Data from the

NATIONAL HEALTH SURVEY

Office Visits to Internists

TheNationalAmbulatoryMedicalCareSurvey

United States, 1975

Using data obtained from a national sample of office-based internists and other specialists, statistics are’ presented which describe

ambulatory medical care rendered in the offices of specialists in

internal medicine. Data are given on physician utilization patterns

developed from selected physician and patient characteristics.

Data describe patients’ demographic characteristics and principal

problems, as well as physicians’ diagnoses, in terms of visit status,

diagnostic and therapeutic services rendered, and seriousness, disposition, and duration of visit. Characteristics of visits to internists

are compared with those of general and family practitioners and

other specialists.

DHEW Publication No. (PHS) 79-1787

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

Public Health Service

Office of the Assistant Secretary for Health

National Center for Health Statistics

Hyattsville, Md. December 1978

Series 13

Number 36
Library of Congress Cataloging in Publication Data

Cypress, Ikulah K

The national ambulatory medical care survey.

(\7it~ ~d he~th statistics:Series 13, Data from the NationaI Health !Xuwy; no. 36)

(DFHW publication (PHS) 79-1787)

Bibliography: p.

1. Physician services utilization–United States–Statistics. 2. Internists-United States–

Statistics. 3. Ambulatory medical care–United States–Statistics. 4. Health surveys–United

States. I. Title. II. Series: United States. National Center for Health Statistics. Vital and

health statist its: Series 13, Data from the National Health Survey, Data on Ut ilizat ion; no 36.

HI. Series: United States. Dept. of Health, Education, and Welfare. DHEIV publication (PI-IS)

79-17 S7. [DNLM: 1. Ambulatory care–United Stat es–Statistics. 2. Health services-Unit cd

States–Statistics. 3. Internal medkine-United States–Statistics. W2 ANl~Svq no. 36]

RA407.3.A349 no. 36 [RA410.7] 362.1’1 ‘0!373s

ISBN 0-8406-0132-8 [362.1’1’0973] 78-60603!3
NATIONAL CENTER FOR I-IEN-THSTATISTICS

DOROTHY P. RICE, Director

ROBERT A. ISRAEL, Deputy Director

JACOB J. FELDMAN, Ph.D., Associate Director for Ana@is

GAIL F. FISHER, Ph.D., Associate Director for the Cooperative Health Statistics Systems

ELIJAH L. WHITE, Associate Director for .?Mu Systems

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

ROBERT C. HUBER, Associate Director for Management

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

PETER L. HURLEY, Associate Director for Operations

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

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

ALICE HAYWOOD, Information Officer

DIVISION OF HEALTH RESOURCES UTILIZATION STATISTICS

Siegfried A. Hoermann, Director

W. Edward Bacon, Ph.D., Chief Hospital Care Statistics Branch

James E. DeLozier, Chiej Ambulatory Care Statistics Branch

Manoochehr K. Nozary, chie~ Technical Services Branch

Stewart C. Rice, Chiej Family Manning Statistics Branch

Joan F. Van Nostrand, chie~ Long-Term Care Statistics Branch

Vital and Health Statistics-Series 13-No. 36

DHEW Publication No. (PHS) 79-1787

Library of Congress Catalog Card Number 78-606039
CONTENTS

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

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

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

Section I. Geographic and Demographic Utilization Patterns ..................................................................

Specialty, Type, and Location of Practice .........................................................................................

Characteristics of Patients .................................................................................................................

Patient’s Ptincipal Problem, Complaint, or Symptom ........................................................................

Most Frequent Principal hoblems .....................................................................................................

Principal Problems and Age of Patient...............................................................................................

Principal Problems and Diagnostic Services .......................................................................................

Seriousness of Patient’s Principal Problem .........................................................................................

Section IL Principal D,agnosis .................................................................................................................

Most Frequent Diagnoses ..................................................................................................................

Principal Dkgnosis and Mean Duration of Vkit .................................................................................

Principal Diagnosis and Sex and Age of Patient .................................................................................

Principal Diagnosis: Status of the Problem ........................................................................................

Principal Diagnosis and Therapeutic Services.....................................................................................

Section III. Condition and Management of Patients ................................................................................

Prior Vkit Statis ...............................................................................................................................

Seriousness ........................................................................................................................................

‘Hme Spent WMr the Physician ..........................................................................................................

Diagnostic and Therapeutic Sewices ..................................................................................................

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

Seriousness, Duration of Visit, and Services According to Prior Visit Status .....................................

Type of Condition Treated and Dkpoaition of Wit ..........................................................................

Section IV. Comparison of Vkits to Internists and to Other Leading Specialists .....................................

Patient Age and Wit Status ..............................................................................................................

Problem Status ..................................................................................................................................

Seriousness of the Patient’s Problem and Duration of Vkit ...............................................................

Type of Condition Treated, Diagnostic and Therapeutic Services, and Referral Patter n...................

Principal Diagnosis: Internists and General and Family Practitioners ................................................

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

L&t of Detailed Tables ............................................................................................................................

Appendixes .............................................................................................................................................

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

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

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

LIST OF FIGURES

1. Percents of visits to office-based internists with principal problem of fatigue by age: United States,

January-December 1975 ...................................................................................................................-

2. Percents of visits to office-based internists with principal problem of chest pain by age: United

States, January-December 1975 ........................................................................................................

2

2

:

4

4

6

8

9

9

9

9

10

11

12

12

12

12

12

13

13

14

14

14

15

16

16

17

19

20

46

47

56

61

5

5

...

11[
3. Percents of visits to office-based internists with principal problem of dizziness by age: United

States, January-December 1975 ........................................................................................................

4. Percents of visits to office-based internists for principal problem of shortness of breath by age:

United States, January-December 1975 .............................................................................................

5. Percents of visits to office-based internists for principal problem of general and required physical

examination by age: United States, January-December 1975 ............................................................

6. Percents of visits to office-based internists with principal problem of cough and cold by age:

United States, January-December 1975 .............................................................................................

7. Percents of visits to office-based internists with principal problem of sore throat by age: United

States, January-December 1975 ........................................................................................................

8. Percents of visits to office-based internists with principal problem of headache by age: United

States, January-December 1975 ........................................................................................................

9. Percents of visits to office-based internists with principal diagnosis of hypertension (ICDA 401) by

age: United States, January-Decemb”er 1975 ......................................................................................

10. Percents of visits to office-based internists with principal diagnosis of ischemic heart disease (ICDA

410-413) by age: United States, January-December 1975 .................................................................

11. Percents of visits to office-based internists with principal diagnosis of diabetes mellitus (ICDA 250)

by age: United States, January-December 1975 ................................................................................

12. Percents of visits to office-based internists with principal diagnosis of acute upper respiratory

infection except influenza (ICDA 460-466) by age: United States, January-December 1975 ............

13. Cumulative frequency polygons: age of patients visiting oftlce-based general and family practitioners and internists: United States, January-December 1975 ..........................................................

LIST OF TEXT TABLES

A. Number, percent, and annual rate of visits per 100 in population by selected specialkts: United

States, January-December 1975 ........................................................................................................

B. Percent dktribution of visits to internists by geographic region: United States, January-December

1975 ..................................................................................................................................................

C. Percent distribution of visits to office-based internists by age of patient: United States, JanuaryDecember 1975 .................................................................................................................................

D. Return visit index by specialty visited and age of patient: United States, January-December 1975 ...

E. Mean patient contact duration in minutes and standard error of mean contact duration by selected

specialties: United States, January-December 1975 ...........................................................................

F. Percent distributions of visits by number of types of diagnostic and therapeutic services ordered or

provided, accorcHmgto medical specialty of physician: United States, January-December 1975 ........

G. Average number of diagnostic or therapeutic services ordered or provided per visit by selected

me~lcal specialties: United States, January-December 1975 ..............................................................

H. Annual rate of blood pressure checks performed per 100 visits by selected medical specialties:

United States, January-December 1975 .............................................................................................

J. Percent of new patient visits referred by other physicians and percent of all patient visits referred

to other physicians by selected specialties: United States, January-December 1975 ..........................

6

6

7

7

8

8

10

10

11

11

15

2

3

4

15

16

16

17

17

17

iv
SYMBOLS

Data not available——.-——---—— .- -

Category not applicable———–—-— . . .

Quantity zero–——---— —

Quantity more than Obut less than 0.05-— 0.0

Figure does not meet standards of

reliability or precision (more than

30 percent relative standard error)—— *

v
OFFICE VISITS TO INTERNISTS

NATIONAL AMBULATORY MEDICAL CARE SURVEY

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

INTRODUCTION

This report, the third series report based

on 1975 data, presents national estimates of the

public’s utilization of ambulatory medical care

services that are provided by non-Federal, officebased specialists in internal medicine in the

conterminous United States during 1975. The

data were collected in the National Ambulatory

Medical Care Survey (NAMCS) by the Division

of Health Resources Utilization Statistics.

General summary statistics for 1973 and

1975, which included national estimates of characteristics of visits to most medical, surgical, and

other specialists, were presented in earlier Series

13 publications.1 ~z Detailed information on the

background and methodology of the survey was

provided in a report in Series 2 of Vital and

Health Statistics. 3 A description of the 1975

survey, including statistical design, data collection and processing, and estimation procedures, may be found in appendix I of this

report. Technical details regarding reliability of

estimates, definitions of terms used in the survey, facsimiles of data-gathering instruments,

and other survey materials are also in the appendixes to this report.

Although the general objective of NAMCS

is to provide basic national estimates on the

utilization of ambulatory medical care services

provided by all non-Federal office-based physicians, the design of the sample used in the survey permits valid national estimates of the

patterns of services provided by internists as well

as other specialists.

The physician who specializes in internal

medicine, or internist, diagnoses and treats diseases of the internal organ systems of adults.

The estimates presented in this report will

amplify this definition according to the clinical

pattern of the internist’s actuzd practice as

measured by the patient encounter in NAMCS.

The report will also contrast statistical estimates

of the specialty in internal medicine with estimates of similar characteristics of other leading

specialties reported in the 1975 NAMCS.

An important distinction should be made

between estimates which describe visits to internists and those which describe visits to the

total physician population defined by the 1975

NAMCS. This dktinction is important when

examining tables and viewing figures, since it is

easy to incorrectly generalize about the whole

population from data which are representative

only of patient visits to internists.

Although complete technical details of the

survey are provided in the appendixes and the

references, a brief description of the scope of

the survey and the source and limitations of the

data is provided before delineation of the topics

concerned with patient encounter data. This

section also describes the selection of the sample

of specialists in internal medicine from which

the estimates for this report were calculated.

Scope of the Survey

The basic sampling unit for the NAMCS is

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

this report. Only visits in the offices of nonFederally employed physicians classified by the

1
American Medical Association (AMA) or the

American Osteopathic Association (AOA) as

“office-based, patient care” were included in the

1975 NAMCS. In addition, physicians in the

specialties of anesthesiology, pathology, and

radiology were excluded from the physician universe. Major types of ambulatory encounters not

included in the 1975 NAMCS were those made

by telephone or home visits and those made in

hospital or institutional settings. If resources

permit, future NAMCS’S will include some of

these types of encounters. However, some complex methodological and sampling problems

must first be resolved.

Source and Limitation of Data

The data presented in this report were derived from information provided by a national

probability sample of office-based physicians. A

sample of 3,507 physicians representing AMA

and AOA listed specialties including internal

medicine was contacted during 1975. Of the

3,069 physicians who were eligible for the

study, 2,472 (80.5 percent) participated in the

study. The sample included 446 internists who

were determined in scope for the survey. Of

these, 347 (77. 8 percent) participated.

Specially trained interviewers visited the

physicians prior to their designated reporting

week, provided survey materials, and informed

each physician and staff member of the methods

and definitions to be used. During a randomly

SECTION 1.GEOGRAPHIC AND

‘Specialty, Type, and Location of Practice

assigned 7-day reporting period, the sample physician maintained a listing of all office visits. For

a systematic random sample of those visits, data

were recorded on an encounter form provided

for that purpose (see appendix 111).

The three appendixes to this report provide

information necessary to correctly understand

and interpret the statistics presented. Since these

statistics are based on a sample of ambulatory

visits rather than on all visits, they are subject to

sampling errors. Therefore particular attention

should be paid to the section in appendix I entitled “Reliability of Estimates.” Charts of

relative standard errors and instructions for their

use are also give in appendix 1.

Definitions of the terms used in this report

and in the survey operations are presented in

appendix II. Facsimiles of survey materials, including letters, patient records, and induction

interview forms, are reproduced in appendix HI.

Another program of the National Center for

Health Statistics, the Health Interview Survey

(HIS), collects data on the utilization of physician services, including internists, from a sample

survey of the civilian, noninstitutionalized population of the United States. The HIS estimates

for visits“to internists are generally larger for the

number of visits than NAMCS estimates because

of differences in collection procedures, populations sampled, and definitions. Data from HIS

are published in Series 10 of Vital and Health

Statistics.

The over 62 million visits to internists during

1975, shown in table A, accounted for almost

11 percent of all visits to office-based physicians

estimated in the NAMCS. This number was exceeded only by the number of visits made to

offices of general and family practitioners (234

million or about 41 percent of all visits).

Table 1 shows the geographic distribution of

visits to internists by the four census regions, by

metropolitan or nonmetropolitan area, and by

type of practice. The highest proportion of visits

(almost 30 percent) occurred in the Northeast

DEMOGRAPHIC UTILIZATION PATTERNS

Table A. Number, percent, and annual rate of visits per 100 in

population by selected specialists United States, JanuaryDecember 1975

I 1 1

Number of Annual rate

Specialty

percent of

visits in

of visits

thousands

visits per 100 in

population

Internal medicine .......

General and family

practice ....................

Obstetrics and

gynecology ...............

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

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

I I

62,117 10.9 30

234,660 41.3 113

_z!Lu

2
Region, with the least number of visits (about

20 percent) in the West Region. However, the

annual rate of visits also shown in table 1, indicates that more frequent visits were made by

the population in the West Region (34 per 100

persons) than by the population in the North

Central Region (28 per 100 persons) or South

(24 per 100 persons). The highest annual visit

rate was in the most densely populated Northeast Region (38 per 100 persons).

This configuration of visits may be partly a

result of the physical location of internists’ offices. Table B compares the 1975 regional distribution of internists estimated from American

Medical Association data with the distribution

of NAMCS visits.

As shown in table 1, 85 percent of the visits

to internists were to offices located within

standard metropolitan statistical areas (SMSA’S).

The visit rate is more than twice as high for visits

to offices in metropolitan locations (37 visits for

each 100 persons) than for visits to nonmetropolitan offices (14 of 100).

Information regarding the type of practice

selected by internists is obtained during the

induction interview.’ Participants designate

whether the y are in solo, partnership, group, or

aSummary data obtained during

interviews are available from NCHS.

NAMCS induction

Table B. Percent distribution of visits to internists by geographic

region: United Statas, January-December 1975

I

Region

k==?=

I

Percent distribution

United States ......o..o..m.......o... I

100.01 100.0

I

,

I

Northeast ......................................... 31.1 29.7

North Central .................................. 23.0 25.1

Wuth ............................................... 25.0 25.6

Weti ................................................. 20.9 19.6

1 Roba~k, G., and Mason, H. R.: Physician Diftributicm and

Medical Licensure in the US. Chicago. American Medical

As ociation, 1975. $Alaska and Hawaii not included.

other types of practice. The number of visits to

internists in solo practice (about 54 percent) indicated in table 2 was probably a reflection of

the fact that about 52 percent of internists estimated by the NAMCS sample were engaged in

solo practice in 1975. In the Northeast Region

the highest concentration of visits (over 68 percent) to internists was to those in solo practice.

A reversal of the solo practice visit trend occurred in the West Region where almost 62 percent of visits to internists were in offices classified as having arrangements other than SO1O

practice.

‘Whiie more visits were made to metropolitan-based offices of internists in solo practice (about 55 percent) than to other types of

office practices (about 46 percent), there was no

significant difference in visits by type of practice

for nonmetropolitan-based offices.

Characteristics of Patients

Distributions of visits by sex, age, and color

are shown in table 3. Since females (51 percent)

outnumbered males (49 percent) in the general

population in 1975, a higher number of visits by

females might be expected. Three of five visits

to internists’ offices were made by females.

Visits by each sex increased with age up to age

65, with the highest proportion in the category

45 to 64 years old, which accounted for almost

40 percent of all male visits and about 37 percent of all female visits.

The rate of visits also increased with eaeh

advancing age group with the visit rate for females exceeding that for males in every age category except under 15 years. The visit rate for

patients 45 to 64 years of age was more than

double the rate for patients 25 to 44 years,

while the rate for the 65 years and over category

was more than three times higher.

The age categories shown in tables 1 and 3

are useful for making demographic comparisons

between the data representing visits to internists and to other specialties. However, the

distribution of visits to internists is more highly

concentrated at the upper end of the age scale

than is the visit distribution for all ambulator

medical care visits. As

percent of internists’

shown in table C, over 53

visits were made by pa3
Tabla C. Parcent diatribtuion of visits to office-based internists

by aga of patient: United States, January-Decambar 1975

Aga of patiant Percent

d istribut ion

All agas ...................................... ................

Under 40 years ................................ .....................

40-54 yBrs ...........................................................

55-69 years ...........................................................

70 years and ovar ..................................................r

100.0

27.8

23.5

28.9

18.9

tients between ages 40 and 69. Therefore, the

age categories shown in table C are used in some

sections of this report to provide additional

detailed analyses of internal medicine data. To

partially overcome any bias which might be introduced by a greater number of visits by older

patients, age groups were redistributed so that

approximately equal numb ers were in each

group. Thus, the effects of variables such as patients’ complaints, diagnoses, and seriousness of

problem can be examined more vdldly.

The proportion of visits by members of the

white race (91 percent) was higher than the proportion made by members of other races (9

percent) paralleling, to some degree, the population ratio. The rate of office visits was higher

for white females, who visited at the rate of 36

per 100, than for females of other races, whose

rate was 26 of 100 in the population. For each

100 white males in the population, 26 visits

were made to internists’ offices whereas males of

other races visited at a rate of 16 of 100.These

data are similar to percentages found for general

and family practitioners and could indicate

that members of other races avail themselves

more often of other means of ambulatory medical care since the NAMCS includes only officebased care. The Health Interview Survey reported that about 9 percent of medical care

visitsby white persons were to hospital clinics or

emergency rooms whereas 21 percent of visits

by members of other races were in similar

settings.4

Thus, a typical patient visit in the internist’s

office was made by a white female from 45 to

64 years old.

Patient’s Principal Problemr Complaint,

or Symptom

“Problem,” “complaint,” and “symptom”

are used interchangeably in this report. Patient

problems have been coded and classified according to a system developed for the NAMCS. 6

The data on patient problems were derived

from an item on the survey form that elicits the

reasons for visit as nearly as possible in the patient’s own words. The patients’ complaints are

recorded by the physician in the order of importance. The “principal problem” is the first

listed.

Most Frequent Principal Problems

The 24 principal problems most frequently

presented to internists are listed in table 4. Because most estimates are not statistically different from other near estimates due to sampling

variability, actual ranks may vary somewhat

when the sampling error is taken into account.

The first six problems accounted for about

25 percent of all visits; the first 12 problems

motivated 40 percent of patient visits; and the

second 12 problems presented by patients increased the total to over 55 percent. If only

illness-related complaints are considered, 22

problems accounted for 48 percent of the visits.

Almost 6 percent of all visits were due to a

general or required physical examination. This

category consisted mainly of visits for routine

checkups. Prominent among the 12 most frequent problems were pain in chest, fatigue,

vertigo (dizziness), and shortness of breath.

Together these four problems caused over 13

percent of visits. Another 8 percent were attributed to the common complaints of cough,

cold, sore throat, and headache.

Similarities and differences exist among lists

of complaints presented during visits to various

specialties. To bring the practice of internal

medicine into clear focus, it is desirable to examine congruence of complaints among specialties. This is discussed in Section IV of this

report.

Principal Problemsand Age of Patient

It is also of practical interest to examine the

relationship of the patient’s principal problem to

4
the age of the patient visiting. The reader is reminded of a limitation in the data as an aid in

interpretation. R is not appropriate within the

scope of the NAMCS to count patients since the

basic unit of measurement is the visit. Thus, in

reporting age we can report only on age of patients visiting. For example, a patient aged 40

years who makes three visits contributes three

times to the calculation of the age category

“40 ;“ a patient aged 70 years who makes six

visits contributes six times to the age category

“70.” By calculating averages from this example

we obtain a visit age of 60, but a patient age of

55. Since the “patient “ is not the NAMCS basic

sampling unit, the average patient age can be

somewhat misleading in certain contexts and is

not used in this report.

The hypothesis that patient symptoms are

not randomly distributed throughout all ages in

the internist’s visit load was investigated by

treating each selected symptom as a focal point

and determining its percent distribution by age.

For example, there were about 2.5 million visits

to internists in which the chief complaint was

“fatigue.” Which age groups visited internists

most often for this problem? Which age group

tended to present this problem in few visits?

Figure 1 shows that fatigue occurred most frequently when the age of the patient visiting was

between 55 and 69 years (36 percent of all visits

prompted by fatigue); and less often when the

patients visiting were younger or older. This

pattern is also demonstrated for the symptoms

of chest pain, dizziness, and shortness of breath

graphed in figures 2, 3, and 4. These data support the above hypothesis that for each of these

four symptoms the proportion of visits increased

with age.

Another group of reasons for visit: general

and required physical examinations, cough and

cold, sore throat, and headache are charted in

figures 5, 6, 7, and 8. The first three symptoms

appear to be inversely related to age, i.e., proportions of visits seem to decrease as age in25.91

LCSS(h,,n 40 4054 55.69 70 and OVW

AGE IN YEARS OF PATl ENT VISITING

Figure 1. Percents of visits to office-based internists with principel

problem of fatigue by age: United States, January-December,

1975

70 -

60 -

50 -

s

Y

m

0

z

~ 40 -

0

u.

17.53

Less than 40 40.54 55.69 70 and over

AGE IN YEARS OF PATIENT VISITING

Figure 2. Percents of visits to office-based internists with principal

problem of chest pain by age: United States, JanuaryDecemberr 1975

5
70 –

60 -

50 –

E

!?

:

11,35

19.37

Lessthan40 40.54 55.69 70 andover

AGE IN YEARS OF PATlENT VISITING

Figure 3. Percents of visits to office-based internists with principal

problem of dizziness by age: United States, Januarv-Dacember, 1975

creases. On the other hand, visits for “headache”

do not seem to be age dependent according to

the data.

While the percents of visits for problems

plotted in figures 1 through 4 show a pattern of

increase up to age 69 years with a decline thereafter, the reasons for visit in figures 5 through 8

exhibit a higher percentage of visits for each

problem in the under’40 years age group, and a

substantial decrease in the percent of visits made

by older groups. Visits for general and required

.ph ysical examinations (figure 5) declined

steadily-ranging from 44 percent of all visits for

that reason by persons less than 40 years to 7

percent by patients 70 years and over. Vkits by

patients under 40 years accounted for 69 percent of all visits for sore throat (figure 7); while

only 9 percent of such visits were accounted for

by patients 55 to 69 years (the age group covering 30 percent of all visits as shown in table C),.

and only 5 percent in the over 70 years age

group. Of all the reasons for visit plotted, figure

10.00

Lessthan 40 40.54 S5.69 70 and over

AGE IN YEARS OF PATlENT VISITING

Figure 4. Ptwcents of visits to office-based internists with principal

problem of shortness of breath by age: United States

January-December, 1975

8 ilkstrates that visits due to headache appear to

be most evenly (and probably randomly) distributed among age groups. Visits for cough and

cold, shown in figure 6, appear to be more frequent in the under 40 year age group (34 percent). and fairly close in the middle range (25

percent for visits bj 40- to 54-year-old patients,

and 28 percent by ages 55 to 69).

Statistical tests of the regression of these

variables on age show a significant inverse

relationship between general and required examination and age, and between sore throat and

age; but not between cough and cold and age,

nor between headache and age.

Principal Problems and Diagnostic Services

The NAMCS was designed to gather data on

the types of diagmstic services ordered or provided by the physician during the current visit.

The 1975 Patient Record did not have the flexibility to probe whether procedures were single

6
or multiple. Diagnostic services data, therefore,

are Iacklng in this dimension. For example, if

“clinical laboratory test” was checked on the

form it was not known whether a blood test

alone was performed or whether blood, urine,

and sputum tests were ordered. (See definitions

in appendix II. ) However, the data provided information about the general nature of the physician’s workup for the problem presented.

Table 5 lists 13 most frequent patient

problems with the percents of limited history

and examination, general history and examination, laboratory procedure, blood pressure

check, electrocardiogram (EKG), and X-ray services which were indicated as having been ordered

or provided when the problem was presented.

Data for therapeutic services are described in

Section II of this report which deal with diagnoses.

Of all internist visits, over 61 percent included limited history and examinations as well

as blood pressure checks. A general examination

44.23

26.69

21.82

Lessthan 40 40.54 55.69 70 and wer

AGE IN YEARS OF PATIENT VISITING

Figure 5. percents of visits to office-based internists with principel

problem of general required physical examination by age:

United States, January-December, 1975

was performed during 20 percent of alI visits.

About 39 percent included a laboratory procedure or test. EKG was the diagnostic tool

used during 14 percent of all visits, and X-rays

were taken in 13 percent of the visits.

Blood pressure was measured during more

than 70 percent of visits when the patient complained about chest pain, high blood pressure,

dizziness, or shortness of breath. An extensive

workup was probably used for chest pain since

over 47 percent of such visits involved EKG’s

and 20 percent included X-rays. Another frequent use of EKG’s occurred when the complaint was shortness of breath (28 percent).

X-rays were also employed often when the reason for visit was problems of the upper extremity (24 percent), abdominal pain (23 percent), and cough and cold (about 21 percent).

Internists performed general examinations in

over one quarter of visits for fatigue, abdominal

pain, and headache. Laboratory procedures were

frequently utilized during visits for diabetes

13.4a

Lessthan 40 40.54 55.69 70 and Over

AGE IN YEARS OF PATl ENT VISITING

Figure 6. Percents of visits to office-based internists with principal

problam of cough and cold by age: United States, JanuaryDecamber, 1975

7
S&fil

17.61

9.17

4.60

Lessthan 40 40.54 55.69 70 and over

AGE IN YEARS OF PATl ENT VISITING

70 –

60 –

50 –

z

:

0

a

.

~ 40 —

0

.

r

~

>

& 30 -

k

z

8

K

E

20 -

10 –

o .

29.59 26.S4

29.81

Lessthan 40 40.54 55.69 70 and over

AGE IN YEARS OF PATIENT VISITING

Figure 7. Percents of visits to office-based internists with principal

problem of sore throat by age: United States, JanuaryDecember, 1975

mellitus (79 percent) and fatigue (52 percent).

Over one-third of visits prompted by chest pains,

10 wer extremity problems, abdominal pain,

dizziness, and shortness of breath also required a

laboratory procedure in the internist’s judgment.

Seriousnessof Patient’s Principal Problem

Data on the seriousness of a patient’s principal problem express the physician’s clinical

judgment as to the extent of impairment that

might result if no care were available. Using this

criterion the physician assigned the principal

Figure 8. Percents of visits to office-based internists with principal

problem of headache by age: United States, JanuaryDacember, 1975

problem to one of four degrees of seriousness:

“very serious,” “serious, ” “slightly serious, ” or

“not serious. ” Since this was the physician’s

subjective evaluation, man y variables may have

been brought to bear on the decision, and the

data should be viewed in this context.

According to table 6 shortness of breath (66

percent) was most often classified as “serious”

or “very serious.” Other symptoms presented in

this table seemed to vary in degree of seriousness

assigned, but differences were not statistically

significant. Degree of seriousness according to

age groups is addressed in Section III, Condition

and Management of Patients.
SECTION Il. PRINCIPAL DIAGNOSIS

Most Frequent Diagnoses

The 24 conditions most commonly diagnosed during visits to internists are listed in table

7. As with table 4, the rank order may be artifical due to sampling variability.

These conditions describe the diagnosis assigned by the physician to the patient’s principal

problem (table 4). In the event of multiple diagnoses, physicians were instructed to list them in

order of importance. The data presented here

deal only with the first listed or “principal”

diagnosis.

Although other significant diagnoses indicated on the survey form are not used in this

analysis, patterns of concomitant diagnoses are

discussed in other publications on selected diagnostic categories.b

Diagnostic groupings and code number inclusions used in the NAMCS and in this text are

based on the International Classification of Diseases (ICDA).7

The diagnoses listed in table 7 accounted for

54 percent of all patient visits to the internist.

Prominent among these are essential benign

hypertension (9 percent), chronic ischemic heart

disease (8 percent), and diabetes mellitus (5 percent). Togetherj these three conditions were

diagnosed in over 22 percent of all internist

visits. Table 8 shows that these diseases also had

very high return visit rates. Thus, it is expected

that they constituted a high proportion of total

visits since total visits included initial and return

visits. However, return visits are significant in

developing a profile of the internist’s practice

since these conditions consume much of the

physician’s time and energy. Heart disease, represented in table 7 by chronic ischemic heart

disease, symptomatic heart disease, and angina

petoris, accounted for almost 11 percent of aU

visits; 6 percent of visits were diagnosed as a

form of arthritis or rheumatism. Of interest is

b For example, see Advance Data Report No. 28, “Office Visits for Hypertension: National Ambulatory Medical Care Survey, 1975 -1976.”

the fact that the diagnostic category “neuroses”

k among the first third of principal diagnoses

treated in visits to internists.

Principal Diagnosis and Mean Duration of Visit

The average number of minutes spent by the

patient in face-to-face encounter with the internist for visits encompassing highly frequent

diagnoses is shown in table 7. The average

time for all visits to internists was 18.2 minutes, which exceeded the average of 15 minut es for all specialties. Z Due to statistical variability there are few significant differences in

time among diagnoses. Visits for medical and

special examinations, osteoarthritis and allied

conditions, obesity, observation, and ill-defined

conditions, on the average, consumed the most

time, possibly due to more intensive workup and

need for counseling. The many routine or

return visits associated with essential benign

hypertension, chronic ischemic heart disease,

and diabetes mellitus were probably made by

patients whose medical history was known to

the physician. This may have contributed to the

close to average time involved in treating patients

with these diagnoses. Lower than average durations were a result of visits for acute upper

respiratory infection, hay fever, other eczema

and dermatitis, and bronchitis. Comparison of

the mean duration of internist visits with that of

other specialists is shown in Section IV of this

rep ort.

Principal Diagnosis and Sex and Age of Patient

Information regarding the relationship of a

patient’s sex to diagnosis is given in table 8. In

some major ICDA groups, notably mental disorders, diseases of the genitounnary system, and

diseases of the musculoskeletal system, female

visits were proportionately greater than visits by

males. Except for chronic ischemic heart disease;

bronchitis, emphysema, and asthma; and medical or special examinations, the number of

female visits exceeded male visits to internists in

all specific three digit ICDA categories shown in

table 8.

9
Figures 9 through 12 provide graphic evidence of the allocation of visits diagnosed as

essential benign hypertension, ischemic heart

disease, diabetes mellitus, and acute upper

respiratory infection across age groups. Like

figures 1 through 8 which illustrate symptoms,

figures 9 through 12 plot the proportions of

diagnosis-related visits by age group. The decline

in proportions of upper respiratory infection

diagnosed during visits, from 54 percent of all

visits for this diagnosis made by patients under

40 years to 9 percent in the 70 years and over

group, is immediately apparent. In the opposite

direction, figures 9 and 11 illustrate that proportions of visits for essential benign hypertension and diabetes mellitus rose with advancing age up to 69 years. While there appears

to be a trend of increasing visits with age for

chronic ischemic heart disease, it is not statistically significant, possibly due to the lack of

reliability in the number of visits by the under

40 age ~oup.

Principal Diagnosis: Status of

the Problem

In NAMCS the sampled visit is classified by

the physician according to whether or not he

had seen the patient before and if he had seen

the patient before, whether it was for the

problem of concern at the current visit. This information yieIds a measure of problem status

independent of the status of the patient. New

problem visits were calculated by adding new

patient, or initial visits, and visits by returning

patients with new problems. Recurring problems

were estimated from visits made by returning

patients with “old” problems.

Applying the problem status concept, table

8 reveals that 66 percent of visits to internists

for all diagnoses were return visits for recurring

problems with higher than average proportions

of old problem visits when the specific diagnosis

was diabetes mellitus; essential benign hypertension; chronic ischemic heart disease; bronLessthan 40 40.54 55.69 70 and over

AGE IN YEARS OF PATl ENT VISITING

—.

Figure Y. Percents of visits to office-based internists with principal

diagnosis of hypertension (lCD/I 401) by age:lJnit~dstates,

January-December, 1975

3.02

Lessthan 40

m.54

40.54 55.69

AGE IN YEARS OF PATl ENT VISITING

36.95

70 and over

Figure 10. Parcents of visits to office-based internists with principal diagnosis of ischemic haart disease ( ICDA 410-41 3) by

aga: United States, January-December, 1975

10
chitis, emphysemzq and asthmw, or arthritis and

rheumatism. Only in the two major ICDA categories of infective and parasitic diseases and of

accidents, poisonings, and violence did new

problem visits substantially exceed return visits

for the same problem.

Principal Diagnosis and Therapeutic Services

Table 9 provides information about the

kinds of therapeutic services ordered or provided

by internists relative to selected ICDA categories

of diagnoses. Lke table 5, which links principal

problems and diagnostic services, these estimates

do not offer guidance on the multiple nature of

each category of services. They show only a profile of the type of therapeutic services associated

with visits. For all diagnoses, 50 percent of visits

included prescription or nonprescription drugs,

14 percent involved injection or immunization,

and in almost 21 percent patients received medical counseling or a form of psychotherapy or

therapeutic listening. Drug therapy was most

often applied when the diagnosis involved diseases of the upper respiratory system (66 percent). Medical counseling or therapeutic listening was employed in 43 percent ‘of visits for

mental disorders.

41.73

Lessthm 40 40.54 55.69 70 andover

AGE IN YEARS OF PATl ENT VISITING

Figure 11. Percents of visits to office-based internists with principal diagnosis of diabetes mellitus (ICDA 250) by age: United

States, January-December, 1975

70 -

60 –

50 –

1?

8

z

w

<

6

~ 40 -

0

.

~

g

>

& 30 —

+

z

:

&

20 –

10 –

o .

Lessthan 40 40.54 5569 70 and cwer

AGE IN YEARS OF PATlENT VISITING

Figure 12. Percents of visits to office-based internists with principal diagnosis of acute upper respiratory infection except

influenza ( ICDA 460-466) by age: United States, JanuaryDecember, 1975

11
SECTION Ill. CONDITION AND MANAGEMENT OF PATIENTS

A rough profile of patient condition and

management in the internist’s office can be

established by examining data on variables included in NAMCS, such as visit status, services,

etc., in terms of the age and sex of the patient

visiting.

Prior Visit Status

The percent of visits labeled “prior visit

status” in table 10 yields measures of patient

status or problem status. In this section, patz.knt

status is the primary concern. Thus, table 10

shows that 87 percent of all patient visits to the

internist were madeb y returning patients (the sum

of columns 2 and 3) with about 3 of 4 return visits

involving a problem the patient had presented in

a prior visit. While only 13 percent of all visits

(column 1) were made by new patients, visits by

patients under 25 years reflected a higher proportion of initial visits than other age groups

with proportions of new patient visits declining

with increasing age. A similar pattern is evident

for visits by returning patients with new problems. Conversely, proportions of visits by returning patients with problems the physician

had previously treated increased with age. However, in terms of whether the patient was making

a first visit

lem status,

proportions

gory for all

both sexes

patient care

Seriousness

or a return visit, regardless of probtable 10 shows that the highest

of visits are in the return visit cateage groups. These patterns apply to

and underscore the continuity of

in the internist’s practice.

Qualification of the problem by its degree of

seriousness was presented earlier. Table 10

focuses on seriousness in terms of age and sex

characteristics of visitors. Of all visits, 38 percent were considered “not serious” by internists.

Proportions judged “not serious” declined with

advancing age for both sexes as the proportions

judged “serious” or “very serious” advanced.

This is not surprising in view of the high percentage of visits made by older patients with

cardiovascular diseases.

Time Spent With the Physician

According to the data described in table 10,

most patient visits fell in the duration interval of

11 to 30 minutes. This time span hovers around

the mean duration of 18.2 minutes given in table

7 for all diagnoses. Again, as in data for “prior

visit status” and “seriousness,” the variable is

age-dependent. A greater proportion of visits by

younger age groups required less time. For

example, 44 percent of visits by patients under

25 years took 10 minutes or less, while only 24

percent of visits by patients 65 years and over

were in that time interval. On the other hand, 31

percent of visits by age group 65 years and over

lasted from 16 to 30 minutes, with only 19 percent of visits by patients under 25 in that category. Table 10 shows that visits exceeding 30

minutes were rare for all ages and both sexes.

Table 10 reveals a fuller utilization pattern

by patients of both sexes, over 45 years of age,

who presented a high proportion of serious

problems and who spent more time in face-toface contact with the physician than did

younger patients.

Diagnostic and

Therapeutic Services

Diagnostic services in connection with the

chief complaint and therapeutic services associated with principal diagnosis were discussed

previously. In this section and in table 11 information about treatments and services are related

to characteristics of the patients.

The proportion of visits which included

blood pressure checks increased with age.

Almost 70 percent of visits by patients 65 years

and over included measurement of arterial

pressure while about 40 percent of visits by

patients under 25 years included this procedure.

Blood pressure was measured more frequently as

patients aged, correlating with NAMCS data

regarding increasing hypertension visit rates for

aging patients.s Electrocardiograms were used

most often when the visiting patient was a male

between 25 to 64 years. This was also consistent

with NAMCS data which indicated a higher pro12
portion of male visits for heart disease.c There

was a decline in the proportion of general examinations performed during visitsby the oldest

group. The increasing proportions of laboratory

procedures used as the visiting patient’s age increased highly correlates with the increasing

number of laboratory tests performed during

diabetes mellitus visits (table 5) and the high

visit incidence of diabetes mellitus among older

patients seen by internists (figure 11).

The use of medical counseling, a service provided in almost 18 percent of all visits, did not

appear to be influenced by the patient’s age or

sex.

Disposition of Visit

Table 12 indicates that more than two-thirds

of the visits to internists’ offices resulted in the

direction to return at a specified time. This

highly correlates with the finding that two of

three visits were made by returning patients with

recurring problems. Another 17 percent were instructed to return if needed. Only in about 9

percent of visits was no followup planned. Of

the approximately 13 percent of visits reported

as having other types of deposition, a small

number (slightly less than 2 percent) were admitted to the hospital. Followup was most often

recommended as patient age increased. Together

with the findhg shown previously that serious

problems were often related to longer visits,

these estimates offer additional evidence of continuity of care.

Seriousness,Duration of Visit, and Sewices

According to Prior Visit Status

Table 13 offers data about the condition

(seriousness of the patient’s principal problem)

and management (duration of visit and diagnostic and/or therapeutic services) of the patient

in terms of the status of the visit. When patients

made initial visits, almost 82 percent were

judged “not serious” or “slightly serious” by the

internist. Similarly, in visits by returning paCA NAMCS report concerningdiseasesof the circulatorysystemis in”preparation.

tients presenting new problems, about 86 percent were evaluated as “not serious” or “slightly

serious.” However, returning patients visiting

because of a recurring problem were judged “not

serious” or “slightly serious“ in about 65 percent of that group’s visits, and “serious” or “very

serious” during 35 percent of return visits.

According to these data, new patients or

new problems were more likely to be judged

“not serious” or “slightly serious” than “serious

or very serious,” but more recurring problem

visits involved a higher degree of seriousness.

The latter can be expected since many of the

chronic diseasesare more often judged “serious”

and they also claim a higher proportion of return visits than of initial visits.

About half of all new patient visits took 15

minutes or less, while more than two-thirds of

visits by returning patients with both new and

recurring problems consumed 15 minutes or less.

Return visits may have consumed less time than

did initial visits because medical data were already in the patient’s record. A higher percentage of new patient visits (21 percent) lasted

from 31 to 60 minutes than did visits by returningpatients for either new problems or old problems (both about 6 percent). This was probably

due to a greater need for data gathering during

the initial visit.

New patient visits had a higher proportion of

general examinations (46 percent of all visitsby

this group) than did returning patients (20 percent for new problems and 15 percent for recurring or old problems), a possible explanation

for the longer visit duration of the new patient

as compared to the returning patient visit. However, 64 percent of return visits in both new and

old problem categories included a limited history

and examination. This procedure was also used

during 41 percent of new patient visits. EKG’s

were taken more often during new patient visits

(23 percent) than in return visits. This was probably due to their inclusion in general examinations and the frequent need for the EKG in acute

eases which, according to table 14, accounted

for 57 percent of new patient visits. Similarly,

X-rays were ordered or provided in a higher

proportion of new patient visits (27 percent)

than in return visits (17 percent) for new

problems and 9 percent for recurring problems.

13
Type of Condition Treated and

Disposition of Visit

Table 14 designates the propositions of

acute and chronic conditions seen by the internist and the disposition of the visit in terms

of the prior visit status. When the physician had

seen a patient during a fwior visit, the patient’s

new problem was likely to be an acute condition-an indication that patients tended to

return frequently to their regular physicians for

treatment of acute, self-limiting conditions or at

an early stage of illness. Since new patients were

less likely to have acute conditions (about 57

percent) than patients the physician had seen

before (76 percent of new problem visits), these

data may also suggest that patients having a

regular physician seek medical attention at an

earlier stage of illness than those without regular

medical care.

In terms of patient status, visitsby returning

patients with recurring problems were more

likely to include the instructions to return at a

specified time (80 percent) than were new

problem visits, either by new or returning

patients. New problem visits were more likely to

have no followup planned than were recurring

problem visits.

Visits for chronic conditions (57 percent of

all visits) exceeded visits for acute conditions

(39 percent) as shown in table 15. However, this

general finding was not consistent among all age

groups. Higher proportions of acute conditions

were found in visits by both females and males

under 25 years of age than for other age groups.

Conversely, there was a higher than average incidence of chronic conditions represented by

visiting patients who were 45 years and over. It

was previously demonstrated that visits for certain chronic diseases (e.g., hypertension, chronic

ischemic heart disease) were more closely related

to older age group visits while acute diseases,

such as upper respiratory infection, were more

likely to be presented by younger patients. The

data in table 15 confirm these findings.

SECTION IV. COMPARISONS OF VISITS TO INTERNISTS

AND TO OTHER LEADING SPECIALISTS

Estimates of visits to specialists in internal

medicine, general and family practice, obstetrics

and gynecology, pediatrics, general surgery, and

cardiovascular diseases by age of patient, problem status, seriousness of the patient’s problem,

and duration of visit are included in table 16.

Table 17 provides comparisons of types of conditions treated, selected diagnostic and/or therapeutic services, and disposition of visit for the

same specialties. Contrasts of visits to internists

and general and family practitioners (GFP) according to ICDA categories and principal diagnoses are made in tables 18 and 19 respectively.

Tables 16 and 17 provide comparative data

for the five most visited specialties according to

the 1975 NAMCS (table A), plus the specialty in

cardiovascular diseases. Whale the latter specialty

was not among the most frequently visited, diseases of the circulatory system were a major

portion of internists’ visits, and a comparison

would not be complete without including the

specialty in cardiovascular diseases.

Patient Age and Visit Status

Two of three visits to the internist were

made by patients 45 years and older. Except for

the specialty in cardiovascular diseases, where 86

percent of visits were made by patients 45 years

and over, this was a higher proportion than any

other leadlng specialty. Differences in visit age

between internists’ visits and those of specialists

in obstetrics and gynecology or pediatrics may

be expected. However, certain assumptions regarding the similarity of general and family

practitioners and internists as primary care providers suggest that visit data for these two

specialties should be viewed in a parallel manner.

Figure 13 presents cumulative frequency polygons derived from visit age percent distributions

14
of general and family practice and of internal

medicine. This figure visually represents the percent of visits falling above or below different age

values. According to figure 13, the median visit

age (or point on the age scale which includes 50

percent of visits) was approximately 50.4 years

for internists and about 40.1 years for GFP’s. In

connection with these findings, it should be

noted that the median age of the resident population of the United States in 1975 was 28.8

yearsog

A return visit index by age group was developed for the two primary care specialties of

intern al medicine and general and family

practice. These return visit indexes displayed in

table D are the ratios of total return visits (including both new and recurring problems) to

total initial visits for each age group, For alI ages

there were 6.65 return visits for each initial visit

to internists’ offices, and a ratio of 6.86 to 1 for

visits to GFP’s offices. .For both specialties,

return visit ratios increased steadily from age 25

o~

16 20 25 30 35 40 45 50 55 60 65 70 75 80 85and

over

AGE IN YEARS OF PATlENT VISITING

Figure 13. Cumulative frequency polygons: age of patients visiting

office-based general and family practitioners and internists:

United States, January-December, 1975

Table D. Return visit index by specialty visited and age of patiarm

Unitad States, January-December 1975

Age of patient

All ages .................................

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

15-19 years ......................................

20-24 years ......................................

25-28 years ......................................

30-34 years ......................................

35-39 years ......................................

40-44 years ......................................

45-49 years ......................................

50-54 years ......................................

55-59 years ......................................

60-64 years ......................................

65-69 years ......................................

70-74 years ......................................

75-79 years ......................................

80 years and over .............................

Specialty

Internal

medicine

6.65

2.49

2.42

2.07

2.93

3.57

5.36

6.07

7.01

9.09

9.57

13.51

12.37

15.18

30.25

19.62

ieneral and

family

practice

6.86

4.77

4.41

3.88

4.55

5.57

6.37

6.59

9.41

9.78

11.30

10.48

13.49

17.15

36.04

17.32

years to age 80 years, with an expected drop at

age 80.

Problem Status

To obtain a measure of problem status, as

opposed to patient status, initial visits and

return visits for a new problem were combined

to form the “new problem” category. It was assumed that initial visits, or new patient visits,

always involved a new problem. On the other

hand, it may have been a lingering probIem for

the patient. This difference should be considered

when using the data.

According to the data in tabIe 16, about

one-third of the internists’ visits concerned new

problems and two-thirds involved treatment of

recurring or continuing problems. Ratios of new

to recurring problems were similar for the specialt ies of obstetrics and gynecology and general

surgery; higher proportions of new problem

visits appeared for general and family practice

and pediatrics. Specialists in cardiovascular diseases, however, treated a higher ratio of recurring to new problem visits than did internists

or any other specialty’~isted in table 16.

15
Seriousness of the Patient’s Problem

and Duration of Visit

Except for specialkts in cardiovascular diseases, internists treated the highest proportion

of serious or very serious problems (29 percent)

of the specialties shown in table 16. That visits

to the internist were longer than visits to the

other four leading specialists is attested to by

the finding that over 60 percent of all internist

visits fell in the intervals of 11 to 15 minutes

(about 36 percent) and 16 to 30 minutes (almost 25 percent). Percents of visits in these time

intervals were smaller for the other specialkts.

Average duration of visit shown in table E indicates that the typical visit to internists’ offices

was longer (18.2 minutes) than the average visit

to the other four leading specialties, and similar

Tabla E. Maen patient contact duration in minutes and standard

error of mean m ntact duration by selected speciaIties:

United States, January-December 1975

I I

Maen Standard

pet ient error of

Specialty contact mean

duration contact

duration

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

l==+’

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

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

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

Pdiatrics .........................................

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

Cardiowscular diseases....................

18.2

12.6

13.1

12.1

12.7

21.5

0.38

0.50

0.48

0.32

0.45

2.00

to the average duration of visits to cardiovascular specialists when the statistical error is

taken into account.

Type of Condition Treated, Diagnostic and

Therapeutic Services, and Referral Pattern

Specialists in internal medicine and cardiovascular diseases treated more chronic problems

than did other leading specialkts, thus showing

similarity of practice with respect to the variables of age of patient visiting, duration of visit,

seriousness of the patient’s problem, and type of

condition.

Compared to the other specialkts in table

17, internists used the limited history and examination most often (61 percent of visits) and

provided medical counseling more frequently

(18 percent of visits). Blood pressure checks performed by internists during 61 percent of visits

was exceeded only by the number provided by

cardiovascular specialists (73 percent). Similarity

between the internist’s practice and that of the

specialist in cardiovascular diseases did not persist for the number of EKG’s employed. The

internist used EKG’s during 14 percent of visits

whale the cardiovascular specialist utilized this

procedure in 42 percent of visits, an expected

difference in view of the greater concentration

of circulatory diseases in the latter practice.

As explained previously, the NAMCS Patient

Record is not structured to collect information

on the number of diagnostic and therapeutic

services rendered within each category; it provides estimates of only the number of types of

services. Table F compares the number of service

Table F. Percent distributions of visits by number of types of diagnostic and therapeutic services ordered or provided, according to

medical spacialty of physician: Unitad States, January -December 1975

Number of types of diagnostic and

therapeutic servicesordered or provided

Specialty Total

No na One Two Three

or more

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

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

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

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

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

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

100.0

100.0

100.0

100.0

100.0

100.0

Percent distribution

M 1-

22.9 61.6

26.9 45.6

40.0 29.3

26.0 26.3

25.6 52.7

31.9 57.2

16
types provided by each specialty. Leading all

other specialties listed except that of cardiovascular diseases, specialists in internal medicine

provided 3 or more types of service in 62 percent of visits. On the average, internists and

cardiovascular specialists provided 3 diagnostic

or therapeutic services per visit, a higher average

than the other specialists shown in table G. According to table H, internists provided 61 blood

pressure checks for each 100 visits made to office-based internists during 1975. Except for

visits to cardiovascular specialists, this exceeded

the number provided during visits to other leading specialists.

The percent of new patient visits referred by

other physicians, and the percent of all patient

visits referred to other physicians are listed by

selected specialty in table J. Internists referred

more patient visits to other physicians than did

other primary care specialists. Of the pt-imary

care specialties, internists’ visits accounted for

the highest proportion (20 percent) of new

patient visits referred by other physicians.

Table G. Avarega number of diagnostic or therapeutic services

ordered or provided per visit by selected medical specialties:

United States, January-December 1975

1

Specialty

Average number

of types of

services ordered

or provided

per visit

Internal medic ine .......................................

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

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

Pdiatrics ....................................................

Genarel surgery ...........................................

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

3.0

2.5

2.5

2.1

1.9

3.0

Table H. Annual rata of blood prassure checks performed per

100 visits by selected medical specia Ities: United States,

January-December 1975

I

Specialty I

Annuel rate

per 100 visits

1

Internal medicine ,,,.,O,.,, .............................

Ganeral and family practice .....................

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

P~iatrics ....................................................

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

Cerdiowmcular diseases ................................

61.0

40.0

57.0

8.0

23.0

72.0

Table J. Percent of new patient visits referred by other physicians

and percent of a II patient visits referred to other physicians

by selected specialties: United Statas, January-December

1975

Specialty

Internal medicske ..................

General and family practice..

Obstetrics and gynecology ....

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

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

Cardiovascular diseases .........

Percent of

naw patient

visits referrad

by other

physicians

19.7

7.6

11.3

7.5

27.5

64.4

Percent

of all

patient visits

referred to

other

physicians

4.4

3.0

1.6

2.9

2.9

3.1

Principal Diagnosis: Internists and General

and Family Practitioners

Percents of visits to internists and to general

and family practitioners according to ICDA categories are given in table 18. Diseases of the

circulatory system accounted for almost onequarter of internists’ visits and close to 12

percent were diagnosed in the diseases of the

respiratory system group. Almost the reverse

was true for general and family practitioners.

About 12 percent were diagnosed in the diseases

of the circulatory system group and a larger

proportion (19 percent ) in the respiratory diseases category. According to NAMCS estimates,

internists had a larger proportion of patient

visits needing care for endocrine, nutritional,

and metabolic diseases, as well as diseases of the

digestive and musculoskeletal systems, than did

general and family practitioners. A larger share

of visits requiring treatment for diseases of the

skin and subcutaneous tissue encountered by

general and family practitioners. Percents of

visits involving accidents, poisonings, and violence were also higher for general and famiIy

practitioners than for internists.

Table 19 sh;ws the differences in the most

frequent principal diagnoses rendered during

visits to internists and general and family practitioners. Diarrheal disease, otitis media, pharyngitis, acute tonsillitis, bronchitis, influenza,

chronic sinusitis, cystitis, menopausal symptoms, sprains and strains of sacroiliac region,

prenatal care, and inoculations and vaccinations

17
each constituted less than 1 percent of internists’ visits. However, they accounted for higher

proportions of visits to general and family

practitioners. On the other hand, GFP visits

included less than 1 percent each of visits for

symptomatic heart disease, emphysema, and

rheumatoid arthritis or allied conditions, which

are prominent on the internists’ list. Proportions

of internists’ visits involving diabetes mellitus,

essential benign hypertension, and chronic ischemic heart disease were higher than proportions of visits to GFP’s for the same reasons.

The observations regarding age-related conditions treated by the internist, coupled with the

difference in visit age distributions between internists and general and family practitioners, are

reflected by this contrast of practice profiles.

—ooo —

18
REFERENCES

lNational Center for Health Statistics: National Ambulatory Medical Care Survey: 1973 Summary, United

States, by J. E. Delozier and R. O. Gagnon. Vital and

Health Statistics. Series 13-No. 21. DHEW Pub. No.

(H RA) 76-1772. Health Resources Administration.

WM.hington. U.S. Government Printing Office, Oct. 1975.

2National Center for Health Statistics: The National

Ambulatory Medical Care Survey: 1975 Summary, by

H. Koch and T. McLemore. Vital and Health Statistics.

Series 13-No. 33. DHEW Pub. No. (PHS) 78-1784.

Public Health Service. Washington. U.S. Government

Printing Office, January 1978.

8National Center for He=th Statistics: National Ambulatory Medical Care Survey: Background and Methodology, United States, 1967-72, by J. B. Tenney, K.

L. White, and J. W. Williamson. Vital and Health Statistics. Series 2-No. 61. DHEW Pub. No. (HRA) 74-1335.

Health Resources Administration. Washington. U.S.

Government Printing Office, March 1974.

4National Center for Health Statistics: Physician

visits, volume and interval since last visit, United States,

1971, b y K. M. Danchik. Vitaland Health Statistics. Series

10-No. 97. DHEW Pub. No. (HRA) 75-1524. Health Resources Administration. Washington. U.S. Government

Printing Office, March 1975.

5National Center for Health Statistics: National Ambulatory Medical Care Survey of Visits to General and

Family Practitioners, by B. K. Cypress. Advance Data

fro~ Vital and Health Statistics, No. 15. DHEW Pub.

No. (HRA) 78-1250. Health Resources Administration.

Hyattsville, Md. Dec. 14, 1977.

6National Center for Health Statistics: The National

Ambulatory Medical Care Survey: Symptom Classification, by S. Meads and T. McLemore. Vital and

Health Statistics. Series 2-No. 63. DHEW Pub. No.

(H RA) 74-1337. Health Resources Administration.

Washington. U.S. Government Printing Office, May

1974.

7National Center for Health Statistics: Eighth Revision International Classification of Dz%eases, Adapted

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

Health Service. Washington. U.S. Government printing

Office, 1967.

8National Center for Health Statistics: Office Visits

for Hypertension: National Ambulatory Medical Care

Survey: United States, January 1975-December 1976,

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

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

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

‘U.S. Bureau of the Census: (k-rent Population Reports, Series P-25, No. 614. Washington. U.S. GovernmentPrinting Office, July 1975. Table 2, p. 17.

10 National Center for Health Statistics: Replication:

an approach to the 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, April 1966.

11National Center for Health Statistics: Pseudoreplication: further evaluation and application of the

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

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

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

Administration. Washington. U.S. Government Printing

Office, Jan. 1969.

19
LIST OF DETAILED TABLES

1.

2.

3.

4.

5.

6.

7.

8.

9.

Number of visits to office-based internists and percent distribution and annual rate per 100 population by geographic region,

metropolitan and nonmetropolitan areas, and type of practice, according to age and sex of the patient: United States,

January -Dacembar 1975 .......................................................................... ............................................................. ........................

Number and percent distribution of visits to office-based internists by type of practice, according to geographic region and

type of area: United States, January -Decambar 1975 ..................................................................................................................

NumM of visits to office-based internists and percent distribution and annual rate by age of patient, according to sex and

color of the patient: United States, January-December 1975 ...................................................................... ...............................

Number, percent distribution, and cumulative percent of visits to office-based internists by the 24 most frequent patient

problems in rank order of number of visits: United Statas, January-December 1976 ...................................................................

Number of visits to office-based internists and percents of visits by selected diagnostic services ordered or provided, by

selected frequent patient problems in rank order of number of visits: United States, January-December 1975 ...........................

Number of visits to office-based internists and percent distributions by seriousness of patient’s principal problem, according to

selected patient problems: United States, January-December 1975 .............................................................................................

Number, percent distribution, cumulative percent, mean duration, and standard error of mean duration in minutes of visits to

office-basad internists by the 24 most common principal diagnoses classified by ICDA category code in rank ordar of number

of visits: United States, January-December 1975 .........................................................................................................................

Number of visits to office-based internists and percent distribution by problem status, time actually spent with the physician,

and sex of the patient, according to principal diagnoses classified by ICDA category code: United States, January-December

1975 ......................................................................................... .. .................................................. .............................. .................

Number of visits to office-based internists and percents by selected therapeutic services ordered or provided by Principal

diagnoses classified by ICDA code: United States,”January -December 1975 ...~..........................................~................~...........~....

10. Number of visits to office-based internists and percent distributions by prior visit status, seriousness of patient’s principal

problem, and time actually spent with physician, according to age and sex of the patient: United States, January-Dacarnber

1975 ......................... .................................................................................. .... .................. ................................ ...........................

11. Number of visits to office-basad internists and percents by selected diagnostic and therapeutic services, by age and sex of the

patient: United States, January-December 1975 ........................................................................................................ ..................

12. Number of visits to office-based internists and percent by disposition of visit, by age and sex of patient: United States,

January-December 1975 ......................................................................................................... .....................................................

13. Number of visits to office-based internists and percent distribution by selected characteristics of the visit, according to prior

visit status: United States, January-December 1975 ............. ........................................................................................................

14. Number of visits to office-based internists and percents by typa of condition treatad and disposition of visit, by prior visit

status: United States, January -Decambw 1975 ................................................ ............................................................................

15. Number of visits to offica-based internists and percents by type of condition treated, by age and sex of patient: United States,

January-December 1975 ..............................................................................................................................................................

16. Numbsr of visits to office-based internists and percent distribution by age of patient and selected characteristics of visit,

according to selected specialties: United States, January-December 1975 ....................................................................................

22

24

25

26

27

28

28

30

33

34

36

36

39

40

41

42

20
17. Number of visits to office-based internists and percents by salected characteristics of the visit, by selected specialties: United

States, January-December 1975 ................................................................................................................................................... 43

18. Number of visits to office-based internists and percent distribution by principal diagnoses classified by ICDA category code,

according to selected specialties: United States, January-December 1975 .................................................................................... 44

19. Number of visits to office-based internists and general and family practitioners and percents by principal diagnosas classified

by ICDA category code, by specialties: United States, January-December 1975 ....... ................................................................... 45

21
Table 1. Number of visits to office-based internists and percent” distribution and

annual rate per 100 population by geographic ”region,metropolitan and nonmetropolitan

areas, and type of practice, according to age and sex of the patient: United States,

January-December 1975

—

1

2

i

5

6

i

1:

11

12

13

34

15

16

17

—

Age and sex

All visits --------------------

ALL AGES

Under 15 years----------------------

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

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

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

65 years and over-------------------

SEX

Female

Under 15 years ----------------------

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

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

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

65 years and over-------------------

Male

Under 15 years----------------------

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

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

$5-64 years-------------- -----------

65 years and over-------------------

Annual rate-------------------------

Number of

visits in

thousands

62,117

2,047

5,474

13,106

23,565

17,925

993

3,291

7,440

13,572

11,683

1,054

2,182

5,667

9,993

6,243

. . .

Total

Northeast North

Central

If I

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

29.7

34.9

29.2

27.1

30.4

30.2

*25.o

27.8

26.4

30.7

30.3

44.2

31.3

28.0

30.1

30.1

25.1

37.9

28.1

26.3

24.9

22.0

47.0

29.7

27.6

23.5

22.3

*29.3

25.6

24.7

26.9

21.6

Visits per 100 in population

29.911 37.6I 27.5

lIncludes partnership and group practices.

22
Table 1. Number of visits to office-based internists and percent distribution and

annual rate per 100 population by geographic region,metropolitan and nonmetropolitan

areas, and type of practice, according to age and sex of the patient: United States,

January-December 1975—Con.

.— I I

Geographic region—Con. I

Area IType of practice

South I

West IMetropolitan

25.6

21.8

27.1

27.3

25.4

24.5

*z(j. 2

24.9

25.4

24.8

23.8

*23.3

30.4

29.9

26.2

26.0

19.6

>k5.5

15.6

19.2

19.3

23.2

*7.9

17.5

20.6

21.0

23.6

>Y3.2

*12.8

17.4

16.9

22.4

Nonmetropolitan

Percent distribution-Con.

84.6

74.1

84.4

84.2

85.6

84.8

68.7

82.5

84.8

86.6

85.8

79.1

87.2

83.4

84.3

82.9

15.4

25.9

15.6

15.8

14.4

15,2

31.3

17.5

15.2

13.4

14.2

>t20.9

<c~2.8

16.6

15.7

17.1

ELIIH!-

54.3

66.9

52.0

51.5

55.2

54.3

64.2

52.7

51.9

57.5

54.8

69.5

51.0

50.9

52.0

53.5

45.7

33.1

48.0

48,5

44.8

45.7

35.8

;;.;

42:5

45.2

30.5

49.0

49.1

48.0

46.5

Visits per 100 in population—Con.

24.0 33.8 ---

——

1

2

:

5

6

;

9

LO

L1

.2

.3

.4

.5

.6

.7

—

23
Table 2. Number and percent distribution of visits to office-based internists by type

of practice, according to geographic region and type of area: united States, JanuaryDecember 1975

Geographic region and

type of area

All visits----------------------

Geographic region

Northeast-----------------------------

North Central-------------------------

South---------------------------------

West----------------------------------

Area

Metropolitan--------------------------

Nonmetropolitan-----------------------

Type of practice

~

Number in thousands

-11- 62,117 33,706

18,452 12,604

15,585 8,465

15,898 7,952

12,182 4,685

*

28,411

5,848

7,120

7,946

7,496

23,921

4,490

Percent distribution

1

100.0 68.3

100.0 54.3

100.0 50.0

100.0 38.5

100.0 54.5

100.0 53.1

45.7

31.7

45.7

50.0

61.5

45.5

46.9

%ncludes partnership and group practices.

24
Table 3. Number ofvisitsto office-based internists and percent distribution and annual

rate by age of patient, according to sex and color of the patient: United States,

January-December1975

Sex and color

All visits-------------

SEX

Female-----------------------

Male-------------------------

COLOR

White

Female-----------------------

Male-------------------------

All other

Female-----------------------

Male-------------------------

All visits-------------

SEX

Female-----------------------

Male-------------------------

COLOR

White

Female-----------------------

Male-------------------------

All other

Female-----------------------

Male-------------------------

Number of

visits in

thousands

62,117

36,978

25,139

33,347

23,091

3,631

2,049

62,117

36,978

25,139

33,347

23,091

3,631

2,049

Age

Al 1

ages Under 15-24 25-44 45-64 65 years 15

years

years years years and over

II I I I I

percent distribution

100.0

100.0

100.0

100.0

100.0

100.0

100.0

29.9

34.7

24.8

36.1

26.2

25.5

15.8

3.3

v

:::

*3.()

*5.6

~isits

3.9

:::

4.1

4.2

2.5

3.2

8.8

8.9

8.7

8.8

8.9

*1O.2

*6.7

21.1

20.1

22.5

18.8

21.7

32.3

31.7

37.9

36.7

39.8

36.9

39.8

34.7

39.0

)er 100 in population

14.0

17.7

11.1

17.7

12.2

12.8

4.9

25.1

27.3

22.1

27.3

22.2

32.7

21.7

55.5

61.3

49.2

62.2

50.3

53.5

39.2

28.9

31.6

24.8

32.9

25.5

19.8

*17.()

82.1

90.6

69.8

93.0

72.8

64.5

40.9

25
Table 4. Number, percent distribution, and cumulative percentof visits to office-based

internists by the 24 most frequent patient problems in rank order of number of visits:

United States, January-December 1975

Rard Patient’sprincipal

NAMCS symptom

problemclassified

classificationl

by

All problems------------------------------------------

Generaland required physical examinations-----------9OO,9Ol

Pain in chest--------------------------------------------322

Problems of lower extremity------------------------------400

Fati~e--------------------------------------------------OO4

Abdominal pain-------------------------------------------54O

High blood pressure--------------------------------------2O5

Problems of back region----------------------------------4l5

Cough----------------------------------------------------3ll

Problems of upper extremity------------------------------4O5

Vertigo-dizziness----------------------------------------O69

Shortness of breath--------------------------------------3O6

Headache-------------------------------------------------O56

Throat soreness------------------------------------------52O

Diabetes mellitus----------------------------------------99l

Cold-----------------------------------------------------3l2

Visits for medication------------------------------------9lO

Nervousness----------------------------------------------8lO

Problems of face, neck----------------------------------+lo

Allergic skin reactions----------------------------------112

Other symptoms referable to cardiovascular system--------22O

Arthritis-rheumatism, including osteoarthritis-----------427

Irregular pulsations and palpitations--------------------2OO

Other symptoms referable to the respiratory system, NEC--33O

Weight gain-obesity--------------------------------------010

All other problemsz---------------------------------Residual

Visits to office-based internists

Number in

thousands

62,117

3,455

2,834

2,724

2,460

2,292

1,823

1,756

1,694

1,500

1,427

1,365

1,262

1,137

1,072

960

884

;;;

716

672

669

667

593

591

27,983

Percent

distribution

100.0

Cumulative

percent

100.0

1:::

14.6

18.6

22.3

25.2

28.0

30:7

33.1

35.4

37.6

39.6

41.4

43.1

44.7

46.1

47.4

48.6

49.8

50.9

52:0

53;1

54.1

55.1

100.1

lSWPtomatic groupings and code number inclusions are based ona symptom classificationdevelopedfor

use in NAM%.

21ncludes 10.1 million !Iprogress”visits 980,985.

26
Table 5, Number of visits to office-based internists and percents ofvisits by selected

diagnostic services ordered or provided, by selected frequent patient problems in rank

order of number of visits: United States, January-December 1975

c

Principal problem classified by

NANCS symptom classification

I

All problems----------------------------

1 P.Iinin chest------------------------------322

2 Problems of lower extremity----------------4OO

3 CouKh and cold-------------------------3ll,3l2

4 Fatixue------------------------------------OO4

5 Abdominiilpain-----------------------------54O

6 High blood pressure-----------------_-----_2O5

7 Problems of back region--------------------4l5

8 Problems of upper extremity----------------4O5

9 Vertigo-dizziness------------------.--_----O6g

10 Shortness of breath------------------------3O6

11 Headache-----------------------------------O56

12 Throat soreness--------------------.--.----52O

13 Diabetes mellitus--------------------------99l

Number of

visits in

thousands

62,117

2,834

2,724

2,654

2,460

2,292

1,823

1,756

1,500

1,427

1,365

1,262

1,137

1,072

Limited General laboratory Blood

Listoryand history and procedure p~e:re

examination examination or test

61.4

64.6

72.2

7h.8

59.0

63.3

69.1

72.6

61.0

68.1

72.8

59.2

75.9

54.4

Percent2

20.1I 38.5

I

-1

22.3 34.0

14.4 33.3

15.0 18.6

26.7 52.3

25.3 37.7

*15.1 28.9

*12.8 27.1

*18.5 9<19-1

.W9.4 46.8

*I8.8 33.4

25.2 *z5.2

,*6.1 29.3

*18.1 79.1

61.4

73.0

58.8

53.0

69.3

58.6

78.2

54.7

44.2

76.5

70.1

64.0

40.6

64.7

14.0

47.3

>*7.1

*5.5

18.8

*10.5

*I4.4

>:6.I

*=3.4

fc15.o

28.0

:4.9

%-3.5

>tll.3

13.1

~

20.4

15.1

20.6

15.9

22.7

.~6.3

~-13.9

23.6

9.9.3

3:17.5

,:12.5

9<2.8

*3.4

!Svmptomaticgroupings and code numbers are based on a symptom classificationdeveloped for use in NANCS.

-Percentswill not add to 100 because most patient visits required the provision of more than one service.

27
Table 6. Number of visits to office-based internists and percent distributions by seriousness of patient’s principal problem, according to selected patient problems:

January-December1975

Ranl Selectedfrequentprincipal

problemand NAMCS codel

All problems----------------------------

Pain in chest------------------------------322

Problemsof lowerextremity----------------4OO

Coughand cold-------------------------311,312

Fatigue------------------------------------OO4

Abdominalpain-----------------------------54O

High blood pressure------------------------2O5

Problems of back region--------------------4l5

Problems of upper extremity----------------4O5

Vertigo-dizziness--------------------------O69

Shortness of breath ------------------------306

FIeadache-----------------------------------O56

Phroat soreness----------------------------52O

)iabetes mellitus--------------------------ggl

Number of

visits in

thousanda

62,117

2,834

2,724

2,654

2,460

2,292

1,823

1,756

1,500

1,427

1,365

1,262

1,137

1,072

Percentdistribution

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

28.6

49.9

35.8

20.4

35.9

29.1

::.;

*19:6

32.1

66.2

*19.4

*4.9

41.2

33.6

28.3

40.5

33.0

32.6

44.3

33.7

42.6

30.9

;;.$

44:3

39.5

39.6

37.8

21.9

23.7

46.6

31.5

26.7

24.0

28.6

49.5

28.0

*.5

36.4

55.6

*19.2

lSymptOmatic groupings and code number inclusions are based on

for use in NAMCS.

a symptom classification developed

28
Table 7. Number, percent distribution, cumulative percent , mean duration, and standard

error of mean duration in minutes of visits to office-based internists bythe24 most

common principal diagnoses classified by ICDA category code in rank order of numb er

of visits: United States, January-December 1975

1

2

;

6

;

1?

11

12

+:

15

16

17

18

19

:!

22

23

24

25

Principal diagnosis classified by

ICDA 3-digit categoryi

All vi#its-----------------------------------------------

Essential benign hypertension-------------------------------4Ol

Chronic ischemic heart disease-----------------------------J+l2

Diabetee mllitus-------------------------------------------25O

Medical or swcial examination------------------------------YOO

Acute upper respiratory infection, site unspecified---------465

NeuroaeB--.-.----.-.--.--.-...-..-..--..-.--.--.----..-----.3OO

Osteoarthritisand allied conditions------------------------713

Sym tomatic heart dieease-----------------------------------427

Medfcal and surgical aftercare------------------------------YlO

Rhe!nnatoidarthritis and allied conditions------------------7l2

Obesity-----------------------------------------------------277

Observationwithout need for further medical care-----------793

EmphyseM---------------------------------------------------h92

Ha fever---------------------------------------------------5O7

Ot;er eczema and dermatitis---------------------------------692

Other nonarticular rheumatism-------------------------------7l7

Synovitis, bursitis-----------------------------------------73l

Arthritis, mspecified--------------------------------------7l5

Symptom referable to the respiratory system----------------783

Bronchitis,wqualified-------------------------------------49O

MFedem----------------------------------------------------2&

Other ill-defined and unknown causes of morbidity and

mortality--------------------------------------------------796

Oiarrheal disease-------------------------------------------OO9

Angina pect0ris--------------------------------------------4l3

All other diagnoses3.-...-.----------------------------Residual

Visits to office-based internists

Wnnber in

thousands

62.117

5,781

4,894

2,777

2,566

1,588

1,430

13414

1,253

1,101

1,011

983

838

837

749

746

727

662

628

614

577

574

527

509

503

28,828

2=Percent Cumulative

Iistribution percent

100.0 100.0

9.3

1?::

::: 21.7

$.: 25.8

28.4

2:3 30.7

2.3 33.0

2.0 35.0

36.8

i:: 38.4

1.6 40.0

1.3 41.3

1.3 42.6

1.2 43.8

1.2 45.0

1.2 46.2

47.3

t:: 48.3

1.0 49.3

0.9 50.2

0.9 51.1

Meau

duration

in

minutesz

1s.2

17.9

18.6

18.9

25.3

14.3

19.1

23.2

19.0

16.7

17.6

22.0

23.2

20.4

11.8

12.8

16.2

18.3

19.1

20.0

14.7

20.7

23.0

17.9

20.8

18.2

Staudard

error of

mean duration

in minutes

0.3s

0.54

0.91

1.10

1.33

0.93

1.27

1.29

1.39

;:9?

2.52

2.57

0.80

0.88

1.22

2.42

2.00

2.79

1.13

3.11

2.48

2.28

1.77

1.77

0.38

‘Diagnosticgroupings and code number inclusions are based on the Eighth Revision InternationalClassificationof Diseases>

,Adaptedfor Use in the United States-

‘Actual time spent in face-to-faceencounter with physician.

3DLaguoseacoded to 280-2S9, 6S0-709, 630-678, or 740-759 and those given ae “none” or “unknown.”

29
Table 8. Number of visits to office-based internists andpe%cent distribution byproblem

status, time actually spent with the physician, and sex of the patient, according to

principal diagnosis classified by ICDA category code: United States, January-December

1975

Principal diagnosis classified by ICDA categoryl

1 All diagnoses --------------------------------------------

2 Infective and parasitic diseases------------------------OOO-l36

3 Neoplasms-------------------~---------------------------l4O-239

4 Endocrine, nutritional, and metabolic diseases----------24O-279

5 Diabetes mellitus -------- ---------------------------------250

6 Mental disorders----------------------------------------29O-3l5

7 Diseases of the nervous system and sense organs---------32O-389

8 Diseases of the circulatory system----------------------39O-458

Essential benign hypertension

1:

-----------------------------401

Chronic ischemic heart disease ----------------------------412

11 Diseases of the respiratory system----------------------46O-5l9

12 Acute upper respiratory infections except influenza---4646666

13 Bronchitis, emphysema, and asthma ---------------------490-493

14 Diseases of the digestive system------------------------52O-577

15 Diseases of the geni.tourinary system--------------------58O-629

16 Diseases of the skin and subcutcmeous tissue------------68O-7O9

17 Diseases of the musculoskeletal system------------------7lO-738

18 Arthritis and rheumatism------------------------------7l2-7l7

19 Symptoms and ill-defined conditions---------------------78O-796

20 Accidents, poisonings, and violence---------------------8OO-999

21 Special conditions and examinations without sickness----yy13yl3

22 Medical or special examinations ---------------------------YOU

Number of

visits in

thousands

62,117

1,737

2,310

5,678

2,777

2,250

2,033

15,436

5,781

4,894

7,295

3,047

2,044

3,422

2,327

1,597

5,332

3,876

4,085

2,674

4,317

2,566

All

visits

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

lDiagnostic groupings and code number inclusions are based on the EiFhth Revision

International Classification of Diseases, Adapted for Use in the United States. Listing

does not include 280-289, Diseases of the blood and blood-forming orzans: 630-678. Complacations of pregnancy and the puerperium;740-759, Congenital ano~ali&; other diagnoses

coded “none” and unknown; blank, noncodeable, and illegible diagnoses.

ZIncludes all new problems regardless of the status of the patient.

31ncludes 420,000 visits during which a patient was provided care by someone other

than the physician and the form entry was “zero” minutes.

30
Table 8. Number of visits to office-based internists and percent distribution byproblem

status, time actually spent with the physician, and sex of the patient, according to

principal diagnosis classified by ICDA category code: United States, January-December

1975—Con.

Problem status Time actually spent with physician

New Return visit

for continuing l~rm~;s 11-15 l~n~i;:~~s

problemz minutes

problem

Percent distribution

34.0

64.9

*15 .2

17.1

*12 .3

34.0

51.1

13.1

49.7

68.2

27.9

39.0

48.3

54.8

29.9

23.9

!5;.;

45:7

60.5

66.0

35.1

84.8

82.9

87.8

66.0

48.9

86.9

91.3

88.7

50.3

31.8

72.1

61.0

51.7

45.2

70.2

76.1

45.9

38.9

54.3

39.5

31.1

41.6

40.3

24.0

23.0

27.7

32.5

28.3

32.5

24.3

40.6

46.4

26.3

26.1

32.5

46.7

21.7

20.5

27.6

38.0

31.9

21.6

35.6

39.0

31.4

43.5

46.6

36.4

35.2

37.7

38.9

38.5

35.8

34.1

38.2

36.3

35.5

31.8

37.7

38.5

28.6

39.1

23.7

21.3

33.3

*19 .4

28.3

32.5

30.4

35.9

32.3

34.0

28.6

37.2

23.6

19.6

35.4

37.6

32.0

*21 .6

40.5

41.0

43.8

22.9

44.4

57.2

Sex of patient

Female Male

59.5

49.3

56.3

64.1

59.2

73.5

56.0

54.4

62.8

43.3

54.3

62.9

47.4

62.0

80.4

56.8

70.2

72.6

61.6

58.5

50.9

46.6

40.5 1

50.8 2

43.7 3

35.9 4

40.8 5

26.6 6

44.0 7

45.6 8

37.2 9

56.7 10

:;.; :;

52:6 13

38.0 14

19.6 15

43.2 16

29.9 17

27.4 18

38.4 19

41.5 20

49.2 21

53.5 22

31
Table 9. Number of visits to office-based internists and percents by selected therapeutic

services ordered or movided. by rminciual diagnoses classified by ICDA code: United

States, January-Decekber 1975 “ ‘

Principal diagnosis classified by ICDA categoryl

All diagnoses--------------------------------------------------------

Infectiveand parasitic diseases------------------------------------OOO-l36

Neoplasms-----------------------------------------------------------l4O-239

Endocrine, nutritional, and metabolic diseases----------------------24O-279

Diabetes mellitus-----------------------------------------------------25O

Mental disorders----------------------------------------------------29O-3l5

ni.seaeesof the nervous system and sense organs---------------------32O-389

Diaeaaes of the circulatory system----------------------------------39O-458

Essential benign hypertension-----------------------------------------4Ol

Chronic ischemic heart disease----------------------------------------4l2

Diseases of the respiratory system----------------------------------46O-5l9

Acute upper respiratory infection, except influenza---------------46O-466

Bronchitis,emphysema, and asthma---------------------------------49O-493

Diseases of the digestive system------------------------------------52O-577

Diseases of the genitourinarysystem--------------------------------58O-629

Diseases of the skin and subcutaneoustissue------------------------68O-7O9

Diseases of the musculoskeletalsystem------------------------------7lO-738

Arthritis and rheumatism------------------------------------------7l2-7l7

Symptoms and ill-definedconditions-----------------.---------------78O-796

Accidents, poisonings, and violence---------------------------------8OO-B99

Special conditions and examinationswithout sickness----------------YOO-Yl3

Selected therapeutic servu-es urdered or provided

Number of

visits in

thousands

62,117

1,737

2,310

5,678

2,777

2,250

2,033

15,436

5,781

;,:;;

3;047

2,044

3,422

2,327

1,597

5,332

3,B76

4,0B5

2,674

4,317

Drug

therapyz

——.

:njection or

nnnunization

49.5

58.1

39.2

39.6

33.2

51.5

63.5

54.5

56.3

52.1

65.8

7s.5

5B.O

52.1

51.2

54.5

55.2

55.5

37.4

45.4

20.7

Percent3

14.2

19.1

32.0

g.7

*8.2

*13.3

*17.2

7.2

*5.6

*8.O

22.3

20.4

17.7

*lo .0

*13.4

*21.2

21.5

20.1

*7.O

*12.3

15.0

Medical

counseling

and psychotherapy or

therapeutic

listening

20.5

*11.8

16.3

30.2

27.0

42.7

21.3

20.4

20.9

22.7

14.2

*lo .5

*18.2

27.6

17.7

15.4

18.9

17.9

18.4

20.1

18.7

Iniagnosticgroupings and code number inclusionsare based on the Eighth Revision InternationalClassification of Diseases,

Adapted for Use in the United States. Listing does not include 280-289, Diseases of the blood and blood-forming organs; 630-678,

Complicationsof pregnancy and the puerperium; 740-759, Congenital anomalies; other diagnoses coded “none” and unknown;

noncodeable, and illegible diagnoses.

blank,

2Pre9criptionand nonprescriptiondrugs.

3Percentswill not add to 100 since most patient visits required the provision of more than one service.

33
Table 10. Number of visits to office-based internists and percent distributions by

prior visit status, seriousness of patient’s principal problem, and time actually

spent with physician, according to age and sex of the patient: United states, JanuaryDecember 1975

——

1

2

:

5

6

7

8

9

10

11

12

13

—

Age and sex of patient

All patients ----------

Both sexes

Under 25 years --------------

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

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

65 years and over -----------

Female

Under 25 years --------------

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

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

65 years and over -----------

Male

Under 25 years --------------

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

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

65 years and over -----------

Number of

visits in

thousands

62.117

7,521

13,106

23,565

17,925

4,284

7,440

13,572

11,683

3,237

5,667

9,993

6,243

Total

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

Prior visit status

=_E=E==

Percent distribution

13.1

30.3

19.4

R

30.7

17.2

H

29.9

22.4

9.6

*6.5

20.9

34.4

23.7

19.0

15.8

32.0

23.1

20.7

16.6

37.5

24.6

16.7

14.1

66.0

35.3

56.8

71.5

78.4

37.4

59.7

69.8

77.9

32.6

53.0

73.7

79.4

‘Includes 420,000 visits during which the patient was under the care of someone

other than the physician and the form entry was “zero!!minutes.

34
Table 10. Number of visits to office-based internists and percent distributions by

prior visit status, seriousness of patient’s principal problem, and time actually

spent with physician, according to age and sex of the patient: United States, JanuaryDecember 1975-Con.

Seriousness of patient’s principal problem

I

Time actually spent with physician

Serious or Slightly Not 10 minutes 11-15 16-30 31 minvery serious serious serious or lessl minutes utes minutes

or more

Percent distribution—Con.

28.6

11.6

20.6

32.5

36.5

9.8

20.8

29.4

33.7

14.0

20.2

36.6

41.7

33.6

27.9

33.0

33.6

36.5

31.7

31.8

35.2

37.8

23.0

34.5

31.5

34.1

37.8

60.5

46.5

34,0

27.0

58.6

47.4

35.5

28.5

63.0

45.3

31.9

24.2

31.1

43.6

36.1

29.8

23.9

42.0

37.5

30.0

23.6

45.7

34.2

29.5

24.5

35.6

31.5

34.8

35.7

37.7

33.1

36.4

36.5

37.7

29.4

32.6

34.7

37.9

24.6

18.6

20.2

24.2

31.0

17.3

18.4

23.3

31.3

20.3

22.5

25.5

30.5

8.7

6.4

1;::

7.4

*7.6

1:::

7.5

*4.7

10.7

10.4

7.2

—

1

2

i

5

6

:

9

.0

.1

.2

.3

—

35
Table 11. Number of visits to office-based internists and percents by selected diagnosticand therapeutic services, byageand sex of the patient: United States, JanuaryDecember 1975

—

1

2

;

5

6

7

8

9

10

11

12

13

—

Age and sex of patient

All patients------------------

Both sexes

Under

25-44

45-64

25 years----------------------

years-------------------------

veals-------------------------

65 yea;s and over-------------------

Female

Under 25 years----------------------

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

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

65 years and over-------------------

Male

Under 25 years----------------------

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

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

65 years and over-------------------

Diagnostic and therapeutic services

Number of

visits in

thousands

62,117

7,521

13,106

23,565

17,925

4,284

7,440

13,572

11,683

3,236

5,667

9,993

6,243

ZzEE!!z

Percent2

61.4

55.7

59.8

59.2

67.7

60.2

63.8

59.5

67.4

49.7

54.7

;:.;

.

20.1

22.9

20.2

22.5

15.8

20.8

17.0

21.7

16.0

25.8

24.5

23.6

15.4

lPrescriptionand nonprescription drugs.

2Percents will not add to 100 because most patient visits required the provision

of more than one treatment or service.

36
I

Table 11. Number of visits to office-based internists and percents by selected diagnostic and therapeutic services, byageand sex of thepatie;t: United Etates, JanuarjDecember 1975-Con.

Diagnostic and therapeutic services-Con.

Laboratory Blood

procedure pr~;~ke

or test

Electrocardiogram

38.5

31.7

36;0

39.7

41.5

37.1

36.4

39.8

42.7

24.6

35.5

39.6

39.3

61.4

39.5

52.4

67.2

69.6

39.0

51.2

67.5

71.4

40,3

54.0

66.8

66.3

14.9

*3.5

11.7

17.0

15.9

*1.9

A!

15.4

*5.7

16.8

21.5

17.0

X-ray Drug Injection or

therapyl immunization

Medical

counseling

Percent2-Con.

13.1

1::;

14.1

12.2

*6.1

11.8

13.6

13.0

*11,8

19.5

14.9

10.7

49*5

45.4

49.4

48.7

52.4

47.9

53.0

50.4

53.7

42.1

44.8

46.2

50.0

——

14.2

14.9

12.4

13.0

16.7

11.7

13.0

16.0

17.9

19.2

11.7

8.9

14.6

17.8

18.5

18.5

18.0

16.8

19.9

19.1

16.7

16.4

16.7

17.8

19.9

17.4

37
Table 12. Number of visits to office-based internists and percent by disposition of

visit, by age and sex of patient: United States, January-December1975

Age and sex of patient

Under

25-44

+?-64

All visits----------

Both sexes

25 years------------

years---------------

years---------------

b> years and over---------

Female

Under 25 years------------

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

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

65 years and over---------

Male

Under 25 years------------

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

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

65 years and over---------

Number of

visits in

thousands

62,117

7,521

13,106

23,565

17,925

4,284

7,440

13,572

11,683

3,236

;,;;;

6;243

Disposition of visit

ZEEz!Ez

Percentz

9.1

21.6

11.9

R

20.3

10.1

::;

23.4

14.3

7.6

*5.7

68.4

38.6

56.8

75.6

79.8

37.9

;;.;

80:1

39.5

55.4

76.2

79.2

16.5

29.9

22.5

13.0

11.2

31.3

23.7

14.3

12.5

28.0

20.9

11.1

8.8

Other

disposition

12.5

15.0

14.4

11.7

11.2

17.1

14.5

12.6

11.1

12.2

14.3

10.3

11.4

lIncludes telephone followup planned, return to referring physician, admit to hospital, and all other dispositions.

‘Percents will not add to 100 because some patient visits had more than one disposition.

38
Table 13. Number of visits to office-based internists and percent distribution by selected characteristics of the visit, according to prior visit status: United States,

January-December 1975

Selected characteristics of the visit

All visits ------------------------------------

Total ------.-------------_--------------------

Seriousness of the Datient’s CKoblem

Serious or very serious -----------------------------

Slightly serious ------------------------------------

Not serious -----------------------------------------

Time spent with the physician

10 minutes or Lessl ---------------------------------

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

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

31-60 minutes ---------------------------------------

61 minutes or more ----------------------------------

Diagnostic and therapeutic services2

Limited history and examination ---------------------

General examination ---------------------------------

Laboratory procedure or test------------------------

Blood pressure check --------------------------------

Electrocardiogram -----------------------------------

X-ray ------------------------------- ----------------

Dr~g-therapys ---------------------------------------

InJection or immunization ---------------------------

kfe~fe$l counseling ----------------------------------

-----------.-----------------------------_----

Prior visit status

Patient seen before

New patient

New Old

problem problem

Number in thousands

8,122 I 12,995 I 41,000

Percent distribution

100.0

18.2

31.0

50.8

25.3

24.6

25.3

21.2

*3.5

41.1

45.8

47.4

55.5

23.2

27.0

42.7

1!:;

16.8

100.0

14.3

32.4

53.3

33.3

35.6

24.8

5.6

*().7

64.0

19.8

33.7

51.6

12.2

17.4

52.0

10.6

14.7

13.3

100.0

35.2

34.5

30.3

31.5

37.8

24.4

5.8

*(3.5

64.6

15.1

38.2

65.7

12.7

5:::

16.4

18.8

11.4

‘Includes 420,000 visits during which a patient was provided care by someone other

then the physician and the form entry was “zero” minutes.

ZPercents will not add to 100 because most patient visits required the provision of

more than one service or treatment.

31ncludes prescription and nonprescription drugs.

41ncludes hearing test, vision test, endoscopy, office surgery, physiotherapy, psychotherapy or therapeutic listening, and all other services or treatments provided.

39
Table 14. Number of visits to office-basedinternistsand percents by type of condition

treated and disposition of visit, by prior visit status: United States, JanuaryDecember 1975

Type of condition treatedland

disposition of visit

All visits-------------------------------------

Type of condition treatedl

Acute-------------------------------------------------

Chronic---------------------------------------------

Disposition of visit2

No followup planned---------------------------------

Return at specified time----------------------------

Return if needed------------------------------------

Telephone followup planned--------------------------

Re@r;ed to other physician-------------------------

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

Prior visit status

New patient

]Patient seen before

New

problem .

Old

problem

Number in thousands

8,122 I 12,995I 41,000

Percents

56.6

23.5

20.6

42.0

23.0

7.3

5.6

8.2

75.6

22.1

14.6

48.2

27.3

::;

3.4

24.6

74.9

8;:;

11.8

3.3

3.4

2.0

lPercentswill not add to 100 because acute and chronic categories include visits

for morbid conditions only. Some visits, such as family planning,”counseling, administrat~ve, and others, were not related to morbidity. .

2perce~ts wiJ-1 not add to 100” because some patient visits had more than one disposition.

31ncludes return to referring physician, admit to hospital, and all other dispositions.

40
Table 15. Number of visits to office-based internists and percents by type of condition

treated, by age and sex of patient: United States, January-December1975

Age and sex of patient

All visits--------------------------------

Both sexes

Under 25 years----------------------------------

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

45-64 vearsAC-.----------------------------------

65 yeaks and over-----;-------------------------

Female

Under 25 years----------------------------------

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

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

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

Male

Under 25 years-----------..----------------------

25-44 yeaks-------------------------------------

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

65 years and over-------------------------------

Number of

visits in

thousands

62,117

7,521

13,106

23,565

17,925

4,284

7,440

13,572

11,683

3,236

;,:;;

6;243

rype of condition treated

Acute Chronic

Percentl

39.4

58.9

46.4

35.5

31.3

60.1

46.1

34.8

32.1

57.3

46.8

36.4

29.9

57.2

26.2

42.8

62.9

73.0

28.5

46.4

65.1

73.0

23.3

38.1

60.0

73.0

lPercents will not add to 100 because acute and chronic categories include visits

for morbid conditions only. Some visits, such as family planning,-counseling,administrative, and others, were not related to morbidity.

41
Table 16. Number of visits to office-based internists and percent distribution by age

of patient and selected characteristics of visit, according to selected specialties:

United States, January-December 1975

Specialty

Age of patient and

characteristic of the visit

All visits------------------

Age of Patient

Total-----------------------------

Under 15 years--------------------

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

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

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

65 years and over-----------------

Problem statua

New probleml--------------------

Return visit for continuing

problem-------------------------

Seriousness of the problem

Serious or very serious-----------

Slightly serious------------------

Not serious-----------------------

Duration of visit in minutes

O minutesz------------------------

1-10 minutes----------------------

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

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

31-60 minutes---------------------

61 minutes or more----------------

I

General

Internal and

medicine family

practice

Obstetrics

and

gynecology

Pediatrics

I

General

surgery

Cardiovascular

diseases

Number of visits

62,117[ 234,6601 48,076 [ 46,684[ 41,292 [ 7,556

Percent distribution

100.0

3.3

2?:?

37.9

28.9

34.0

66.0

28.6

33.6

37.8

3:::

35.6

24.6

;:;

100.0

14.4

16.0

24.1

27.5

18.0

43.2

56.8

17.0

35.1

47.9

5;::

24.9

17.0

1.7

*().1

100.0

3:::

50.3

11.7

2.4

32.2

67.9

*().1

50.1

30.1

17.4

2.3

*0.O

100.0

92.7

::2

*0.4

*().2

50.7

49.3

10.1

29.6

60.4

5:::

27.9

12.0

1.3

*0.2

100.0

1::2

28.7

34.0

17.8

34.9

65.1

18.0

28.8

53.2

5:::

26.0

16.4

1.9

*0.1

100.0

*1.4

*2.4

10.3

43.9

42.1

23.3

76.7

32.4

42.1

25.6

*().7

19.4

28.9

38.8

11.2

*1.O

lInclude$ all visits for new problems regardless of the Patient status21ncludes visits duringwhich the patient was under the care of someone other than the physician and

the form entry was ‘8zero”minutes.

42
Table 17. Number of visits to office-based internists and percents by selected characteristics of the visit, by selected specialties:

1975

United States, January-December

Characteristic of

the visit

All visits------------------

Type of condition treatedl

Acute-----------------------------

Chronic---------------------------

Selected diagnostic and

t~

ordered or provided

No treatment or services---------

Drug therapyj---------------------

Limited history or examination----

General hf.storyand examination---

Laboratory procedure or test------

Blood pressure check--------------

Electrocardiogram-----------------

X-ray-----------------------------

Medical counseling----------------

Disposition of viait4

No followup planned---------------

Return at specified time----------

Return if needed------------------

Telephone followup planned--------

Referred to other physician

or agency-----------------------

Return to referring physician-----

A&# to hospital-----------------

-----------------------------

Specialty

General

Internal Obstetrics and and Pediatrics General

medicine family gynecology surgery

practice

62,117 I

39.4

57.2

4$:2

61.4

20.1

38.5

61.4

14.0

13.1

17.8

$~

5:0

4.4

0.8

1.7

*(j.7

234,6601

53.7

35.4

5;::

55.6

12.6

21.6

40.2

2.3

1::;

15.5

51.3

2;.;

.

3.0

0.4

1.2

0.6

Number in thousands

48,076 ] 46,684

Percent

19.6

15.4

3.1

35.6

54.1

25.4

52.4

57.4

*().3

1;::

7::;

13.0

2.5

1.6

*13.7

3.2

1.2

4:::

41.0

33.4

22.4

7.7

*().2

1;:;

23.6

44.5

23.6

9.9

2.9

*O-3

*0.9

*o.8

41,292

40.2

29,6

2;::

46.6

11.O

11.8

23.1

2.1

1::;

10.5

61.6

18.2

1.7

2.9

;::

2.2

Cardiovascular

diseases

7,556

38.1

60.3

*1.1

43.5

47.0

22.1

25.2

72.5

41.5.

14.8

5.9

4.5

78.2

9.6

*1.O

*3.1

6.5

*1.8

*().3

lpercenta will not add to 100 becauae acute and chronic condition categories include visita for morbid conditions only. Some visits, such as family planning, counseling, adminiatrative, and others, were

not related to morbidity.

‘Percents will not add to 100 because most patient viaits required the provision of more than one

treatment or service.

jprescription and nonprescription drugs.

hpercents will not add to 100 because some patient visits required more than one disposition.

43
Table 18. Number of visitsto office-based internistsand percent distributionby principal diagnoses classified by ICDA category code, according to selected specialties:

United States, January-December1975

Specialty

Pr%ncipal diagnosis classified by ICDA categoryl

Internal General and

medicine family practice

I

Number in thousands

All principal diagnoses------------------------------ 62,117 I 234,660

I

Percent distribution

Total------------------------------------------------I 100.OI 100.0

Infective and parasitic diseases--------------------OOO-l36

Neoplasms-------------------------------------------l4O-239

Endocrine, nutritional, and metabolic diseases------24O-279

Diseases of the blood and blood-formingorgans------28O-289

Mental disorders------------------------------------29O-3l5

Diseases of the nervous system and sense organs-----389-389

Diseases of che circulatory system------------------39O-458

Diseases of the respiratory system------------------46O-5l9

Diseases of the digestive system--------------------52O-577

Diseases of the genitourinarysystem----------------58O-629

Diseases of the skin and subcutaneoustissue--------68O-7O9

Diseases of the musculoskeletalsystem -------------710-738

Symptoms and ill-definedconditions-----------------78O-796

Accidents~ poisonings and violence-----------------800-999

Special conditions and examinations.without

sickness-------------------------------------------YOO-Yl3

Other diagnoses2--------------------------.--------Residual

2.8

;:;

3:6

2::;

11.7

5.5

3.8

U

::;

7.0

1.4

4.6

;:;

1.3

3.0

$;

18.5

3,9

12.9

1.3

lDiagnosticgrouping and code number inclusions are based on the Eighth Revision

InternationalClassificationof Diseases, Adapted for use in the United States.

zIncludesdiagnoses 630-678 Complicationsof pregnancy and the puerperium; 740-759

Congenital anomalies; and “none” or unknown.

44
Table 19. Number of visits to office-based internists and general and family practitioners and percents by principal diagnoses classified by ICDA category code,by specialties: United States, January-December 1975

Principal diagnosis classified by ICDA

3-digit categoryl

All visits-------------------------------------------

Diarrheal disease---------------------------------------OO9

Diabetes mellitus---------------------------------------25O

Obestty-------------------------------------------------277

Neuroses------------------------------------------------3OO

Otitis media--------------------------------------------38l

Essential benign hypertension---------------------------401

Chronic ischemic heart disease--------------------------4l2

Symptomatic heart disease-------------------------------427

Acute pharyngitis---------------------------------------462

Acute tonsillitis---------------------------------------463

Acute upper respiratory infection-----------------------465

Influenza,unqualified----------------------------------470

Bronchitis,unqualified---------------------------------49O

Emphysema-----------------------------------------------492

Chronic sinusitis---------------------------------------5O3

Hay fever-----------------------------------------------5o7

Cystitis------------------------------------------------595

Menopausal symptoms-------------------------------------627

Other eczema and dermatitis-----------------------------692

Rheumatoid arthritis and allied conditions--------------7l2

Osteoarthritisand allied conditions--------------------7l3

Arthritis, unspecified----------------------------------7l5

Other nonarticular rheumatism---------------------------7l7

Swynovitis,bursitis-------------------------------------73l

Symptoms referable to respiratory system----------------783

Sprains, strains of sacroiliac region-------------------846

Medical or special examinations-------------------------YOU

Inoculationsand vaccinations---------------------------YOU

Prenatal care-------------------------------------------Y06

Medical and surgical aftercare--------------------------Ylo

Specialty

E

Number in thousands

62,117 I

Percent

(2)

~.;

2:3

(2)

9.3

;::

(2)

(2)

2.6

(2)

(2)

1.3

~2~

(;)

(2)

1.2

1.6

:::

1.2

1.1

1.0

(2)

4.1

(2)

$2~

.

234,660

1.2

2.5

2.1

1.8

;:;

2.2

$2$

1:7

3.6

2.1

1.7

$2;

1:1

1.4

1.1

1.2

1.2

$2&

6:3

1.0

2.3

2.4

1

‘Diagnosticgroupings and code number inclusions are based on the Eighth Revision

InternationalClassification of Diseases, Adapted for Use in the United States.

‘Less than 1 percent.

45
APPENDIXES

CONTENTS

I. Technical Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..47

Statistical Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..47

Data Collection and Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Estimation Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...49

Reliability of Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Tests of Significance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

Population Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Systematic Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..54

II. Definition of Certain Terms Used in This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...56

TermsRelatingto the Sumey.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...56

Terms Relatingto the Patient Record Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...57

111. Survey Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...61

I.

II.

I.

11.

Introductory Letter From Director, National Center for Health Statistics . . . . . . . . . . . . . . . . . . 61

Patient Recordand Patient Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..62

Induction Interview Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

LISTOFAPPENDIX FIGURES

Approximate relative standard errors for estimated numbers of office visits, 1975 National

Ambulatory Medical Care Sumey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..5I

Approximate relative standard errors for percentages of estimated numbers of office visits, 1975

National Ambulatory Medical Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...52

LISTOFAPPENDIX TABLES

Dktribution of physicians in the universe (American Medical Association and American Osteopathic Association) and in the National Ambulatory Medical Survey sample, by physician’s

specialty: United States,January-December 1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Estimates of the civilian noninstitutionalized population of the United States, by age, race, sex,

geo~aphic re@on, andmetropolitan andnonmetropolitan areaasof July l,l975 . . . . . . . . . . . 54

46
APPENDIX i

TECHNICAL NOTES d

Statistical Design

Scope oj”t?le suruey. –The target population

of the NAMCS encompasses office visits within

the conterminous United States made by ambulatory patients to nonfederally employed

physicians who are principally engaged in office

practice, but not in the specialties of anesthesiology, pathology, and radiology. Telephone

contacts and nonoffice visits are excluded.

Sampling frame and sample size. –The sampling frame for the NAMCS is composed of all

physicians contained in the master files maintained by the American Medical Association

(AMA) and American Osteopathic Association

(AOA) as of December 31, 1974, who met the

following criteria:

Office-based, as defined by the AMA and

AOA;

Principally engaged in patient care activities;

Nonfederally employed;

Not in the specialties of anesthesiology,

pathology, clinical pathology, forensic pathoIogy, radiology, diagnostic radioIogy,

pediatric radiology, or therapeutic radiology.

The 1975 physician universe included

180,125 doctors of medicine and 9,696 doctors

of osteopathy.

The 1975 NAMCS sample included 3,507

physicians, Sample physicians were screened at

‘Prepared by Thomas McLemore, M. S.P. H., Division

of Health Resources Utilization Statistics.

the time of the survey to assure that they met

the above-mentioned criteria; 438 physicians did

not meet all of the criteria and were, therefore,

ruled out of scope (ineligible) for the study.

The most frequent reasons for being out of

scope were that the physician was retired,

deceased, or employed in teaching, research, or

administration. Of the 3,069 in-scope (eligible)

physicians, 2,472 (80.5 percent) participated in

the study. The physician universe, sample size,

and response rates by physician specialty are

shown in table I. Of the participating physicians,

391 physicians saw no patients during their

assigned reporting period because of vacations,

illness, or other reasons for being temporarily

not in practice.

Sample design. –The 1975 NAMCS utilized a

multistage probability design that involved probability samples of primary sampling units

(PSU’S), physician practices within PSU’S, and

patient visits within practices. The first-stage

sample of 87 PSU’S was selected by the National

Opinion Research Center (NORC), the organization responsible for field operations under contract to the National Center for Health Statistics

(NCHS). A PSU is a county, a group of adjacent

counties, or a standard metropolitan statistical

area (SMSA). A modified probabilityproportional-to-size procedure using separate

sampling frames for SMSA’S and for nonmetropolitan counties was employed. After ,sorting

and stratifying by size, region, and demo~aphic

characteristics, each frame was divided into

sequential zones of 1,000,000 residents, and a

random number was drawn to determine which

PSU came into the sample from each zone.

47
Table 1. Distribution of physicians in the universe (American Medical Association and American Osteopathic Association) and the

National Ambulatory Medical Care Survey sample, by ph

Physician’s specialty

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

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

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

Internal medicine ........o...................................................................

Pdiatrics .....................o............l ......................................................

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

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

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

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

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

Other specialties ..............................................................

Psychiatry .......................................................................................

Other specialties ..............................................................................

fician’ssoecialtv: United States. Januarv-December 1975

out Non- ~eGross of NetReUniverse

retotal total

spond- sponse

scope

spond- ents rate

ents

Number of physicians

189,821 1 3,507 1 438 I 3,0691 597 1 2,472 I 80.5

53,069 911 122 789 179 610 77.3

49,801 942 121 821 165 656 79.9

26,125 505 59 446 99 347 77.8

12,229 239 39 200 28 172 86.0

11,447 198 23 175 38 137 78.3

65,434 I 1,255 I 89 I 1,166 I 214 I 952 I 81.6

19,606 371 22 349 63 286 81.9

15,124 311 25 286 53 233 81.5

30,704 573 42 531 98 433 81.5

21,517 I 399 I 106 I 293 I 39 I 254 I 86.7

12,993 242 32 I

210 20 190

I

90.5

8,524 157 74 83 19 64 77.1

The second stage consisted of a probability

sample of practicing physicians selected from

the master files maintained by the American

Medical Association (AMA) and American Osteopathic Association (AOA). Within each PSU, all

eligible physicians were arranged by nine specialty groups: general and family practice,

internal medicine, pediatrics, other medical specialties, general surgery, obstetrics and gynecology, other surgical specialties, psychiatry, and

other specialties. Then, within each PSU, a

systematic random sample of physicians was

selected in such a way that the overall probability of selecting any physician in the United

States was approximately constant.

The final stage was the selection of patient

visits within the annual practices of sample

physicians. This involved two steps, First, the

total physician sample was divided into 52

random subsamples of approximately equal size,

and each subsample was randomly assigned to 1

of the 52 weeks in the survey year. Second, a

systematic random sample of visits was selected

by the physician during the assigned week. The

sampling rate varied for this final step from a

100-percent sample for very small practices to a

20-percent sample for very large practices as

determined in a presurvey interview. The

method by which the sampling rate was determined is described in the Induction Interview

form displayed in appendix III.

Data Collection and Processing

Field procedures. –Both mail and telephone

contacts were used to enlist sample physicians

into the NAMCS. Physicians received introductory letters from the NCHS (see appendix III)

and the 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 sample physician to briefly explain the study

and arrange an appointment for a personal

interview. An initially nonresponding physician

was generally recontacted via a telephone call or

special explanatory letter and requested to

reconsider participation in the study.

During the personal interview the field representative determined the sample physician’s

eligibility, ascertained his cooperation, delivered

46
survey materials with verbal and printed instructions, and assigned a predetermined Monday

through Sunday reporting period. A short interview concerning basic practice characteristics,

such as type of practice and expected number of

office visits, was administered. Office staff who

were to assist with data collection were invited

to attend the instruction session or were offered

separate instruction sessions.

Before the beginning of and again during the

week assigned for data collection, the interviewer telephoned the sample physician to answer possible questions and to insure that

procedures were going smoothly. At the end of

the survey week, the participating physician

mailed finished survey materials to the interviewer who edited the forms for completeness

before transmitting them for central data processing. Problems or “missing data at this stage were

resolved by interviewer telephone followup to

the sample physician; if there were no problems,

field procedures were complete with respect to

the sample physician’s participation in the

NAMCS. After the end of the survey year each

sample physician was sent a thank-you letter

from the NCHS along with one of the survey’s

statistical reports.

Data collection. –The actual data collection

for the NAMCS was carried out by the physician

aided by his office staff when possible. Two data

collection forms were employed by the physician: the Patient Log and the Patient Record

(uppendix 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 visit

for which data were to be recorded. A perforation between the patient names and patient visit

characteristics permitted the physician to remove patient names and protect confidentiality.

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

Records were completed during the assigned

reporting week. Physicians expecting 10 or

fewer visits each day recorded data for all of

them, while those expecting more than 10 visits

per day recorded data for every second, third, or

fifth visit, based on the predetermined sampling

intcmal. These procedures minimized the data

collection workload and maintained approximate equal reporting levels among sample physicians regardless of practice size. For physicians

assigned a patient sampling ratio, a random start

was provided on the first page of the log, so that

predesignated sample visits on each succeeding

page of the log provided a systematic random

sample of patient visits during the reporting

period.

Data processing. –In addition to completeness checks made by the field staff, clerical edits

were performed upon 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 data items.

Information contained in item 5 (patient’s

problem) of the Patient Record was coded

according to a special classification system developed for that purpose. 6 Diagnostic information,

item 9 of the Patient Record, was coded

according to the Eighth Revision International

Classification of Diseases, Adapted for Use in

the United States(ICDA).T A maximum of three

problems and three diagnoses were coded. A

two-way independent verification procedure

with 100-percent verification was used to control the medical coding operation. Differences

between coders were adjudicated at the National

Center for Health Statistics.

Information from the Induction Interview

,and Patient Record was keypunched, with 100-

percent verification, and converted to computer

tape. At this time, extensive computer consistency and edit checks were performed. Data

items still unanswered at this point were imputed by assigning a value from a Patient Record

with similar characteristics; imputations were

based on physician specialty, major reason for

visit, and broad diagnostic categories.

Estimation Procedures

Statistics produced from the 1975 National

Ambulatory Medical Care Survey were derived

by a multistage estimating procedure. The procedure produces essentially unbiased national estimates and has basically three components:

(1) inflation by reciprocals of the probabilities

NOTE: A list of references follows the text.

49
of selection, (2) adjustment for nonrespcmse,

and (3) a ratio adjustment to fixed totals. Each

of these components is described briefly below.

Inflation by reciprocals of sampling probabilities. —Since the survey utilized a three-stage

sample design, there were three probabilities:

(1) the probability of selecting the PSU, (2) the

probability of selecting a physician within the

PSU, and (3) the probability y of selecting a

patient visit with the physician’s practice. The

last probability was defined to be the exact

number of office visits during the physician’s

specified reporting week divided by the number

of Patient Records completed. All weekly estimates were inflated by a factor of 52 to derive

annual estimates.

Adjustment for nonresponse.–Estimates

from the NAMCS data were adjusted to account

for sample physicians who did not participate in

the study. This was done in such a manner as to

minimize the impact of nonresponse on final

estimates by imputing to nonresponding physicians the practice characteristics of similar responding physicians. For this purpose, similar

physicians were judged to be physicians having

the same specialty designation and practicing in

the same PSU.

Ratio adjustment. –A poststratification adjustment was made within each of nine physician specialty groups. The ratio adjustment was

a multiplication factor which had as its numerator the” number of physicians in the universe in

each physician specialty group, and as its denominator the estimated number of physicians

in that particular specialty group. The numerator was based on figures obtained from the

AMA-AOA master files, and the denominator

was based on data from the sample.

Reliability of Estimates

Since the statistics presented in this report

are based on a sample, they will differ somewhat

from the figures that would be obtained if a

complete census had been taken using the same

forms, instructions, and procedures. However,

the probability design of the NAMCS permits

the calculation of sampling errors. The standard

error is primarily a measure of sampling variability that occurs by chance because only a sample

rather than the entire population is surveyed. As

calculated in this report, the standard error also

reflects part of the variation which arises in the

measurement process. It does not include estimates of any systematic biases that may be in

the data. The chances are about 68 out of 100

that an estimate from the sample would differ

from a complete census by less than the standard error. The chances are about 95 out of 100

that the difference would be less than twice the

standard error and about 99 out of 100 that it

would be less than 21/2 times as large.

The relative standard error of an estimate is

obtained by dividing the standard error by the

estimate itself and is expressed as a percentage of

the estimate. For this report, asterisks (*) are

presented along with the estimate for any

estimate with more than a 30-percent relative

standard error.

Estimates of’ sampling variabilityy were calculated using the method of half-sample replication. This method yields overall variability

through observation of variability among random subsarnples of the total sample. A description of the development and evaluation of the

replication technique for error estimation has

been previously published.1O~11

Approximate relative standard errors for

aggregates and percentages are presented in

figures I and II. In order to derive error

estimates that would be applicable to a wide

variety of statistics and could be prepared at

moderate cost, several approximations were required. As a result, the relative standard errors

shown in figures I and II should be interpreted

as approximate rather than exact for any specific estimate. Directions for determining approximate relative standard errors from the figures

follow.

1. Estimates of aggregates: Approximate

relative standard errors (in percent) for

aggregate statistics, such as the number

of office visits with a given characteristic, are obtained from the curve in figure

I, or calculated by the formula

NOTE: A list of references follows the text,

50
Fiaure 1. Arwoxirnate relative standard errors for estimated numbers of office visits, 1975 National Ambulatory Medical Care

Survey

ul

. .

I I 1 1=4 1 1 I 1 1 t! I ,

I 11111111~~~ I I I I 111111111~ I I I I 1111111 ~111 I I I I 11111 30 I

r

20

1!

8

7

6

5

4

T rl r Illluill 1 1 1 1 I 1 1 1 1 1 It#l Ill I 1

1 1 1 1 1 1

I I I Illlllm 1- 1 I I Illmtmtttl I I I I 1111~ 3

I I I I Illllllll+pll

2 I I I 111 I I I I I I I 1111111 I

1

:2

.7

.6

.5

.4

.3

.2

.1

log

80

70

60

50

40

30

20

~.

Jo

8

7

6

5

4

3

2

A2 3 456789A 2 3 456789A 2 3 456789 A2 3 456789A

100 1,000 10,000 100,000 1,000,000

SIZE OF ESTIMATE (IN THOUSMJDS)

Example of use of this chart: An estimate of 10 million office visits (read from scale at bottom of chart) has a relative

standard error of 7.5 percent (read from scale at left side of chart) or a standard error of 750,000 office visits (7.5 percent of 10

million visits).

,“’
Figure 11. Approximate relative standard errors for percentages of estimated numbers of office visits,

1975 National Ambulatory Medical Care Survey

(Base of uercenta~eshown on curvesinmillions)

UJ

>

i=

aJ

w

a

100

90

80

70

60

50

40

30

20

1:

8

7

6

5

A

3

2

1

.9

.8

.7

.6

.5

.4

.3

.2

,1

: 100

:90

: 80

- 70

- 60

- 50

- 40

30

,

6

5

4

3

20

10

9

a

7

2

1

.9

.8

.7

.-

.5

.4

.3

.2

1

1 1 I I I I I I I 1 11111 44 .6

A 2 3456789A 2 3456789A

..

1 10 100

ESTIMATED PERCENTAGE

Example of use of this chart: An estimate of 20 percent (read at bottom of chart) based on an

estimate of 10 million office visits has a relative standard error of 13.4 percent (read from scale at left

of chart) or a standard error of 2.7 percentage points (13.4 percent of 20 percent).

52
/

RSE (x) = .001160252 +

44.6697. loo

x

where x is the aggregate of interest in

thousands.

2. Estimates of percentages: Approximate

relative standard errors (in percent) for

estimates of this type can be calculated

from the curve in figure I as follows.

Obtain the relative standard error of the

numerator and denominator. Square

each of the relative standard errors,

subtract the resulting value for the

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 figure II. Alternatively, the

formula

J

44.6697 ● (1 -~) .100

RSE @)= ~ex

can be used to calculate RSE for any

percentage (p) and base (x, in thousands).

3. Estimates of rates where the numerator

is not a subclass of the denominator:

Approximate relative standard errors for

rates where the denominator is the total

U.S. population or one or more of the

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

obtained from figure L

4. Estimates of differences between two

statistics: The relative standard errors

shown in this appendix are not directly

applicable to differences between two

sample estimates. The standard error of a

difference is approximately the square

root of the sum of the squares of each

standard error considered separately.

This formula will represent the standard

error quite accurate] y 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. There is no way to compute the

magnitude of these errors. However, these types

of errors were kept to a minimum by methods

built into the survey procedures. Extensive

pretesting and careful attention was given to

phrasing of the questions and the terms employed and their definitions in order to eliminate ambiguities and encourage uniformity.

Steps taken to reduce nonresponse bias were

discussed in the sections on field procedures and

data collection. Errors in coding and processing

were reduced by verification and consistency

checks.

Tests of Significance

In this report, the determination of statistical

inference 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 were statistically significant. Terms such as “similar,” “no

difference,” etc., mean that no statisticrd signifi- —

cance exists between the statistics being compared. Lack of comment regarding the difference between any two statistics does not mean

the difference was tested and found to be not

significant.

Hypotheses involving the regression of symptom and diagnosis variabIes on age groups were

tested by a weighted least squares technique

based on a modified regression model.

Population Figures

The base population used in computing

annual visit rates is presented in table II. These

figures are based on provisional estimates for the

civilian noninstitutionalized population as of

July 1, 1975, provided by the U.S. Bureau of

the Census. Because the NAMCS includes data

for only the coterminous United States, the

original census estimates were modified to

account for the exclusion of Alaska and Hawaii

from the study. For this reason the population

estimates should not be considered as official

population estimates and are presented here

53
Table 11. Estimates of the civilian noninstitutional ized population of the United States, 1 by age, race, sex, geographic region, and

metropolitan and nonmatropolitan area as of July 1, 1975

[Used in the calculation of rates for tables 1 and 2]

Race, sex, geographic region, and area

R aca

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

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

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

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

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

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

All other races ........................................................................

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

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

Geographic region

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

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

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

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

Area

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

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

lExcludes Alaska and Hawaii.

solely for the purpose of providing denominators for rate computations.

Systematic Bias

There have been no attempts to determine

systematic bias in the data reported here or to

measure the impact of any biases. There are

several factors, however, that the user of these

data should understand, all of which indicate

that these data underrepresent the total number

of office visits to office-based physicians. These

factors are as follows:

Age

Number in thousands

207,808

101,166

108,643

180,568

88,162

92,406

27,242

13,005

14,237

49,030

56,607

66,122

36,059

141,310

66,499

52,307

26,681

25,627

43,685

22,342

21,343

8,622

4,339

4,284

. . .

. . .

. . .

. . .

. . .

. . .

39,003

19,599

19.404

33,324

16,825

16,499

5,679

2,774

2,905

. . .

. . .

. . .

. . .

. . .

. . .

52,203

25,635

26,568

45,627

22,635

22,991

6,578

3,001

3,576

. . .

. . .

. . .

. . .

. . .

. . .

42,455

20,308

22,147

38,062

18,269

19,791

4,394

2,039

2,356

. . .

. . .

. . .

. . .

. . .

. . .

21,840

8,943

12,897

19,872

8,092

11,780

1,969

851

1,117

. . .

. . .

. . .

. . .

. . .

. . .

1. The sampling universe for the 1975

NAMCS was the files of “office-based,

patient-care” physicians maintained by

the AMA and AOA. There are certainly

physicians not so classified who, at the

time of the survey, would have met the

criteria for that classification. Visits to

these physicians are not represented in

these data.

2. A frequent reason for not participating

in the NAMCS was given as “too busy”

54
or “too busy right now. ” This is an tious job in keeping the Patient Log;

indication that the busier physician was however, the probability that a patient

not as likely to participate as the less was accidentally omitted from the surbusy physician. vey is much greater than the probability

that a patient was included who did not

3. Physicians who participated in the make a visit. This factor could also

NAMCS did a thorough and conscien- introduce a slight bias.

—ooo —

55
APPENDIX II

DEFINITIONS OF CERTAIN TERMS USED IN THIS REPORT

Terms Relating to the Survey

Office(s). –Premises that the physician identifies as locations for his ambulatory practice.

Responsibility over time for patient care and

professional services rendered there generally

resides with the individual physician rather than

with any institution.

Ambulatory patient. –An individual seeking

personal health services, who is neither bedridden nor currently admitted to any health care

institution on the premises.

Physician. –Can be 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-of-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. –Can be classified as either:

In-scope: All patients seen by the physician

or member of his staff in hk office(s).

Out-of-scope: Patients seen by the physician

in a hospital, nursing home, or other extended care institution, or the patient’s

home. [Note: If the physician has a pn”vate

o f f ice (fitting the definition “office”)

located in a hospital, the ambulatory patients seen there would be considered inscope.] The following types of patients are

also considered out of scope:

Patients seen by the physician in an

institution (including outpatient clinics

of hospitals) for which the institution

has the primary responsibility for the

care of the patient over time.

Patients who telephone and receive

advice from the physician.

Patients who come to the office only to

leave a specimen, pick up insurance

forms, or pay their bills.

Patients who come to the office only to

pick up medications previously prescribed by the physician.

56
Visit.–A direct, personal exchange between

an ambulatory patient and a physician (or members of his staff) for the purpose of seeking care

and rendering health services.

Physician specialty. –Principal specialty (including general practice) as designated by the

physician at the time of the survey. Those

physicians for whom a specialty was not obtained were assigned the principal specialty

recorded in the master physician files maintained by the American Medical Association or

the American Osteopathic Association.

Region of practice location. –The four geographic regions, excluding Alaska and Hawaii,

\vhich correspond to those used by the U.S.

Bureau of the Census, are as follows:

Region

Northeast . . . . . . .

North Central . . .

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

Wfxt. . . . ... .. ..

States included

Connecticut, Maine, Massachusetts, New Hampshire,

New Jersey, New York,

Pennsylvania, Rhode Island,

Vermont

Illinois, Indiana, lows, Kansas, Michigan, Minnesota,

Missouri, Nebraska, North

Dakota, Ohio, South

Dakota, Wisconsin

Alabama, Arkansas, Delaware, District of Columbia,

Florida, Georgia, Kentucky,

Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia,

West Virginia

Arizona, California, Colorado, Idaho, Montana, Nevada, New Mexico, Oregon,

Utah, Washington, WyOmin~

iUt’tropolitan status of practice location. —

Physician’s practice is classified by its location in

metropolitan or nonmetropolitan areas. Metropolitan oreas are standard metropolitan statistical areas (SMSA’S) as defined by the U.S.

Office of Management and Budget.

l’he definition oi an individual SLISA intwlves two considerations: first, a city or cities

of specified popLdation which constitute the

central city and identify the coLmty in which it

is located as the central county; second, economic and social relationships with “contigLlous” counties which are metropolitan in

character so that the periphery of the specific

metropolitan area may be determined. SMSA’S

may cross State lines. In New England SMSA’S

consist of cities and towns rather than counties.

Terms Relating to the

Patient Record Form

Age. –The age calculated from date of birth

was the age at last birthday on the date of visit.

Color or race. –On the Patient Record, color

or race includes four categories: white, Negro/

black, other, and unknown. The physician was

instructed to mark the category which in his

judgment was most appropriate for the patient

based Llpon observation and/or prior knowledge

of the patient. “Other” was restricted to Orientals, American Indians, and other races neither

Negro nor white.

Patient k principal problem(s), complaint(s),

or symptom(s) (in patien t‘s own words). —The

patient’s principal problem, complaint, symptom, or reason for the visit as expressed by the

patient. Physicians were instructed to record key

words or phrases zwrbatim to the extent possible, listing that problem first which in the

physician’s judgment was most responsible for

the patient’s visit.

Seriousness of problem in itcm 5a.–This

item includes foLm 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 physician’s clinical jLldgment as to the extent of

the patient’s impairment that might result if no

care were given.

Major reason(s) for this uisit. –The patient’s

major reason(s) for the visit were classified by

the physician into one or more of the following

categories:

Acute problem: A condition or illness having

a relatively sudden m- recent onset (i. e.,

within 3 months of the visit).

57
Acute problem, follow up: A ret~lrn visit

primarily for continued medical care of a

pretriously treated acute problem.

Chronic problem, routine: A visit primarily

to receive regular care or examination for a

preexisting chronic condition or illness (onset of condition was 3 months or more

before this visit).

Chronic problem, flareup: A visit primarily

due to a sudden exacerbation of a preexisting chronic condition.

Prenatal care: Routine obstetrical care provided prior to delivery.

Postnatal care: Routine obstetrical care or

examination provided following delivery or

termination of pregnancy.

Postoperative care: A visit primarily for care

required following surgical treatment. Includes changing dressing, removing sutures

or cast, advising on restriction of activities or

routine after surgery checkup.

Well adult and/or child examination: General health maintenance examinations and

routine maintenance examinations and routine periodic examinations of presumably

healthy persons, both children and adults.

Includes annual physical examinations, wellchild checkups, school, camp, and insurance

examinations.

Family planning: Services or advice that

enable patients to determine the number and

spacing of their children. Includes both

contraception and infertility services.

Counseling and/or advice: Information of a

health nature which would enable the patient to maintain or improve his physical or

mental well-being. Included would be advice

regarding diet, changing habits or behavior,

and general information regarding a specific

problem.

Zmmwization: Administration of any inoculation of specific substances to produce a

desired immunity; this includes oraI vaccines. (Allergy shots are not included in this

category, but are entered in “other.”)

Referred by another physician or agency:

Medical attention prompted by advice or

referral for consultation by advice or referral

for consultation or treatment from another

physician, hopsital, clinic, health center,

school nurse, minister, pharmacist, etc. Does

not include self-referral or referral by family

or friends.

.4dministrative purpose: Reasons such as

completing insurance forms, schuol forms,

work permits, or discussion of patient’s bill.

Other: The reason for this visit is not

covered in the preceding list.

Principal diapzosis. –The physician’s diagnosis of the patient’s principal problem or complaint. In the event of multiple diagnoses, the

physician was instructed to list them in order of

decreasing importance; “principal” refers to the

first-listed diagnosis. The diagnosis represents

the physician’s best judgment at the time of the

visit and may be tentative, provisional, or

definitive.

Other sipificant current diagnosis. –The diagnosis of any other condition known to exist

for the patient at the time of the visit. Other

diagnoses may or may not be related to the

reason for that visit.

Treatments and services ordered or provided. —These include the following:

Limited history andjor examination: History

and/or physical examination which is Iirn

ited to a specific body site or system, 01

which is concerned primarily with the patient’s chief complaint, for example, pelvic

examination or eye examination.

General hktory and/or examination: History

and/or physical examination of a comprehensive nature, including all or most body

systems.

Clinical laboratory 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.

58
Hearing test: Auditory acuity test.

Vision test.’ Visual acuity test.

Endoscopy: Examination of the interior of

any body cavity, except ear, nose, and

throat, by means of an endoscope.

Oj~icc 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.

Drug prescribed: Drugs, vitamins, hormones,

ointments, suppositories, or other medications ordered or provided, except injections

and immunizations.

X-ray: Any single or multiple X-ray examination for diagnostic or screening purposes.

Radiation therapy is not included in this

category.

Injection: Administration of any substance

by syringe and needle subcutaneously, intravenously, or intramuscularly. This category

does not include immunizations, enemas, or

douches.

Immunization and/or desensitization: Administration of any immunizing, vaccinating,

or desensitizing agent or substance by any

route, for example, syringe, needle, orally,

gun, or scarification.

Physiotherapy: Any form of physical therupy ordered or provided, including any

treatment using heat, light, sound, or physical pressure or movement, for example,

ultrasonic, ultraviolet, infrared, whirlpool,

diathermy, cold therapy, and manipulative

therapy,

Medical counseling: Instructions and recommendations regarding any health problem,

including advice or counsel about diet,

change of habit, or behavior. Physicians are

instructed to check this category only if the

medical counseling is a significant part of the

treatment.

Psychotherapy and/o~ therapeutic listening:

All treatments designed to produce a mental

or emotionaI response through suggestion,

persuasion, reeducation, reassurance, or support, including psychological counseling,

hypnosis, psychoanalysis, and transactional

therapy.

Other: Treatments or services rendered

which are not listed in the preceding categories.

Disposition. –Eight categories are provided

to describe the physician’s disposition of the

case as follows:

iVo followup planned: No return visit or

telephone contact was scheduled for the

patient’s problem on this visit.

Return at specified time: The patient was

told to schedule 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 considers it necessary.

Telephone followup planned: The patient

was instructed to telephone the physician on

a particular day to report on his progress, or

if the need arises.

Referred to other physician or agency: The

patient was instructed to consult or seek

care from another physician or agency. The

patient may or may not return to this physician at a later date.

Returned to refern”ng physician: Patient was

referred to this physician and was now

instructed to consult again with the physician or agency which referred him.

Admit to hospital: Patient was instructed

that further care or treatment will 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.

59
Duration of visit. –Time the physician spent tests results, and so forth. In the event a patient

with the patient, but does not include the time was provided care by a member of physician’s

patient spent waiting to see the physician, time staff but did not see the physician during the

patient spent receiving care from someone other visit, “duration of visit” was recorded as zero

than the doctor without the presence of the minutes.

physician, and time spent reviewing records,

—ooo —

60
APPENDIX Ill

SURVEY INSTRUMENTS

INTRODUCTORY LETTER FROM DIRECTOR,

NATIONAL CENTER FOR HEALTH STATISTICS

@

#* ~~,,

%*

.

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE :*4 .:

% “,, .+”’ PUBLIC HEALTH SERVICE

HEALTH RESOURCES ADMINISTRATION

ROCKVILLE. MARVLAND -

NATIONAL CENTER FOR

HEALTH STATISTICS

Endomlng Organizations

American Madlcal Auoclatlon

James H. Sammons, M.D.

Exacutlva WC* Prasld.nt

Natlomt M,dkd AssoC18U0.1

Alfrad F. FINmr

EX*CUOV*Dlr.ctor

Amwlcsn Ac8d#mY of D9rm8tO10#Y

John M. Shaw, M.D.

S.cr.tMY.Tr..aur.r

Am8rlewI AcadamY of Family

PhY11ct8ns

Row Tu%kan

EXOCUtiV*Dlrutor

Am#rlcan Acad9my of N.ur.10W

Wanly A. N91son

EXUUNV. Dlmctor

Am.rlea. Academy of Orth.Pndl.

s.rs..ns

Charlas V. HUN, M.D.

Executlw Dlr.ctor

Amarlcan Acad9mY of ?adtatrlcs

Robat G. Frazlar, M.D.

Ex*cutlv. Dlr*ctOr

Am.rkan CON*W of omt.trlcls.s

and QYnUoloslsts

warm. H. Paars.. M.O.

Dlr*ctOr

Amert.an CON9W of PhY11C18n1

Edward C. Rosenow, Jr., M.D.

Exccutlve Vlca Pr*sldmt

Amarlean CON*W of ●r*v*nOva

MUdlcln.

Ward B.ntl.Y

Executlva Dkector

Am.,lc.” CON*,* O* surs.n.s

C. ROlllnS hNIIOn. M.L_J.

EX9CUNV. ❑ w8ctor

Arnwkan Ostaonathlc Ast0c18ti0n

Edward P. Crow.11, D. 0.

Enacutlva Dwector

Am.rlcan Proctoloslc S.cletY

Alejandro F. Castro, M.D.

Sacr*tary

Am,,loa” P,yohlatrlC &SSOC1.tiOn

Malvln %bshln, M.D.

M.dlcal Director

Am,rl.an SOCNW of Internal

M9dlcln*

Wllllam R. R.ms.Y

EX8CUOW Dk9ctor

Am,rtcmI Socl,ty of Plasttcand

Raconstruotlva surwons, lnO.

Dallas F. Whal*Y

Exec.tl.e vice Presld.nt

Awl,,lca” UrOlOSIC Assc.dSNOn

Ml B. J.n.lmm, Jr., M.D.

Executive Olrector

Assa,laNon of Am.IIcm M.dlcal

Collmges

John A. D. copper, M. D., Ph.D.

Presle*”t

Dear Dr.

The National Center for Health Statistic, as part of its

continuing program to pr@Jide information on the health

status of the American people, is conducting a National

Ambulatory Medical Care Survey (NA..ICS).

The purpose Df this survey is to collect inffJrmation

about ambulatory patients, their problems, and the

rescmrces used for their care. The resulting published

statistics will help your profession plan fDr more

effect ive health services, determine health msnpDwer

requirements, and imprcwe medical educat icm.

Since practicing physicians are the only reliable source

of this information, we need your assistance in the NAMCS.

Aa one of the physicians selected in our national sample,

your participation is essential to the success of the

survey. Of course, all information that yDu provide is

held in strict confidence.

Msny organizations and leaders in the medical profession

have expressed their support frm this survey, including

those ahown to the left. They join me in urging your

cooperation in this important research.

Within a few days, a survey representative will telephone

you for an appointment to discuss the details of your

participaticm. We greatly appreciate your cooperation.

Sincerely yours,

DDrothy P. Rice

Director

61
CONFIDENI!IAL*

NORC-4233

!OR OFFICE USE

ONLY:

m

5-61

m

7-101

INDUCTION INTERVIEW FORM

BEGIN DECK 3

lZZZ&=l ——

NATIONAL AMBULATORY MEDICAL CARE SURVEY

INDUCTION INTERVIEW

BEFORE STARTING INTERVIEW

1. ENTER PHYSICIAN 1.D. NUMBER IN BOX TO

RIGHT.

2. ENTER DATES OF ASSIGNED REPORTING WEEK IN

Q. 2, P. 2.

m

1-4/

TIME AM

BEGAN: PM

Doctor, before I begin, let me take a minute to give you a little background about

this survey.

*

The National Ambulatory Medical Care Survey is authorized by

Congress in Public Law 93-353, section 308. It is a voluntary

study and there are no penalties for refusing to answer any

question. All information collected is confidential and will

be used only to prepare statistical sunmaries. No information

which will identify an individual or a physician’s practice

will be released.

Although ambulatory medical care accounts for nearly 90 per cent of all medical care

received in the United States, there is no systematic information about the characteristics and problems of people who consult physicians in their offices. This kind

of information has been badly needed by medical educators and others concerned with

the medical manpower situation.

In response to increasing demands for this kind of information, the National Center

for Health Statistics, in close consultation with representativesof the medical

profession, has developed the National Ambulatory Medical Care Survey.

Your own task in the survey is simple, carefully designed, and should not take much

of your time. Essentially, it consists of your participation during a specified

7-day period. During this period, you simply check off a minimal amount of information concerning patients that you see.

Now, before we get into the actual procedures, I have a few questions to ask about

your practice. The answers you give me will be used only for classificationand *

analysis, and of course all information YOU provide iS held in strict confidence. —

1. First, you are a Is that right?

(ENTER SPECIALTY FROM CODE ON FACE SHEET LABEL.).

Yes . . . . . . . . . ..X

No. . . . (AsKA) . . . . y

A. IF NO: What is your specialty (includinggeneral practice)?

1111 (Nameof Specialty) 11-13/

63
2. Now, doctor, this study will be concerned with the ambulatory patients you will

see in your office during the week of (MAD REPORTING DATES ENTERED BELCW).

(that’s a (that’s a

I

=— date

Are you likely to see

Monday) through I Sunday)

month date

~ ambulatory patients in your office during that week?

Yes . . . . ..(GOTOQ.3).

No . . . . . . (ASKA) . . .

A. IF NO: klhyis that? RECORD VERBATIM, ‘HEN READ PARAGRAPH BELW

.x

.Y

Since it’s very important, doctor, that we include any ambulatory patients

that you &happen to see in your office during that week, I’d like to

leave these forms with you anyway--just in case your pla& change. I’ll

plan to check back with your office just before (STARTINGDATE) to make

sure, and I can explain them in detail then, if necessary.

GIVE DOCTOR THEA PATIENT RECORD FORMS AND GO TO Q. 9, P. 6.

64
3. A. At what office location will YOU be seeing ambulatory patients during that

T.dayperiod? RECORD UNDER A BELOW AND THEN CODk B.

B. FOR EACH OFFICE LOCATION ENTERED IN A, CODE YES ORNO TO “IN SCOPE.”

IN SCOPE (Yes) [OUT OF SCOPE (No) [

Private offices Hospital emergency rooms

Free-standingclinics Hospital outpatient departments

(non-hospitalbased) College or university infirmaries

Groups, partnerships Industrial outpatient facilities

Kaiser, HIP, Meyo Clinic Family planning clinics

NeighborhoodHealth Centers Government-operatedclinics

Privately operated clinics (VD, maternal iichildhealth, etc.)

(except family plaming)

IN CASE OF DOUBT, ASK: Is that (clinic/facility/institution)hospital based?

Is that (clinic/facility/institution)government

operated?

c. Is that all of the office locations at which you e~ect to see ambulatory

patient=uring that waek?

Yes. . . . . . . . . . . X

No . . . . . . . . . . .Y

IF NO: OBTAIN ADDITIONAL OFFICE LOCATION(S),EN2ER IN “A” BELOW, ANO RBPEAT.

A. B.

OffAce Location In Scope?

(1) x Y

(2) x Y

(3) x Y

(4) x Y

IF ALL LOCATIONS ARE OUT OF SCOPE, THANKTHE DOCTOR AND LEAVE.

65
4. A.

B.

DECK 3

During that week (REPEATDATES), how many ambulatorypatients do you expect

to see in your office practice? (DO NOT COUNT PATIENTS SEEN AT [OUT-OF-SCOPE

LOCATIONS]-CODED IN 3-B.)

ENTER TOTAL UNDER “A” BELON AND CIRCLE ON APPROPRIATE LINE.

And during those seven days (REPEATDATES IF NECESSARY), on how many ~ do

you expect to see any ambulatory patients? COUNT EACH DAY IN WHICH DOCTOR

EXPECTS TO SEE ANY PATIENTS AT AN IN-SCOPE OFFICE LOCATION.

ENTER TOTAL UNDER “B” BELOW AND CIRCLE NUMBER IN APPROPRIATE COLUMN.

DETERMINE PROPER PATIENT LOG FORM FROM CHART BELCXi. READ ACROSS

ON ‘lTIJTALpATIENTS” LINE I.JNDER“A” AND CIRCLE LETTER IN APPROPRIATE

“DAYS” COLUMN UNDER “B.”

THIS LETTER TELLS YOU WHICH OF THE FOUR PATIENT LOG FO~S (A, B, C, D)

SHOULD BE USED BY THIS DOCTOR.

LOG FORM DESCRIPTION

A. B.

Expected total Total ~ in practice

patients during during week.

survey week. ENTER TOTAL

ENTER TOTAL FROM FROM Q. 4-B. DAYS

A--Patient Record is to be . -.

completed for ALL

patients liste=n Log. 14-16/

“m” 111111 1234567

1- 12 PATIENTS AA AAAAA’

13- 25 “ B AAAAAA

B--Patient Record is to be 26- 39 “ CBAAAAA

completed for every

SECOND patient listed 40- 52 “ CBBAAAA

on Log. 53- 65 “ DCBBAAA

166-79’’ !DCBB BAA

C--Patient Record is to be

completed for every

THIRD patient listed

on Log.

.~

*D--Patient Record is to be

comleted for every

FIF~ patient list~d

on Log.

132-145 “ DDDCCBB

146-158 “ DDDCCBB

159-171 “ DDDC CCC

172-184 “ DDDCCCC

185-197 “ DDDDDDD

I 198-210 “ ID DDDDDD

I

211+ “ DDDDDDD

*

In the rare instance the physician will see more than 500 patients during his

assigned reporting week, give him two D Patient Log F=s and instruct him to complete a patient record form for only every Then you are to draw an X

through the Patient Record on every other page of the two folio pads, starting with

page 1 of the pad. The physician then completes the Patient Log on-page, but

completes the Patient Record on every second page.

66
5. FIND LOG FOLIO WITH APPROPRIATE LETTER AND CIRCLE LETTER, ENTER FIRST FOUR

OF THE FORN AND NUNBER OF LINES STAMPED “BEGIN ON NEXT LINE” FOR THE B-C-D

FORMS (if no lines are stamped, enter 1’0”)BELOW.

FOLIO No. Lines FOR OFFICE USE ONLY

Stamped “BEGIN Number patient record

Letter .Nh.er ON NEXT LINE” forms Completed.

A

B

c

D

DECK 3

NUMBERS

LOG

17-21/

22-24/

6. HAND DOCTOR HIS FOLIO AND EXPLAIN HOW FORMS ARE TO BE FILLED OUT. SHOW DOCTOR

INSTRUCTIONSON THE POCKET OF FOLIO, ITEMS 11 AND 12 DEFINITIONS ON CARD IN POCKET

OF FOLIO AND ITEM DEFINITIONS ON THE BACK OF FOLIO, TO WHICH HE CAN REFER AFTER

YOU LEAVE.

EMPHASIZE THAT EVERY PATIENT VISIT EXCEPT ADMINISTRATIVEPURPOSE ONLY IS TO BE

RECORDED ON THE LOG FOR ENTISE REPORTING PERIOD. FOR EXAMPLJ3,IF A MEDICAL

ASSISTANT GAVE THE PATIENT AN INOCULATION,OR A TECHNICIAN ADMINISTEREDAN

ELECTROCARDIOGRAMAND THE PATIENT DID NOT SEE THE DOCTOR, THIS VISIT IS TO BE

LISTED ON THE LOG.

RECORD VERBATIM BELOW ANY CONCERN> PROBLEMS OR QUESTIONS THE DOCTOR RAISES.

7. IF DOCTOR EXPECTS TO SEE AMBULATORY PATIENTS AT MORE THAN ONE IN-SCOPE LOCATION

DURING ASSIGNED WEEK, TELL HIM YOU WILL DELIVER THE FORMS TO THE OTHER LCCATION(S).

ENTER THE FORM LETTER AND NUMBER(S) AND NUMBER OF LINES STAMPED “BEGIN ON NEXT

LINE” FOR THE B-C-D LOG FOR THOSE LOCATIONS BELOW, BEFORE DELIVERING FORM(S).

FOLIO No. Lines FOR OFFICE USE ONLY:

Location Stamped “BEGIN Number patient record

Letter .Nnm~er ON NEm LINE!! forms completed

25-29/

30-32/

33-37/

38-40/

41-45/

46-48/

67
DECK 3

8. During the survey week (REPEATEXACT DATES), will anyone be available to help

you in filling out these records (at each IN-SCOPE location)?

Yes . . . . (ASKA). .OX

No . . . . . . . . . ..Y

A. IF YES: V/howould that be?

RECORD NAME, POSITION AND LOCATION.

NAME IPOSITION i

LOCATION

PERSONALLY BRIEF EACE PERSON LISTED ABOVE.

ENPHAS12E THAT EVERY PATIENT VISIT DURING THE ENTIRE WEEK IS TO BE RECORDED ON THE

LOG EXCEPT “ADMINISTRATIVEPURPOSE ONLY.”

9. Do you have a solo practice, or are you associated with other physicisnB in a

partnership, in a g;oup practice, or-in some other way? -

solo. . . . . (GO TO.Qo 10)

Partnership . . (ASK A-C) .

Group . . . . . (ASK A-C) .

<--- Other (SPECIFYAND ASKA-C)

IF PARTNERSHIP. GROUP, OR OTHER:

A,

B.

c.

Is this a prepaid group practice?

[1] IF YES TO A: What per cent

of patients are

prepaid?

How many other physician are

associatedwith you? NUMBER

What are the

(How many of

(1)

specialties of the other

these are there?)

Specialty

Yes . . (ASK [l]) .

No . . . . . . . .

. . 1 49/

. . 2

. . 3

. . 4

. . 1 50/

. . 2

per cent 51-53/

OF PHYSICIANS: 54-56/

physicians associatedwith you?

Number of Physicians

(2)

(3)

(4)

(5)

68
BEGINDECK4

10. Now I have justone more questionaboutyourpractice. (NOTE: IF DOCTORPRACTICES

IN LARGEGROUP,THE FOLLOWINGINFORMATIONCAN BE OBTAINEDFROM SOMEONEELSE.)

A.

B.

What is the total number of full-time (35 hours or more per week) employeesof your (partnership/

group) practice? Includepersons resularlyemployedwho are now on vacation,temporarilyill,

etc. Do ~ includeother physicians. RSCORO ON BOTTOM LINE OF COLU3# A BELcXJ.

(1) How many of these full-timeemployeesare a . . . (READCATEGORIESBELWAS NECESSARY

AND RSCORD NUNEBR OF EACH IN COLUMN A.)

And what is the total number of part-time (less than 35 hours per week) employeesof your

(partnership/group)practice? Again, includepersons regularlyemployedwho are now on vacation,

ill, etc. Do not includeother physicians. REC080 ON BOTTOM LINB OF COLUMN B BELOW.

(1) How many of these part-timeemployeesare a. . . (HRAOCATEGORIESBELUJAS fWCESSARY

ANo HSCORD NUMBER OF EACH IN COLUMN B.)

I “A. I B. I

Employees Full-time Part--time

(35 ar more hourslweek) (=ss than 35 hours/week) I

(1)

(2)

(3)

(4)

(5)

(6)

(7)

RegisteredNurse . . . . . . . . . . . 11-13/

Licensed PracticalNurse . . . . . . . 14-16/

Nursing Aide. . . . . . . . . . . . . 17-19/

I%ysicianAssistant* . . . . . . . . . 20-22/

Technician. . . . . . . . . . . . . . 23-25/

Secretaryor Receptionist . . . . . . 26-28/

Other (sPECIFY) 29-31/

TOTAL: 32-34/

35-37/

38-40/

41-43/

44-46/

47-49/

50-52/

53-551

‘ML: 56-58/

*

ShysicianAssistantmust be a Sraduate of an accreditedtraining program for physician

Assistants (PhysicianExtenders,S4edex,etc.) or certifiedby the NationalBoard of F$sdical

Examiners through the CertificationExam for Assistantto the PrfmaryCare Physician.

BEFOREYOU LEAVE,AGAIN STRESSTHAT~H AND m AMBULATORYPATIENTSEENBYTI@

DOCTOROR HIS STAFFDURINGTHE 7-DAYPERIODAT ALL IN-SCOPEOFFICELOCATIONS(REPEAT

THEM) IS TO BE INCLUDEDIN THE SURVEY,THAT EAC=ATIENT IS TO BE RECORDEDON THE LOG,

AND ONLY THE APPROPRIATENUMBEROF PATIENTRECORDSCOMPLETED.

Thankyou for your time,Dr. If you have any (more)questions,

pleasefeel free to callme. ~ phonemder is writtenin the folio. 1’11

call ~ on Monday morning of your survey week just to remind you.

11. TIME INTERVIEWENDED . . . . . . . . AM

PM

12. DATEOFINTERVIEW . . . . . . . . . . . . . . . 1111 I

(Month) (Day) (Year)

*U. S.00VENNMSWT PRmT12iGOFFICE:1978 2S1-259/30

69
IIWERVIEWERNUMEER

111111

INTERVIEWER’SIGNATURE

FOR OFFICEUSE ONLY:

No. of PatientsSeen:

m 5’-’”
VITAL AND HEALTH STATISTICS Series

S,ri,x 1, Pro#rams and Collection Procedures. –Reports which describe the general programs of the National

Center for Health Statistics and its offices and divisions and data collection methods used and include

definitions and other materiaf necessary for understanding the data.

Srri/’s 2. 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.

S~YiL’s3. Analytical 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.

S(.ri,.s 4. Docunwnts 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.

S~ri,’s 10. Data From the Health Interview Survey .-Statistics on illness, accidental injuries, disability, use of

hospital, medical, dentaf, and other services, and other health-related topics, all based on data collected

in a continuing national household interview survey.

.$,arit~ 11. .Datti 1+’rom the Health Examination Survey and the Health and Nutrition Examination Survey .–Data

from direct examination, testing, and measurement of national samples of the civilian noninstituticmalized population provide the basis for two types of reports: (1) estimates of the medically defined

ptwvafence of specific diseases in the United States and the distributions of the population with respect

to physicaf, physiological, and psychological characteristics and (2) analysis of relationships among the

various measurements without reference to an explicit fhtite universe of persons.

S,rit’x 12, Ilaia From the Institutionalized Population Survey s.–Discontinued effective 1975. Future reports from

these surveys will be in Series 13.

S~ri(’s 13. Data on Health Resources Utilization. –Statistics on the utilization of health manpower and facilities

providing long-term care, ambulatory care, hospital care, and family planning services.

Sf%ri(qs14, Data on Health Resources: Manpo tuer 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.

S(-rit-s 20. Data cm 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.

S(ric.s 21. Data on Natality, h~arriage, and Divorce. –Various statistics on natality, marriage, and divorce other

than as included in regular annual or monthly reports. Special analyses by demographic variables;

\lco&waphic and time series anafysa; studies of fertility; and statistics on characteristics of births not

mmilable from the vital records based on sample surveys of those records.

S,.ri(,s z?. ~ata From th~ National Mortality and Natality Surveys. —Discontinued effective ~9 ~5. Future reports

from these sample surveys based on vital records will be included in Series 20 and 21, respectively.

S<’ric’s 23. Data From the National Survey of Family Growth. —Statistics on ferti~ity, family formation and dissolution, family planning, and related maternal and infant health topics derived from a bienniaf survey

of a nationwide probability sample of ever-married women 15-44 years of age.

For a list of titles of reports published in these series, write to: Scientific artd Technical Information Branch

National Center for Health Statistics

Public Health Service

Hyattsville, Md. 20782