Use of

%

c tlmicrobial

in Offke=

Based Practke

unitedStates, 1-1

Data on the use of antimicrobial drugs

during Offb visitstodk—bSSd

physicians are presented. Emphask is

placed on the types of drug used:

peniallins, cephatosporins, macroliis and

Iincosamides, tetraoyctks, the

sulfonamides andkw trimethoptim, and

miscellaneous antimicrobial medications.

The level of use of the various types of drug

is assessed by comparing drug mention

frequencies and rates. The characteristics of

the drugs used afso are investigated.

Various aspects of the visits involving the

use of these drugs are examined. These

include the demogrephii characteristics of

the patients who made the visits, patient

complaints, dwnoees recoded, d~nostic

and therapeutic sentices ordered or

provided, patient disposMon, and visit

duration.

Dsts Ffomthe Nstiond H8elth Sunfey

series Iq No. 8s

DHHS Publiition No. (PHS) 86-1746

U.S. Department of Health and Human

services

PubIii Heanh service

National Center for Health Statistics

Hyattsville, Md.

June 19S6
I

Copyright Information

The National Center for Health Stabs.tics has obtained permission from the

copyright holders to reproduce ceriam quoted material in this report. Further

reproduction of this material is prohibited without specific permission of the

copyright holders. All other material contained in the reporl is in the public

domain and may be used and reprinted without special permission; citation as

to source, however, is appreciated.

Suggested Citatiin

National Center for Health Statistics, G. J. Gardocld: Use of antimicrobial drugs

in office-based practice, United States, 1980-61. Vita/ and Hea/th Statistics.

Series 13, No. 85. DHHS Pub. No. (PHS) 86-1746. Public Health Service

Washington. U.S. Government Printing Gffice, June 1988.

L~ry 01 Congress Cataloging-in~ Data

Gardocld, Gloria J.

Use of antimicrobial drugs in office-baaed practice.

(Vital & health statistics. Series 13, Data from the national health survey;

no. 85) (DHHS publication; (PHS) 66-1746)

Author: Gloria J. Gardocki.

Bibliography: p.

$upt. of D~s. no.: HE20.6209:13/85

1. Drug utlltzatior+Unitad Statee-Statistics. 2. Anti-infective agenteThera@utic usa-+tetktics. 3. Physician services utiliiatiin-Unitad StatesStatistics. 1.National Center for Health Statiafks (U.S.) Il. Ttle. Ill. Vial and

health statistics. series 13, Data from the national health suwey; no. 65.

IV. Series: DHHS puMkation; no. (PHS) 6$-1746. [DNLM: 1. Anti-lnfaotive

Agents+harapautic uflnitad Statea--atatistics. 2. Diug Utilization-United

States-statistics. 3. Gffii Visits-United Statea-+teMca. W2 A NI 46vm

no. 65]

RM261 .3.U6G37 1966 61 S.329 66-60Wt29

ISBN 0-6406+331-2

lTor sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402
National Center for Health Statistics

Manning Feinleib, M. D., Dr. P. H., Director

Robert A. Israel, Deputy Director

Jacob J. Feldman, Ph. D., Associute Director for Anulysis und

Epidemiology

Garrie J. Losee, Associute Director for Dutu Processing and

Services

Alvan O. Zarate, Ph. D., Assistant Director for international

Statistics

Peter L. Hurley, Acting Associute Director for Interview und

Examination Statistics

Stephen E. Nieberding, Associute Director for Management

Gail F. Fisher, Ph. D., Associate Direclor for Program Planning,

Evaluation, and Coordination

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

Methodology

Peter L. Hurley, Associate Director for Vital and Health Cure

Statistics

Alice Haywood, Information 0J7icer

Vital and Health Care Statistics Program

Peter L. Hurley, Associate Director

Gloria Kapantais, Assistant to the Director for DUIUPolicy,

Planning, and Analysis

Division of Health Care Statistics

W. Edward Bacon, Ph. D., Director

Joan F. Van Nostrand, Deputy Director

James E. Deiozier, Chief, Ambulatory Care Statistics Branch
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..l

Information highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........2

Data background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -. ...-..4

Scope of the report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Data source and limitations.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -...--..4

Selection and classification of antimicrobial drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - ...--..10

Dmgmention information . . . . . . . . . . . . . . . . . - . . . . . . . . . . - . . . . . - - . . . . . . . . . 10

Visit information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - . . . . ...15

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -....-.30

List of detailed tables . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...--.31

Appendmes ,

I. Technical notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...42

11. Definitions of certain terms used in this report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

111.Patient Log and Patient Record form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...52

IV. American Hospital Formulary Service classification system and therapeutic categov codes . . . . . . . . . . . 53

Iistoftextfigures

1. Classification of antimicrobial generic entities appearing in the National Ambulatory Medical Care Survey:

United States, 1980-81 ..-.-.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6

2. Drugs named by physician respondents in reporting the order or provision of ’wnicillins: United States,

1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................. ....” 7

3. Drugs named by physician respondents in reporting the order or provision of cephalosporins: United States,

1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......”.....”..... .. 7

4. Drugs named by physician respondents in reporting the order or provision of macrolides and Iincosamides:

United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . .....-.......”...-. .. 7

5. Drugs named by physician respondents in reporting the order or provision of tetracycline: United States,

1980-81 . . . . . . . . . . ..-. . . . . . . . . . . . . . . . . . . . ................... .’ 8

6. Dregs named by physician respondents in reporting the order or provision of sulfonamides and trimethoprim:

United States, 198(k81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -. 8

7. Drugs named by physician respondents in reporting the order or provision of miscellaneous antimicrobial:

United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .- 9

List of text tsbles

A. Number and percent distribution of antimicrobial drug mentions, by type of antimicrobial drug: United

States, 198&81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................... .- 10

B. Number and percent distribution of the 20 generic ingredients most frequently appearing in antimicrobial drug

mentions: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

C. Number and percent distribution of the 30 antimicrobial drugs most frequently mentioned in office-based

practice: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....12

..

w
D. Number and percent distribution of antimicrobial drug mentions, by American Hospital Formulary Service

therapeutic category : United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

E. Number and percent distribution of antimicrobial drug mentions by composition status, according to type of

antimicrobial drug: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F. Number and percent distribution of antimicrobial drug mentions by entry status, according to type of a,ntimicrobial drug: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

G. Number, percent distribution, and average annual rate (per 1,000 civilian noninstitutionalized population) of

antimicrobial drug mentions by sex and age of patient, according to type of antimicrobial drug: United

States, 198&81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

H. Number and percent distribution of antimicrobial drug visits, by type of antimicrobial drug ordered or

provided: United States, 1980--8l. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

J. Number and percent distribution of antimicrobial drug visits by major reason for visit, according to type of

antimicrobial drug ordered or provided: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . .

K. Number and percent distribution of the 20 specific principal reasons for visit most commonly given during

antimicrobial drug visits: United States, 198&81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

L. Number and percent distribution of antimicrobial drug visits, by class of principal diagnosis: United

States, 198W81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

M. Number and percent distribution of the 20 specific principal diagnoses most commonly made during antimicrobial drug visits: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

N. For visits associated with each type of antimicrobial drug, number and percent distribution of the most

common specific principal diagnoses: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . .

0. Number of all visits, number of antimicrobial drug visits, antimicrobial drug visits as a percent of all visits, and

the most frequently mentioned types of antimicrobial drug, for each of the 20 principal diagnoses most

commonly made during antimicrobial drug visits: United States, 1980-81 . . . . . . . . . . . . . . . . . . . .

P. Number of all new-problem and return visits and percent of new-problem and return visits involving antimicrobial,

for each of the 20 principal diagnoses most commonly made during antimicrobial drug visits: United

States, 198@81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Q. Number, percent distribution, and average annual rate (per 1,000 civilian noninstitutionalized population) of antimicrobial

drug visits by sex and age of patient, according to type of antimicrobial drug ordered or provicled:

United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

R. Median age of patients making antimicrobial drug visits, by type and selected subtype of antimicrobial drug

ordered orprovided: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

S. Number and percent distribution of antimicrobial drug visits by physician specialty, according to type of

antimicrobial drug ordered or provided: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . .

T. Number and percent of antimicrobial drug visits, by type of antimicrobial drug ordered or provided and

diagnostic service ordered or provided: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . .

U. Number and percent of antimicrobial dmg visits, by type of antimicrobial drug ordered or provided and

nonmedication therapeutic service ordered or provided: United States, 1980-81 . . . . . . . . . . . . . . . . .

W. Average number of co-occurring medications per antimicrobial drug visit, by type of antimicrobial drug

ordered or provided and sex and age of patient United States, 1980-81 . . . . . . . . . . . . . . . . . . . .

Y. Number and percent distribution of co-occurring drugs ordered or provided during antimicrobial dmg visits

by therapeutic category of co-occurring dreg, according to type of antimicrobial drug ordered or provicled

United States, 198&81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z. Number and percent distribution of the 10 co-occurring drugs most frequently ordered or provided dluing

antimicrobial drug visits, by drug name: United States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . .

12

13

13

14

15

16

16

17

17

18

20

21

22

23

24

25

26

27

28

28
Symbols

--- Data not available

. . . Category not applicable

Quantity zero

0.0 Quantity more than zero but less than

0.05

z Quantity more than zero but less than

500 where numbers are roundedto

thousands

* Figure does not meet standard of

reliabilityor precision

# Figure suppressedto complywith

confidentialityrequirements
Use of Antimicrobial Drugs

in W~ce-Based Practice:

United States, 1980-81

by Gloria J. Gardocki, Ph.D.,

Division of Health Care Statistics

In this report, physicians’ patterns of ordering or providing impact on public health by allowing a previously unknown

antimicrobial medications to ambulatory patients in the offlce- level of control over infective diseases. When used prophylactibased setting are examined. The importance of these drugs tally under certain condhions, antimicrobial drugs also help

and their use cannot be overemphasized. The development prevent the development of infections complicating primary

of antimicrobial drugs in the last 40 years has had a strong disease processes.

.
Information highlights

●

●

●

●

●

During 1980 and 1981, office-based physicians prescribed

or administered at least one antimicrobial drug in 188.8

million office visits, or approximately 1 ofevery6 visits.

An average of l.10 antimicrobial drugs was used during

each of these visits.

The most frequently used types of antimicrobial drug

were the penicillins (with an average of 41.4 million

drug mentions per year), macrolides and lincosamides

(20.1 million mentions per year), and the tetracycline

(16.9 million mentions per year).

Approximately half of all active generic ingredients included in the antimicrobial drug mentions were accounted

for by only four antimicrobial generic ingredients—

penicillin, erythromycin, amoxicillin, and tetracycline.

Most antimicrobial drug mentions were single ingredient

drugs and were available to the patients only with a physician’s prescription.

Physicians reported that they used brand names in ordering

antimicrobial drugs much more frequently than they used

generic names (61 percent compared with 38 percent).

The rate of antimicrobial drug mentions was significantly

higher for females than for males (50 1.8 mentions per

1,000 female population per year compared with 431.1

per 1,000 male population per year). Similarly, the rate

for children under 15years of age (698.4 per 1,000 population per year) was higher than the rate for any other

age group.

In three-fourths (71.8 percent) of the visits involving antimicrobial drugs, the patients were suffering from acute

problems. Visits involving the penicillins had the largest

proportion of patients with acute problems (84.7 percent).

The reasons for visit given by the patients who made

antimicrobial drug visits were usually symptoms (84.7

percent of visits). A set of only eight specific patient

complaints accounted for half of all antimicrobial drug

visits. These were symptoms referable to the throat,

cough, fever, head cold (upper respiratory infection),

earache or ear infection, acne or pimples, skin rash, and

nasal congestion.

When physicians used antimicrobial drugs, the most common type of principal diagnosis reported was diseases

of the respiratory system (42.4 percent of visits). Half

of the antimicrobial drug visits were accounted for by

only eight specific diagnoses: suppurative and unspecified

otitis media; acute upper respiratory infections of multiple

and unspecified sites; acute pharyngitis; diseases of the

●

●

●

●

●

●

●

●

sebaceous glands; bronchitis, not specified as acute or

chronic; acute tonsillitis; chronic sinusitis; and disorders

of the urethra and urinary tract not elsewhere classified.

Antimicrobial drugs were used in a larger proportion of

all new-problem visits (23.4 percent) than of all return

visits (12. 1percent).

Females accounted for the majority of ail antimicrobial

drug visits (55.7 percent) and a majority of the visits

associated with each major type of antimicrobial drug

except the cephalosporins. Similarly, children 0-14 years

of age made one-third (34.9 percent) of all antimicrobial

drug visits.

General and family practitioners and pediatricians were

the prescribing physicians in almost two-thirds (65.6 percent) of all antimicrobial drug visits.

Antimicrobial drug visits were more concentrated in the

South than other visits were (38. 8 percent compared with

31.4 percent) and less concentrated in the Northeast and

West (20. 1percent compared with 24.3 percent, and 15.2

percent compared with 19.0 percent, respectively).

In most of the visits involving antimicrobial drugs (95.9

percent), at least one diagnostic service was ordered or

provided. The most commonly used diagnostic services

were a limited examination and/or history (72.8 percent

of all antimicrobial drug visits), clinical laboratory testing

(24.7 percent), and blood pressure checks (23.9 percent).

A minority of the visits in which antimicrobial drugs

were used (34. 8 percent) also entailed the order or provision of at least one nonmedication therapeutic service.

The two most frequently provided services were medical

counseling (22.0 percent of all antimicrobial drug visits)

and oftlce surgery (6.4 percent).

In half of the visits in which antimicrobial drugs were

used, the patients were asked to return at a specified

time, and in one-third of the visits the patients were

asked to return if needed.

Two-thirds of all antimicrobial drug visits involved 6-15

minutes of physician-patient contact.

During the 1980 and 1981 antimicrobial drug visits, 172.5

million mentions of other drugs were made; this was

an average of 0.91 co-occurring drugs per visit. The

average number of co-occurring drugs per visit increased

with patient age, from 0.71 for children O-14 years of

age to 1.34 for persons 65 years of age and older.

The four types of drug most frequently used in combination

with the antimicrobial medications were antihistamines

2
(17.7 percent of all co-occurring drugs); skin and mucous

membrane preparations (16.6 percent), expectorants and

cough preparations (14.2 percent), and central nervous

system drugs (12.7 percent).

. During 1980 and 1981, two or more antimicrobial drug

mentions were reported for the same visit in 19.0 million

visits, or 10.1 percent of all antimicrobial drug visits.

The six specific combinations that appeared at least 1

million times each over the 2-year period were two or

more penicillins used together, macrolides and lincosamides used with tetracycline, penicillins used with

macrolides and Iincosamides, penicillins used with tetracycline, two or more macrolides and lincosamides used

together, and penicillins used with miscellaneous antimicrobial drugs.

. The antimicrobial drugs examined in this report were

ordered or provided in combination with topical antimicrobial drugs in 1I.7 million visits. This represents 6.2 percent of all 1980 and 1981 antimicrobial drug visits included

in this report and 25.5 percent of all 1980 and 1981

visits in which topical antimicrobial drugs were used.

3
Data background

Scope of the report

The information reported here was obtained through the

National Ambulatory Medical Care Survey (NAMCS), a sample survey of the medical care provided in the office setting

by physicians primarily engaged in office-based practice. Conducted annually by the National Center for Health Statistics

(NCHS) from 1973 through 1981, the survey was converted

to a triennial cycle beginning in 1985. Omitted from the

analyses presented here are all antimicrobial medications

known to be used only topically, as a separate report on

the use of those drugs has been published. 1All antineoplastic

antibiotics also are omitted.=

It is important to note that, because of the nature of

the data collected by means of NAMCS, this investigation

is limited to an inspection of the patterns in physicians’ ordering

or providing antimicrobial drugs to patients. It is not possible

to describe the drug dosages ordered for patients or the extent

to which patients actually filled prescription orders and complied with instructions for use. It also is not possible to assess

the appropriateness of antimicrobial drug use. The usual drug

of choice in the treatment of a given infective disease may

not be the drug of choice for a particular patient. For example,

the patient may be allergic to the preferred drug, may have

experienced negative side effects from it in the past, or may

have complicating conditions rendering its use inadvisable.

Consequently, a valid judgment regarding the appropriateness

of medication therapy can be made only after detailed inspection of all the relevant aspects of an individual case. NAMCS

was not designed for this purpose. Numerous guidelines on

the medical indications for the use of antimicrobial drugs

with outpatients have been published in the medical literature,

and the reader is urged to consult them if needed.24

Data source and limitations

Detailed information on the background and methodology

of NAMCS has been published.7 In brief, the basic sampling

unit for the survey is the physician-patient encounter or visit.

The scope of NAMCS includes all office visits within the

conterminous United States made by ambulatory patients to

nonfederally employed, office-based physicians as classified

aThese drugs accounted for only a small number of the drugs ordered or

provided in office-based practice over the 1980-81 period. (Bleomycin, dactinomycin, doxorubicin, mithramycin, and mitomycin were ordered or provided a total of 700,000 times. )

by the American Medical Association or the American Osteopathic Association. The NAMCS physician universe excludes anesthesiologists, pathologists, and radiologists, as well

as all physicians principally engaged in other professional

activities, such as teaching, research, or administration. Telephone contacts and visits conducted outside the physician’s

office also areexcluded.

The data collected on sample patient visits include patient

demographic and medical characteristics (for example, age

and significant diagnoses) and information on the conduct

of the visits (for example, diagnostic tests ordered o]rprovided

and duration of physician-patient contact). The latter information includes prescription and nonprescription therapeutic

medications ordered or provided during each visit (that is,

drug mentions). The medications with antimicrobiid activity

and the visits associated with them (that is, antimicrobial

drug visits) are the subject of this analysis.

Because the unit of measurement used in NAMCS is

the patient visit, and because the average member of the

civilian noninstitutionalized population makes multiple patient

visits each year, NAMCS data reflect considerable duplication

of persons. For this reason, use of the term “patient” in

discussing the characteristics and treatment of the persons

who made the visits examined in this report is avoided wherever

practicable. When needed for clarity, the term “patient” is

used. It refers to the person who made a particular visit,

rather than to a person who may receive continuing care

by making a number of visits.

The 1980 and 1981 surveys were conducted in identical

fashion using the same instruments, definitions, and procedures. The 2 years of data were combined to provide more

reliable estimates. Therefore, the reader should note that estimates of numbers of visits and drug mentions-contained in

this report are totals for the 2-year period, but ratios and

rates represent average annual estimates.

Data from individual sample visits were inflated to produce

national estimates. Because of the complexity of the survey

design and estimation procedures, appendixes I–IV should

be reviewed to ensure accurate understanding and interpretation

of the statistical estimates presented. Appendix I presents

a description of the 1980 and 1981 surveys, including the

survey design, data collection and processing procedures, and

estimation procedures. Guidelines for judging the precision

of estimates also are included in this appendix. Appendix 11 contains definitions of terms used in the survey. A

facsimile of the Patient Record forrr-the survey instrument

A
used to report visit information-appears in appendix 111.

Appendix IV presents the American Hospital Formulary Service classification system and therapeutic category codes.~

Selection and cktssification of antimicrobial

drugs

In selecting the specific drugs to be included in this analysis, AMA Drug Evaluations, Ftfth Edition9 was uti[ized first

to establish a comprehensive list of drug ingredients (accordng

to generic or nonproprietary name) considered to have antimicrobial activity. All drug mentions (that is, all drugs listed

by physicians as ordered or provided to patients) in the 1980

and 1981 NAMCS were then screened for these ingredients.

The resulting list of antimicrobial drugs was divided into

two sets: those known to be used only topically and all others.

The topical drugs, and the patient visits associated with them,

were discussed in an earlier report.’ Information on the use

of the remaining antimicrobial drugs, which are referred to

in this report simply as “antimicrobhd drugs” or “antimicrobial

medications,” is presented here.

It cannot be assumed that all of these medications were

ingested, injected, or otherwise administered systemically.

In some sample cases, physicians reported the order or provision of an antimicrobial medication using a generic drug name,

an incomplete trade name, or a trade name not known to

be complete. In those cases, the exact drug products used

are not known. When the active antimicrobial agents in question could be used either systemically or topically, the actual

usage of the agents also is unknown. Consequently, the antimicrobial medications encompassed by this analysis include

both drug products known to be used only by ingestion or

another route of systemic administration and drugs frequently

used systemicallyy, but with unknown routes of administration

in these visits.

Seventy-two specific antimicrobial generic entities appeared in the antimicrobial drug mentions recorded in the

1980 and 1981 NAMCS. They have been grouped into six

types based on the classification scheme used in AMA Drug

Evaluations, Fijlh Edition9 and on their frequencies of mention

in the 1980 and 1981 surveys. These major types are the

focus of the analyses presented in this report. in addition,

some aspects of the utilization of selected subtypes contained

within the six major ty~s are presented. Further information

on the use of the antimictdhl drug types and subtypes is

contained in detailed tables 1–11 following the text and references. The types of generic substance areas follows:

1.

2.

3.

4.

5.

6.

Penicillins (including the subtypes penicillin, amoxicillin,

and ampicillin}.

Cephalosporins (including the subtypes jirst generation

cephalosporins and second generation cephalosporins).

Macrolides and Iincosamides (including erythromycin and

other macrolides and lincosamides).

Tetracycline (including short-acting tetracycline and intermediate- and long-acting tetracycline).

Sulfonamides and trimethoprim (including sulfonamides

and trimethoprim in combination and other sulfonamides

andtrimethoprim).

Miscellaneous antimicrobial (including the subtypes urinary tract antiseptics and antifungal agents for nonsystemic mycoses).

The classification of specific antimicrobial generic entities

into these types and subtypes is illustrated in figure 1. Similarly, figures 2–7 show the classification in these groups of

the specific drugs named in the 1980 and 1981 NAMCS.b

% use of trade names in this report is for identification only and does

not imply endorsementby the PabIic Health service or the U.S Depsrtmcnt

of HealthandHumanservices.
PenkiHins

PeniciBin

penicillin

Macrolides and

Lincosamides

Erythromycin

Other

sulfacytine

sulfadiazine

sulfameter

Amoxicinfn

erythromycin sulfamethizole

sulfamethoxazole

amoxiciliin Other sulfapyridine

AmpiciHin

ampicillin

Other

bacampacillin

carbenicillin

cloxacillin

d~cloxacillin

methicillin

nafcillin

oxacillin

ficarcillin

First generatkrf

cefadroxil

cefazolin

cwhalexin

caphalothin

cephapirin

cephradine

Second generatkn

cefaclor

cefamandole

Other

caphalosporinb

clindamycin

Iincomycin

froleandomycin

Tetrecyciines

Short-acting

oxytetracycline

tetracycline

tetracycline

hydrochloride

and tong-acting

demeclocycline

doxycycline

methacycline

minocycline

Sulfonamides and

Tritnethoprim

Sulfonamides and

trimethoprim, in

combination

sulfadiazine

sulfamerazine

sulfamethazine

sulfamethoxazole

sulfisoxazole

sulfasalazine

suifisoxazole

trimethoprim

Miscellaneous

Antimiirobials

Urinary tract

~-septks

methenamine

nalidixic acid

nitrofurantoin

urinary antiseptic

Antifungal agents for

nonsystemk mycoses

griseofulvin

nystatin

Other

antibiotic agen~

anti-infective agenF’

aminosalicylic acid

amphotericin B

chloramphenicol

colistin

dapsone

ethambutol

gentamicin

isoniazid

kanamycin

metronidazole

polymyxin

polymyxin B

potassium iodide

pyrazinamide

rifampin

streptomydn

sulfoxone

tobramycin

aAlthoughavailableat the time of data collection,this substancenow has been removedfromthe market.

%4ameused by physicianfor data ent~ specificgenericname unknown.

Figure 1. CbdfkWh of an”bmcrolM “ generio entitiesappearing in the Nefienat Ambulatmy MadiorSCare Survey: Un-hd StatiwS19S0-S1
PeniciHins

Pen-killin

Sicillin

Sicillin C-R

Sicillin Long-Acting

Crysticillin

Duracillin

K-Cillin500

Ledercillin VK

Pen-Vee K

Penapar VK

penicillin

penicillin G

penicillin procaine

penicillin

penicillin VK

Pentids

Pfizerpen

Repen-VK

Robicillin VK

SK-Penicillin VK

Uticillin VK

V-Cillin

V-Cillin K

Veetids

Wyciliin

Wyciliin Injection and

Probenecid Tablets

Amoxiciflin

amoxicillin

amoxicillin trihydrate

Amoxil

Larotid

Polymox

Robamox

Sumox

Trimox

Wymox

AmpiciUin

Amcili

ampicillin

Omnipen

Penbritin

Pensyn

Polyciliin ‘

Principen

Principen w/ Probenecid

Supen

Other

carbeniciliin

cloxacillin

cyclacillin

Cyclapen

dicloxacillin

Dynapen

Geocillin

Geopen

oxaciliin

Prostaphlin

Spectrobid

Staphcillin

Tegopen

Ticar

Unipen

Cephalosponns

Firstgeneration

Ancef

Anspor

cefadroxil

Cefadyl

cefazolin

cephalexin

cephaloridine

Cephradine

Duricef

Keflex

Keflin

Kefzol

Loridine

Ultracef

Velosef

Second generation

Ceclor

Mandol

Other

cephalosporin

F@Jre3. Drugs rramedbyphysi&n m~detirn*ngtieo*r

or provision of ce@dos@ns: United Steteq 1SS0-S1

Macrdiies and

Lincossmides

Erythromyan

E.E.S.

E-bmtic

E-Mycin

Erypar

Erythrocin

erythromycin

Ethril

Ilosone

Hotycin

Pediamycin

Pediazolea

SK-Erythromycin

Wyamycin

Other

Ck30cin

Cleocin Phosphate

clindamycin

Lincocin

Iincomycin

TAO

, ‘Product includes sulfisoxszole.

I !

Fi9ure4. Dru9snsmed byphysicisn resmdentsh rewtingtheorder

or~ ofmecNMeS end hCOsmlii Unite!dswat+ 19s0-s1

Fiiure 2. Drugs rrmed by physicianreqmndentsin reportingthe order

of provisionof pen.Mlins: Uniied Ststeq 1ss0-s1

7
Tetracycline

Short-acting

Achromycin

Achromycin V

Achrostatin W

Azotrexb

Cyclopar

Mysteclin-Fc

Nor-Tet

oxytetracycline

Panmycin

Robtiet

Sumycin

Terramycin

Tetra

tetracycline

tetracycline

hydrochloride

Tetracyn

Tetrex

Urobiotic-250d

Intermediate-act&m

length and brig-acting

Declomycin

doxycycline

Minocin

minocycline

Rondomycin

Vectrin

Vibra

Vibramycin

“Productincludesnystatin.

bProducfincludessulfathiazole.

“ProductincludesamphotericinB.

‘Product includessulfamethizole.

Figure 5. Orugs nsrned by physician respondents in repdng the order

or provisim of tatracycfin* United Stste* 1960-61

Sulfonam.kles and

Tnmethopnm

Suffonamidessnd

tnmethroprim, in

combination

Bactrim

Bactrim-DS

Septra

Septra-DS

Sulfonamides Duplex

Terfonyl

trimethoprim W/

sulfisoxazole

triple sulfa

trisulfapyrimidines

Other

AzoGantanol

Azo Gantrisin

Azo-Sulfisoxazole

Azulfidine

Gantanol

Gantrisin

Profoprim

Renoquid

sulfapyridine

sulfasalazine

sulfasoxazole

sulfisoxazole

Sulla

Thiosulfil

Thiosulfil-A

Thiosulfil Forte

Thiosulfil-A Forte

Trimpex

trimethoprim

Uremide

Urifon

1

Figure 6. Orugs nmad by physician respondents in reporting the order

or~ofs~ s and trimathoprirm Unitad Stata* 196041

8
Miscellaneous

Antimicrobisls

Unnarytractantiseptios

Azo Methalate

Azo-Mandelamine

Cystex

Furadantin

Hiprex

Lanased

Macrodantin

Mandelamine

methenamine

NegGram

Nitrex

nitrofurantoin

Renalgin

Thiacide

Trantoin

Urex

urinary antiseptic

urised

Uritral

Uro-Quid Acid

Antifungal agents for

nonaystemic mycoses

Fulvicin

Grifulvin

Gris-PEG

Grisactin

griseofulvin

Mycostatin

Nilstat

nystatin

Other

Aerosporin

Amphicol

antibmtic agent

anti-infective agent

chloramphenicol

Chloromycatin

Coly-Mycin

CoIy-Mycin S

CoIy-Mycin S Pediatric

Dapsone

Di-lsopacin

Diasone Sodium Enterab

ethambutol

Flagyl

Fungizone Intravenous

Garamycin

gentamicin

INH

isoniazid

kanamycin

Kantrex

metronidezole

Myambutol

Nebcin

polymyxin

potassium iodide

pyrazinamide

rifampin

streptomycin

tobramycin

Triniad

Trobicin

----’

,--

..

,.

9

---—=
NAMCS data confirm that antimicrobial drugs were used

extensively in office-based practice during 1980 and 1981.

Overthis 2-year period, there were 1.2 billion visits to officebased physicians, of which 0.7 billion (61.8 percent) were

drug visits (that is, visits during which at least one therapeutic

medication wasordered or provided). Thedrug visits involved

l.3billion drug mentions. Atotalof 208.3 million antimicrobial drug mentions were made during 188.8 million visits,

an average of 1.10 antimicrobial drugs per antimicrobial drug

visit. Antimicrobial drug mentions constituted 15.7 percent

of all drug mentions. Visits involving antimicrobial drugs

constituted 16.3 percent of all visits and 26.3 percent of

all drug visits. Thus approximately 1 of every 6 visits to

an office-based physician during these years involved the use

of an antimicrobial drug.

Drug mention information

Types of antimicrobial drug

A breakdown of all antimicrobial drug mentions into the

major types and subtypes outlined above can be seen in

table A. The penicillins were the most commonly used major

type, with 82.9 million drug mentions during 1980 and 1981,

or 39.8 percent of the total. “The penicillins are bactericidal

antibiotics which include both natural and semisynthetic derivatives . . . . In addition to the prototype compound, penicillin

G, this class includes an acid stable penicillin G derivative

(penicillin V), penicillinase-resistant penicillins, the ampicillin, and the extended spectrum derivatives (carbenicillin,

ticarcillin, mezlocillin, and piperacillin) . . . . Amoxicillin and

cyclacillin are closely related to ampicillin.’”o Of all the

penicillin subtypes, penicillin itself was the most frequently

mentioned, with 34.0 million drug mentions, or 41.0 percent

of all penicillins. This was fdowed by amoxicillin, with

23.5 million drug mentions (28.3 percent of all penicillins),

and ampicillin, with 21.8 million drug mentions (26.3 percent

of all penicillins). All other penicillins accounted for a significantly smaller number of drug mentions—3. 6 million, or

4.3 percent of all penicillins.

The second largest group of antimicrobial drugs consisted

of the macrolides and lincosamides, with 40.1 million drug

mentions in 1980 and 1981. This was 19.3 percent of all

antimicrobial drug mentions. “Erythromycin, troleandomycin,

rosaramicin, and josamycin comprise the macrolide group

of antibiotics . . .. Erythromycin and its derivatives are antibacterial agents of major clinical importance . . . . Lincomycin and

Table A. Number and percent d~tnbution of antimicrobialdrug

mention% by type of antimicrobial drug United States, 1980-31

Number of

mentions Percent

Type of antimicrobial drug in thousands distribution

All antimicrobial drug mentions . . . . . 208,288 100.0

Penicillins . . . . . . . . . . . . . . . . . . . 82,896 39.8

Penicillin . . . . . . . . . . . . . . . . . . 34,025 16.3

Amoxicillin . . . . . . . . . . . . . . . . . 23,470 11.3

Ampicillin . . . . . . . . . . . . . . . . . . 21,819 10.5

Other . . . . . . . . . . . . . . . . . . . . 3,583 1.7

Cephalosporins . . . . . . . . . . . . . . . 16,044 7.7

First generation . . . . . . . . . . . . . . . 12,024 5.8

Second generation . . . . . . . . . . . . . 3,984 1.9

Unknown generation . . . . . . . . . . . “37 “0.0

Macrolides and Iincosamides . . . . . . . . . 40,106 19.3

Eryfhromycin . . . . . . . . . . . . . . . . 32,746 15.7

Ofher . . . . . . . . . . . . . . . . . . . . 7,361 3.5

Tetracycline . . . . . . . . . . . . . . . . . 33,767 16.2

Short-aefing . . . . . . . . . . . . . . . . . 25)690 12.3

Intermediate- or Iongacting . . . . . . . . 8,096 3.9

Sulfonamides and trimethoprim . . . . . . . 18,607 8.9

Sulfonamide(s) with trimethoprim . . . . . 12,786 6.1

Other . . . . . . . . . . . . . . . . . . . . 5,820 2.6

Miscellaneous antimicrobial drugs . . . . . . 16,848 6.1

Urinary tract antiseptics . . . . . . , . 4,858 2.3

Antifungal agenta for

nonsystemic mycoses. . . . . . . . . . 3,674 1.8

Other . . . . . . . . . . . . . . . . . . . . 6,316 4.0

clindamycin comprise the Iincosamide group of antibiotics.

They are considered with the macrolides because their antibacterial spectra, mechanisms of action and resistance, and

clinical applications are similar (Steigbigel, 1979).’’’9’11Erythromycin accounted for a large majority—32.7 million, or

81.6 percent+f all macrolide and Iincosamide antibiotic drug

mentions. All other macrolides and Iincosamides accounted

for only 7.4 million drug mentions, or 18.4 percent of this

major type.

The third most commonly ordered or provided type of

antimicrobial drug was the tetracycline. During 1980 and

1981 there were 33.8 million mentions of tetracycline, accounting for 16.2 percent of all antimicrobial drug mlentions.

“The tetracycline are broad spectrum antibacterial agents extracted from species of Streptomyces or produced by chemical

modification of the naturally occurring compounds. All members of this class are closely related chemically . .. .The tetracycline differ considerably in their pharmacology, and these

antibiotics are usually subdivided into short-..., intermediate..., and long-acting.. .analogues .“9 In the NAM(X3 data,

10
the short-acting tetracycline constituted a large majority—

25.7 million, or 76.0 percent+f all tetracycline mentions.

There were only 8. I million mentions of intermediate- or

long-acting tetracycline (24.0 percent of all tetracycline drug

mentions).

The remaining three major types of antimicrobial drugs

were each mentioned less frequently than tetracycline, but

there were no significant differences among the three. During

1980 and 1981 there were 18.6 million mentions of sulfonamides and trimethoprim (8.9 percent of all antimicrobial

drug mentions), 16.0 million mentions of cephalosporins (7.7

percent), and 16.8 million mentions of miscellaneous antimicrobial drugs (8. 1 percent). Sulfonamides are broad spctrum

antibacterial agents, and trimethoprim is a chemically and

pharmacologically distinct antibacterial agent. “[T]he combination of trimethoprim with a sulfonamide.. results in a synergistic antibacterial effect.”9 Because of the desirability of this

interaction effect, sulfonamides and trimethoprim are used

in combination frequently. In oftlce-based practice during 1980

and 1981, fully two-thirds (68.7 percent), or 12.8 million,

of the dmg mentions in this group were compounds of

trimethoprim and one or more sulfonamides. Only 5.8 million

(31.3 percent of all sulfonamide and trimethoprim mentions)

contained only trimethoprim or one or more sulfonamides.

“The cephalosporins are structurally and pharmacologically related to the penicillins .... Cephalosporins may be bactericidal or bacteriostatic .... The cephalosporins possess a

broad spectrum of activity.”lo Furthermore, “it is convenient

to consider the cephrdosporins and other agents related to

them as first, second, or third generation compounds. The

first generation cephalosporins were the initial agents developed and they have a narrower spectrum of antibacterial

activity than the compounds discovered later.... Second generation cephrdosporins generally are more active against gramnegative entenc bacteria than first generation analogies ....

The third generation cephalosporins have a still broader in

vitro antibacterial spectrum against gram-negative organisms,

includlng bacteria resistant to the other cephalosporins.”g In

1980 and 1981 no office-based usage of third generation

cephalosporins was reported to NAMCS. Of the cephalosporins

that were used, the majority (74.9 percent, or 12.0 million

dmg mentions) were first generation drugs. Only 4.0 million

mentions (24.8 ~rcent of all cephalosporin mentions) were

made of second generation drugs.

The final group, miscellaneous antimicrobial drugs, includes urinary tract antiseptics, which are “[a]nti-infective

agents that are excreted primarily in the urine”g and antifungal

agents for nonsystemic mycoses, which are ingestible antifimgal compounds that can be used for dermatophytic infections

and fungal intestinal infections. During 1980 and 1981 there

were 4.9 million mentions of urinary tract antiseptics (28.8

percent of all miscellaneous antimicrobial drugs) and 3.7 million mentions of antifungal agents for nonsystemic mycoses

(21.8 percent). The remaining drugs in this residual group

(that is, aminoglycosides and spectinomycin, polymyxins,

antifungal agents for systemic mycoses, antimycobacterial

agents, amphenicols, miscellaneous antibacterial agents, and

unidentified antibiotic or anti-infective agents) together accounted for only 8.3 million drug mentions.

Drug ctwaeteristiee

The 20 most common generic ingredients contained in

the antimicrobial drug mentions are shown in table B. All

of these leadkg substances have antimicrobial activity; none

has other primary therapeutic effects. These 20 ingredients

accounted for the vast majority (93. 1 percent) of all active

generic substances appearing in the antimicrobial drug mentions. The relative absence of ingredients with other therapeutic

effects indicates that use of drugs combining antimicrobial

with other active ingrdents is unusual. The predominance

of the leading 20 antimicrobial ingredients also indicates that

the use of antimicrobial medications is strongly concentrated

in a narrow range of active antimicrobial substances. In fact,

just the leading four substances (penicillin, erythromycin,

amoxicillin, and tetracycline) accounted for approximately half

(51.3 percent) of all generic ingrdents.

The 30 specific antimicrobial drugs that were used most

frequently are listed in table C according to the names under

which they were ordered or provided. These drugs accounted

for a majority (78.7 percent) of the 208.3 million antimicrobial

drug mentions. The leading 10 drugs alone accounted for

half (51.6 percent).

NAMCS data files also contain American Hospital Formulary Service information as to the expected therapeutic

effects of the drugs mentioned. Table D confirms the expectation that most of the antimicrobial drug mentions (96.7 percent)

were classified as anti-infective agents, principally antibiotics

(which constituted 84.6 percent of all antimicrobial drug mentions). Of the remaining antimicrobial drugs, the largest group

was classified as anti-infective skin and mucous membrane

preparations (5. 1 million drug mentions, or 2.4 percent of

the total).

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

...

Allgemerio ingredenta . . . . . .

Pen”@*n . . . . . . . . . . . . .

Erythmrnycin . . . . . . . . . . .

Amoxicillin . . . . . . . . . . . .

Tetraoydbe.. . . . . . . . . . .

Ampicillin. . . . . . . . . . . . .

Slhmethoxazole . . . . . . . .

Trimethopim . . . . . . . . . . .

Cephalexin . . . . . . . . . . . .

Clindemyoin . . . . . . . . . . .

Doxyoycline . . . . . . . . . . . .

cefaolor . . . . . . . . . . . . . .

Ntmfurantoin . . . . . . . . . . .

Suni-soxazde . . . . . . . . . . .

Minooycline . . . . . . . . . . . .

Nyetatin . . . . . . . . . . . . . .

CWtetracyolin e . . . . . . . . .

Lincomycin . . . . . . . . . . . .

Metroniiole . . . . . . . . . .

Cephredine . . . . . . . . . . . .

Gentemioin . . . . . . . . . . . .

All other generic ingredient . . .

221,474

34,025

32,746

23,470

23,263

21,646

13,888

13,134

8,528

5,037

4,852

3,914

3,397

2,886

2,774

2,526

2,427

2,283

2,237

1,705

1,627

15,207

100.0

15.4

14.6

10.6

10.5

9.7

6.2

5.9

3.9

2.3

2.2

1.8

1.5

1.3

1.3

1.1

1.1

1.0

1.0

0.8

0.7

6.9

11
Table C. Number and percent diatnbution of the 30 antimicrobial drugs

most frequently mentioned in offiie-based practice

United Statea, 1980-ftl

Number of

Name of drug and antimicrobial mentions Percent

Rank ingredients, if different in thousands distribution

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

.,.

All antimicrobial drug mentions . .

Ampicillin . . . . . . . . . . . . . .

Tetracycline . . . . . . . . . . . . .

Penicillin . . . . . . . . . . . . . .

Amoxicillin, . . . . . . . . . . .

Erythromycin . . . . . . . . . . . .

E.E.S. (erythromycin) . .

Keflex (cephalexin)

Amoxil (amoxicillin) . . . .

E-Mycin (erythromycin)

Pen-Vee K (penicillin) . . .

Cleocin (clindamycin) . . .

Ceclor (cefaclor) . . . . . . .

Vibramycin (doxycycline) . .

Bacfrim (trimethoprim,

sulfamethoxszole . . . .

Septra (trimethoprim,

sulfamethoxezole . . . .

Larotid (amoxicillin) . . . .

Macrodantin (nitrofurantoin) . .

V-Cillin K (penicillin) . . .

Ilosone (erythromycin) . . .

Minocin (minocyciine) . . .

Septra DS (Irimethoprim,

sulfamethoxszole) . . . . . .

Bactrim DS (trimethoprim,

sulfamethoxszole) . . . . .

Terramycin (oxytetracycline) . .

Lincocin (Iincomycin) . . . . . . .

Flagyl (metronidezole) . . . . . .

Gantriain (aulfisoxezole) . . . . .

Bicillin C-R (penicillin,

penicillin G procaine) . . . . .

Mycostatin (nystatin) . . . . .

Sumycin (tetracycline) . . . . .

Penicillin VK (penicillin) . . . . . .

All other antimicrobial drugs . . .

208,288

18,98%

16,089

14,107

11,353

10,968

9,711

8,462

7,634

5,095

4,787

4,667

3,914

3,801

3,677

3,630

3,179

3,129

3,103

2,976

2,706

2,626

2,603

2,344

2,254

2,182

2,130

2,091

1,956

1,653

1,622

44,469

I00.0

9.1

7.7

6.6

5.5

5.3

4.7

4.1

3.7

2.4

2.3

2.2

1.9

1.8

1.6

1.7

1.5

1.5

1.5

1.4

1.3

1.3

1.2

1.1

1.1

1.0

1.0

1.0

0.9

0.9

0.9

21.3

Table D. Number and percent distribution of antimicrobial drug

mention$ by American Hospital Formulary Sewice therapeutic category

United States 1980-S1

Number of

American Hospital Formulary mentions Percent

Service therapeutic category’ in thousands distribution

All therapeutic categories . . . . . . . . . 208,288 100.0

Anti-infective agents . . . . . . . . . 201,457 96.7

Antibiotics . . . . . . . . . . . . . . . . 176,193 84.6

Sulfonamides . . . . . . . . . . . . . . . . 17,405 8.4

Trichomonacides . . . . . . . . . . . . 2,237 1.1

Urinary germicides . . . . . . . . 4,858 2.3

Other . . . . . . . . . . . . . . . . . . 764 0.4

Expectorants and cough preparations . . ●73 ‘0.0

Eye, ear, nose, and throat

preparations . . . . . . . . . . . . . 1,692 0.8

Anti-infectivea . . . . . . . . . . . . . . . . 1,336 0.6

Anti-inflammatory agents . . . . . . . “356 “0.2

Skin and mucous membrane preparations

(anti-infectives) . . . . . 5,066 2.4

1Based on American Hospital Formulary Servbe Classificsfion System and Therqoautic

Category Codes. Washington.AmericanSocielyof HospitalPharmacists,Inc. 198o.

Table E shows that most antimicrobial drug mentions

were indeed single ingredient drugs (187.2 million, or 89.9

percent of all). Only 19.3 million (9.3 percent) were combination drugs. The proportion of single ingredient drugs varies

according to the type of antimicrobial drug, however. Four

of the major types were composed almost entirely of single

ingredient drugs--cephalosporins (99. 8 percent), tetracycline

(98.7 percent), penicillins (97.3 percent), and macrcdides and

Iincosamides (96.7 percent). A significantly smaller proportion

of the miscellaneous antimicrobial, 82.4 percent, was composed of single ingredient drugs. The smallest proportion of

single ingredient drugs (24. 1 percent) was found in Ithe group

of sulfonamides and trimethoprim. This finding is not surprising, because two-thirds of the drugs in this group combine

one or more sulfonamides with trimethoprim to obtain a desirable synergistic effect. The 14.1 million combination drugs

in this group accounted for almost three-fourths (72.4 percent)

of all antimicrobial combination drugs.

Virtually all of the antimicrobial drug mentions (206.5

million, or 99.2 percent) were of drugs available to patients

only with a physician’s prescription. Similarly, 206.5 million

of the drug mentions (99.2 percent) were not subject to the

regulatory control of the Drug Enforcement Administration

(DEA) of the U.S. Department of Justice. Most of the remaining drugs were of indeterminate prescription or control status

and were concentrated in the group of miscellaneous antimicrobial, which includes all unclassifiable entries, such as “anti-infective agent.”

Table F displays the distribution of antimicrobial drug

mentions among entry status categories, that is, the types

of names used by responding physicians in reporting the order

or provision of drugs.’ The data indicate that brand names

were used to order drugs much more frequently than generic

names were (127. 3 million drug mentions, 61.1 percent of

all antimicrobial drug mentions, compared with 79.3 million,

or 38.1 percent). Only 1.8 million drug mentions (O.8 percent)

were reported according to their therapeutic effect. However,

the different types of antimicrobial drugs were not equally

likely to be ordered under brand names. Cephalosporins, as

well as the sulfonamides and trimethopnm, were almost always

ordered under their trade names (98.4 percent and 98.(1 percent,

respectively), followed by miscellaneous antimicrobial (8 1.1

percent) and then macrolides and lincosamides (72.3 percent).

Even less frequently ordered under their trade names were

tetracycline (49.9 percent), followed by penicillins (40.7 percent). Thus, office-based physicians used generic names more

frequently than trade names for only two types of rmtimicrobiak-penicillins and tetracyclines-but these were the first

and third most commonly ordered antimicrobial. Undoubtedly

the frequency of using trade names in ordering the different

‘Although sample physicians were requested to report drug use by listing

the drug names entered in patient medical records or on prescription forms,

some physicians reported a portion of drug use in terminology describing

or implying the desired therapeutic effect. ConsequentI y, NAMCS uses

“therapeutic effect” as an entry status category, as well as “generic name”

and “brand name.”

12
Table E. Number and percent distribution of antimicrobial drug mentions by composition SWIJ% according to type of antimicrobbd drug

United States, 1980-81

Composition status’

Type of Single ingredient Combination

antimicrobial drug Total drug drug Undetermined

Allantimicrobial drugmentlons . . . . . . . . . . . . . . . . . . . . . . . .

Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cephalospwins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Macrolides andlincosamides . . . . . . . . . . . . . . . . . . . . . . . . .

Tetracycline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sulfonamides andtrimethoprim . . . . . . . . . . . . . . . . . . . . . . .

Mkcellaneousa ntirnicrobials. . . . . . . . . . . . . . . . . . . . . . . . .

Allantimicrobial drug mentions . . . . . . . . . . . . . . . . . . . . . . . .

Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cephalosporins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Macrolides andtincosamides . . . . . . . . . . . . . . . . . . . . . . . . .

Tetracycline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sulfonamidesandtrimethoprim . . . . . . . . . . . . . . . . . . . . .

Miscellaneousantimicrobials... . . . . . . . . . . . . . . . . . . . . . .

208,288

82,896

16,044

40,106

33,787

18,607

16,648

100.0

100.0

100.0

100.0

100.0

100.0

100.0

Number inlhousands

187,188 19,346

80,677 2,219

16,007

38,771 1,335

33,360 “427

4,492 14,115

13,881 1,250

Percent distribution

89.9 9.3

97.3 2.7

99.8

96.7 3.3

98.7 “1.3

24.1 75.9

82.4 7.4

1,754

’37

1,717

0.8

“0.2

10.2

Tabfe F. NumWrand @rcenttistiWbn ofantimicrtiI dqmen@ns byen@sWt~a~ting to~ofantmkr*d~: United States, 1980-81

Entry status%

Type of Generic Brand Therapeutic

antimicrobial drug Total name name effect

Allantimicrobial drug mentions . . . . . . . . . . . . . . . . . . . . . . . .

Penicillins, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cephalosporins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Macrolides and fincosamides . . . . . . . . . . . . . . . . . . . . . . . . .

Tetracycline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sulfonamides andtrimethoprim . . . . . . . . . . . . . . . . . . .

Miscellaneous antimicrobials . . . . . . . . . . . . . . . . . . . . . . . . .

Allanlimicrobial drugment!ons . . . . . . . . . . . . . . . . . . . . . .

Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cephalosporins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Macrolides andlincosamides . . . . . . . . . . . . . . . . . . . . . . . . .

Tetracycline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sulfonamidesandtrimethoprim . . . . . . . . . . . . . . . . . . . . . . .

Miscellaneous antimicrobials . . . . . . . . . . . . . . . . . . . . . . . . .

208,288

82,896

16,044

40,106

33,787

18,607

16,648

100,0

100.0

100.0

100.0

100.0

100.0

100.0

Number in thousands

79,255 127,278

49,191 33,705

●2I 9 15,788

11,093 29,014

16,914 16,873

’373 18,233

1,466 13,665

Percent distribution

38.1 61.1

!59.3 40.7

‘1.4 96.4

27.7 72.3

50.1 49.9

“2.0 98.0

8.7 81.1

1,754

’37

1,717

0.8

“0.2

10.2

‘The entry ststus of a drug mention ISthe lyps of drug narns used by the responding physician in repormg the drug’s use

types of antimicrobial was influenced both by the desirability

of ordering a particular combination drug (as with the sulfonamides and trimethoprim, which are frequently used in

combination) and by the availability of very similar products

from different manufacturers. (A number of penicillin compounds, for example, are manufactured by a variety of

companies.)

Population-based rates

The last aspect of antimicrobial drug mentions to be investigated in this report concerns the relationship of certain demographic characteristics-patient sex and patient age—to the

useof these drugs. (See table G.) For all antimicrobial drugs,

the average annual rate of use was 467.7 drug mentions per

1,000 civilian noninstitutionalized population. The rates of

use of the major types differed significantly according to

the same pattern described for the numbers of drug mentions,

with one exception. The average annual rate for macrolides

and lincosamides was not significantly greater than that for

tetracycline.

Significantly more antimicrobial drugs were ordered or

provided for female patients than for male patients—1 15.7

million compared with 92.6 million, or 25 percent more.

Controlling for the relative sizes of the male and female populations by comparing rates reduces the magnitude of this difference, but it remains significant (501.8 antimicrobial drug mentions per 1,000 population per year for females compared

13
Table G. Number, percent distribution, and average annual rate (per 1,000 civilian noninetitutionaliied population) of antimicrobial drug mentions by aex

and age of patien~ according to type of antimicrobial drug: United States, 1980-61

Type of antimicrobial drug

Macro/ides Sulfonamides

Cephalo- and and/or Miscellaneous

Sex and age of patient All types Penicillins sporins Iincosamides Tetracycline trimethoprim arrtimicrobials

All antimicrobial drug mentions . . .

Sex

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

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

Age

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

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

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

4S-64years . . . . . . . . . . . . . . . . . . . . . . . . .

65yearsand over . . . . . . . . . . . . . . . . . . . . . .

Allantimicrobial drugmantions . . . . . . . . .

Sex

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

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

Age

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

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

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

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

65yearsandover . . . . . . . . . . . . . . . . . . . . . .

Allanfimicrobial drug mentions. . . . . . .

Sex

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

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

Age

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

15-24yesrs . . . . . . . . . . . . . . . . . . . . . . . . .

25-44yeers . . . . . . . . . . . . . . . . . . . . . . . . .

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

65yearsandover . . . . . . . . . . . . . . . . . . . . . .

208,288

92,632

115,656

71,003

36,352

46,604

31,636

20,694

100.0

44.5

55.5

34.1

18.4

22.4

15.2

9.9

467.7

431.1

501.8

698.4

471.0

371.9

359.8

422.1

82,696

38,462

44,434

40,157

12,995

15,183

9,598

4,962

100.0

46.4

53.6

48.4

15.7

18.3

11.6

6.0

186.1

179.0

192.8

395.0

159.6

121.2

109.2

101.2

16,044 40,106

7,765 17,833

8,279 22,473

5,426 14,315

2,168 8,447

3,952 8,852

2,983 5,581

1,495 2,911

Percent distribution

100.0 100.0

48.4 44.0

51.6 5&o

33.8 35.7

13.6 21.1

24.6 22.1

18.6 13.9

9.3 7.3

Average annual rate

36.0 90.1

36.1 82.1

35.9 97.5

53.4 140.8

26.9 103.7

31.5 70.6

33.9 63.5

30.5 59.4

33,787

15,050

18,737

2,230

9,609

10,519

6,637

4,592

100.0

44.5

55.5

6.6

29.0

31.1

19.6

13.6

75.9

70.0

81.3

21.9

120.5

83.9

75.5

93.7

18,607

7,981

10,626

6,033

1,869

3,599

3,461

3,645

100.0

42.9

57.1

32.4

10.0

19.3

18.6

19.6

41.6

37.1

46.1

59.3

23.0

26.7

39.4

74.3

16,848

5,741

11,106

2,641

3,044

4,499

3,376

3,088

100.0

34.1

65.9

16.9

18.1

26.7

20.0

18.3

37.8

26.7

46.2

27.9

37.4

35.9

36.4

63.0

with 431.1 for males, or 16 percent more). The residual

category of miscellaneous antimicrobial, however, was the

only major group in which the annual average rate for females

(48.2 per 1,000 population) significantly exceeded that for

males (26.7).

Age differences in the use of arttimicrobial drugs also

are shown in table G. The largest number of antimicrobial

drugs (71.0 million, or 34.1 percent of all) was ordered or

provided for children 14 years of age and younger. This

group also accounted for the highest rate (698.4 per 1,000

population per year). Young adults 15–24 years of age had

the second highest average annual rate (471.0). Although

theratecontinued to fluctuate with increasing age,the changes

were not statistically significant. Thus, these data indicate

that overall antimicrobial usage dropped with age up to 25-44

yearsofage,atwhich pointusagechanged little.

14

For the specific types of antimicrobial drug, however,

different patterns emerge. For both penicillins and cephalosporins, which are verysimilarboth chemically and pharmacologically, the sole difference from the overall pattern was that

therates for persons 15–24 years of agedidnot differ significantly from those for persons 25-44 years of age (159.6

per 1,000 population per year compared with 121.2, and

26.9 compared with 31.5, respectively). Thus, for these drugs,

usage by children was significantly higher than usage by the

next youngest age group, but no further significant changes

betweensuccessive agegroupswereobserved.

Usage rates for the sulfonamides and trimethoprim followed the same pattern as those for the penicillins and cephalosporins, except that usage among the elderly washi.gher than

usage among persons 45-64 yearsof age. (The average annual

rate was 39.4 per 1,000 population for persons aged 45-64
and 74.3 for those aged 65 and older.) This pattern reflects

the relative susceptibility of children and the elderly to urinary

tract infections.

Usage rates for the tetracycline also followed the same

pattern as those for the penicillins and cephalosporins, with

only one difference. Children [0-14 years of age] were ordered

or provided with tetracycIines significantly less often than

were persons 15–24 years of age (21.9 per 1,000 per year

compared with 120.5). In fact, they were ordered or provided

with these drugs significantly less frequently than any other

age group. This finding is undoubtedly a result of the fact

that, unless no other satisfactory treatment plan can be devised,

use of tetracycline in young children is contraindicated because these drugs can cause permanent dkcoloration of developing teeth.

Finally, usage of macrolides and Iincosamides and of

miscellaneous antimicrobial was similar in that successive

age groups displayed no significant differences between rates.

Only differences between the rates for successive age groups

have been discussed here; readers interested in making other

comparisons should consult the discussion of significance testing presented in appendix I.

Wit information

The 208.3 million antimicrobial drug mentions made during 1980 and 1981 involved 188.8 million patient visits. The

remainder of this report concentrates on examining the characteristics of these visits and of the patients who made them.

Of all antimicrobial drug visits, by far the largest proportion (41.2 percent) was made by patients for whom one or

more penicillins were ordered or provided. (See table H.)

Substantially smaller than this was the set of visits made

by patients who received one or more macrolides and lincosarnides. These visits composed 20.5 percent of the total.

Visits involving one or more tetracycline constituted 17.5

percent of the total, a proportion that was significantly, but

not substantially, smaller than that involving macrolides and

Iincosamides. The three remaining groups of antimicrobial

drug visits each accounted for significantly smaller proportions

of the total.

Tabfe H. Number and percent distribution of antirniimbial drug viai@ by

type of antimicrobial drug ordered or providerk United State& 1960-81

Number of

visits Percent

Typs of antimicrobial drug in thousands distribution

All antimicrobial drug visits . . . . . . . . . . 1a8,754 100.0

Penicillins . . . . . . . . . . . . . . . . . . . 77,811 41.2

Cephalosporins . . . . . . . . . . . . . . . . 15,699 6.3

Macrolides and Iincosamides . . . . . . . . . 36,663 20.5

Tetraoycfines . . . . . . . . . . . . . . . . . 33,104 17.5

Sulfonamides and tnmethoprim . . . . . . . 18,515 9.8

Mk=daneous antimicrobial . . . . . . . . . 16,262 8.6

iPercents will nof lotsl 100.0 becsuse some visits involved drugs from more than one

antimicrobial drug group.

Patiints’ reasons for visit

The distribution of antimicrobial

to maior reason for visit is shown in

drug visits according

table J. Based on t@

assumption that many infective disease processes are acute

in nature, it was expected that a large proportion of NAMCS

visits involving antimicrobial drugs would be prompted by

a need for care of an acute problem. This expectation was

suppor!ed by the data, with almost three-fourths of all antimicrobial drug visits (71.8 percent) being for the care of an

acute problem. In contrast, only one-third (29.5 percent) of

all other NAMCS \’isits were precipitated by an acute problem.

As a consequence of this difference, antimicrobial drug visits

accounted for 16.3 percent of all NAMCS visits but for fully

32.1 percent of all acute-problem visits.

The proportions of antimicrobial drug visits associated

with other major reasons for visit were, of course, all significantly smaller. Visits for routine care of a chronic problem

accounted for 13.8 percent of ail antimicrobial drug visits,

and visits for care of a chronic problem flareup accounted

for a significantly smaller 10.0 percent.

Although acute problems represented the major reason

for visit for more than half of the visits associated with each

type of antimicrobial drug, the proportion of acute problem

visits varied significantly with drug type. The penicillins had

the largest proportion of acute problem visits (84.7 percent),

followed by the cephalosporins (71.6 percent) and macrolides

and lincosamides (70.4 percent). The remaining three drug

types had the smallest proportions of acute-problem visits

(less than 60 percent each).

One other notable difference appeared in the distribution

of visits involving the different types of antimicrobial drugs

among the various major reasons for visit. Visits in which

tetracycline were ordered or provided were more likely to

be visits for routine care of a chronic problem (28.3 percent)

than were visits invoIving any other type of antimicrobial

drug. This is because of the relatively high frequency of

diseases of the sebaceous glands (including the common

chronic skin condition, acne) as the principal diagnosis in

visits involving tetracycline.

Physicians participating in NAMCS are asked not only

to report the major reason for visit, but also to provide verbatim

accounts of the specific reasons for the visit given by each

sample patient. These reasons are coded according to ‘GA

Reason for Visit Classification for Ambulatory Care,”lz which

both assigns codes to specitlc reasons and groups the specific

reasons into meaningful categories. As would be expected

in any group of visits predominantly precipitzzted by acute

problems, by far the most common category of principal reason

for visit cited by patients making antimicrobial drug visits

during 1980 and 1981 was symptoms. Fully five of every

six of these visits (84.7 percent) fell into this category. Patient

complaints of a disease accounted for only 6.1 percent of

all antimicrobial drug visits, and visits made for diagnostic,

screening, and preventive reasons and for treatment reasons

accounted for even smaller proportions (3. 1 percent each).

15
Table J. Number and percent distnbutiin of antimicrobial drug visits by major reason for vis~ according to type of antimicrobial drug orderedl or provided:

United States, 1980+31

Major reason for visit

All Acute Chronic problem, Chronic problem Post surgery Nonillness

Type of antimicrobial drug reasons problem routine visit flareup or iniurv care

Number in thousands’

Allantimicrobial drug visits . . . . . . . . . . . . . . . . . . . 188,754 135,534 26,104 18,913 3,704 4,499

Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cephalosporins . . . . . . . . . . . . . . . . . . . . . . . . .

Macrolides andlincosamides. . .

Tetracycline, . . . . . . . . . . . . . . . . . . . . . . . . . .

Sulfonamidesandtrimethoprim . . . . . .

Miscelianeousantimicrobiais . . . . .

77,811

15,699

38,663

33,104

18,515

16,282

65,697

11,245

27,234

18,661

10,852

8,762

4,601 4,728

1,193 2,130

6,410 3,974

9,367 4,319

3,634 3,021

3,417 2,191

921

846

’356

’356

462

879

1,663

*284

689

’400

545

1,032

Percent distribution

Allantimicrobial drugvisits . . . . . . . . . . . . . . . . . . . 100.0 71.8 13.8 10.0 2.0 2.4

Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cephalosporins . . . . . . . . . . . . . . . . . . . . . . . . . .

Macrolidesand lincosamides. . . . . . . . . . . . . . . .

Tetracycline . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sulfonamidesandtrimethoprim . . . . . . . .

fkfiscellaneo usantimicrobiais . . . . . . .

100.0

100.0

100.0

100.0

100.0

100.0

84.7

71.6

70.4

56.4

58.6

53.8

5.9 6.1

7.6 13.6

16.6 10.3

28.3 13.0

19.6 16.3

21.0 13.5

1.2

5.4

‘0.9

“1.1

2.5

5.4

2.1

‘1.6

1.8

‘1.2

2.9

6.3

lSumsof antimicrobialdrug categories do notequal totals bemuse some viaitsinvolved drugs from more than oneantimicmhal dmg group.

Tabfe K. Number and~-nt dat&Mon &tie 20speticprincipal rea~nsforvisti moWmmonlygtien dunngantimicroMal dmgvia@

United States, 1980-81

,’

/

/

Number of visits

Rank

Percent

Principal reason for visit and WC code 7 in thousands distribution

Allprincipal reasons forvisit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188,754 100.0

1 Symptoms referable tothroat . . . . . . . . . . . . . . . . . . . . . . ..(S455) 22,007 11.7

2 Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(S440) 17,818 9.4

3 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (solo) 12,958 6.9

4 Head cold, upperrespiratoryinfection . . . . . . . . . . . . . .(S445) 12,086 6.4

5 Earacheorearinfection . . . . . . . . . . . . . . . . . . . . . . . . . . . . (s355) 11,435 6.1

i 6 Acneorpimples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(S830) 11,016 5.8

7 Skin rash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(s860) 3,626 1.9

8 Nasal congestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(S400) 3,542 i .9

9 Abdominal pain, cramps, spasms . . . . . . . . . . . . . . . . . . .(S550) 3,312 1.8

10 Painful urination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(S650) 3,178 1.7

11 Progressvisit, NOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(T800) 2,873 1.5

12 Othersymptoms referabletoears, NEC . . . . . . . . . . . . . . .(S365) 2,501 1.3

13 General medical examination.. . . . . . . . . . . . . . . . . . . . . . . . (Xloo) 2,170 1.1

14 Frequencyand urgency ofurination . . . . . . . . . . . . . . . (S645) 2,126 1.1

15 Headache, paininhead . . . . . . . . . . . . . . . . . . . . . . . . . . ..(S210) 2,065 1.1

16 Skin lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (S865) 1,859 1.0

17 Congestion inchest . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(S475) 1,747 0.9

18 Chest pain and related symploms (not referable tobodysystem) . . . . . .(S050) 1,698 0.9

19 Sinusproblems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(S410) 1,592 0.8

20 Vaginal discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(S760) 1,486 0.8

.. Allotherprincipal reasonsforvisit . . . . . . . . . . . . . . . . . . . . . . . . . . . 67,636 35.8

lBased onA Reasonfor Vi.sitClassificationforAmbu/aforyCare, (RVC).’2

In contrast to these visits, fewer than half (48.1 percent)

of all other visits, which reflected a much larger proportion

of chronic problems, were made by patients who principally

complained of symptoms.

The 20 specific reasons for visit most commonly given

for antimicrobial drug visits are shown in table K. The data

indicate that the visits are concentrated in a small number

of codes which are primarily symptoms, thereby reflecting

the narrow range of complaints presented by patients with

underlying infective disease processes. Eighteen of these 20

reasons were symptoms, and together accounted for almost

two-thirds (64.2 percent) of all antimicrobial drug visits. In

fact, half of all antimicrobial drug visits (50.1 percent) were

accounted for by the eight leading patient complaints alone:

symptoms referable to the throat, cough, fever, head cold

(upper respiratory infection), earache or ear infection, acne

or pimples, skin rash, and nasal congestion.

Diagnoses

For NAMCS, diagnoses recorded during patient visits

are coded according to the International Classification of Diseases, 9th Revision, Clinical Modijkation (ICD–9-CM).’3

16
The distribution of the principal diagnoses associated with

antimicrobial drug visits among the major diagnostic classes

of the ICD-9-CM is shown in table L. By far the most

common diagnostic class was diseases of the respiratory system, which accounted for 42.4 percent of these visits. This

is not unexpected because of the large proportion of complaints

related to the respiratory system among the principal reasons

for visit cited by patients. (See table K.) The rank of second

most common type of principal diagnosis is shared by three

diagnostic classes. They are diseases of the nervous system

and sense organs (13. 8 percent), diseases of the skin and

subcutaneous tissue (12.6 percent), and diseases of the

genitourinary system (11.7 percent). Thus, the four most common classes of diagnosis together accounted for 4 of every

5 antimicrobial drug visits (80.5 percent).

This finding is in sharp contrast to the diagnostic distribution of all visits not involving antimicrobial drugs. Only 24.9

percent of the latter were associated with these four classes

of principal diagnosis. It is apparent that those organ systems

most vulnerable to infective contamination by the environment

develop a highly disproportionate share of the problems that

precipitate the use of antimicrobial medications.

The limited diagnostic range of visits involving the use

of antimicrobial drugs is even more clearly shown in

table M, which presents the specific principal diagnoses most

frequently encountered in these visits. It is important to note

that this ranking of diagnoses is only approximate, as some

differences among the diagnostic frequencies are not statistical y significant. Two-thirds (66.5 percent) of all antimicrobial

drug visits during 1980 and 1981 were attributable to only

Tabfe L. Number and percent dmtributionof antirniirobiel drug vW@ by otass of principal diegnoa& United stat- 1980-81

Number of antimicrobial Percent

Class of principal diagnosis and ICD-KM codesq drug visita in tfrousands distribution

All principal diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188,754 100.0

Infectious andparasitic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(001-139) 10,162 5.4

Oiseases of the nervous system and sense organs . . . . . . . . . . . . . . . . . . . . . . (320-389) 26,088 13.a

Oiseases of thecirculatoty system... . . . . . . . . . . . . . . . . . . . . . . . . . . . .(39+$59) 3,116 1.7

Oiseases of therespiratofy system... . . . . . . . . . . . . . . . . . . . . . . . . . . . .(460-519) 80,031 42.4

Oiseaaes of thedigestive system... . . . . . . . . . . . . . . . . . . . . . . . . . . . .(520-579) 5,C06 2.7

Diseaeea of thegenitourinary system . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(580-629) 22,038 11.7

Diseaeas of theskin and subcutaneous tissue . . . . . . . . . . . . . . . . . . . . . . . . (880-708) 23,742 12.6

Oiseases of the musculoskeletal system and connective tissue . . . . . . . . . . . . . . . . (710-739) 1,784 0.9

Symptoms, signs, and ill-defined conditions. . . . . . . . . . . . . . . . . . . . . . . . . . (780-799) 3,446 1.8

lnjuryand poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(800-999) 4,457 2.4

Supplemental classification of factors influencing health status

andcontact with health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (VO1-V82) 3,770 2.0

Another principal diagnoses2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Residual 5,111 2.7

1Based on the /rrIernafiona/ C/assifka@sof Diseases,9fh Revision,C/ir!ica/W;fhatbn (lCD-%CM).is

‘Includes neoplssms (140-239k endocrine, nutritional, and metabolic dk.ssees, and -n”@ dwrdere (240-279); mental &sorders (290-319); and blank, noncodab4e, and illegible diagnoses,

Number of visits

Rank

Percent

Princi@d diagnosis and ICD-5WW code’ in Urousands distribution

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

...

Allprincipal diagnosea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Suppurative and unspecified otitis media . . . . . . . . . . . . . . . . . . . (382)

Acute upper respiratory infections of multiple or unspecified sites . . . . . . (465)

Acute phatyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (462)

Diseases ofsebaceous glands . . . . . . . . . . . . . . . . . . . . . . .. (708)

Bronchitis, not specified as acute or chronic . . . . . . . . . . . . . . . . . (490)

Acute tonsillitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (483)

Chronic sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (473)

Other disorders of urethra and urinary tract . . . . . . . . . . . . . . . . . . (599)

Cystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (595)

Acute bronchitis anctbronchiolitis . . . . . . . . . . . . . . . . . . . . . . . (488)

Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (487)

Streptococcal sore throat and scarlet fever . . . . . . . . . . . . . . . . , . (034)

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (493)

Pneumonia, organism unspecified . . . . . . . . . . . . . . . . . . . . . . . (486)

Inflammatory diseasea of prostate . . . . . . . . . . . . . . . . . . . . . . . (801)

Other celkrlitia andabscess . . . . . . . . . . . . . . . . . . . . . . . . . . (682)

Oisordere ofextemal ear . . . . . . . . . . . . . . . . . . . . . . . . . . ..(3aO)

Inflammatory disease of cervix, vagina, and vulva . . . . . . . . . . . . . . (616)

Nonsuppurative otitis media and Eustachian tuba dkordets . . . . . . . . . (381)

Inflammatory disease of ovary, fallopian tube, pelvic cellular

tissue, andparitoneum . . . . . . . . . . . . . . . . . . . . . . . . . . .. (614)

Atlotherprincipal diagnoses . . . . . . . . . . . . . . . . . . . . . . . .. Residual

188,754

19,175

1a,795

13,859

13,426

9,947

8,318

5,653

5,402

4,628

4,204

3,397

2,916

2,26a

2,231

2,202

2,131

1,928

1,785

1,836

1,802

100.0

10.2

10.0

7.3

7.1

5.3

4.4

3.0

2.9

2.5

2.2

1.8

1.5

1.2

1.2

1.2

1.1

1.0

1.0

0.9

0.9

33.5

i Based on the /rrk?matk+w/ C/assificafionoff?isesses,9fh Revisbn, C/irrica/Modification(ICO-S-CM)?3

---

17

-—--- . .... ..._ _.
20 diagnoses. In contrast. only 7.3 percent of all other visits

were associated with these principal diagnoses. All but one

of these diagnoses fall into the four ICD–9–CM diagnostic

classes that account for most antimicrobial drug visits. Half

of the antimicrobial drug visits (50. 1 percent, or an average

of 47.3 million visits per year) were accounted for by only

eight diagnoses: suppurative and unspecified otitis media; acute

upper respiratory infections of multiple and unspecified sites;

acute pharyngitis; diseases of the sebaceous glands; bronchitis,

not specified as acute or chronic; acute tonsillitis; chronic

sinusitis; and other disorders of the urethra and urinary tract.

For the visits associated with each major group of antimicrobial drug, table N shows the principal diagnoses wiith combined 1980 and 198 I visit frequencies of at least 1 million.

A remarkable consistency in the ranking of diagnoses can

be observed. Suppurative and unspecified otitis media was

the most common diagnosis for 3 of the 5 antimicrobial groups.

This accounted for 1~.8’ percent of the’visits associated with

Table N. Forvisits associated with eachtype ofantimicroMal drug, number and~rceW tistnbtion of themost wmmons~cfic ptin~ldagnosex

United States, 1980-61 //

~

Type of antimicrobial drug, Number of visits

Rank

Percent

principal diagnosis, and\CD-9-CMcodel in thousanda distrlwtion

1

2

3

4

5

6

7

8

9

10

11

...

1

2

.,.

1

2

3

4

5

6

7

8

.

1

2

3

4

5

1

2

3

4

Penicillins

All principsl diagnoses in visits involving penicillins . . . . . . .

Suppurative and unspecified otitis media . . . . . . (382)

Acute upper respiratory infections of multiple or unspecified sites . . . (465)

Acute pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (462)

Acute tonsillitis.......,..,.. . . . . . . . . . . . . . . . . . . .. (483)

Bronchitis, notspecified asacute or chronic . . . . . . . (49o)

Streptococcal sore throat and scarlet fever . . . . . (034)

Chronic sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (473)

Acute bronchitis and bronchiolitis . . . . (466)

Influenza . . . . . . . . . . . . . . . . ,, . . . . . . . . . . . . . . . . .. (487)

Disorders ofexternal ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . (380)

Pneumonia, organism unspecified . . . . . . . . . . (466)

Another principal cfiagnoses . . . . . . ... . . . . . . . . . . . . . . .. Residual

Cephalosporins

All principal diagnoses invisits involving cephalosporins . . . .

Suppurative andunspecified otitis media . . . . . . (382)

Acute upper respirato~ infections ofmultipie or unspecified sites . . . . . (465)

Another principal diagnoses ..,.... . . . . . . . . . . . . . . . . .. Residual

Macrolides and Lincosamides

All principal diagnoses in visits involving macrolides orlincosamides . . . .

Diseases of sebaceous glands . . . . . . . . . . . . . . . . . . . . . . . . (706)

Acute upper respiratory infections of multiple or unspecified sites . . . , . (465)

Bronchitis, not specified as acute or chronic . . . . . . . . . . . (490)

Acute pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (462)

Suppurative and unspecified otitis media . . . . . (382)

Acute tonsillitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (463)

Acute bronchitis and bronchiolitis . . . . . . (466)

Chronic sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (473)

Another principa.l diagnoses . . . . . . .Residual

Tetracycline

Allprincipal diagnoses invisits involving tetracychnes . . . . . . . .

Diseases of sebaceous glands . . . . . . . . . . . . . . . . . . . . . . . (706)

Acute upper respirato~ infections ofmultiple or unspecified sites . . (465)

Bronchitis, not specified asacute or chronic . . . . . . . . (49o)

Chronic sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (473)

Acute pharyngitis, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (462)

Another principal diagnoses . . . . . . . Residual

Sulfonamides and trimethoprim

All principal diagnoses invisits involving sulfonamides

and fortrimethoprim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Suppurative andunspecified ofitis media . . . . . . . (382)

Other disorders ofurethra andurinarytrad . . . . . . (599)

Cystitis . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . .. (595)

Inflammatory diseases of prostate . . . (601)

Another principal diagnoses . . . . . . . . . . . . . . . . . . . . . . . .. Residual

77,611

12,293

9,392

9,061

6,210

3,909

2,293

2,077

1,819

1,670

1,070

1,061

26,957

15,699

1,941

1,685

12,373

38,663

6,170

5,205

3,248

2,858

2,251

1,538

1,241

1,097

15,058

33,104

8,587

3,212

2,154

1,797

1,197

16,156

18,515

2,856

2,675

2,571

1,217

9,196

1Ocl.o

1!5.8

i 2.1

11.6

a.o

5’.0

2.9

2.7

2.3

2.2

1.4

1.4

34.6

100.0

12.4

10.7

76,9

100.0

16.0

13.5

8.4

7.4

5.8

4.0

3.2

2.8

38.9

100.0

25.9

9.7

6.5

5.4

3.6

48.8

100)0

15.4

14.5

13.!9

6.I5

49.’7

‘Based on the /ntemationa/C/ossificationof Diseases,9#1 Revision, C/irrica/ Modir7cattm (ICO-9-CM),’3

NOTES: Wscellaneous antimicrobial drugs areomiRed from twistable.

More than one type of antimicrobial drug was ordered or provided during some visits,

18
the use of penicillins, 15.4 percent of the visits in which

sulfonamides and/or trimethoprim were used, and 12.4 percent

of the visits associated with cephalosporins. Diseases of the

sebaceous glands constituted the leading diagnosis for the

remaining antimicrobial drug groups. This diagnosis, which

includes acne, accounted for 25.9 percent of all visits in

which the tetracycline were used and 16.0 percent of those

in which the macrolides and Iincosamides were used. Orally

administered tetracycline and erythromycin (a macrolide antibiotic) are used frequently in the treatment of acne, as are

topical applications of the Iincosamide clindamycin. (NAMCS

does not gather information on the route of administration

of medications that are ordered or provided. Consequently,

topical antimicrobial medications can be itemized for separate

analysis only when their use is reported under names of drug

preparations that are solely for topical application. Those drug

mentions reported under names indicating drugs that can be

used either topically or systemically are included in this

analysis. )

Furthermore, 4 of the 5 antimicrobial groups had the

same diagnosis as the second most common one—acute upper

respiratory infections of multiple or unspecified sites. This

diagnosis accounted for 13.5 percent of the visits in which

the macrolides and Iincosamides were used, 12.1 percent of

the visits involving penicillins, 10.7 percent of the visits involving cephalosporins, and 9.7 percent of the visits in which

the tetracycline were used. Substantial overlap among the

remaining diagnoses also can be seen in the visits associated

with each antimicrobial group except the sulfonamides and/or

tnmethoprim. For the visits in which drugs from the latter

group were used, all leading diagnoses except the first-ranked

one were diseases of the genitourinary system, which tend

to be particularly amenable to treatment with this type of

medication.

Although the diagnostic distributions presented in

tables M and N contribute to an understanding of the principal

uses made of antimicrobial drugs in office-based practice,

they do not address the equally important question of the

extent to which alI occurrences of these conditions were treated

by using antimicrobial drugs of various types. Table O investigates this issue. The 20 diagnoses most commonly reported

for all antimicrobial drug visits are presented with the total

numbers of all visits assigned these principal diagnoses during

1980 and 1981. Also included are the numbers and percents

of these visits that were antimicrobial drug visits, and the

antimicrobial drugs most frequently mentioned in the treatment

of these conditions. The diagnoses are listed according to

their rank order among all antimicrobial drug visits. A cutoff

point of 750,000 visits was used in selecting the most frequently mentioned types of antimicrobial drug for presentation.

NAMCS recorded a total of 196.2 million visits with

these 20 principal diagnoses during 1980 and 1981. One or

more antimicrobial drugs was ordered or provided during 125.5

million, or 64.0 percent, of these visits. For individual diagnoses, however, the proportion of all visits that were antimicrobial drug visits ranged from about 20 percent to almost 90

percent. The diagnoses with the largest proportions of antimicrobial drug visits were acute tonsillitis (87.2 percent); streptococcal sore throat and scarlet fever (81.7 percent); acute

bronchitis and bronchiolitis (79.2 percent); bronchitis, not

specified as acute or chronic (78.0 percent); acute pharyngitis

(77.7 percent); and suppurative and unspecified otitis media

(77.2 percent). The diagnoses with the smallest proportions

of antimicrobial drug use were asthma (20.9 percent); inflammatory disease of cervix, vagina, and vulva (25.5 percent);

disorders of external ear (26.6 percent); and nonsuppurative

otitis media and Eustachian tube disorders (30.2 percent).

Consequently, it is apparent that although antimicrobial drugs

were used in a substantial majority of all visits concerned

with the most common diagnoses, the frequency of the use

of these drugs in the treatment of specific diagnoses varied

considerably.

An inspection of the leading antimicrobial drug groups

for these diagnoses reveals that the penicillins were the most

frequently used type of dmg for 14 of the 20 diagnoses.

Of these, the majori~ (10 diagnoses) were diseases of the

respiratory system. For 3 of the 20 diagnoses, all of which

were diseases of the genitourinary system, the sulfonamides

and trimethoprim were the most commonly used antimicrobial. For diseases of the sebaceous glands, including acne,

the tetracycline were the leading antimicrobial used. For

one diagnosis—nonsuppurative otitis media and Eustachian

tube disorders—no antimicrobial drug group met the visit

cutoff point.

The structure of NAMCS also permits differentiation between initial visits made to obtain care for a new problem

and return visits made to obtain care for a continuing problem.

At least one antimicrobial medication was ordered or provided

for 23.4 percent of the patients in all new-problem visits

recorded by NAMCS. This is in sharp contrast to all return

visits, of which only 12. I percent involved these drugs. This

difference was expected because a large proportion of antimicrobial drug visits, in comparison to all other visits, were

precipitated by acute problems. The difference also could

be the result of differing diagnostic distributions among newproblem and return visits.

These observations raise the question of the extent to

which antimicrobial drug use for a specific condition depended

on whether or not a particular visit was the initial one or

was a return visit made to obtain continuing care for that condltion. Table P was constructed to address this question. For

each of the 20 principal diagnoses most frequently mentioned

among antimicrobial drug visits, the table presents the 1980

and 1981 total numbers of new and return visits, and the

percents of each that were antimicrobial drug visits. These

data indicate that usage of antimicrobial drugs did tend to

vary according to whether or not the patient had previously

seen the reporting physician for the same condition. For 8

of these 20 diagnoses, the use of antimicrobial drugs was

significant] y lower in return visits than in new-problem visits.

These diagnoses were pneumonia (organism unspecified); inflammatory diseases of the prostate; asthma; cystitis; streptococcal sore throat and scarlet fever suppurative and unspecified otitis medi~ bronchitis, not specified as acute or

chronic; and chronic sinusitis. The use of antimicrobial drugs

was significant y higher for return visits than for new-problem

19
Table O. Number of all visits, number of antimicrobial drug visits, antimicrobial drug visits as a percent of all visits, and the most frequently mentioned

types of antimicrobial dru~ for each of the 20 principal diagnoses most commonly made during antimicrobial drug visits United States, 1980-81

Antimicrobial drua visits

Principal diagnosis

and ICD-9-CM code’

Suppurative and unspecified olifis media (382)

Acute upper respirato~ infetions

of multiple or unspecified sites (465)

Acute pharyngitis . . . . . . . . . . . . . . .. (462)

Diseases ofsebaceous glands . (706)

Bronchitis, notspecified asacute or chronic. (490)

Acute tonsillitis . . . , (463)

Chronic sinusitis . . . (473)

Ofher disorders of urethra and

urinarytract . . . . . . . . . (599)

Cystitis . . . . . . . . . . . . . . . . . . . ..(595)

Acute bronchitis and bronchiolitis . . (466)

Influenza . . . . . . . . . . . . ., . . . . ..(487)

Streptococcal sore throat andscarlet fever (034)

Asthma . . . . . . . . . . . . . . . . . . . ..(493)

Pneumonia, organism unspecified (466)

inflammatory diseases of prostate . . . (601)

Ofhercellulitisand abscess . . . . (662)

Disordersofexternalear . . . . . . . (360)

Inflammatorydkease of cervix,

vagina, andvulva . . . . . . . . . . . . . ..(816)

Nonsuppurative otitis media and Eustachian

tubedisordere . . . . . . . . . . . . . . . ..(381)

lnflammato~ disease of ovary, fallopian tube,

pelvic cellular tissue, and peritoneum. . (614)

Numberof Numberof Percent

all visikin visits in of all Most frequently mentioned types

thousands thousands visits of antimicrobial drugs

24,653

29,903

17,834

20,239

12,755

9,541

8,068

8,604

6,109

5,312

5,922

3,567

10,945

3,476

3,041

3,606

7,246

6,995

5,411

2,719

19,175

18,795

13,659

13,426

9,947

8,318

5,653

5,402

4,628

4,204

3,397

2,916

2,288

2,231

2,202

2,131

1,928

1,785

1,636

1,602

77,2

62.9

77.7

66.3

78.0

87.2

70.1

62.8

75.6

79.2

57.4

81.7

20.9

64.2

72.4

59.1

26.6

25.5

30.2

58.9

Penicillins (12,293,000 visits)

Sulfonamides and trimethoprim (2,856,000 visits)

Macrolides and Iincosamides (2,251 ,000 visits)

Cephalosporins (1,941,000 visits)

Penicillins (9,392,000 visits)

Macrolides and Iincosamides (5,205,000 visits)

Tetracycline (3,21 2,000 visits)

Cephalosporins (1 ,685,000 visits)

Penicillins (9,061 ,000 visits)

Macrolides and lincosamides (2,658,000 visits)

Tetracycline (1, 197,000 visits)

Cephalosporins (869,000 visits)

Tetracycline (8,587,000 visits)

Macrolides and Iincosamides (6,170,000 visits)

Penicillins (3,909,000 visits)

Macrolides and Iinmsamides (3,246,000 visits)

Tetracycline (2,1 54,000 visits)

Cephalosporins (650,000 visits)

Penicillins (6,21 0,000 visits)

Macrolides and Iincosamides (1,538,000 visits)

Penicillins (2,077,000 visits)

Tetracycline (1,797,000 visits)

Macrolides and Iincosamides (1,097,000 visits)

Sulfonamides end trimethoprim (2,675,000 visits)

fdkCekNWOUS anfimicrobials (1,081,000 visits)

Penicillins (982,000 visits)

Sulfonamide and trfmethoprim (2,571,000 visits)

Miscellaneous antimicrobial (1,096,000 visits)

Penicillins (814,000 visits)

Penicillins (1,819,000 visits)

Macrolides and Iincosamides (1,241,000 visits)

Tetracycline (961 ,000 visits)

Penicillins (1,670,000 visits)

Macrolides and Iincosamides (941,000 visits)

Penicillins (2,293,000 visits)

Penicillins (895,000 visits)

Penicillins (1,061 ,000 visits)

Macrolides and Iinmsamides (851 ,000 visits)

Sulfonamides and trimethoprim (1,217,000 visits)

Penicillins (996,000 visits)

Penicillins, (1 ,070,000 visits)

Miscellaneous antimicrobial (768,000 visits)

Penicillins (975,000 visits)

‘Based on the /rr(emationa /C/assificatio nofDiseases, 9th Rew’siorr, C/irrica/ Modification (lCO-WM).’s

NOTE: More than one~peof antimicrobial dmgwasordered orprovided during some visits,

visits foronly 2diagnoses-diseases of the sebaceous glands,

and acute upper respiratory infections of multiple or unspecified sites. There was no significant difference in antimicrobial drug use between the new-problem and return visits

for the remaining 10 diagnoses.

The differences highlighted here illustrate that the greater

use of antimicrobial drugs in new-problem visits than in return

visits tended to be diagnosis-specific as well as general. Thus,

the overall difference between antimicrobial drug visits and

all other visits in this respect was not caused solely by the

higher concentration of acute condition diagnoses, which were

relatively likely to be new-problem visits, among antimicrobial

drug visits. However, it is not possible touse NAMCS data

to determine the extent to which the observed differences

between the new-problem and return visits were the result

of demonstrated improvement that obviated the need for antimicrobial treatment, of terminating courses of antimicrobial

therapy that had failed, or of failure on the part of participating

physicians to report the continuing use of previously prescribed

medications as completely as the initial use of meclications.

Logic favors the first of these explanations, however, for

two reasons. First, physicians dealing with unsuccessful anti20
TableP. Number of all new-problem and return visits and percent of new-probkm and return visits involving antimii for each of the 20 principal

dmgnoses moat cornrnonty made during antimicrobial drug viaik United Ststeaj 1980-81

New-problem visits Return visits

Percent Percent

that were that were

Principal diagnosis Number in antimicrobial Number in antimicrobial

and /CD-9-CM code’ thousands dmg visits thousands drug visits

Suppurativeandunspecifiedotitismedia . . . . . . . . . . . . . . . . . . . . . . . (382) 11,539 86.6 13,315 66.9

Acute upper respiratory infections of multiple or unspecified sites . . . . . . . . . (465) 18,803 56.4 11,100 70.5

Acute pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (462) 11,557 75.5 6,277 81.7

Oiseases ofsebaceous glands . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (706) 5,320 53.0 14,920 71.1

Bronchitis, not specified as acute or chronic . . . . . . . . . . . . . . . . . . . . . (490) 6,793 85.2 5,963 69.8

Acute tonsillitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (463) 5,.569 66.6 3,952 65.2

Chronic sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (473) 4,150 76.2 3,916

Other disorders ofurethra and urinary tract . . . . . . . . . . . . . . . . . . . . . . (599)

63.5

4,344 87.6

Cystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (595)

4,260 57.9

2,923 66.6 3,186 65.8

Acute bronchitis and bronchiolitis . . . . . . . . . . . . . . . . . . . . . . . . . . . (466) 3,099 81.4 2,213 76.0

Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(487) 4,507 55.6 1,415 63.2

Streptoeoccal sorethroatand scarlet fever . . . . . . . . . . . . . . . . . . . . . . (034) 2,363 88.6 1,204 6$.3

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(493) 2,023 38.6 8,923 16.9

Pneumonia, organism unspecified. . . . . . . . . . . . . . . . . . . . . . . . . . . (486) 1,544 78.8 1,932 52.6

Inflammatorydiseasesofprostate . . . . . . . . . . . . . . . . . . . . . . . . . . . (601) 836 91.1 2,205

Othercellutitisand abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..(662)

65.3

1,837 66.9 1,769

DLsordersofexfernaiear.... . . . . . . . . . . . . . . . . . . . . . . . . . . ..(360)

51.0

4,860 29.3 2,388

Inflammatory disease ofcervix, vagina, and vulva. . . . . . . . . . . . . . . . . . (616)

21.0

3,765 26.1 3,230 24.8

Nonsupportive otitismedia and Eustachian tube disorders . . . . . . . . . . . . . . (361) 1,889 37.0 3,521 26.6

Inflammatory disease of ovary, fallopian tube, pelvic cellular tissue,

and peritoneum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (614) l,loa 66.2 1,552 53.4

~Based on the lntematkwral Classificsfion of Diseases, Sth Revision, Clinical hkdir?cation (lCD-S-CM).~3

microbial therapy may substitute different antimicrobial medications for the ineffective ones. To the extent that they occurred, such changes of medication are not reflected in these

data. Second, although all of the statistics on the continuing

use of medications may reflect some incomplete reporting,

there is no reason to expect the amount of such incomplete

reporting to vary among the specific diagnoses examined here

as substantially asthe observed usage differences varied.

Patient demographics

A significant majority (55.7 percent) of all antimicrobial

drug visits were made by females (see table Q). It is noteworthy

that this proportion is significantly smaller than the proportion

of all other visits made by females (61.2 percent).

Female patients also accounted for a majority of the visits

associated with each major type of antimicrobial drug except

the cephalosporins.. The proportion of visits made by females

did not vary significantly among the groups of visits associated

with the different antimicrobial drug ~pes, with one notable

exception. Females made a larger proportion of the visits

in which miscellaneous antimicrobial were used than of the

visits associated with any other antimicrobial drug type except

the sulfonamides and trimethoprim. This may be attributable

to the inclusion of urinary tract antiseptics in the miscellaneous

antimicrobial drug category, with females receiving a disproportionate share of that drug subtype because they are particularly susceptible to urinary tract infections.

The relative youth of patients receiving antimicrobial drugs

is apparent in a comparison of the percent distribution of

all antimicrobial visits according to patient’s age with the

comparable distribution for all other visits. Fully one-third

(34.9 percent) of all antimicrobial drug visits were made by

children under the age of 15. In contrast, the proportion of

all other office visits made by children was less than half

of this (15.5 percent). The proportion of antimicrobial drug

visits made by the next youngest age group, 15–24 years,

again was larger (17.7 percent) than the proportion of all

other visits made by that age group (13.1 percent), but the

difference is not as striking. Visits involving antimicrobial

drugs were correspondingly less concentrated in each of the

older patient age groups than all other visits were.

Children under the age of 15 years made almost half

of all visits involving the penicillins (49.0 percent), and also

made about one-third of the visits associated with the use

of macrolides and lincosarnides (36.4 percent), cephalosporins

(33,9 percent), and the sulfonamides and trimethoprim (32.4

percent). Undoubtedly because of the medical limitations on

the use of tetracycline, children accounted for only 6.6 percent

of all visits in which these drugs were used.

The overall rate of antimicrobial drug visits for the civilian

noninstitutionalized population was 423.8 per 1,000 per year.

The major drug type with the highest rate was the penicillins

(174.7 per 1,000 population per ye8r). This was approximately

double the rate of each of the two groups that ranked second

(maerolides and Iincosamides, with a rate of 86.8, and tetracycline, with a rate of 74.3). The visit rates for the remaining

three major types of antimicrobial drug did not differ significant]y among themselves.

For all antimicrobial drug visits, the female rate of 456.1

per 1,000 population per year was 17 percent higher than

the male rate of 389.3. With only one exception, the remaining

rates for the sex, age, and antimicrobial drug groups displayed

the same patterns that appeared among the corresponding drug

mention rates. The exception was that the age-specific rates

for visits involving macrolides and lincosamides showed a

significant decrease with age, followed by stable use rates.

The visits associated with the different major groups and

subtypes of antimicrobial drugs dk+playedstriking differences

21
Table Q. Number, pereent diatrbulfon, and averaga annual rate (per 1,000 civilian noninabhdionalized “ population) of antimicrobialdrug visits bysex and

age ofpatient aceonthgto typeofan6nrierobial drugorderedor provided:United State% 19SLW61

Type of antimicrobial drug

Macrolides Sulfonamides

Cephalo- arrd and

Sex and age of patient

MisceIlanaous

Ail types Penicillins spon”ns Iirrsossmidas Tetracycline tnmethoprim antimismbials

Allantimicrobial drug visits . . . . . . . . . . . . . . . . . .

Sex

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

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

Age

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

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

2544yeara . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 yeara . . . . . . . . . . . . . . . . . . . . . . . . .

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

Allantimicrobial drug visits . . . . . . . . . . . . . . . . . .

Sex

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

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

Age

Under 15yeara . . . . . . . . . . . . . . . . . . . . . . . .

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

25+4years . . . . . . . . . . . . . . . . . . . . . . . . .

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

65yearsandover . . . . . . . . . . . . . . . . . . . . . .

Allantimicrobialdrugvisits.... . . . . . . . . . . . . . .

Sex

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

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

Age

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

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

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

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

65yearsandover . . . . . . . . . . . . . . . . . . . . . .

188,754

63,636

105,117

65,603

33,463

41,915

28,864

16,669

100.0

44.3

55.7

34.9

17.7

22.2

15.3

9.9

423.8

389.3

456.1

647.3

411.0

334.5

328.5

381.2

77,611

36,206

41,605

38,112

11,977

14,286

6,817

4,609

100.0

46.5

53.5

49.0

15.4

18.4

11.3

5.9

174.7

168.5

180.5

374.9

147.1

114.1

100.3

94.0

Numbarin thousandal

15,699 38,663 33,104

7,639 16,991 14,696

8,060 21,672 18,408

5,325 14,067 2,201

2,118 7,951 9,766

3,646 8.550 10.141

2;963 5;458 6;514

1.425

100.0

48.7

51.3

33.9

13.5

24.5

19.0

9.1

35.3

35.6

35.0

52.4

26.0

30.7

33.9

29.1

2,617

Percent distribution

100.0

43.9

56.1

36.4

20.6

22.1

74.1

6.8

Average annual rate

86.8

79.1

94.0

138.6

97.7

66.2

62.1

53.4

4,4S2

100.0

44.4

55.6

6.6

29.5

30.6

19.7

13.5

74.3

66.4

79.9

21.7

119.9

80.9

74.1

91.4

18,515

7,889

10,626

5,991

1,869

3,599

3,441

3,615

100.0

42.6

57.4

32.4

10.1

19.4

18.6

19.5

41.6

36.7

46.1

58.9

23.0

28.7

39.1

73.7

16,282

5,478

10,s04

2,754

2,807

4,395

3,325

2,901

100.0

33.6

66.4

16.9

17.9

27.0

20.4

17.6

36.6

25.5

46.9

27.1

35.7

35.1

37.8

59.2

%ums of types do not equal totals baosuse mora rftarrone typ.sof anlinicmbial drug was ordered or providsd during some vista.

in patient age, which are best illustrated by using medkin

patient ages. Table Rshowsthat the median patient age for

all antimicrobial drug visits was 23.5, substantially lower

than the median patient age of 39.1 observed for all other

visits. This undoubtedly reflects both the relatively great susceptibility of youth to infection and the relatively low preva-

]enceofchroniccondhions amongyouth.

The major antimicrobial di-uggroup visits with the lowest

median patient ages were the visits associated with the penicilIins(with amedian patient ageof 15.9),the visits involving

the macrolides and lincosamides (with a median patient age

of 20.1), and the visits in which the cephalosporins (with

amedian patient ageof 27.6) were used. The median patient

ages for the groups of visits involving the remaining major

types of drug ranged from 31.0 to 34.8.

22

The low median patient age for the visits involving the

penicillins is partly attributable totheextremely low median

patient age (4.6 years) for the visits in which the subtype

amoxicillin was used. Similarly, the low median patient age

for the visits involving the cephalosporins reflects the inclusion

ofvisits inwhich the subtypeofsecond generation cephalospotins (for which the median patient age was only 6.9 years)

was used. The extremely low median patient ages for the

visits in which these two drug subtypes were used result

from the high proportion of visits during which suppurative

and unspecified otitis media were recorded as the principal

diagnosis. This condition, which occurs most frequently in

children under 5 years of age, accounted for one-third of

the visitsin which amoxicillin or second generation cephalosporins were used.
Table R. Med@nage ofpstients making antimicrobml drugvisits, bytype

and selected subtype of antimicrobial drug ordered or provided:

United States, 1980-61

Median age

Type and selected subtype of antimicrobial drug in years

Allantimicrobial drugvisite . . . . . . . . . . . . 23.5

Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . 15.9

Penicillin . . . . . . . . . . . . . . . . . . . . . . . . 19.5

Amoxicillin . . . . . . . . . . . . . . . . . . . . . . . 4.6

Ampicillin . . . . . . . . . . . . . . . . . . . . . . . . 23.1

Cephalosporins . . . . . . . . . . . . . . . . . . . . . . 27.6

Frrstgeneration . . . . . . . . . . . . . . . . . . . . . 31.8

Second generation . . . . . . . . . . . . . . . . . . . 6.9

Macrolidesand iincosamides. . . . . . . . . . 20.1

Erythromycin . . . . . . . . . . . . . . . . . . . . . . 19.9

Other . . . . . . . . . . . . . . . . . . . . . . . . . . 21.0

Tetracycline . . . . . . . . . . . . . . . . . . . . . . . 31.0

Short-acting . . . . . . . . . . . . . . . . . . . . . . . 30.7

Intermediate- andlong-acting . . . . . . . . . . . . 32.6

Sulfonamides andtrimethoprim . . . . . . . . . . . . . 31.9

Sulfonamidea andttfmethoprimin combination . . . . 26.5

Mieeellaneousantimicrobials . . . . . . . . . . . . . . . 34.8

Urinarytractantiseptics . . . . . . . . . . . . . . . 55.1

Antifungal agents fornonsystemic mycoses. . . . . 29.1

NOTE Morethan one&F orsubwpe ofantimicrotialdmgwasordered orprovideddunng

same visits

Vkhs associated with the use ofmiscellaneous antimicrobial showed a similar effect in that the overall median patient

age of 34.8 was raised through the inclusion of visits in

which urina~ tract antiseptics were used. In the Iatter visits,

the median patient age was 55.1, reflecting the relatively

high susceptibility of the elderly, particularly women, tourinary tract infections.

The final patient demographic characteristics to be considered are race and ethnicity. Of all antimicrobial drug visits,

89.2 percent were made by white persons, 9.7 percent were

made by black persons, and 1.1 percent were made by persons

of other races. Also, 4.9 percent of the visits were made

by persons of Hispanic origin. Neither of these distributions

differs significantly from those observed in the visits not involving antimicrobial drugs.

Physicisn characteristics

The distribution of antimicrobial drug visits among the

various physician specialties is dLsplayed in table S. General

and family practitioners handled the largest proportion of these

visits (43.3 percent), followed by medical specialists (40.3

percent). Approximately half of all visits to medical specialists

were made to pediatricians (22.3 percent of all antimicrobial

drug visits). Surgical specialists handled a significantly smaller

proportion ofallantimicrobial drug visits (14.1 percent), and

other specialists handled the smallest amount (2.3 percent).

This distribution was quite different from that observed for

all other visits. Antimicrobial drug visits were made to general

and family practitioners and to medical specialists substantially

more often than all other visits were. (Of all other visits,

30.8 percent were made to general and family practitioners

and 29.2 percent were made to medical specialists.) Correspondingly fewer antimicrobial drug visits were made to surgical

and other specialists. (Of all other visits, 33.9 percent were

made to surgical specialists and 6.0 percent were made to

all other specialists. ) Because the conditions for which the

antimicrobial drugs were used are usually managed medically,

rather than surgically, this relatively high concentration of

antimicrobial drug visits among medical practitioners was

expected.

The physician specialty distribution of the antimicrobial

drug visits varies with the major type of antimicrobial drug

used. The proportion of visits made to general and family

practitioners was smaller for miscellaneous antimicrobial than

foranyother major drug group (29.3 percent compared with

a range of 40.4 percent to 47.2 percent). This stems from

the fact that this drug group includes urinary tract antiseptics

used for urinary tract infections, which are frequently treated

by gynecologists. In fact, visits to obstetricians and

gynecologists accounted for a substantially larger proportion

of the visits involving this major drug group than of the

visits associated with any other major drug group (15. 2 percent

compared with a range of 1.1 percent to 3.3 percent ).

The visits during which the n-iacrolides and lincosamides

were ordered or provided were made to medical specialists

more frequently than were the visits involving the other types

of antimicrobial drug (50.5 percent, compared with a range

of 26.7 percent to 41.7 percent). These visits, along with

those involving tetracycline, were made to dermatologists

more frequently than were the visits during which the other

types of antimicrobial drug were ordered or provided (19.4

percent and 29.5 percent, respectively, compared with a range

of 0.6 percent to 8.2 percent). This is because of the relatively

high frequency of diseases of the sebaceous glands as the

principal diagnosis in the visits involving these two types

of drug.

Solo practitioners accounted for the majority (56. 7 percent) of all antimicrobial drug visits. Although this was significantly higher than the comesponding proportion for all

other visits (54.4 percent), the difference was only a slight

one. Most antimicrobial drug visits were divided almost equally

between physicians under 45 years of age (42.5 percent) and

physicians 45-60 years of age (43.3 percent). Neither of these

proportions differed significantly from the corresponding proportions for all other visits.

A comparison of the regional distributions of the antimicrobial drug visits and of all other visits reveals that the

former were significantly more concentrated than the other

visits in the South (38.8 percent compared with 31.4 percent).

In addition, the antimicrobial drug visits were significantly

less concentrated in the Northeast (20.1 percent compared

with 24.3 percent) and West ( 15.2 percent compared with

19.0 percent). Although the South had the highest average

annual rate of antimicrobial drug visits for the civilian noninstitutionalized population (496.8 per 1,000), the rates for the

other regions did not differ significantly among themselves.

The average annual rate of antimicrobial drug visits was 412.2

per 1,000 population for the North Central Region, X! 1.-1

for the Northeast, and 350.3 for the West.

Finally, 72.5 percent of all antimicrobial drug visits took

place in metropolitan areas. Although this was significantly

23

,
Table S. Number and percent distribution of antimicrobml drug visits by physician speciatty, according to type of antimicrobial drug ordered or provided:

United States 1980-81

Type of antimicrobial drug

Macrolides Stdfonamidea

Caphalo- and and Miscellaneous

Physician special~ All types Penicillins sporins Iincosamides Tetracycline trimethoprim antimicmbiajs

All specialties . . . . . . . . . . . . . . . . . . . . . . .

General and family practice . . . .

Medical specialties . . . . . . . . . . . . . . . . . . . . .

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

Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatology . . . . . . . . . . . . . . . . . . . . . . .

ofher medical specialties . . . . . . . . . . . . . . . . .

Surgical specialties . . . . . . . . . . . . . . . . . . . . . .

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

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

Urology, . . . . . . . . . . . . . . . . . . . . . . . . . .

Other surgical specialties . . . . . . . . . . . .

All other specialties . . . . . . . . . . . . . . . . . . . . . .

All specialties . . . . . . . . . . . . . . . . . . . . . . . . .

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

Medical specialties . . . . . . . . . . . . . . . . . . . . . .

Internal mecticine . . . . . . . . . . . . . . . . . . . .

Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatology . . . . . . . . . . . . . . . . . . . . . . . .

Other medical specialties . . . . . . . . . .

Surgical specialties . . . . . . . . . . . . . . . . . . . . . .

General surgety . . . . . . . . . . . . . . . . . . . . . .

Obstetrics andgynecology. . . . . . . . . . . . .

Urology . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other surgical specialties . . . . . . . . . . . .

All other specialties . . . . . . . . . . . . . . . . . . . . . .

188,754

81,811

76,025

14,692

42,022

16,698

2,412

26,606

5,853

6,726

6,120

7,907

4,312

100.0

43.3

40.3

7.8

22.3

9.0

1.3

14.1

3.1

3.6

3.2

4.2

2.3

77,811

36,702

31,722

4,681

25,671

481

688

7,501

2,354

2,335

’411

2,401

1,886

100.0

47.2

40.8

6.3

33.0

0.6

0.9

9.6

3.0

3.0

“0.5

3.1

2.4

15,699 38,663

7,350 15,851

4,596 19,514

1,381 2,806

2,812 8,832

“167 7,511

’236 ’365

3,269 2,729

1,327 981

’285 “442

“428 “14

1,229 1,292

484 569

100.0

46.8

29.3

6.8

17.9

“1.1

“1.5

20.8

8.5

●1.8

‘2.7

7.8

3.1

Percent distribution

100.0

41.0

50.5

7.3

22.8

19.4

“0.9

7.1

2.5

‘1.1

“0.0

3.3

1.5

33,104

14,814

13,794

3,070

“419

9,751

555

3,777

884

1,102

886

906

718

100.0

44.7

41.7

9.3

“1.3

29.5

1.7

11.4

2.7

3.3

2.7

2.7

2.2

18,515

7,484

6,470

1,661

4,187

“197

’426

4,216

●304

617

2,630

666

“344

100.0

40.4

34.9

9.0

22.6

‘1.1

“2.3

22.8

*1.6

3.3

14.2

3.6

“1.9

18,282

4,777

4,4339

1,172

1,659

1,329

“180

6,774

!581

2,4s0

1,972

1,740

100.0

29.3

26.7

7,2

10.2

8.2

‘1.1

41.6

3.6

15.2

12.1

10.7

‘2.4

lSums of types do not equal totals because more than one lype of antimicrobial drug was ordered or provided during some visits.

smaller than the comparable proportion of all other office

visits (76.7 percent), the difference was not a substantial

one.

Visit conduct

At least one specific diagnostic service was ordered or

provided during most antimicrobial drug visits (95.9 percent).

Antimicrobial drug visits were more likely than all other visits

to involve a single diagnostic service (57.9 percent compared

with 41.6 percent) and less likely to involve two, three or

more, or none at all (27.3 percent compared with 31.2 percent,

10.7 percent compared with 18.3 percent, and 4.1 percent

compared with 8.9 percent, respective]y).

The specific diagnostic service most commonly ordered

or provided during antimicrobial drug visits was a limited

examination and/or history, which was done in almost threefourths (72.8 percent) of these visits (see tabie T). The next

most common diagnostic services, clinical laboratory tests

and blood pressure checks, appeared only one-third as frequently (in 24.7 percent and 23.9 percent of visits, respectively), followed by a general examination and/or history,

which was performed in 14.1 percent of visits. Least common

were x rays, ordered or provided in 4.6 percent of the visits,

and Pap tests, ordered or provided in 1.7 percent of the

visits. The usage of every one of these tests during these

24

visits differed significantly from their usage in all other visits.

In all other visits, a limited examination and/or history was

used less frequently (62.7 percent of visits), as was clinical

laboratory testing (21.4 percent). All other diagnostic services

were used more frequently: blood pressure check (used in

36.2 percent of all other visits), x ray (8.0 percent), Pap

test (4.9 percent), and a general examination and/or history

(15.7 percent).

The visits associated with the different major types of

antimicrobial drug show some variation in the use of diagnostic

services. Clinical laboratory tests were utilized most frequently

in visits involving the sulfonamides and/or trimethoprim (47. 1

percent) orone or more of the miscellaneous antimicrobial

(37.5 percent). In contrast, only 15.9 percent to 24.5 percent

of the visits associated with any other major drug type involved

these tests. Similarly, a Pap test was ordered or provided

in almost one-tenth (9.1 percent) of the visits associated with

use of the miscellaneous antimicrobial, compared with only

0.3 percent to 2.6 percent of the visits associated with the

use of each other drug type. This is undoubtedly a consequence

of the fact that the visits involving miscellaneous antimicrobial

were made to physicians who specialized in obstetrics and/or

gynecology far more frequently than any other group of visits

was.

.,

‘- —_

-— -1
Table T. Nmkrand ~rcentof antMwroM4dmg tiafis, by~ofanti*tial dwtiertim~ad~~ti~

United Stateaj 1960-S1

ordered or provMed

Type of antimicrobial drug

Macrolides .Wfonamties

CephaloDiagnostic serviceand and Misoellarreous

All ~S Penicillins spwins Iincosamides Tetracyciirres trimethoprim antimicrobial

Limited historylexam . . . . . . . . . . . . . . . . . . . . .

General historyfexam . . . . . . . . . . . . . . . . . . . . .

Paptest . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Clinical labtest . . . . . . . . . . . . . . . . . . . . . . . .

Bray . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bloodpressurecheck . . . . . . . . . . . . . . . . . . . .

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

Limitedhistory/exam . . . . . . . . . . . . . . . . . . . . .

Generalhistory/exam . . . . . . . . . . . . . . . . . . . . .

Paptest . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Clinical labtest . . . . . . . . . . . . . . . . . . . . . . . .

Bray, . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bloodpressure check . . . . . . . . . . . . . . . . . . . .

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

137,466

26,582

3,270

46,662

6,738

45,201

9,836

72.8

14.1

1.7

24.7

4.6

23.9

5.2

56,663

13,004

750

19,067

2,905

16,346

3,336

73.1

16.7

1.0

24.5

3.7

21.0

4.3

Numberinthousandsl

11,660 29,499 23,730

2,326 4,377 3,278

“55 “131 538

3,498 6,132 5,425

1,099 1,662 1,782

4,385 7,336 9,514

611 1,696 1,537

Percent

74.3 76.3 71.7

14.6 11.3 9.9

‘0.4 ‘0.3 1.6

22.3 15.9 16.4

7.0 4.6 5.4

27.9 19.0 26.7

5.2 4.4 4.6

12,713

2,816

462

8,719

650

5,384

1,522

66.7

15.2

2.6

47.1

3.5

29.1

8.2

10,924

2,353

1,461

6,108

661

5,034

1,566

67.1

14.5

9.1

37.5

4.1

30.9

9.6

~Sumsof antim”krobial drug types donotequaltotsls because more than one type of drug waaordered or provided during some visirs.

An examination of the specific diagnostic services used

in the antimicrobial drug visits with the 20 most common

principal diagnoses reveals significant differences. The visits

most likely to involve no diagnostic services were those in

which the patients were diagnosed as having diseases of the

sebaceous gkmds (28.4percent) .Alimited examination and/or

history was conducted in approximately 6 of every 7 visits

in which the patient’s principal diagnosis was nonsuppurative

otitis media and Eustachian tube disorders (86.1 percent) or

other cellulitis andabscess (84.4 percent). Ageneralexamination and/or history was ordered or provided in 33.2 percent

of the visits made by patients with inflammatory disease of

ovary, fallopian tube, pelvic cellular tissue, and peritoneum,

and27.6percent ofthevisits made bypatientswith pneumonia

(organism unspecified). For four of the diagnoses, clinical

laboratory tests were ordered or provided in more than half

of the visits: cystitis (75.6 percent) ; other disorders of urethra

and urinary tract (74.3 percent); inflammatory diseases of

prostate (65.0 percent); and inflammato~ disease of cervix,

vagina, and vulva (54.8 percent). The only other diagnostic

service that was frequently ordered or provided was a blood

pressure check, which was done in more than two-fifths of

the vists for three of the most common principal diagnoses:

inflammato~ disease of ovary, fallopian tube, pelvic cellular

tissue, and peritoneum (46.8 percent); inflammato~ disease

of cervix, vagina, and vulva (44.3 percent); and other disorders

ofurethra andurinary tract (40.3 percent). The two remaining

services each were used extensively in the visits associated

with only one of the most common diagnoses: x rays were

ordered or provided during 44.7 percent of the visits made

by patients with pneumonia, organism unspecified; and Pap

tests were used in 42.0 percent of the visits made by patients

with inflammatory disease of cervix, vagina, and vulva.

In addition to these diagnostic services, some visits in

which antimicrobial drugs were ordered or provided also involved the use of nonmedication therapeutic services. LJsage

of these services, however, was significantly lower in these

visits than in all other visits. Two-thirds (65.2 percent) of

the antimicrobial drug visits, but only half (51.6 percent)

of all other visits, involved no nonmedication therapy. One

of these services was used in 30.6 percent of the antimicrobial

drug visits; two or more were used in only 4.2 percent. Of

all other visits, 40.2 percent involved one nonmedication

therapeutic service, and 8.2 percent involved two or more

of these services.

Specific therapeutic services involved in the antimicrobial

drug visits are shown in table U. The most common service

was medical counseling, which was reported for 22.0 percent

of these visits. The second most common was office surgery

(6.4 percent). Both of these services were ordered or provided

during all other visits at similar rates (23.2 percent and 7.6

percent, respectively). Less commonly used services during

antimicrobial drug visits were diet counseling (3.9 percent),

physiotherapy (3.7 percent), and all other nonmedication

therapeutic services (3.2 percent). Each of these types of

service was used significantly more frequently during all other

visits—8.9 percent, 5.1 percent, and 12.3 percent,

respectively.

The use of these therapeutic services varied little among

the groups of visits associated with the use of the different

major types of antimicrobial drug. The sole exception was

office surgery, which was used in the visits made by patients

who received tetracycline significantly more frequently than

in the visits made by patients receiving any of the other

drugs (13.8 percent compared with a range of 2.7 prcent

to 8.5 percent).

Far more variation in the use of the therapeutic services

appears when the visits with the 20 most common principal

diagnoses are inspected. Patients with diseases of the sebaceous

glands had the lowest rate of visits with no nonmedication

therapeutic services. Only 39.1 percent of the visits made

by these patients resulted in none of these services being

25
Table U. Number and percent of antimicrobial drug visits by type of antimicrobial drug ordered or provided and nonmedication therapeutic service

ordered or provided: United States, 1980-61

Type of antimicrobial drug

Macrolides Sulfonamides

Cephafo- and

Nonmedication therapeutic service

and Miscellaneous

All types Penicillins sporins Iirmosamides Tetracyc\ines trimethoprim antimicrobial

Number in thousands’

Physiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . 6,924 1,822 843 1,762

Otfice surgery . . . . . . . . . . . . . . . . . . . . . . . . .

2,193 “353 527

12,109 2,065 1,093 3,276

Diei counseling . . . . . . . . . . . . . . . . . . . . . . . .

4,563 1,036

7,429

1,306

2,251 609 1,249

Medical counseling ..,.... . . . . . . . . . . . . . . .

1,505 1,396 797

41,604 17,415 3,750 7,297

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

6,785 4,756

6,112

4,198

1,690 586 1,005 1,082 818 1,290

Percent

Physiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . 3.7 2.3 5.4 4.6

Officesurgery . . . . . . . . . . . . . . . . . . . . . . . . .

6.6 “1.9

6.4

3.2

2.7 7.0 8.5

Dietcounseling . . . . . . . . . . . . . . . . . . . . . . . .

13.8 5.6

3.9

8.0

2.9 3.9 3.2 4.5 7.5 4.9

Medical counseling.....,,. . . . . . . . . . . . . . . 22.0 22.4 23.9 18.9

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

20.5 25.7 25.8

3.2 2.2 3.7 2.6 3.3 4.4 7.9

‘Sumsof anfimicmblaldrugtypesdo notequaltolalabecausemorethanone rypeofdrugwas orderedor providedduringsomevisits.

ordered or provided. In contrast, at least three-fourths of the

visits made by patients with four ofthese diagnoses involved

none of these nonrnedication therapeutic serv ices: streptococcal

sore throat and scarlet fever (80.7 percent): acute pharyngitis

(79.7 percent): acute upper respiratory infections of multiple

or unspecified sites (77.4 percent); and intluenza (75.5 percent). Visits made by pdtients with diseases of the sebdceous

glands involved office surgery far more frequently than did

the visits made by patients with any of the other leading

diagnoses (38.2 percent, compared fith a range of 0.0 percent

to 15.6 percent). These visits also hadthehighest statistically

reliable proportion of visits with physiotherapy ( 12.9 percent).

The disposition of patients who received antimicrobial

drugs differed substantially from that of other patients. In

almost half of all antimicrobial drug visits (48.7 percent),

the patients were instructed to return at a specified time,

and in one-third of these visits (34.1 percent) the patients

were told to return if needed. During the visits in which

antimicrobial drugs were not used, patients were asked to

return at a specified time more frequently (63.0 percent),

and were asked to return if needed less frequently (20.5 percent). This Iarge difference reflects therelatively high concentration of acute, rather than chronic, conditions among the

patients who made the antimicrobial drug visits. The patients

who made these visits also were significantly more likely

than all other patients to be told they needed no followup

(12.9 percent of visits compared with 11.2 percent) or to

be requested to follow up by telephone (4.9 percent compared

with 3.2 percent), and were significantly less likely to have

any other disposition (2.8 percent compared with 6.3 percent).

An inspection of thepatient disposition data forthe antimicrobial drug visits during which the 20 most common principal diagnoses were recorded reveals that disposition also varied

with diagnosis. For two of the most common diagnoses-diseases of the sebaceous glands and inflammatory disease of

ovary, fallopian tube, pelvic cellular tissue andperitoneum—

the patients were asked to return at a specified time in at

least three-fourths of the visits (87.8 percent and 76.3 percent,

respectively). For another three of the diagnoses, the patients

26

were asked to return if needed during at least half of the

visits. These diagnoses were influenza (58.3 percent), acute

respiratory infections of multiple of unspecified sites (51.5

percent), and acute pharyngitis (5 1.4 percent).

The duration of visits is the last aspect of visit conduct

to be investigated. In a large majority of all antimicrobial

drug visits (67.9 percent), the physician spent 6-15 minutes

with the patient. A significantly smaller proportion of visits

( 18.0 percent) lasted 16 minutes or longer, and the smallest

proportion ( 14.0 percent) involved O-5 minutes of physicianpatient contact. Antimicrobial drug visits differed from all

other visits in that they were more likely to last 6-15 minutes

(67.9 percent compared with 55.9 percent) and significantly

less likely to last O-5 minutes ( 14.0 percent compared with

15.4 percent) or 16 minutes or longer ( 18.0 percent compared

with 28.7 percent). The relatively small concentration of antimicrobial drug visits in the longest duration category can

be explained by the relatively limited and acute nature of

the diseases being treated and by the relative youth of the

patients. Younger patients are less likely than older patients

to have multiple conditions complicating diagnosis and

treatment.

Co-occurring drugs

The final topic to be considered in this report concerns

the extent to which other medications were used in conjunction

with antimicrobial medications. There were 172.5 million coo.ccurring drug mentions during the 1980 and 1981 antimicrobial drug visits. This was an average of 0.91 co-occurring

drugs per visit. (See table W.) The averages for visits made

by male patients (0.85) and by female patients (0.96) did

not differ significantly.

However, other medications were used in conjunction

with the antimicrobial medications significantly less frequently

among the younger patients than among the older patients.

The average number of co-occurring drugs for each of the

three youngest age groups-O. 71 for visits made by children

under 15 years of age, 0.88 for visits made by patients 15–24

years of age, and 0.90 for visits made by patients 25-44

–—----
Table W. Average narrber of cO-oocurrirlgmedkatW*per “ -

paaent Unii state% 1960-81

~wmbwmd~ drugatkrodorprwidsdmdsexmdagsof

TMX?oisnthhbWdrug

Capirab- &

Sex and age ofpakvrt

andwscswmw

All ~/X?S Pmricwra LyOrina huwwMas Wrsqc#as Winmw@n mMwmbah . . .

Allantimicrobialdrugvisits . . . . . . . . . . . . . . . . . . 0.91 0.89 0.96 1.18 1.38 0.62 0.s6

sex .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.85 0.88 0.91 1.10 1.31 0.72 0.60

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.96 0.90 1.00 1.24 1.45 o.@ 1.05

Age

Under15yeam . . . . . . . . . . . . . . . . . . . . . . . . 0.71 0.73 0.80 0.66 1.37 0.76 0.76

15-24years . . . . . . . . . . . . . . . . . . . . . . . . . 0.66 0.87 0.76 1.27 1.37 0.85 0.65

25-44yeare . . . . . . . . . . . . . . . . . . . . . . . . . 0.20 0.84 1.01 1.27 1.21 0.72 0.76

45-84years . . . . . . . . . . . . . . . . . . . . . . . . . 1.16 1.18 1.23 $.51 1.54 0.85 1.@

S5yearsandover . . . . . . . . . . . . . . . . . . . . . . 1.34 1.60 1.18 1.50 1.61 1.08 1.42

years ofage—was significantly lower than each ofthecorrespending averages for the two oldest age groups (1.16 for

visits made by persons 45-64 years of age, and 1.34 for

those made by persons 65 years of age and older). This

finding is at least partly explained by the gradual accretion

of chronic conditions requiring maintenance medication

therapy among the elderly and aging.

The average number of co-occurring drugs per visit for

the groups of visits associated with each of the major types

of antimicrobial drug ranged from 0.82 for the sulfonamides

and trimethoprim to 1.39 for tetracycline. Of the visits made

by patients 15–24 years of age, those involving tetracycline

and those involving macrolides and lincosamides also involved

the order or provision of significantly more co-occurring drugs

than did the other groups of visits (1.37 per visit and 1.27

per visit, respectively, compared with a range of 0.65 to

0.87 per visit). Because diagnoses of diseases of the sebaceous

glands were particularly common in the visits associated with

these two types of drug, this difference may result from a

high rate of ordering skin preparations to treat this condition.

The distribution of the types of co-occurring drugs, as

classified in the American Hospital Formulary Service classification system,s are displayed in table Y. For all antimicrobial

drug visits, four specific thug types were used in conjunction

with the antimicrobial drugs significantly more frequently than

any other type was used. These were antihistamines (an average

of 15.3 million drug mentions pr year, or 17.7 percent of

all co-occurring drug mentions); skin and mucous membrane

preparations (14.3 million per year, or 16.6 percent); expectorants and cough preparations (12.2 million per year, or 14.2

percent); and central nervous system drugs (10.9 million per

year, or 12.7 percent).

The most commonly used co-occurring drugs varied

among the groups of visits associated with the different major

types of antimicrobial drug. In the visits in which one or

more of the penicillins were used, the patients also were

ordered or provided with 40.3 percent of all co-occurring

dregs. During these visits, the most frequently used drugs

were antihistamines (21.9 percent of the co-occurring drugs

associated with the penicillins), expectorants and cough preparations (16.5 percent), and central nervous system drugs (13.9

percent).

The visits involving the macrolidcs and lincosamides accounted for 26.4 percent of ail co-occurring drugs, with four

categories used significantly more frequently than any other

category. These categories wem skin and mucous membrane

preparations (21.3 percent of all drugs used concurrently with

the macrolides and lincosamides), antihistamines (15.8 percent), expectorants and cough preparations (13.2 percent),

and anti-infective agents (12.8 percent). The latter drug category includes all anti-infective preparations except those classified as macroli&s and lincosamides; those classified as eye,

ear, nose, or throat preparations; and those classified as skin

and mucous membrane preparations.

The visits in which one or mote tetracycline wete used

accounted for 26.6 percent of all co-occurring drugs. Of these,

the largest category was skin and mucous membrane preparations (27.5 percent). The visits involving the misdaneous

antimicrobial mdlcations accounted for only 9.1 percent of

all co-occurring drug mentions. During these visits, the two

most frequently used drug categories were anti-infective agents

(20.2 pement) and skin and mucous membrane preparations

(20. 1 percent). (For the miscellaneous antimicrobial drug via-,

its, the anti-infective agent category excludes anti-infective

agents classified as miscellaneous antimicrobial in this repoti,

anti-infective drugs classified as skin and mucous membrane

preparations; and anti-infective drugs classified as eye, ear,

nose, or throat preparations.)

Of all co-occurring drugs, 8.7 percent were associated

with the use of cephalosporins, and 8.8 percent were associated

with the use of the sulfonamides and trimethoprim. The visits

associated with the use of these two major types of antimicrobial drug did not involve any one category of co-occurring

drug to a noteworthy degree.

Table Z presents the 10 specific dmg names most frequently mentioned in conjunction with the antimicrobial med.

cations. Together they accounted for only 15.5 percent of

all co-occurring drug mentions. This illustrates how the co-occurring drug mentions wem spread across a wide variety of

drug products rather than concentrated injust a few.

27
TsWr Y. Number and perqent distributionof co-ooourring druga ordered or provided during antimicrobial drug visits by therapeutic category of

ctwccurring dq according to type of antirniirobial drug ordered or providesk United State% 19S0-S1

Type of antimicrobial drug

Macro fides Sulfonamides

Cephalo- and and

Therapeutic category’

Miscellaneous

All types Penicillins sporins Iincosamides Tetracycline trimethoprim an,timicrobials

Allco-occurring drugs . . . . . . . . . . . . . . . .

Antihistamines . . . . . . . . . . . . . . . . . . . . . . . .

Anti-infecfive agentss . . . . . . . . . . . . . . . . . . . . .

Autonomic drugs . . . . . . . . . . . . . . . . . . . . . . .

Cardiovsacular drugs . . . . . . . . . . . . . . . . . . . . .

“Centralnervous system drugs . . . . . . . . . .

Electrolytic, caloric, and water balance agents. . . . . . .

Expectorants and cough preparations . . . . . . . . .

Eye, ear, nose, and throat preparations . . . . . . . . . . .

Gaatrointesfinal drugs . . . . . . . . . . . . . . . . . . . .

Hormones and synthetic substances . , . . . . . . . . . . .

Skin and mucous membrane preparations . . . . . , . .

Spssmolyfic agents . . . . . . . . . . . . . . . . . . . . . .

Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . .

other . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allco-occurring drugs . . . . . . . . . . . . . . . . . . . .

Antihistamines . . . . . . . . . . . . . . . . . . . . . . . .

Anti-infacfive agentes . . . . . . . . . . . . . . . . . . . . .

Autonomic drugs . . . . . . . . . . . . . . . . . . . . . . .

Oerdiovascuiar digs . . . . . . . . . . . . . . . . . . . . .

Oentrst nervous system drugs . . . . . . . . . . . . . . . .

Eleefrolytic, csforic, andwater balance agents. . . . . . . .

Expectorants and cough preparations . . . . . . . . . . .

Eye, ear, nose, and throat preparations . . . . . . . . . . .

Gsetfoinleatinal drugs . . . . . . . . . . . . . . . . . . . .

Hormones and synthetic substitutes . . . . . . . . . . . . .

Skin and mucous membrane preparations . . . . . . . .

Spaamolytic agents . . . . . . . . . . . . . . . . . . . . . .

Viiamine . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ofhef l . . . . . . . . . . . . . . . . . . . . . . . . . . . .

172,531

30,527

2,080

7,670

7,537

21,861

6,851

24,470

7,787

4,474

10,266

28,673

6,372

4,015

9,949

100.0

17.7

1.2

4.4

4.4

12.7

4.0

14.2

4.5

2.6

6.0

16.6

3.7

2.3

5.8

69,510

15,190

6,435

3,036

2,335

9,696

1,907

11,496

3,559

1,925

2,712

4,288

2,093

1,044

3,795

100.0

21.9

9.3

4.4

3.4

13.9

2.7

16.5

,5.1

2.8

3.9

6.2

3.0

1.5

5.5

Number in thousand~

15,080 45,504

2,560 7,211

1,593 5,830

779 1,519

766 979

1,662 3,605

“361 1,165

2,166 6,013

749 2,105

’398 ’505

952 1,952

1,345 9,711

“558 2,170

’265 695

707 2,024

Parcent distribution

100.0 , 100.0

17.0 15.8

10.6 12.6

5.2 3.3

5.1 2.2

12.3 7.9

‘2.5 2.6

14.4 13.2

5.0 4.6

“2.6 ‘1.1

6.3 4.3

6.9 21.3

●3.7 4.8

“1.8 1.5

4.7 4.4

45,895

4,572

5,431

1,324

1,541

3,839

1,629

4,998

928

809

3,047

12,616

1,179

1,536

2,444

100.0

10.0

11.8

2.9

3.4

6.4

3.5

10.9

2.0

1.6

6.6

27.5

2.6

3.3

5.3

15,194

1,934

2,177

925

1,309

2,150

1,037

909

’419

666

993

1,240

“366

’409

659

100.0

12.7

14.3

6.1

8.6

14.2

6.8

6.0

“2.8

4.4

6.5

8.2

●2.4

‘2.7

4.3

15,686

743

3,165

“538

902

1,737

952

●199

815

“425

1,209

3,146

“217

’592

1,044

100.0

4.7

20.2

‘3.4

5.8

11.1

6.1

“1.3

5.2

“2.7

7.7

20.1

*1.4

●3.8

6.7

lArnarican Hospital Fonnulary Service Cfa.saificatisrrSystem and 7harapwaic Category rlxbs.e

‘SUMS of enfimicrobial drug types do M equal totals b%cauee some visits involved more than one type of entimicrob!al drug.

3For efl antimicmtial drug visii, tiia category includes only those drugs that are classified by the .4rrerican Hospila/FomruhryServiceclassification system as anti-infective agents and that are

nol inoluded in the typofogy of anfimicmbial madkafikms used in this rspat (for example, entivirals). For aach type of antimicrobial drug, this category also includes all antimicrobial drugs of other

types. (For example, for visits in wfIWI one or more penicillins were ordered or pmvidad, the anti-infective agent category of co-occurring drugs includes cephalosporins, tetracyclimes, and other

antimicrobial drugs, as well as antiviral and other anti-infective agents.)

4hsohstes smfinaoplasfii agentq bkd derfvafiveq blood formation and coagulation agenfq diagnostic agentq enzyrnew gold compounds, heavy metal antagonists; local snesthetiq oxytccics;

radiieofiie ege~ serums, toxoids and vaccines devicaq Ptrarmaceuk akk; and unclassified therapeutic agents.

T@rleZ. NterWr end percent dwtributiortof the 10 co-occurring drugs

most ffwfuentty ordered or provided during antirnii drug vieii by

dru(f narm United Stat= 19S0-S1

Number of

mentions Percent

Rank Co-occumng drug name in thousands distribution

All co-occurring drugs . . . . . . . 172,531 100.0

1 Oimetapp . . . . . . . . . . . . . . 5,544 3.2

2 Acfifed . . . . . . . . . . . . . . . 4,598 2.7

3 Phenergan expectorant

with codeine . . . . . . . . . . . 2,834 1.5

4 Retin-A . . . . . . . . . . . . . . . 2,250 1.3

5 Nsfdecon . . . . . . . . . . . . . . 2,105 1.2

6 Corfisporin . . . . . . . . . . . . . 2,084 1.2

7 A.S.A . . . . . . . . . . . . . . . . . 1,96s 1.1

6 Aspirin . . . . . . . . . . . . . . . 1,968 1.1

9 Tuss-Omade . . . . . . . . . . . . 1,819 1.1

10 Tylenol . . . . . . . . . . . . . . . 1,708 1.0

... All ofhere . . . . . . . . . . . . . . 145,856 84.5

Drug mention frequencies of 1million or more for specific

co-occurring drugs appeared in the 1980 and 1981 visits associated with only two of the major antimicrobial drug types.

Among the 38.7 million visits associated with the macrolides

and lincosamides during these 2 years, tetracycline was mentioned 1.4 million times, Dimetapp 1.3 million times, and

Actifed and Retin-A 1.1 million times each. Among the 33.1

million visits associated with the tetracycline during 1980

and 1981, Cleocin was mentioned 1.8 million ti]mes and

Retin-A was mentioned 1.4 million times. It is apparent that

acne patients accounted for many of these observations.

The final aspect of antimicrobial drug use to be ccmsidered

is the question of the extent to which two or more antimicrobial

drugs were used during the same visit. During 1980 and

1981, this occurred in a total of 19.0 million visits,, or 10.1

percent of all antimicrobial drug visits. Six specific combina28
tions of the major antimicrobial drug groups occurred at least

1million times each during these 2 years:

●

●

●

●

Two or more drug mentions classifiable as penicillins

were made in 5.1 million visits.

One or more macrolides and lincosarnides were used in

conjunction with one or more tetracycline in 3.0 million

visits.

One or more penicillins were used in conjunction with

one or more macrolides and Iincosamides in 1.7 million

visits.

One or more penicillins were used with one or more

tetracycline in 1.6 million visits.

. Two or more drugs of the macrolide and lincosamide

type were used simultaneously in 1.4 million visits.

. One or more penicillins were used in combination with

one or more of the miscellaneous antimicrobial drugs

in 1.1 million visits.

In addition, the antimicrobial drugs focused on in this report

were used in combination with the topical antimicrobial drugs

appearing in an earlier report in 11.7 million visits.’ This

represented 6.2 percent of all the 1980 and 1981 antimicrobial

drug visits examined in this report and 25.5 percent of all

the visits that involved topical antimicrobial drugs during these

2 years.

29
References

‘National Center for Health Statistics, G.J. Gardocki: Use of topical

antimicrobial drugs in office-based practice, United States, 1980-81.

Advance Data from Viral and Health Statistics. No, 106. DHHS

Pub. No. (PHS)85–1 250. Public Health Service. Hyattsville, Md.,

Apr. 10, 1985.

‘E. Abrutyn: A guide to antibiotics for ambulatory patients. Med.

Times. 109(3): 10G1O6, Mar. 1981.

3S Levin and G. M. Trenho]me: Use of antibiotics in the OU@derM

se;ting. Primary Care. 6(1): 3-12, Mar. 1979.

4M. C. McHenry and A. J. Weinstein: Antimicrobial drugs and

infections in ambulatory patients, some problems and perspectives.

Med. ClinicsN. Am. 67 ( 1): 3-66, Jan. 1983.

5The choice of antimicrobial drugs. Med. Letter. 24 (604): 2 1–28,

Mar. 5, 1982.

% J. Rehm and M. C. McHenry: Oral antimicrobial drugs. Med.

Cl;nicsN. Am. 67 (1): 57–98, Jan. 1983.

TNationa] Center for Health Statistics, J. B. Tenney, K. L. white!

and J. W. Williamson: National Ambulatory Medical Care Survey,

background and methodology, United States, 1967–72. Vital and

Health Statistics. Series 2, No. 61. DHEW Pub. No. (HRA)74-1 335.

Health Resources Administration. Washington. U.S. Government

Printing Office, Apr. 1974.

8American Hospital Formulaq Service c[aSSl~Catrbrr sYsk7?r and

Therapeutic Category Codes. Washington. American Society of Hospital Pharmacists, Inc., 1980.

9AMA Drug Evaluations, 5th ed. Chicago, 11. American Medical

Association, 1983. pp. 1651, 1667, 1734, 1618, and 1743. (Copyright

1983: Used with permission of the American Medical Association. )

“Drug Facts and Comparisons, 1983 ed. St. Louis, Mo. J.B. LippinCott co., 1982. pp. 1208 and 1274 (Copyright 1982: Used with

the permission of J.B. Lippincott.)

1IN H Steigbigel: E~thromycin, hncornycin, and clindamycin > . .

in G. L. Man dell, et. al., eds., Principles and Practice of infectious

Diseases, Vol. 1. New York. John Wiley and Sons, 1979.

pp. 290-300.

IzNational Center for Health Statistics, D. Schneider, L. Appleton ~

and T. McLemore: A reason for visit classification for ambulatory

care. Vital and Health Statistics. Series 2, No. 78. DHEW Pub.

No. (PHS)79–I 352. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1979.

ISpublic Health Senice and Health Care Fhrancing Administration:

International Classification of Diseases, 9th Revision, Clinical Modification. DHHS pub. No- (pHS)8Gl 260. Public Health Service.

Washington. U.S. Government Printing Office, Sept. 1980.

14Nationa1 Center for Health Statistics, B. K. Cypre;s: patterns of

ambulatory care in internal medicine, the National Ambulatory Medical Care Survey, United States, January 1980-December 1981. Vital

and Health Statistics. Series 13, No. 80. DHHS Pub. No. (PHS)84-

1741. Public Health Service. Washington. U.S. Government Printing

Office, Sept. 1984.

‘sNational Center for Health Statistics, B. K. Cypress: Patterns of

ambulatory care in office visits to general surgeons, the National

Ambulatory Medical Care Survey, United States, January 1980-December 1981. Vital and Health Statistics. Series 13, No. 79. DHHS

Pub. No. (PHS) 84-1740. Public Health Service. Washington. U.S.

Government Printing Office, Sept. 1984.

“National Center for Health Statistics, B. K. Cypress: Pattens of

ambulatory care in obstetrics and gynecology, the National Ambulatory Medical Care Survey, United States, January 1980-December

1981. Vital and Health Statistics. Series 13, No. 76. DHHS Pub.

No. (PHS) 84-1737. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1984.

lTNational Center for Health Statistics, B. K. Cypress: patterns of

ambulatory care in pediatrics, the National Ambulatory Medical Care

Survey, United States, January 1980-December 1981. Vital and

Health Statistics. Series 13, No. 75. DHHS Pub. No. (PHS) 84-1736.

Public Health Service. Washington. U.S. Government Printing Office, Oct. 1983.

IgNationaI Center for Health Statistics, B. K. Cypress: patterns of

ambulatory care in general and family practice, the National Ambulatory Medical Care Survey, United States, January 1980-Dlecember

1981. Vital and Health Statistics. Series 13, No. 73. DHHS Pub.

No. (PHS) 83–1734. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1983.

‘9Nationai Center for Health Statistics, H. Koch and W. H. CampbeI1:

The collection and processing of drug information, National .Ambulatory Medical Care Survey, United States, 1980. Vital and Health

Statistics. Series 2, No. 90. DHHS Pub. No. (PHS) 82–1 364. Public

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

Mar. 1982.

20National Center for Health Statistics, P. J. McCarthy: Replication,

an approach to the analysis of data from complex surveys. Vital

and Health Statistics. Series 2, No. 14. PHS Pub. No. 1000. Public

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

Apr. 1966.

‘l National Center for Health Statistics, P. J. McCarthy: Pseudoreplication, further evaluation and application of the balanced half-sample

technique. Vital and Health Statistics. Series 2, No. 31. DHEW

Pub. No. (HSM) 73–1 270. Health Services and Mental Health Administration. Washington. U.S. Government Printing Office, Jan. 1969.

zzNational Center for Health Statistics, G. J. Gardocki, T. McLemore,

and J. E. DeLozier: The National Ambulatory Medical Care Complement Survey, United States, 1980, Vital and Health Statistics. Series

13, No. 77. DHHS Pub. No. (PHS) 84-1738. Public Health Service.

Washington. U.S. Government Printing Office, May 1984.

.

30
List of detailed tables

1.

2.

3.

4.

5.

/’

Number, pcrccnt distribution, and average annual rate (per

1,000 civilian noninstitutionalized population) of antimicrobial dmg mentions by sex and age of patient,

according to type of antimicrobial drug: United

States, 198&81 . . . . . . . . . . . . . . . . . . . . . . . . . .

Number and percent distribution of the principal diagnoses

most commonly made during antimicrobial drug visits

for selected subtypes of antimicrobial drugs: United

States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . .

Number and percent distribution of antimicrobial drug visits

by patient’s principal reason for visit, according to type

of antimicrobial drug ordered or provided: United

States, 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . .

Number, percent distribution, and average annual rate (per

1,000 civilian noninstitutionalized population) of antimicrobial drug visits by sex and age of patient, according to

type and selected subtype of antimicrobial drug ordered

or provided: United States, 1980-81 . . . . . . . . . . . .

Number and percent distribution of antimicrobial drug visits

by race and ethnicity of patient, according to type of

antimicrobial drug ordered or provided United

States, 198&81 . . . . . . . . . . . . . . . . . . . . . . . . . .

33

34

35

36

38

6. Numkrand prcenttistribution ofantimicrobial drugvisits

by referral status of patient, according to type of antimicrobial drug ordered or provided: United States,

1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...38

7. Number andprcent distibution ofantimicrobial dmgvisits

by type of physician practice and age of physician, according to type of antimicrobial drug ordered or provided:

United States, 1980-81 . . . . . . . . . . . . . . . . . . ...39

8. Number andpercent distribution ofantimicrobial dmgvisits

by geographic region and metropolitan status, according

to type of antimicrobial drug ordered or provided:

United States, 1980-81 . . . . . . . . . . . . . . . . . . ...39

9. Number andpercent distribution ofantimicrobial drugvisits

by number of diagnostic services ordered or provided, accordhtgto type of antimicrobial drug ordered or provided:

United States, 1980-81 . . . . . . . . . . . . . . . . . . ...40

10. Numkrandpercent distribution ofantimicroblal dmgvisits

by number of nonmedication therapeutic services ordered

or provided, according to type of antimicrobial drug ordered

or provided: United States, 1980-81 . . . . . , . . . . . . 40

11. Number andpercent ofantimicrobial dmg visits, by type

of antimicrobial drug ordered or provided and disposition

of patienti United States, 1980-81 . . . . . . . . . . . . . 40

31
Tsbk 1. Number, percent diatribut@ and average annual rate (per 1,000 WIian ndnethWMb# popuMon. ~ti=. .

hwobial drug men60rra by sex

and age of pafien~ eoomfxrg to type of anthicrobied drw United S- 1980-S1

Tjfpe of antimicrobial drug

Macrokfes Sulfonamir%s

-~ and and Miscellaneous

Sex and age ofpafierrt All ~wS Perkillins sporirrs Iirrcossrnicks Tetracycline tn.metfrcprim antimicrobial

All antimicrobial drug mentions . . . . . . . . . . . . . . . . 40,106

Male

Alleges . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

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

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

65yearsandover . . . . . . . . . . . . . . . . . . . . . .

Female

Alleges . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

l%24years . . . . . . . . . . . . . . . . . . . . . . . . .

25-14years . . . . . . . . . . . . . . . . . . . . . . . . .

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

65yearsandover . . . . . . . . . . . . . . . . . . . . . .

206,288 82,896 16,044 33.787

7,765

3,062

1,034

1,621

1,318

73CI

8,279

2,364

1,154

2,331

1,665

764

100.0

46.4

19.1

6.4

10.1

6.2

4.6

51.6

14.7

7.2

14.5

10.4

4.8

36.0

36.1

56.9

25.8

26.6

31.6

36.4

35.9

47.6

28.0

36.2

36.0

26.4

18.607 16,848

5,741

1,289

817

1,016

1,317

1,301

11,108

1,552

2,227

3,463

2,059

1,787

100.0

34.1

7.7

4.8

6.0

7.8

7.7

65.9

9.2

13.2

20.7

12.2

10.6

37.6

26.7

24.6

20.3

16.7

31.6

64.6

48.2

31.2

54.0

54.1

44.5

61.7

92,632

36,426

15,604

17,608

13,237

9,756

36,462

20,223

5,166

6,556

4,122

2,373

17,633

7,583

3,392

2,964

2,065

1,600

15,050

1,147

4,792

4,181

2,826

2,105

7,961

3,112

*382

1,2X)

1,590

1,647

115,656

34,576

22,749

28,895

16,369

10,837

44,434

19,934

7,809

8,625

5,478

2,669

22,473

6,723

5,055

5,668

3,516

1,312

Percent distribution

100.0

18,737

1,063

5,017

6,339

3,811

2.467

10,626

2,921

1,467

2,349

1,871

1.886

Allantimicrobialdrug mentions. . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0

Male

Alleges . . . . . .

Under 15 years . .

15-24years . . .

25-44years . . .

45-64years . . .

65 years and over

44.5

17.5

7.5

8.5

6.4

4.7

46.4

24.4

6.3

7.9

5.0

2.9

44.0

18.9

8.5

7.4

5.1

4.0

44.5

3.4

14.2

12.4

8.4

6.2

42.9

16.7

‘2.1

6.7

8.5

8.9

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

. . .

. . .

. . .

. . .

. . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

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

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

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

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

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

Femate

Alleges . . . . . .

Under 15years . .

15-24years . . .

25-44years . . .

45-64years . . .

65 years and over

55.5

16.6

10.9

13.9

8.8

5.3

53.6

24.0

9.4

10.4

6.6

3.1

56.0

16.8

12.6

14.6

8.8

3.3

Average annual rate

80.1

55.5

3.2

14.8

18.8

11.3

7.4

57.1

15.7

6.0

12.6

10.1

10.7

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

. . .

. . .

. . .

. . .

. . . . .

. . . . .

. . . . .

. . . . .

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

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

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

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

. . .

Allantimicrobialdrug mentions. . . . . . . . . . . . . . . .

Male

Alleges . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

15-24yeaE . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

05yearsandover . . . . . . . . . . . . . . . . . . . . . .

Female

Alleges . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

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

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

65yearsandover . . . . . . . . . . . . . . . . . . . . . .

467.7 166.1 75.9 41.8

431.1

70~.1

368.6

266.8

317.4

465.8

179.0

369.3

129.2

107.6

98.8

118.2

82.1

146.2

64.5

48.9

49.5

79.6

70.0

22.1

119.4

68.6

67.6

104.8

37.1

59.9

“9.5

20.5

36.1

62.0

501.8

695.5

551.2

450.6

386.0

377.9

192.8

401.0

189.4

134.1

118.5

89.5

97.5

135.2

122.5

91.2

76.1

45.3

81.3

21.8

121.6

96.5

62.4

85.9

46.1

58.6

36.0

36.5

40.5

69.0

NOTE MorefhsnonelypeofantimisroMaldwgwasordaradorprovidedduringsc#3vk4r.s.

33
Tabte2. Number andpercent dstibtin &thepnncipal dmgno-most amon~m* dutiganWmrtil dqtis"ti tirsek~dsu~pesof

antimicrobial drugs United States, 1980-81

Number of visits Percent

Rank Principal diagnosis and ICD-9-CM code’ in thousands (distribution

Penicillin

All principal diagnoses in visits involving penicillin . . . . . . . . . . .

Acute pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (462)

Acute tonsillitis . . . . . . . . . . .. . . . . . . . . . . . . . (463)

Acute upper respirato~ infwtions ofmultiple orunspecifiedsfies . . . . . (485)

Suppurative andunspecified otiis media . . . . . . . . . . (382)

Streptococcal sore throat and scarlet fever . . . . . . . (034)

Bronchitis, notspecified asacute or chronic . . . . . . . . . (490)

Another principal diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32,373

5,869

4,323

4,184

2,092

2,004

1,353

12,548

100.0

18.1

13.4

12.9

6.5

6.2

4.2

38.8

1

2

3

4

5

6

...

Amoxicillin

Allprincipal diagnoses invisite involving amoxicillin . . . . . . . . . . .

Suppurative andunspecitiad otitismadia . . . . . . . . . . . . . . (382)

Acute upper respirato~ infections ofmultiple orunspecifid sites . . . . . . (465)

Acute pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (462)

Bronchitis, not specified as acute or chronic . . . . . . . . . . . . (490)

Another principal diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23,419

7,600

3,048

1,524

1,368

9,878

100.0

32.4

13.0

6.5

5.8

42.2

1

2

3

4

...

Ampicillin

All principal diagnoses in visits involving ampicillin . . . . . . . . . . . . . .

Suppurative and unspecified otitis media . . . . . . . . . . . . . . . . . . . (362)

Acute upper respiratory infections of multiple or unspecified sites . . . . (465)

Acute pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (462)

Bronchitis, not specified as acute or chronic . . . . . . . . . . . . . . . (490)

Acute tonsillitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (463)

Another principal diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21,510

2,743

2,548

1,921

1,267

1,176

11,856

100.0

12.6

11.8

8.9

5.9

5.5

55.1

1

2

3

4

5

. .

First generation cephalosporins

Allprincipal diagnoses invisi@ involving first generation wphalospofins. . . . . .

Acute upper respirator infections ofmultiple orunspecified sites . . . . . . (465)

Another principal diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0

9.4

90.6

11,749

1,106

10,643

1

...

Second generation cephalosporins

Allprincipal dagnoses invisits involving second generation cephalosporins. . . . .

Suppurative andunspecified otitis media . . . . . . . . . . . . . . . . (382)

Another principal diagnosea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3,964

1,290

2,694

100.0

32.4

67.6

1

...

Eryfhromycin

Allprincipal diagnoses invisits involving erythromycin . . . . . . . . . . . . . .

Acute upper respirato~ infWions ofmultiple orunapwified sites . . . . . . (465)

Bronchitis, not specified as acute or chronic . . . . . . . . . . . . . (490)

Acute pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (462)

Diseases ofsebaceousglands . . . . . . . . . . . . . . . . . . . . . . . . (706)

Suppurative and unspecified ofitis media . . . . . . . . . . . . . . . . . (362)

Acute tonsillitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (463)

Acute bronchitis and bronchiolitis . . . . . . . . . . . . . . . . . . . . . . . (466)

Chronic sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (473)

Another principal diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32,334

4,991

3,040

2,722

2,385

2,160

1,286

1,206

1,009

13,535

100.0

15.4

9.4

8.4

7.4

6.7

4.0

3.7

3.1

41.9

1

2

3

4

5

6

7

6

...

Short-acting tetracycline

Allprincipal dagnoses invisits involving shoti-acting tetracyclines . . . . . . .

Disesses of sebaceous glands . . . . . . . . . . . . . . . . . . . . . . . . (706)

Acute upper respirato~ infections ofmultiple or unspecified sites . . . (465)

Bronchitis, notspecified asacute or chronic . . . . . . . . . . . . . . . . . (490)

Chronic sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (473)

Another principal diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25,224

7,235

2,580

1,400

1,015

12,993

100.0

28.7

10.2

5.6

4.0

51.5

1

2

3

4

...

Intermediate- and long-acting tetracycline

All principal diagnoses in visita involving intermedisteandlong-acting tetracyclines . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Disesses ofsebaceous glands . . . . . . . . . . . . . . . . . . . . . . . . (706)

Another principal diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8,066

1,430

6,635

100.0

17.7

82.3

1

...

See footnotesat endof table.

34
Table 2. Number and percent distribution of the principal diagnoses most commonly made during antimicrobial drug visits for selected subtypes of

antimicrobml drugs: United States, 1880-81 +hrt.

—

Number of visits Percent

Rank Principal diagnosis and ICD-9--CM code’ in thousands distribution

Sulfonamides and trimethoprim in combination

All principal diagnoses in visits involving sulfonamides

andtrimethoprim in combination . . . . . . . . . . . . . . . . . . . . . . . . . . . 12,724 100.0

1 Suppurative and unspecified otitis media . . . . . . . . . . . . . . . . . (382) 2,322

2

18.3

Other disorders of urethra and urinary tract . . . . . . . . . . . . . . . . . (599) 1,977

3

15.5

Cystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (595) 1,368

4

10.8

lnflaMMatOIy ciiseases of prostate . . . . . . . . . . . . . . . . . . . . (601) 1,031 8.1

... Another principal diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,026 47.4

1Bsaad on the /nfenrationa/C/aasificaficm of Diseases, 9th Revision, Chid Mcdir7cation (ICO-S-CM).l 3

NOTE: More than one subtype of antimicrobial drug waa ordered or provided durirg some visits.

Table 3. Number and percent d~tribution of antimicrobial drug vis-ti by patient’s ptincipd reason for viaii according to type of antimicrobial drug ordered

or provided: United States, 1980-S1

Principal reason for visit and RVC code’

Diagnostic, injuries and

screening, and adverse

All principal Symptom Disease preventive Treatment effects

reasons module module module module mtiule

Type of antimicrobial drug for visit (S001-S999) (DOO1-LW9) (XIOO-X599) (TIOC-T899) (JOO1-J999) Othe?

Number in thousands3

All antimicrobial drug visita . . . . . . . . . . . . . . . . . . 188,7ti 159,955 11,505 5,933 5,914 3,674 1,772

Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . 77,811 68,519 3,902 1,876 1,462

Cephalosporins . . . . . . . . . . . . . . . . . . . . . . . .

1,492 560

15,699 12,329 1,540 “189 892 661 “88

Macrolides and Iincosamides . . . . . . . . . . . . . . . . . 38,683 34,095 2,042 635 715 616

Tetracycline . . . . . . . . . . . . . . . . . . . . . . . . .

“361

33,104 28,402 1,653 1,041 1,144 “385

Sulfonamides and trimethoprim . . . . . . . . . . . . . . .

479

18,515 14,78s 1,458

Miscellaneous antimicrobial . . . . . . . . . . . . . . . . .

965 954 ●94 “275

16,282 11,614 1,456 1,1s6 1,152 554 ’319

Percent distribution

All antimicrobial drug visits . . . . . . . . . . . . . . . . . . 100.0 84.7 6.1 3.1 3.1 1.9 0.9

Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 88.1 5.0 2.4 1.9

Cephalosporins . . . . . . . . . . . . . . . . . . . . . . . .

1.9 0.7

100.0 78.5 9.8 “1.2 5.7

Macrolides and Iincosamides . . . . . . . . . . . . . . . . .

4.2 ‘0.6

100.0 88.2 5.3 2.2 1.9

Tetracycline . . . . . . . . . . . . . . . . . . . . . . . . .

1.6 ‘0.9

100.0 85.8 5.0 3.1 3.5

Sulfonamides and trimethoprim . . . . . . . . . . . . . . .

●1.2 1.4

100.0 79.8 7.9

Miscellaneous antimicrobial . . . . . . . . . . . . . . . . .

5.2 5.2 “0.5 ●1.5

100.0 71.3 8.9 7.3 7.1 3.4 “2.0

1Baaedon A rasson for visit sfaasification for ambulatory owe. 12

‘Inoludes raaaons codad in the test resufta and administrative modules, as well as blanks, problems, and complaints not elsewhere claaa”fied, entries of “none,” and illegible entries.

3Sums o’ antimffirobial drug categories do not equal totals bacauae some visits invoived drugs from more than one antimicrobial drug group,

35
cd

0) Tebla 4. Number, paroent distribution, and average annual rate (per 1,000 civiliin noninatitudonalizadpopulation) of antimicrobialdrug viaita by aex and age of patient according to type and aekoted

subtype of antirniirobial drug ordered or provided United State& 196(H1

Type of antimicrobial drug ordered or provided

Sulfonamides

and

trimethoprim

Sulfon- Miscellaneous

Macrolides and

amides antimicrobial

Iincosamides Tetracycline

All and All

All lrrter- sulfon- trime- miscelmacrolides mediatePerricillins amides thoprim Ianeous Urinary

and All and and in anti- tract

Sex and age All All Cephalo- lirrccwa- Erythro- tetra- Short- long- trime- combi- microof patient

anticeptypes penicillins Penicillin Amoxicillin Ampicillin sporins mides mycin Other cyclines acting acting thoprim netion bials tics

All antimicrobial

drug visits . . . . . . . . . . . . . .

Male

All ages . . . . . . . . . . . . . . . .

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

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

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

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

65yearsand over . . . . . . . . . .

Female

All ages . . . . . . . . . . . . . . . .

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

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

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

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

65 years andover . . . . . . . . . .

All antimicrobial

drug visits . . . . . . . . . . . . . .

Male

All ages . . . . . . . . . . . . . . . .

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

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

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

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

65yearsandover . . . . . . . . . .

186,754

63,636

33,571

13,414

15,824

12,073

6,754

105,117

32,232

20,049

26,090

16,611

9,936

100.0

44.3

17.8

7.1

8.4

6.4

4.6

77,611

36,206

19,235

4,716

6,210

3,670

2,173

41,605

18,877

7,259

6,067

4,947

2,436

100.0

46.5

24.7

6.1

8.0

5.0

2.6

32,373

14,901

6,623

2,504

2,994

1,667

1,113

17,472

6,642

3,577

3,688

2,369

1,196

100.0

46.0

20.5

7.7

9.2

5.1

3.4

23,419

11,661

9,073

728

912

561

●366

11,758

6,128

967

1,426

666

“371

100.0

49.6

36.7

3.1

3.9

2.5

‘1.6

21,510

9,129

3,441

1,461

2,093

1,438

697

12,361

, 4,152

2,676

2,920

1,658

775

100.0

42.4

16.0

6.6

9.7

6.7

3.2

15,699

7,639

2,994

961

1,617

1,318

730

6,060

2,332

1,137

2,231

1,665

694

100.0

46.7

19.1

6.2

10.3

6.4

4.7

36,663

16,991

7,463

3,229

2,937

2,022

1,320

21,672

6,603

4,722

5,613

3,436

1,297

100.0

43.9

i 9.4

8.4

7.6

5.2

3.4

32,334

14,477

7,087

1,829

2,574

1,750

1,237

17,857

6,084

3,051

4,475

3,034

1,213

7,267

2,913

465

1,549

●395

’282

“223

4,354

604

1,655

1,337

473

●85

Percent distribution

100.0 100.0

44.8 40.1

21.9 6.4

5.7 21.3

6.0 ‘5.4

5.4 ‘3.9

3.6 ‘3.1

33,104

14,696

1,134

4,776

3,942

2,797

2,046

18,408

1,067

4,990

6,199

3,716

2,436

100.0

44.4

3.4

14.4

11.9

8.4

6.2

25,224

11,202

932

3,716

3,062

1,891

1,600

14,022

694

3,909

4,691

2,637

1,891

100.0

44.4

3.7

t 4.7

12.1

7.5

6.3

8,066

3,613

’202

1,076

982

906

’446

4,453

’373

1,099

1,553

679

550

100.0

44.8

●2.5

13.3

12.2

11.2

5.5

18,515

7,889

3,069

’382

1,250

1,570

1,618

10,626

2,921

1,487

2,349

1,871

1,996

100.0

42.6

16.6

‘2.1

6.6

8.5

8.7

12,724

6,046

2,403

’294

663

1,229

1,237

6,676

2,350

1,110

1,074

1,051

1,093

100.0

47.5

18.9

●2.3

6.9

9.7

9.7

16,282

5,476

1,257

765

989

1,275

1,213

10,804

1,497

2,142

3,426

2,050

1,686

100.0

33.6

7.7

4.7

6.0

7.8

7.4

4,766

1,426

’21

’29

’176

513

688

3,340

“170

482

1,001

804

664

100.0

29.9

‘0.4

‘0.6

‘3.7

10.8

14.4
Female

Alleges................

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

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

25-44 yeare.............

45-64 yeara.............

65yearsandover..........

All antimicrobial

dmgvisits..............

Male

Alleges................

Under 15yeara............

16-24yWdrS.............

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

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

65yearsandover..........

Female

Allages................

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

16-24years............,

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

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

65yeareandover..........

55.7

17.1

10.6

13.6

6.9

5.3

423.8

369.3

646.2

334.1

259.5

289.5

435.9

456.1

646.4

485.6

405,5

363.6

343.3

53.5

24.3

9.3

10.4

6.4

3.1

174.7

166.5

370.2

117.5

101.6

92.6

106.2

160.5

379.7

175.9

125.7

107.0

84.2

54.0

20.5

11.0

11.4

7.3

3.7

72.7

69.4

127.5

62.4

49.1

40.0

55.4

75,6

133.6

66.7

57.3

51.2

41.3

50.2

34.7

4.1

6.1

3.7 ●1.6

52.6

54.3

174.6

18.1

15.0

13.9

‘16.2

51.0

163.5

23.4

22.2

16.7 ●12.8

57.6

19.3

12.4

13.6

6.6

3.6

48.3

42.5

66.2

36.4

34.3

34.5

34.7

63.7

63.5

64.6

45.4

40.2

26.8

51.3

14.9

7.2

14.2

10.6

4.4

35.3

35.6

57.6

24.4

26.5

31.6

36.4

35.0

46.9

27.6

34.7

36.0

24.0

56.1

17.1

12.2

14.5

8.9

3.4

66.8

79.1

144.0

80.4

46.2

48.5

65,7

94.0

132.6

114.4

87.2

74.3

44.8

55.2 59.9

18.6 6.3

9.4 25.5

13.6 16.4

9.4 6.5

3.6 ‘1.2

Average annual rate

72.6

67.4

136.4

45.6

42.2

42.0

61.6

77.5

122.4

73.9

69.6

65.6

41.9

16.3

13.6

8.9

36.6

“6.5 ●6.6

“11.1

16.9

12.2

44.9

20.6

10.2 ●2.9

55.6

3.2

15.1

18.7

11.2

7.4

74.3

68.4

21.8

119.0

64.7

67.1

101.9

79.9

21.5

120.9

96.3

80.4

64.2

55.6

2.8

15.5

18.6

11.2

7.5

56.6

52.1

17.9

92.5

50.2

45.4

79.7

60.6

14.0

94.7

72.9

61.4

65.3

55.2

*4.6

13.6

19.2

10,9

6.8

16.1

16.6

*3.9

26.8

16.1

21.7

‘22.2

19.3

47.5

26.6

24.1

19.0

19.0

57.4

15.8

8.0

12.7

10.1

10.8

41.6

36.7

59.1 ●9.5

20.5

37.7

80.5

46.1

58.8

36.0

36.5

40.5

69.0

52.5

16.5

6.7

8.4

8.3

6.6

26.6

28.1

46.3

‘7.3

14.5

29.5

61.6

29.0

47.3

26.9

16.7

22.7

37.6

66.4

9.2

13.2

21.0

12.6

10.4

36.6

55.5

24.2

19.1

15.9

30.6

60.4

46.9

30.1

51.9

53.2

44.3

56.3

70.1

“3.6

10.1

21.0

16.9

16,5

10.7

6.6

‘0.4

40.7

‘2.9

12.3

34.3

14.5 ●3.4

11.7

15.6

17,4.

30.5
Tabfes. Nurnbwand peroant dbtrb@mofan8mimw drugvisita byracaandethnii ofpatkntj acoordingto typeofantkniirobiat drugordarador

~wf=f-lwl

Typa of antimicrobial drug

Macro/ides Sulfonamides

Cephalo- and and Miscellaneous

Reca and ethntity of patient All typr3S Penicillins spot-ins Iincosemides Tetracycline trimethopnm antimicrobial

Number in thousands’

@lanf@crobial drtgvisite . . . . . . . . . . . . . . . . . . 188,764 77,811 15,689 38,663 33,104 18,515 16,282

Race

We ... . . . . . . . . . . . . . . . . . . . . . . . . . .

B&k.. . . . . . . . . . . . . . . . . . . . . . . . . . . .

O@r . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ethniciiy

Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

168,277

18,388

2,108

67,012

9,557

1,241

14,864 35,150

866 3,212

“170 ’301

30,460

2,352

“301

16,751

1,654

“110

14,586

1,652

●64

1,329

31,775

897

17,616

9,159

178,584

3,802

73,809

1,038 1,700

14,661 38,983

Percent distribution

100.0 100.0

15,186

Allentimicrobietdrugvisits..... . . . . . . . . . . . . .

Race

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

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

C4tw r . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Efhni@y

Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ofher . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0 100.0 100.0 100.0 100.0

69.2

9.7

1.1

66.1

12.3

1.6

93.4 90.9

5.5 8.3

“1.1 “0.8

92.0

7.1

●0.9

90.5

6.9

“0.6

69.5

10.1

‘0.4

4.9

95.1

5.0

95.0

6.6 4.4

93.4 95.6

4.0

86.0

4.6

95.2

6.7

93.3

‘8umsrdtypesdo noteqordtotslsbstause ~mttmnonetype ofsntimkmbialdmg weeordmdorprovided duringeomevisite.

Typeofantimicrobial drug

Macrolidsa Sulfonamides

Caphaio- and and Miscellaneous

Referralstatusof Wient All tvDSS Penicillins sporins Iincosamides Tetracycline trimethorxim arltimicrobials

Number in thousands’

Allantimicrobiafdrugvi!dta..... . . . . . . . . . . . . . 188,754 77,611 15,699 36,663 33,104 18,515 16,262

Patiantw~referredforthisviait.. . . . . . . . . . . . . . 5,559 1,518 585 660 1,110 836 808

Patientweenotreferredforthiavisit . . . . . . . . . . . . . 183,194 76,293 15,114 37,783 31,984 17,678 15,474

Percent distribution

Allantimicrobialdrugvisife...... . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Pefientweereferredforthiivksit.. . . . . . . . . . . . . . 2.9 2.0 3.7 2.3 3.4 4.5 5.0

Patientwasnotreferredforfhkaviaif . . . . . . . . . . . . . 97.1 98.0 96.3 97.7 96.6 95.5 95.0

‘Ewnsofsnthkmtisl drugiypeetincd equaltotstsbeosueemorethsnonetypa ofdrugwssordered orprovkhdduring somevisits.

,.’
Tabte 7. Number and percent diahibution of antimicrobial drug v“~s by type of phys”~n pmctioe end age of physiciem accorchg to type of anhhobial

drug ordered or provided: United States 1960-81

TW of antimicrobial dNg

Macrolidas Sulfonamides

Cephab- and and Miscellaneous

Type of physician practice and age of physician All tyJXW Penicillins spon”ns Iincosamties Tetrscyclines trimethoprim arriimicrobials

Number in thousands’

33,104 18,515 16,282

23,493 8,64t 8,968

9,611 9,671 7,314

All antimicrobial drug visits . . . . . . . . . . . . . . . . - . 188,754 77.611 15,698 36,663

Type of practice

solo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Othe~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Age of physician

Under 45 . . . . . . . . . . . . . . . . . . . . . . . . . . .

4H0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

61 Andover . . . . . . . . . . . . . . . . . . . . . . . . . .

8,976 22,856

6,723 15,607

107,061

61,693

41,600

36,011

60,160

81,716

26,878

32,368

34,173

11,270

7,573 17,s60

6,511 15,465

1,675 5,219

13,925

14,633

4,546

7,605

8,033

2,877

6,086

7,386

2,798

Percentdistribution

Allarrtimicrobial drugvisits . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Type of physician practice

solo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

Age of physician

Under45 . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-60 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

61 andover . . . . . . . . . . . . . . . . . . . . . . . . . .

56.7

43.3

63.7

46.3

57.2 59.1

42.8 40.9

71.0

28.0

47.6

52.2

55.1

44.9

47.9 46.5

41.5 40.0

10.7 13.5

42.1

44.2

13.7

41.1

43.4

15.5

37.4

45.4

17.2

42.5

43.3

14.2

41.6

43.9

14.5

lSumsof typesdonotequal totalsbacausemOreihanOrretYPeof antimicmbialdrugwasorderadorprovkledduringeomevisk

‘Includes partnership, group, and other fyxs of practice.

Table8. Number andpercent dwtfibutimn ofantimkM dfU9v”*bY~ - rqion and

orderedorprovideck UnitedStster% 1880-81

matqothn atatu~ accwdhg to type of antimicrobial drug

Tjpeofanfirrricrvbialdrug .

Mecmlides Suirbnamides

Geographic region Cephab and and M3cellanews

and metrq.wlitan status AII types Penidirrs aporina Kncrx.smides Tetraoyclines trimatiwprim antimbvbiata

Numberinthouaanda’

15,699 36,663 33,104 18,515

2,875

5,013

7,015

3,611

12,936

5,577

100.0

15.5

27.1

37.9

19.5

69.9

30.1

16,282

3,010

3,853

6,651

2,767

12,060

4,222

100.0

18.5

23.7

40.8

17.0

74.1

25.9

Allantimicrobialdrugvisits.... . . . . . . . . . . . . . .

Geographic region

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

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

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

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

Metropolitan status

Metropolitan area . . . . . . . . . . . . . . . . . . . . . . .

Nonmatropolitanarea . . . . . . . . . . . . . . . . . . . . .

166,754

37,855

49,030

73,175

28,693

136,835

51,818

100.0

20.1

26.0

38.8

15.2

72.5

27.5

77,811

2,CK16 8,818 7,775

3,266 10,631 8,566

8,324 +3,487 10,875

2,063 5,526 5,665

15,197

19,906

32,474

10,231

64,722

23,069

10,986 28,878 25,174

4,702 9,787 7,930

Percentdistributkm

Allantimicrobialdrugvisits.... . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0

Geographicragion

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

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

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

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

Metropolitan status

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

19.5

25.6

41.7

13.1

12.8 22.8 23.5

20.9 28.0 25.9

53.0 34.9 32.9

73.3 14.3 17.8

Northeast . . . . .

North Central . . .

South . . . . . . .

West . . . . . . .

Metropolitan area . 70.3

29.7

70.1 74.7 76.0

Nonmetropotitanarea . . . . . . . . . . . . . . . . . . . . . 29.9 25.3 24.0

lSums of rypes do not equal totals because more than one type of antimkmbial drug was prem’ibd during some visits.

39
Tabfe9. Nw@rand percent d&tnb@bn ofantimicroMal dr~vistis bynumbr ofdagnotic sewices ordered orproti&d, accordngto~of

antimicrobml drug ordered orprovideck United States, 19S0-S1

Type of antimicrobial drug

Macro/ides Sulfonamides

Cephalo- and and Miscellaneous

Number of diagnostic services All types Penicillins sporins Iinwsamides Tetracycline trimethoprim antimicrobial

Number in thoussnds’

Allantimicrobial drug visits . . . . . . . . . . . . . . . . . . 188,754 77,811 15,699 38,663 33,104 18,515 16,282

No services . . . . . . . . . . . . . . . . . . . . . . . . . 7,818 1,302 469 2,404 3,506 “271

Oneservice . . . . . . . . . . . . . . . . . . . . . . . . .

670

109,195 46,650 8,936 24,476 17,754 8,532 7,385

Twosewices . . . . . . . . . . . . . . . . . . . . . . 51,490 21,120 4,549 9,284 8,279 5,966

Threeservicesormore . . . . . . . . . . . .

4,888

20,250 6,539 1,745 2,498 3,565 3,726 3,339

Percent distribution

Allantimicrobialdrugvisits.... . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Noaewices . . . . . . . . . . . . . . . . . . . . . . . . 4.1 1.7 3.0 6.2 10.6 ‘1.5 4.1

Oneservice . . . . . . . . . . . . . . . . . . 57.9 62.8 56.9 63.3 53.8 46.1 45.4

Twoaervices . . . . . . . . . . . . . . . . . . . . . . . . . 27.3 27.1 29.0 24.0 25.0 32.3 30.0

Threeeervicesormore . . . . . . . . . . . . . . . . . . . . 10.7 8.4 11.1 6.5 10.8 20.1 20.5

‘Sums Ofantimicrobialdrug types do not equal totals because more than one type of drug was ordered m provided during some visits,

Tabfe 10. NuWrand @rcetid~~@on ofantimicmb@l dmgvia& bynumbrof nonm*tition tkra~tic sem~soWerd orprovidwi, a-rtingto

type of antimkrobwl drug ordered or provided United states, 1980-S1

Type of antimicrobial drug

Macro fides Sulfonamides

Cephalo- and and Miscellaneous

Number of nonmedioation therapeutic sewices All types Penicillins sponns Iincosamides Tetracycline trimethoptim antimicrobial

All antimicrobial drug visits . . . . . . . . . . . .

Noservices . . . . . . . . . . . . . . . . . .

Oneservice . . . . . . . . . . . . . . . . . . .

Twosetvices or more . . . . . . . . . . . . . . . . . . . . .

Allantimicrobisl drug visits . . . . . . . . . . . . . . . . .

Noservicaa . . . . . . . . . . . . . . . . . .

Oneservice . . . . . . . . . . . . . . . . . . . . . . . . . .

Twoservices or more . . . . . . . . . . . . . . . . . . . . .

166,754

123,021

57,802

7,930

100.0

65.2

30.6

4.2

V,811

54,976

20,539

2,294

100.0

70.7

26.4

2.9

Number in thousands’

15,699 38,663 33,104

9,465 25,660 18,943

5,603 11,159 12,233

611 1,644 1,928

Percent distribution

100.0 100.0 100.0

60.4 66.9 57.2

35.7 28.9 37.0

3.9 4.3 5.8

18,515

11,477

5,616

1,220

100.0

62.0

31.4

6.6

16,282

9,289

5,950

1,043

100.0

57.0

36.5

6.4

‘Sums of antimicrobialdrug Iypes do not equal totals because more than one type of drug was wdered m provided during some visits.

Tabfe 11. Number and percent of antimicrobial drug visitq by type of antimicrobial drug ordered or provided and diapositiin of patient

United State% 19S0-81

Type of antimicrobial drug

Macro fides Sulfonamides

Cephalo- and and Miscellaneous

Patient disposition’ All types Peniallins sporins Iincosamides Tetracycfines trimethoprim antimicrobial

Number in thousands

No followup . . . . . . . . . . . . . . . . . . . . . . . . . 24,257 11,988 1,619 5,569 3,671 994 1,606

Return atspacified time . . . . . . . . . . . . . . . . . . . 91,956 31,581 7,922 17,860 18,627 12,518 10,154

Return if needed . . . . . . . . . . . . . . . . . . 64,281 30,531 5,352 13,836 9,761 4,190 3,856

Telephone followup . . . . . . . . . . . . . . . . . . . . . . 9,210 4,506 627 1,970 1,016 928 491

other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,194 2,003 803 595 553 770 672

Percent

No followup . . . . . . . . . . . . . . . . . . . . . . . . . . 12.9 15.4 10.3 14.4 11.1 5.4 9.9

Return atspecifiedtime . . . . . . . . . . . . 48.7 40.6 50.5 46.2 56.3 67.6 62.4

Return if needed . . . . . . . . . . . . . . . . . . . . . . . 34.1 39.2 34.1 35.6 29.5 22.6 23.7

Telephone followup . . . . . . . . . . . . . . . . . . . . . 4.9 5.8 4.0 5.1 3.1 5.0 3.0

other . . . . . . . . . . . . . . . . . . . . . . . . . 2.6 2.6 5.1 1.5 1.7 4.2 4.1

lMwethanane patient dkposifion wsarecorded torsome visita.

‘Sums of types do not equal totals because more than one type of antimicrobialdrug was ordered or provided during some visits.

40

‘\
Appendixes

Contents

I. Technical notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..- . . . . . . . . . . . . . . . . . . . . . . . . .. 42

Statistical design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Scopeofthesurvey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Sample design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~

Datacollection andprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fieldprocedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Datacollection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Data processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Estimation procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Inflation byreciprocals ofprobabilities ofselection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Adjustment fornonresponse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Ratioadjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M

Reliability ofestimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Estimates ofaggregates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Estimates ofpercents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Estimates of rates where thenumerator isnotasubclass of the denominator . . . . . . . . . . . . . . . . . . . . . . 47

Estimates ofdifferences between two statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Tests ofsignificance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Population figures and ratecomputation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Rounding ofnumbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... 48

Systematic bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

H. Definitions ofcertain termsused in this report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Terms relating tothesurvey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Terrnsrelating to thePatientRecord form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 50

111.Patient Log andPatientRecord form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

IV. American Hospital Formulary Service classification system and therapeutic category codes . . . . . . . . . . . . . . . . 53

Iistofappendixfigures

1. Approximate relative standard emors for estimated numbers ofoffice visits based on all physician specialties(A), and

individual specialties (B), 1980-81 National Ambulatory Medical Care Survey . . . . . . . . . . . . . . . . . . . . . . . . 45

II. Approximate reiative standard emorsfor estimated numkrsof dmgmentions b=donall physician s~cialties(A), and

individual specialties (B), 1980-81 National Ambulatory Medical Care Survey . . . . . . . . . . . . . . . . . . . . . . . . 46

Listofappendixtsbles

I. Distributionofphysiciansinthe1980-81 NationalAmbulatoryMedicalCare Surveysampleandresponserates,byphysician specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

11. Estimates ofthecivilian noninstitutionalized population ofthe United States used in computing average annual rates in

this report, by ageandsex: 1980-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

41
Appendix I

Technical notes

This report is based on data collected during 1980 and

1981 in the National Ambulato~ Medical Care Survey

(NAMCS), an annual sample survey of office-based physicians

conducted by the Division of Health Care Statistics of the

National Center for Health Statistics (NCHS). The two surveys

were conducted with identical instruments, definitions, and

procedures. Two years of data were combined to increase

the reliability of the estimates. The annual survey design

and procedures are presented in the following sections.

Ststisticsl design

Scope of the survey

The target population of NAMCS includes ol%ce visits

made within the conterminous United States by arnbulatoxy

patients to nonfederally employed physicians who are principally engaged in office-based patient care practice, but not

in the specialties of anesthesiology, pathology, or radiology.

Telephone contacts and nonot%ce visits are excluded from

NAMCS.

Sample design

The NAMCS utilizes a three-stage survey design that

involves probability samples of primary sampling units

(PSU’S), physician practices within PSU’S, and patient visits

within physician practices. The first-stage sample of 87 PSU’S,

was selected by the National Opinion Research Center (NORC)

of the University of Chicago, the organization responsible

for NAMCS field and data processing operations under contract

to NCHS. A PSU is a county, a group of adjacent counties,

or a standard metropolitan statistical area (SMSA). A modified

probability-proportional-to-size procedure using separate sampling frames for SMSA’S and for nonmetropolitan counties

was used to select the sample PSU’S. Each frame was stratified

by region, size of population, and demographic characteristics

of the PSU’S, and was divided into sequential zones of 1

million residents; then, a random number was drawn to determine which PSU came into the sample horn each zone.

The second stage consisted of a probability sample of

practicing physicians, selected from the masterflles maintained

by the American Medical Association (AMA) and the AmeriNOTE Prepared by Thomas McLemore, Division of Health Care Statistics.

can 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 pathology, radiology, diagnostic

radiology, pediatric radiology, or therapeutic radiology.

Within each PSU, all eligible physicians were sorted by

nine specialty groups: general and ‘family medicine, internal

medicine, pediatrics, other medical specialties, general

surgery, obstetrics and gynecology, other surgical specialties,

psychiat~, and all other specialties. Then, within each PSU,

a systematic random sample of physicians was selected so

that the overall probability of selecting any physician in the

United States was approximately constant.

During 1980 and 1981 the NAMCS physician sample

included 5,805 physicians. Sample physicians were screened

at the time of the survey to ensure that they met the aforementioned criteriw 1,124 physicians did not meet the criteria

and were, therefore, ruled out of scope (ineligible) for the

study. The most common reasons for being out of scope

were that the physician was retired, deceased, or employed

in teaching, research, or administration. Of the 4,681 inscope

(eligible) physicians, 3,676 (78.5 percent) participated in the

study. Of the participating physicians, 509 saw no patients

during their assigned reporting period because of vacations,

illnesses, or other reasons for being temporarily out of officebased practice. The physician sample size and response data

by physician specialty are shown in table I.

The third stage was the selection of patient visits within

the annual practices of the sample physicians. This stage

involved two steps. First, the total physician sample was

divided into 52 random subsamples of approximately equal

size; then 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 reporting week. The visit 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. The

method for determining the visit sampling rate is described

later in this appendix. During 1980 and 1981 sample physicians

completed 89,447 usable Patient Record forms.

42
Table L Distribution 01 physicians in the 1980-S1 National Ambulatory Medical Care Survey aarnplea and response rateaj by physician apeeMy

Response

Physician specialty Gross total out of scope Net total Nonrespondents Respmdents rate

All specialties . . . . . . . . . . . . . . . . . . . . . . . . . 5,805

GeneraI and family practice . . . . . . . . . . . . . . . .

Medical specialties . . . . . . . . . . . . . . . . . . . . . .

Internal madicine . . . . . . . . . . . . . . . . . . . . . .

Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . .

Other medicel specialties . . . . . . . . . . . . . . . . .

Surgical specialties . . . . . . . . . . . . . . . . . . . . . .

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

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

Other surgical specialties . . . . . . . . . . . . . . . . .

Other specialties . . . . . . . . . . . . . . . . . . . . . . .

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . .

Other specialties . . . . . . . . . . . . . . . . . . . . . .

1,340

1,695

871

414

410

1,978

521

484

973

792

414

378

1,124

289

296

158

83

55

246

75

71

100

293

96

197

4,681

1,051

1,399

713

331

355

1,732

446

413

873

499

318

181

1,005

272

298

182

42

74

351

115

63

173

84

43

41

3,676

779

1,101

531

289

261

1,381

331

350

700

415

275

140

78.5

74.1

78.7

74.5

87.3

79.2

79.7

74.2

64.7

80.2

83.2

86.5

77.3

Data collection and processing

F* procedures

Both mail and telephone contacts were used to enlist

sample physicians for NAMCS. Initially, physicians were sent

introductory letters horn the Director of NCHS, facsimiles

of which have been published. 1**8When appropriate, a letter

from the physician’s specialty organization endorsing the survey and urging his participation was enclosed with the NCHS

letter. Approximately 2 weeks prior to the physician’s assigned

reporting period, a field representative telephoned the physician to explain briefly the study and arrange an appointment

for a personal interview. Physicians who did not initially

respond were usually recontacted via telephone or special

explanatory letter and requested to reconsider participation

in the study.

During the personal interview the field representative determined the physician’s eligibility for the study, obtained

his cooperation, delivered survey materials with verbal and

printed instructions, and assigned a predetermined MondaySunday reporting period. A short induction interview concerningbasic practice characteristics, such as type of practice

and expected number of office visits, was conducted. Facsimiles of the induction interview form also have been published. 1418Office staff who were to assist with data collection

were invited to attend the instructional session or were offered

separate instructional sessions.

The field representative telephoned the sample physician

prior to and during the assigned reporting week to answer

questions that might have arisen and to ensure that survey

procedures were going smoothly. At the end of the reporting

week, the participating physician mailed the completed survey

materials to the field representative who edited the forms

for completeness before transmitting them for central data

processing. At this point problems of missing or incomplete

data were resolved by telephone followup by the field representative to the sample physician; if no problems were found,

field procedures were considered complete regarding the sample physician’s participation in NAMCS.

NOTE A tist of referencesfo-llowsthe text.

Data cdection

The actual data collection for NAMCS was carried out

by the physician, assisted by his ot%ce staff when possible.

Two data collection forms were employed by the physician:

the Patient Log and the Patient Record form (see appendix III). The Patient Log, a sequential listing of patients

seen in the physician’s office during his assigned reporting

week, served as the sampling frame to indicate the office

visits for which data were to be recorded. A perforation between the patient’s name and patient visit information permitted

the physician to detach and retain the listing of patients,

thus assuring the anonymity of the physician’s patients.

Based on the physician’s estimate of the expected number

of office visits and expected number of days in practice during

the assigned reptiing week, each physician was assigned

a visit sampling rate. The visit sampling rates were designed

so that about 30 Patient Record forms would be completed

by each physician during the assigned reporting week. Physicians expecting 10 or fewer visits per day recorded data for

all visits. Those physicians expecting more than 10 visits

per day recorded data for every second, third, or fifth visit

based on the predetermined sampling interal. These visit sampling procedures minimized the physician’s data collection

workload and maintained approximately equal reporting levels

among sample physicians regardless of practice size. For physicians recording data for every second, third, or fifth patient

visit, a random start was provided on the first page of the

Patient Log so that the predesignated sample visits recorded

on each succeeding page of the Patient Log provided a systematic random sample of patient visits during the reporting period.

Data processing

In addition to followups for missing and inconsistent data

made by the field staff, numerous clerical edits were performed

on data received for central data processing. These manual

edit procedures proved quite efficient, reducing item nonresponse rates to 2 percent or less for data items.

Information contained in item 6 (Patient’s problem or

reason for visit) of the Patient Record form was coded according to A Reason for Visit Classification for Ambulatory Care

(RVC).’2 Diagnostic information (item 9 of the Patient Record

form) was coded according to the International Classification

43
of Diseases, 9th Revision, Clinical Mod&ation (ICD-9–

CM). 13 A maximum of three entries were coded from each

of these items. Prior to coding, Patient Record forms were

grouped into batches with approximately 650 forms per batch.

Quality control for the medical coding operation involved

a two-way 5-percent independent verification procedure. Error

rates were defined as the number of incorrectly coded entries

divided by the total number of coded entries. The estimated

error rates for the 1980-81 medical coding operation were

1.7 percent for item 6 and 2.3 percent for item 9. Additionally,

a dependent verification procedure was used to review and

adjudicate all records in batches with excessive error rates.

Tinis procedure further reduced the estimated error rates to

1.6 percent for item 6 and 2.1 percent for item 9.

The NAMCS medication data (item 11 of the Patient

Record form) was classified and coded according to a scheme

developed at NCHS based on the American Society of Hospital

Pharmacists’ Drug Product Information File. A description

of the new drug coding scheme and of the NAMCS drug

data processing procedures is contained in Vital and Health

Statistics, Series 2, No. 90.’9 A two-way 100-percent independent verification procedure was used to control the medication

coding operation. As an additional quality control, all Patient

Record forms with differences between drug coders or with

illegible drug entires were reviewed and adjudicated at NCHS.

Information from the Induction Interview and Patient

Record forms was keypunched with 100 percent verification

and converted to computer tape. At this point, extensive computer consistency and edit checks were performed to ensure

complete and accurate data. Incomplete data items were imputed by assigning a value from a randomly selected Patient

Record form with similar characteristics; patient sex and age,

physician specialty, and broad diagnostic categories were used

as the basis for these imputations.

Estimation procedures

Statistics from NAMCS were derived by a multistage

estimation procedure that produces essentially unbiased national estimates and has three basic components: (1) inflation

by reciprocals of the probabilities of selection, (2) adjustment

for nonresponse, and (3) a ratio adjustment to fixed totals.

Each component is briefly described below.

Inflation by reciprocals of probabilities of selection

Because the survey utilized a three-stage sample design,

three probabilities of selection existed: (1) the probability

of selecting the PSU, (2) the probability of selecting the

physician within the PSU, and (3) the probability of selecting

an office visit within the physician’s practice. The third probability was defined as the number of office visits during the

physician’s assigned reporting week divided by the number

of Patient Record forms completed. All weekly estimates were

inflated by a factor of 52 to derive annual estimates.

NOTE: A listof references follows the text.

Adjustment for nonresponse

NAMCS data were adjusted to account for sample physicians who were in scope, but did not participate in the study.

This adjustment was calculated in order to minimize thle impact

of response on final estimates by imputing to nonresponding

physicians the practice characteristics of similiar responding

physicians. For this purpose, physicians were judged similar

if they had the same specialty designation and practiced 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 and AOA mastefilles,

and the denominator was based on data from the sample.

Reliability of estimates

As in any survey, results are subject to both sampling

and nonsampling errors. Nonsampling errors include reporting

and processing errors, as well as biases due to nonresponse

and incomplete response. The magnitude of the nonsampling

errors cannot be computed. However, these errors were kept

to a minimum by procedures built into the survey’s operation.

To eliminate ambiguities and encourage uniform reporting,

careful attention was given to the phrasing of questions, terms,

and definitions. Also, extensive pretesting of most data items

and survey procedures was performed. The steps taken to

reduce bias in the data are discussed in the sections on field

procedures and data collection. Quality control procedures

and consistency and edit checks discussed in the data processing section reduced errors in data coding and pralcessing.

However, because survey results are subject to sampling and

nonsampling errors, the total error will be larger than the

error due to sampling variability alone.

Because the statistics presented in this report rtre based

on a sample, they differ somewhat from the figures that would

be obtained if a complete census had been taken using the

same forms, definitions, 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. The

standard error, as calculated in this report, also reflects part

of the variation that arises in the measurement process, but

does not include estimates of any systematic biases that may

be in the data. The chances are about 68 out of 100 that

an estimate from the sample would differ from a complete

census by less than the standard error. The chances are about

95 out of 100 that the difference would be less than twice

the standard error, and about 99 out of 100 that it would

be less than 2Y2 times as large.

The relative standard error of an estimate is obtained

44
60

50

40

30

20

10

6

5

4

3

2

;.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

A 2 3 456789A 2 3 456789A 2 3 456789A 2 3 456789A 2 3 456789A

100 1,000 10,000 100,000 1,000,000 10,000,000

%ze f+f estimate (m thousands)

EXAMPLE: An estimate of 20 m]lhon office VISIIS 10 general surgeons (read from scale at bottom of chart) has a refatwe standard error of 7.7 percent (read from curve 8 on scale at left of chart) or a standard error

of 1.540.000 office vIsIts (7.7 percent of 20 mdlton vmlts).

Figure 1. Approximate relativo standard ●rrors for estimated numbers of office visit- based on all physician specialties ~), and individual specialties (B), 1980-81 National Ambulatow Madioal

* Care Survay

or
50

40

30

20

10

9

8

7

6

5

4

3

2

0.:

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

100

90

80

70

60

50

40

30

20

10

9

8

7

6

5

4

3

2

1

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

A 2 3 456789A 2 3 456789A 2 3 456789A 2 3 456789A 2 3 456789A

100 1,000 10,000 100,000 1,000,000 10,000,000

Size Of estimate (in thousands)

EXAMPLE: An estimate of 60 million drug mentions (read from scale at bottom of than) has a relative standard error Of 5.1 percent (read from cuwe A on scele et left of chart) or a standard error of 3,060,000 drug

mentions (5.1 percent of 60 millmn drug mentions).

Fgure Il. Approximate relativestandard errors for estimated numbers of drug mentions based on all physician specialties (A), and individual specialties (B), 1980-81 National Ambulatory Medical

Care Survey
by dividing the standard error by the estimate itself and is

expressed as a percent of the estimate. For this Ieport, an

asterisk (*) precedes any estimate with more than a 30 percent

relative standard error.

Estimates of sampling variability were calculated using

the method of half-sample replication. This method yields

overall variability through observation of variability among

random subsamples of the total sample. A description of the

development and evaluation of the replication technique for

error estimation has been published.20’21 Approximate relative

standard errors for aggregate estimates are presented in figures

I and II. To derive error estimates that would be applicable

to a wide variety of statistics and could be prepared at moderate

cost, several approximations were required. As a result, the

relative standard errors shown in figures I and II should be

interpreted as approximate rather than exact for any specific

estimate. Directions for determining approximate relative standard errors follow.

Estimates of aggregates

Approximate relative standard errors (in percent) for

aggregate statistics are presented in figures I and H. The

approximate relative standard errors for aggregate estimates

of office visits are shown in figure I, and the approximate

relative standard errors for aggregate estimates of drug mentions are shown in figure II. In each figure, curve A represents

the relative standard errors appropriate for estimates based

on all physician specialties, and curve B represents relative

standard errors appropriate for estimates based on an individual

physician specialty. For the specific case where the aggregate

estimate of interest is the number of mentions of a specific

drug, for example, the number of mentions of Dyazide,

figure I, curve B should be used to obtain approximate relative

standard errors.

Instead of using figures I and II, relative standard errors

for aggregate estimates may be calculated directly using the

following formulas where x is the aggregate estimate of interest

in thousands. For visit estimates based on all physician specialties,

RSE(.Y) =

d

0.001111 +

39.84195

.100.0

x

For visit estimates based on an individual physician specialty,

Rs’@)=@==nTooo

For drug mention estimates based on all physician specialties,

For drug mention estimates based on an individual physician

specialty.

‘s’(x)=~’ooo

Estimates of percents

Approximate relative standard errors (in percent) for estimates of percents may be calculated from figures I and H

as follows. From the appropriate curve obtain the relative

standard error of the numerator and denominator of the percents. Square each of the relative standard errors, subtract

the resulting value for the denominator from the resulting

value for the numerator, and extract the square root. This

approximation is valid if the relative standard error of the

denominator is less than 0.05, or if the relative standard

errors of the numerator and denominator are both less than

0.10.

Alternatively, relative standard errors for percentages may

be calculated directly using the following formulas where

p is the percent of interest and x is the base of the percent

in thousands. For visit percentages based on all physician

specialties,

RSE@) =

d

39.84195 .(1 –p)

.100.0

px

For visit percentages based on an individual physician specialty,

-)=el’’o.o

For drug mention percentages based on all physician specialties,

Rs’@)=7YT-”o

For drug mention percents based on an individual physician

specialty,

‘sE@)=e’”o

Estimates of rates where the numerator

is not a subclass of the denominator

Approximate relative standard errors for rates in which

the denominator is the total United States population or one

or more of the age-sex-race groups of the total population

are equivalent to the relative standard error of the numerator

that can be obtained from figure I or H.

Estimates of dtierences 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 squares of each standard error

considered separately. This formula represents the standard

error quite accurately for the difference between separate and

uncorrelated characteristics, although it is only a rough approximation in most other cases.

NOTE A list of references foIIows the text.

47
Table Il. Estimatea of the civilian noninstitutionalized population of the United Stafea used in computing average annual rates in this report, by age and

sex: 1980-61

All Under 15–24 25-44 45-64 65 years

Sex ages 15 years years years years and over

Number inthousands

Both sexes . . . . . . . . . . . . . . . . . . . . 222,674 50,632 40,710 62,658 43,963 24,512

Male . . . . . . . . . . . . . . . . . . . . . . . 107,429 25,976 20,076 30,467 20,849 10,042

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . 115,244 24,856 20,634 32,171 23,114 14,470

NOTE: ExcludesAlaskaand Hawaii.

Figuresmay notaddto totaldueto rounding,

Tests ofsignificance

In this report, the determination of statistical inference

is based on the Bonferroni test for multiple comparisons,

a modification of the t-test. Terms relating to differences,

such as “higher,” and “less” indicate that the differences are

statistically significant at the p < .05 level. Terms such as

“similar” or “no difference” mean that no statistical significance exists between the estimates being compared. A lack

of comment regarding the difference between any two estimates

does not mean that the difference was tested and found to

be not significant.

Population figures and rate

computation

The population figures used in computing annual visit

rates are presented in table II. The figures are based on an

average of the July 1, 1980, and July 1, 1981, estimates

of the civilian noninstitutionalized population of the United

States provided by the U.S. Bureau of the Census. Because

NAMCS includes data for only the conterminous United States,

the original population estimates were modified to account

for the exclusion of Alaska and Hawaii from the study. For

this reason, the population estimates should not be considered

official andare presented here solely toprovi& denominators

for rate computations.

Estimates of numbers of visits and drug mentions in this

report are for a 2-year period, but ratios and rates represent

average annual estimates. For example, the average annual

visit rates precalculated as follows. Thenumerator is obtained

by dividing the estimated number of office visits for 1980-81

by 2 to obtain an average annual number of office visits.

This number is then divided by the appropriate population

figure to obtain an average annual visit rate. As previously

discussed, estimates of reliability for average annual visit

rates may be calculated from figures I and II.

Rounding of numbers

Estimates presented in this report are rounded to the nearest

thousand. For this reason detailed figures within tables do

not always add to totals. Rates and percents are calculated

on the basis of the original,

necessarily agree precisely

rounded data.

48

unrounded figures and may not

with percents calculated from

Systematic bias

No formal attempt was undertaken to determine c)rmeasure

systematic bias in the NAMCS data. But it should be noted

that there are several factors affecting the data which indicate

that these data underrepresent the total number of office visits.

Some of these factors are briefly discussed below.

. Physicians who participated in NAMCS did a.thorough

and conscientious job in keeping the Patient Log; however,

post survey interviews with participating physicians indicate that a small number of patient visits may have been

accidentally omitted from the Patient Log; although this

number is quite small, such omissions would result in

an undercoverage of office visits.

The same post survey interviews indicate that the

inclusion of patient visits that dld not actually occur was

infrequent and would have a negligible effect on survey

estimates.

● As previously stated, the physician universe for the 1980

and 1981 NAMCS included all nonfederal, office-based,

patient-care physicians on the AMA and AOA masteril]es.

NAMCS was designed to provide statistically unbiased

estimates of office visits to this designated population.

Not included in the universe were physicians who were

classified as federally employed; or hospital-based, or

who were principally engaged in research, teaching, administration, or other nonpatient care activity. Consequently, ambulatory patient visits to these physicians

in an office setting would not be included in NAMCS

estimates. In an attempt to measure the number of office

visits to physicians not in the NAMCS universe, a NAMCS

Complement Survey was conducted in 1980. This study

involved a sample of approximately 2,000 physicians

selected from among the 230,000 physicians in the AMA

and AOA masterllles who were not eligible (in scope)

for the 1980 NAMCS. Results indicate that about 17

percent of the Complement Survey physicians saw some

ambulatory patients in an oftice setting and that an estimated 69 million office visits were made to these physicians in 1980.22

NOTE A list of referencesfollowsthetext.
Appendix II

Definitions of certain terms

used in this report

Terms relating to the survey

O&ce—Premises identified by physicians as locations

for their ambulatory practices. The responsibility over time

for patient care and professional services rendered there generally resides with the individual physician rather than with

any institution.

Ambulato~ patient—An individual seeking personal

health services who is neither bedridden nor currently admitted to any health care institution on the premises.

Physician-Classified as either

● Zn scope—All duly licensed doctors of medicine or doctors of osteopathy currently in practice who spend some

time caring for ambulatory patients at an off]ce location.

● Out of scope—Those physicians who treat patients only

indirectly, includlng physicians in the specialties of

anesthesiology, pathology, forensic pathology, radiology, therapeutic radiology, and diagnostic radiology,

and the following physicians:

● Physicians who are federally employed, including

those physicians in military service.

. Physicians who treat patients only in an institutional

setting, for example, patients in nursing homes and

hospitals.

● Physicians employed full time in industry or by an

institution and having no private practice, for example, physicians who work for the Veterans’ Administration or the Ford Motor Company.

. Physicians who spend no time seeing ambulatory

patients, for example, physicians who only teach,

are engaged in research, or are retired.

Patients-Classified as either

. Zn scope—All patients seen by the physician or a staff

member in the office of the physician.

. Out of scope—Patients seen by the physician in a hospital, nursing home, or other extended care institution, or

in the patient’s home. (Note: If the physician has a private ofllce, meeting the definition of “ot%ce,” located

in a hospital, the ambulatory patients seen there are

considered in scope.) The following types of patients

are considered out of scope

● Patients seen by the physician in an institution, including outpatient clinics of hospitals, for whom the institution has primary responsibility over time.

. Patients who contact and receive advice from the

physician via telephone.

. Patients who come to the ot%ce only to leave a specimen, to pickup insurance forms, or to pay a bill.

. Patients who come to the office only to pick up

medications previously prescribed by the physician.

Visit—A direct, personal exchange between an ambulatory patient and a physician or a staff member for the purpose of seeking care and rendering health services.

Physician special~—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 recorded in

the physician master files maintained by the American Medical Association or the American Osteopathic Association.

Region of practice location—The four geographic regions, excluding Alaska and Hawaii, that correspond to

those used by the U.S. Bureau of the Census:

Rs@M StatesinWded

Northeast . . . . . . . . . QXmeoticut, Maina, Massachusetts, MW

Hamp6hire, New Jersey, New York, Pennsylvania, Rhafe Island, and Vermont

North Central . . . . . Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Miiri, Nebraska, North Dakota,

Ohio, South Dakota, and W=nsin

South . . . . . . . . . . . . Alabama, Arkansas, Delaware, District of Columbia, Fbrida, Georgia, Kentucky,

Louisiana, Maryland, Miissippi, North

Carolina, Oklahoma, South Carolina, Ten.

nessea, Texas, Virginia, and West Virginia

West . . . . . . . . . . . . Arizona, Caiiiomia, Colorado, Idaho, Montana,

Navadaj NW Mexico, Oregon, Utah,

Washington, and Wyoming

Metropolitan status of practice Iocation—A physician’s

practice is classified by its location in a metropolitan or nonmetropolitan area. 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.

49
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.

Race-White, Black, Asian or Pacific Islander, or American Indian or Alaskan Native. Physicians were instructed to

mark the category they judged to be the most appropriate

for each patient based on observation or prior knowledge.

The following definitions were provided to the physician.

lWriw—A person having origins in any of the original

peoples of Europe, North Africa, or the Middle East.

Black—A person having origins in any of the black racial

groups of Africa.

Asian or Pacl~c Islander—A person having origins in

any of the original peoples of the Far East, Southeast

Asia, the Indian subcontinent, or the Pacific Islands, including, for example, China, India, Japan, Korea, the

Philippine Islands, and Samoa.

American Indian or Alaskan Native—A person having

origins in any of the original peoples of North America

and who maintains cultural identification through tribal

affiliation or community recognition.

Ethnicity-Category judged by the physician to be the

most appropriate. The following definitions were provided:

● Hispanic origin—A person of Mexican, Puerto Rican,

Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

. Not Hispanic—Any person not of Hispanic origin.

Patient’s complaint(s), symptom(s), or other reason(s)

for this visit (in patient’s own words+-The patient’s principal

problem, complaint, symptom, or other reason for this 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.

Major reason for this visit—The one major reason

(selected from the following list) for the patient’s visit as

judged by the physician:

●

●

●

●

●

50

Acute problem—A visit primarily for a condition or illness

having a relatively sudden or recent onset (within 3 months

of the visit).

Chronic problem, routine—A visit primarily to receive

regular care or examination for a preexisting chronic condition or illness (onset of condition was 3 months or

more before the visit).

Chronic problem, jlareup-A visit primarily to receive

care for a sudden exacerbation of a preexisting chronic

condition or illness.

Postsurgery or postinju~—A visit primarily for followup

care of injuries or for care required following surgery,

for example, removal of sutures or cast.

Nonillness care (routine prenatal, general exam, wellbaby)-General health maintenance examinations

routine periodic examinations of presumably healthy

sons, both children and adults, including prenatal

and

perand

postnatal care, annual physicals, well-child exanninations,

and insurance examinations.

Diagnostic services this vi.~it—Physicians were instructed

to check any of the following services that were ordered

or provided during the current visit:

●

●

●

●

☛

●

●

●

●

●

Limited history andlor examination—History or physicial

examination limited to a specific body site or system

or concerned primarily with the patient’s chief complaint,

for example, pelvic examination or eye examination.

General history andior examination—History or physical

examination of a comprehensive nature, including all or

most body systems.

Pap test—Papanicolaou test.

Clinical lab test—One or more laboratory procedures or

tests, including examination of blood, urine, sputum,

smears, exudates, tl”ansudates, feces, and gastric content,

and including chemistry, serology, bacteriology, and

pregnancy test; excludes Pap test.

X ray—Any single or multiple x ray examination for

diagnostic or screening purposes; excludes radiation

therapy.

Bloodpressure check.

EKG—Electrocardiogram.

Vision te.s—Visual acuity test.

Endoscopy—Examination of the interior of any Ibody cavity except ear, nose, and throat by means of an endoscope.

Mental status exam—Any formal, clinical evaluation designed to assess the mental or emotional status of the

patient.

Other—All other diagnostic services ordered or provided

that are not included in the preceding categories.

Principal diagnosis—The physician’s diagnoses of the

patient’s principal problem, complaint, or symptom. In the

event of multiple diagnoses, the physician was instructed to

list them in order of decreasing importance. The term “principal” refers to the first-listed diagnosis. The diagnosis represents

the physician’s best judgement at the time of the visit and

may be tentative, provisional, or definitive.

Other significant current diagnoses—The diagnoses of

any other condition known to exist for the patient at the

time of “the visit. Other diagnoses may or may not Ibe related

to the patient’s reason for visit.

Have you seen patient before ?—’’Seen before” means

provided care for at any time in the past. Item 10b refers

to the patient’s current episode of illness.

Medication therapy this visit—The physician was instructed to list, using brand or generic names, all medications,

including drugs, vitamins, hormones, ointments, and suppositories ordered, injected, administered, or provided this

visit including prescription and nonprescription drugs, vaccinations, immunization, and desensitization agents. Also included

are drugs and medications ordered or provided prior to the

visit that the physician instructed or expected the patient to

continue taking. Medications for the principal diagnosis are

listed in item 11a; all other drugs are listed in item 11b.

Nonmedication therapy—Physicians were instructed to
check any of the following services that were ordered or

provided during the current visit:

●

●

●

●

●

●

●

●

Physiotherapy—Any form of physical therapy ordered

or provided, including any treatment using heat, light,

sound, or physical pressure or movement; for example,

ultrasonic, ultraviolet, infrared, whirlpool, diathermy,

cold, and manipulative therapy.

Ofice surge~—Any surgical procedure performed in the

oftlce this visit, including suture of wounds, reduction

of fractures, application or removal of casts, incision

and draining of abscesses, application of supportive materials for fractures and sprains, irrigations, aspirations,

dilations, and excisions.

Family planning—Services, counseling, or advice that

might enable patients to determine the number and spacing

of their children, including both contraception and infertility services.

Psychotherapy or therapeutic listening—Ail treatments

designed to produce a mental or emotional respmse

through suggestion, persuasion, reeducation, reassurance,

or support, inchdhg psychological counseling, hypnosis,

psychoanalysis, and transactional therapy.

Diet conse/ing—Instructions, recommendations, or advice

regarding diet or dietary habits.

Family or social counseling-Advice regarding problems

of family relationships, including marital or parent-child

problems, or social problems, including economic, educational, occupational, legal, or social adjustment

difficulties.

Medical counseling—Instructions and recommendations

regarding any health problem, including advice or counsel

about a change of habit or behavior. Physicians were

instructed to check this category only if medical counseling

was a significant part of the treatment. Family planning,

&let counseling, and family or social counseling are

excluded.

Other—Treatments or nonmedication therapies ordered

or provided that are not listed or included in the preceding

categories.

Was patient referred for this visit by another physician?—

Referrals are any visits that are made at the advice or direction

of a physician other than the one being visited. The interest

is in referrals for the current visit and not in referrals for

any prior visit.

Disposition this visit—Eight categories are provided to

describe the physician’s disposition of the case. The physician

was instructed to check as many of the categories as apply:

●

●

●

●

●

●

●

●

Nofollowup planned—No return visitor telephone contact

was scheduled for the patient’s problem.

Return at speczjied time—Patient was told to schedule

an 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 considered it necessary.

Telephone followup planned-Patient was instructed to

telephone the physician on a particular day to report either

on progress, or if the need arose.

Referred to other physician-Patient was instructed to

consult or seek care from another physician. The patient

may or may not return to this physician at a later date.

Returned to referring physician—Patient was instructed

to consult again with the referring physician.

Admit to hospital—Patient was instructed that further care

or treatment would be provided in a hospital. No firther

ofllce visits were expected prior to hospitrd admission.

Other—Any other disposition of the case not included

in the prec~ing categories.

Duration of this visit—Time the physician spent with

the patient, not including time the patient spent waiting to

see the physician, time the patient spent receiving care from

someone other than the physician without the presence of

the physician, and time the physician spent in reviewing such

things as records ad test results. If the patient was provi&d

cam by a-member of the physician’s staff but did not see

the physician during the visit, the duration of visit was recorded

as Ominutes.

51
8 Appendix !!!

Patient Log and

,

%!? 382826 i

T

PATIENTjLOG

As each patient arrives, re ord name and

time of visit on the log Jelow. For the

patient entered on line #2, also tom.

plete the patient record tb the right.

[

coNTINuE LISTING f@TIENTS

ON NEXT PAGE

1

Patient Record form

ASSURANCE OF cONFIDENTALITV– AI! <n(ornw!w. w,>.. would ,,,rrm, ,den,,,,u,,on

o, ,. ,nd,.,d..l. . “.,.,,.,, w 8$, e,,abl,,hnwn! ,,,,! lx he,d ,O!,l,(!,. ”,,.1. ,%!11b. ,,!ml on,”

b, “er$o”$ ,“(WWI I“ and for !h. “urwx{+ of ,IW SW.,, ,,,’, v,,, ! no, b, .,,,c,mwl o, ,,

1,.,.,1 !0 O(IW 0.,$.”. “r .,,{1 Ior a., o,her “.rue,.

lm DATE OF VISIT

//

1 ❑ ACUTE PROBLEM

2 ❑ CHRONIC PROBLEM. ROUTINE

3 ❑CHRON!CPROEIEM. FLARE”,

4 ❑ POSTSURGERY,POST INJ”RY

5 ❑ NONILLNESSCARE (FICI”,,NE

PRENATAL, GENERAL EXAM

WELL BABY. ETC. I

IF Y&. FOR THE

CONDITION IN

ITEM 9.,

0w3r,w”, d H,,lth .,,d ““mm Ss,,,.,<

Pubk H,,,,, Se,,,,, B Oflm. ofHealth R?,emh. Stats, tr,,, ar,d T,chno,oq,

N3, !orw cl.,,! I., Hea,,h S,,,,,,,,!

N!

PATlENT RECORD

NATIONAL AMBULATORY MEDICAL CARE SURVEY

!. COLOR OR RACE I 5= ETHNIcITY

B. DIAGNOSTIC SERVICES THIS VISIT

{Check all ordcmd or pmvidedl

I ❑NONE 8 ❑ EKG

2 ❑ LIMITEO H,STORY,EXAN , ❑ V,SION TEST.

3 ❑ GENERAL HIsToRY/ExAk4 ,. ❑ ENDOSCOPY

4 HPAP TEST ,, ❑ M~;ENT;LSTATUS

—

5 UC LINICAL LAB TEST

6 ❑X.RAY

,2 ❑ OTHER ,Sp,.=,,r,

7 ❑moom,s s”., CHECK

am PATlENT’S COMPLAINT(S), SYMPTOM(S), OR OTHER

REASON(S) FOR ~ VISIT /In patient’s own words/

a MOST lMPOBTAN1

b. OTHER

90 PHYSICIANS DIAGNOSES

,. PRINCIPAL DIAGNOS, S,PRo&LEM ASSOCIATED WITH ITEM &

b OTHER SIGNIFICANT CURRENT DIAGNOSES

11. MEDICATION THERAPY THIS VISIT ❑ NONE

I lAinR brnmi 0? generic names, recomi all new and con tinmd medications ordered, injected, administered, m otherwise

provtdcd a t this vist. IncA8de inmunizitzK and desmsi niing agen tsl

a. FOR PRINCIPAL OIAGNOSES IN lTEM9a.

1.

2.

3,

4

b.

1

2.

3.

4,

FOR ALL OTHER REASONS

lzm NON-MEDICATION THERAPY

\Chzck a!l s?r.ices wdwed w provided thi.! .is;t/

1❑ NONE 6 ❑ DIET COUnSeling

2 ❑ PHYSIOTHEF7APV 7❑ FAMILY,S(3CIAL

3UOFFICE SURGERY

COUNSELING

4 H,AMILYPLANN,NJG

8 ❑ MELMc.4LcO”NSELING

5❑ PSYCHOTHERAPYI

9 ❑ OTHER,.WIVV

THERAPEUTIC LISTENING

13. WAS PATIENT

REFERRED

FOR THIS VISIT

BY A~HER

PHYSICIAN?

, ~ ,,s

1- zUNO

~~u ~~c~:;lO:::l: )OSIT

I nND FOLLOV+UP PLANNED

2 ❑RET”RNA7SPECIFIED TIME

3 ❑RETLIFIN IF NEEDED. P.R.N.

~ ❑TELEPHONE FoLKJW.LWPL.ANNED

5 ❑REFERRED TO CITHER pws,c14N

s m.... ~.c ,dR:,zB -Li3 RE;-ZRR:NG FhiYSIC,AN

‘cl ADMIT TO HOSPITAL

B❑ OTHER ,S,..,,,,

15. DURATION

CF THIS

VISIT

[Time acrually

spent with

physician /

I

PHS-61 05-6 (9/79) f? U.S. GOVERNMENT PRINTING OFF,CS: ,S~O.72!.50Z ,., OMB No. 6S.R1498
Appendix IV

American Hospital Formulary

Service classification system

and therapeutic category codes

AMERICAN

HOSPITAL

FORMULARY

SERVSCE

CLASSIFICATION

SYSTEM

AMERICAN HOSPITAL FORMULARY SERVICE CLASSIFICATION SYSTEM

AND THERAPEUTIC CATEGORY CODES (AHFS#)

(Clmitiutions in puenthe= are pmniicmd but may be used in DFIF) —

04:00

08:00

08:04

08:08

ANTIHISTAMINEDRUGS

ANH.1NFECT3VEAGENTS

AmcbacLdes

Anthelnrintms

08:12 AnObiotics

08:12.02 Aminoglycosi&s

08: 12.M Antifunga3Antibiotics

08:12.04 C@tdOtpO,i!lS

08:12.08 Chloramphenicol

08:12.12 Erythromycmr

08:12.16 Penicitlrns

08:12.24 TCtIICYCtiM

08:12.24 Other Antibioucs

08:16

08:18

08:20

08:24

08:26

08:28

08:32

08:36

08:40

10:00

12:00

12:04

12:08

12:12

12:16

12:20

16:C4

20:00’

Antmberculosis Agentr

Antlvlrak

Pk$modic]des

Sulfonmnrde$

.%lfones

Treponemicr4cs

Tnchomomcdcs

Urinary GcrtrucKIcs

Odmr An*Infective

ANT1NEOPLA8TK!AGENTS

AUTONOMIC DRUGS

P8ruympsthominretic Agmtu

Pumympatho[ytic &nts

Symparhorninretic .@ntt

Sympatholytic Agents

SkcleUl Muwle Relaxants

BLOODDERfVATIVZS

BLOOD FORMATIONANDCOAGULATION

20:M Antmnemia DruP

20:04.04 bon Preparauons

20:04.08 Lrier and Stomach

Repxmtionr

20:12 Coa@mrr and Antico@ants

2012.04 Anticoagulmtr

2012-08 Andhepuin A@lfs

20:12.12 Coagulsnu

20:12.16 Hemostitics

20:40 llrrombolytic ~nu

24:00 CARDIOVASCULARDRUGS

24:04 Qrdisc DrusI

24:06 Antilipunic @rtr

24:08 Hypotensive Agents

24:12 Varodilating .4gtntr

24:16 Sckro@ API,,,

28:00 CENTRAL NERVOUSSYSTEMDRUGS

28:04 GemerdAnasthetict

28:08 Atmf@cs urd Antipyretics

28:10 Narcotic A.tasonittr

28:12 Anticorwulrantr

28:16 Prychothempcutic Agcntr

28:16.04 Amideprcsrants

28:16.08 Tmnquitizers

28:16.12 Other Prychotherapeutrc

Agents

28:20 Respuatory and Cerebral

Stimutattts

28:24 Sedatwcs and Hypnottcs

36:00

36:04

36:08

36:t2

36:16

36:18

36:24

36:23

36;26

36:28

36:30

36:32

36:34

36:36

36:38

36:40

36:44

36:48

36:52

36:S6

36:60

36:61

36:62

36:64

3666

36:68

36:72

36:76

36:78

36:80

36:84

36:88

4000

40:04

40:08

40:10

40:12

4016

40:18

4n:20

4024

4028

40:36

4040

U:oo

48:00

S2:O0

S2:04

DIAGNOSTICAGENTS

Adrenocortwat lnsufficmtcy

Amyloidosis

Blood Volume

BruceUodr

Cardiac Function

Circulation Time

(Cystic Fibrotir)

Diabetcr Meltitu$

Diphtheria

131ucHypcr$enritivity

Fut@

GaUbtdder Funcuon

Gastric Function

Inte!timl Abrormion

t&ilCY Function

Sivcr Function

Lymphogmrrulorru Vencreum

Mumps

Mysrthenia Gmti

Myxc&nrs

Pmrczatic Function

Phenylkctonuria

Plleochrormcytom

pituitary Function

Roent~nography

scarlet Ftver

SWCW*

(Thyroid Function)

Trichinair

Tuberculorir

UrirwContents

ELECTROLY2TC,CALORfC, AND

WATERBALANCE

AcidifymSxnti

.

Alkabms ~nu

AnrrrrOnkDetox.k.ants

Repkmrtrcnt Sohnionr

8odiurmRenrotinI Rcdnr

Porsr$ium-RerrmtigReaim

tAtOric.@Ittt

Sltt and SttprsuLutitutet

Ltiuretkr

3rriptin# sdutionr

UrkosudcApnu

SNZYMES

EXPECTORANTSAND COUGH

PREPARATIONS

EYE, EAR, NOSE ANDTHROAT

PREPARATIONS

,hti-lnfectiver

52M.04 Antibkotici

52M.06 AntStiak

5204.08 SUtfOnmrlidt$

S2:04.12 34iJc.Anti.Infeetkvcs

S208 krti-hrthnmatory @nt$

S210 Ckrbonic Anhydra$e frrhibitors

S2:12 Contact Las Solutioni

S2: 16 LOal Anuthcticr

52:20 Mioticr

52:24 MYdriatiu

S2: 28 Mouth Wuhes and Gargkes

52:32 Va$oconstrictors

52:36 Unclurincd A@nts

S6,00 GABTROINTEST3NALDRUGS

56:o4 A.tAds and Adrorb$trtr

56:08 Awi-Di?rrhea Aprts

56:10 Anrifktuknrr

56:12 ~thutic$ and h.xmives

56:16 Digwants

S6:20 Enrttics md Anu-Etrrcticr

S6:24 Lipotropic AWnts

56:40 Misc.G1Dnw,

60:00 GOLD COMPOUNDS

64:oO HEAVYMETALANTAGONISTS

68:00 HORMONSSANDSYNTHETIC

SUBSTITUTES

68:M Adrenats

68:08 An&ogens

68:12 Contraceptives

68:16 Estropnr

68:18 Gmudotropmr

68:2o hmdii and Anti-Dubctic

&rttl

68:20.08 Insulins

68:24

68:28

68:32

68:34

68:36

72:00

76:Oit

78:00

So:oo

SO:03

So:os

SO:12

84:0+2

S4:04

PaMhyroid

Pituitlry

pr~stogens

Other Corpus Luteum Hormones

Thyroid d Amithyroid

SAXALANESTHETICS

oxYTtxm.s

RADIOACHVE AGENTS

SERUMS,TOXOIDSAND VACCINES

Serums

Toxotdr

Vaccinrs

SYJN ANDNUCOUS MEMBRANE

PREPARATIONS

Anri-hfectlveI

84:lM.04 Anubtot]cs

34:04.0S Furu,ades

S4:04.12 Scsbmdm mwlPed]cultcrdet

B4:04.16 Mr# Lord Artti-krfec:met

34:06 Anb-lnfkmmatory ~enu

U :08 Antrprtuiwrad L.oul

Arertktticr

84:12 Adtt@rts

S4: 16 cell Stintulants snd Prollfcrurts

u: 20 Dctcrmlts

B4:24 Emdhctru,LMmulccnuznd

Rotectmlu

84:24.04 BarK f.dtom and Lnrtmenu

P4:24.OS Ssrsc OIISand Other SaIvcnu

34:24.12 ~rtc Otntmctrt$and

Rotocunts

84:24.16 Bsmcpowder! and Demulcents

84:28 KcraiolYticA#tnts

84:32Keratopbst:c Apnts

34:36 Mncdlmtous Amtts

S4:S0 Pksrttentitq& 2&rttmn1~ Apnu

S4:S0.M Dcp~ntinI A~nts

84:S0.06 ~nti~ *nts

S4:S0 Sunrcmctt *nt*

86:00

88:00

88:04

88:0s

88:12

88:16

88:20

88:24

88:28

92:00

94:@3

%:00

SPASMOLYTICAGENTS

VITAMINS

V:ttmkt A

Vltamitr B Complex

V:tamtn C

V:mmin D

vnuntn E

Vlumin K AcuvrfY

MuttwmamrnPrepsratmnr

UNCLASSIFIEDTHERAPEUTICAGENTS

(DEVICES)

(PHARMACEUTICSAIDS)

Copyright @1980. Drug Products Information File; American Society of Hospital Pharmacists, Bethesda, Maryland.

All rights reserved. Reprinted with permission.

53
the JikaZth LowIncomeChild...

ReportProfiles

HealthCareof

Pmr Children

Medicaid coverage does affect the health care of services, and expenditures for physician visits.

children from low-income families, according to The report also presents data on potential access

Insurance Coverageand ArnhAtory Medical to medical care, such as the presence ~ ~

Care of Low-Income Children; United States, and convenience of regular sources

n~h~

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children, their insurance coverage, use of health i[tl

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❑ ~, please send me _ copies of Insurance Coverage and Ambulatory Medical

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GPO Stock Number-O17-022-O0896-3 Price $1.50

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*U.S. GOVERNMENT PRINT’ING oFFl~ ~ g ~ 6- 49 1..335-400 () 4
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