of office visits for coronary haart disease (410-413) listed as first, second, or third diaonosis, bv other

most frequent diagnoses: United Statas, 1975-76

Diagnosis and ICDA code]

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

Diabetis mellitus...,.. ................................................... .........................................................25O

Obesity ................................................................................................................................277

Cerebrovascular disease ........................ .............. ........................................................ ..43 O.438

Bronchitis, emphysema, asthma .................. .................................................................49O.493

Arthritis and rheumatism, except rheumattc fever ................................. .................... ...71 O.7l8

Coronary heart

disease listed as

first diagnosis

+

Number Perof visits cent

in thou- Of

sands visits

31,314 100.0

2,029 6.5

1,079 3.5

623 2.0

838 2.7

1,469 4.7

-..

2oronary heart dis-

,asa listed as second

or third diagnosis

Number

of visits

in thousands

20,887

—.

1,574

*

618

847

1,344

Percent

of

visits

100.0

7.5

*

3.0

4.1

6.4

lDia~no~tic ~rouPin~s and code inc]u~ions are based on the Eighth Revision International Cbsification OfDiseases,Adaptedfor use

in the United States, 1965.

second or third diagnosis. Neuroses; arteriosclerosis; bronchitis, emphysema, and asthma;

as well as arthritis and rheumatism (except

rheumatic fever) also appeared in conjunction

with essential benign hypertension in a substantial number of visits.

Four types of diagnoses most commonly

coincident with hypertension also co-occurred

with coronary heart disease (although essential

benign hypertension itself did not, as pointed

out earlier). Diabetes mellitus; obesity; bronchitis, emphysema, and asthma; and arthritis and

rheumatism (except rheumatic fever) together

accounted for about 17 percent of the visits in

which coronary heart disease was a principal

diagnosis. Excluding obesity, these diseases

were primarily responsible for 18 percent of

visits when coronary heart disease was listed

second or third by the physician. It may seem

unlikely for coronary heart disease to be

“second” to bronchitis or arthritis, but the

reader is reminded that the assignment precedence of one diagnosis over another on the

NAMCS Patient Record was not dictated by its

severity but by its relationship to the most

important reason for that visit expressed by the

patient. Cerebrovascular disease, which did not

occur frequently in conjunction with hypertension, emerged as a concomitant diagnosis with

coronary heart disease during visits. Since cerebrovascular disease is often a consequence of hypertension, it is not surprising that cerebrovascuIar disease and hypertension were not frequently

concurrent much as coronary heart disease, which

is also a potential consequence of hypertension,

was not frequently concurrent with essential

benign hypertension.

The number of visits for diseases belonging

to other major ICDA groups that co-occurred

with arteriosclerosis, cerebrovascular disease,

and diseases of veins were insufficient to use as

a basis on which to determine two-way relationships within the limits of good reliabilityy. However, arteriosclerosis and cerebrovascular disease

were concurrent with other members of their

own ICDA group. Arteriosclerosis numbered

among diseases that were extant with essential

benign hypertension, while cerebrovascular disease figured among those associated with

coronary heart disease, as pointed out previously.

Patient’s Principal Problem,

Complaint, or Symptom

It is instructive to examine data on visits

that culminated in diseases of the ckculatory

system diagnoses in terms of the problems

that motivated patients to visit physicians.

These problems help to explain why patients

seek ambulatory medical care and are therefore useful indicators of health resources utilization.

14
The problem, complaint, symptom, or other

reason for visit expressed by the patient, which

in the physician’s judgment was most responsillle for the patient making the visit, was entered

on the Patient Record. It was coded according

to a symptom classification developed especially

for NAMCS.Z3 (The principal diagnosis is the

physician’s ewduation of the patient’s condition associated with this chief complaint.) The

terms “problem,” “complaint,” and “symptom”

are used interchangeably in this report.

Essential benip hypertension. –The problems presented most frequently when the visiting patient was diagnosed as hypertensive are

listed in table 8. It is known that essentiaI

benign hypertension is generally asymptomatic

for- a long period of time. However, the closely

related symptoms of headache, vertigo, fatigue,

and nervousness appeared in about 16 percent

of visits and represented the most frequent

patient symptoms (after deletion of nonsymptomatic reasons of “high blood pressure” and

medical examinations).

A1though abnormally high blood pressure

may be a si~ of essentizd benign hypertension,

studies have shown that patients have little

sensory awareness of blood pressure. Usually

elevated blood pressure is determined objectively

through measurement by a medical provider.

.Therefore, it is probable that in the 27 percent

of visits in which “abnormally high blood pressure” was coded, patients were visiting for a

checkup and were repeating a prior professional evaluation rather than articulating their

own physicial discomfort. In this sense, high

blood pressure would not necessarily be considered a symptom arising from internzd stimulus

such as headache would be. Under this assumption, high blood pressure (27 percent) together

with visits for which no patient symptom was

indicated by the physician (40 percent) and

generaI medical examination (2 percent)–a total

of 69 percent of visits with a diagnosis of essential benign hypertension–when compared to the

16 percent of visits made because of headache,

vertigo, fatigue, and nervousness, provides a

rough measure of asympt omatic versus symptomatic reasons for visit expressed by patients.

The most frequently reported symptoms

were not more likely to be presented by one sex

than by the other. Neither did the number of

visits for each symptom differ significantly when

presented by patients under 65 years of age or

by patients 65 years and older.

Coronary heart disease. –The most frequent

problems presented by patients during visits

for this disease are shown in table 9. Unlike

visits made for essentiaI benign hypertension,

visits made because of coronary heart disease

were more often subjectively symptomatic than

they were asymptomatic. About one-third of all

such visits occurred because of chest pain,

shortness of breath, and other symptoms referable to the cardiovascular system. Fatigue,

vertigo, and headache were general symptoms .

which together accounted for another 10 percent. Pain, swelIing, and injury of the lower

extremities was given as a reason in about 2

percent of the visits made because of coronary

heart disease.

Patients visiting for checkups such as those

designated by “abnormally high blood pressure” (4 percent) and “progress visit” (30 percent) may have also experienced symptoms of

heart disease and general symptoms, but these

symptoms may not have been expressed by the

patient at that visit.

Coronary heart disease patients under 65

years of age were more likely to present the

problem of chest pain than were older patients,

but other symptoms were not significantly related to one age group or the other.

Differences by sex among patients presenting varous symptoms were also not statisticzdly

significant.

Other diseases of the circulatory system. –

Patients visiting for treatment of symptomatic

heart disease were also likely to complain of

physicial difficulties. Predictably, the two ,most

common reasons were irregular pulsations and

palpitations (22 percent) and shortness of breath

(16 percent). An additional 10 percent involved

various other symptoms referable to the cardiovascular system. Pain, swelling, and injury of the

lower extremities was reported during 5 percent

of visits.

Patients complained mainly of vertigo (23

percent) during visits for cerebrovascular disease.

Vertigo and fatigue together motivated 28 percent of arteriosclerosis visits.

15
Complaints associated with diseases of the

veins were clearly physiczd manifestations of the

conditions. “Problems of the lower extremities” and “varicose veins” were mainly responsible for visits diagnosed “varicose veins of the

lower extremities. ” Phlebitis patients ako complained mainly of lower extremity problems.

Equally obvious problems caused visits for

hemorrhoids.

Visit Status and Seriousness

of the Problem

Although complaints and diagnoses identify

the nature of patient visits, problem status and

the degee of seriousness of the problem describe the intensity of patients’ problems. Data

for these two variables are presented in table 10.

It was mentioned earlier that new-problem

encounters (those visits in which a problem is

presented for the first time, whether by a new

patient or by a patient the physician had seen

before) were not the rule for the major ICDA

group of cirmdatory diseases. There was some

variation on that score among specific principal

diagnoses, however, which was worthwhile

examining. It can be seen from table 10 that

visits for diseases of veins (phlebitis and thrombophlebitis, varicose veins of lower extremities,

and hemorrhoids) were proportionally more

frequently new-problem encounters than were

other circulatory diseases. Equally apparent is

the fact that visits for hypertension and chronic

ischemic heart disease were more likely to be

continuing problems than were visits for other

diagnoses shown in the table.

Visit status in terms of patient sex and age

is provided in table H for hypertension visits,

and in table J for coronary heart disease visits.

“Seriousness” refers to the physician’s clinical judgment as to the extent of the patient’s

impairment that might result if no care were

Table H. Number and percent distribution of office visits for essential benign hypertension (401 ) by visit status, seriousness of problem,

and disposition of visit, according to sex and age of patient: Unitad States, 1975-76

Visit status, seriousness, and disposition

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

Visit status

New patient ................................................................ .........................................................

Returning patient, new problem ................ ..........................................................................

Returning patient, continuing problem ...................... ..........................................................

Seriousness

Serious or very serious ................................... .. ...... ........ .................................. ....................

Slightly serious ............................................................ ....... ............. .. ...................................

Not serious ........ .............. .. ................................................................................... ........ ........

Disposition

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

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

Referred to other physician or returned to referring physician ............................................

Otherz ....................... ..........................................................................................................

Sex I

Age

Female I

Male I

Under I

65 years

65 years and over

Number of visits in thousands

29,287 I 16,840 I 29,596 I 16,532

Percant distribution

100.0

5.0

5.8

89.3

20.8

47.0

32.2

86.8

10.0

*2.O

4.2

100.0

4.8

6.0

89.2

24.7

45.2

30.1

84.9

10.7

*2.3

5.8

100.0

5.9

5.7

88.4

22.7

47.2

30.1

87.2

9.0

2.5

5.1

100.0

3.0

6.3

90.7

21.3

44.8

33.9

84.1

12.5

*1.5

4.3

lperCent~willnOtaddtO100,0b~~~”sesome patient visits had morethan1diwositiors.

21nc]udeSadmitto hos.~it~],*Ofollo~p planned, telephone followuP, or other disposition.

16
Table J. Number and percent distribution of office visits for coronary heart disease (410413) by visit status, seriousness of problem,

and disposition of visit, according to sex and age of patient: United States, 1975-76

Visit status, seriousness, and disposition

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

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

Visit status

New patient ............................................................................................... ..........................

Returning patient, new problem ................... ........................................ ...............................

Returning patient, continuing problem ............................................... .................................

Seriousness

Serious or very serious ................................ ................................ ................................ .........

Slightly serious .....................................................................................................................

Not serious ............................................................................. ..............................................

Disposition 1

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

Return if neaded ........ ..... .....................................................................................................

Refer[ed to other physician or returned to referring physician ............................................

Otherz .................................................................................................................................

Sex Age

Female I

Male

Under

65 years

65 years

and over

Number of visits in thousands

14,828 I 16,485 [ 14,093 I 17,221

Percent distribution

100.0

available. Using this criterion, physicians were

requested to rate the patient’s condition on a

4-point scale ranging from “not serious” to

“very serious.” Although the same definition of

“seriousness” was provided to all participants

in the survey, it is difficuIt to determine the

degree of adherence to it. Medical specialists

vary in training emphasis and degree of prognostic Iatitude. The data shouId be viewed in

this context.

Degree of seriousness appeared to vary from

one type of diagnosis to another. Essential

benign hypertension was more often judged in

the two less serious categories, and coronary

heart disease was more frequently judged in the

more serious categories. Except for phlebitis

visits which were about equally divided on each

half of the seriousness range, diseases of the

veins were assigned to the less serious categories

more frequently than to the more serious cate5.0

7.1

88.0

51.5

33.4

15.1

86.6

8.7

*3.8

5.4

I percents will not add to 100.o because some patient visits had ImXe than 1 disposition.

21ncludes admit to hos~ital, no fo]lomp planned, telephone followup, or other disposition.

100.0

4.9

7.1

88.0

52.9

32.3

14.8

86.1

7.7

++3.1

8.1

100.0

8.0

6.3

85.7

55.9

29.5

14.6

85.7

7.2

++4.1

8.0

100.0

2.4

7.8

89.9

49.2

35.6

15.2

86.9

9.1

*2.9

5.9

gories. Arteriosclerosis visits were also among

;he group evaluated as less serious.

The relationship of seriousness to patient or

probIem status was examined and results are presented in tabIe K for hypertension visits and

table L for coronary heart disease visits. For

both of these diagnoses, the judgment of severity was apparently not reIated to the status of

the visit (new or returning patient) or to the

status of the problem (new or recurring problem), because variations among estimates were

not statistically significant. That is, new patients

were not more often categorized as “serious”

or “very serious” than were returning patients,

nor were new-problem visits more often judged

“serious” or “very serious” than were oldproblem visits.

Because the estimates yieIded by the seriousness scale that was used to judge these chronic

problems were not conclusive, some comment

17
Table K. Number and percent dlstrlbutlon of office wsits for essential benign hypertension (401 ) by seriousness of problem, according

to visit status: United States, 1975-76

Visit status

New patient ...................................... ............... .................... ....................................

Patient seen before, new problem ............. ........................... .. .............................

Patient seen before, continuing problem ..................................................................

Number

of visits

in thousands

2,254

2,709

41,165

II I I

*k

Percent distribution

!Ell%EE

Table L. Number and percent distribution of office visits for coronary heart disease (410-413) by seriousness of problem, according to

Visit status: United States, 1975-76

Number

of visits Serious

Visit status Total

Slightly Not

in thou- or very serious serious

sands serious

Percent distribution

New patient ........................... ........................ .......................................................... 1,538 100.0 57.1 26.2 16.7

Patient seen before, new problem ............................................................................ 2,220 100.0 52.1 23.8 24.1

Patient seen before, continuing problem ..... ............................................................. 27,556 100.0 52.0 33.9 14.1

on the complexity of this scale is indicated. A

cursory examination seems to indicate that the

seriousness of patients’ problems may have been

judged on the basis of the patient’s ability to

function while receiving medical care. For

example, if left untreated, essential benign

hypertension has potentially very serious consequences. But patients who visit physicians and

adhere to a treatment regimen ordinarily function very well (and it has been shown that most

visits were made by returning patients with continuing problems). The frequent assignment of

essential benign hypertension visits to a “not

serious” or “slightly serious” category suggests

that the basis for assignment might have been

ability to function rather than amount of impairment that would result if the condition were

not treated, since it is acknowledged that a

great deal of impairment would result if essential

benign hypertension were not treated or no care

were available for it. A similar assumption could

be made about other life-threatening diseases

which were not frequently classified as “serious”

or “very serious. ” While the proportion of

coronary heart disease visits classified at the

serious end of the scale was statistically greater

than its opposite category, the difference between proportions of not serious and very serious

visits was not as great as might be expected for a

disease that is so often fatal without proper

medical care. The slightly higher proportion

designated “serious” or “very serious” could be

due to the fact that patients complaining of

shortness of breath and chest pain clearly do

not function very well, which also suggests

ability to function as a criterion for judging

seriousness.

However, ability to function may be only

one dimension of the multidimensional nature

of the seriousness attribute. If a factor analytic

approach to measurement of seriousness were

taken, the results could differ considerably.

Duration of Visit

Visit duration is the amount of time spent

by the physician in direct encounter with the

patient as estimated by the physician. The mean

cent act duration is the average number of

minutes per visit when the visit included a con18
tact with the physician. Thus, contact duration

when only other staff was contacted is included

in the survey but excluded from the calculation

of the mean.

Time spent by the physician is an important

factor in patient management and is a useful

index of medical care utilization by the pubIic.

Although some visits require and consume much

of the physician’s time, others do not. This is

not to imply that care is not rendered. In the

framework of the NAMCS definition, visits may

use none of the physician’s time, but treatment

may have been appropriately delegated to the

physician’s staff. Physicians also devote time to

patient care that is not necessarily performed in

the presence of the patient, such as evaluating

test results, reading X-rays, reviewing histories,

and consulting with other physicians. Duration

estimates for principal diagnoses are presented

for comparative purposes and not as the total

time spent in patient care.

Table 11 lists the mean contact durations

for selected circulatory problems. For proper

interpretation of these estimates, the standard

errors also shown in tabIe 11 should be taken

into consideration using appropriate methodolOgy.i For each disease, table 11 provides mean

contact duration separately for patient age, sex,

and visit status.

The mean contact duration of all NAMCS

visits was 15.3 minutes (+0.2 minutes). The average duration of visits for heart disease was significantly longer than the overall average, but

visits for hypertension, cerebrovascular disease,

and other diseases of the circulatory system

took about the average time.

The average time spent in treating patients

for some disorders was affected by patient status

(new or returning) in some cases, and by problem status (new or recurring) in others. When

hypertension was presented as a new problem to

the physician, either during an initial encounter

or on a return visit, the visit lasted longer (24.0

minutes and 18.7 minutes, respectively) than

did visits involving returning patients with hypertension as a continuing probIem (13.5

‘See appendix I for “Estimates of differences between two statistics. ”

minutes). The duration of the new-patient

encounter was significantly Ionger than that of

the returning patient with a new problem.

Initial visits for ischemic heart disease (acute or

chronic) and symptomatic heart disease were,

on the average, longer than visits in which the

patient had previously consulted the physician.

New patients seeking treatment for angina pectoris and cerebrovascuhr disease also required

more time than patients returning for continuing care of these problems required. Differences

among types of visits for other dia~oses were

not statistically significant.

The longer duration of initial encounters

for some circulatory diseases may be due to the

need for more intensive workup in new-patient

visits. For example, 57 percent of all initial

visits for hypertension included a general examination as opposed to 23 percent of return visits

for a new problem and only 10 percent of visits

for an oId problem.

Disposition of Visit

Continuity of care is an important aspect of

patient management especiaUy for the aging and

chronically ill. The intent of physicians regarding ongoing care is reflected by the disposition

of the visit. Office-based physicians treating

patients for the most frequently reported diseases of the circulatory system concluded the

majority of visits with instructions to return

at a specified time. Patient compliance with

these instructions was shown in the high proportions of visits that included patients returning for further treatment (table 10). For each

diagnosis listed, visits that culminated in instructions to return at a specified time were proportionately comparable with return visits for treatment of continuing problems.

Instructions were not disproportionately

given to males and females making visits for

hypertension and coronary heart disease. Neither

did age make a significant difference insofar as

the proportions of visits with these instructions

was concerned (tables H and J).

Attesting to the asymptomatic nature of

most visits made for essential benign hypertension, the disposition of very few visits was admittance to a hospital. As might be expected,

a higher proportion of acute ischemic heart

disease patients (14 percent) were recommended

19
for hospitalization than were those with other

forms of heart disease.

The seriousness of the patient’s problems appeared to be related to the physician’s followup

decision in hypertension and coronary heart

disease visits. Proportions of visits in which no

followup was planned became pro~essively

smaller as the probIem became more serious

(table M). For example, no followup was planned in 4 percent of all visits for hypertension

judged not serious as opposed to 2 percent of

visits for hypertension judged serious or very

serious. For coronary heart disease, the contrast

was even broader. For those visits evaluated as

not serious no followup was scheduled in seven

of ten visits compared with less than one in ten

of those considered serious or very serious.

Conversely, proportions of hypertension visits

that included instructions to return at a specified time grew progressively larger as the problem increased in seriousness. For coronary heart

disease, any increase in seriousness also warranted

instructions to return at a specified time. The

more casual instruction, “return if needed,”

was used more frequently following visits judged

not serious than after those of a more serious

nature.

Table M. Percent of office visits for essential benign hypertension (401 ) and coronary heart disease (410-41 3), by disposition of visit and seriousness of problem: United States,

1975-76

Diagnosis, ICDA code,l

and seriousness

of problem

Essential benign

hypertension (401 )

Serious or very serious .........

Slightl vserious...................

Not serious ..........................

Coronary heart

disease (410-413)

Serious or very serious .........

Slightly serious ....................

Not serious ..........................

No

foliowup

planned

1.7

2.2

3.8

0.6

1.4

6.6

Return

at

specified

time

Percent

90.0

88.0

80.5

87.2

88.1

79.2

Return

if

needed

6.8

9.2

14.2

6.8

7.8

14.2

lDiagno~ti~ groupings and code inclusions are based on the

Ei.ghth Revision Interns tional Classification of Diseases, Adapted

fo; Use in the United States, 1965.

20

Referral

About 3 percent of patient visits folr diseases

of the circulatory sys tern were referred to other

physicians; this was close to the avera,ge for all

ICDA !#OUpS. Only about 2 percent of all

essential benign hypertension visits and 3 percent of alI coronary heart disease visits were

referred. GeneraI and family practitioners referred 4 percent of their total visits for essential

benign hypertension and coronary heart disease

to other physicians or agencies. For internists, the referral rate for these two diagnoses

was 2 percent.

Diagnostic-Therapeutic Services

The NAMCS was designed to produce data

on the diagnostic and therapeutic services ordered

or provided by the physician during the current

visit. The Patient Record did not have the flexibility to probe whether procedures were single

or multiple. Therefore, estimates provide information about the general nature rather than the

extent of the physician’s workup. For example,

if “clinical lab test” was checked on the form it

was not known whether a blood test alone was

performed or whether blood, urine, and sputum

tests were ordered. Similarly, an indication of

“X-ray” provided no clue as to the number or

sit e(s) of X-rays taken during a single visit. As a

result, total estimates of clinical lab tests or Xrays indicate the number of each type of service

rather than the total number of all such services.

Estimates of services that are usually rendered

once during a visit such as a history or examination, EKG, or blood pressure check, are closer

to the actual number of times each was done.

This caveat also applies to therapeutic services

such as drug prescription and injection which

could be single or multipIe.

Number of services. –The number of different types of services is a useful indicator of ambulatory medical care utilization by patients

presenting different conditions. In general,

physicians tended to order or provide a higher

than average number of types of services during

most visits made for diseases of the circulatory

system, while such visits in which no services

were provided were less than the average numb er

for aH NAMCS visits. Except for diagnoses of
Table N. Percent distribution of office visits for diseases of the circulatory system by number of types of diagnostic and therapeutic

services ordered or provided, according to selected principal diagnoses: United States, 1975-76

Principal diagnosis and ICDA codel

All principal diagnoses ............... ............................................ ...............

Essential benign hypertension .................... ................................ .... .................4Ol

Acute ischemic heart disease ....................................... .....................! .......4lo4ll

Chronic ischemic heart disease ........................................................................4l2

Angina pectoris ...... ................................. .................... ...... .......................... ....4l3

Symptomatic heart disease ............................................................. ................427

Cerebrovascular disease .............................................. ..............................43O~38

Arteriosclerosis ...............................................................................................440

Phlebitis and thrombophlebitis .......................................................................45l

Varicose veins of lower extremities .................................................................454

Hemorrhoids ..................... .................... ..........................................................455

I

Total

No

services

100.0 _

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

One

type

of

service

Two

types

of

services

Percent distribution

2.5

0.8

0.3

0.7

0.3

0.9

0.9

1.0

0.8

1.3

2.6

26.0

16.1

9.7

10.8

9.6

12.3

14.2

17.9

14.6

38.8

31.9

30.6 —

28.3

17.9

23.6

16.5

24.1

26.7

24.2

32.4

26.5

33.8

Three

types of

services or

more

40.9

54.8

72.1

64.9

73.7

62.8

58.3

57.0

52.2

33.4

31.7

1Diagnostic grouPing5 and code inclusions are based on the Eighth Revision International Classification of Diseases, Adapted for use

in the United States,’194s.

varicose veins of lower extremities and hemorrhoids, visits for the diagnoses listed in table N

included higher than average proportions of

visits characterized by three types of services

or more. These proportions clearly exceeded

those of the same diseases in which two services

or less were included.

Selected diapostic services. –Tables O and P

relate specific diagnostic and therapeutic services

to visits for the most frequently diagnosed circulatory diseases. For visits diagnosed “hypertension” and ‘~coronary heart disease,” tables

Q and R link patient management, exemplified

by diagnostic and therapeutic services, to patient

condition, as evidenced by visit status and problem seriousness. Provision of services according

to sex and age of patients visiting for essential

benign hypertension and coronary heart disease

is described in tables S and T.

The limited history and examination was

clearly the preferred method of gathering basic

data by physicians since about half or more

visits for the various circulatory disorders included this type of procedure. The comprehensive general history and examination was used

more often when the diagmosis was heart disease

or cerebrovascular disease than when other

circulato~y disorders were dia~osed. The less

liberzd use of the generaI history and examination than the limited type during all visits for

diseases of the circulatory system is reasonable

in view of the high rate of return visits. The

more comprehensive examination was used in

57 percent of visits when new patients were

diagnosed as having essential benign hypertension in contrast to ordy 10 percent when such

hypertension was a recurring problem. It was

also more frequently chosen for initial visits due

to coronary heart disease (68 percent) than for

such “old’’-probIem visits (13 percent). On the

other hand, the limited history and examination

was more often selected as the appropriate type

when the physician had seen essential benign

hypertension and coronary heart disease patients

before, whether for new or recurring problems.

It appears that less exhaustive examinations

were necessary when physicians had prior knowledge of or medical records for returning patients.

Predictably, EKG’s were used more often

during heart disease visits than when other

circulatory diseases were principaJ diagnoses.

Heart activity was tested more often during

coronary heart disease new-problem visits than

during visits in which that disorder was a recurring problem. However, EKG’s were used sparingly in the absence of hypertension, coronary

21
Table O. Number and percent of office visits for selected diseases of the circulatory system, by diagnostic and therapeutic services

ordered or provided: United States, 1975-76

Diagnostic or therapeutic service

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

Diagnostic services:

Limited history and examination ..................... .................................... ........ .. ..........

General history and examination ............................... ...............................................

Laboratory procedure or test ............................ .......................................... .. ...... .....

X.ray ......................................................... .................................. .............................

Blood prassure check... .............................. ...............................................................

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

Therapeutic services:

Drug administered or prescribed2 .............................................................................

injection or immunization ......................................... ................ ...............................

Medical counseling and psychotherapy or therapeutic listening ................................

Other services3 .............................................................................................................-

Essential

benign

hypertension

(401 )

Coronary

heart

disease

(410-

413) T

Sympto- Carebromatic vascular

heart disease

disease (430-

(427) 438)

Number of visits in thousands

46,128

54.9

12.8

20.6

4.7

79.9

7.7

)

61.0

9.8

16.6

5.0

31,314 I 7,052

Percentl

62.9

16.2

25.4

7.0

76.6

25.8

55.6

12.1

21.2

5.9

61.6

20.8

23.9

10.4

67.2

32.7

55.9

13.2

16.4

7.3

4,505

62.2

18.4

25.2

*5.9

71.7

*6.7

52.1

12.8

21.0

7.7

lpercents will not add to 100.0 because most patient visits required the prOVkiOII of more than 1 treatment or ‘ervice.

*Includes prescription and nonprescription drugs.

3Jnc]udes no sewice5 rendered, hearing test, vision test, endoscopy, office surgerY, physiotherapy, and other ‘ewices.

Table P. Number and percent of office visits for selected diseases of the circulatory systam, by most frequent diagnostic and therapeutic services ordered or provided: United States, 1975-76

Diagnostic or therapeutic service

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

Limited history and examination .......................... ....... ................................................ ......

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

Laboratory procadure or test .......................................................................... ............ .......

Encloscopy ........................ ..... .... ... ..................................................................................

Drug administered or prescribed2 ......................................................................................

Medical counseling and psychotherapy or therapeutic listening ....................................... ..

Phlebitis Varicose

Arterioand veins of

throm- Iower Hemorsclerosis bophle- extremi- rhoids

(440) bitis ties (455)

(451 ) (454)

Number of visits in thousands

2,019 I 2,930 I 2,428 I 3,686

62.3

58.6

*16.9

6i :5

27.5

Pert

68.3

50.3

28.3

56:6

20.6

,tl

53.8

27.1

*8.5

36:9

23.6

48.6

28,5

*8.1

22.3

42.8

*11.2

lpercents will not add to loo-obe~au~e most patient visits required theprovisim of more than I treatment or service

*In~l~des prescription and nrmprescripticm drugs.

22
TableQ. Numberand percentof office visits for essential benign hypertension (401), by visit status, seriousness of problem, and

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

Diagnostic or therapeutic service

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

Limited history and examination ........................................................

General history and examination ............ .................... ........................

Laboratory procedure or test ....................... ............ ..........................

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

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

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

Drug administered or prescribed .......................................................

Injection or immunization .............................................................. ....

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

0ther3 ............................ ................................ ...... ..............................

Visit status I Seriousness of problem

Numberof visitsin thousands

2,254 I 2,709

28.3 56.9

56.7 22.8

43.1 34.6

21.7 *8.O

78.6 73.3

22.7 *19.8

57.0 62.5

*3.1 *5.O

●11.6 *1 5.3

*16.6 ‘$7.7

41,165 I 10,244

Percentl

56.2

9.8

18.4

3.6

80.4

6.1

61.1

10.5

14.8

5.0

55.0

16.5

23.4

6.3

79.2

10.5

63.3

11.2

17.4

7.7

21,373

56.4

11.1

19.8

3.7

82.2

7.0

63.8

9.4

15.3

5.4

14,510

52.5

12.8

19.6

5.1

77.1

6.7

55.3

9.5

11.7

6.7

lPercentsWill~otaddto Ioo.obecause rnostpatientvisitsrequiredtheprovisionofrncmtlsmI tr~~trnentor SeWice.

2~nc]U&Sprescription and nonprescription drum

31n~ludes hearing test, vision test, endoscopy, office surgery,physiotherapy,Psychotherapyor tkerweuticlisteni% findother

services.

heart disease, and symptomatic heart disease

(table U).

Electrocardiograms were also more likely to

be used during coronary heart disease visits

evaluated as “serious” or “very serious” than

,when the problem was less serious.

X-rays appear to have been used with restraint during visits for circulatory diseases,

occurring more frequently during hypertension

and coronary heart disease new-probIem visits

than in visits for recurring problems.

Clinical laboratory tests were ordered in

about 1 in 4 visits for coronary heart disease,

symptomatic heart disease, cerebrovascular disease, and phlebitis and thromb ophlebitis;

and about 1 in 5 hypertension visits. Use of

laboratory tests did not differ significantly

among types of visits when coronary heart

disease was the dia~osis. However, laboratory

tests were less likely to be ordered for patients

presenting hypertension as a recurring problem.

In general, the data pointed to a tendency

of physicians to use EKG’s, X-rays, and laboratory tests conservatively. For the two leading

dia~oses (essential benign hypertension and

coronary heart disease), emphasis was placed on

providing most services during first visits.

Patient sex and age were not deciding fact ors

in the use of examinations, X-rays, or lab tests.

Patients under 65 years of age were more likely

than older patients were to have heart activity

measured by EKG during visits made for coronary heart disease, but differences by sex were

not statisticzdly significant.

Blood pressure measurement. –Blood pressure measurement is an efficient and economical

diagnostic tooL It was used more often during

visits made for diseases of the circulatory system than for any other ICDA group. About 8

of 10 visits for essential beni=m hypertension and

coronary heart disease included blood pressure

checks, and about 7 of 10 for cerebrovascular

disease (table O). Blood pressure was measured

less often for diseases of the arteries and veins

than for other types of circulatory system diseases.

23
Table R. Number and percent of office vmts for coronary heart disease (410-413), by visit status, seriousness of problem, and

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

Diagnostic or therapeutic service

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

Limited history and examination ............................................... .........

General history and examination ........................................................

Laboratory procedure or test ...... ........................................................

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

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

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

Drug administered or prescribed2 .......................................................

Injection or immunization ..................................................................

Medical counsel ing ...... ........................................................................

0ther3 ................................................................................................

Visit status Seriousness of prc}blem

Patient seen before

Serious

New Contin- or Slightly Not

patient New uing very serious serious

problem problem serious

Number of visits in thousands

1,538 I 2,220

22.9

67.5

41.4

31.6

79.1

56.7

40.6

2.0

21.5

13.3

58.9

25.1

26.8

14.8

70.4

42.4

52.8

11.0

15.6

4.6

27,556 I 16,357

Percentl

65.4

12.6

24.4

5.0

76.9

22.7

56.7

12.7

18.2

8.3

65.5

16.8

26.2

7.3

75.9

31.3

58.1

11.6

21.5

7.9

10,284

61.3

15.0

25.8

7.3

77.3

21.0

53.8

13.5

16.4

8.6

4,673

57.2

16.6

22.0

5.1

77.1

17.0

50.7

10.4

10.4

9.0

lpercent~ ~ill not add to I 00.0 be~a~~e most patient visits required the provision of more than I treatment or se~ice.

or therapeutic listening, and other

.21nclude5 prescription and nonprescription drugs.

31ncludes hearing test, vision test, endoscopy, office surgery, physiotherapy, psychotherapy

services.

Table S. Number and percent of office visits for essential benign hypertension (401), by sex and age of patient and diagnostic and

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

Diagnostic or therapeutic service

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

Limited history and examination .........................................................................................

General history and examination .............................................................................. ...........

Laboratory procedure or test ......................................................... ......................................

X.ray ....................................................................................................................................

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

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

Drug administered or prescribed ... .....................................................................................

Injection or immunization .......................................................................... ........ ............ .....

Madical counsel ing ...................................... .........................................................................

Psychotherapy or therapeutic listening ............................................. ...................................

0ther3 ..................................................................................................... .. ..........................

Sex I Age

Female H-l&?&65 years

and over

Number of visits In thousands

29,287 I 16,840 I 29,596 I 16,532

55.1

12.5

20.9

4.2

79.7

6.7

63.1

11.6

14.5

2.2

3.7

Percent 1

54.5 53.7

13.4 14.4

19.9 20.3

5.5 5.2

80.2 79.4

9.4 8.9

57.4 60.7

6.7 9.4

14.9 16.4

‘1.6 2.1

5.0 4.2

lpercent~ ~il[ not add to 100,0 because most ~atient visits reauired the cmovision Of mOre than 1 treatment or service.

57.0

10.1

21.0

3.8

80.8

5.5

61.5

10.6

11.4

++1.7

4.2

21ncjudes prescription and nonprescription dr~gs.

SlncJudes hearing test, vision test, endoscopy, office surgery, physiotherapy, and other services.

24
Table T, Number and percent of office visits for coronary heart disease (410-413), by sex and age of patient and diagnostic and

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

Diagnostic or therapeutic service

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

Limited history and examination ............................................................................. .... ........

G=neral history and examination .........................................................................................

Laboratory procedure or test .................. ............ ........................................ ........................ .

X.ray .......................................................................................................... ..........................

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

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

Drug administered or prescribed ........................................................................................

injection or immunization ........................................ .......................... ...... ...........................

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

Psychotherapy or therapeutic listening ....... ............................................................ .............

0ther3 ........................................................ .........................................................................

Sex I Age

Female I

Male I

Under I65 years

65 years and over

Number of visits in thousands

14,828 I 16,485 I 14,093

Percent]

64.1

15.6

24.2

6.9

76.6

22.5

58.4

15.4

16.8

*3.1

4.7

61.8

16.7

26.5

7.0

76.6

28.8

53.1

9.0

19.4

*3.O

5.7

60.8

18.5

25.1

8.2

78.4

30.9

52.1

8.5

19.5

*3.7

5.4

17,221

64.6

14.3

25.7

5.9

75.1

21.6

58.5

15.0

17.1

*2.5

5.1

lpe,cents ~,ill not add to 100.cI ijec~”se most patient visits required the prOViSiOn Of more than 1 treatment or ‘ewice21n~1udeS prescription m-id nonprescription dr@.

31ncludes hearing test, vision test, endoscopy, office surgery, physiotherapy. and other se~ices.

Table U. Percent of office visits by selected diagnostic and therapeutic services ordered or provided in the presence and absence of

selected principal diagnoses: United States, 1975-76

—

Principal diagnosis and ICDA codel

Essential benign hypertension (401 ):

Present .................................................. .............................................................

Absent ............................................................................................. ..................

Coronary heart disease (410413):

Present .................................................................................. .................... .........

Absent .. ............................................. .................... .......................... ...... .. ..... .....

Symptomatic heart disease (427):

Present .............................. .................................................... ............ .............. ...

Absent ................................... ............................................. ...............................

Carebrovascular disease (430-438):

Present ............. .............. .. ................................. .................................................

Absent .......................... .......................................................................... ...........

LeboraDrugs,

Blood

Electro- tory

preprescardio- X-ray

scription

sure

pro- and

check gram cedure

nonpreor test scription

79.9

31.2

76.6

32.0

67.2

33.0

71.7

33.0

7.7

3.2

25.8

2.7

32.7

3.2

6.7

3.3

Percent

4.7

7.7

7.0

7.6

10.4

7.5

5.9

7.6

20.6

22.9

25.4

22.7

23.9

22.8

25.2

22.8

61.0

42.8

55.6

43.2

55.9

43.5

52.1

43.5

1DiagnoStj~ ~rouP jn~s and code jnclusjons are based on the Eighth Revision Irrterna tional Classification Of Diseases, Adapted for use

in the United States, 1965.

25
The recognition of the importance of continuous blood pressure monitoring for patients

suffering essential benign hypertension and coronary heart disease is evident in the almost equal

proportions of blood pressure measurements

included in new- and return-patient visits (tables

Q and R).

It was observed that only about one-third

of the visits for diagnoses other than diseases of

the circulatory system included blood pressure

measurement. The data also showed that although

such measurement was included very frequently

in the presence of hypertension, it was not as

often included in its absence. Fi~re 8 illustrates

the dramatic differences in blood pressure measurement between visits in which essential benign

hypertension was present (as principal, second.

or third diagnosis) and those in which it was not

Iisted as a diagnosis. The procedure was included

in visits from males and females alike when

essential benign hypertension was present, but

without such dia~osis, the blood pressure of

females was more often measured than was the

blood pressure of males. This was probably due

to more frequent measurement of blood pressure for female patients during the childbearing

years. Blood pressure measurement during nonhypertension visits increased with age, but

was not dependent on age if essential benign

hypertension was present.

Although essential benign hypertension visits

were the prime targets for blood pressure meas-

‘“”r

HYPERTENSION DIAGNOSIS LISTED

80

Female = 79%

Male = 78%

60

HYPERTENSION DIAGNOSIS NOT LISTED

40

Female = 34%

Male = 24%

20

0- 1 I I 1 I I I

Urider 15.24 25-34 3544 45-54 55.64 65.74 75 and

15 over

VISIT AGE tN YEARS

I

Figure 8. Percent of office visits that included blood pressure measurement in the presence and absence of hypertension, by vkit age:

United States, 1975-76

26
urement, such monitoring was also done with

great frequency for heart disease and cerebrovascular disease visits as shown in table U.

However, the significantly decreased use of such

measurement in the absence of these diseases

deserves comment.

Periodic blood pressure measurement is

import ant both in treating essential benign

hypertension and as a screening device to detect

the disease. The Joint Nationa.I Committee on

Detection, Evaluation, and Treatment of High

Blood Pressure has recommended that all health

care professionals routinely take a patient’s

blood pressure regardless of the patient’s reason

for visit.24 Physician visits would appear to be

the lo@ca.I environment for implementation of

this recommendation, but according to NAMCS

data the suggestion has not yet been widely

adopted.25

It should be noted that some underreporting

of blood pressure measurement in NAMCS

may have produced estimates somewhat lower

than the actual number of measurements made.

Visits often include a general examination in

which blood pressure is routinely checked. A

review of data for essential benign hypertension

visits which included general examinations re-

‘veaIed that bIood pressure was separately recorded (as it was supposed to be) in 85 percent

of such visits. This may be an indication of

underreporting, or such measurement may have

really been omit ted in some examinations (although it is not likely). In any case, underreporting probably accounted for only a small part of

the fewer number of blood pressure checks during some visits than in others. Furthermore,

there does not appear to be any systematic

bias connected with such underreporting.

Selected therapeutic services. –Drugs were a

highly frequent form of therapy during most

visits made for diseases of the circulatory system. Except for varicose veins of the lower extremities and hemorrhoids, drugs were prescribed

or administered in over half of visits for the

most frequently diagnosed circulatory diseases.

Drugs were prescribed more often when

hypertension, coronary heart disease, and symptomatic heart disease were present than when

they were absent, but seriousness of the problem,

or patient sex or age did not affect the decision.

Medical counseling frequency did not differ

significantly by sex for the disease groups

essentia.I benign hypertension and coronary

heart disease. Hypertensive patients less than 65

years of age were counseled more often than

were older patients with that disorder.

000

27
REFERENCES

1National Center for Health Statistics: National

Ambulatory Medical Care Survey: Background and

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

K. L. White, and J. W. Williamson. Vital and Health

Sta tis tics. Series 2-No. 61. DHEW Pub. No. (HRA)

74-1335. Health Resources Administration. Washington. U.S. Government Printing Office, Apr. 1974.

2National Center for Health statistics: The Nation~

Ambulatory Medical Care Survey: 1975 Summary,

United States, January-December 1975, by H. Koch

and T. McLemore. Vital and Health Statistics. Series 13-

No. 33. DHEW Pub. No. (PHS) 78-1784. Public Health

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

Jan. 1978.

3National Center for Health Statistics: 1976 Summary: National Ambulatory Medical Care Survey, by

H. Koch, R. Gagnon, and T. Ezzati. Advance Data From

Vital and Health Statistics, No. 30. DHEW Pub. No.

(PHS) 78-1250. Public Health Service. Hyattsville, Md.,

July 13, 1978.

4National Center for Health Statistics: Office visits

for hypertension, National Ambulatory Medical Care

Survey: United States, January 1975-December 1976,

by B. K. Cypress. Advance Data From Vital and Health

Statistics, No. 28. DHEW Pub. No. (PHS) 78-1250.

Public Health Service. Hyattsville, Md., Apr. 28, 1978.

5National Center for Health Statistics: Office visits to

dermatologists, National Ambulatory Medical Care Survey: United States, January 1975-December 1976, by

H. Koch and T. McLemore. Advance Data From Vital

and Health Statistics, No. 37. DHEW Pub. No. (PHS)

78-1250. Public Health Service. Hyattsville, Md., Aug.

29, 1978.

6Nationa1 Center for Health Statistics: Office visits to

orthopedic surgeons, National Ambulatory Medical

Care Survey: United States, January 1975-December

1976, by H. Koch. Advance Data From Vital and Health

Statistics, No. 33. DHEW Pub. No. (PHS) 78-1250.

Public Health Service. Hyattsville, Md., July 18, 1978.

7National Center for Health Statistics: Office visits to

ophthalmologists: National Ambulatory Medical Care

Survey, United States, 1976, by H. Koch and T. Ezzati.

Advance Data From Vital and Health Statistics, No. 31.

DHEW Pub. No. (PHS) 78-1250. Public Health Service.

Hyattsville, Md., July 14, 1978.

8 National Center for Health Statistics: Office visits to

doctors of osteopathy: National Ambulatory Medical

Care Survey, United States, 1975, by H. Koch. Advance

Data From Vital and Health Statistics, No. 25. DI-IEW

Pub. No. (PHS) 78-1250. Public Health Service. Hyattsville, Md., Mar, 22, 1978.

9 Nation~ Center for Health Statistics: Office visits to

general surgeons: National Ambulatory Meclical Care

Survey, United States, 1975, by R. O. Gagnon. Advance

Data From Vital and Health Statistics, No. 23. DHEW

Pub. No. (PHS) 78-1250. Public Health Service. Hyattsville, Md., Mar. 24, 1978.

10National Center for Health statistic?: Office visits

by persons aged 65 and over: National Ambulatory

Medical Care Survey, United States, 1975, ‘by R. O.

Gagnon. Advance Data From Vital and Health Statistics,

No. 22. DHEW Pub. No. (PHS) 78-1250. Public Health

Service. Hyattsville, Md., Mar. 22, 1978.

11Nation~ Center for Health Statistics: Office visits to

obstetrician-gynecologists: National Ambulatory Medical Care Survey, United States, 1975, by T. Ezzati. Advance Data From Vital and Health Statistics,, No. 20.

DHEW Pub. No. (PHS) 78-1250. Public HealtJ~ Service.

Hyattsville, Md., Ma-. 13, 1978.

12National Center for He~th Statistics: Office visits to

internists: National Ambulatory Medical Care Survey,

United States, 1975, by B. K. Cypress. Advance Data

From Vital and Health Statistics, No. 16. DHEW Pub.

No. (PHS) 78-1250. Public Health Service. Hyattsville,

Md., Feb. 7, 1978.

13Nation~ Center for He~th Statistics: Nation~ Ambulatory Medical Care Survey of visits to general and

family practitioners, January-December 1975, by B. K.

Cypress. Advance Data From Vital and Health Statistics,

No. 15. DHEW Pub. No. (PHS) 78-1250. Public Health

Service, Hyattsville, Md.. Dec. 14, 1977.

14National Center for Health Statistics: Ambulatory

medical care rendered in pediatricians’ ofilces during

1975, by T. Ezzati. Advance Data From Vital and

Health Statistics, No. 13. DHEW Pub. No. (HRA) 77-

1250. Health Resources Administration. Hyattsville,

Md., Oct. 13, 1977.

15National Center for Health Statistics: l?igkth Revision International Classification of Diseases, Adapted for

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

Health Service. Washington. U.S. Government Printing

Office, 1967.

16National Center for Health Statistics: physician

visits: Volume and interval since last visit, United States,

1971, by K. M. Danchik. Vital and Health Statistics.

Series 1O-NO. 97. DHEW Pub. No. (HRA) 75-1524.

Health Resources Administration. Washington. U.S.

Government Printing Office, Mar. 1975.

28
17Goodm~, L. J., and Mason, Il. R.: Physician Distribution and Medical Licensure in the U.S. 1975. Chicago z

Center for HeaJth Services Research and Development,

American Medical Association, 1976.

18National Institutes of Health: Some characteristics

related to the incidence of cardiovascular dk.ease and

death: Framingham Study, 16 year follow-up, by D.

Shurtleff, in W. B. Kannel and T. Gordon, eds, The

Framingham Study. Pub. No. 74-599. Public Health

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

1974.

19Nation~ Center for Health Statistics: vital Statistics

of the United States, 1975, Vol. II, Part B. DHEW Pub.

No. (PHS) 78-1102. Public Health Service. Washington.

U.S. Government Printing Office, 1977.

20Kanne1, w. B., wolf, P. A., Verter, J., and McNamara, P. M.: Epidemiologic assessment of the role of

blood pressure in stroke, the Framingham Study.

J.A.M.A. 214(2): 301-310, Oct. 1970.

21Nation~ Center for Health Statistics: Annual summary for the United States, 1976: Births, deaths, marriages, and divorces. Monthly Vital Statistics Report.

Vol. 25, No. 13. DHEW Pub. No. (PHS) 78-1120. Public

Health Service. Hyattsville, IUd., Dec. 12, 1977.

22National Center for Health Statistics: Blood pressure

levels of persons 6-74 years, United States, 1971-1974,

by J. Roberts and K. Maurer. Vital and Health Statistics.

Series 1l-No. 203. DHEW Pub. No. (HRA) 78-1648.

Health Resources Administration. Washington. U.S.

Government Printing Office, Sept. 1977.

23Nation~ Center for He~th 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. HeaIth Resources Administration. Washington.

U.S. Government Printing Office, hfay 1974.

24NationaI Heart, Lung, and Blood Institute: Report

of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. DHEW

Pub. No. (NIH) 77-1088. National Institutes of Health,

Bethesda, Md.

25Cypress, B. K.: The role of ambulatory medical

care in hypertension screening. Am. Pub. Health Assoc.

]. (In press).

26National Center for Health Statistics: Replication:

An approach to the analysis of data from complex surveys, by P. J. hlcCarthy. Vital and Hea{th Statistics.

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

Services and Mental Health Administration. Washington.

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

27National Center for Health Statistics: Pseudoreplication: Further evaluation and application of the balanced half-sample technique, by P. J. McCarthy. Vital

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

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

Administration. Washington. U.S. Government Printing

Office, Jan. 1969.

29
LIST OF DETAILED TABLES

1. Number, percent distribution, and average annual rate cf office visits for diseases of the circulatory system, by age, sex, and

race of patient: United States, 1975-76 .. ................ ...... ......... ...... ...................................... .......................................................

2. Number and percent distribution of office visits for diseasas of the circulatory system by type of practice, according to $leographic region and metropolitan and nonmetropolitan areas, with average annual visit rates: United States, 1975-76 ........ ......

3. Number and percent distribution of office visits for diseases of the circulatory systam by age, sex, and race of patient,

according to selected principal diagnoses: United States., 1975-76 ..... ............ ........................ .. .............. .. ..... ............................

4. Median visit age and standard error of the median for diseases of the circulatory system, by sex and race of patient and

selected principal diagnoses: United States, 1975-76 ............... .......... .......... ...... .. ....................................... ....... .......................

5. Number, percent distribution, and average annual rata of office visits for diseases of the circulatory system by geographic

region, metropolitan and nonmatropol itan areas, and type of practice, according to selected principal diagnoses: United

States, 1975-76 .. ............... ................ .......... .................................................. ................ ............................................................

6. Number, parcent distribution, and average annual rate of office visits for assential banign hypertension (401), by most frequently visited specialty, geographic region, metropolitan and nonmetropolitan areas, and type of practice: United States,

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

,7. Number, percent distribution, and averaga annual rate of office visits for coronary heart disease (410-413), by most frequently visited specialty, geographic region, metropolitan and nonmetropolitan areas, and type of practice: United States,

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

8. Number and percent of office visits for essential benign hypertension (401), by sex, age, and most frequent principal problem of patient: United Statesr 1975-76 ........ ............ ................................ ...... ...................... .. ...... ............... .. ............................

9. Number and percent of office visits for coronary heart disease (410-413), by sex, age, and most frequent principal problem

of patient: United States, 1975-76 ....................... ............................................. ............................ ...........................................

10. Number and percent distribution of office visits for diseases of the circulatory system by problem status, seriousness of

problem, and disposition of visit, according to selected principal diagnoses: United Statesr 1975-76 .. .... ................ ............. ....

11. Mean contact duration and standard error of mean contact duration of office visits for diseases of the circulatory system,

by age and sex of patient, visit status, and selected principal diagnoses: United States, 1976-76 ......... ........ .......... .. .................

12. Mean contact duration and standard error of mean contact duration of office visits for diseases of the circulatory system,

by age of patient, visit status, and selected principal diagnoses: United States, 1975-76 ........ ................. ..................................

31

32

32

33

33

34

34

35

35

36

36

37

30
Table 1. Number, percent distribution, and average annual rate of office visits for diseases of the circulatory system, by age, sex, and

race of patient: United States, 1975-76

Sex and race

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

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

Black and otherl .........................................

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

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

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

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

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

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

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

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

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

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

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

Number I II I I

110,617 100.0

62,656 100.0

47,961 100.0

99,634 100.0

55,789 100.0

44,044 100.0

10,783 100.0

6,866 100.0

3,916 100.0

$

.265.1

. . . 290.2

. . . 238.3

. . . 275.4

. . . 298.5

. . . 250.8

. . . 197.3

. . . 236.6

. . . 152.8

55-64 65-74

years years

75 years

and over

Percent distribution

6.8 7.0 17.4 25.0 26.8 17.0

6.3 6.5 15.8 23.3 28.2 20.0

7.4 7.8 19.4 27.1 25.0 13.2

6.3 6.7 16.9 24.9 27.4 17.8

5.7 6.0 14.8 23.6 28.8 21.1

7.1 7.6 19.5 26.6 25.5 13. ?

11.2 10.4 21.8 25.2 22.0 9.4

11.4 10.6 23.4 20.7 23.3 10.5

*1 0.8 *10. I 19.1 33.0 19.7 *7.4

Visit rate per 1,000 in population

30.8 I 174.4

32.2 174.7

29.4 174.0

30.5 165.5

30.2 175.7

I

=t%i

411.5

408.6

414.7

386.1

426.1

583.4

316.8

703.9

703.8

704.1

704.2

699.7

700.4

746.7

1,088.2

1,143.8

1,015.5

1,147.9

1,052.6

1,104.4

671.2

1,199.9

1,272.4

1,078.3

1,307.0

1,137.3

688.2

*5 I 7.9

lAbO”t 87 percent were visits by members of the black ‘ace.

31
Table 2. Number and percent distribution of office visits for diseases of the circulatory system by type of practice, according to

geographic region and metropolitan and non metropolitan areas, with average annual visit rates: United Statesr 1975-76

Geographic region and area

Number

of visits

in thousands

All

types

of

practice

solo Otherl

Average

annual

visit

rate per

1,000 in

population

Percent distribution

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

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

110,617

29,594

30,334

31,627

19,061

80,632

29,984

100.0

100.0

100.0

100.0

100.0

100.0

100.0

65.2

75.5

68.6

59.7

52.9

62.7

71.9

34.8

24.5

31.4

40.3

47.7

37.3

28.1

265.1

302.9

270.5

235.3

261.2

281.8

228.8

lInc]ude5 group and partnership a~angernents.

Table 3. Number and percent distribution of office v!sbts for diseases of the circulatory system by age, sex, and race of pat!ent, according to selected principal

diagnoses: United States, 1975.76

Age ISex Race

I

Black

White and

other

Number

of wsits

In thousands

Total Under

75

35

35-44 45-54 55-64 65-74 years

Female

years years years years and Male

years

over

Prlnclpal diagnosis and ICDA codel

Percent distribution

30.2

26.4

23.2

25.0

1B.6

18.1

‘12.1

20.1

25.7

14.2

25.2

29.9

31.3

28.2

31.2

29.3

29.8

21.6

‘15.2

‘1O.6

10.6

‘1 3.5

26.4

‘1 2,6

23.6

38.9

50,6

“8.0

+’9.3

“3,1

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

Acute ischemic heart d!sease .,.., ......... .....410.41 1

Chronic ]schemic heart disease ...........412.. .......4l2

Angina pectoris .... .................... ., ...................413

Symptom.stlc heart disease ....... .......427............427

Cerebrovascular disease .... .... ... ... ... ..430438

Arteriosclerosis .,.........,....,....,....,....,.,..,.........44•

Phlebltls and thrombophlebltls .. ..... .......... ....451

Varicose veins of lower extremities ., .... ........454

Hemorrhoids ... ........................... ,..,, ......... .....455

46,128

2,319

26,020

2,975

7,052

4,505

2,019

2,930

2,428

3,686

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

5.9

●2.1

“1.2

“2.1

9.0

‘2.0

●o .5

“14.8

“14.2

29.5

8.2

“6.9

3.6

“3.2

“6.7

“1.0

●4.5

“12,2

‘1 3.6

19.1

19.9

21.2

14.3

28.9

11.0

●1O.6

‘2.5

23.3

21.9

23.5

63.5

42.9

47.8

47.0

51.1

49.6

63.4

68.7

81.5

44.4

36.5

57.1

52,2

53.0

48.9

50.4

36.6

31.3

18.5

55.6

87.6

94.0

92.2

92.5

91.5

94.0

94.7

93.5

93.2

91.2

12.4

6.0

7.8

7.5

8.5

6.0

5.3

6.5

6.8

8.8

1Diagnostic groupings and code inclusions are based on the Eighth Revision International Classification of Diseases, Adapted for Use in the United States, 1965.

32
Table 4. Median visit age and standard error of the median for d!seases of the circulatory system, by sex and race of patient and selected principal diagnoses:

United States. 1975-76

Sex Race Both sexes

Standard

error

of the

Female Male Wh !te I Black andother

Standard

error

of the

median

in

years

0.8

4.7

1.0

5.1

3.0

3.4

3.4

3.9

4.3

4.5

!

StandLStandard

Median error

wsit of the

age median

in

years

57.6 0.9

60.1 4.7

64.1 1.4

59.6 3.9

66.5 1.9

68.7 2.2

75.1 4.6

57.8 5.4

●58.6 7.9

45.4 4.4

Standard

error

of the

median

in

years

Principal diagnosis and lCDA code]

Median

wsit

aw

ard

error

of the

median

on

Median

visit

age

Med!an

wsit

age

63.8

62.5

67.5

61.3

66.5

71.2

75.1

53.9

55.1

45.6

Median

visit

age

62.0

64.9

70.5

63.6

66.7

75.0

75.1

53.4

54.0

45.9

medtan

sn

years

0,7

3.4

0.8

3.0

1.4

2.0

1,8

2.7

3.5

3,1

years

Essentml benign hypertension .... ..... ..... ..... ........ .......401

Acute ischemic heart disease ...... ..... ..................4l 0411

Chron,c ischemic heart disease ... ....................... .......412

Angina pectoris .... ..... ....... .......... ..... ..... ..... ........ ..... ..4l3

Symptomatic heart disease ....... .......... ..... ..... ..... .......427

Cerebrovascular disease ............ ..... ....... ........ .....43O43.

Arteriosclerosis .... ............... ..... ................................44C

Phlebitis and thrombophlebit!s ....... ... ..... ........ .. .......451

Varicose veins of lower extremities .... ..... ..... ............454

Hemorrhoids ... ..... ..... ............... ....... ... ..... ..... ............455

60.8

63.2

67.8

0.7

3.5

0.8

56.8

●51.3

62.3

1.9

5.3

1.5

7.9

7.8

6.2

7.0

16.4

18.6

9.9

61.9 3.3 “56.5

67.1 1.6 60.5

71.5 2.2 “67.8

75.1 2.9 “75.1

55.7 3.3

55.0 0.5

45.9 3.3

‘49.0

●58.4

●41.7

‘Diagnostic groupings and code inclusions are based onthe Eigi?tlz Rct,ision Intemarional Classification of Disemes, Adaptetifor UscintJ?e United States, 1965.

Table5. Number, percent distribution, and average annual rate of office visits fordiseases of thecirculatory system bygeographic region, metropolitan

andnonmetropol itanareas, andtype ofpractice, according toselemed principal diagnoses: United States, 1975-76

Principal diagnosis and lCDAcodel

Number

of visits

in thousandk

Area

Type of

practice

I

solo Other2

*

Metropolitan

Nonmetropolitan

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

Acute ischemic heart disease . . ... .. .. .. . ... .. .. .. . . ...41 O-4l 1

Chronic ischemic heart disease ... .. ... . .... .. .. .. ... .. .. ....412

Angina pectoris .. . ... . ... .. ... .. .. ... . .... ... .. . .... . .... .. ... . .. .. .413

Symptomatic heart disease .... . ... .. .. .. . ... .. .... . .. ... . ....427

Cerebrovascular disease .... . ... .. .... . ... .. .. .. . . .. .. ....430438

Arteriosclerosis . .. ... . .... . .... . .... .. ... . .... . .... . ... .. ... .. ... ...44o

Phlebitis and thrombophlebitis .. . .... . .... . .... . .... . .. ....461

Varicose veins of lower extremities . . .. ... .. .. . .. ... . .....454

Hemorrhoids ... .. .... . .... . .... . ... .. .. ... ... .. ... .. ... .. . .... . ......455

46,128

2,319

26,020

2,975

7,052

4,605

2,019

2,930

2,428

3,686

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

100.0 27.0

100.0 ●24.7

100.0 27.6

100.0 23.0

100.0 24.9

100.0 26.9

100.0 26.0

100.0 27.0

100.0 ‘23.4

100.0 23.0

29.0

30.7

26.0

23.6

24.1

29.3

42.7

24.0

*18.B

28.0

28.1

28.2

31.8

33.2

30.1

●19.3

29.3

43.4

35.5

16.1

●16.5

18.2

21.5

17.9

13.8

●1 2.0

“19.6

‘14.3

19.2

71.7

70.2

73.6

75.4

73.5

73.5

68.8

74.6

73.4

77,0

28.3

29.8

26.4

24.6

26.6

26.5

31.2

25.4

26.6

23.0

69.7

64.9

64.9

55.2

53.9

66.6

74.0

63.6

52.3

58.0

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

30.3

35.2

35.1

44.9

46.1

33.4

26.0

36.4

47.7

42.0

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

22.4

Visit rate per 1,000 in population

95.9

4.8

54.6

7.0

17.4

10.1

●2.9

6.4

7.8

9.7

101.4

‘5.2

64.9

8.8

17.3

8.5

‘3.3

●7.9

‘4.8

9.7

115.5

5.7

66.9

7.8

18.1

11.6

4.9

7.6

6.2

9.9

99.6

5.3

52.4

5.6

14.3

9.1

4.8

5.7

4.9

6.5

Essential benign hypertension . . ... .. .... . . ... . ... .. ... .. .. ..4Ol

Acute ischemic heart disease . .. . .... . ... .. ... .. ... .. ..41 O4l 1

Chronic ischemic heart disease .. ... . .... . .... . ... .. .. ... . ...412

Angina pectoris .. .. .. .. ... .. ... .. . ... .. ... . .... . . .. .. . .... . .. ... .. ..413

Symptomatic heart disease ... .. .... . ... .. .. .. . . ... . .. ... . ....427

Cerebrovascular disease ... .. . .... .. ... . ... .. .... . . ... . ...43O438

Arteriosclerosis .. .... . ... .. ... .. .. ... .. .. . . .. .. .. ... .. . .. . .. ... .. ...44O

Phlebitis and thrombophlebitis . .. . .... . .... . .... . ... .. .. ...45l

Varicose veins of lower extremities..., ... . .... . ... .. .....464

Hemorrhoids . .. .. .. ... . .... .. ... . .... . .... . ... .. .. ... . .... .. ... . .....456

I 10.5 127.5

5.6 ●5.9

62.3 73.6

7.1 7.0

16.9 17.9

10.8 12.4

4.8 *5.4

19.3

6.4

60:2

6.3

15.1

11.8

7.7

6.3

●4.1

7.4

7.0 8.1

5.8 ●5.8

8.8 8.7

lDiagno~tjc grouPing~ and code jnclusion~ are b~~ed On the Eighth Revision International Cla.WIicaD”On of Diseases Adawdfw use in the united

States, 196S.

‘Includes group and partnership arrangements.

33
Table 6. Number, percent distr!butlon, and average annual rate of of flea visits for essential benign hypertension (401), by most frequently visited

specialty, geographic region, metropolitan andnonmetropolitan areasrand type of practice: United States, 1975-76

Most frequently visited specialty

General and family practice ... .. .. ... ... .. .. ... .. ... . .... .. ... ..

Internal medicine . ... .. .. ... .... . ... .. ... .. .. .. . . .. .. .... . .. ... ... .. .. ..

General surgery .. .. .. ... .. ... .. ... .... . .. ... .. ... ... .. ... .. ... .. ... .. . ...

Cardiovascular diseases .. .... . ... .. ... ... ... . .... . .... . ... .. .... . ....

General and family practice .... ... .. .. ... . ... .. . ... .. ... .. ... .. ...

Internal medicine .. ... .. .. .... .. ... .. . .... .. .. .. .... .. ... .. ... .. ... . ....

General surgery . .. .. ... .. ... .. ... ... .. . .... ... .. . ... . .. ... .. ... .. ... .. .. ..

Cardiovascular diseases .. ... . .... .. .. .. .... . .... . .... .. ... . .... . ... ..

Number

of visits

in thousands

27,179

12,779

2,190

1,461

.

. .

,..

. . .

II Geographic region I

Area

Tots I

North- North MetroNonCentral

South West

east

metropolitan polltan

100.0 22.9

100,0 35.2

100.0 ‘16.8

100.0 45.2

65.1 63.6

30.6 46.0

5.2 ‘4,2

3.5 6.8

Percent distribution

32.8 29.9 14.4 62.9 37,1

23.5 21.3 20,1 87.6 12.4

36.8 29.3 ‘15.0 66.8 33.2

‘8.2 ‘27.3 ‘19.3 98.5 *1.6

Vmit rate per 1,000 in population

79.5

26.8

7.2

‘1.1 w

Type of

practice

solo

I

Otherl

75.9

55.9

76.4

65.7

24.1

44.1

23.6

34.3

--1-..

..

...

... ...

lIncludes group and partnership arrangements.

Table 7. Number, percent distribution, and average annual rate ofoffice visits forcoronary heart disease (41 0-413), bymostfrequently visited specialty,

geographic region, metropolitan andnonmetropolitan areas, andtype of practice: United States, 1975-76

Geographic region

Type of

Number Araa

practice

Most frequently wsited specialty

of visits

Total in thouNorth- North

NonMetro- sands

Central

So,uth West

east

metropolitansolo Otherl

politan

General and family practice ... .... . . .... .. ... . .... .. ... . .... .. .. ...

Internal medicine ... . .... . ... .. .. .. . ... .. .. .. . ... .. ... .. .... . .. ... . .... . .

Cardiovascular diseases .... . .... . .... . ... .. . ... .... . ... .. . ... . ... .

General and family practice .. . .... . .... . .... . . .. .. ... .. .. .. . .. .. . ..

Internal medicine . .. . .... ... .. . .. .. .. ... . .... . .... . .... . .... . .... . ... .. . .

Cardiovascular diseases .... .. ... .. ... . .... .. ... .. ... .. ... .. ... . .. ... .

14,920

11,722

3,089

100.0II21.3

100.0 32.0

100.0 36.1

Percent distribution

27.8 I

31.9 19.0 I61.3 38.7 72.1

26.3 24.7 17.1 83.6 16.4 58.5

*9.9 30.8 23.3 97.2 “2.9 38.5

I I

Visit rata per 1,000 in population

,.. 35.7 II32.5 I

37.0

I

35.4 38.9 I

31.9 44.1

. 28.1 38.4 27.4 21.5 27.5 34.2 14.6

7.4 11.4 ‘2.7 7.1 9.8 10.5 ‘0.7

27.9

41.6

61.5

. . .

I

...

... ...

.. .,.

l~nclude~ group a“d partnership arrangements

34
Table8. Number and percent of office visits foressential benign hypertension (401), bysex, age, andmost frequent principal problem

of patient: United States, 1975-76

Principal problem and NAMCScodel

All principal problems .........................................................

Progress visit ..........................................................................98O. 985

Abnormally high blood pressure ....................................................2O5

Headache .......................................................................................O56

Vertigo ..........................................................................................O69

Fatigue ..........................................................................................oo4

General medical examination .........................................................9oo

Nervousness ...................................................................................81 O

Number

of visits

in thousands

46,128

18,336

12,582

2,759

2,471

1,216

973

696

Percent

of

visits

100.0

39.8

27.3

6.0

5.4

2.6

2.1

1.5

Sex Age

1 i 1

Female I

Male I

Under

I

65 years

65 years and over

Number in thousands

29,287 [ 16,840 i 29,596 ] 16,532

37.2

27.0

6.6

5.6

3.2

●2.O

*1.7

Percent

44.2 40.8

27.7 27.5

4.9 6.4

4.9 4.6

*1.7 2.3

●2.2 2.2

*1.2 *1.6

37.9

26.9

5.1

6.7

*3.2

“2.0

*1.3

lSYmPtomatic ~rouPin~s and code number inclusions are based on a symptom classification developed for use in NAMCS.

Table 9. Number and percent of office visits for coronary heart disease (410-41 3), by sex, age, and most frequent principal problem of

patient: United States, 1975-76

Principal problem and NAMCS codel

All principal problems ............................... ............ ........ ......

Progress visit ..........................................................................98O. 985

Chest pain ......................................................................................322

Other symptoms referable to cardiovascular system ......................220

Shortness of breath ........................................................................3O6

Fatigue ..........................................................................................oo4

Abnormally high blood pressure ...... ............................................ ..2O5

Vertigo ................................................................................... .......O69

Pain, swelling, injury of lower extremities .....................................400

Headache ...................... .............................................................. ...O56

of visits

in thousands

31,314

9,527

6,429

2,073

1,978

1,632

1,218

830

678

608

Percent

of

visits

100.0

30.4

20.5

6.6

6.3

5.2

3.9

2.7

2.2

1.9

Sex IAge

Female IIMale

Under 65 years

65 years and over

Number in thousands

14,828 I 16,485 I 14,093 I 17,221

Percent

26.4

19.4

7.4

7.4

6.7

4.8

3.0

●2.8

*2.8

34.0

21.5

5.9

5.4

3.8

3.0

2.3

*1.6

●1.1

31.4

26.5

5.8

4.0

‘3.8

●3.2

●1.5

*I .1

*2.1

symptomatic groupings and code number inclusions are based on a symptom classification developed for use in NAMCS.

29.6

15.6

7.3

8.2

6.3

4.5

3.6

●3.1

*1.9

35
Table 10. Number and percent d(str(butson of office wslts for diseases of the c!rculamry system by problem status, seriousness of problem, and disposition of visit,

accmd!ng to selected prlnclpal dlagnmes. United States, 1975.76

Pr#nclpal diagnos!s and ICDA codel

N umber

of Vlslts

In thou.

sands

Total

Seriousness of

problem Problem status D!spositmn2

I

New

COntlnuIIlg

problem

I

22.2

66.5

50.5

56.3

48.1

49.3

38.9

53.3

19.3

13.7

Essent!al benign hypertension ....... .......... ...... ..,..401

Acute !schemm heart dmease.,. ..,.., ......... .......410411

Chronic lschemsc heart disease ...... ..... . ,............ ....412

Angina pectorls ..,....,.,..,.,..,.,,...,....,....,.,.,,. .,.413

Symptomatic heart disease . .. .... ...... .. . .... .........427

Cerebrovascular d!sease ..... ..... ..... ..... .......... ....43O438

Artermsclerosns ................. ..... ..... ............... .. ... ......44O

Phlebmis and thrombophlebms ............... ......451

Varicose veins of lower extremities ...... ......... ......454

Hemorrhoids .... . . . . ... ..........455

46,128

2,319

26,020

2,975

7,052

4,505

2,019

2,930

2,428

3,686

100.0

100,0

100,0

100,0

100,0

100,0

1000

100.0

100.0

100.0

10.8

18.1

10.3

22.4

18.3

15.2

19.2

29.0

31.8

52.8

89.2

81.9

89.7

77.6

87.7

84.8

80.8

71.0

68.2

47.2

77.8

33.5

49.5

43.7

51.9

50.8

61.1

46.7

80.7

86.3

86.1

76.3

.S7,8

81,1

78.6

78.7

70,0

72.9

68.6

51.1

11.3

11.7

8.7

13.8

12.7

14.4

22.7

?6.0

16.5

30.0

0.6

13.8

2.1

2.6

5.3

5,4

2.0

8.7

8.8

6.1

——

5.3

4.4

5.3

13.3

9.2

7.7

13.5

8.3

9.6

18.8

1Diagnostic grou PI ngs find code mclusmns me based on the Eighth Revision Internn tional Classification of Diseases, Adapted for Use in the United Stc7teS, 196S.

2Perce”ts will “ot add to 100,0 became some oatmnt vmits had more than 1 dxsvosition.

3[ncludes no followup planned, referred to other physicitm. returned to referring physician. and other disposition.

Table 11, Mean contact duration and standard error of mean contact duration of office visits for diseases of the circulatory system, by aga and sex of

patient, visit status, and selected principal diagnoses: United States, 1975-76

All

ages

Patient age Patient sex Visit status

65 years

and over

Patient seen before

Principal dlagnosls and ICDA codel

Under

55 yaars

New

patient New

problem

COntinuing

problem

Female Male

Mean contact duration in minutes

Essential ben!gn hypertension .. .. .. ... .. ... .. . .... .. ... ... .. .. .. .. .... .. .. .. ... ...4Ol

Acute !schemic heart disease ... ... .. .. ... .. .. . . .... .. ... ... .. .. .. . . ... . .. ...41 O4l 1

Chronic ischemic heart d!sease ... .. . .... .. ... .... . .. ... ... .. .... . ... .. .... .. .. . . ..4l2

Angina pectoris .... .. ... ... .. .... . . .. .. ... .. ... .. .... . .... .. ... . .. .. .... . .. .. . .. ... .. .. ...4l3

Symptomatic heart disease .. ... .. .. .. . .. .. . .... . .... . .... .. ... .... . ... .. .... . .... ...427

Cerebrovascular disease .. ... .. ... .. .... .. ... . .... . .... . ... . . .... ... .. .. ... . ....43 O.438

Arteriosclerosis .... . .. .. . .... . .... .. ... ... .. ... .. ... .. .... . .... . .... . .. .. . .... .. .. . ... .. ..44O

Phlebitls and thrombophlebitis ... . .. .. .. . . .. .. . .. ... .. .. . . .... .. .. . .... ...451

Varicose veins of lower extremities ... . .. .. . .... . .... .. ... . .... . ... . . .. .. .... ...454

Hemorrhoids ... . ... .. .... .. ... ... .. .. .. . ... .. .... . .... . .... . ... .. .... .. ... . .... .. ... .. .....455

14.3

17.7

16.9

18.7

18.2

15.8

16.1

14.6

13.7

16.1

14.7

17.2

17.3

18.3

17.8

16.6

20.7

14.9

12.9

16.6

13.6

18.3

16.6

19.3

18.5

15.5

15.0

14.0

16.2

19.1

14.1

18.6

18.9

18.8

18.0

15.4

17.0

14.5

13.6

16.6

14.7

17.0

16.9

18.6

18.3

16.3

14.6

14.8

14,4

15.7

24.0

36.6

29.8

29.6

30.0

28.4

26.1

22.5

16.3

19.0

18.7

16.2

20.2

23.4

20.0

20.4

18.5

15.9

16.7

15.1

13.5

16.9

16.0

16.6

17.1

14.7

14.5

13.3

12.6

15.3

Standard error of mean contact duration in minutes

Essential ben!gn hypertension . . .. . . .. . .. .. ... . ... . . . . .. .. 401

Acute ischem,c heart disease, ... . .... .. ... . ... . .... . ... .. ... .. ... ... .. ....410411

Chronic lschemic heart disease .. .. .. . .. . . ... . .. .. .. .. . . .. .. .. . .. .. .. .. . ....412

Angina pectorcs. ... .. ... ... . .. . . . . ... .. .. . .. .. . ... . .. .. . 413

Symptomatic heart disease...,.. . . . . .. . .. . ... . .. .. . .. .. . .... .. .. .. ....427

Cerebrovascular disease ... . .... ... .. . .... ... .. .... . .... . ... .. ... .. .. .. . .... ...430-438

Arterloscleros!s . . ... ... ... . .. .. . ... . ... ... .. .. . .. . .. .. . ,..., . ....440

Phlebitls and thrombophlebltls .. .... . ... ... ... .. ... . .... . .... .. ... . .. .. .... . .....45l

Varicose ve!ns of lower extremities. .. .. . . . . ... .. ... ... ... .. ... . ....454

Hemorrhoids . . .... ... .. .. . . .. . ... ... . .. .. .. . . . ... . .. ... .. . .. .. .. .. .....455

029

0,91

0,42

0.72

0.63

0.87

0.88

0.65

1.27

0.67

0.35

1.18

0.61

0.86

0.82

0.85

2.67

0.78

1.43

0.71

0.33

1.30

0.48

1.28

0.77

1.24

0.85

1.05

1.39

1.26

0,32

1.64

0.57

1.33

0.66

1.48

1.47

0.81

1.57

0.82

0.40

0.93

0.49

0.95

0.99

0.69

1.20

0.74

0.74

0.80

1.62

7.26

2.02

3.64

3.57

3.96

6.96

3.77

3.49

1.77

1.12

2.67

1.72

3.11

1.55

2.28

4.02

1.43

2.20

1.31

0.29

0.88

0.44

0.82

0.61

0.84

0.67

0.57

1.16

0.79

.

lDlagnostlc groupings and code mclus]ons are based on the Eighth Revision Znternan”onal Classification of Diseases, Adapted for Use in the United

States, 1965.

36
Table 12. Mean contact duration and standard error of mean contact duration of office visits for diseases of the circulatory system, by

age of patient, visit status, and selected principal diagnoses: United States, 1975-76

Principal diagnosis and ICDA codel

Essential benign hypertension .................................. ............ ......4Ol

Acute ischemic haart disease ............ ...................................41 O4l 1

Chronic ischemic heart disease ... ..... ......................... ........ ..........4l2

Ang[na pectoris ................. .........................................................4l3

Symptomatic heart disease .................................... .....................427

Cerebrovascular disease .......................................................43O438

Arteriosclerosis ....... ........................................ ...........................44O

Phlebitis and thrombophlebitis .................. ................................45l

Varicose veins of lower extremities ................. ...........................454

Hemorrhoids ...... ................................................................ ........455

Essential benign hypertension ....................................................4Ol

Acute ischemic heart disease ................................ ...............41 O.4l 1

Chronic ischemic heart disease ............................. ..... ....... ...... ....4l2

Angina pectoris ..................................................... ................ .....4l3

Symptomatic heart disease ......... ................................................427

Cerebrovascular disease ................. ......................................43O438

Arteriosclerosis .................................................................... ......44O

Phlebitis and thrombophlebitis ........... ....... ............ ...... ..............45l

Varicose veins of lower extremities ............................................454

Hemorrhoids .............. ....................................... .........................455

Under 65 years

New

patient

23.6

34.9

29.6

28.3

27.1

24.8

30.7

22.7

15.6

19.0

Patient seen before

I

ConNew tinu -

problem ing

problem

65 years and over

~ Patient seen before

Mean contact duration

w

in minutes

20.7

18.2

22.0

18.6

18.0

22.2

13.6

15.6

16.2

14.5

13.7

16.1

16.0

16.4

16.5

15.0

17.7

13.4

11.0

14.6

25.1

39.0

30.4

33.5

39.7

32.7

22.1

20.9

22.4

18.6

15.5

14.1

19.1

26.9

23.4

19.3

20.0

16.5

11.0

19.8

Standard error of mean contact duration in minutes

1.72

12.34

2.53

4.20

3.61

4.56

5.27

4.06

3.79

1.91

1.61

4.10

3.94

2.82

1.91

3.48

5.53

1.77

2.46

1.47

0.34

0.97

0.60

1.13

0.98

0.58

1.63

0.68

1.09

0.85

3.39

5.56

2.56

7.15”

7.24

6.68

9.59

8.54

10.29

3.25

0.96

5.41

1.58

5.65

2.15

3.19

4.98

2.61

4.49

2.14

13.1

18.1

16.1

16.5

17.5

14.5

13.9

13.0

16.0

19.0

0.32

1.17

0.48

0.98

0.75

1.16

0.69

1.08

1.42

1.86

lf)ia~nostic ~rouPin~s and code inclusions are based on the Eighth Revision In tematiomd chSSifiCUtiO?I Of Diseases; A dap~~d .fo~ use

in the United States, 1965.

37
I.

II.

111.

I.

II.

I.

II.

APPENDIXES

CONTENTS

Technical Notes .............................................................................................................................

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

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

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

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

Tests of Si~ificance ........................................................................................................ ........

Population Fi~resand Wte Computation ...............................................................................

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

Definition of Certain Terms Used in This Re~ort ...........................................................................

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

Terms Relating totbe Patient Record Fom .............................................................................

Survey Instmments ........................................................................................................................

Introductory Letter From Director, National Center for HeAth Statistics ................................

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

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

LIST OF APPENDIX FIGURES

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

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

Estimates of the civilian noninstitutionalized population of the United States used in computing

average annual rates in this publication, by age, race, sex, geographic region, and metropolitan

and nonmetropolitan areas: United States, 1975-76 ....................................................................

39

39

40

42

42

45

45

46

47

47

48

51

51

52

53

43

44

40

45
APPENDIX 1

TECHNICAL NOTESj

This report is based on data cdIected in the

National 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 Health

Statistics. The present report is based on information coIlected 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@..-The N~lCS 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 fieId 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 probabiIity-proportional-to-size procedure using separate sampling frames for

SMSA’S and for nonmetropolitan counties was

employed. After sorting and stratifying by size,

region, and demographic characteristics, each

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

frame was divided into sequential zones of 1

milIion 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 files maintained by the American

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

Office-based, as defined by AMA and AOA.

Principally engaged in patient care activities.

Nonfederally employed.

Not in the specialties of anesthesiology,

pathology, clinical pathology, forensic pathoIogy, radiology, dia~ostic radioIogy,

pediatric radiology, or therapeutic radiology.

Within each PSU, all eligibIe physicians were

arranged by nine specialty groups; general and

family medicine , intemaI medicine, pediatrics,

other medical specialties, general surgery, obstetrics and gynecology, other surgical specialties, psychiatry, and all other specialities. Then,

within each PSU, a systematic random sample of

physicians was selected in such a way that the

overalI probability of seIecting any physician

in the United States was approximately constant.

During 1975-76 the total NAIk4CS 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)

39
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 (eli@ble) 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

small 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 collect ed on 113,921 patient

visits by means of NAMCS.

Data Collection and Processing

Field procedures. –Both mail and teIephone

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 physicizin 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. Distribution of physicians in the 1975-76 National Ambulatory Medical Care Survey sample and response rates, by physician

specialty

Physician’s specialty

Number of physicians

6,529

1,687

1,765

938

435

392

2,316

679

558

1,079

761

468

293

925 5,604

260 1,427

245 1,520

124 814

74 361

47 345

189 2,127

54 625

48 510

87 992

231 530

79 389

152 141

1,128 4,476

333 1,094

337 1,183

202 612

53 308

82 263

381 1,746

113 512

94 416

174 818

77 453

45 344

32 109

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

40
representative determined the sample physician’s

eligibilityy. ascertained his cooperation, delivered

survey mat erials with verbal and printed instructions, and assi~ed 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 assigned 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 111). The Patient Log is a sequential

listing of patients seen in the physician’s office

during his assigned reporting week. This Iist

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

assi~ed a patient sampling ratio. These ratios

were desi=~ed 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 sampIing 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 NORC 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 Medical 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 deveIoped for that purpose.zs The diagnostic information, item 9 of the Patient Record,

was coded according to the Eighth Revision International Classification of Diseases, .4dapted

for Use in the United States (ICDA).IS 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 still 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.

41
Estimation Procedures

Statistics produced from NA.MCS 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.

Inflation 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 selecting a physician

within the PSU, and (3) the probability y of selecting a patient visit within the physician’s practice.

The last probability was defined to be the exact

numbqr 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 figures 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 standard

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 incIude 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 2Y2 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 estimate with more than a 30-percent relative standard error.

Estimates of sampling variability were calculated using the method of half-sample replica- ‘

tion. This method yields overall variability

through observation of variability 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.zG~z 7

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 X and H should be interpreted as approximate rather than exact for any specific e:stimate.

Directions for determining approximate relative

standard errors from the figures foHow.

1. Estimates of aggregates: Approximate

relative standard errors (in percent) for

aggregate statistics, such as the number

of office visits with a given characteristic,

42
are obtained from the curve in figure I,

or calculated by the following formula:

RSE (x) = d 0.0009113499 + 54”1;306 -100

where x is the aggegate of interest in

thousands.

2. Estimates of percentages: Approximate

relative standard errors (in percent) for

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 denomiThis calculation has been made for several percentages and bases and is presented in figure H. Alternatively, the

formula

54.14306 (1 -~) .100 RSE(@=~ ~.%.

can be used to calculate RSE for any

percentage (p) and base (x, in thousands).

3. 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 standnator from the ~esulting value for the

.

ard error of the numerator

numerator, and extract the square root. obtained from fi,gure I.

Figure 1. Approximate relative standard errors for estimated numbers of office visits, 1975-76 National Ambulatory

that can be

Medical Survey

ii

5

4

5

.$

3 3

2 ~

.1 .1

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).

43
Figure 11. Approximate relative stendard errors for percentages of estimated numbers of c,ffice visits, 1975-76 National Ambulatory

Medicel Care Survey

100

90

80

:

50

40

30

20

10

9

8

:

5

4

3

2

1

:

7

6

5

,4

,3

2

.1

1

2 346 ‘78910 2 345

6 7 B 9100

ESTIMATED PERCENTAGE

Example of use of this graph: An estimate of 20 percent (read from scale at bottom of graph)

based on an estimate of 10 million visits has a relative standard 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 11 and 12 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 empIoyed and their definitions in order to eliminate

ambiguities and encourage uniformity,, Steps

taken to reduce nonresponse bias were discussed

44
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

level of significance). The Bonferroni technique

is used for simultaneous testing of multiple

comparisons. Terms relating to differences, such

as “higher,” “Iess,” 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 sibgpificant.

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 excIusion of Alaska and

Hawaii from the study. For this reason the populati~n estimates should not be considered as

officml poptdation estimates and are presented

Table II. Estimates of the civilian non institutionalized population of the United Statesl used in computing average annual rates in this

publication, by age, race, sex, geographic region, and metropolitan and non metropolitan areas: United States, 1975-76

All

ages

75

years

and

over

Race, sex, geographic region, and area

Race and sex

All races .............. ...................................................

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

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

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

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

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

All other ........... ..........................................................

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

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

Geographic region

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

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

Number in thousands

208,610 13,634

5,914

7,721

12,337

7,844

2,931

4,913

7,159

121,822 22,353 23,349 19,608

100,639

107,971

181,285

60,575

61,247

103,702

10,737

11,616

19,571

11,242

12,107

20,790

9,240

10,368

17,727

87,823

93,462

27,324

12,816

14,509

48,849

56,063

67,212

36,486

143,086

65,524

51,881

51,821

18,120

9,513

10,058

2,782

10,063

10,727

2,558

8,376

9,352

1,881

5,339

6,998

1,298

2,652

4,507

685

8,694

9,426

. . .

.-.

---

. . .

. . .

. . .

1,224

1,558

. . .

-..

..-

. . .

---

. . .

1,179

1,379

..-

. . .

---

---

---

..-

864

1,016

..-

. . .

-..

---

-..

-..

575

723

---

---

. . .

-..

. . .

---

279

406

-..

---

---

---

-.. ,

. . .

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

Area

Metropolitan ..........................................................................

Nonmetropolitan .................... ........ ............................... ........

lE~~ludes Alaska and Hawaii.

45
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

data

that

factors, h~wever, that the user of these

should understand, all of which indicate

these data underrepresent the total number

o

of office visits to office-based physicians. Some -.

of those factors are:

1.

2.

The sampling frame for the 1975 and

1976 NAMCS included all nonfederally

empIoyed, “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.

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 incIuded who did not make

a visit. This factor could also, introduce

a bias into the data.

00

46
DEFINITIONS

Terms Relating to the Survey

APPENDIX II

OF CERTAIN TERMS USED IN THIS REPORT

Patients. –Can be classified as either:

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 individual physician rather than

with any institution.

Ambulatory patient. –An individual presenting for personal health services, neither bedridden nor currently admitted to any health care

institution on the premises.

Physician. –Can be classified as either:

In-scope: AH duly licensed doctors of medicine and doctors of osteopathy currentIy in

practice who spend some time in caring for

ambulatory patients at an office Iocation.

Out-ofscope: Those physicians who treat

patients only indirectly, including specialists

in anesthesiology, pathology, forensic pathoIogy, radiology, therapeutic radiology,

and diagnostic radiology, and the following

physicians:

●

●

●

●

physicians in miIitary service

physicians who treat patients only in an

institutional setting (e.g., patients in

nursing homes and hospitak)

physicians employed full time by an

industry or institution and having no

private practice (e.g., physicia,~s who

work for the Veterans Administration,

the Ford Motor Company, etc.)

physicians who spend no time seeing ambulatory patients (e.g., physicians who

onIy teach, are engaged in research, or

are retired).

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 p7ivate

office (which fits definition of “office”)

located in a hospital, the ambulatory patients seen there would be considered “inscope.”] The foIIowing types of patients are

aIso 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

47
recorded in the Master Physician fdes maintained by AMA or AOA.

Rega”on 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, Nlassachusetts, 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 CaroIina, 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 social 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 extent 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, sIightly 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, follow up: A return visit

primarily for continued medical care of a

previously treated acute problem.

Chronic problem, routine: A visit primarily

to receive reguIar care or examination for a

preexisting chronic condition or illness (onset of condition was 3 months or more

before this visit).

48
Chronic problem, jlareup: 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 primariIy 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. IncIudes 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

weI1-being. Included would be advice regarding diet, changing habits or behavior, and

general information regarding a specific

problem.

Immunization: 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, health center,

school nurse, minister, pharmacist, and so

forth. 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 list.

Principal diagnosis. –The physician’s diagnosis of the patient’s principal probIem or compIaint. 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 dia~osis. –The dia~osis 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 semices ordered or provided. —These include the folIowing:

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 example, pelvic exam or eye exam.

General histoy/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: Self-expkmatory.

EKG: Electrocardiogram.

Hearing 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 surgicaI 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

49
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 intramuscularly. 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, whirIpool,

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.

Psych o therap y/therapeu tic 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 are not listed in the preceding categories.

Disposition. –Eight categories to (describe the

physician’s disposition of the case are provided as folIows:

No followup planned: No return visit or

telephone contact was scheduled for the

patient’s problem on this visit.

Return at specified time: The patient was

told to schedule dn appointment or was

instructed 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 consuIt 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 wj.11be provided in a hospital. 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 the

visit, “duration of visit” was recorded as zero

minutes.

50
APPENDIX Ill

SURVEY INSTRUMENTS

INTRODUCTORY LETTER FROM DIRECTOR,

NATIONAL CENTER FOR HEALTH STATISTICS

@

**,...-%,,

‘% :

DEPARTMENTOF HEALTH. EDUCATION. AND WELFARE :. ~.

% “Sk .+’s PUBLIC HEALTH SERVICE

HEALTH RESOURCES ADM lNISTRATION

RDCKVILLE, MARVLANO X4X

NATIOFIALCENTER FOR

HEALTH STATISTICS

Endoriitw Orwnimtions

Am,rk,. M,dlcal A“OClal10.

Jam.% H. SammOns, M.D.

Exuutlb’* WC*Prwla.nt

Natle”U M.dlc81 AmOGlallOn

Alff*d F. Flm.r

Exu.utlv. Olroctor

Annrlean AUd.mYOt O-mitoloss

John M. Sliaw, M.D.

s8.r.t.w.T,Us.r.r

Am.rkan AUeamY O* Family

?hy$lelmls

Rawr Tu%k9n

ExCCUtlW Dlrcctor

Am.rlcm A8ademY of N..r.WsY

SmlaY A. N.l%on Ex.c.tl.. Olrut.r

A~y:;;,AudB my of OrthOmndlC

Charlsiv. Hwk. M.0.

Exm.ttb’c Olroctor

Am.rle.tI A..a9mY of P4.tcias

Rolnrt G. Fraz!ar, M.D.

Exocutlw Dir.ctor

Amdc.n Cell.so of Omtatrktam

,.* Cy”...si%tsts

grrr:tnor+. Purm, M.D.

Am.rlc8. Cd19W d FbY!4.h.1

Edward C. Roo.now. Jr., M.D.

Executw. vtic9Pwl*nt

AnlwYc,” COIIW9 .t P?OV9.IIW

Med1cln9

ward IMntl.y

Exocutlv. Dlr.ctor

Ammrlc,” CO11W8 Of SU~#*Onl

c. Ro!l!ns H..1O.. M.D.

EXUUUV9 00rutoI

Am.rlc.n Ost*on*thk AIm.1.flom

Edward P. Crow*lLO. 0.

E.u.tlv. Du.ctor

Am.rlca” PmCtOlOW S0C19tY AlblmdroF. Cutro,M.D.

sur*tarY

Am,,lc.” PsyChlatrlC A1lOCl&ttO.

M4vln sabmln, M.O.

M9dlc.1 Olr.ctor

mi.rk.. sect.ty d Int.rnal

A4mdlcln*

Wlllhm R. Ramw

Ex.cutlv. Dlroctor

Am.rk,n sOcl*tY of Plasm ●nd

R..o”,lwcl Iv. s.rs-ns. Inc.

Dallas F. WM1*Y

Ex9cutlv. Vlc. Pr.Sld.M

Dear Dr.

The NatiDnal Center for Health Statistics, aa part of its

continuing program to provide information on the health

status of the American people, is conducting a National

Ambulatory Medical Care Survey (NA.YCS).

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 assistance 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.

Many organizations and leaders in the medical profession

have expreaaed 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 diacusa the detaila of your

participation. We greatly appreciate your cooperation.

Sincerely yours,

Oorothy P. Rice

Oirector

Am.,lcan u,oIo.Ic A19=W1O.

Hal a. J.n”l.9&Jr., M.0.

Exuuth- 01r9ctor

A,,.a,l,tlo”.f AmOrlc.. M.dl-l

COII.,*S

John A, 0, COOP.1, M. D., UI.O.

Prnf$d.nt

51
PATl ENT RECORD AND PATl ENT LOG

C532204

PATIENT LOG

~~each oat,,”! am.,,, record name andt,me

of .,s, $ c,” the log below F., the @!ent en.

lewd . . I,ne *3. ako corwkle !he pawnt

record 10 !he r,ght

1---am

1

pm

1

3

Record Items 1

L----all

for thw pattent

Pm

t

CONTINUE LISTING PATIENTS

ON NEXT PAGE

ASS URANCEOF CO NFIDENTIALITY– AII “fwma!,on >,h#ct.,vo.tdvc rm\ldcnt,f,catnonO fa”, nd,v,dual

a pmct, c?, m an e,tablmhmwt wII be held Conf,den! aal, wJI b. used ..!, b. wrson$ ewwgcd m and fcr C532204 thepurpow of the.. r.evndwll not l,ed,.ck.cd oc .4wwJ,0.ww, rww..r .sed for any.lherp.wxe

1. DATE OF VISIT PATIENT RECORD

.=7$T7+

NATIONAL AMBULATORY MEDICAL CARE SURVEY

2. DATE OF BIRTH 4. COLOR OR 5. PATIENTS PRINCIPAL PROBLEM(S) 6. SERIOUSNESS PROBLEM ,, ,,EMOF ,, ] 7. ;G;:E::Z:E,

RACE COMPLAINT(S). LIR SYMPTOM(S) ~ VISIT

=7%7’+ —

(In paftenr’xown words] (Check OITe)

, D WHITE YES ‘. NO

: VERY SE RICUS

3. SEX

z O NEGRO/ a MOST t

8LACK IMPORTANT : SERIOUS // YES, 10! the problem

, D FEMALE I @ OTHER : SLIGHTLY SERIOUS ,

mdicaled m ITEM 5a ‘

6. MAJOR REASON(S) FOR THIS VISIT IChect a//maw rea.wml

u, ❑ ACUTE PROBLEM s L WELL AD(JLTICHILD EX4M

L: a ACUTE PROBLEM. FOLLOW-UP . Z FAMILY PLANNING

o. ❑ CHRONIC PROBLEM, ROUTINE :: COUNSELING, ADVICE

.. @ CHRONIC PROBLEM. FLARE-LIP ~ IMMUNIZATION

., ~ PRENATAL CARE G REFERRED BY OTHER PHYS, AGENCY

., ❑ POSTNATAL CARE , C ADMINISTRATIVE PURPOSE

,- ❑ POSTOPERATIVE CARE

1

. E OTHER (SWcdy)

fOmradve mocedure)

10. DIAGtiOSTIC/THERAPEUTIC SERVICES flFIOEREO/PROVIOEO THIS VISIT fChecka//thafapp/y)

01 n NONE

02 ❑ LIMITED HISTORY/EXAM

03 n GENERAL HISTORYIEXAM

04 ❑ CLINICAL LAB. TEST

05 0 BLOOO PRESSURE CHECK

D6 •l EKG

07 0 HEARING TEST

08 ❑ VISION TEST

09 0 ENWSCOPY

10 II OFFlcEsURGERY

II Cl DRUG PRESCRIBED

12 D X-RAY

13 ❑ INJECTION

M o iMMUNIZATION/DESENSITIZATION

15 Q PHYSIOTHERAPY

16 ❑ MEDICAL COUNSELING

17 n P8YCHOTHERAPYITHERAPEUTIC

LISTENING

18 ❑ OTHER (S+wcifyl

?A-34-4 DEPARTMENT OF HEALTH, EDUCATIO

:V. S.75 PUBLIC HEALTH SERVI

HEALTH RESOURCES ADMINIS

NATIONAL cENTER FoR HEALTH

9. PHYSICIAN’S PRINCIPAL OIAGNOSIS ~S VISIT

a DIAGNCSS ASSOCIATED WITH ITEM 5, ENTRY

—— ——

b OTHER SIGNIFICANT CURRENT OIAGNOSES

(In order of ,mportance)

II. OfSPOSITION ~VISIT

(Check 8// lhaf apply)

❑ NO FOLLOW-UP PLANNED

❑ RETURN AT SPECIFIEO TIME

0 RETURN IF NEEDED, P R N

❑ TELEPHONE FOLLOW-UP PLANNEO

❑ REFERREO TO OTHER

PHYSICIANIAGENCY

❑ RETURNED TO REFERRING

PHYSICIAN

D AOMIT TO HOSPITAL

I U OTHER (Specify)

LND WELFARE O.M.B

ATIoN

ATISTICS

12. DURATION OF

~ VISIT [Tree

actuallyspenf wifh

phyx;clzn)

MINUTES

fS8.S72106
INDUCTION INTERVIEW FORM

CONFIDENTIAL*

NORC-4233

TIME AM

BEGAN : PM

Form Approved.

OMB No. 68R1498 1

NATIONAL AMBULATORY MSDICAL CAKE SURVEY

INDUCTION INTERVIEW 11111

(Phys. ID Number)

I

BEFORE STARTING INTERVIEW

1. ENTER PHYSICIAN I.D. NUM8ER IN BOX TO RIGHT, AEOVE

2. ENTER DATES OF ASSIGNED R31PORTINGWEEK IN Q. 2, P.2

Doctor, before I begin, let me take a minute to give you a little background about

this survey.

Although ambulatory medical care accounta for nearly 90 per cent,of all medical care

received in the United States, there is no systematic Information about the characteristics and problems of people who consult physicians in their offices. ‘lhiskind

of information has been badly needed by medical educators end others concerned with

the medical manpower situation.

In response to increasing demands for this kind of information, the National Center

for Health Statistics, in close consultation with representatives of the medical

profession, has developed the National Ambulatory Medical Care Survey,

Your own task in the survey is simple, carefully designed, and should not take much

of your time. Essentially, it consists of your participation during a specified

7-day period. During this period, you simply check off a minimal amount of inforniation concerning some of the patients you see.

Now, before we get into the actual procedures, I have a few questions to ask about

your practice. The answers you give me will be used only for classification and *

analysis, and of course all information you provide is held in strict confidence. —

1. First, you are a

(ENTER SPECIALTY FROM CODE ON FACE SHEET LABEL,)”

Yes . . . . . . . . .

No. . . . (ASKA) , .

A. IF NO: What is your specialty (including general practice)?

Is that right?

. . 1

. . 2

(Name of Specialty)

*

All information which would permit identification of an individual, a

practice, or an establishment will 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.

a

53
2. XOW,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

—f Monday) through I Sunday)

month date month date

Are you likely to see ~ ambulatory patients in your office during that week?

Yes, . . . . .(GOTOQ. 3). . 1

No . . . . . . (ASKA) . ...2

A. IF NO: why is that? RECORD VERBATIM, THEN READ PARAGIQPH 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 ~E ~ PATIENT RECO~ FORMS AND GO TO Q. 9, P. 6.

54
3. A. At ~hat office location will you be sseing ambulatory patients during that

7-day period? RECORD UNDER A BELOW AND ASK B WHEN INDICATED.

B. IF HOSPITAL EllERGENCYROOM’OR HOSPITAL OUTPATIENT DEPARTMENT, OR OTHER

INSTITUTIONAL LOCATION IN A: Thinking about the ambulatory patients you see

in (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 LJNDERB BELOW.

c. Is that all of the office locations at which you expect to see ambulatory

patients~ring that week?

Yes. . . . . . . . . . 1

No . . . . . . . . . .2

IF NO: OBTAIN ADDITIONAL OFFICE LOCATION(S), ENTER IN “A” BELLW, AND REPEAT.

A. I B.

Principal

Office Location Responsibility?

Insti- Physician tution

(1) 1 2

(2) 1 2

(3) 1 2

(4) 1 2

J

D.

In Scope?

Yes 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)

Private offices

Free-standing clinics

(non-hospital based)

Groups, partnerships

Kaiser, HIP, Mayo Clinic

Neighborhood Health Centers

Privately operated clinics

(except family planning)

IN CASE OF DOUBT, ASK: Is that

I OUT OF SCOPE (No) [

Hospital emergency rooms

Hospital outpatient departments

College or university infirmaries

Industrial outpatient facilities

Family planning clinics

Government-operated clinics

(VD, maternal & child health, etc.)

(clinic/facility/institution) hospital based?

IS that (clinic/facility/institution) government

operated?

IF ALL LOCATIONS ARE OLIT OF SCOPE, THANK THE DOCTOR AND LEAVE.

PATIENT RECORDS MUST BE COLLECTED FROM ALL IN-SCOPE LOCATIONS

) REGARDLESS OF ANSWER TO B -- PRINCIPAL FWSPONSIi31i.iTY.

55
4, A. During that week (REPEAT DATES), how many ambulatory 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 AND CIRCLE ON APPROPRIATE LINE.

B. And during those seven days (REPEAT DATES IF NECESSARY), on how many ~S do

you expect to see any ambulatory patients? COUNT EACH DAY IN WHICH DOCT~R

EXPECTS TO SEE ANY PATIENTS AT AN IN-SCOPE OFFICE LOCATIOPT.

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

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 be

completed for every

THIPD patient listed

on Log.

>kD--patient Record is to be

completed for every

FIF~ patient listed

on Log,

A. B.

Expected total Total ~ in practice

patients during during week.

survey week, ENTER TOTAL

ENTER TOTAL FROM FROMQ. 4-B, DAYS

Q. 4-A.

1 2 3 4 5 6 7

1- 12 PATIENTS AAAAAAA

13- 25 “ B AAAAAA

26- 39 “ ICBAAAAA

40- 52 “ CBBAAAA

53- 65 “ ID C B B AA A

66- 79 “ DCBBBAA

80- 92 “ DDCBBBB

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+ “ DDDDDDD

*

In the rare instance the phyeician will see more than 500 patients during his

assfgned 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.

56
5. FIND PATIENT LOG FOLIO WITH APPROPRIATELETTERAND ENTER LETTERAl!llNUMBER

OF THIS FORM HERE.

(FolioNumber)

6. HAND DOCTOR HIS FOLIO AND EXPLALN HOW FORMS ARE TO BE FILLED OUT. SHOW DOCTOR

THE INSTRUCTIONSON POCKET OF FOLIO Am ITEM 10 DEFINITIONSON CARD IN FOLIO,

TO WHICH HE CAN REFER AFTER YOU LEAVE.

RECORD VERBATIM BELOW ANY 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). .

Location Patient Record Form Letter & Number

8. During the surveyweek (REPEATEXACT DATES),will anyone be available to 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 I LOCATION

B.

‘INTERVIEWER:

WAS PERSON

BRIEF

BY YOU?

Yes I No

1 2

1 2

1 2

1 2

;?

INTERVIEWERSHOULD BRIEF SUCH PERSON IF POSSIBLE,

57
g. 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 . . . ..(AC)A-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

[11 IF YES TO A: What per cent

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 Physician

(1)

(2)

(3)

(4)

(5)

10. Now I have just one more question about your practice. (NOTE: IF DOCTOR PRAC’rICES

IN LARGE GROUP, THE FOLLOWING INFORMATION CAN BE OBTAINED FROM SOMEONE ELSE.) ,

A. What is the total n,mnberof full-time (35 hou’rsor more per week) employees of your (partnership/

group) practice? Include persons regularly employed who are now on vacation, temporarily ill,

etc. Do ~ include other physicians. RECORD ON TOP LINE OF COLUNN A BEWW.

(1) How many of these full-time employees are a . . . (READ CATEGORIES BEWW AS NECESSARY AND

RECORD N[C;13CROF EACH lN COLUNN A.)

B. And what is the Lotal number O{ part-time (less than 35 hours per week) employees of y&r

(partnership/group)practice? Again, include persons regularly employed who are now on vacation,

ill, etc. Do not include other physicians. RKCORD ON TOP LINE OF COLUMN B BELOW.

(1) How many of these part-t,me employees are a . . . (READ CATEGORIES BELOW AS NECESSARY

AND RECORD NUNhER OF IAcH IN COLUNN B.)

1

A. B.

Employees Full-time Part-time

(35 or more hours fweeh) (Less than 35 hours lweek)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

ToTAL:

Registered Nurse . . . . . . . . . . . . . . .

Licensed Practical Nurse , . . . . . . . . . .

NursingAide. . . . . . . . . . . . . , . . ,

Physician Assistant* . . . . . . . . . . . , .

Technician. . . , . . . . . . . , . . , . . .

Secretary or Receptio”~st . . . , . , . . . .

other (SPECIFY)

TOTAL:

—

,’,

Physician AS SISLJTIL must he a gr.oduateof an accredited training program for Physician Assistants

(ptljSICi,~:]Xt118d LrS, ;hdc , etc.) or certified by the I!ailonal Board of Nedical Examiners through the

Ler Llll C:l!l On Lxam fur ilsslstant to the Prlrnary Care Pnysician,

..

58
11. During the past seven (7) days, shout hnw 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

500rmore . . ...5

BEFORE YOU LEAVE, STRESS THAT ~ AMBULATORY PATIENT SEEN BY THE DOCTOR DURING

THE 7-DAY PERIOD AT ALL IN-SCOPE OFFICE LOCATIONS (REPEAT THEM) IS TO BE INCLUDED IN THE SURVEY~HAT EACH PATIENT IS TO BE RECORDED ON THE LOG, AND ONLY

THE APPROPRIATE NUMEER 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. 1’11

call ~ on Monday morning of your survey week just to remind you.

13. TIME INTERVIEW ENDED . . . . . . . . AM

PM

14. DATE OF INTERVIEW . . . . . . . . . . . . . . .

I i I II II

(Month) (Day) (Year)

COMPLETE ITEMS I AND 11 ON THE LAST PAGE

IMMEDIATELY AFTER THE INTERVIEW.

59
i. How much interest do you think the

doctor has in the survey?

Great interest . . . 1

Some interest . . . . 2

Little interest . . , 3

No interest . . . . . 4

Can’t tell , . . , . 5

-8-

11. How confident are you that the

doctor will complete the forms?

Definitely will . . 1

Probably will . . . 2

Doubtful . . . . . 3

INTERVIEWER NUM6ER INTERVIEWER’S SIGNATURE

60 ●U.S. GOvEmJMsNT PKtNT2NG OFFICE : 1979 O-2 B1+259/5
VITAL AND HEALTH STATISTICS Series

Series 1. ProL~ams and Collection Procedures. –Reports which describe the general programs of the National

Center for Health Statistics and its offices and divisions and data collection methods used and include

definitions and other material necessa~ for undmstandinq the data.

Series 2. Data Ezsaluation and Mctlzods Research. –Studies of new statistical methodolo~ including e::perimentaf tests of new survey methods, ztudies of vital statistics collection methods, new analytical

techniques, objective evaluations of reliability of collected data, and contributions to statistical theory.

Series 3. Analytical Studies. –Reports presenting anaivticd or interpretive studies based on vital and health

statistics, carrying the analysis further than the expositor types of reports in the other series.

Series 4 Documents and Committee Reports.– Final reports of major committees conc~rned v;ith ~ital and

health statistic~ and documents such as recommended model vital registration Im.A.xand revised birth

and death certificates.

Series 10. Data From the Health Interz’ieul Suroey. –Statistics on illness, accidental injuries, disability, use of

hospital, medical, dental, and other services, and other health-related topics, all based on data collected

in a continuing national household interview survey.

Serifs 11. Datu From the Health Examination Survey and the Health and Nutriticm Examination Survey. –Data

from direct examination, testing, and measurement of national samples of ihc civilian noninztitutionalized population provide the basis for two types Of reports: (1) estimates Of the medically defined

prewdence of specific diseases in the L’nited States and the distributions of the population v:ith respect

to physicaf, physiological, and psychological characteristics and (2) analysis of relationships among the

various measurements without reference to an explicit finite uni~~erse of perscms.

.Wies 12. Data From the Institutionalized Population Surzwys, –Discontinued effective 1975. Future reports ftwm

these surveys will be in Series 13.

Series 13. Data on Health Resources L’tilization. –Statistics on the utilization of health manpower and facilities

providing long-term care, ambulatory care, hospital care, and family planning Gervices.

Series 14. Data on Health Resources: Manpo uw and Facilities. –Statistics on the numbers. geographic di~tribution, and characteristics of health resources including physicians, dentists, nurses, other health

occupations, hospitafs, nursing homes, and outpatient facilities.

Series 20. Data on Mortality. –Various statistics on mortality other than as included in regular annual or monthly

reports. Special analyses by cause of death, age, and other demo~~aphic variables; georyaphic and time

series analyses; and statistics on characteristics of deaths not ava~lable from the vital records based on

sample surveys of tho~e records.

Series 21. Data on Natality, Marriage, and Diz,orcc. –\ ’arious statistics on natdity, marriage, and divorce other

than as included in regular annual or monthly reports. Special analyses by demokwaphic variables:

geographic and time series analyses; studies of fertility: and statistics on characteristics of births not

available from the vital records based on sample surveys of those records.

Series 22. Data From the National Mortality and Nutality Surveys. –Discontinued effective 1975. Future report~

from these sample surveys based on vital records will be included in Series 20 and 21, respectively.

Series 23. Data From the National Survey oj” Family Gro zoth. –Statistics on fertility. family formation and dissolution) family phsnning, and related maternal and infant health topics drrived from a biennial sz.m.wy

of a nationwide probability sample of ever-man-id v.wnsen 15-44 ;:ears of ase.

For a list of titles of reports published in these series, t,:rite to: Scientific and Teehnical Information Branch

National Center for IHedth Statistics

Public Health Semicc

EI\a,ttsvilir. Md. 207S2