Use ofHoaith

sefv&esfor Disodem

Ofthoemde

Repmdudv 8 system:

United States, 1977-78

Using data from the National Ambulatory

Medical Care Survey and the National Hospital

Discharge Survey, statistics are presented on

visits to office-based physicians for care and

treatment of female reproductive disorders

and on patients discharged from short-stay

hospitals with related surgery. Visits are de

scribed in terms of patient, physician, and

clinical characteristics. Breast and gynecological surgery is shown in terms of associated

diagnoses and is charted for 1970-78.

Dete From the Nationel Heelth Suwey

Series 13, No. 63

DHHS Publication No. (PHS) 82-1724

U.S. Department of Health and Human

Services

Public Health Service

Office of Haalth Research, Statistics, and

Technology

National Center for Health Statistics

HyattsviHe, Md.

March 1982
Library of Congress Cataloging in Publication Data

Cypress, Beulah K,

Use of health aewices fordisorders of the femaie reproductive systern, United States, 1977-78.

(Vital and health statistics. Series 13, Data from the national

health survey ; no. 63) (DHHS publication ; no. (PHS) 82-1724)

Includes bibliographical references.

Supt. of Dots. no.: HE 20.6209: 13/63

1. Generative organs, Female–Diseases–United States–Statistics.

2. Women’s health sewices–United States–Utilization–Statistics.

3. Physician sewices utilization–United States–Statistics. 4. Gynecology, Operative–United States—Statistics. 5, Breast–Surgery—United

States-.Statistics. 6. Health surveys-United States. 7. United States–

Statistics, Medical, i. National Center for Health Statistics (U. S.)

11. Title. Ill. Series. IV. Series: DHHS publication ; no. (PHS) 82-

1724. [DNLM: 1. Ganital disaases, Female–Therapy. 2. Health

sarvices-Utilizat ion-United States. W2 A N 148vm no. 63]

RA407.3.A349 no. 63 362.1 ‘1 ‘0973s 81-607149

[RG106.4.U6I 362.1’981’00973] AACR2

1,’!,!’wI<, lIy tl!v S!l[l$,ri lllcllllcsllt of IIoc(! mouth. [’. S. (;ovm’lllll(>llt l’rilltil)x otlive, lY:isliiligt,,ll, 1).(’. 204(12
National Center for Health Statistics

DOROTHY P. RICE, Director

ROBERT A. ISRAEL, Deputy Director

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

and Epidemiology

GAIL F. FISHER, Ph.D., Associate Director for the

Cooperative Health Statistics System

GARRIE J. LOSEE, Associate Director for Data Processing

and Services

ALVAN O. ZARATE, Ph. D., Assistant Director for

International Statistics

E. EARL BRYANT, Associate Director for Interview and

Examination Statistics

ROBERT C. HUBER, Associate Director forklanagement

MONROE G. SIRKEN, Ph.D., Associate Director for Research

and Methodology

PETER L. HURLEY, Associate Director for Vital and Health

CareStatistics

ALICE HAYWOOD, Information Officer

Division of Health Care Statistics

W. EDWARD BACON, Ph.D., Director

JAMES E. DELOZIER, ChieJ Ambulatory CareStatistics

Branch

MARY MOIEN, Chie~ Hospital CareStatistics Branch

MANOOCHEHR K. NOZARY, Chiej Technical Services

Branch
In accordance with specifications established by the

National Center for Health Statistics, the U.S. Bureau of the

Census, under a contractual arrangement, participated in plrmning the survey and collecting the data in the National

Hospital Discharge Survey.

Analysis of data and interpretation of findings contained

in this report were performed by the Division of Health Care

Statistics, National Center for Health Statistics.

i
Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Description andscope ofthesurveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Source and limitations ofthedata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............. 2

Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Diagnostic scope andintensityof physician utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Breast diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Genital tract diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Return visit rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Diagnostic concomitance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Patient characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

patient age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

patient race . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Physician characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Utilization by specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Proportion ofphysician’s practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Clinical characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Timesince onsetofcomplaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Seriousness ofcondition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Diagnostic services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Therapeutic services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Disposition ofvisit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Duration ofvisit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Inpatient surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Diagnosis and surgical procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Diagnosis and breastsurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Diagnosis andgynecological surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Listofdetailed tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Appendixes

Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

1. Technical notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

...

Ill
Il. Definition of terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

111. Survey instrument . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

List of text figures

1.

2.

3.

4.

5.

6.

7.

8.

9.

Percent distribution of office visits by patients 15 years of age and over fordisorders of the female reproductive system

andother most frequent principal diagnoses: United States, l977-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Percent distribution of office visits by women 15 years of age and over for neoplasms and breast disorders, by physician’s

specialty :United States, 1977-78.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Percent distribution of office visits by patients 15 years of age and over for neoplasms and diseases of the female genital

tract, byphysician’s specialty :United States, 1977 -78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Average annual rate of office visits including a Pap test, by age of patient: United States, 1977-78 . . . . . . . . . . . . . . . . 12

Average annual rate of office visits for neoplasms and diseases of breast and all-1 isted breast surgery in short-stay hospitak., byageof patient: United States, 1977-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Rate of all-listed breast surgery per 100,000 females 15 years of age and over: United States, 1977-78 . . . . . . . . . . . . . 17

Average annual rate of office visits for neoplasms and diseases of the female genital tract and rate of all-listed gynecological surgery in short-stay hospitals, by age of patient: United States, 1977-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Rate of selected all-listed gynecological surgery in short-stay hospitals for females 15 years of age and over: United

States, 1970-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Rate of all-listed tubal ligation or occlusion procedures in short-stay hospitals for females 15-44 years of age: United

States, 1970-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

List of text tables

A.

B.

c.

D.

E.

F.

G,

H.

Number, percent distribution, and return visit rate of office visits for disorders of the female reproductive system, by

selected principal diagnoses: United States, 1977-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Number and percent distribution of office visits for disorders of the female reproductive system, by second-listed diagnoses: United States, 1977 -78... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Number and percent distribution of office visits for principal diagnoses of diseases of the female genital tract, by most

frequent second-listed diagnoses: United States, 1977-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Number and percent of office visits, percent of patient contact time, and mean contact duration of office visits for disorders of the female reproductive system, by selected physicians’ specialties: United States, 1977-78 . . . . , . . . . . . . . . 10

Number of office visits, percent by disposition of visits, and percent distribution by duration of visits, according to breast

andgenital tract disorders: United States, 1977 -78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Number of new patients referred by another physician, and percent distribution by physician’s specialty to which patients were referred, according to disorders of the breast and female genital tract and for all other diagnoses: United

States, 1977 -78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Number of selected all-listed breast procedures in short-stay hospitals and percent by most frequent all-listed medical

diagnoses andsurgical procedures: United States, 1977-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Number of selected all-listed gynecological procedures in short-stay hospitals, and percent by surgical procedures and alllisted diagnoses: United States, 1978... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

iv
Symbols

. . .

. . .

0.0

z

#

Data not available

Category not applicable

Quantity zero

Quantity more than zero but less than

0.05

Quantity more than zero but less than

500 where numbers are rounded to

thousands

Figure does not meet standards of

reliability or precision

Figure suppressed to comply with

confidentiality requirements

v
Use of Health Services for

Disorders of the Female

Reproductive System

by Beulah K. Cypress, Ph. D., Division of Health Care Statistics

Introduction

Findings of the 1977-78 National Ambulatory

Medical Care Survey and the National Hospital Discharge Survey, conducted by the Division of Health

Care Statistics in the National Center for Health Statistics, indicate that disorders of the female reproductive system have a major impact on the utilization of

at least two of the nation’s health care systems:

ambulatory care, exemplified by office-based medical

practice, and inpatient care provided in short-stay

hospitals. Extensive use of these health resources suggests that disorders of the female reproductive system

account for a large portion of direct and indirect

costs of health care.

The primary focus of this report is the characteristics of visits to office-based physicians by women

15 years of age and over with reproductive disorders.

Rates of breast and gynecological surgery also are included and based on data collected in the National

Hospital Discharge Survey from 1970 through 1978.

The category of disorders of the reproductive system used in this analysis includes neoplasms and diseases of the breast, and neoplasms and diseases of the

female genital tract. It does not include infective and

parasitic diseases, venereal diseases, diseases of the

urinary system, and complications of pregnancy and

the puerperium, although these conditions may give

rise to or be associated with reproductive disorders.

Detailed tables are based primarily on the principal, or f~st-listed, diagnosis which the physician

indicated as his evaluation of the patient’s condition

related to the chief complaint or other reason for the

visit. Diagnoses were classified and coded according

to the Eighth Revision International Classification of

Diseases, Adapted for Use in the United States

(ICDA).1

Background

Utilization of health care resources by patients

with specific health problems has its roots in the

prevalence of these problems in the population.

About 20 of each 1,000 women interviewed during

the 1978 National Health Interview Survey, a

population-based survey conducted by the National

Center for Health Statistics, claimed they suffer from

“female troubles” (not including breast problems).’

The proportion that reported physician visits for

“fema]e troubles” was higher than that of any other

chronic condition reported in the same survey, even

though prevalence rates for some of the other conditions were higher than the 20 per 1,000 prevalence

rate of the group of conditions characterized as

“female.” An estimated 92 percent of the women

who reported these problems claimed to have visited

a physician at least once during the past year. About

one-third of the respondents reported that they had

been hospitalized at some time before the survey, and

45 percent said they spent one or more days in bed

during the past year because of the problem. The

number of women who reported physician visits and

hospital stays would be higher if breast problems,

which were not reported, were included.

Data on physician visits and hospital stays also

were collected in the National Health Interview Survey (NHIS), but estimates differ from those collected

in the National Ambulatory Medical Care Survey and

the National Hospital Discharge Survey because of

differences in populations sampled, definitions, and

collection procedures. Data on specific conditions reported by household participants in the NHIS, as

opposed to data collected from physicians in the

NAMCS, tend to be underestimated.

Measured by patient population, the physician’s

private office is the major setting for health care, and

women are the major consumers. According to data

collected in the NAMCS, women 15 years of age and

over made an estimated 592 million visits to officebased physicians during the 2-year period 1977-78, an

average annual rate of 3.5 visits for each woman that

age group in the population. About 45.5 million, or

7.7 percent, of these visits were for reproductive disaUnpublished data from the 1978 National Health Interview Survey.

1
orders (figure 1). The relative magnitude of these

problems becomes apparent when this proportion is

compared with that of visits for prenatal care, which

was the leading specific condition for which physician

visits were made and which accounted for 7.3 percent

of all visits by women 15 years of age and over.

In the hospital setting, women also are the predominant users of surgical services. Gynecological

surgery (usually elective surgery related to diagnoses

made in the physician’s office) was the leading type

of surgery performed in short-stay hospitals during

1977-78, according to data collected in the NHDS.2

For women 15-44 years of age, the rate of61 gynecological and breast procedures per 1,000 exceeded the

rate of 48 per 1,000 for normal delivery.

Prior to data presentation, the scope of the

NAMCS and NHDS and limitations of the data are

described briefly to assist the reader in interpreting

the estimates.

Disorders of female

Prenatal reproductive system

care \

Figure 1. Percent distribution of office visits by patients 15 years of

age and over for disorders of the female reproductive system and

other most frequent principal diagnoses: United States, 1977-78

Description and scope of the surveys

The National Ambulatory Medical Care Survey is

a sample survey conducted annually by the Division

of Health Care Statistics of the National Center for

Health Statistics.

Data collection and processing for the 1977 and

1978 National Ambulatory Medical Care Surveys

were the responsibility of the National Opinion Research Center at the University of Chicago. Sample

selection was accomplished with the assistance of the

American Medical Association and American Osteopathic Association.

The basic sampling unit, for the National Ambulatory Medical Care Survey was the physician-patient

encounter or visit. The current scope of the National

Ambulatory Medical Care Survey includes all office

visits within the conterminous United States made by

ambulatory patients to non-Federally employed,

office-based physicians as classified by the American

Medical Association or the American Osteopathic

Association. The National Ambulatory Medical Care

Survey physician universe excludes anesthesiologists,

pathologists, and radiologists, and physicians principally engaged in teaching, research, or administ.ration.

Telephone contacts and visits conducted outside the

physician’s office also are excluded. The definitions

for office, physician, patient, and visit that were used

to determine eligibility for the National Ambulatory

Medical Care Survey are presented in appendix 1[1.

Data presented on hospital discharges are from

the National Hospital Discharge Survey, an ongoing,

nationwide sample survey of short-stay hospitals in

the United States. The scope of the NHDS encompasses patients discharged from hospitals, excluding

military and Veterans Administration hospitals,

located in the 50 States and the District of Columbia.

Only hospitals that have six beds or more for patient

use and in which the average length of stay for all

patients is fewer than 30 days are included.

Definitions of terms relating to the NHDS maybe

found in appendix II of Vital and Health Statistics,

Series 13, No. 46.s

Source and limitations of the data

Estimates of office visits in this report are based

on information obtained from a patient encounter

form, the Patient Record (see appendix HI) for a

sample of visits provided by a national probability

sample of office-based physicians. The combined samples for the 1977 and 1978 National Ambulatory

Medical Care Surveys included 6,007 physicians, 973

of whom were ineligible because they were out of

scope at the time of the survey. Of 5,034 eligible

physicians, 3,782 (75.1 percent) participated (see

appendix I).

Sample physicians listed all office visits during a

randomly assigned, 7-day reporting period. During

the 2-year period, information was recorded on

Patient Records for a systematic random sample of

98,335 visits.

Facsimiles of survey materials used in NAMCS

such as the introductory letter and induction interview form were published in Vital and Health Statistics, Series 13, No. 44.4

The 1977 and 1978 NHDS samples of discharges

obtained from participating hospitals included

approximately 224,000 and 219,000 medical records

respectively. Additional information relating to the

1977 and 1978 NHDS samples was published in Vital

and Health Statistics, Series 13, Nos. 41 and 46.395

2
These reports included a facsimile of the NHDS Medical Abstract.

The appendixes to this report and the appendixes

in the NHDS references should be read to properly

understand and interpret the statistics presented.

Appendix I contains a general description of the

NAMCS methods, the sample design, and the data

collection and processing procedures. Methods of

estimation and imputation also are presented. The

statistics in this report are based on samples of office

visits and hospital discharges rather than on all visits

and discharges and are subject to sampling errors.

Therefore, particular attention should be given to the

section on “Reliability of estimates” in appendix I

and in references 3 and 4. Charts of relative standard

errors and instructions for use also are shown in

appendix I of this report and the NHDS references.

The 1977 and 1978 NAMCS 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 contained in this report are for a 2-year period,

but ratios and rates represent average annual

estimates.
Highlights

. During the 2-year period 1977-78, women made

an estimated 45.5 million visits to office-based

physicians for care and treatment of reproductive

disorders.

. Breast conditions diagnosed during visits were

chiefly chronic cystic disease and other (nonneoplastic) diseases of breast.

. Diagnoses related to the uterus were the most

likely conditions found in the genital tract, followed by disorders of menstruation.

. Visits for malignant neoplasms of the breast were

proportionately more frequent than those of a

benign nature because patients with malignant

conditions made about five return visits for each

visit in which the condition was presented as a

new problem, but patients with benign neoplasms

of breast made only about one return visit.

. Three times as many visits were made for benign

neoplasms of the genital tract as for malignant

neoplasms, but patients returned more frequently

for care of malignancies.

. White women visited physicians more frequently

than black and all other women did for breast

conditions and menopausal symptoms; the visit

rate for black and all other women was higher for

diseases of parametrium and pelvic peritoneum

(chiefly pelvic inflammatory disease).

. Among physician specialties, general surgeons received the largest proportion of visits for breast

diseases. Obstetrician-gynecologists received the

majority of visits for genital tract disorders. General and family practice was the second-ranking

specialty in visits for reproductive disorders.

. The rate of office visits that included a Pap test

decreased as the age group of the patie:nts advanced.

. The rate of partial mastectomy performed in

short-stay hospitals declined from 1975 to 1978.

Rates for complete or radical mastectomy were

consistently lower than rates for the partial procedure but were more stable from 1970 tc] 1978.

. From 1970 to 1977, diagnostic dilaticm and

curettage (D & C) of uterus was the mcst frequently performed type of gynecological surgery.

. During 1978, the rate of tubal sterilization by

ligation or occlusion exceeded the rate of D & C.
Diagnostic scope and intensity

of physician utilization

The distinction between prevalence or incidence

of a disease and physician visits for a disease should

be noted when interpreting these data. The rate of

physician visits does not necessarily reflect the degree

to which a condition is present or arises in the population, notwithstanding that visits to the physician’s

office may be motivated by a pathological condition

or the visit may result in detection of the condition.

The NAMCS was designed to provide information

concerning provision and use of certain ambulatory

medical care services and is, therefore, a valuable

source of data concerning utilization of physicians’

services when visits are characterized by specific diseases. Prevalence and incidence data may be obtained

from other surveys conducted by NCHS}

Of the estimated 45.5 million visits made during

1977-78 for care and treatment of reproductive disorders, 8.6 million were attributed to breast conditions and 36.9 million to disorders of the female

genital tract (table A).

Breast diagnoses

The majority of visits that involved breast conditions were for chronic cystic disease and other (nonneoplastic) diseases of the breast (54.7 percent).

Visits for malignant neoplasms of the breast were

twice as numerous as those for benign and unspecified neoplasms–2.6 million compared with 1.3

million.

Genital tract diagnoses

The most common diagnoses that involved the

genital tract were related to the uterus (8.9 million

visits), followed by disorders of menstruation (7.9

million).

Unlike visits for neoplasms of the breast, visits for

bFor example, see publications of NHIS (Series 10).

neoplasms of the genital organs were more likely to

involve neoplasms of a benign or unspecified nature—

3.6 million visits involved conditions classified as benign or unspecified, and .9 million visits involved

conditions considered malignant.

Return visit rate

The extent of utilization of physicians’ services

is influenced by many variables other than prevalence

of diseases. Among these are availability of care, attitude toward health care, and health insurance

coverage. NAMCS was not designed to provide such

information. But the intensity of utilization for

specific conditions, after the choice is made to use

physicians’ services, may be estimated by the return

visit rate (RVR). The RVR is the ratio of return visits

for continuing care to the number of visits in which

the patient presented that condition as a new problem (table A). A high RVR indicates many return

visits relative to the number of new problem visits.

There is not necessarily a positive correlation between

the RVR and the number of visits. For example,

malignant neoplasms of the breast had the highest

RVR in the breast conditions group (5.4), but the

total number of visits (2.6 million) did not exceed the

number for chronic cystic disease and other nonneoplastic diseases of breast (4.7 million). Similarly,

malignant neoplasms of the genital organs exhibited

the highest RVR (3.6) in the group with that condition but had the fewest number of visits (942,000).

Thus these problems may be presumed more retumvisit intensive than others.

On the other hand, an RVR of less than one indicates a low return-visit intensive condition because

new problem visits exceeded return visits. On the

average, benign and unspecified neoplasms of breast,

diseases of ovary and fallopian tubes, diseases of parametrium and pelvic peritoneum, diseases of uterus,

and disorders of menstruation were low return-visit

intensive. It is possible that early surgical intervention

5
Table A. Number, percent distribution, and return visit rate of office visits for disorders of the female reproductive system, by selected principal

diagnoses: United States, 1977-78

Principal diagnosis and ICDA code 1

Number

Return

of visits Percent

in distribution

visit

thousands

rata2

Total neoplasms and diseases of breast . . . . . . . . . . . . . . . . .174, 217, 233, 610-611 8,606 100.0 1.9

Benign andunspecified neoplasms of breast . . . . . . . . . . . . . . . . . . . . . . . . . . . ...217.233 1,261 15.1 0.8

Malignant neoplasms of breast.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...174 2,624 30.2 5.4

Chronic cystic disease and other (nonneoplastic) diseases of breast . . . . . . . . . . . . .610-611 4,722 54.7 1.5

Total neoplasms and diseases of female genital

tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180-184, 218-221, 234-236,612-616,620-629 36,901 100.0 1.2

Benign andunspecified neoplasmsof female genital organs . . . . . . . . . . . .218-221, 234-236 3,563 9.7 1.4

Malignant neoplasms of female genital organs . . . . . . . . . . . . . . . . . . . . . . .180-184 942 2.6 3.6

Diseases ofovary and fallopian tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...612-615 1,734 3.1 0.9

Diseases ofparametrium andpelvic peritoneum3 . . . . . . . . . . . . . . . . . . . . . .616 1,970 5.3 0.7

Infective diseases of cervix uteri and other diseases of cervix . . . . . . . . . . . . . . . . . .620-621 3,305 9.0 1.6

Infective diseases of uterus (except cervix), vagina, and vulva; and other diseases of

uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 622-625 8,912 24.2 0.9

Other diseases of female genital organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...629 1,473 4.0 0.5

Disorders of menstruation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 626 7,933 21.5 0.7

Menopausal symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...627 6,678 18.1 3.4

Sterility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...628 990 2.7 2.2

lBa~ed~ntheEi~hth Revi$ion International Classification of Diseases, Adapted for Use in the United States (l CDA).

2Therati~of ~eturn visits to newproblemvisi@. Areturnvisit rate of less than l. Oindicates that newproblem visits exceeded retUrn ViSitS.

Schiefly pelvic inflammatory disease (616.0).

forsome ofthese occasionally acute conditions (especially if bleeding is present) reduced the numberof

return visits to the physician. (Gynecological surgery

related to these problems is discussed in the section

of this report on inpatient surgery.) Because menopausal symptoms, for which surgical interventionor

hospital care usually is not indicated, had a relatively

high RVR (3.4), this suggestion implausible. Therelatively high RVR’S for malignant conditions, for which

surgical intervention and hospital care usually are

indicated, seem to refute this idea. However, prolonged postsurgical monitoring is needed in these

cases. Conditions related to the reproductive system

were not as return-visit intensive as were chronic conditions such as diabetes mellitus (RVR = 7.7), hypertension (9.4), and chronic ischemic heart disease

(12.4).6

Diagnostic concomitance

Although the principal, or first-listed, diagnosis is

the primary emphasis of this report, second-listed

diagnoses also provide information on the extent of

use of physicians’ services for disorders of the reproductive system.c Multiple related diagnoses are common in gynecology. In this event, the first- and

second-listed diagnoses may be within the reproductive disorder group. These conditions also may be

present in patients who visit physicians for other uncUp to three diagnoses may be listed on the Patient Record. Because

approximately 93 percent of the visits used in this report had no thirdIisted diagnosis, only second-listed diagnoses were used in the analysis.

related problems, such as hypertension, which are

more closely related to the patient’s chief cc~mplaint

or other reason for visit. If the reproductive (disorder

is known to exist in the patient or it is diagnosed

during the visit, it is likely to be listed second on the

Patient Record. It is also instructive to examine the

conditions that may coexist when the principal diagnosis is a disorder of the reproductive system,

whether the conditions are in the same categc~~ or in

an unrelated group.

The combined number of first- and second-listed

diagnoses of selected specific disorders of the reproductive system may be obtained by adding the number of visits for a condition shown in table A to the

number of visits for the same condition shown in

table B. This result is divided by two to prcwide an

average annual number of mentions of the condition.

For example, there were 7.9 million principal (table

A) and 1.8 million second-listed (table B) diagnoses

of disorders of menstruation– a total of 9.8 million

mentions, or an annual average about 4.9 million

mentions of this diagnosis.

Table C shows the diagnoses that most commonly

were listed second when a disorder of the femade genital tract was the principal diagnosis. As expected,

three types of anatomically related diagnoses

accounted for approximately 12 percent of !secondlisted diagnoses. These diagnoses were benign and

unspecified neoplasms of the genital organs, cystitis

and other diseases of bladder and urinary tract, and

diseases of the genital tract.

Obesity, neuroses, and hypertension also were

included among second-listed conditions, but these

6
Table B. Number and percent distribution of office visits for disorders of the female reproductive system, by second-listed diagnoses: United States,

1977-78

Second-listed diagnoses and ICDA code’ of visits Percent

in distribution

thousands

Totairreoplasms anddiseases of breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174, 217,233,610-611 1,465 100.0

Benign andunspacified neoplasms of breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...217.233

Malignant neoplasms of breast... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Chronic cystic disease andothar (nonneoplastic) diseases of breast . . . . . . . . . . . . . . . . . . . . . . .. 610-611

Total neoplasms and diseases of female genital tract . . . . . . . . 180-184,218-221,234-236,61 2-616,620-629

Benign and unspecified naoplasms of female genital organs . . . . . . . . . . . . . . . . . . . . . .218-221,234-236

Malignant neoplasms of female genital organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...180-184

Diseases ofovary and fallopian tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...612-615

Disease of~arametrium andpelvic peritoneum2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...616

Infective diseases of cervix uteri and other diseases of cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . .620-621

*216

386

863

12,070

1,228

414

351

555

1,142

14.7

26.3

58.9

00.0

10.2

3.4

2.9

4.6

9.5

Infective diseases of uterus (except cervix), vagina, and vulva; and other diseases of uterus . . . . . ...622-625 3,590 29.7

Other diseases of female genital organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...629 582 4.8

Disorders of menstruation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..626 1,829 15.2

Menopausal symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..627 2,202 18.2

Sterility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...628 *177 1.5

lBased~n the Eighth Revision International CXassificationof Diseases, Adaptad for Useinthe Unitad States (lCDA).

2Chief Iy paivic inflammatory disease (61 6.0).

Table C. Number andparcent distribution ofoffice visits forprincipal diagnows ofdiseases of the femalagenital tract, bymoti frequent secondlisted diagnoses: United States, 1977-78

Second-listed diagnoses and ICDA code 1

Number

of visits Percent

in distribution

thousands

Allvisits for principal diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36,901 100.0

Nosacond diagnosis listed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24,368 66.0

Benign and unspecified neopiasms of female genital organs . . . . . . . . . . . . . . . . . . . . . ..218-221.234-236 536 1.5

Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...277 422 1.1

Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...280.285 *279 0.8

Neuroses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..3oo “320 0.9

Essential benign hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...401 744 2.0

Cystitis and other diseasesofbladder and urinary tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 595-599 548 1.6

Disaasesofthefemalegenital tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...612-618. 621-629 3,448 9.3

Medical or special examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..Yoo 465 1.3

Surgical aftercare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...............YIO 958 2.6

Allotherdiagnosas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..Residual 4,813 13.0

lBasadon the Eighth Revision International Classification of Di~ases, Adapted for Useintha United States (lCDA).

diagnoses maybe expected inalist ofdiseases found Medical or special examinations (chiefly laboraduring women’s visits because they were among the tory or pregnancy examinations) and surgical aftertop-ranking conditions diagnosed in all women’s care were listed second inpatient Record formsfora

visits during 1977.7 It is quite probable that oneor total ofapproximately 4percent ofvisits.

more of these conditions would appear frequently no

matter what principal diagnosis was under scrutiny.

7
Patient characteristics

Patient age

Table 1 presents the percent distribution and

average annual visit rate per 1,000 women for disorders of the reproductive system by age and race.

Age of the patient appears to be a factor in the

nature of neoplasm found during visits. When visits

were made for benign and unspecified neoplasms of

breast, approximately 62 percent involved women

1544 years of age. However, when malignancies of

breast were involved, approximately 84 percent of

visits were by women over 44 years of age. Among

specific 10-year age groups, the highest visit rate for

benign and unspecified neoplasms of breast was 16.1

per 1,000 women 3544 years of age; for malignancies

of breast, the highest rate was 37.6 per 1,000 women

65 years of age and over. Women 3544 years of age

also had the highest visit rate for chronic cystic disease and other (nonneoplastic) diseases of breast

(51.4 per 1,000 women).

Except for menopausal symptoms and malignant

neoplasms of the genital organs, visits for genital tract

disorders were proportionately more frequent among

patients in their reproductive years, 15-44 years of

age, than among older patients. Similar to the age

division of visits for breast conditions, women 15-44

years of age were more likely to visit for benign and

unspecified neoplasms of genital organs, while older

wo,men were more likely to visit for malignancies.

About two-thirds of the visits for benign and unspecified neoplasms included patients 15-44 years of age,

but approximately 72 percent of the visits for malignant conditions were made by women 45 years of age

and over. Among 10-year age groups, the highest visit

rate for benign and unspecified neoplasms was attributed to patients 25-34 years of age. Rates for

malignant conditions did not vary significantly among

age groups, but this probably was due to the small

sample of visits, which tended to result in large sampling error.

Patients 45-54 years of age with menopausal

symptoms visited at a higher rate (151 per 1,000

women) than did any other age group for any of the

specific reproductive system disorders included in this

report. Women 55-64 years of age continued to visit

for this problem but at about half the rate (62 per

1,000 women) of the next younger group.

Except for diseases of parametrium and pelvic

peritoneum (chiefly pelvic inflammatory disease) in

which the highest rate among age groups was 26 per

1,000 for patients 15-24 years of age, visit rates for

other diseases of female genital organs were highest

for visits made by patients 25-34 years of age. Within

this age group, rates for disorders of menstruation (73

per 1,000) and diseases of uterus (72 per 1,000) were

the most prominent.

Patient race

The visit rate for the total of breast conditions

shown in table 1 was higher for white women than

for women of all other races (54 per 1,000 white

women compared to 33 per 1,000 of all other races).

Because of the large sampling error for the number of

visits by black and all other women with specific

breast conditions, differences among those rates were

not statistically significant.

The rate of white women who visited for treatment of menopausal symptoms was about twice that

of black and all other women (42 per 1,000 compared with 21 per 1,000). However, women other

than white visited for diseases of parametrium and

pelvic peritoneum at a rate of 26 per 1,000 compared

with 10 per 1,000 by white women.

Differences in other visit rates by race were not

statistically significant.
Physician characteristics

Utilization by specialty

General surgeons received the largest share (47

percent) of visits for neoplasms and diseases of the

breast (figure 2), but the majority of visits for genital

tract disorders (57 percent) were made to obstetriciangynecologists (OBG’S) (figure 3). General and family

practitioners (GFP’s) were the second ranking providers-they received 32 percent of the visits for genital tract disorders and 18 percent of visits made for

breast problems. Although internists received only 5

percent of all visits for diseases of the genital organs,

they had a larger proportion of visits for breast conditions. The difference between the proportions of

visits for breast conditions to internists (13 percent)

Obstetrics Internal

and medicine

gyne~logy

1

medical .,

specialties

-J 4.5% ~

“al and

f practic(

Other

/

surgical

specialties

Irgeons

and to OBG’S (12 percent) was not statistically significant. However, closer analysis of the data revealed

that the majority of visits for breast conditions to

internists was due to malignant neoplasms (58 percent); 79 percent of all visits for breast conditions

made to OBG’S were for chronic cystic disease (data

not shown). This probably reflects the age distribution among patients who visited the two types of

practitioners. Patients who visited internists were

likely to be 45 years of age and over, while patients

who visited OBG’S generally were younger than 45

years of age. As shown in table 1, malignant neoplasms were more likely to be diagnosed for women

55 years of age and over than for younger women;

chronic cystic disease and other (nonneoplastic) disInternai

Other medicine General and

>“”’

surgical family practice

specialties ... L

.,:.::j.y:.:.: /

Other .::f.y..:.:.:.x. -1

medical

specialties

1.2% 2

Obs&rics and

gynecology

Figure 2. Percent distribution of offica visits by women 15 years of

aga and over for neoplasms and diseases of breast, by physician’s

specialty: United States, 1977-78

Figure 3. Percent distribution of office visits by patients 15 years of

age and over for neoplasms and diseases of the female genital tract,

by physician’s specialty: United States, 1977-78

9
eases of breast were diagnosed proportionately more

frequently for women younger than 55 years of age

than for older women.

Proportion of physician’s practice

The impact of patients with diseases of tt.e reproductive system on the practices of various specialties

may be evaluated by estimating the proportion of the

specialist’s practice devoted to treating these problems. Table D shows that two surgical specialties,

obstetrics and gynecology, and general surgery had

proportionately larger caseloads of patients with

these conditions than other specialties did. OBG’S

saw patients with reproductive disorders in 21 percent of all visits (prenatal care and other special

examinations accounted for another 57 percent).

General surgeons treated patients with reproductive

disorders in about 8 percent of their visits.

Because of the broad spectrum of conditions seen

by GFP’s, reproductive disorders accounted for only

about 4 percent of all their visits. Simila~rly, the

average internist’s practice included about 2 percent

of visits for reproductive disorders.

Proportions of practices were distributed similarly

among the various specialties shown in Table D when

the unit of measurement was the total amount of

time spent in direct patient encounter. If only a member of the physician’s staff saw the patient, the visit

was counted, but time spent between physician and

patient was considered as zero minutes and, therefore,

was not included in total time for this calculation,

Duration of visit is discussed further in the section

“Clinical characteristics.” There was a slight variation

between the percentages based on time and those

based on number of visits, but the comparative magnitude remained unchanged. The average duration of

a visit varied by specialty but, for patients who visited

for reproductive disorders, it did not differ significantly from the comparable average of all oth~ervisits

for each specialty.

Table D. Number and percent of office visits, percent of patient contact time, and mean contact duration of office visits for disorders of the female

reproductive system, by selected physicians’ specialties: United States, 1977-78

Mean contact duration

Number Percent in minutesq

Percent of visits of total

Physicians’ specialty in of ail patient Disorders

thousands

visits contact of the

time 1

All visits

reproductive

system

All primary care specialties, except pediatrics . . . . . . . . . . . . . . . . . . . . . . . 38,092 5.7 6.6 . . . . . .

General and family practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13,272 3.1 3.6 15.9 12.9

Internal madicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,814 2.1 2.2 19.9 19.2

Obstetrics and gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22,006 21.1 25.3 16.7 14.1

General surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,777 8.3 8.8 14.4 13.5

Allothar specialties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,638 0.4 0.5 . . . . . .

1 Exc,@e~ vj~it~ ~ithOut face-to-face contact between phvsician and patient.

10
Clinical characteristics

Time since onset of complaint

Table 2 shows that 55 percent of the visits for

new problems of the breast and 46 percent of visits

for new problems of the female genital tract were

made within 3 weeks of the onset of the problem or

the patient’s sensory awareness of the complaint. Patient education regarding self-examination may be responsible for women seeking early care of newly detected symptoms. About 41 percent of the visits for

new problems diagnosed as benign and unspecified

breast neoplasms occurred within 1 week and 68 percent within 3 weeks.

Time that elapses between the patient’s awareness

of the problem and the visit to the physician may be

attributed partially to scheduling of appointments.

Women reported they must wait an average of 7.8

days for an appointment with their physicians.g The

urgency of a problem is suggested when the average

time since onset is less than the average time spent

waiting for an appointment. Approximately 53 percent of patients with pelvic inflammatory disease, a

condition that causes great distress, were examined

by physicians within 1 week and 85 percent within

3 weeks. For all new problem visits made by women,

the comparable proportions were 37 percent and 55

percent.

In contrast, patients hoping to conceive wait a

considerable length of time before they seek medical

help. According to NAMCS data, 78 percent of visits

for sterility were made 3 months or more after onset

or first perception of the problem. The amount of

time probably was much greater, but the Patient

Record did not include a more detailed breakdown of

the length of time.

Compared with the average time for all visits between onset of complaint and visit to physician,

women with menstrual disorders and menopausal

symptoms waited longer to see physicians. Approximately 32 percent of women with menstrual disorders visited within 1 to 3 months of onset, and 27

percent waited 3 months or longer. For women with

menopausal symptoms, 31 percent and 36 percent

were the comparable proportions. For all conditions,

these proportions were 14 percent and 18 percent,

Seriousness of condition

Malignant neoplasms of breast (86 percent) and

of female genital organs (74 percent) more frequently

were evaluated as serious or very serious by the physician than other conditions were (table 3). As mentioned, these conditions also had the highest return

visit rates. Benign neoplasms were the second ranking

conditions most likely to be judged serious or very

serious, with 30 percent of visits for the breast site

and 22 percent of those of the genital organs so classified. These proportions exceeded the average proportion of 18 percent for all conditions with the same

degree of seriousness.

The majority of visits for other reproductive disorders were classified as not serious or slightly serious

proportionately more often than as more serious.

Menopausal symptoms and sterility-probably the

least life-threatening diagnoses in the reproductive

disorder group-more often were evaluated as not

serious than other reproductive disorders were. The

conditions of 72 percent of patients with menopausal

symptoms, and 67 percent of patients with sterility

problems were considered not serious by the physician compared with 51 percent of patients with diagnoses other than reproductive disorders.

Diagnostic services

A limited history and/or examination was proportionately more frequent than average when the diagnosis was chronic cystic disease and other (nonneoplastic) diseases of breast (table 4). About 72 percent

of these visits included the limited type of examination compared with the average of 60 percent for all

diagnoses other than reproductive disorders. The item

on diagnostic services in the NAMCS did not include

11
breast examinations but, if a breast examination was

performed during the visit, it probably was included

on the Patient Record under the limited examination

category option.

Pap tests were proportionately more common

when reproductive disorders (except breast neoplasms) were diagnosed than when other conditions

were present. Proportions of Pap tests shown in

table 4 range from approximately 16 percent for patients with chronic cystic disease and other diseases

of breast (excluding breast neoplasms) to approximately 40 percent for conditions diagnosed as disorders of menstruation.

Figure 4 shows the variations in the rate of visits

that included a Pap test according to the patient’s age

group. For patients 15-24 years of age, approximately

333 visits per 1,000 women included a Pap test. The

rate peaked at 530 per 1,000 for the age group 25-34,

declined to approximately 382 per 1,000 for the age

group 35-44 and decreased to 163 per 1,000 for

women 65 years of age and over. This was a 69-

percent decrease from the age group 25-34 years to

the group 65 years of age and over. A reduction in the

frequencies of Pap tests for older women is contraindicated by other NAMCS data and by the incidence data of cervical cancer. According to table 1,

550

500

[

450 —

&

E

s

400 —

o

0

0.

; 350 -

a

al

z

.

75 300 —

2

c

m

$j 250 -

g

<

200 -

150 -

0

I I I I I 1

15-24 25-34 3544 45-55 55.64 65 and

over

Age in years

Figure 4. Average annual rate of office visits including a Pap test, by

age of patient: United States, 1977-78

12

visit rates for many genital tract disorders (often precursors of malignant neoplasms) remained high until

at least 54 years of age. Data from the National

Cancer Institute indicate that, during 1973-76, incidence rates of cervical cancer increased as patients

grew older–from approximately 5 cases per 100,000

women 25-29 years of age to 16 cases per 100,000

women 65-69 years of age.g In an analysis of 1973

data from the National Health Interview Survey,

Kleinman and Kopstein reported that women 45-64

years of age were 2.8 times more likely than women

25-44 years of age to report never having undergone a

Pap test.lo Fruchter et al. found that 51 percent of

women diagnosed with primary invasive cervical

cancer in two hospitals between July 1976 and

December 1978 were over 50 years of age, and 64

percent of those cancer patients over 50 years of age

never had undergone a Pap test. 11 Yet, despite

recommendations by these researchers for increased

screening during ambulatory care visits, older women

proportionately underwent fewer Pap tests during

physician visits than younger women, at least until

1978.

Higher than average proportions of clinical laboratory tests were ordered or provided during visits for

malignant neoplasms of breast and female genital

organs (approximately 35 percent for each); diseases

of cervix, uterus, vagina, vulva and other female genital organs (32 percent); disorders of menstruation

(32 percent); and sterility (45 percent).

X-rays tended to be proportionately more frequent when breast conditions were presented than

when genital tract disorders or other diagnoses were

presented.

Because menopausal symptoms and hypertension

correlate positively with each other and with age, it

is not surprising to find that cautious physicians

measured blood pressure during more than one-half

of visits by menopausal women, a higher proportion

than the 43 percent of visits by women whc~visited

for problems other than reproductive disorders. In

fact, blood pressure measurement was more common

during women’s visits for all reasons (44 vercent)

than ~en’s (33 percent).T

Therapeutic services

NAMCS data showed

reported, prescription and

.-

that, as with other visits

nonprescription drugs was

the most commonly used therapy for women with reproductive disorders. Most patients with menopausal

symptoms were treated with drugs (78 percent), as

were patients who visited for diseases of ovary and

fallopian tubes and for diseases of pararnetrium (70

percent). However, patients with breast diseases and

neoplasms of the female genital tract received less

than average proportions of drug therapy. Other

types of therapy for neoplasms, such as chemo-
therapy and radiation therapy, are not commonly

administered in physicians’ offices. Beginning in

1980, data on specific drugs ordered or administered

during visits were collected in NAMCS. Future publications will include this information.

The higher than average proportions of office

surgery performed during visits for some reproductive

conditions reflect the high rate of gynecological surgery associated with these conditions. (Surgery rates

and associated diagnoses are discussed in the section

“Inpatient surgery.”) Follow-up visits to the physician’s office after hospitalization for major surgery

related to reproductive disorders sometimes include

minor surgery such as suture removal, draining of

abscesses, and excision. In some cases, office visits

for the latter two procedures eliminate the need for

inpatient care. Approximately 16 percent of visits for

all breast conditions and 11 percent of visits for diseases of cervix, uterus, vagina, vulva, and other female

genital organs included office surgery, compared with

the average of 7 percent for all other diagnoses.

Disposition of visit

The relationship between ambulatory care and inpatient care of reproductive disorders also is suggested by the higher than average proportions of visits

that resulted in admission of the patient to a hospital.

Table 5 shows that 7 percent of patients with neoplasms and diseases of breast, 7 percent of patients

with neoplasms and diseases of female genital organs,

and 8 percent of patients with disorders of menstruation were sent to the hospital compared with an

average of 2 percent of patients who visited for all

other diagnoses.

Table E shows that patients with problems judged

by the physician to be serious or very serious were

more likely to be admitted to the hospital than patients with less serious problems were. Approximately

11 percent of patients deemed to be in serious or very

serious condition due to breast disorders and 21 percent of similarly evaluated patients with genital tract

disorders were admitted to a hospital.

As with other visits reported in the NAMCS, most

patients were told to return to the physician’s office

at a specified time. When no followup was planned, it

was more likely to be for patients judged to be not

in serious condition.

Patients with neoplasms and diseases of breast

and female genital organs were more likely to be referred to another physician or agency than patients

with other conditions were (table 5). About 6 percent

of patients with breast conditions and 5 percent of

patients with genital conditions were referred compared with about 2 percent with all other diagnoses.

Of all new patients referred because of breast

disorders, 83 percent were examined in the offices of

general surgeons (table F). OBG’S examined 77 percent of patients referred with disorders of the genital

tract. This referral pattern reflects the recognized

specialties of these practitioners. Of 20.2 million new

patients with other diagnoses who visited physicians

by referral, 78 percent visited specialties other than

general surgery and obstetrics-gynecology.

Table E. Number of office visits, parcent by disposition of visits, and percent distribution by duration of visits, according to braast and

genital tract disorders: United States, 1977-78

Breast disorders Genital tract disorders

Disposition and duration Serious Slightly Not Serious

or very

Slightly Not

serious serious or very serious serious serious sarious

Number in thousands

All visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,184 2,560 2,862 4,336 12,343 20,223

Dispositiorsl Percent distribution

No followup planned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *2.7 ●1.3 12.9 *0.7 3.0 5.7

Return atspecified time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74.1 73.4 64.4 59.2 64.4 57.9

Return if needed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *7.5 ● 12.3 16.4 10.9 21.5 31.6

Telephone followup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *2.2 *5.7 *1.4 *3.5 6.5 4.2

Refarred to another physician or agency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ●9.2 *5.O ●2.8 9.6 3.4 2.2

Admit to hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.9 ●6.3 ●2.4 21.4 8.1 ●1.O

Duration2

O minutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *2.8 ●1.5 ●1.2 *2.5 !5.3

1-10 minutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34.3 38.3 47.8 18,7 29.3 31.1

11-15 minutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33.5 32.9 32.0 30.0 33.0 34.9

16-30 minutas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.3 21.5 18.0 41.5 31.3 25.3

31 minutes or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *2.3 * 5.9 ●2.3 8.6 3.9 3.5

Ipercent$ will not to~l 100.o because more than 1 disposition was possible.

2Time vent in face-to-face ancounter between physician and Petient.

13
Table F. Number of new patients referred by another physician, and

percent distribution by physician’s specialty to which patients

were referred, according to disorders of tha breast and female

genital tract and for all other diagnoses: United States, 1977-78

Disorders

Breast of the All other

Ph ysician’s specialty disorders female diagnoses

genital

tract

Number in thoueands

All new patients raferred . . . . . 952 1,590 20,247

Percent distribution

All specialties . . . . . . . . . . . . . . 100.0 100.0 100.0

General surgery . . . . . . . . . . . 83.1 “10.6 11.5

Obstetrics and gynecology . . . *4.8 76.7 10.4

All other specialties . . . . . . . . *12.1 *1 2.7 78.1

Duration of visit

The mean duration of a visit and the proportion

of total visit time spent by physicians in treating patients with reproductive disorders were discussed in

the section on physician characteristics. Visit duration also relates to the clinical aspects of the visit in

the context of diagnoses.

Visits during which the patient saw only a member of the physician’s staff were not counted in the

calculation of total time spent by the physician, but

these visits were included in the category zero

minutes in table 5, in which visits are distributed by

selected time intervals.

A higher than average proportion of patients who

visited for menopausal symptoms were in the zero

minutes category. This directly reflected the higher

than average proportion of the same group who received drug therapy, inasmuch as many of these

patients probably received an injection of medication

from a nurse or other professional on the physician’s

staff. Administration of medication also partially may

account for the relatively high return visit rate because medication usually is administered regularly to

patients with menopausal symptoms.

The distribution of visits for other conditions by

time interval did not vary significantly from the

average.

It was not clear whether duration of visits was related to the degree of seriousness attributed to the

problem by the physician (table E). When the condition of patients with breast disorders was considered

not serious, visits were more likely to last from 1-10

minutes (48 percent) than for a longer period If the

degree of seriousness was correlated with visit duration, the expected corollary would be that breast

disorders that were evaluated as serious or very

serious would fall proportionately more often within

longer intervals. But, as table E shows, this was not

the case. It may be that the limited extent of breast

examination does not require lengthy visits.

On the other hand, the majority of visits for serious or very serious genital tract disorders fell within

longer intervals (42 percent lasted 16-30 minutes and

9 percent lasted 31 minutes or longer). However, unlike visits for breast disorders, conditions rated not

serious were not noticeably associated with shorter

visits. This also may be a reflection of the type and

extent of examination.

14
Inpatient surgery

Using NAMCS and NHDS data, a direct connection cannot be shown between patients referred for

hospital care of reproductive disorders and patients

discharged from short-stay hospitals after breast and

gynecological surgery. This is due partially to methodological differences between the two surveys.

Other than methodological considerations, two obvious reasons are that (1) patients may be admitted to

hospitals from many sites other than physicians’

offices as defined in NAMCS, and (2) not all admitted

patients undergo surgery. During 1977-78, 2.7 million

office visits by women with reproductive disorders

resulted in hospital referral; 5.1 million patients 15

years of age and over with the same first-listed diagnoses were discharged from short-stay hospitals.3~5

During the same period, NHDS data showed that 8.5

million all-listed breast and gynecological procedures

were performed. Counting all-listed procedures implies that more than one procedure may have been

performed for a discharged patient. This method also

contributes to the difficulty in comparing NA.MCS

and NHDS data, but it is a practical measure of

utilization for hospital events.

It is reasonable to assume, however, that patients

who were referred to a hospital according to NAMCS

findings were represented in a subset of the discharged patients in the NHDS. Because the purpose

of this section is simply to demonstrate some of the

sequelae of the problems seen in physicians’ offices,

survey estimates need not necessarily agree.

Diagnosis and surgical procedure

Except in rare cases, breast and gynecological

surgery was probably preceded by illnesses for which

ambulatory care was provided. The most frequent

all-listed diagnoses shown on NHDS medical records

in the presence of selected all-listed breast and

gynecological procedures are shown in tables G and

H. These are the final diagnoses assigned by the

Table G. Number of selected all-listed breast procedures in short-stay hospitals and percent by most frequent all-listed medical diagnoses and surgical

procedures: United States, 1977-78

All-listed breast procedures

and ICDA code 1

All-listed diagnoses and ICDA code 7

Partial Complete or

mastectomy radical

(65.2) mastectomy

(65.3-65.6)

Number in thousands

Number of procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.2 11.5

Percent3

Malignant neoplasms of breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 11.1 85.7

Secondary and unspecified malignant neoplasms of lymph nodes . . . . . . . . . . . . . . . . . . .. 196.3, 196.9 *0.9 13.3

Lipoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...214 3.7 *0.O

8enignand unspecified neoplasmsof breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...217.233 25.8 1.6

Hemangioma (of skin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...-.....227.0 1.8 “0.5

Chronic cystic disease and other (nonneoplastic) di=ases of breast . . . . . . . . . . . . . . . . . . . ..610,61 I 68.4 16.6

?Bawd on the Eighth Revi$ion ln~ernational Classification of Diseases, Adeptad for Use in the United Ste.tES ( ICDA).

2Mastectomy, complete (65.3) also includes mastectomy, not otherwise specified.

3percants ~ill not ~OtaI 100. o because more than I diagnosis may have been listed on each record having one or more Procedures.

15
Table H. Number of selected all-listed gynecological procedures in short-stay hospitals, and percent by surgical procedures and all-listed diagnoses:

United States, 1978

A 11-listad diagnoses and ICDA code 1

A Ii-listed procedures and ICDA code q

Oophorectomy- Ligation and

division of

Dilation and

saipingo,

fallopian

Hysterectomy curettage,

oopherec tomy (69. 1-69.5) diagnostic

(67.2-67.5) tubes

(68.5, 68.8)

(7’0.3)

Number in thousands

Number of procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434 553 644 967

Percent2

Malignant neoplasms of female genital organs . . . . . . . . . . . . . .180-184 11.7 11.9 6.2

Banign and unspecified neoplasms of female genital

organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .218 -221,234-236 56.4 4.0 47.7 21.9

Iron deficiency anemias, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...280 2.6 2.7 2.5

Peritoneal adhesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...568 7.7 5.0

Diseases ofovary and fallopian tubes . . . . . . . . . . . . . . . . . . .613-615 27.5 1.1 12.5 4.2

Diseases ofparametrium and pelvic peritoneum . . . . . . . . . . . . . .616 15.0 1.0 11.0 4.1

Cervicitis and other diseases of cervix uteri . . . . . . . . . . . . . . . .620-621 15.7 1.9 22.2 19.7

Infective diseases of uterus (except cervix), vagina, and vulva . . . . . . . . .622 3.8

Uterovaginal prolapse, malposition of uterus, endometriosis, and other

diseases of uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...623-625 51.3 3.7 81.2 25.4

Disorders of menstruation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...626 19.0 6.1 30.2 55.3

Sterility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...628 1.8

Other diseases of female genital organs . . . . . . . . . . . . . . . , . . . . . . .629 1.1

Pre-eclampsia, eclampsia, andtoxemia, unspecified . . . . . , . . . . . . . . .637 1.2

Abortion induced for medical indications, with sepsis . . . . , . . . . . . ...640.0 3.0

Delivery without mention of complications . . . . . . . . . . . . . . . . . . . .650 25.0

Delivery with complications . . . . . . . . . . . . . . . . . . . . . . . . .,..651-662 16.9

Adverse effects ofprogestogens . . . . . . . . . . . . . . . . . . . . . . . . . ...962.6 1.5 1.0

For sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Y09.O 32.0 3.0

1Bawd on the Eighth Revi~i~n I nternatjonal Classification of Diseases, Adapted for Use in the United States ( I CDA).

2percent~ will not ~otal 100.0 becausa more than 1 diagnosis may have been I isted on each record having one or more procedures.

physican to hospital medical records of discharged

patients; the y are not necessarily the principal diagnoses for which patients were admitted to the

hospital for surgery. In the 1978 NHDS, up to 5

diagnoses were coded according to the ICDA.1 In this

presentation of NHDS data, a one-to-one relationship

between diagnosis and procedure should not be

assumed.

Although causality is not implicit in these tables,

the data provide additional clinical information concerning women who receive ambulatory care for

reproductive disorders. The NAMCS data showed that

many diagnoses assigned to patients during visits also

are assigned to hospital inpatients and are particularly

evident in candidates for breast and gynecological

surgery.

Diagnosis and breast surgery

Two classes of breast surgery-partial mastectomy

and complete or radical mastectomy—are shown in

table G. When a partial mastectomy was performed,

the most frequently listed diagnosis was chronic

cystic disease of other (nonneoplastic) diseases of

breast (68 percent). For patients undergoing complete or radical mastectomies, malignant neoplasm of

breast was the most likely diagnosis (86 percent).

Benign and unspecified neoplasms were present in

about 26 percent of patients who had a partial

mastectomy. Secondary and unspecified malignant

neoplasms of lymph nodes were present in about 13

percent of complete or radical mastectomies. Data on

complete and radical mastectomies were combined

in this report. If only data on radical mastectomies

had been examined, the proportion of lymph node

diagnoses may have been higher. It should be noted

that the ICDA code for complete mastectomy (65.3)

also includes mastectomy, unspecified. Therefore, if

the mastectomy procedure listed on the medical

record were not qualified, it would be coded as a

complete mastectomy, which it may not have been.

This coding problem may account for at least part of

the 17 percent of complete or radical mastectomies

that were assigned a diagnosis of chronic cystic

disease or other (nonneoplastic) disease of breast,

generally an unlikely diagnosis for the patient who

undergoes a radical mastectomy. It also may be possible that the less serious breast diagnosis was listed

on the same medical record as a malignant neoplasm

of the breast for which the radical procedure was

performed.

Figure 5 shows that the rate of office visits for

neoplasms and diseases of breast increased from 24

per 1,000 women 15-24 years of age to81 per 1,000

16
90 —

80 —

70 -

60 -

50 —

40 -

30 -

20

r

10 — Surgery

------------- . . . . . . . . . . . . . . . . . . . .

---- #-----

0

I I 1 I I

15-24 25-34 35-44 45-54 55-64 65 and

over

Age in years

Fiwre 5. Average annual rate of office visits for neoplesms and dis.

Complete or radical

mastectomy

,-----

-.’ -----------------------

t

.-

,,’

,------ ,.

110 ,,

,,’

,.

,.

-------

90

1970 1971 1972 1973 1974 1975 1976 1977 1978

Year

eases of breast and all-listed breast surgery in short-stay hospitals,

byage of patient: United States, 1977-78

Figure6. Rate of all-iisted breast sumervper 100.000 females 15vears

for women 3544 years of age and decreased to51

per 1,000 women 65 years of age and over. However,

rates of breast surgery did not vary significantly based

on age of the patient—rates ranged from approximately 2 per 1,000 women 15-24 years of age to

approximately 6 per 1,000 women 35-54 years of

age. Fluctuation in rates of breast surgery during

1970-78 were related to the type of procedure performed. Figure 6 illustrates trends in rates of breast

surgew during 1970-78. Partial mastectomy increased

from 217 operations per 100,000 women in 1971 to

269 in 1975 but, by 1978, the rate decreased to 181

per 100,000. Rates of complete or radical mastectomies throughout the 9-year period were much lower

than rates for partial mastectomies. Rates increased

from 94 per 100,000 women in 1970 to 128 per

100,000 women in 1974 and remained relatively

constant until 1978. The decreasing rate of the less

complex procedure from 1975 may be related to the

increasing popularity of ambulatory surgery, which is

discussed at the end of this report.

The average length of stay was correlated with

the complexity of the surgery. In 1978, patients who

had partial mastectomies stayed in hospitals an average of 4.3 days; patients who underwent complete or

of age-and ”over: United States, 1977-78

radical mastectomies were discharged after approximately 9.9 days. In addition to increased costs for the

longer period of hospitalization required by the more

complex procedure, higher physicians’ fees also contribute to the higher direct economic costs of breast

cancer. For example, in the New York City area in

1980, the average prevailing charge for a partial

mastectomy ranged from $248.70 to $570.00

(depending on the locality) compared to a range of

$829.00 to $1,658.00 for a radical mastectomy.lz

Diagnosis and gynecological surgery

The association between office visits for care of

neoplasms and diseases of female genital organs and

gynecological surgery is illustrated by the curves in

figure 7. The rate of gynecological surgery increased

from 25 per 1,000 women 15-24 years of age to 81

per 1,000 women 25-44 years of age and decreased to

approximately 15 operations for each 1,000 women

65 years of age and over. Office visit rates for related

conditions naturally were much higher but followed

a similar fluctuation pattern by patient age.

17
r

200 —

180 —

160 —

c

E

z

140 —

o

0

0.

~ 120 —

Q

aJ

G.

~ 100 —

s

a

a)

~ 80 ,------.-.

~

‘. ,’ ‘.

a

,’ ‘.. ,’

,’ ‘.

60 —

‘. ,’ ‘. ,’ ‘., ,’

,’ ‘$

‘. ,’

40 —

‘. ,’ ‘.

,’ ‘.

,’ ‘.,. Surgery ~’

‘.

20 — .....

---

---

15-24 25-34 35.44 45-54 55-64 65 and

over

Age in years

Figure 7. Average annual rate of office visits for neoplasms and diseases of the female genital tract and rate of all-listed gynecological

surgery in short-stay hospitals, by age of patient: United States,

1977-78

The diagnoses most commonly listed on hospital

records when certain gynecological procedures were

performed are shown in table H. Most of these diagnoses also were found frequently during women’s

office visits (table A). Uterovaginal prolapse, malposition of uterus, endometriosis, and other diseases of

uterus were included in the Iartest proportion of

office visits for reproductive disorders. These conditions were the most likely diagnoses to be listed when

hysterectomies were performed (81 percent). They

also were prominent in oophorectomies (51 percent)

and dilation and curettage (25 percent). Disorders of

menstruation, which constituted the second largest

proportion of office visits relative to other reproductive disorders, was more likely than other conditions

were to be listed for patients undergoing D & C (55

percent). On the other hand, menopausal symptoms,

which accounted for the third largest proportion of

office visits, was not likely to be a diagnosis involved

in gynecological surgery.

Malignant neoplasms of genital organs, which

18

accounted for about 3 percent of all office visits for

reproductive disorders (excluding breast), was listed

in about 12 percent of all oophorectomies, 12 percent of hysterectomies, and 6 percent of D & C procedures. For benign and unspecified neoplasms of

genital organs, the comparable proportions of the

same procedures were 56 percent, 48 percent and 22

percent.

Diseases of ovary and fallopian tubes were listed

as diagnoses in 28 percent of oophorectomies (the

procedure directly related to the anatomical site of

the condition) and in 13 percent of the more extensive

hysterectomies. Diseases of pararnetfium and pelvic

peritoneum also were associated with oophorectomies

(15 percent) and hysterectomies (11 percent), as were

cervicitis and other diseases of cervix uteri (16 percent oophorectomies and 22 percent hysterectomies).

Conditions of the cervix also were involved in 20 percent of D & C procedures.

Deliveries, with and without complications, were

likely to be listed when the surgical procedure was

tubal ligation or occlusion, which demonstrated a

common preference for performing these procedures

postpartum. Because the methodology used in this

table yields a duplicated count of discharged patients,

the 32 percent of tubal ligation or occlusion procedures that were listed “for sterilization” may well

have been the same postpartum patients, that is, a

second-listed diagnosis.

Iron deficiency anemia and peritoneal adhesions,

which were not proportionately as frequent during

office visits as other diagnoses were, are implicated

commonly when the patient is a candidate for

surgery.

Rates per 100,000 women 15 years of age and

over for the four types of surgery shown in table H in

terms of diagnoses are plotted for the years 1970-78

in figures 8 and 9. Three of the four most common

types of gynecological surgery performed from 1970

to 1978 are shown in figure 8. Because they were

plotted on the same scale by rate per 100,000

women, their relative frequency becomes clear—diagnostic dilation and curettage of uterus consistently

had the highest rates of the three, followed by hysterectomy and oophorectomy. A striking similarity

is apparent among the yearly trends, with the three

procedures reaching a peak in 1975 and showing a

downward trend until 1978. Minor fluctuations from

year to year probably were due to sampling variabilityy rather than real change.

Utilization measured by the average length of stay

reflects the complexity or risk level of the surgery.

The average stay involving D & C’s was approximately

3.4 days; hysterectomy and oophorectomy each required an average stay of approximately 9 days.

The sharp increase in tubal sterilization is illustrated in figure 9. By 1974, the rate of sterilization

by tubal ligation or occlusion performed on women

1544 years of age outranked hysterectomy. By 1977,
1,300 r

[JDilation and curettage

of uterus, diagnostic

1,200

1,100

1,000

I

Oophorectomy,

600 salpingo-oophorectom y

I

#------- ..------

.

500

-..

>..” .

,..

,.

400 .------

Oi

1970 1971 19721973 19741975 1976 1977 1978

Year

1,300 r

1,200 —

1,100 —

1,000 —

&

g 90(3 —

3

0

0

~ 800 —

&

o.

g 700 —

K

600 —

/“

500

400 [/

1970 1971 1972 1973 1974 1975 1976 1977 1978

Year

hospitals for females 15 years of age and oven United States,

1977-78

Figure 8. Rate of selected alMisted gynecological surgery in short-stay Figure 9. Rate of all-listed tubal ligation or occlusion procedural in

short-stay hospitals for females 1544 years of age: United States,

1970-78

sterilization by tubal ligation or occlusion was performed more commonly than diagnostic D & C was.

The curve shows a slight downturn in 1978 (as it did

for the first three operations), but it is too early to

determine whether this signals the beginning of a decline in gynecological surgery. The development of

simplified techniques is reflected in the average length

of stay in the hospital. In 1978, the average length of

stay for tubal ligation was 4.4 days, but patients who

underwent the less complicated endoscopic tubal

occlusion used only 2.3 days of hospital care. Patients

25-34 years of age had the highest rate of tubal

sterilization (21 per 1,000), followed by patients

35-44 years of age ( 12 per 1,000) (data not shown).

19
Discussion

In every age group from 15 years and over,

women constitute a higher proportion of the United

States population than men do. For this reason and

because of their biological role in reproduction, they

are the major users of health care. This report has

presented national statistics on disorders of the

female reproductive system that emphasize the role

of these conditions in the health care provided by

office-based physicians and in short-stay hospitals.

The total contribution of these conditions to the

direct and indirect economic costs of health care

should not be measured solely in terms of impact on

the two major health care systems discussed in this

report. Of the 532.7 million physician visits (excluding telephone calls and home visits) reported by

women in the 1975 NHIS, the sites of about 19 percent or about 102 million were hospital clinics,

emergency rooms, other, or unknown.1s If the distribution of visits by diagnosis in hospital outpatient or

other facilities was similar to that of office-based

physicians in the NAMCS, it would add another 7.8

million visits per year, or about 15.7 million visits for

reproductive disorders in a 2-year period, to the 45.5

million visits estimated in the NAMCS during

1977-78.

The development of new techniques in anesthesia,

drugs, and medical instrumentation, as well as recent

developments in patient education and recovery

methods, have encouraged the use of ambulatory

surgery. Demonstrated savings in costs have accelerated the growth of ambulatory surgery in hospitals

and freestanding facilities. According to a 1980 sur-

,vey conducted by the American Hospital Association’s Division of Ambulatory Care, ambulatory

surgery accounted for an average of 18 percent of the

total number of surgical procedures performed in

about 1,506 non-Federal hospitals that offered such

surgery in the 134 largest SMSA’S in the United

States in 1979.14 This represented about 70 percent

of the hospitals surveyed. According to this study,

the ratio of the average number of inpatient procedures per hospital to the average number of outpatient procedures was about 5 to 1. Applying this

ratio to the NHDS 1978 estimate of 20.8 million

inpatient surgical procedures and correcting for the

estimated proportion that offer ambulatory surgery,

a rough estimate of ambulatory surgery for the NHDS

sample is about 2.8 million procedures for patients of

both sexes and all ages.z

It is apparent that, even with this crude estimate,

outpatient surgery performed in hospitals is an important part of the total cost of illness. However, no

national data are available on surgical case-mix or the

number of breast and gynecological procedures performed in hospitals on an outpatient basis. Published

reports of studies conducted at various sites reveal

similarities in the frequency of certain breast and

gynecological procedures. The Presbyterian Hospital

of Dallas, which initiated a program of ambulatory

surgery in 1970, found that D & C, breast biopsy, and

tubal ligation currently are among the most frequently performed operations.ls A report from the

526-bed Methodist Medical Center of Illinois at

Peoria indicated that gynecological surgery accounted

for 18 percent of all procedures performed in the

Methodist Ambulatory Surgery Center in 1978.16

Interestingly, this is the same proportion as that of

inpatient gynecological surgery reported by the

NHDS in 1978. When this proportion is applied to

the estimated 2.8 million hospital outpatient operations, a crude estimate is yielded of 504,000 outpatient gynecological procedures per year. This does not

include estimates of breast procedures, which may

well equal or exceed the number of gynecological

procedures.

In addition to surgery performed within organized ambulatory surgery programs in hospitals, surgery also is provided at other sites described as freestanding surgery centers that are independent of

hospitals. At least 100 of these centers exist in the

United States.lA However, no statistics have been

published on the number and type of operations

performed. However, the frequency of breast and

gynecological surgery appears to be similar to that

20
reported by hospitals. A report from Crouse-Irving

Memorial Hospital One-Day Surgery Center, a freestanding surgical facility, lists D &C, tubal ligation,

and breast biopsy among frequently performed procedures.17 Among the nine most frequently performed surgical procedures at the Wichita (Kansas)

Minor Surgery Center, another freestanding ambulatory surgical facility, were laparoscopy with bilateral

tubal coagulation, D &C, and breast mass excisions.l 8 According to preliminary statistics from the

Freestanding Ambulatory Surgical Association, D & C

was the most commonly performed surgical procedure in 36 of 69 member facilities in 1980. Tubal

ligation was third. Gynecologic procedures accounted

for the largest proportion (31 percent) of the total

procedures reported by members.lg

Ambulatory surgery also is performed commonly

in some health maintenance organizations in which

surgical services are similar to the services of freestanding facilities devoted entirely to surgery. A

study of ambulatory surgery at the Kaiser-Permanente

Medical Care Program in the Oregon Region compared costs and other variables related to inpatient

and outpatient surgery using 10 selected procedures

that accounted for 74 percent of all incisional ambulatory procedures performed during 1974.20 Among

procedures selected for the study were D &C, biopsy

of breast and partial mastectomy, and trachelectomy.

Rates of these procedures in the ambulatory or outpatient mode per 100,000 health plan members were

higher than the comparable rates in the inpatient

mode for the same procedures.

Because these statistics were derived from local

studies, they are not representative of national statistics. However, they do provide an indication of the

relative magnitude of surgery due to reproductive

disorders at sites other than the short-stay hospitals

used in this report.

21
References

1National Center for Herdth Statistics: Eighth Revision International Classification of Diseases, Adapted for Use in the

United States. PHS Pub. No. 1693. Public Health Service.

Washington. U.S. Government Printing Office, 1967.

2National Center for Health Statistics: Detailed diagnoses and

surgical procedures for patients discharged from short-stay

hospitals: United States, 1978, by B. J. Haupt. DHHS Pub.

No. (PHS) 80-1274. Public Health Service. Washington. U.S.

Government Printing Office, Sept. 1980.

3National Center for Health Statistics: Utilization of shortstay hospitals, amurd summary for the United States, 1978,

by B. J. Haupt. Vital and Health Statistics. Series 13-No. 46.

DHEW Pub. No. (PHS) 80-1797. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1980.

4National Center for Health Statistics: The National Ambulatory Medical Care Survey, 1977 summary: United States,

January-December 1977, by T. Ezzati and T. McLemore. Vital

and Health Statistics. Series 13-No. 44. DHEW Pub. No. (PHS)

80-1795. Public Health Service. Washington. U.S. Government

Printing Office, Apr. 1980.

5 National Center for Health Statistics: Utilization of shortstay hospitals, annual summary of the United States, 1977, by

B. J. Haupt. Vital and Health Statistics. Series 13-No. 41,

DHEW Pub. No. (PHS) 79-1792. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1979.

6National Center for Health Statistics: Office visits for diseases

of the circulatory system: The National Ambulatory Medical

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

and Health Statistics, Series 13-No. 40. DHEW Pub. No. (PHS)

79-1791. Public Health Service. Washington. U.S. Government

Printing Office, Jan. 1979.

7National Center for Health Statistics: Office visits by women,

by B. K. Cypress. Vital and Health Statistics. Series 13-No. 45.

DHEW Pub. No. (PHS) 80-1796. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1980.

8National Center for Health Services Research: Waiting times

in different medical settings: Appointment waits and office

waits. Data Preview 6. DHHS Pub. No. (PHS) 81-3296. Public

Health Service. Hyattsville, MD, Mar. 1981.

9National Institutes of HeaIth: Cancer Incidence and Mortality

in the United States, 1973-76. DHEW Pub. No. (NIH)

78-1837.

10Kleinman, J. C., and Kopstein, A.: Who is being screened

for cervical cancer? American Journal of Public Health. 71(1):

73-76, Jan. 1981.

11Fruchter, R. G., Boyce, J., and Hunt, M.: Missed opportunities for early diagnosis of cancer of the cervix. American

Journal of Public Health. 70(4):418420, Apr. 1980.

12Blue Cross Blue Shield of Greater New York: Medicare Part

B Prevailing Charges for All Covered Services, Fee Screen Year

1981. MC 874, Feb. 1980.

13National Center for Health Statistics: Physician visits:

Volume and interval since last visit: United States, 1975, by

A. Gentile. Vital and Health Statistics. Series 1O-NO. 128.

DHEW Pub. No. (PHS) 79-1556. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1979.

14Bums, L. A,, and Ferber, M. S.: Ambulatory surgery in the

United States: Development and prospects. The Journal of

Ambulatory Care Management. 4(3): 1-13, Aug. 1981.

15Hawthorne, D. D.: Presbyterian Hospital of Dallas: An

ambulatory surgery program. The Journal of A mbulatozv Care

Management. 4(3): 53-60, Aug. 1981.

16Barren, E., and Knoble, J.: Ambulatory surgery offers quality, savings. Hospital. 54(3): 74-76, Feb. 1, 1980.

17Maher, J. W.: Crouse-Irving Memorial: A free standing surgery center that exceeds expectation. The Journal of A mbulato~ Care Management. 4(3): 61-73, Aug. 1981.

18Knapp, M. R.: The Wichita Minor Surgery Center: Perspective of the independent free-standing surgery center. The

Journal of A mbulatory Care Management. 4(3): 75-84, Aug.

1981.

19 Anonymous: FASA statistics reveal top 10 procedures.

Same-Day Surgeiy. 5(4): 47-49, Apr. 1981.

20 Marks, S., et al.: Ambulatory surgery in an HMO, A.study

of costs, quality of care, and satisfaction. Medical Care. 18(2):

127-146, Feb. 1980.

21National Center for Herdth Statistics: A reason for visit classification for ambulatory care, by D. Schneider, L. Appleton,

and T. McLemore. Vital and Health Statistics. Series 2-No. 78.

DHEW Pub. No. (PHS) 79-1352. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1979.

22 National Center for Health Statistics: Replication: An approach to the analysis of data from complex surveys, by P. J,

McCarthy. Vital and Health Statistics. Series 2-No. 14. DHEW

Pub. No. (HSM) 73-1269. Health Services and Mental Health

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

Apr. 1966.

23 National Center for Health Statistics: Pseudoreplication:

Further evaluation and application of the brdanced half-sample

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

Series 2-No. 31. DHEW Pub. No. (HSM) 73-1270. Health Services and Mental Health Administration. Washington. U.S. Government Printing Office, Jan. 1969.

22
List of detailed tables

1. Number of office visits for disorders of the female reproductive system and percent distribution by age and rata of patients, according to principal diagnoses: United States,

1977-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Number and percent distribution of new problem office visits

for disorders of the famalereproductive system by time since

onset of complaint, according to principal diagnoses: United

Statesr 1977-78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Number and percent distribution of office visits fordisorders of the female reproductive system by seriousness of the

problem, according to salected principal diagnoses: United

States, 1977-78 . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Number of office visits by selected disorders of the breast,

female genital tract, and another diagnoses and percent by

selected disorders of the breast, female genital tract, another

24 diagnoses, and diagnostic or therapeutic services ordered or

provided: United States, 1977-78 . . . . . . . . . . . . . . . . 26

5. Number of office visits for disorders of the female reproductive system and all other diagnoses, and percent distribution

25 of visits by disposition and duration of the visits, according

totypes of disorders: United States, 1977-78 . . . . . . . . . 27

25

23
U .

6

Tablel. Number ofoffice visits fordisorders of the femelereproductive system andpercent distribution byageand receofpatients, according toprincipal diagnoses: United Stetes,1977-78

Principal diagnosis and ICDA code 1

Number Age of patien t Race of patient

of visits

in 15-24 25-34 35-44 45-54 55-64 65years Black

thousands Total

years years years years years

Whita and ovar

and all

other

All diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total neoplasms end diseases of breast . . . . . . . . . . . . . . . . . . . . . . . . ..174.217. 233. 6I@6Il

Benign andunspecified neoplasms of breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...217.233

Malignant neoplasms of breast... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...-174

Chronic cystic disease and other (nonneoplastic) diseases of breast . . . . . . . . . . . . . . . . . 61@61 1

Total neoplasms anddiseases of female genital trect . . . . . . . . . . ...180-184.218-221.234-236.

612-616,620-629

8enign and unspecified neoplasms of female genital orgens . . . . . . . . . . . . . ...21 &221, 234-236

Malignant neoplasms of female genital organs . . . . . . . . . . . . . . . . . . . . . ...,,4......18@184

Diseases ofovary and fallopian tubas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...612.615

Diseases of parametrium and pelvic peritoneum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 616

infective diseases ofcewix uteri andother diseases ofcewix . . . . . . . . . . . . . . . . . . ...620-621

Infective diseases of uterus (except cervix), vagina, and vulva; and other diseases

of uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...622-625

Other diseases of female genital organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...629

Disorders of menstruation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .626

Menopausal symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...627

Sterility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...628

592,100

8,606

1,261

2,624

4,722

36,901

3,563

942

1,134

1,970

3,305

8,912

1,473

7,933

6,678

990

Percent distribution

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

19.0

11.2

●12.4

17.1

23.3

15.5

*1 0.4

37.4

52.0

26.8

26.5

‘20.7

34.3

‘0.3

●18.2

Total neoplasms anddiseases of breast . . . . . . . . . . . . . . . . . . . . . . . . ..174 .2 I7.233.61O-6T1

8enignand unspecified neoplasms of breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...217.233

Malignant neoplasms of breast... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Chronic cystic diseases andother (nonneoplastic) diseases of breast . . . . . . . . . . . . . ...610.611

Total neoplasms and diseases of famale genital tract . . . . . . . . . . . ..180-184.218-221,234-236,

612-616,620-629

8enign and unpacified neoplasms of femele genital organs . . . . . . . . . . . . . ...218-221. 234.236

Malignant neoplasms of female genital organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..18s3-184

Disaases ofovary and fallopian tutws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..c. o.+a 612.615

Diseases ofparamatrium and pelvic paritoneum2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...616

Infective diseases of cervix uteri and other diseases of cervix . . . . . . . . . . . . . . . . . . . . .620-621

Infective disaases of uterus (except cervix), vagina, and vulva, and other diseases

of uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...622.625

Other diseases of female genital organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...629

Disorders of menstruation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .625

Menopausal symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...627

Sterility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . . . . . . . . . . . ...628

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

50.8

7.4

15.5

27.9

218.0

21.0

5.6

6.7

11.6

19.5

52.6

8.7

46.9

39.5

5.9

20.7

16.0

* 18.9

●4.5

21.7

26.1

23.7

●7.1

46.0

26.9

39.3

26.9

31.7

30.8

●4.4

76.8

12.8

22.7

31.0

●12.O

26.4

16.2

28.0

●1O.9

●12.3

●11.2

19.1

14.2

*9.9

15.5

17.7

45.1

14.1

21.0

‘20.5

18.7

22.4

20.1

21.3

+15.0

*3.9

●6.5

●8.5

10.9

*18.1

15.6

53.7

14.3

13.5

‘7.9

27.1

7.4

8.6

‘6.0

‘25.2

‘0.4

●2.4

4.3

9.7

*1 0.4

●2.7

19.6

19.2 89.4

15.7 91.8

●9.4 92.3

37.8 91.8

5.1 91.7

5.8 86.5

‘5.5 84.4

*31.5 85.3

81.6

‘0.9 72.1

●2.O 85.5

11.8 87.3

+9.3 85.3

●1.1 85.4

●4.3 93.3

88.5

10.6

8.2

●7.7

‘8.2

8.3

13.5

15.6

●14.8

* 18.4

27.9

14.5

12.7

*14.7

14.6

6.7

*11.5

Average annual visit rate per 1,000 women

23.9 41.4

●3.9 ●7.1

*3.5

20.0 30.7

213.1 288.8

13.7 25.3

● 2.4 ●2.O

10.5 15.6

25.5 15.9

22.0 39.0

58.7 71.9

*7.6 2.0

67.6 73.3

*0.5 ●8.8

●4.5 22.8

80.4 76.0

16.1 *1 0.9

●13.O 20.7

51.4 44.5

246.2 311.6

6.0 11.2

●4.2 *5.9

*5.8 ●1.8

●9.1 *5.4

26.1 ●9.9

52.3 40.7

●4.2 ●5.9

50.7 52.1

48.8 150.7

●2.1 -

54.4

*4.7

33.3

16.4

149.3

● 10.0

*11.1

●0.2

*2.3

6.7

40.4

*11.1

● 10.0

61.5

51.1

●4.5

37.6

9.1

81.0

‘7.5

*11.2

●0.7

2.5

39.9

*11.2

*3.2

*1 0.9

53.5

7.9

16.3

29.3

215.9

20.4

5.4

6.3

9.6

19.1

52.7

8.5

45.8

42.2

5.9

32.8

*4.5

●1.O

18.2

232.2

25.8

●6.5

●9.7

25.6

22.2

52.4

‘10.1

53.9

20.8

●5.3

1ga~ed on the Eighth flevi~i~n International Classification of Diseases, Adapted for Uae in the Unitad Stata5 (l CDA).

2Chiefly pelvic inflammatory diseasaa (616.0).
!

Table 2. Number and percent distribution of new problem office visits for disorders of the female reproductive system by time since onset of

complaint, according to principal diagnoses: United States, 1977-78

Number of Time since onset of complaint

new problem Principal diagnoses and lCDA codel

visits in Total Less than 1-3 weeks 1-3 3 months Not

thousands 1 week months or more applicable

Percent distribution

All visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.1 14.0

Total neoplasms and diseases of

breast . . . . . . . . . . . . . . . ...174.217. 233,610-611

Benign andunspecified neoplasmsof breast . . . ..217, 233

Malignant neoplasms of breast . . . . . . . . . . . . . . .. 174

Chronic cystic disease and other (nonneoplastic)

diseases of breast . . . . . . . . . . . ., . . . . . . ..610-s311

Total neoplasms and diseases of female genital

tract . . . 180-184,218-221,234-236, 612-616,620-629

Benign and unspecified naoplasms of female genital

organs . . . . . . . . . . . . . . . . . . . ...218-221.234-236

Malignant neoplasms of female genital organs . . .180-184

Diseases of ovary and fallopian tubas . . . . . . ...612-615

Diseasas of parametrium and pelvic peritoneum . . . .616

Infective diseases of cervix uteri and other diseasesof

cervix . . . . . . . . . . . . . . . . . . . . . . . . . ...620-621

Infective diseasas of utarus (except cervix), vagina, and

vulva; and othar diseases of uterus . . . . . . . . . .622-625

Other diseases of female genital organs . . . . . . . . . . .629

Disorders ofmanstruation . . . . . . . . . . . . . . . . ...626

Menopausal symptoms . . . . . . . . . . . . . . . . . . ...627

Sterility . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...628

214,176 100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

36.5 18.1 12.6

3,008

699

408

29.2

40.7

*1 8.4

25.8 19.9

‘27.7 “16.9

‘14.0 ●35.2

16.6

*4.2

‘30.2

8.6

*1O.5

“2.2

1,901 27.3 27.6 17.7 18.2 ‘9.3

16,670 22.4 23.1 23.1 21.9 9.6

1,457

“206

596

1,179

● 14.4

*33.2

*21 .5

52.5

●19.7 22.0

*11.1 *5.6

●26.4 ●40.6

32.2 ●5.5

26.1

*24.7

‘8.1

●9.8

●17.9

*25.5

3.4

1,275 +11.4 24.8 29.3 14.8 19.7

4,595

977

4,570

1,503

“312

31.5

“25.3

17.1

●5.8

27.0 17.4

40.8 ●11.6

18.3 31.8

‘1 3.4 31.3

*2.5

14.8

●I 5.4

27.4

36.0

*78.1

9.3

*6.9

*5.5

*1 3.6

*19.4

1Ba=d on the Eighth Rwi~ion International Classification of Diseases,Adapted for Use in the United States ( ICDA).

2Chiefly pelvic inflammatory disaase(61 6.0).

Table 3. Number and percent distribution of office visits for disorders of the female reproductive system by seriousness of the problem, according

to selected principal diagnoses Unitad States, 1977-78

Seriousness of problem

Number

in Not Slightly Serious

thousands Total serious serious or very

serious

Principal diagnosis and ICDA code I

Percent distribution

All diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592,100 100.0 51.0 30.8 18.3

Total neoplasms and diseases of breast . . . . . ...174. 217, 233, 610-611 8,606 100.0 33.3 29.8 37.0

Benign and unspecified neoplasms of breast . . . . . . . . . . . . . ..217, 233 1,261 100.0 30.8 39.7 29.5

Malignant neoplasms of breast... . . . . . . . . . . . . . . . . . . . . . . . . 174 2,624 100.0 *4.2 *9.7 86.1

Chronic cystic disease and other (nonneoplastic) diseases of

breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...610-611 4,722 100.0 50.0 38.3 11.7

Total neoplasms and diseases of female genital tract . . . 180-184, 218-231,

234-236,612-616,620-629 36,901 100.0 54.8 33.5 11.8

Benign and unspacifiad neoplasms of female genital organs . . ...218-221.

234-236 3,563 100.0 32.1 46.1 21.8

Malignant naoplasms of female genital organs . . . . . . . . . . . . . .180-184 942 100.0 ●18.2 *7.8 74.0

Diseases of ovary and fallopian tubas . . . . . . . . . . . . . . . . ...612-615 1,134 100.0 55.3 34.5 ●10.2

Diseases of parametrium and pelvic peritonaumz . . . . . . . . . . . . . . 616 1,970 100.0 36.8 47.3 15.9

Infective diseases of carvix uteri and other diseases of cewix . . .. 620-621 3,305 100.0 56.5 32.2 11.3

Infective diseases of uterus (except cervix), vagina, and vulva; and other

diseases of uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...622-625 8,912 100.0 5B.6 32.7 8.7

Other diseases of femala genital organs . . . . . . . . . . . . . . . . . . . .. 629 1,473 100.0 50.3 41.2 *8.5

Disorders of menstruation . . . . . . . . . . . . . . . . . . . . . . . . . . ...626 7,933 100.0 54.0 35.2 10.9

Menopausal symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627 6,678 100.0 71.6 25.4 *3.1

Sterility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...628 990 100.0 66.8 *23.4 ●9.8

1Based on the Eighth Re”ision International Classification of Diseases,Adapted fOr Use in the Unitad States (l CD A).

2Chiefly pelvic inflammatory disease (616.0).

25
u

a

Table 4. Number of office visits by selected disorders of the breast, female genital tract, and all other diagnoses and percent by selected disorders of the breast, female genital tract,

all other diagnoses, and diagnostic or therapeutic services ordered or provided: United States, 1977-78

Diagnostic or therapeutic sewice

Benign

and unspecified

neoplasms

of breast

(21 7, 233)

Malignant

neoplasms

of breast

(1 74)

Chronic

cystic

disease and

other (nonneoplastic)

diseases

of breast

(610-61 1)

Benign

and unspecified

neoplasms

of femala

genital

tract

(218-221,

234-236)

Malignant

neoplasms

of female

ganital

tract

(180- 184)

Diseases

of ovary,

fallopian

tubes and

parame trium

(612-616)

Diseases

0 f cervix,

uterus,

vagina,

and other

female

genital

organs

(620-625,

629)

Disorders

of menstruation

(626)

Menopausal Sterility

symptoms (628)

(627)

Number in thousands

Ail visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,261 2,624 4,722 3,563 942 3,104 13,690 7,933 6,678 990

Diagnostic service

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *10.7

Limitedhistory/examination . . . . . . . . . . . . . . . 62.5

Generalhistory/examination . . . . . . . . . . *24.1

Paptest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ●4.2

rlinical laboratorytest . . . . . . . . . . . . . . . . . . . *9.8

X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ●12.8

Blood pressurecheck . . . . . . . . . . . . . . . . . . . . *22.3

Percent 2

*5.2 “5.4 *3.1 *7.3 +0.7 3.1 *3.5 25.2 *14.4

64.6 72.0 52.5 55.0 63.2 52.4 55.9 39.1 44.7

18.1 19.7 36.9 22.8 33.8 27.6 33.4 27.5 32.8

*2.2 15.8 33.4 ‘30.7 24.5 35.6 39.8 29.4 33.2

35.4 11.6 26.4 34.8 27.6 31.7 35.8 22.8 44.8

17.4 11.9 *3.4 *5.9 ‘0.5 *2.1 *1.O *4.1 *10.2

27.2 30.2 52.5 40.2 45.3 38.3 51.6 54.8 49.9

Therapeutic service

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44.8 28.5 38.8 43.3 32.6 13.1 20.0 24.2 8.5 *16.5

Drugs (prescription and nonprescription) . . . . . . . ●11.5 40.4 20.9 26.0 45.2 69.6 57.4

Dietcounseling . . . . . . . . . . . . . . . . . . . . . . . .

51.2 77.8 ●28.1

*0.5 ‘0.4 ●1.1 *1.9 ‘0.9 *4.2 2.9 4.1 5.3 ●1.3

Familypianning . . . . . . . . . . . . . . . . . . . . . . . *1.6 ‘0.2 *3.5 *3.2 4.2

Medicai counseling . . . . . . . . . . . . . . . . . . . . . .

8.2 *1.O *18.7

25.4 19.2 27.7 23.7 ’21.5 23.3 25.1 32.9

Officesurgery . . . . . . . . . . . . . . . . . . . . . . . . .

22.3 36.9

●19.1 14.7 15.5 *7.4 *3.6 *2.5 11.1 5.4 ●1.3 *7.9

Psychotherapy /therapeutic listening . . . . . . . . . . *4.7 ●2.8 *3.5 * 2.9 ●2.8 ●4.6 2.4 4.6 7.4 ●9.5

lBa~ed~nthe Ei~hth Revision International Classification of Diaaases, Adepted for U$einthe United States (lCDA).

ZperceRtswiil nottotai 100. Obeceusa more than 1 serviceman have been ordered or provided.

All

othar

diagnoses

546,593

10.3

60.3

19.4

8.2

25.6

7.5

43.0

20.0

54.4

8.3

2.5

20.0

6.7

6.5
Table5. Number ofoffica visits fordisordersof the female reproductive system andallother di~nows, and@rcent dstribution ofvisitsby

disposition andduration of thevisits, according to Wpesofdsorders: United States, 1977-78

Neoplesms

Neoplasms and diseases

and diseases of female Disorders of Menopausal

Disposition and duration

Sterility

of breast

All other

genital organs menstruation symptoms

(174. 217.233. (?80-184. 218-221. (s526) (627) (628) diagnoses

6-70-611) - 234-236; 612-616;

620-625, 629)

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

Disposition

No followup planned . . . . . . . . . . . . . . . . . . .

Return ataspacifiad time . . . . . . . . . . . . . . . .

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

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

Referred toanother physician oragenq . . . . . . .

Return to referring physician . . . . . . . . . . . . . .

Admit to hospital . . . . . . . . . . . . . . . . . . . . . .

Other disposition . . . . . . . . . . . . . . . . . . . . . .

Duration2

Ominutes . . . . . . . . . . . . . . . . . . . . . . . . . . .

l-lOminutes . . . . . . . . . . . . . . . . . . . . . . . . .

ll-15minutes . . . . . . . . . . . . . . . . . . . . . . . .

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

31 minutesormore . . . . . . . . . . . . . . . . . . . .

8,606

5.7

70.7

11.9

+3.0

5.8

*1.2

6.7

4.2

*1.5

40.0

32.8

22.5

●3.3

21,300

5.1

61.4

22.1

3.8

4.5

●1.1

6.8

1.7

+0.7

28.8

35.2

31.2

4.1

Number in thousands

7,933

Percent

●3.5

57.1

24.8

8.4

‘2.0

●1.2

8.4

*2.6

●1.1

28.9

34.8

29.7

5.5

6,678 990

●2.4

58.2

39.6

*2.3

*1.8

‘0.5

“0.5

2.0

73.8

‘20.4

*5.6

2.9

*0.4

*2.8

17.9

30.5 *24.4

27.7 33.5

20.9 37.6

*3.O ●4.5

546,593

8.7

65.8

20.6

3.2

2.4

0.8

1.9

1.0

3.0

42.5

26.9

21.3

6.4

lp~rc~nl$willno~~o~al loo.obe~~u~~rn~~~than 1 di~p~~jti~nw~~p~~sibl~+

2Time spent in face-to-face encountar between physician and Patient.

27
Appendixes

Contents

1. Technical notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Statistical design.,.....,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Data collection andprocessing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..t. 30

Estimation procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Reliability ofestimates. ,... , . . . . . . . . . . . . . . . . . ..$ .,......mm,cocm..-..c ... . . . . . .. O...... 31

Tests ofsignificance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Population figures and ratecomputation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Systematic bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

il. Definition ofterms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Terms relating tothesurvey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Terms relating tothe Patient Record form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

111. Survey instrument . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

List ofappendix figures

1.

Il.

Ill.

Approximate relative standard errors for estimated numbers of office visits based on all physician specialties (A), and

individual specialties(B), 1977-78 National Ambulatory Medical Care Survey. . . . . . . . . . . . . . . . . . . , . . . . . . . . . . 33

Approximate relative standard errors forpercentages ofestimated numbers ofoffice visikbased onallphysician specitllties, 1977-78 National Ambulatory Medical Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Approximate relative standard errors for percentages of estimated numbers ofoffice visits based on individual physician

specialties, 1977-78 National Ambulatory Medical Care Survey . . . , . . . . . , . . . . , . . . . . . . . . . , . . . . . . . . . . , . . 35

List of appendix tables

1. Distribution of physicians in the 1977 -78 National Ambulatory Medical Care Survey sample andresponse rates, byphy -

sician specialty ...,... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Il. Estimates of the civilian noninstitutionalized population ofthe United States used in computing annual visit rates inthis

report, by age, race, sex, geographic region, and metropolitan and nonmetropolitan area: United States, 1977-78. . . . . . 36

28
Appendix L Technical notes

This report is based on data collected during 1977

and 1978 in the National Ambulatory Medical Care

Survey (NAMCS), an annual sample survey of ofticebased physicians conducted by the Division of Health

Care Statistics of the National Center for Health

Statistics (NCHS). Because the 1977 and 1978

surveys were conducted with the same instruments,

definitions, and procedures, the 2 years of data are

readily combined to provide greater reliability of

data. Details of the annual survey’s design and

procedures are presented in the following sections.

Statistical design

Scope of the survey. –The target population of

NAMCS encompasses office visits made within the

conterminous United States by ambulatory patients

to nonfederally employed physicians who are principally engaged in office practice, but not in the

specialties of anesthesiology, pathology, or radiology.

Telephone contacts and nonoffice visits are excluded.

Sample design. –The NAMCS utilizes a multistage

probability design that involves probability samples

of primary sampling units (PSU’S), physician practices

within PSU’S, and patient visits within practices. The

first-stage sample of 87 PSU’S was selected by the

National Opinion Research Center 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 employed.

After sorting and stratifying by size, region, and

demographic characteristics, each frame was divided

into sequential zones of 1 million residents, and a

random number was drawn to determine which PSU

came into the sample from each zone.

The second stage consisted of a probability

sample of practicing physicians selected from the

master files maintained by the American Medical

Association (AMA) and the American Osteopathic

Association (AOA) who met the following criteria:

Office-based, as defined by AMA and AOA.

Principally engaged in patient care activities.

Nonfederally employed.

Not in the specialties of anesthesiology, pathology,

clinical pathology, forensic pathology, radiology,

diagnostic radiology, pediatric radiology, or therapeutic radiology.

Within each PSU, all eligible physicians were

arranged by nine specialty groups: general and family

medicine, internal medicine, pediatrics, other medical

specialties, general surgery, obstetrics and gynecology, other surgical specialties, psychiatry, and all

other specialties. Then, with 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 1977-78 the NAMCS physician sample

included 6,007 physicians. Sample physicians were

screened at the time of the survey to ensure that they

met the aforementioned criteria; 973 physicians did

not meet all 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 5,034 in-scope

(eligible) physicians, 3,782 (75. 1 percent) participated

in the study. Of the participating physicians, 560 saw

no patients during their assigned reporting period

because of vacations, illnesses, or other reasons for

being temporarily not in practice. The physician

sample size and response data by physician specialty

are shown in table I.

The final stage was the selection of patient visits

within the annual practices of the sample physicians.

This stage involved two steps. First, the total physician sample was divided into 52 random subsamples

29
Table 1. Distribution of physicians in the 1977-78 National Ambulatory Medical Care Survey sample and response rates, by physician specialty

Physician specialty

Gross out Net Non- Respond- Response

total of total respondscopeen ts rate

en ts

All specialties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,007 973 5,034 1,252 3,782 75.1

General and family practice. . . . . . . . . . . . . . . . . . . . . . . . . . 1,496 269 1,227 365 862 70.3

Medical specialties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,646 255 1,391 355 1,036 74.5

Internal medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 851 126 725 193 532 73.4

Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 71 340 74 266 78.2

Other medical speciaities . . . . . . . . . . . . . . . . . . . . . . . . . . 384 58 326 88 238 73.0

Surgical specialties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,120 217 1,903 438 1,465 77.0

General surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 586 76 510 109 401 78.6

Obstetrics and gynecology . . . . . . . . . . . . . . . . . . . . . . . . . 494 43 451 115 336 74.5

Other surgical specialties . . . . . . . . . . . . . . . . . . . . . . . . . . 1,040 98 942 214 728 77.3

Otherspecialties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 745 232 513 94 419 81.7

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441 84 357 68 289 81.0

Otherspecialties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304 148 156 26 130 83.3

of approximately equal size, and each subsample was

randomly assigned to 1 of the 52 weeks in the survey

year. Second, a systematic random sample of visits

was selected by the physician during the assigned

week. The sampling rate varied for this final step

froma 100-percent sample forvery small practicesto

a 20-percent sample for very large practices. The

method by which the sampling rate was determinedis

described laterin this appendix and in the Induction

Interview form.1 During 1977-78, 98,335 useable

Patient Record forms were completed by physicians

participating in NAMCS.

Data collection and processing

Field procedures. –Both mail and telephone contacts were used to enlist sample physicians for

NAMCS. Physicians received introductory letters

from NCHS4 and AMA or AOA. When appropriate, a

letter from the physician’s specialty organization

endorsing the survey and urging his participation was

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

field representative telephoned the physician to explain briefly the study and arrange an appointment

for a personal interview. A physician who did not

respond initially was generally recontacted via a

telephone call or special explanatory letter requesting

him to reconsider participation in the study.

During the personal interview the field representative determined the physician’s eligibility, ascertained

his cooperation, delivered survey materials with verbal and printed instructions, and assigned a predetermined Monday-Sunday reporting period. A short

interview concerning basic practice characteristics,

such as type of practice and expected number of

office visits, was conducted. Office staff who were to

assist with data collection were invited to attend the

instruction session or were offered separate instruction sessions.

Before the beginning of and again during the

week assigned for data collection, the interviewer

telephoned the sample physician to answer questions

that might have arisen and to ensure that procedures

were going smoothly. At the end of the survey week,

the participating physician mailed the finished, survey

materials to the interviewer, who edited the forms for

completeness before transmitting them for central

data processing. Problems of missing or incc}mplete

data were resolved at this stage by interviewer

telephone followup to the sample physician, if no

problems were found, field procedures were considered complete regarding the sample physician’s participation in NAMCS. After the end of the survey

year, each sample physician was sent a thank-you

letter from NCHS along with one of the survey’s

statistical reports.

Data collection. –The actual data collection for

NAMCS was carried out by the physician, aided by

his office staff when possible. Two data collection

forms were employed by the physician: the Patient

Log and the Patient Record (appendix III). The

Patient Log is a sequential listing of patients seen in

the physician’s office during his assigned reporting

week. This list served as the sampling frame to

indicate the visits for which data were to be recorded.

A perforation between the patient names and patient

visit characteristics permitted the physician to remove

and retain the patient names, thus protecting the

confidentiality of the patients.

Based on the physician’s estimate of the expected

number of office visits, each physician was assigned a

patient sampling ratio. These ratios were designed so

that about 30 Patient Record forms were completed

during the assigned reporting week. Physicians expecting 10 or fewer visits each day recorded dlata for

all visits, those expecting more than 10 visits per day

recorded data for every second, third, or fifth visit,

based on the predetermined sampling interval. These

procedures minimized the data collection wc}rkload

and maintained approximately equal reporting levels

among sample physicians regardless of practice size.

30
For physicians assigned a patient sampling ratio, a

random start was provided on the first page of the

log, so that predesignated sample visits recorded on

each succeeding page of the log provided a systematic

random sample of patient visits during the reporting

period.

Data processing. –In addition to completeness

checks made by the field staff, clerical edits were

performed on receipt of the data for central processing. These procedures proved quite efficient, reducing

the item nonresponse rates to a negligible amount–2

percent or less for all 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.21 Diagnostic information

(item 8 of the Patient Record form) was coded

according to the Eighth Revision International Classification of Diseases, Adapted for Use in the United

States (ICDA).1 A maximum of three entries were

coded from each of these items. Quality control in

the medical coding operation involved a two-way

independent verification procedure with 100-percent

verification. Coding differences were adjudicated at

NCHS.

Information from the Induction Interview and

Patient Record forms was keypunched, with 100-

percent verification, and converted to computer tape

(see Series 13, No. 44 for a complete listing of survey

instruments). At this point, extensive computer consistency and edit checks were performed. Incomplete

items were imputed by assigning a value from a

Patient Record form with similar characteristics;

physician specialty and broad diagnostic categories

were used as the basis for these imputations.

Estimation procedures

Statistics from the NAMCS were derived by a

multistage estimation procedure, which 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 described briefly.

Injlation by reciprocals of sampling probabilities. –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 a physician within the PSU, and (3) the

probability of selecting a patient visit within the

physician’s practice. The last probability was defined

to be the exact number of office visits during the

physician’s specified reporting week divided by the

number of Patient Record forms completed. All

weekly estimates were inflated by a factor of 52 to

derive annual estimates.

Adjustment for nonresponse. –Estimates from the

NAMCS data were adjusted to account for sample

physicians who did not participate in the study. This

adjustment was performed to minimize the impact of

response on final estimates by imputing to nonresponding physicians the practice characteristics of

similar 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 of which the numerator was the number

of physicians in the universe in each physician

specialty group and the denominator the estimated

number of physicians in that particular specialty

group. The numerator was based on figures obtained

from the AMA-AOA master files, and the denominator was based on data from the sample.

Reliabilityy of estimates

Because the statistics presented in this report are

based on a sample, they differ somewhat from the

figures that would be obtained if a complete census

had been taken by using the same forms, instructions,

and procedures. However, the probability design of

NAMCS permits the calculation of sampling errors.

The standard error is primarily a measure of sampling

variability that occurs by chance because only a

sample rather than the entire population is surveyed.

The standard error, as calculated in this report, also

reflects part of the variation that arises in the

measurement process. It does not include estimates of

any systematic biases that may be in the data. The

chances are about 68 out of 100 that an estimate

from the sample would differ from a complete census

by less than the standard error. The chances are about

95 out of 100 that the difference would be less than

twice the standard error, and about 99 out of 100

that it would be less than 2Y2 times as large.

The relative standard error of an estimate is

obtained by dividing the standard error by the

estimate itself and is expressed as a percent of the

estimate. For this report, an asterisk (*) precedes any

estimate with more than a 30-percent relative standard error.

Estimates of sampling variability were calculated

by 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.’2j9js

Approximate relative standard errors for aggregates and percentages are presented in figures I-III. 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-III should be interpreted as approximate

31
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 figure I. Curve A presents relative

standard errors appropriate for estimates based on all

physician specialties, such as the number of visits by

females under 15 years of age. Curve B presents

relative standard errors appropriate for estimates

based on an individual physician specialty, such as the

number of visits to internists by males over 65 years

of age.

Alternatively, relative standard errors can be

calculated directly by using the following formulae.

For estimates based on all physician specialties,

J

30.676864

RSE(X) = 0.000811 + “ 100.0

x

Where x is the aggregate of interest in thousands. For

estimates based on an individual physician specialty,

‘s’(x)=~” 1000

where x is the aggregate of interest in thousands.

Estimates of percentages, –Approximate relative

standard errors (in percent) for estimates of percentages can be calculated from figure I as follows. Obtain

the relative standard error of the numerator and

denominator. Square each of the relative standard

errors, subtract the resulting value for the denominator from the resulting value for the numerator, and

extract the square root. This calculation has been

made for several percentages and bases, and is

presented in figures II and III. Relative standard

errors appropriate for percentages based on all physician specialties are presented in figure II. These errors

may be calculated directly by using the following

formula:

r

30.;76864 “ (1 -p) . ~Oo o

RSE@) = —

P “x

where p is the percentage of interest and x is the base

in thousands. Relative standard errors appropriate for

percentages based on an individual physician specialty

are presented in figure III. These errors may be

calculated directly by using the following formula:

‘s’’)=- “100-0

where p is the percentage of interest and x is the base

in thousands.

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 U.S. population or one or more of the

age-sex-race groups of the total population are equivalent to the relative standard error of the numerator

that can be obtained from figure 1.

Estimates of differences between two statistics, –The relative standard errors shown in this

appendix are not directly applicable to differences

between two sample estimates. The standard error of

a difference is approximately the square root of the

sum of the squares of each standard error considered

separately. This formula 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.

In addition to sampling error, survey results are

subject to reporting and processing errors and biases

due to nonresponse or incomplete response. The

magnitude of these errors cannot be computed.

However, they were kept to a minimum by procedures built into the survey operation, Careful attention and extensive pretesting were given to the

phrasing of the questions and the terms (and their

definitions) employed to eliminate ambiguities and

encourage uniformity of reporting. The steps taken to

reduce nonresponse bias 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 processing.

Tests of significance

In this report, the determination of statistical

inference is based on the t-test with a critical value of

1.96 (0.05 level of significance). Terms relating to

differences, such as “higher,” “less,” etc., indicate

that the differences are statistically significant. 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 base population used in computing annual

visit rates is presented in table 11. The figures are

based on an average of the July 1, 1977 and July 1,

1978 provisional estimates for 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 census estimates were modified to

account for the exclusion of Alaska and Hawaii from

32
I I 1~11111111I I I

+-: 1 E

= 1 I , , [ 1 1 ,

, I 1 I ! I !

i

m

u)

C9

r=

N

m

.llIl!l!! 1

m

rl

N

111 1 I I I

I

I I t I I I

Ill I I I I

k“l’ft[[

,,, ,,

r I 1 I 11111 ,,, ,, ,1,, 1 I 1 1 1~ 1 1 1 I I 1 1 I 4

33
100

90

80

70

60

50

40

30

20

1:

8

7

6

5

4

3

2

0.;

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

NOTE :

w

I 1 t I 1 1 1

2 3 4 56789A 2 3 4 56789A 2 3 456789A

1 10 100 1Ficl

Estimated percentage

Base of percentage shown on curves in millions.

100

90

80

70

60

50

40

30

20

10

9

8

7

6

5

4

3

2

:.9

0,8

0.7

0.6

0.5

0.4

0.3

0.2

0,1

Example of use of chart: An estimate of 20 percent (reed from scale at bottom of chart) basad on an estimate of 100 million office visits

has a relative standard error of 3.5 Percent (read from scala at left of chart) or a standard error of 0.7 percentage points (3.5 percent of

20 percent).

Figure II. Approximate relative standard errors for percentages of estimatad numbers of office visits based on all physician specialties,

1977-78 National Ambulatory Medical Care Survey

34
100

90

80

70

60

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

I x I I N

I lx I I [

t I u I I 1=

I

>{ I WI I I u

I

I I I I I 1 Illlu

[ 1 , , I

I

I

I

I 1 I 1 I I I II

I I I I

, 1 ,

I 1 d

I ! 1 I I 1 1 Hi I

I I I I I I I I

AH

, , , , , M I I I 1 1 i 1 1

J.

100

90

80

70

60

50

40

30

20

10

9

8

7

6

5

4

3

2

)9

0,8

0.7

0.6

0.5

0.4

0.3

0.2

01

A 2 3 4 56789A 2 3 4 56789A 2 34 56789A

1 10 100 1,000

Estimated percentage

NOTE: Base of percentage shown on curves in millions,

Example of use of chart: An estimate of 40 percent (read from scale at bottom of chart) based on an estimate of 50 million office visits

has a relative standard error of 3.2 percent (read from scale at left of chart) or a standard error of 1.3 percentage points (3.2 percent of

40 percent),

Figure I I 1. Approximate relative standard errors for percentages of estimated numbers of office visits based on individual physician specialties,

197778 National Ambulatory Medical Care Survey

35
Table 11. Estimates of the civilian noninstitutional ized population of the United Statas used in computing annual visit rates in this report, by age,

race, sex, geographic region, and metropolitan and nonmetropolitan area: United States,l 1977-78

Race, sex, geographic

region, and area

Age

A II Under 15-24 25-34 35-44 45-54 55-64 65 years

ages 2 15 years years years years years years and over

Race

All races . . . . . . . . . . . . . . . . . .

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

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

White, . . . . . . . . . . . . . . . . . .

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

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

Black and another . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . ,.

Female ., ., . . . . . . . . . . . . . .

Geographic region

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

North Central........,..,..

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

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

Area

Metropolitan . . . . . . . . . . . .

Nonmetropolitan . . . . . . . . . . .

211,679

102,137

109,541

183,351

88,883

94,468

28,328

13,255

15,073

48,555

56,966

69,057

37,1OI

144,767

66,911

50,804

25,917

24,887

42,111

21,539

20,572

8,693

4,378

4.315

. . .

.

,..

. .

,..

. . .

Number of persons in thousands

39,554 32,365 23,331

19,422 15,707 11,210

20,132 16,658 12,121

33,719 28,207 20,405

16,684 13,873 9,926

17,036 14,335 10,478

5,835 4,157 2,927

2,738 1,834 1,284

3,097 2,323 1,643

22,965

11,078

11,887

20,343

9,872

10,471

2,622

1,206

1,416

. . . .,. .,.

. . . .,. .

. . . . . . . .

,.. . . .,.

. . .,,

. . . . . .,.

20,200

9,535

10,664

18,238

8,636

9,603

1,961

900

1,062

. .

. .

.

22,460

9,267

13,193

20,327

8,353

11,974

2,132

914

1,218

. . .

. .

lExcl”des Alaska and Hawaii.

2FigureS may notadd to tOtal due to rounding.

the study. For this reason, the population estimates understand, indicate that these data underrepresent

should not be considered official and are presented the total number of office visits to office-based

here solely to provide denominators for rate com- physicians. Some of these factors are:

putations. Estimates of numbers of visits in this 1

report are for a 2-year period, but ratios and rates -

represent average annual estimates. The average

annual estimates were calculated as follows. The

numerator was obtained by dividing the estimated

number of office visits for 1977-78 by2to obtainan

average annual number of office visits. This number

was then divided by the appropriate population figure

to obtain an average annual visit rate. As previously z

discussed, reliability estimates for average annual visit ‘

rates may be calculated from figure 1.

Systematic bias

No attempts were undertaken to determine the

systematic bias on the data reported here. However,

several factors, which the user of these data should

The sampling frames for the 1977 and 1978

NAMCS included all nonfederally employed,

“office-based, patient care” physicians on the

AMA-AOA master files. Certainly physicians who

were not classified thus at the time of the survey

would have met the criteria for that classification.

Visits to these physicians are not represented

here.

Physicians who participated in NAMCS did a

thorough and conscientious job in keeping the

Patient Log; however, the probability that a

patient visit was accidentally omitted from the

survey is much greater than the probability that a

patient was included who did not make a visit.

This factor also introduces an unknown bias into

the data.

36
Appendix Il. Definition of terms

Terms relating to the survey

O~~ice(s). –Premises identified by the physician as

locations for his ambulatory practice. The responsibility over time for patient care and professional services

rendered there generally resides with the individual

physician rather than with any institution.

Ambulatory patient. –An individual seeking personal health services who is neither bedridden nor

currently admitted to any health care institution on

the premises.

Physician. –Classified as either:

In scope: All duly licensed doctors of medicine

and doctors of osteopathy currently in practice

who spend some time in caring for ambulatory

patients at an office location.

Out o~scope: Those physicians who treat patients

only indirectly, including specialists in anesthesiology, pathology, forensic pathology, radiology,

therapeutic radiology, and diagnostic radiology,

and the following physicians:

Physicians in military service.

Physicians who treat patients only in an

institutional setting (e.g., patients in nursing

homes and hospitals).

Physicians employed full time by an industry

or institution and having no private practice

(e.g., physicians who work for the Veterans

Administration, the Ford Motor Company,

etc.).

Physicians who spend no time seeing ambulatory patients (e.g., physicians who only teach,

are engaged in research, or are retired).

Patients. –Classified as either:

In scope: All patients seen by the physician or a

member of his staff in his office(s).

Out c~fscop~: Patients seen by the physician in a

hospital, nursing home, or other extended care

institution, or the patient’s home. [Note: If the

physician has a private office (fitting the definition “office”) 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 the primary

responsibility y over time.

Patients who telephone and receive advice

from the physician.

Patients who come to the office only to leave

a specimen, pick up insurance forms, or pay

their bills.

Patients who come to the office only to pick

up medications previously prescribed by the

physician.

Visit. –A direct, personal exchange between an

ambulatory patient and a physician (or members of

his staff) to seek care and to render health services.

Physician specialty. –Principal specialty (including

general practice) as designated by the physician at the

time of the survey. Those physicians for whom a

specialty was not obtained were assigned the principal

specialty recorded in the master physician files

maintained by the AMA or the AOA.

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:

Region States included

Northeast . Connecticut, Maine, Massachusetts, New

Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont

North Central . . Illinois, Indiana, Iowa, Kansas, Michigan,

Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin

37
Region States included

South. . Alabama, Arkansas, Delaware, District of

Columbia, Florida, Georgia, Kentucky,

Louisiana, Maryland, Mississippi, North

Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia

West . Arizona, California, Colorador Idahor

Montana, Nevada, New Mexico, Oregon,

Utah, Washington, Wyoming

Metropolitan status of practice location. –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 a specified

population which constitute the central city and

identify the county in which it is located as the

central county; second, economic and social relationships with “contiguous” counties that are metropolitan in character so that the periphery of the specific

metropolitan area may be determined. SMSA’S may

cross State lines. In New England, SMSA’S consist of

cities and towns rather than counties.

Terms relating to the Patient Record form

Age. –The age calculated from date of birth was

the age at last birthday on the date of visit.

Color or race. –On the Patient Record form, color

or race includes four categories: white, Negro or

black, other, and unknown. The physician was

instructed to mark the category, which in his judgment, was most appropriate for the patient based on

observation or prior knowledge of the patient or

both. The term “All other” was restricted to Orientals, American Indians, and persons of all other

races.

Was patient referred for this visit by another

physician ?–Referrals are any visits that are made

because of 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.

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.

Time since onset of complaint or symptom in

item 6a.–Physicians were instructed to check the

category corresponding to the length of time since

the known beginning of the patient’s most important

problem. The term “not applicable” was used when

the reason for visit was not a complaint or symptom

(e.g., annual and well-baby examinations). For postoperative visits, the term “onset” refers to the length

of time since surgery. For routine prenatal visits,

onset refers to the length of time since conception.

For a flareup of a chronic condition (e.g., arthritis),

onset refers to the length of time since the flareup,

not the onset of the original condition.

Principal diagnosis. –The physician’s diagnosis 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 judgment at the time of the visit and

may be tentative, provisional, or definitive.

Other significant current diagnosis. –The diagnosis

of any other condition known to exist for the patient

at the time of the visit. Other diagnoses may or may

not be related to the reason for the visit.

Seriousness of problem in item 8a.–This item

includes four categories: very serious, serious, slightly

serious, and not serious. The physician was instructed

to check one of the four categories according to his

own evaluation of the seriousness of the patient’s

problem causing this visit. Seriousness refers to the

physician’s clinical judgment regarding the extent of

the impairment that might result if care was not

given.

Diagnostic services this visit, –Physicians were

instructed to check any of the following services that

were ordered or provided during the current visit:

Limited exam~history: History and/or physical

examination which is limited to a specific body

site or system or which is concerned primarily

with the patient’s chief complaint, for example,

pelvic examination or eye examination.

General exam/history; History and/or physical

examination of a comprehensive nature, including

all or most body systems.

Pap test: Papanicolaou test, self-explanatory.

Clinical lab test: One or more laboratory procedures or tests, including examination of blood,

urine, sputum, smears, exudates, transudates,

feces, and gastric content, and including chemistry, serology, bacteriology, and pregnancy test

(excludes Pap test).

X-ray: Any single or multiple X-ray examination

for diagnostic or screening purposes. Radiation

therapy is not included in this category.

EKG: Electrocardiogmm, self-explanatory.

Vision test: Visual acuity test.

Endoscopy : Examination

body cavity, except ear,

means of an endoscope.

of the interior of any

nose, and throat, by

38
Blood pressure check: Self-explanatory.

Other: All other diagnostic services ordered or

provided that are not included in the preceding

categories.

Therapeutic services this visit. –Physicians were

instructed to check any of the following services that

were ordered or provided during the current visit:

Immunization/desensitiza tion: Administration of

any immunizing, vaccinating, or desensitizing

agent or substance by any route, for example,

syringe, needle, oral, gun, or scarification.

Drugs (prescription/nonprescription): Drugs, vitamins, hormones, ointments, suppositories, or

other medications ordered or provided, except

injections and immunizations. Includes both prescription and nonprescription (over-the-counter)

medication.

Diet counseling: Instructions, recommendations,

or advice regarding diet or dietary habits.

Family planning: Services, counseling, or advice

that might enable patients to determine the

number and spacing of their children. Includes

both contraception and infertility services.

Medical counseling: Instructions and recommendations regarding any health problem, including

advice or counsel about change of habit or

behavior. Physicians were instructed to check this

category only if the medical counseling was a

significant part of the treatment. (Excludes diet

and family planning counseling.)

Physiotherapy: Any form of physical therapy

ordered or provided, including any treatment

using heat, light, sound, or physical pressure or

movement, for example, ultrasonic, ultraviolet,

infrared, whirlpool, diathermy, cold therapy, and

manipulative therapy.

Office surgery: Any surgical procedure performed

in the office this visit, including suture of

wounds, reduction of fractures, application and/

or removal of casts, incision and draining of

abscesses, application of supportive materials for

fractures and sprains, and all irrigations, aspirations, dilatations, and excisions.

Psychotherapy/therapeutic listening: All treatments designed to produce a mental or emotional

response through suggestion, persuasion, reeducation, reassurance, or support, including psychological counseling, hypnosis, psychoanalysis, and

transactional therapy.

Other: Treatments ordered or provided that are

not included in the preceding categories.

Disposition this visit. –Eight categories are provided to describe the physician’s disposition of the

case as follows:

No followup planned: No return visit or telephone contact was scheduled for the patient’s

problem.

Return at specified 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 follo wup planned; Patient was instructed to telephone the physician on a particular day to report either on his 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

referred to this physician and was now instructed

to consult again with the physician who referred

him.

Admit to hospital: Patient was instructed that

further care or treatment would be provided in a

hospital. No further office visits were expected

prior to that admission.

Other: Any other disposition of the case not

included in the above categories.

Duration of this visit. –Time the physician spent

with the patient, not including the 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 spent reviewing records, tests results, and so

forth. If patient was provided care by a member of

the physician’s staff but did not see the physician

during the visit, the duration of visit was recorded as

zero.

39
Appendix Ill. Survey instrument

PATIENT LOG

4, ●*. .,,.C”I “,..., ,CCC4 “.*. ti ,“...

PATIENT’S NAME

1

2

J

4

+

COSkllNkX LISTING PATIENTS

TIME OF

VISIT

ON ?StXT PAOC

ASS”fi ANCt OF COW ,0.$ N71AL,7 Y.. M I.lo,,,u,,c.n ,whkm would em,, tm.,i, )c.,,c+ d m ,nd,.,.auti,

. l,r M ,,’.. ., . .. ●,laM,UmUn, will * hold .Odldm,,.l. w,,, b. .“’4 rml” la” U., *., .“- ,“ -d 10,

,h. .u.,bOs.. 01 $h. ,“-., .“d All “.1 b. d,xl.”ti w ,.1.mml ,0 Mb, 09,80”, w M4d II), .“, o,h” ““<w” I

1. OATEOFVISIT

*

2. DATE OF BIRTH

*

PATlENT RECORD

NATIONAL AMBULATORY MEDICAL CARE SURVEY

3. SEX 4. SOLOR OR 5. WAS PATIENT 6. PATISFST3 COWkAINTIS1. SYMPTOMS). OFl OTHER

RACE FtE$ERRED FOR n6Asork4s) Fon TMIS VISIT

THIS VISIT av //” AU,-!,’ mwl Wck)

10 WHITE AFsOTlkEn

ID FEUALE , 0 MEGRO/ PHVSICIAN? . . 9.!OST

BLACK IMPORTANT

3 D MALE I n “Es

~ o OTHER — b. OTliE R

7. TIMESINCE ONSET

OF c41WLAINTI

::~VhW:,kFk ITEM&

I n LESS THAN S DAY

I o 1.3 OAYS

9 0 1.3w ESKS

. n UN ICN09S+4 IUNO I

8. ●MUSICIANS OIAGNGSES

. . PRINCIPAL DIAGNOSISIPROBI.EM ASSOCIATED WITH

ITEM s*

l), OTHER SIGNIFICANT CURRENT DIAGNOSES

9. ISAVEVOUSEEN PATtENT BEFOklEt

I n YES *ONO

t

1* VES. eon THE

COMOITION Its

ITEM ●,z

10. SERIOUSNEU OF

CoNotlkold IN

ITEM b Ichd mu)

1 D Vl!nv sEn10u9

a ❑ Sl?RlO-

,* SUQHILV

sEnlOuE

. n 1.3 MONTHS I ~ ‘“YES‘“N”I

*oNor SE R1OUS

r! MORE THAN

‘ u 3 MONTHS I I I

11. ObAOFSOStlCSSSWKCS THIS

WW iCRu!k ●ll or&m4 w wovtid

, 0 NONE

2 0 Lm.kITEO EXAW81STORY

h O GSN611AL SXAW/MISTOFi Y

. 0 ●AP TEST

, 0 CLINICAL ua TEST

6 0 x.n Av

, 0 SUG

, 0 vIsl Oki T6ST

, 0 tr.IGoscOPY

, ● D mLOOO PmEsSuns CMeclc

, t Cl ornem 1*4.1

RA.14.2

acv. S.?S

12.TFSEnA?EUTkC SSnVICES TkkLS

VISIT Ickt 4/ of&.wd W PMUIC44

* c1 NGWE

s u lmwwslz A1l ONl

OESENSITIZATlON

8 D DRUGS i? R6scn#PT10Nl

NO@lPmESCRIPTIGWl

. ❑ WET COUNSELING

k •l fAA91Lv rLArsts Iss6

. 0 WOtiCAL Courdsst. iw

1 n WSVS1OTHE*APV

* c1 OPFICE Sunaenv

9 n PSVCMOTHEnA?Vl

TbIkslAPl Uric LlsTENINa

t. U oT”’R /+c,f”)

O& PARTMENT OF WEALTH. EOUCAII1 PUBLICMEALTMSERVI

He ALTW *C SWRCES AGUINU

t4A710NAL cmsrE n fon HEAL71

13. D15POU1NIMTtklS VISIT

lChoch # tit M“)

* o NO fOLLOW.W PLANNED

‘ ~ RETUnN AT SPEClfl EO TIME

‘ o nETURN IF NEEOEO. P.*.N.

‘ o TELEPHONE FOLLOW-UP PUNNSO

* Q REP CmMEO TO OTMEM PISVSICIAN

, ~ :;::I&RN: TO REFCRnlNG

1 D AGS41T TO HoSPITAL

‘ Cl OTnen (*tvt

1AND WELFAnE

iSATIGtd ;TAYISTICS

14. OUnATkON OF

Tlws Vkskl

wi!-amNuF

-1 -’t*

Piwicw

_ MINUTES

O.kl.m, ws-n14u

40 *us. CJWEIW4ENT PRINTING OFFICE: 1982-36 I-16I:507
Vital and Health Statistics series descriptions

SERIES 1.

SERIES 2.

SERIES 3.

SERIES 4.

SERIES 10.

SERIES 11.

SERIES 12.

SERIES 13.

Programs and Collection Proceduree.-Reports describing

the general programs of the National Center for Health

%tk.tlCS and its offices and divisions and the data COI.

Iection methods used. They also include definitions and

other material necessa~ for understanding the data.

Data Evaluation and Methods Research. -Studies of new

statistical methodology including experimental tests of

new survey methods, studies of vital statistics collection

methods, new analytical techniques, objective evaluations

of reliability of collected data, and contributions to statistical theory.

Analytical and Epidemiological Studies. –Reports presenting analytical or interpretive studies based on vital

and health statistics, carrying the analysis further than the

expository types of reports in the other series.

Documents and Committee Reports.– Final reports of

major committees concerned with vital and health statistics and documents such as recommended model vital

registration laws and revised birth and death certificates.

Data from the National Health Interview Suwey.–Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other

health-related topics, all based on data collected in the

continuing national household interview survey.

Date From the National Health Examination Survey and

the National Health and Nutrition Examination Survey. –

Data from direct examination, testing, and measurement

of national samples of the civilian noninstitutional ized

population provide the basis for ( 1) estimates of the

medically defined prevalence of specific diseases in the

United States and the distributions of the population with

respect to physical, physiological, and psychological

characteristics and (2) analysis of relationships among the

various measurements without reference to an explicit

finite universe of persons.

Data From the I nstitutionalizad Population Surveys. –Discontinued in 1975. Reports from these surveys are included in Series 13.

Data on Health Resources Utilization. –Statistics on the

utilization of health manpower and facilities providing

SERIES 14.

SERIES 15.

SERIES 20.

SERIES 21,

SERIES 22.

SERIES 23.

long-term care, ambulatory care, hospital care, and family

planning services,

Data on Health Resources: Manpower and Facilities.–

Statistics on the numbers, geographic distribution, and

characteristics of health resources including physicians,

dentists, nurses, other health occupations, hospitals,

nursing homes, and outpatient facilities,

Data From Special Surveys. –Statistics on health and

health-related topics collected in special surveys that are

not a part of the continuing data systems of the National

Center for Health Statistics.

Data on Mortality .–Various statistics on mortality other

than as included in regular annual or monthly reports.

Special analyses by cause of death, age, and other demographic variables; geographic and time series analyses; and

statistics on characteristics of deaths not available from

the vital records based on sample surveys of those records,

Data on Natality, Marriage, and Divorce. –Various statistics on natality, marriage, and divorce other than as

included in regular annual or monthly reports. Special

analyses by demographic variables; geographic and time

series analyses; studies of fertility; and statistics on

characteristics of births not available from the wtal

records based on sample surveys of those records.

Data From the National Mortality and Natality Surveys. –

Discontinued in 1975. Reports from these sample surveys

based on vital records are included in Series 20 and 21,

respective y.

Data From the National Survey of Family Growth.–

Statistics on fertility, family formation and dissolution,

family planning, and related maternal and infant health

topics derived from a periodic survey of a nationwide

probability sample of ever-married women 1544 years of

age,

For a list of titles of reports published in these series, wrjte to:

Scientific and Technical Information Branch

National Center for Health Statistics

Public Health Service

Hyattsville, Md. 20782
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Office of Health Research, Statistics, and Technology

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

OFFICIAL BUSINESS

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DHHS Publlcatlon No. (PHS) 821724. Ser+es 13, No. 63

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For hstlngs of publications In the VITAL AND HEALTH STATISTICS series, call 301436 NCHS