I

For HEALTH STATISTICS 

VITAL and HEALTH STATISTICS

PROGRAMS AND COLLECTION PROCEDURES

Origin, Program, and

Operation of the U.S.

National Health Survey

A description of the developments leading to enactment of the Nationa I Health Survey Act ~ and

a summary of the ~licies, initial program, and

operation of the Survey.

Washington, D.c. Reprinted April 1965

U.S. DEPARTMENT OF

HEALTH, EDUCATION , AND WELFARE

Anthony J. Celebrezze

Secretary

Public Health Service

Luther L. Terry

Surgeon Genero I
NATIONAL CENTER FOR HEALTH STATISTICS

Forrest E. Linder, Ph. D., Director

Thecdore D. Woolsey, Assistant Director

O. K. Sagen, Ph. D., Assistant Director

Carl C. Dauer, M. D., Medical Advisor

Louis R. Stolcis, M.A., Executive Officer

OFFICE OF ELECTRONIC SYSTEMS

Charles E. Greene, Chief

OFFICE OF HEALTH STATISTICS ANALYSIS

Iwao M. Moriyama, Ph. D., Chief

NATIONAL VITAL STATISTICS DIVISION

O. K. Sagen, Ph. D., Chief

NATIONAL HEALTH SURVEY DIVISION

Theodore D. Woolsey, Chief

Public Health Service Publication No. 1000-Series 1-No. 1
-.

I

.

CONTENTS

The Need for Health S~tisrics ------------------------------------------

The Dvelopmenr of Healti SEtisucs ------------------------------------

Problems of hfeasurement ---------------------------------------------

Data Available Prior tothe National Health Survey ------------------------

The Experience in Health Statistics Collection ----------------------------

Important Early Srudies ---------------------------------------------

Activities of the Years 1949-55--------------------------------------

The Nariollal Health Survey Act-----------------------------------------

Policies and Organization of the Survey ----------------------------------

Program of tie U.S. National Health Survey ------------------------------

The Health Interview Survey --------------------------------------------

The Health Examination Survey -----------------------------------------

The Health Records Survey ---------------------------------------------

Ikvelopmental and Evaluation Studies -----------------------------------

Reporting the Results --------------------------------------------------

Potentials and Limitations of the Survey Program -------------------------

Appendix I

Recommendations for the Collection of Data ontheDistriburion and Effects

of Illness, Injuries, and Impairments in the Unired States ---------------

Pm-t I

Summary ---------------------------------------------------------

Part 11

The Work of Previous Committees and tie Task of The Present Subcomminee ---------------------------------------------------------

Part HI

Current and Potential Uses of hlorbidity and Related Dara ---------------

Broad Areas of Need for Morbidity Statistics and Related Data --------

Parr I\’

Types of Dara, Detail, and Frequency of Collection Required ------------

General h40rbid~ Data -------------------------------------------

Frequency of Collection ---------------------------------------------

Geographical Dtati -------------------------------------------------

hd\'idual Smdies ---------------------------------------------------

i
CONTENTS-Continued

Page

Part V

Review of Present Sources of National Morbidity Statistics -------- ------

The National HealthSurvey ----------------------------------------

Advances in Sampling and Survey Techniques -----------------------

Other Recent Studies ---------------------------------------------

Llorbidity Statistics Applicable to Large Segments of the Population---

How Other Countries Have Met This Problem -----------------------

Part VI

Recommendations: Types of Data to be Collected in Order to Meet U.S.

Needs ------------------------------------------------------------

Function of National Morbidity Surveys -----------------------------

Function of Special Smdies ----------------------------------------

Requests for Data That are not Feasible to Meet --------------------

Part VII

Recommendations on SurveyDesign -----------------------------------

Major Specifications of Accuracy and Derail ------------------------

Major Specifications of the Survey Design --------------------------

Special S~dies --------------------------------------------------

Part VIII

Suggested hfethods for Obtaining Dataon Need for Medical Care ----------

Appendix II

National Health Survey Act------------------------------------------

An Acr----------------------------------------------------------

National Health Surveys and Studies --------------------------------

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41
U.S. NATIONAL HEALTH SURVEY

A cotxtnumg survey of the United States to obtain information about health conditions of the general population was authorized by legislation

signed by the President in July 1956. The new law

established, within the Public Health Service, the

U.S. National Healti Survey which soon launched

a program to produce statistics on disease, injury,

impairmem, disability, and related topics on a

uniform basis for the Nation. This marked a significant step in the efforts of the Federal Government to provide tools for improving the health of

the American people.

THE NEED FOR HEALTH STATISTICS

Comprehensive heal~h statistics are needed

in this country because a healthy people is perhaps the Nation’s greatest resource. Thehighposition of health in the national scene is justified

whether the evaluation of it is smictly in monetary

terms or in terms of less well-defined but more

appropriate scales of national vitality, morale, individual well-being, and other human values. The

measuremem of this important fac~or—the people’s health —is found in the statistical measuremem of well-being.

Primary users of general health statistics,

particularly of morbidity data, include the directors of operaung health agencies. An accurate

appraisal of the extent and character of disease

and the dismiburion and mends of morbidity are

essential to the effective planning and evaluation

of their programs and for extending the scope and

improving the balance of their work.

Public and private health agencies, which

first devoted their efforts primarily to the control

of infectious diseases, have seen their responsibilities broaden in several dimensions. As emphasis shifted to the conmol of chronic diseases,

many health deparunents began to be concerned

methods and- coordinating

v a. .G.y “1 DLL GG1lL1lg

~heir medical care

efforts. An adequa~e supply of beds for ~he car

chronic disease patients in special and gen

hospitals and nursing homes and the establishme

of home nursing care and rehabilitation program

and in some areas public medical care progra

for tie medically indigent, all became of int-c

to these healrh deparunems. The nature of o

pational health programs and maternal and 

hygiene programs has changed in recent ye

and the importance of health education and o

techniques of the behavioral sciences has 

creased,

In me United States this evolu~ion in the 

ture of activities of official health agencies 

been accompanied by a growth in tie number 

variery of voluntary health agencies and by g

ing efforts in the area of medical resear

New types of statistics were required 

identify the problems which arose and to dev

and appraise the new programs. Quantitative 

formation on tie prevalence of chronic disea

and impairments, “the volume and degree of 

ability, the use of medical services and hosp

beds, and tie patterns of behavior of chronica

ill persons are but a few of the types of 

needed by modern health agencies.

The needs of the social security and v

tional rehabilitation agencies for health statis~

are similar to those of the heal~h agencies. 

example, total benefit payments for unempl

ment and disability ,ae related to the volume 

nature of illness, and tie question of how m

could benefit by vocational rehabilitation is 

ticularly important.

In a more tangential way, s~ati.wits of m

bidity contribute IO the field of medical researc

Clues to the etiology and pathogenesis of dise

often emerge horn studying the association 

tween the incidence or prevalence of disease 

va’rious demographic, social, and geograp

factors.

An increasing general awareness of econo

problems has brought to the fore some o
. .

more direct economic applications of morbidity

statistics. Some of these applications relate to

improved evaluation of manpower resources for

civilian and defense purposes. The economic loss

of productive capacity due co illness is recognized

as an important factor in the changing economic

picture. The more stable component of this loss,

attributable to chronic diseases and impairments,

represents a potential source of extra productive

capacity if available methods for the rehabilitation of workers can be used effecriveIy.

In another application, morbidity statistics

related to demographic factors form the actuarial

cornerstone in developing voluntary hospiml and

medical insurance plans. As these plans increase

in number and scope, health data covering all

segments of the population become indispensable.

Closely related to these uses of health statistics

is the interest of drug and appliance manufacturers

in estimating potential markets for new products

and the use of such statistics as general guidelines in market analysis and production scheduling.

THE DEVELOPMENT

OF HEALTH STATISTICS

Just as the original activities of health agencies were focused largely on controlling infectious

diseases, so the early health statistics wereconfined largely to reportable diseases and mortality.

The expmding prugrmns of the health agencies

indicated a serious need for a corresponding extension of the field of health statistics. In view of

tiis, it is remarkable that the health aspects of

~he national economic and social life remained for

such a long time without the systematic statistical

measurements that were generally available for

agriculture, finance, m mu factoring, employment,

foreign trade. ~nd population.

-PROBLEMS OF MEASUREMENT

The comparatively slow development of statistics of illness for the general population can be

ascribed to inherently difficult problems of measurement. In the case of health and vital statistics,

death is a clearly defined event, occurring once

for each person and m a closely determinable

point in time. ‘The existence of a morbid condition,

on the other hand, is by no means always clearly

distinguishable from acceptable good health. Likewise, the beginning and end of the condition of

morbidity cannot always be accurately specified,

even by the person affected.

2

As has often been pointed our, there is a continuous scale of well-being extending from good

health to severe sickness. The point on the scale

which appropriately represents the dividing line

between illness and heakh depends on the purpose

for which tie statistics are to be used, as do the

appropriate srandards of measuremem. For some

purpcses this point must be based on medical

evidence, and the whole scale must be marked off

in terms of clinicaI and pathological criteria. For

other purposes it is more appropriate to consider

a person ilI when he considers himself to be ill

and to mark off the scale in terms of the actions

he takes as a result of his ilIness-the extent to

which he cuts down on his usual activities because

of his condition, rakes to his bed, calls upon a

physician for help, and so on. The application of

two such different means of measurement will,

with many individuals, produce quite disparate

results in terms of a health-illness scale.

Difficulties in dealing with morbidity statistics aIso srem from the many ways in which the

events may be counted and classified. The basic

measures are point p~-eualence, or simply prez’aLe)zce, meaning the number of a specified type of

conditions existing at any given time, and incideuce, meaning the number of new cases of a certain type starting in a defined period of time.

There also are variants and combinations of these

measures. The classifications may be numerous:

such as whether the condition can be considered

as acute or chronic; or it may be classified according to the diagnosis, the prognosis, the severity, the kind and amount of care received or required, or the consequences of the condition to the

individual’s family and to the community. Each of

the possible units of tabulation and each of the

various axes of classification may provide the

statistics required for some important application

of the data.

The variety of rypes of data is paralleled by

the number of sources from which morbidity data

can be obtained. Three principal types of sources

are: (1) those that provide data as a by-product

of the operanon of some medical care or insurance plan; (2) those that derive data from other

types of existing medical records, such as the

records of physicians and hospitals; and (3) those

that are based on records created specifically for

the morbidity statistics, such as interview records

and special health examinations. Because of the

greater ~ssibilities for relating the data to samples of the general ppulation, the last of these

classes has notable advantages in the compilation

of health data. However, with regard to any of
con1 13~

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rpose

io the

some

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:ed off

a. For

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be ill

ctions

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ally for

‘ecords

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pilation

any of

m

these sources of data, the full potentialities are

only beginning to be explored.

For example, there are certain types of information which can best be obtained tiom the sources

horn which persons seek health care. To gather

information of this kind it is desirable to sample

not tie general population but the health care

sources themselves. For the most part the basic

darum in such sampling might be an exisdng record, but often a record may have to be created for

the purpxes of the survey.

DATA AVAILABLE PRIOR TO THE

NATIONAL HEALTH SURVEY

Before the National Healfi Survey was established, information on the extent and characterstics of illness was limited largely to that derived

from physicians’ reports of selected communicable diseases as required by State laws; to the results of a large number of specialized and local

health studies and surveys; and to scattered, disparate reports from hospitals, clinics, and health

and hospital insurance plans. Whatever the quality

and adequacy of these data for the purposes for

which they were developed, their ad hoc and varied

character provided no basis for consmucting a

uniform and valid nationwide measure of the essential features of the health of Americans. A

single exception in the field of health statistics

was the statistical information relating to mor -

tal.iry. In tiis field legal demands for conmolling

the disposition of lmdies and for proof of death

led to the early establishment in every State of a

system requiring medical certification and official

registration of every death. The death-registration system has provided data for an annual series

of detailed, narional mortality statistics for a number of years. These statistics serve many essential scientific and adminis~ative purposes in the

medical, demographic, and actuarial fields. Until

1956 most of the exisdng evidence concerning the

dismibution and mends of morbidity was based on

the study of tiese mortality statistics. However,

there was a constant awareness tiat mortality

statistics alone could not serve the meat varieqr

of needs for information akut illness and disability. For example, it was well known thar death

rates could be misleading indexes of the reladve

volume of disability resulting from different diseases.

THE EXPERIENCE IN HEALTH

STATISTICS COLLECTION

As the health statistics exisdng in 195

far short of meedng national needs, so the 

niques of data collection in the health 

suffered from underdevelopment. Neverthele

the experience of a number of earlier stu

surveys, and commirtee projects was of 

benefit to the National Health Survey in the 

ning of its first activities. Without this ex

ence the new program would have had to sp

number of years in experimentation before 

extensive collection of statistics for publica

could begin.

Important Early Studies

‘The last previous effort to obtain compreh

sive illness statistics for the general popul

of the Nation was tie nationwide health surve

1935-36. This was a memendous undertaking 

which interviewers visited 737,000 urban ho

holds to learn which members of the house

had experienced disabling illness and which 

specific chronic diseases or impatiments.

While this survey was by far the largest 

had ever been devoted to le~g the facts o

ness and injury in the general population, i

not the first of its kind in the United State

number of smaller studies had demonstrated 

the interviewer method could provide useful 

formation about @e amount and distribution 

disease, the circumstances of injury, the lo

time tiom work or other usual activities resul

horn disease and injury, and tie use of med

care in connection with morbidity. Besr know

these are the Hagerstown, Md., studies o

early 1920’s and the survey made during the y

1928-31 by the Commirtee on the Costs of Me

Care. The smaller community -rype studies 

tinued after 1936 and additional refinementswer

made in techniques. An important example 

intensive community study was the Eastern H

Disrncr Study conducted in Baltimore from 

to 1943 by the Public Health Service, the Mil

Memorial Fund, tie Johns Hopkins Univer

Schcml of Hygiene and Public Health, and the 

timore City Health DeparQnent.

At the same time, great advances were m

in the science of population sampling, with 

Bureau of the Census leading the way in deve
ing practical methods of applying the theory of

probability sampling in the field. In 1943, the Bureau of the Census, building on am earlier survey

by the Works Progress Administration, began

collecting information on the labor force by conducting monthly interviews in a national sample

of households. Now known as the Current Population Survey, it was used almost from the beginning to satisfy some of the demand for national

morbidity statistics by the addition from time to

rime of special questions or supplements to the

basic questionnaire. The Current Population Survey, however, originally was designed to have and

still has as its foremost task the collecrionof information on tie characteristics of the labor

force.1

Activities of the Years 1’949-55

In January 1949 the United States National

Committee on Vital and Health Statistics was

established. Recognizing the inadequacy of available sources and the obsolescence of exisring data, the committee imme&ately gave its attention

to the problem of obtaining adequate national morbidiry statistics. Two successive subcommittees

were appointed by the chairman of the national

committee “to frame the problems in morbidity

statistics, including chronic diseases and medical

care staustics, in order tha~ morbidity data may

be directly related to demographic factors.” These

subcommittees recommended the study of a number of methodological questions, but even as rhe

recommendations were being made steps were being taken in several parts of the counmy to get

some of the answers in community surveys. About

the same time legisladon calling for an 18-month

study of medmds of measuring illness passed the

Senate but failed to pass the House of Representatives.

Within the next few yeas there was an upsur_ge of interest in illness surveys as various

groups set out to fill the gaps in available statistics or to answer particular questions with which

they were faced.

lIn 1959 tic ~=sPnsibLLcy for malysis and publication of labor force data from LIIe surrey wma m-ansferrcd to be Bureau of Latar StaUsUcs. Tim Bureau of tbe Census continues m collect and

rabulatc rhe d~ca under canmcc wicb tbe BuremJ of Lab SratisUCS. ~ 1961 tbe BIXCmJ ❑f dm Census initked s new ssmple panel czkd cbc Quarterly Household Smmple, which fmm time to time

will be used ta collect, among I rmriccy of subjects, heakb dam of

a specialized nature.

4

Tn New York City a committee undertook to

compare the health of members of the Health Insurance Plan of Greater New York with that of the

people of the city in which these members lived,

by parallel surveys in the NO populations.

The California Deparfmem of Public Health

first launched a study of methods to measure illness in San Jose and then initiated a statewide

survey to compile statistics to guide the activities

of the health deparment.

The Graduare School of Public Heahh of the

University of Pittsburgh established a series of

community studies in the Arsenal Health Dismict

and in the city as a whole, partly to train scientists and partly to study patterns of illness in relation to demographic and social facmrs.

The Commission on Chronic Illness sponsored two impntant surveys to obtain data on the

prevalence of chronic illness and disability and

to estimate what rhese data meant in Ierms of

medical care. One was carried out in a rural area

(Hunterdon County, N. J.) and the other h an urban

locality (Baldrnore, Md.). These surveys were

unique in that they marked the first attempt to

combine results of household interviews with comprehensive medical examinations offered to representative samples of the population.

In Kansas City, Mo., Community Studies, Inc.,

began a survey to identify a sample of persons

witi handicapping conditions who were examined

IO determine whether they could benefit from rehabilitation. Those that could benefit were offered

the services which they required. These persons

rhen were followed to evaluare their rehabilitation.

These and many other studies initiated during

the late 1940’s and early 1950’s conmibuted to the

knowledge of how morbidi~ data could k made

more accurate and useful. The Bureau of the Census acted as the collecting agent in several of the

surveys, and the Public Health Service served in

a consultant capacity in nearly all of them. Both

agencies thereby gained experience which was to

be of great value later.

Meanwhile, anticipating progress in the solution of the methodological problems raised by the

earlier subcommittees, the chairman of the U.S.

National Commirtee on Vital and Healti Statistics

established a new sulxommittee in February 1951.

This was the Subcommittee on NationalMorbidity

Survey which was charged with dra~g “a plan

for a nationaI morbidi~ survey keeping in view

the interests of local areas.” The re~rt of this

group, ‘rProposal for Collection of Data on ILlness

and Impairments: United States ,“ submitted in

October 1953, was the basis for specific legislative authorization for a continuing national health
-trek to

dth In-

]tof the

lived,

lations.

Health

ure illatewide

:tivities

h of the

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lismict

t sciensin rex3nsor -

on the

lity and

:rms of

.-al area

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~6 were

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tie U.S.

tatistics

ry1951.

orbidity

, “a plan

, in view

“t of this

nIIJness

,litted in

legislaal health

survey program. (See Appendix I for the complete

text of the report.) In view of the fact tiat the report set the initial pattern for the National Health

Survey, it is a basic document of the program.

Other activities during the years immediately

prior to the enacmnent of the National Health Survey Act helped to clarify tie purposes and concepts of the Survey. hong these were a series of

meetings held within the Public Health Service at

which the staff of each of the major programs discussed their needs for the type of statistical data

that a survey might supply, the results of the

meetings being summarized in a report to the

Surgeon General; and the discussions of tie Working Group on General Illness Statistics of tie Public Healfi Conference on Records and Statistics,

which were devoted to the definition of terms.

Of interest also was the health survey experience in other coumries. In Great Britain a number

of local or special studies were followed by the

nationwide Survey of Sickness which was carried

on from 1944 to 1952, Canada made a nationwide

survey in 1950-51, and Japan and Denmark have

made health surveys on a national basis.

THE NATIONAL HEALTH

SURVEY ACT

In 1955 the DepsrIment of Health, Education,

and Welfare proposed a plan under which the Surgeon General of the Public Health Service would

be authorized to conduct a continuing survey of

illness and disability in the Nation. A recommendation that Congress enact such legislation was

included in the President’s legislative program

on health matters. Bills incorporating the proposals were inmoduced in both the Senate and

House of Representatives in February 1956, and

after hearing testimony on the needs for improved

health s~atistics~13 Congress passed the National

Health Survey Act (Public Law 652, 84th Congress). The bill was signed by the President on

July 3, 1956, and later in the same month funds

were appropriated for the first fiscal year 

operation. The tea of the National Health Surv

Act is given in Appendix II.

Several salient points of this legislation d

serve special mention since they determine som

of tie unique aspecm of the program of the N

tional Health Survey.

The fact tha~ previously etistig data on 

health of tie Nation’s population was seriously

out of date and tiat current information w

urgently needed for many purposes is explicitl

recognized in the Act. But in the stated broa

terms of reference for the authorized Survey pr

gram, it is clear that Congress had in mind 

limited or sporadic attempts to collect bett

healti information bur an earnest and sustained

program directed toward tie solution of the prob

lem of producing current health information.

Anotier point of interest is that the subjecc 

methodology is explicitly mentioned in this legis

lation. The methods to be used in accomplishing

the purposes of the Act are specified only in ge

eral terms, bur the need for studying the technica

problems of methodology is smessed. It might 

assumed that in any authorized program the a

mfistering agency would give attention to 

methodology relating to the work being undertaken,

but the National Health Survey law goes beyo

this and specifically provides for the study 

methods and survey techniques in the health st

tistics field with a view to tieir continued im

provement.

The Act also recognizes that otier agencie

have an interest in health survey information 

may have available technical resources or m

rerials useful to the program. Thus, the Act giv

broad authority for cooperation with such age

cies m-d for the use, by written agreement, of f

cilities tiar can be made available. In a simila

sense, inasmuch as the program of rhe Nationa

Health Survey cannot serve all needs for healt

data, it is recognized that other agencies and o

ganizations will carry on their own special-purpose studies, and the Surgeon General is author

ized to make available to them technical advic

and assistance in dte application of statistical

methods to their surveys or studies in the healt

and medical fields.

%1.s.Gn~ress, senate: ~ntinuing =mey snd specinl smdics

of sickness xnd disability in he United States. Repofl No. 171S co

accompany S. W76, B4dI timng. 2d. SCSS. Vksbingmn, D. C., U.S.

Government ptinting office, 1956.

%S. Cmgre.s, House OF Represencsciwm Nntiond Heal~

key Act Report No. 210S to sccompsny S. N76, 84ch (3mg. Id.

scss. Wmshingmn, D. C., U.S. Government Prim&g Office, 1956.

POLICIES AND ORGANIZATION

OF THE SURVEY

The scope of the authbrizalion in the Nationa

Health Survey Act is such that to be productive
and economical the operating plan of the Survey

program had to be carefulIy delimited.

Any artempt to cover mo broad a range of

health statistics could only result in a program

which would be not only cumbersome butwouldbe

scattered in character. For this reason outlines

of the prObTaM had to be clearly drawn.

Yet the need for a great variety of different

rypes of data also had to be recognized. This

meant that within definite outlines the goals and

methods had to be diversified, concenmating on

the most productive objectives and procedures,

and the program had to be flexible enough to deal

consecutively with many areas of interest and to

respond readily to changing requirements.

The unique responsibility of the Survey program is to collect ~ypes of data which are based

either on a sample of the general population of the

United States or are relatable to separately

gathered general population statistics. This is in

conmast to studies based on the records of particular health agencies or health adminismative

programs which cannot be relaredto a populationat-risk or which have as a population-at-risk a

group of members of a plan or beneficiaries of a

program, lmth of which are in whole or in part

self-selected or otherwise not representative.

The importance of data relatable to a known

general population stems from the fact that statistical measures of health or morbidity take on

their scientific meaning, contrasted with certain

adminismative applications, only when these can

be expressed as propor~ions or rates.

It is not sufficient to know, for example, that

at a given time so many persons of such-and-such

population group are ill with such-and-such disease. The importance of this aggregate figure

takes on a fuller meaning when it is expressed in

relation to the total number of persons of tie

same ~pulation group.

To serve the purposes of general health statistics, the collection of data on sick persons by

age, sex, occupation, area of residence, etc.,

must be accompanied by a parallel collection of

corresponding data for the population as a whole.

Focusing the Survey program onpopulation-based

types of studies meets this technical requirement.

Using a population sample as the origin of the

data takes advantage of the fact that there is only

one point from which au the needed information

is generated—this point is the individual.

Starting with a known sample of individuals

data can be gathered horn a variety of sources,

These include the person himself or members of

his family, along with hospital records of physicians and dentists, as well as the results of spe6

cially conducted measurements, tests, and examination procedures.

The particular smength of such surveys derives from the ease with which healti data concerning the individual can be related to social,

economic, and ocher demographic characteristics

which are determined for the sick and well alike

as part of tie same survey plan. Hence, many of

tie data-collecung activities of the Survey start

with samples of the population.

However, there are other sampling methods

which can produce valid statistical information

relatable to a general population-at-risk and

which may be more efficient for some purposes.

Much of the data in which the Survey has an interest originates in the places where people obtain

hospital, other medical, dental, and nursing care.

Consequently, when the objective is to produce

statistics on care received, it is often preferable

to sample the sources of the care directly. In this

type of survey the population-at-risk is no~ determined as part of the same collecting process.

It must be determined separately, usually from

general-purpose-population eratistics. Naturally,

care must be taken to insure that both bcdies of

data relate to the same universe.

Both of these general types of survey procedures are used. However, in all cases the target universe is the general population or some

important segment of that population.

The Survey program has another basic characteristic-one which distinguishes it from anumber of other studies in the health field. Except for

the general mortality and natality data compiled

by the National Vital Statistics Division, most

statistical projects of the Public Health Service

are designed to serve a particular program interest. Such programs collect detailed dara on a

particular disease entity, test specific hypotheses

related to the etiology or pathogenesis of certain

conditions, or measure or assist in the administrative conmol of some heakh-operating program. Other types of statistical projects, especially those carried on by State, county, or city

health agencies, are designed to determine health

conditions or study some problem related to a

selected population group or to a limited local

area.

In contrast, the National HeaIth Survey is not

designed to serve any single health-program interest nor to meet the needs for detailed Iocal

data. Its task is to provide general background

data which present the overall health situation and

which show various components of the health

probIe,m in proportionate relation to each other

and in relation to important population variables.
reys delta consocial,

erisucs

:Ll alike

many of

ey start

methods

rmation

isk and

reposes.

s an inie obtain

,ngcare.

produce

eferable

.’.In this

not de3rocess.

lly from

mmally,

-mdies of

vey prothe tarar some

jic charn anum-

<cept for

mrnpiled

m, most

1Service

-~am iniata on a

potheses

f certain

5 adrnining pro-

?4pecialor city

ne health

,ted to a

ted local

:ey is not

gram inled local

ckground

]ation and

Ie health

~ch Othariables.

general sense means that its activities will sup

plement but till not duplicate special or local

statistical projects. Ir can serve as a background

or a reference point for various local studies, but

it cannot replace nor serve the specific needs

which underlie such studies.

The absence from the Survey of subjectmat-

~er interesta of its own is consonant with the policy of providing service, in the form of statistical

information, to those responsible for health research or operating programs. Here, too, a narrow view is not admissible.

The program must not be unduly weighted ti

tie direction of selected subject marter imerests,

even though these may be the most demanding at

the particular moment. The entire group to be

served comprises the legislator and the public

health administrator-Federal, State, and local—

the medical research scientist, the privatehealth

agent y, the range of health and related professions, the demographer, economist, and sociologist, the teaching institution, the life and health

insurance agency, the manufacturer of drugs

and other health supplies, the market analyst, and

numerous other activities and imeresta related to

the health of tie population.

A major task in designing and administering

the Survey is tie consideration of the statistical

needs of this heterogeneous audience and the conversion of the major common elemems of these

multitudinous needs into a clearly defined, pracucal, timely, and economical survey program.

The proper design of such a program is possible only when there etist effective channels

through which these needs can be expressed. One

of the first steps taken in tie organization of the

Survey was to devise a system whereby the planning could proceed with the benefit of advice and

suggestions from many quarters. To this end several advisory committees were appointed and

their advice is sought, not only through periodic

meetings for general discussions but through requesting their review and opinion of specific, proposed courses of action.

The objective of the Survey—to provide a

service to a range of heahh interests-requires

not only that the data collection be designed in

consideration of the various needs, but a 1so that

special emphasis be given LOthe speedy release,

on a rapid time schedule, of compiled statistics

that are consistent with high technical and scientific standards.

The publication program, described in more

detail below, is designed to facilitate early release of the compiled data togetier with such an

y y 

This publication policy requires that stati

cal tables be accompanied by technical no

qualifications, definitions, and such illustrati

analyses as are necessary for a clear apprec

tion of the meaning, uses, and limitations o

statistical information.

The analyses included in the publications 

the Survey must, however, be limited in sc

consisting primarily of exposition and illusm

tive uses of the data. This limitation is desirab

since the function of the Survey is to provide 

jective and accurate facts but not to interp

these facts so as to indicate any par~icular cou

of action or to support any particular health p

cy or program. Policy implications of the sta

tical data are the responsibility of the legislat

and the administrator.

The activities of the Survey in collectin~ 

through various channels throughout the Na

obviously require an understanding and acceptan

of ~hem by the public as well as by all health 

fessions. This is particularly important in a d

collecting program based on the voluntary co

eration of the respondents, and the Survey rec

nizes the need to develop rhis general understand

ing of the purpose of rhe program and the meth

to be used.

In developing the organizational arrang

ments for the Survey, it was considered advan

geous to make mtimurn use of the provisions o

National Heakh Survey Act which authorized 

Surgeon General to conmact for the services 

facilities of any agency, organization, group, 

individual. The use under conmact of exist

~echnical facilities and materials makes availab

to the Survey valuable, special, and professiona

ralents and resources which could not otherwi

be duplicated, and permits the limitig of the S

vey staff to a relatively small group primari

concerned with planning, research, and analys

The fact that the Survey operates by c

tacting for many phases of its work with ot

agencies does not &Iply, however, that it i

any sense a gram-in-aid program. Contracts 

made with other agencies for conducting specifi

studies or operations which are aspects of 

conmibute to the Survey program as an integ

part of its own work.

Authority for grants-in-aid for prosecutio

of surveys by other groups is not included in 

National Health Survey Act, nor are funds ava

able for this purpose. There is in The Act, h

ever, authoriry to make available to appropriat

persons and agencies technical advice and assis
health surveys.

Any active statistical program should also be

an evolving program. It is significant that a proportion of tie total resources is allocated to evaluating Survey results, to assessing the reliability

of data, and to exploring possible improvements

in method.

Modifications of the Survey program may be

expected as experience pints the way to improvements in method or to different emphasis on objectives. This means that occasionally comparability with earlier data collected by the Survey

will be sacrificed if by doing so it appears highly

likely that the quality or usefulness of the data

can be raised. For example, certain features of

both the questionnaire and the sampling structure

of the household-interview ,,survey were being redesigned almost from the beginning, and tabulating

plans are subject to change each year. The methodological work and the continuing evaluation of

results undoubtedly will lead to further revisions.

PROGRAM OF THE U.S.

NATIONAL HEALTH SURVEY

The varied nature of the dara desired for

planning and evaluating all phases of public and

private heaIth work and the requirement that corresponding information be obtained for both the

ill and the well population determirze the main

lines of content of the program of the National

Health Survey.

This is not a single survey with only one

method and a fixed set of objectives. Rather, it is

a program of surveys, using different approaches

and changing its end objectives as both the techniques and needs for data evolve. But basic to all

the present and funzre surveys is the fundamental

idea that the data colkction must refer IO a represenra~ive population.

. . The activities of the National Health Survey

ma-y be divided into three parts: (1) the Health Inte~view SZmJey —a continuing nationwides ampling

and interviewing of households; (2) the Health

Examination Survey —physical examination and

testing of samples of individuals proceeding in a

series of separate surveys or cycles; and (3) the

Health Records .%m’ey —another series of sample

surveys in which the sources of information are

establishments which provide hospital, other medical, dental, nursing, and other types of health-related care to the general population.

These three survey activities are supported

by a program known as Developmental and Evalu8

studies through which rhe quality of data is evalu

ated and improved methods are devised and tested.

A brief description of each of these parts of

the program follows. Later publications in this

series will consider the major surveys separately

and will describe rhe statistical design, concepts,

and definitions associated with each survey.

The order in which the surveys have been

listed above is the order in which these parts of

the programs were initiated, except that the Developmental and Evaluation Studies have proceeded concurrently and were undertaken as needed.

The Health Interview Survey, planned during

the fall and winter of 1956, was pretested in February 1957 in Charlome, N. C., and nearby areas,

was tested again in a national “dress rehearsal”

in May-June 1957, and was officially launched on

July 1 of that year. Data collection has been continuous since that time.

The first cycle of the Health Examination

Survey was plamed over a period of more than a

year. Ic was tested in three successive pilot studies which took pIace in Washington, D.C., in June

1958, and in Fort Wayne, Indiana, and Howard

County, Iowa, in the spring of 1959. Examinations

of the first cycle sample were begun in Philadelphia in October 1959. Work was carried on slowly

at first because of a lack of equipment and staff.

Full-scale data collec~ion on this survey dates

from April 1961.

The variety of survey activities making up

the Health Records Survey began to take shape in

1961. Consbnzction of a sample frame, or list, of

medical, nursing, and personal care institutions

in the United States was he first field task in this

survey. After existing lists were consolidated on

a preliminary basis a mail inquiry was sent out

in April 1962. This inaugurated the third major

subdivision of the National Health Survey.

In all of these works of the National Health

Survey, the Bureau of the Census played and continues to play an important role. Participation by

che Bureau takes four forms: (1) the givingof advice on survey design and methods; (2) the actual

selecting and identifying of units for the sample;

(3) the conducting of importam par~ of the field

work, including the selection, training, and supervision of interviewers in the Health Interview

Survey; and (4) the performing of many largescale tasks of processing.

The paztern of participation by the Bureau of

the Census varies in the different surveys. While

administratively the arrangement resembles a

contract on the part of the Bureau of the Census

to do specified work for ~he Public Health Service,
ested.

rts of

n this

rately

:epts,

mvey.

been

‘rts of

]e DeJceed-

:eded.

~uring

1 Febmeas,

arsal”

led on

n connation

than a

t studn June

Iowarcl

Lathns

Lladel-

; 10W1y

i staff.

dates

:ing up

iape in

list, of

tutions

in this

~ted on

em out

major

Health

Id conuon by

~of adactual

ample;

le field

super-

.erview

largereau of

While

ibles a

Census

ervice,

,

m

interest in the quality of data collected and contributes greatly horn its fund of knowledge of survey methods.

THE HEALTH INTERVIEW SURVEY

The Health Interview Survey covers the civilian, noninsutuuonal population of the United

States. The purpose of tie Survey is 10 provide

data on the incidence of illness and accidental injuries; the prevalence of diseases and impatimems; the extent of disability; the volume and

kinds of medical, dental, and hospital care received; and other health-related topics.

The data are obtained from the people themselves and therefore measure the social and

demographic dimensions of health-the impact of

illness and disability and actions taken as a resulr of these conditions, in various population

groups.

Household interviews are conducted conun -

ually with interviewing taking place each week in

a probability sample of the population. Samples

for successive weeks can be combined into larger

samples to obtain data for a quarter, a year, or a

longer period of time. The design thus permim

continuing measurement of characteristics of

high frequency to show trends and to show, by consolidation into larger samples, analysis of characteristics of low tiequency or of smaller subclasses of the population. Data collected over a

year can be presented as annual estimates which

are free of seasonal biases.

The interview sample is a highly stratified,

multistage probability design. The firs~ stage

consists of an area sample drawn born about

1,900 geographically defined primary sampling

units (PSU’S) into which the Nation has been diwded. A PSU is a counry, a group of contiguous

counties, or a standard metropolitan statistical

area. The number of PSU’S selected inthe sample has varied with che sample design. Currently,

there are 357 such areas.

Second and subsequent stages consist of a

series of steps for further subsampling within

the chosen PSU’S. For discussion purposes, these

steps may be combtied and described as a process of drawing clusters of neighboring households

or addresses. Such clusters, called segments, included an expected six households during the

fist 5 years of the Survey; currently, these contain an expected nine addresses. With minor exceptions the sample encompasses all persons residing at the selected places.

stage tie ratio factor is the count of population in

the 1960 decennial census divided by the estiated

1960 population for tie first-stage sample PSU’S.

This adjustment is applied separately to residence and color cells, currently 25 in number. In

the second stage, ratios of the official Bureau o

the Census current population figures to sampleproduced estimates of the current population are

applied to some 60 age-sex-color classes.

Through contractual arrangements, the Bureau of the Census provides assistance and cooperation on many phases of the Survey design and

adrninis~ation. This enables tie Survey to take

advantage of the long experience, comprehensive

statistical organization, and field resources of the

Bureau.

In keeping wirh specifications and requirements established by the Public Health Service,

Lhe Bureau of tie Census designs and selects the

sample, cooperates in the development of me

questionnaire and related manuals, conducts the

fieId interviewing, codes the data, and carries out

quality -conmol procedures for interviewing and

coding. The Public Health Service edits, tabulates,

analyzes, and publishes the results of the Survey.

Interviews are conducted with each individual

adult who is at home at the time of the interview.

For persons not at home the interview is conductedwith a responsible family member —spouse,

parent, or adult son or daughter residing in the

household. The noninterview rate is almut 5 percem, including 1 percent from refusals and the

remainder horn households in which no one was 

at home during repeated calls.

Variation and bias among interviewers are

potential hazmds to data on health conditions derived from household interviews. For this reason, interviewers are carefulIy selected, are

given a comprehensive initial maining course, 

and are given group retaining semiannually and

home maining exercises about eight times a year.

In addition, programs of regularly scheduIed observation and independent reinterviews by regional field supervisors are conducted.

During processing in the cenmal office, all

questionnaires are examined for interview errors

of question coverage and consistency. Results of

all of tie procedures for quality con~ol are

manumitted through the supervisors to the interviewers as guides to self-improvement or to the

need for individual retraining.

All maining, observation, and review procedures are oriented to a detailed Interviewer’s Manual. This includes instructions on the question9
.,

g q

The questionnaire contains items to identify

households and persons and to classify persons

according to meir demographic characterisdcs.

It also includes questions on illnesses, impairments, or other conditions; on the occurrence of

accidental injuries; and on the use of hospital

care. For each person to whom these questions

apply, additional questions are asked about the

nature of reported conditions, number of days of

disability, degrees of chronic limitation of acrivi[y, ~es of accidents, and the duration of and

reasons for hospitalization.

Items of the type described above are continuously included in the quesdonnaire as a basic core

of inquiries. Other items, such as the use of medical and dental care or the extent of health insur -

ante coverage, are repeated at intervals of several years. Still others, of specialized or timely

interest, are included for a single ye= with no

definite plans to repeat these at a later date.

Annual modifications of the questionnaire

permit collection of data on a larger number of

topics than could be included in a fixed singlevisit interview. Other methods are also used to

extend the scope of the survey. At times, a selfenumeracion questionnaire is left with the respondent when the basic interview is completed.

This is mailed in by the respondent, with norrresponse follow-ups conducted by letter, telephone,

or personal visit. Self-enumeration questionnaires are usually employed on topics for which

the respondent may wish to consult records, on

topics for which more accurate and complete information can be obtained horn persons who may

not be at home at the time of the interview, or

simply to shorten the interview.

Users of data often require more detail abou~

pe:sons with a particular health characteristic

than can be included within the interviewMg time

or the space limits of the basic questionnaire. k

these cases, persons with such a characteristic

can be identified &om the basic questionnaire.

These persons, or a sample of them, are then

s em a second questionnaire to obtain additional

data which are imeg-rated with other health and

demographic information obtained in the first

visit.

All new questions or topics are subjected to

one or more pretests to assess alternative methods of collection, under standtig by respondents,

and the length of time for which respondents can

recall events without excessive memory loss.

10

topics are forrmdated in consultation with persons who are specialists in the subject. Planning

and conducting of pretests are carried out imperatively with the Bureau of the Census.

Household ques~onnaires are mamsmitted

weekly from field supervisors to the cenmal office

where these are checked for completeness of field

coverage, omissions, and other errors. “Coding

then is done according to specifications set forth

in detailed coding and Uanscription manuals.

Code categories for health and medicaI care items

are established by the Public Health Service to

maintain consistency with the concepts and definitions and to fulfill requirements for health information. Illnesses, diseases, and injuries are

coded, with certain modificauons, according to

the International Classification of Diseases. Code

categories for demographic and economic items

are, in most cases, established by the Bureau of

the Census to conform with standard classificauons used in other operations of the Bureau. The

coding process is routinely subjec[ed to qualityconmol procedures requiring defined standards of

proficiency.

Coded data are manscribed on magnetic tape

for compmer processing by the survey staff.

These steps include assigning weights and ratio

adjusunents; combhing weekly and quarterly data

into longer periods; carrying out a program of

internal edits and consistency checks among various items of data; regrouping of ages, diagnostic

codes, and other information to facilitate tie preparation of later tabulations; conducting operations

necessary to derive national annual estimates;

and finally, producing the statistical tables.

Tabulations include not only data on health

and medical caxe items but population figures for

the various groups for which the survey is designed to produce estimates. In addition, sampling

variances are computed for a Iarge number and

range of statistics. These tabulations form the

basis for analyses and publication of a series of

reports on separate health topics and on health

and medical care ti differ em population groups.

THE HEALTH EXAMINATION

SURVEY

The basic purpose of the Heikh Examination

Survey is to conduct those studies of tiehealth of

the population of the Nation which require, or can
:epts,

- new

per-

,nning

coopnitted

office

if field

Zoding

forth

nuals.

items

~ice to

1 defilth mes are

ling to

. Code

items

:eau of

sificaU. The

laZity -

ards of

ic tape

staff.

d ratio

-ly data

Y= of

,gvari-

~ostic

:preprations

mates;

tables.

health

mes for

is dernpling

ber and

rm the

:ries of

I health

groups.

4

nination

,ealti of

., or can

m

ments. The survey involves collection of health

data on small, representative samples of the population through direct exarrdnations of the persons

in ~he sample.

Such a method is necessary to provide statistics on the medically defined prevalence of a variety of specific diseases and on the dentalhealth

of the population. This is the best—perhaps the

only-way of obtaining data on previously undiagnosed, unattended, and nonmanifest chronic diseases and of obtaining distributions of the population concerning such physical and physiological

measurements as blood pressure, serum

cholesterol, and auditory and visual acuity.

The broad plan of operation of the Health

Examination Survey calls for the study of specific

segments of the total population in successive,

separate cycles of examinations. The program is

planned so that at any one time the Health Examination Survey will be engaged in a three-level

operation: (a) the analysis and publication of the

findings from a completed cycle of examinations

on one segment of the population; (b) the field

collection of data for another cycle, dealing with

another defined problem and population segment;

and (c) the planning and development of detailed

procedures for the succeeding cycle of examinations dealing with still snother population segment and defined problem. The goal is to plan

pmticul~- cycles so fiat the data-collection

phase can be completed in approximately a 2-to3-year period.

During the first cycle, the feasibility of conducting direct, single-visit examinations onprobability samples of the population on a nationwide

basis was confirmed. Procedures and methods

for carrying out this task were developed, and

considerable experience was gained in dealing

with the problems encountered.

The Health Examination Survey has two specially designed mobile examination centers. Each

consists of several mailers, drawn by trucks,

which, when set up and connected by passageways,

provide the setting for examination and testing.

At the outset of the program, it was uncertain

whether a sufficiently large portion of a scientifically selected probability sample could be examined. The experience gained in the first cycle indicates that it is possible to obtain the necessary

cooperation. The experienced field staff and the

tools developed make ir possible ro plan on the

continued application of this survey techtiique.

The first cycle of the Health Examination

Survey was designed to collect information on the

,

population. PrimariIy, these were cardiovascular

diseases, arthritis and rheumatism, and diabetes.

‘The population studied in the first cycle w

limited ro the civilian, noninstitutional population

of the 48 contiguous States between the ages of 

and 79 years, inclusive. In addition to collecting

information on the selected diseases, the first

cycle survey obtained a variety of measurement

data, including data on height, weight, skinfolds,

visual acuity, blood pressures, elecmocardio 

graphic tiacings, and the results of other Tes

and procedures. The program also included a d

tailed dental examination. The plan and initia

pro~am were published in 1962.4 Collection of th

data on some 6,700 persons examined in this pro

gram was completed late in 1962. Analysis of th

data is now in process.

The second cycle of the Health Examin-ation

Survey will focus attenuon on children between

the ages of 6 and 11 years, inclusive. Since th

prevalence of chronic disease in this population

is quite low, attention will be directed to a variety

of measurements and to characteristics associated with growth and development. A physical

examination will be given, and a selected battery

of psychomemic tests will be adrntiistered. Careful examinations will be made for visual an

auditory acuity. Considerable anthropometiic dat

will be collected. A dental examination will als

be made. Finally, tests of respiratory function

and exercise tolerance will be included, as wi

X-rays and certain other tests and procedures.

A key characteristic of tie Health Examina- 

tion Survey is that each of its programs is based

on a probability sample of the population of th

Nation. The method by which this sample is se

lected closely parallels that described above fo

the Health Lnterview Survey. The publication 

data from the Health Examination Survey will in

clude detailed descriptions of the sampling an

estimating processes, including the nature of a

significant adjustments. The reports will also in

clude information on the sampling error and th

measurement variation.

4u-~. N~&nd Hcnkb S-cy. P[an ad Initia[ Program of tb 

Hea[tb Exmninatz”on 5mveY, Hedtb SmmisUcs. Series A-4. Public

Hemltb Service Publication No. SS4-A4. Public Heal& Serwice.

msbgmn, D. c., M~Y196z.

II
Much effort is devoted to problems of standardization of observations, validadonofthe measurement processes, and other aspects ofquality

conmol in connection with the HealthExamination

Survey; likewise, much amennonis giventoproblems of sampling and problems of response. In

all of these areas, as in all of the work of the

Health Examination Survey, interest arises from

two different viewpoints. First, attention is given

to these matters so as to improve the quality of

the output of the survey. Second, attention is given

to conmibucing generally to the knowledge of

methods and survey techniques for securing statistical information on healtn. In connection with

this latrer goal, the Health Examination Survey

undertakes various methodological studies which

should benefit not only the. National Health Survey

programs but all research workers in this fieId.

This methodology work is the subjec~ of more detailed comment elsewhere in this report.

Future programs of rhe Healti Examination

Survey will consider other population segments

and other problems. The first of these srudies

(cycle 3) is expected to concern children and

youth from the ages of 12 to 17, inclusive. This

cycle will complement the findings of cycle 2 to

provide broad and comprehensive data on the

health of the children and youth of the Nation.

THE HEALTH RECORDS SURVEY

The Health Records Survey is a family of

undertakings with two characteristics: (1) tie

first stage of sampling is the facility or establishment which provides hospital, medical, nursing, personal, or residential services; and (2) a

major part of the information collected has its

source in records of the sample facilities, in contrast to such origins as the interviewing or the

direct examination of persons.

The main objective of the Health Records

. . Survey is the production of sta~istics on the characteristics of health services received by the

American people and the characteristics of those

receiving the services. As an important byproduct, the program will also produce statistics

on the institutions and the other health facilities

providing the services—their numbers and types,

their staffs, their charges, and their general

policies.

Thus, the Health Records Survey is broad in

scope. The concept of the Survey encompasses

records not only horn hospitals and nursing homes

but also tiom such facilities as clinics, physicians’ and dentists’ offices, indus~ial and union

12

dispensaries, and a v&-iety of residential and

correctional institutions.

Among the several surveys in the program,

early emphasis has been ~laced on five projects:

(1) a Master Facility List of establishments; (2) an

area sample survey, known as the Complement

Survey, to identify establishments which are nor

included on the Master Facility LisE (3) a Hospital Discharge Survey; (4) an T.nsticution Population Survey; and (5) a series of ad hoc surveys.

Since all but the first of these are still in the developmental stage, their descriptions must be

considered preliminary. A brief description of

each of these activiues follows:

1. The Master Facility List. —-A keysmne of

the Health Records Survey will be the creation

and maintenance of a master list of all or a major

proportion of all establishments or institutions

within the scope of the program.

To establish this inventory, a number of lists

previously assembled by the Public Health Service, Bureau of tie Census, and lists published by

nongovernment agencies were collated and merged.

Then, to bring this file up to date, a questionnaire

was mailed to each establishment listed. The information requested varied with the type of place

queried, but in general, it related to size, ownership, type of service, and number and type of

staff. This file is called the Master Facility List

(MFL).

Thus constituted, the Master FaciIity List

serves two major functions. First, in itself it

provides significant data on the number, types,

size, and geographical distribution of the subject

establishments, and on the” numbers of persons

which can be served. Second, it provides a frame

or list which can be stratified and sampled for a

wider variety of allied purposes.

It is desirable that the Master Facility List

be both comprehensive and current. Currency is

provided by additions and deletions from the list

using several sources of information concerning

new and discontinued establishments, including administrative documents horn the Social Security

Adminismation and Public Health Service programs.

2. The CornpLement Surwey.-Despite the advamage of a comprehensive and current list, it

would be uneconomical to attempt to maintain a

continuing inventory in the Master Facility List

tiat was really complete. It is more efficient ro

keep the Master Facility List ar a high level of

coverage and to augmem it with art auxiliar ys ample procedure. For this purpose, the Complement

Survey is made a part of the total program.

I

r

..

I
tial and

-ogram,

rejects:

:s; (2) an

plement

are not

) a Hosn Popuwrveys.

the demust be

priori of

:stone of

creation

a major

umtions

:r of.lists

lth Servlished by

i merged.

tionnaire

. The in-

, of pIace

~, ownerJ rype of

ility List

dity List

itself it

:r, types,

(e subject

persons

~ a frame

)Ied for a

:ility List

mrency is

.n tie list

mc erning

: uding ad -

\ Security

vice proite the ad-

.nr list, it

11aimain a

cility List

:fficient ro

$h level of

iiary sam-

>mplernent

program.

make maximum use of existing resources. A number of periodic interview surveys are routinely

conducted across the Nation. Using the probability

design of an ongoing survey and interviewers for

the survey, a list will be made of the names and

addresses of all establishments in specified

blocks or segments of PSU’S during the course of

the interviewer’s regular assignments. Each

establishment identified in the Complement SWvey that is not on the Master Facility List will be

asked zo complete a questionnaire so tiat the

establishment can be properly classified. The

Complement Survey will dms become the basis

for completing the universe of facilities of interest in the Health Records Survey.

3. The Hospital Discharge Survey. —This

will be a continuing survey of short-sta yhospitals

to obtain comprehensive statistics on tie use of

hospitals, on services provided in hospitals, and

on characteristics of their patients. Initiation of

the Hospital Discharge Survey will greatly increase the potential of the National Health Survey

to provide statistics on hospitalization, parucularly on the kinds of cases being cared for in hospitals of various sizes and types, on methods of

financing the care, and on differing patterns in the

use of care in various sections of the Nation.

While the Health Interview Survey data on hospitalization provide satisfactory information on

the socioeconomic correlates of hospitalization

and on the relationship of hospitalization to other

facts shut the illness, they cannot provide the

de~ailed characceris~ics of the patient’s care or

the geographic detail.

According to present plans, this survey will

involve a two-stage probability sample, the first

stage being a sampling of short-term hospitals

and the second stage, a sampling of discharges.

Information horn the discharges will be copied on

a standard absu-act form which will not include

the patient’s name.

The project will differ &om most of the other

undertakings of the National Heahh Survey in that

it will meat the universe of all discharges over a

period of tie, rather than the universe of persons living at a point in time. Estimates tiom tie

sample will be related 10 independently compiled

population statistics tiom census sources.

~. institution Po@zdatiOn Suwey.—Thepopulation sampled in the Health Interview Survey

(described above) does not include the population

of resident institutions. This is due to the fact

tiat neither the rype of sampling nor the manner

of gathering the information is entirely suitable

for this segment of the population of the Nation.

only about 1 percem of the total ciWian p

tion, it is an important 1 percent from the 

point of health. Many of the most severely 

abled persons, for example, are found in re

institutions of one type or another, and cert

the published estimates from the Health Inte

Survey and the Hea.kh Examination Surve

less useful because of the exclusion of this 

For tiese reasons it, has been consi

important to collect data of certain types 

institutionalized ~pulation that would add 

formation obmined in the Health Interview S

Hence. a special procedure for surveying 

~pulation (making use of the Master F

List as a basis for the sample) is being pl

This Institution Population Survey would co

types of resident institutions in the Uni~ed 

both medical and nonmedical. This includ

types of long-stay hospitals, penal institu

orphanages, nursing homes, homes for the 

and other types of facilities providing domic

or personal care. It does not include such 

as convents, summer camps, hotels, studen

mitories, and other places where president

the responsibility of caring for themselves. 

latter are not considered to be institution

are therefore part of the universe covered 

Health Interview Survey.

5. Special ad hoc surveys. —The su

which have just been described are desig

collect data for specific purposes. However

anucipated that tiom time to time there wi

need for special data regarding the institu

population which cannot be met from 

sources. Consequently, special one-tie su

of specified parts of the Health Records 

universe will aLso be conducted.

To illusmate, much current kterest ex

data on the health of the aged, infirm, and 

ically ill who are being cared for in reside

stitmions of various types. More specialize

formation is required than the Health Int

Survey ordinarily collects. Thus, the pro

Institution Population Survey would not be 

able resource. For example, there is need 

formation abut the characteristics of this 

which bear upon the problems of nursing o

sonal care, such as, hearing andvision prob

mental status, awareness of surroundings

abiliry to control feces and urine. In ad

other data are needed which relate to tie 

of these institutionalized older individuals, 

as information on the sraff available to ca

rheir needs and the rype of establishment in 

the persons are domiciled. For this purpose, 
..

has been undertaken an ad hoc survey entitled

Survey oj Resident Places Providing Nursing Or

Personal Care, which will obtain statistic softhis

kind.

DEVELOPMENTAL AND

EVALUATION STUDIES

The primary purposes of tie methodological

studies are to appraise the effectiveness and

efficiency wirh which various aspects of tie Survey program are meeting their objectives, and to

develop new and improved methods of artaining

~he goals of the Survey; to design studies and devise data-collection methods in connection with

new types of morbidity measurement; and to conduct pilot projects wherein new methods and new

undertakings are prepared for full use in the

Survey.

Some methodological studies are conducted

entirely by the staff of the National Health Survey,

but studies which involve the special field collection of data and which extend over any long period

of time are usually carried on jointly with the

Bureau of the Census or other government agencies, or are performed by nongovernmental research organizations chosen for their competence

and interest in the particular areas of study.

The fact that some of these studies are carried out as research contracts with nongovernmental research organizations has two major advantages for the Survey. First, it provides greater

flexibility in conducting the program by permitdng

the staff working on the methodological research

to be, in effect, expanded and contracted on fairly

short notice as the need arises. Second, an even

greater advantage is thar it stimulates fresh

thinking about the many difficult problems chat

are encountered. Already, at the time of this

writing,a number of highly competent statisticians around the countiy have begun to focus

their attention and bring their experience to bear

on improving the quality of the surveys which

make up this program.

At the same time, it is essential that members

of the National Health Survey staff associate themselves closely with the work being carried on

under research contract. They must acquaint the

contractor with the viewpoint and objectives of

the Survey, and they mus~ have a fullunderstanding of the results, since they will be responsible

for putting the findings into effect. Consequently,

at least one and usually two members of the Survey staff are assigned LOwork with the contractor

on each project. In many of the. studies they are

14

responsible for part of tie work, and they are

usually responsible for editing the contractor’s

report to produce a brief version for publication

in the regular methodological series of the National Center for Health Statistics.

The Bureau of the Census likewise has an understandably deep interest in this part of the program. Eventually, the Bureau may be asked to

apply in the field newly developed methods from

the studies. Furthermore, some of the results

can be applied to other Census projects. Hence,

s tacisticians from that agency often are involved

in the planning and carrying out of tie investigations.

Not all methodological research is performed

under contract, however. A number of studies are

done with the Survey staff or jointly with tie Bureau of the Census. This is often the case when

the srudy relates to improving interview-survey

techniques as these apply to health. Such studies

can often be done by adding some special procedure in a subsample of households in the regular Health Interview Survey. In such cases, the

Public Health Service makes a separate financial

arrangement with the Bureau of the Census co

cover rhe extra costs.

‘The types of projects undertaken under the

general heading of methodological research are

highly varied. However, certain characteristics

give unity to the program.

First, the problems dealt with are those arising in the course of developing and evaluating the

Health Interview Survey, the Health Examination

survey, and the Heakh Records Survey. That is,

these problems represent applied research. While

the use of resources of the National Health Survey

for general health-data-collection research is not

barred, the urgency of the many problems faced

in the program until now has led to using those

resources solely to develop and improve the surveys which were about to be stained or were already in process.

Second, the methodological research can be

subdivided quite easily into developmentals tudies

and evaluative srudies —hence, the title of this

section, which is the name used to describe this

part of the work of the National Health Survey.

Occasionally, a study contains both elements: (1)

an evaluation of the methods currently in use, and

(2) the trial of a new method. However, most

srudies can be identified as predominantly one or

the other.

Third, because of the inherent difficulties of

the subject matter, the studies tend to be concerned with that component of the error of surveys known as measurement bias., Evaluating the
ractor’s

bliCaIiOII

the NaM an unthe prosked to

)ds from

results

. Hence,

involved

vestigarformed

]dies are

the Bu-

~se when

‘-survey

I studies

.ial pro-

,le reguwes, the

financial

ensus to

,nder the

arch are

teristics

~se arisating the

.mination

That is,

:h. While

ti Survey

rch is not

ms faced

ing those

tie surwere al-

:h can be

21srudies

e of this

ribe this

I Survey.

lents: (1)

I use, and

er, most

ly one or

:ulties of

be conr of surlating the

them appears to be the first order of business in

health surveys. These are biases which would

etist even if no sampling was employed. Biases

due to tie sample design are of distinctly secondary importance. (On the other hand, minimizing random errors of sampling can be most important because of the low relative frequencies

often encountered in healti statistics.)

Because of this concern with measurement

biases, much attention is given to such matters

as: memory of health events, clarity of concepts,

motivation of persons falling into the sample to

take part or to report accurately, replication of

measurements, calibration of insmuments, and

standardization of measurement techniques. This

same concern also leads to a constant search for

special situations where independent sources of

reliable information are available, such as health

insurance plans, or where replicate measurements can be made to evaluate results of the survey.

A few examples of research projects undertaken will illusmate the general description above:

1. A single-tisit cardiovascular examination,

using controlled and standardized procedures, was designed and compared wirh a

much more extensive examination as well

as records of previous examinations for

the same group of persons. Interobserver

differences were also studied through

repetition of the examination on the same

examinees.

2. Atitudes and other factors influencing acceptance or rejection of an offer of a tiee

heakh examination were studied with a

view to discerning problem areas of nonresponse in the Health Examination Survey

and suggesting means for reducing nonre -

sponse.

3. The reporiing of meated chronic conditions

in the standard version of the Health Interview Survey was studied by administering

the intertiew to families for whom medical-visit data were available from the

records of a health insurance plan.

4. Reporting of hospitalization in the Health

Interview Survey and tie effect of a second interview were studied in a group of

families containing at least one member

for whom hospital-records data were

available.

5. l%e results of using a paticular piece of

equipment for measuring visual acuity

were calibrated against a newly stand6.

carrying out both procedures in a sam

of patients attending an optome~ic cli

lle interviewer-contributed component 

total mean square error in the Health 

tertiew Survey was studied by usin

part of the total sample within which 

terviewer assignments had been rando

ized.

In addition to special methodological researc

studies of tie types described above, a number 

smaller investigations are made, sometimes c

ducted through exploitation of data collected 

another purpose. For example, frequent analy

of the yield of specific illness probe questions 

the Health Interview Survey are conducted 

means of hand tallies. Furthermore, every ma

new topic in the Health Interview Survey, 

new examination protocol for the Health Exam

nation Survey, and each questionnaire empl~yed 

the Health Records Survey is pretested in 

field. In these pretests, evaluation of the rel

bility of the new information is carried out 

whatever means appears feasible.

REPORTING THE RESULTS

A basic premise governing the disseminatio

of the Survey results is that findings should 

made available to interested persons as rapi

as possible.

In keeping witi this principle, tie publicatio

plan provides for issuance of most Survey 

ports topic by topic. This conmasts with the ho

tig of tabulated material for use in a more to

prehensive but necessarily delayed periodic p

lication such as an annual or semiannual volum

Reports must be in a form usable for 

largest number of consumers of health statistic

This requirement dictates the arrangement of 

ports in series to the extent that this is applic

ble; reports within each series are then relat

in terms of the source horn which the inform

tion is drawn, the uses of the data, or other 

propriate criteria. ,

Through 1962 four different series of pub

cations had been initiated by the National Hea

Survey: Sem.es A (program descriptions, surv

designs, concepts, and definitions); Series 

(Health Interview Survey results by topics); 

?+es C (Health Interview Survey results for p

ulation groups); and Series ~ (Developmental 

Evaluation Reports).

Late in 1962, however, a unified system 

publication series was designed for the Nation
Health Survey is a component. Under this system, Series A and D were redesignated as NCHS

Series 1 and 2; these cover the same subject

matter as they had previously but will now be

used for the Center as a whole. The Series numbered 10-19 have been set aside for other publications which will be issued by the National

Health Survey. Number 10 will be a condnuation

of former Series B and C. Numbers 11 and 12

will include reports from the Health Examination

Survey and the Health Records Survey, respectively. Other series will be originated as needed.

The timetable for issuing publications depends, of course, on the availability of results

from the surveys. Since in most cases tie results

are estimates derived from samples, the publication depends on the accumulation of a sufficiem

amount of data to permit the making of estimates

with a useful sampling reliability. For example,

for most topics covered by the household interview questionnaire, data from a full year of interviewing are needed to compile national statistics in a reasonable degree of detail and a 2-year

sample is needed 10 publish selected estimates by

geographic region. Occasionally, as much as 4

years of sample data are combined to provide

more detailed tabulation.

Frequency of reporting on a particular topic

also depends on the rapidity of the change in tie

of the health characteristics included under thar

topic. For example, reports on the incidence of

acute illness will appear more frequently than

reports on the prevalence of physical impairments. ACtie same time, early reporting of preliminary results is not intended to preclude a

more intensive treaanent of the same topic at a

later date.

Thus, it may be seen that the system of reporting results of the surveys is based on a division imo several publication series, according to

the source of the data or type of report, with in-

. .

di;iduaI issues usually devoted to a single topic.

Periodic summaries of data on a number of topics

for a particular period of time are not etiinatedr

but the reporting of all results in a regular-issue

amual or biennial volume is not part of tie plan.

The system of issuing reports in established

series does not preclude preparation of such additional reports as circumstances and feasibilities

may warrant. In addition to the reports issued in

series, special publications may be prepared

horn time to dine. The weekly Provisional Tabulation— Current Slafistics on Res#irat@y fis -

eases is an example

ple is not large enough to yield current esdmates

for items of low incidence or prevalence, weekly

or monthly tabulations were not planned. However, in the fall of 1957 when it appeared that

cases of influenza-like diseases would have a

higher than usual incidence, an investigation was

made to learn if in this instance the householdinterview data, obtained infrequent time intervals,

would yield useful information.

A special tabulation of questionnaires, showing upper respirator y diseases severe enough to

cause persons to go to bed for a day or more, indicated thar the data were an adequate basis for

issuing provisional tabulations on new cases which

appeared each week and on the average number of

persons contied to bed each day. These two indexes were incorporated in a weekly publication

beginning in November 1957. A special publication such as this would be condnued only through

the period of its topical interest.

In addition to the publications of the Survey,

Public Health Refioyts and professional journals

serve as a means of circulating information obtained from the Survey program. These media

are particularity appropriate for publication of

some of the research papers emanating from the

Developmental and Evaluation Studies. The contractors and cooperating agencies working on

these aspects of the Survey often are in a position

to contribute notably to the literature in specialized subject areas.

Finally. the Survey attaches importance to the

obligation s~ated in Public Law 652 to ‘rMake

available, to health officials? scientists, and appropriate public and other nonprofit institutions

and organizations, technical adtice and assistance

on the application of statistical methods to experiments, studies, and surveys in health and

medical fields. ” The consultation which tiis responsibility implies is an important part of the

overall plans to disseminate the knowledge which

the Survey produces.

Potentials AND LIMITATION:

OF THE SURVEY PROGRAM

Effectively pursued, the Survey program

should provide a comprehensive cross-sectional

and changing picture of illness, accidental injuries, disability, and the use of hospital and other

medical and dental services. However, recogni-”

don of the value of the program in defining more

[6
# samimates

weekly

Hewed that

Iave a

cm was

;ehold -

srvals,

, show-

>ugh to

re, insis for

which

nber of

two indication

ublicahrough

:urvey,

mrnals

ion obmedia

ition of

‘om the

le conking on

msition

pecial-

:e to the

“Make

.nd ap -

,Sutions

istance

to exth and

his re-

: of the

: which

y$

M

rogram

sctional

al injuid other

ecogni-”

ig more

clearly tie health and factors affecting the health

of the Nation should not obscure the fact that the

various surveys have definite limitations. These

exist both in the individual surveys and in the surveys grouped collectively as a system.

Concerning the Health Interview Suey, for

example, the facts of the circumstances of fllness or injury and the resulting action taken by

the person, such as going to bed or seeing a physician, can be more accurately obtained horn

household members than from any other source.

The same is mue of the demographic, economic,

and social information with which it is useful to

relate morbidity information.

However, there are limi~ations to the accuracy of the diagnostic information collected. At best,

the household respondent can pass onto the interviewer orly the information which the physician

has given to the family; and the respondent may

not have been told about a condition or he may

have misunderstcmd or forgorten what tie physician said.

For conditions not medically amended, the

diagnostic information supplied by a household

respondent may be no more than a description of

symptoms, and for nonmanifest diseases the

household interview will report no condition.

Furthermore, it is known fiat by no means

are all chronic conditions treated by a physician

reported by tie family in an interview. Onlythose

of significance to the family are reported, and

occasionally a respondent, despite the assurance

of confidentiality, will conceal information for

one reason or anotier.

Thus, when clinical or diagnostic detail is

required or when the statistics mustpresenttypes

of information which are available in physicians r

records, interview data are insufficient. These

data must be supplememed by information such as

that produced by the health examinations. However, the Health Examination Survey has its own

limita~ions. Because of the high cost of performing

the examinations and difficult logistic problems,

the sample must be relatively small. As a result,

this survey canner supply the volume of material

on the demographic, social, and economic aspects

of health which is available from household interviewing.

A disadvantage of giving the health examina

tion only once is that it cannot provide diagnose

of the many conditions which require repeate

and continuous observation and tests before t

can be identified. Also, the limited character 

the examination precludes the use of differentia

diagnostic tests or complicated procedures.

A further general limitation ~f the Hea

Examination Survey is the size of thenonresponse.

However, ir is hoped that appropria~e use of 

information elicited in the household intervie

for the health examination sample will minimiz

the impact of the nonresponse on final result

Together, the three types of surveys wh

make up the program—interviewing, examina

tions, and sampling of the sources of care-provide useful information on a wide range of va

ables. However, under present plans, the samp

sizes are such as to give estimates for maj

geographic areas only. No estimates for indivi

ual States or cities (other than the largest metro

politan areas) can be made.

A similar resmiction of the system a

whole, as it is now contemplated, is its inabili

ro provide statistics for persons in small grou

of the population such as, for example, a sma

hazardous occupational group. The same ho

mue for diseases of rare occurrence. These of

are of interest to a degree far greater than t

which their frequency migh~ warrant.

Statistics from the program do not provi

crirical tests of clinical and epidemiological

hypmheses. For example, the program could 

rest the hypthesis fiat a special vaccine wo

prevent a certain disease. For this, an exper

mental design, a control group, and similar co

ditions would be required. However, the program

may suggest hypotheses that can be tested 

other appropriate means.

Aside horn these limitations imposed 

medmds being used and resources available, 

program is free 10 collect any statistics on 

incidence, prevalence, or other measures of d

ease, injury, or impairment; the disability 

other effects of this morbidity; and the medic

care used in its treatment. The sole guide, with

the technical and administrative possibilities, 

the usefulness of the data.

I
APPENDIX I

(Raprint=d below is tha text of Public Henlth %rvice publication No. 333. A list of the members of the U. S.

Notional Commiiiae on Vital and H,alth Statistics ond of the Subcommittee on Notionol Morbidity Survey app.ars en page 39. This R-port W.S p.blishcd in October 1953.)

RECOMMENDATIONS FOR THE COLLECTION OF

DATA ON THE DISTRIBUTION AND EFFECTS OF ILLNESS, INJURIES,

AND IMPAIRMENTS IN THE UNITED STATES

A REPORT OF THE SUBCOMMITTEE ON NATIONAL M@l?BIDITY SURVEY

U. S. NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS

PART I

Summary

This report contains a reveiw of the needs for

statistics on illness in the general population, and

the current and potential uses of morbidity statistics and related data. On the basis of this review

and study of the present sources of morbidity and

medical care utilization statistics, a proposal is

made for a national morbidity survey 10 provide

needed information on illness in the United States.

The report describes the data collection mechanism with specifications as to the types of data to

be secured, the geographic area to be covered,

and accuracy of data.

Part H of this report provides background information and a general frame of reference for tie

parts which follow. Included are statements regarding the work of the two earlier ad hoc committees which did certain exploratory work in this

general area, and the specific charge to this Subcommittee by the U.S. National Committee on Vital

and Health Statistics.

Part 111 presents art omline of some of 

more important currem and potential uses of mo

bidity statistics and related data.

In Part IV there is discussion of the genera

types of data, the degree of detail and the frequen

cy of collection which appear necessary to serv

rhe purposes outlined in Part 111.

Part V is largely devoted to consideration 

the question of whether etistig programs of da

collection can serve to satisfy the needs for mo

bidity statistics which have been identified. First

there is discussion-of recent improvements in t

methodology of data collection in this field. Nex

the presem sources of morbidity and medical ca

utilization statistics are reviewed and evaluated

Finally, the conclusion is reached that adequat

current morbidity data on a national basis cann

be derived from any of the present sources

Parts VI and VII contain the recommendation

that a continuing national morbidity survey be co
of data which should be collected and a proposed

design for such a survey. The recommendations

may be summarized as folIows:

1. That a continuing national morbidity survey be conducted which is adequate to provide statistical estimates for 50 regions of the counmy at

intervals of two years and estimates for the narion

as a whole at quarterly intervals. The puqmse of

this survey would be to obtain data on the prevalence and incidence of diseases, injuries, and impairments, on the nature and duration of the

resulting disability, and on the amount and type

of medical care received. The data should be

holds .

2. That a series of special studies be undertaken in addition to the continuing national survey.

The principal purposes of these studies would be

as folIows:

(a)

(b)

To obtain data on undiagnosed and nonmanifest disease, by means of labora~ory

screening, detection, and physical examinations of subsamples drawn from the

general surveys.

To provide other types of auxiliary data,

and to study methodological problems relating to the measurement of morbidity.

PART II

/

The Work of Previous Committees and the Task of the Present Subcommittee

Since its establishment in January 1949, the

United States National Committee on Vital and

Health Statistics has given attention on several

occasions to the need for more adequate national

morbidity statistics. Two successive adhoc committees were established by the Chairman of tie

National Committee “to frame the problems in

morbidity statistics, including chronic diseases

and medical care statistics, in order that morbidity data may be directly related to demographic

factors.”’

In December 1949, che first of these committees made its report which was a review of the

background of the problem. It also contained an

outline of the major sources of morbidity and other vital and demographic statistics. The broad approach taken by this committee is indicated by the

face that recommendations were made in the following fieIds:

1. Study and revision of reporting system for

notifiable diseases.

2. Adaptation of survey techniques for health

purposes.

3. Chronic disease statistics.

4. Development of standards and definitions

for hospital morbidity statistics.

5. Study of means of obtaining adequate current population data for small areas.

6. Longitudinal studies.

7. Place of case registers in morbidity statistics.

8. Development of mechanism for providing

civilian casualty statistics in time of war.

The second ad hoc commirtee submitted its

report in October 1950. This covered an almost ‘

equally broad area and recommendations were

made for further study in each of the fields listed

above except the Iast but with the addition of a

recommendation regarding the development of

I

standards and definitions for general morbidity

statistics. Moreover, by this time the committee

was able to take note of several new facts: (1) that

a thorough overhauling of the notifiable &sease

reporting system had been initiated by the Public

Health Service; and (2) that a special Subcommittee on Hospiral Morbidity Statistics had been sec

up to which the problem of standards and definitions for hospital morbidity statistics could be re- ,

ferred.

Both committees had urged an investigation of ~

the methodological problems in the collection of

statistics on chronic illness and disability by

means of surveys. The types of investigations

needed were listed under three major headings: :.

A. Study of survey techniques.

B. Investigation of specialized health, hos -

pital, and medicaI records for utilization

on subsamples of the population.

C. Investigation of specialized respondents

such as physicians for utilization on sub- .

samples of the population.

Even as these recommendations were being .

made, moves were under way to study all three of :

these matters in conjunction with surveys in several parts of the coun~. As will be indicated in I

Part V of this report, answers to some of the ]:

::

20
ouserider -

mvey.

lld be

i non-

‘ator y

>xamm the

data,

IS relidity.

ttee

:ed its

.lmost

were

listed

nofa

mc of

‘bidity

nittee

1) that

sease

Public

,nmit-

‘en set

iefinibe re-

.tion of

[ion of

ity by

ations

dings:

, hos-

?arion

ndents

n subbeing

ree of

.n sevxed in

of the

methodological questions will soon be available

from studies in New York City; Humerdon Coumy,

New Jersey San Jose County, California; and

Pittsburgh, Pennsylvania. Other experiments by

the Public Health Service and new surveys now

being planned will provide further information that

should lead to improvements in techniques.

With the knowledge that the time was at hand

for specific recommendations regarding the collection of national data on morbidity and medical

care by means of surveys, the Chairman of the

National Committee established the present Subcommittee in February 1951 and charged it with

the task of drafting “a plan for a national morbidity survey keeping in view the interests of local

areas. ” Because of ambiguity in the use of the

term, the Subcommittee was also asked to consider a definition of “morbidity.”

The Sulxom.mittee has attempted to fulfill

this task. It reviewed carefully the reports of the

ad hoc committees and attempted to take up where

these groups had left off. The Subcommittee has

studied the needs for morbidity statistics, tie

present sources and their inadequacies, and the

type of survey mechanism and special studies that

would meet the apparent needs. The conclusions

PART

Current and Potential Uses of

“hiorbidity statistics ,“ as used in this report,

means quantitative data usable as measures of

deviations from health in the general ppulation or

in specific population groups. The term does not

denote any statistics regarding health or sickness

which, while meaningful for other purposes, cannot be related to a particular population at risk.

The purpose of this section is to outline some

of the practical questions relating to health and

medical care which require accurate and detailed

morbidity statistics for their solution. It is realized that an important element of the problem is

tie specification of the degree of accuracy and detail needed in morbidity statistics for each of the

uses listed. However, discussion of these matters

has not been attempted in this outline.

There will be found below a summary of the

broad areas in which demands for morbidity data

exist, as determined from the experience of the

members of the Sukommittee, from the files of

the Public Health Service, horn the responses of a

and recommendations are contained in the sec

that follow.

To the matter of the definition of “morbid

the Subcommittee gave careful artention. No 

cise limited definition of the term has been 

for the following reasons:

1. The term “morbidity” is and should 

main a general word to be used to designate 

ness (manifest and nonmanifest), injuries, an

pairments.

2. The definition of The particular m

conditions that one wishes to count or describ

studies and surveys must vary according 

objectives of the particular study or sur

Hence, no one definition of a “morbid condit

can easily be adhered to.

3. For any regular program of national 

bidity surveys an operational definition of w

to be counted or described must be devised. 

operational definition must be shaped to sui

particular purposes tiat the statistics are to 

and yet must be a definition that can actually 

applied in the field.

4. The task of devising an operational de

tion will be left to those who will carry ou

more detailed phases of planning for the prog

of national morbidity surveys.

Ill

Morbidity cnd Related Data

limited number of &tential users of morbi

data who were quesuoned by members of the 

committee, and from otier sources. I It mu

emphasized that there is no implication inte

that all of the data needed can feasibly be obtai

nor =at collection of data on all the items 

lined below would necessarily be warranted 

national morbidity survey.

l%e categories in the outline are not inten

to be mutually exclusive in every in.mm

IIC j~ &]i=red hat ● mom complere and represcnmciw 

of the needs of pnmntinl consumers for morbidity dmra shou

mmdc. To da c.his usk tbomughly would require more time -

MUCCS dmn the !Mtcommimee h~s ntilrnble. I-fowemr, c

letters mnd oher c7idcnces of ❑eeds snd uses of morbidiry 

ucs on r.hc generml ppukion collecred by AC SuLxommimee 

on file.
Morbidity Statistics and Related Date

A. Statistics for use as a guide to administrative planning and evaluation of official and voluntary programs in the field of health.

In this area morbidiry statistics would be

used direcLly for the purposes at hand.

Examples in tiis area are:

(i)

(2)

(3)

(4)

(5)

B.

Use of various measures of morbidity

and disability for ranking of problems of

public health in order of importance and,

in general, for determining how resources should be divided among numerous programs.

Checking on the adequacy of reporting of

notifiable diseases and establishing baselines of endemic prevalence.

Provision of quantitative data for planning

new programs of contiol and for estimating probabIe maximum expenditures

needed for such programs.

Determination of trends in incidence and

prevalence of specific diseases for evacuation of the effect of preventive and

therapeutic innovations.

Cohort-t~e studies for evaluation of preventive and therapeutic measures.

Statistics for the evaluation of the current

morbidity experience in relation to the provision

of medical and dental services, facilities andpersonnel for meeting the heaIth needs of the nation

or of a community.

(1)

(2)

(3)

(4)

Provision of quantitative information on

which co base sound estimates of needs

for general, chronic, and other special

hospital facilities, nursing home beds,

and home care facilities, either in the

nation or in particular localities.

Estimation of che numbers of persons requiring particular rehabilitation services, to assist in planning for the provision of such services.

Statistics on the frequency of chronic disease, injuries, and resulting disability,

for use in considering the cost of extending the scope of medical care insurance

or compensatory insurance of various

types.

Numbers of persons covered by various

types of insurance plans, and amounts

spent and methods of payment for medical care, so that study of the economics

of medical care may reflect modern conditions.

(5)

(6)

Statistics on the use of medical services

and personnel in various income and

occupation groups, for establishing the

actuarial base of new insurance plans

designed to cover the medical expenses

of particular groups of the population,

such as the members of a tiatemal

order.

Statistics on the various categories of

disease and on the receipt of medical

care, to be used to guide the planning of

medical and nursing education by indicating where emphasis in education can

most usefully be placscl.

c. Statistics for medical research. While

morbidity staustics from surveys of the general

population cannot usually be used to make conclusive tests of hypotheses in medical research, they

can be useful in suggesting hypotheses for further

testing and in providing other aids to research.

Examples in this area of use are:

(i)

(2)

(3)

(4)

(5)

(6)

D.

The provision of rosters of cases for the

intensive investigation of disease etiology.

Information on the association between

the incidence or prevalence of various

diseases and demographic faccors, such

as age, sex, marital status, occupation,

and economic status.

Provision of data to help research workers ti the field of preventive medicine

select segments of the population having

the greatest risk of developing specified

morbid conditions, thereby permitig

the selection of smaller groups for followup in tests of preventive measures.

Statistics on the prevalence of certain

diseases, for use in estiating gene frequencies in the population.

Geographic distribution of diseases, such

as allergic conditions, numiuon~ diseases, and nephritis, to provide clues as

to etiology.

Description of the natural history of diseases, both acute and chronic, in representative samples of the population to

provide more quantitative lmowledge of

the preventive aspects of the disease as

it occurs in nature.

Statistics relating to certain manpower

problems and civilian defense. Both civilian and

military agencies concerned wizh problems of

manpower civil defense need information on the

physical fimess of the population and the numbers

of persons falling into various categories by type

,

22
mhces

ne and

ing the

e plans

Tenses

nation,

sternal

ries of

,ledical

ning of

)y indiion can

While

~eneral

:onclu-

:h, they

further

earth.

for the

? etiol -

]etween

rarious

;, such

pation,

I workedici.ne

having

]ecified

mimg

or folasures.

certain

me tie-

.S , such

al dis-

:lues as

.,

of dis -

repretion to

edge of

sase as

.npower

.ian and

ems of

I on the

mbers

by type

and degree of disability and occupation. Examples

in this area are:

(1)

(2)

(3)

(4)

(5)

Information on absenteeism resulnng

from disease and injury, for use in estimating economic loss to industry through

various types of morbidity.

Information on the numbers of persons

with chronic diseases and handicapping

conditions by type of disease or handicap,

and the employment status of such persons, for use in estimating potential additions to tie labor force.

Similar information on young men of

draft age, for estimates of numbers who

might be drawn into the Armed Services

in limited duty categories.

Data on the morbidity rates of handicapped persons as compared with the

nonhandicapped; data on the personnel

and facilities required to correct handicaps that are subject 10 correction, for

the use of indusmy and the Armed Services.

Statistics to answer the following types of

questions for civilian defense agencies:

(a) What proportion of physicians and

nurses are physically fit so as to be

available for duty in the event of bombing

artacks or for other types of disaster?

(b) Whar proportion of the general population in an area would need special attention because of disability in making

plans for evacuation of the population in

anticipation of, or following, bombing

artacks? (c) What proportion of thepopulation could be considered suitable as a

potential source for providing blood?

(d) What proportion of the population

would require special attention such as

extra rations or vitamin supplies, in

planning for the nutrition needs of a

bombed area? (e) In the event that evacPART

(6)

E.

uation camps are established, what p

portion of the population of these cam

would require such drugs as insulin 

diabetes or liver exmact for pernicio

anemia? (f) What are the endemic lev

of the incidence of nonreportable ac

diseases, such as gasmoenteritis, 

planning for defense against biologic

warfare?

Incidence of chronic disease in old

workers, for the use of indusmial fir

interested in knowing the risk in e

ploying such workers.

Statistics for the use of dru~ firms 

appliance manufacturers in estima&g mark

for particular preparations or appliances. T

use requires not only the usual types of inform

tion on incidence and prevalence of diseases, 

juries, and impairments, but aLso statistics on 

current utilization of medical services of Wrio

types, for example, frequency of particular oper

tions, and also frequency of prescriptions and 

use of hearing aids, artificial limbs, and so for

Incidence and prevalence of disabilities by par

the bcdy affected are Requently needed.

F. Statistics for public health education p

grams. This is one of the most tiequent of 

types of request for statistical information 

ceived by health agencies. Examples in this a

of use are:

IV

(1)

(2)

Types of Data, Detail, and Frequency

Estimates of the national ticidence of 

cidental injuries by type and degree 

disability caused, for accidem preventi

agencies; estiates of tie prevalence 

cerebral palsy, multiple sclerosis ,bli

ness, deafness, and many other diseas

and impairments, for voluntary hea

agencies concerned with these con

tions.

Similar information for use in advertisi

campaigns with a public health educatio

objective.

of Collection Required

General Morbidity Data dence, prevalence and the duration of disabil

for the major categories of disease and impa

A minimal adequate program to provide sta- ment. The data should allow subclassification 

tistics for the uses listed in Part HI would neces- sex, by several age groups, and by employmen

sitate collection of data of national scope on inci- educational, income and occupational status, 
to be usable by the Health Officers of States or

cities.

The amount of diagnostic detail required

v=ies greatly wirh the particular application. A

classification by major diagnostic categories

would probably be sufficient for a general appraisal of tie principal health problems in an area, as

mentioned under heading A of Part 111. With some

diseases, much more detail would be needed ti

order to provide background data for estimates of

tie professional services and facilities needed in

a program of prevention and care. For many of

the uses described in Part 111, it appears that the

data should include undiagnosed illness. Nonrnanifest disease or heretofore unrecognized cases of

disease should also be included, at least in so far

as appropriate followup measures can be specified.

In order to be most useful, the general morbidity data must include more than simple incidence and prevalence rates. The data must describe:

1. Some of the facts about the natural history

of morbid conditions, such as duration, type,, and

extent of incapacities (hth primary and secondary).

2. Some of the facts almut the social consequences of morbid conditions, such as: changes in

employment status, source of support, housekeeping assistance and nursing service required.

3. Morbidity indices should be related 10 data concerning membership in prepaid health insurance plans, and the types and amoums of services received from such plans.

4. The data should include information on

udlization of medical services and facilities. The

followinz woes are of interest:

(a)

(b)

(c)

(d)

Physician’s services (classified as to

home visits of general practitioners, office visits 10 general practitioners, ofice

visits TO specialists, hospital visits of

physicians of all types).

Dental services (classified as to visits to

general practitioners, visits to specialists).

Nursing services (classified as to home

visits, services in hospitals, services in

other institutions).

Hospital services (classified as to services in general, tuberculosis, mental, and

other types of hospitals, and “near hospital” care, such as nursing home care

and convalescent home care).

5. Another ads of classification of the medical services and facili~ies is also frequently

needed:

24

(b)

(c)

mary - prevention of disease occurrence;

and secondary - prevention of disease

progression by periodic examinations,

prevendon of sequelae, and other preventive services).

Diagnosis and ~eaunent services (classified as to inpatient and outpatient services).

Rehabilitation services (classified as to

inpatient and outpatient services).

Frequency of Collection

The requests for data cited in Parr HI do not

specifically mention any particular frequency of

collection that would be desired. It is to be noted,

however, that practically all the data requested

are for the purpose of future planning of some

kind. Thus, the requests are predicated on tie

assumption that the data would be current, or at

least sufficiently up to dare so that pIans for the

future could safely be based upon them. How up to

date the data need be in practice depends, of

course, on the rapidity witi which changes in morbidity or in the major health problems occur. This

wiII vary from item to item.

An efficient program of data collection to

meet the requests in Pare III should have the following features. It should permit the publication of

basic data on the prevalence and incidence of disease, injuries, and impairmems, on tie nature

and duration of the resultig disability, and on the

amount and type of medical care received, at intervals of two years. ‘The program should also

have considerable flexibility for the foHowing

reasons:

1. For some data, publication at less frequent intervals than two years will be adequate.

The program should permit such data to be obtained at relauvel y little exma expense.

2. Although it is ~ssible to rank the various

requests for data, at least roughly, in their order

of importance at the present time, this ranking

will change as time proceeds. The program should

make it possible to obtain, at relatively short

notice, data which become of paramount impor -

~ance.

3. In the event of an intensificaaon of the international crisis, there may be a sudden demand

for data at more frequent intervals or for certain

specific dara at very short notice.

As will be discussed in Part VI, these considerations point toward a continuous program

of data collection, rather than toward a rigid, intermittent schedule of surveys any two or five

years apart.
as pri-

:rence;

Lsease

iatiOnS,

.r pre-

(clasLtserv-

,d as to

,1do not

lency of

? noted,

ques~ed

)f some

on the

it, or at

for the

3Wup to

mds, of

inmor -

lr. This

crion to

the folcation of

? of disnature

Id on the

1, at inlld also

>Ilowing

~ss &eiequate.

o be obVarious

:irorder

ranking

m should

~y short

impor-

.f tie inI demand

r certain

ese conprogram

.-i@d, inJ or five

Geographical Detail

Most of the needs for morbidiry data, of

which the examples in Part III are illustrative,

are encountered on national, regional, and local

levels; therefore data are necessary that will have

sufficient geographic specificity to be useful at all

of these levels. The designation of tie degree of

geographic detail in which sta~istics are required

for the purposes of, let us say, the Health Officer

of a cicy is, of course, a function of the accuracy

demands of the particular job. However, the

specification of desirable geographic detail is further complicated by a lack of data on the gmgraphical variation of the common indices of morbidity. If a particular index is relatively stable

horn one area to another, men obviously the

Health Officer’s needs may be adequately served

by population rares for all cities of the size of his

own in the broad geographic region of the counmy

in which the city lies. On the other hand, if geographic variation is very great, perhaps nothing

will serve the Health Officer but data specifically

relating to his own city. For the me being this

matter must be semled on the basis of the judgment of experts unsupported by evidence. Such

judgment will seek to find a reasonable compromise between the ideal of ~eat geographic detail

and the practical dictates of cost. As is well

known, the cost of obtaining the data increases

rapidly with the geographic detail required.

Individual Studies

Several of the examples cited in Part 

would require specialized studies which 

little relation to one another or to a national 

gram of data collection. Examples are: tie 

vision of rosters of cases for investigation of 

ease etiology [C(l)], and statistics to indi

the propcruon of physically fit physicians 

nurses [D 5(a)]. Such studies would be best 

ducred individually by the interested bod

Interest has also been expressed in stu

showing: (1) the modifications brought about i

usual course of chronic diseases by adequate 

fessional care; and (2) the manner in which 

of the social consequences of prolonged illn

may be avoided and economic savings bro

about by adequate medical, social, and rehabili

tion services. However, the Subcommittee 

that these were beyond tie scope of its ass

ment. Such investigations should be made 

means of independent studies.

The use of’ the indices of morbidity and m

cal care produced by this survey to estimate 

personnel, facilities and services required 

meeting the health needs of the nation or 

communicy presents difficult problems. No si

approach to such estimation is ideal but sev

methods may be considered. These are discus

in this Appendix.

PART V

Review of Present Sources of

Those unfamiliar wirh sources of morbidity

statistics relating to the general population someties have the impression that there is no dearti

of estimates of the prevalence of various diseases and impairments. Speeches by public officials, testiony before Congressional committees,

repcms of conferences and statistical’ ‘fact” books

are full of estimates that might seem to satisfy

the needs for such statistics. If the genealogy of

these estimates is mated back (and their lineage

is often complex), a remarkably high proportion

of them are found to have descended from the

findings of the National Heslrh Survey of 1935-

1936.

National Morbidity Statistics

The National Health Survey

This survey was an attempt on the part o

Public Health Service to find out tie number, 

sex, income level, and occupation of people 

urban population of the United Stares who had 

perienced disabling illness witiin the 12 mo

prior 10 the visit of an interviewer or who 

time of the interview were believed to ha

specified chronic illness or impairment (whe

disabling or not). The Survey, despite its ma

tude (737 ,000 households) and complexity w

very well-planned project. The staff incl

many competent statisticians and, because o
U.S. Employment Service and the W. P. A., it was

possible to obtain a reladvely high grade of workers for interviewing, coding, and so ford’t. Though

critics have lately pointed to a number of shortcomings of the survey plan, the knowledge of survey design upon which these criticisms are based

was, for the most part, not available to those who

did the planning. The period, 1935-1950, was one

of very rapid development in all phases of the science of data collection in ~pulation surveys.

There is no question but that the data from

the National Health Survey have been put to very

wide use. Owing to the lack of really appropriate

statistics, the information has been made to serve

purposes for which it was not well suited. Dr.

Leonard A. Scheele, Surgeon General of the Public

Health Service, in testimony before the Subcommittee on Health of the Senate Committee on Lalmr

and Public Welfare (August 23, 1951), stated as

follows:- “In the past 15 years, findings from che

National Health Survey of 1935-1936 have formed

tie basis for about two hundred reports, articles,

and comparative studies. The survey data have

been used to project estimates for more recent

years and for individual communities in an

attempt to measure needs for hospital and other

facilities and community services. Many of the

National Health Survey figures are of somewhat

doubtful applicability to present-day conditions.”

The extensive use of that material right up to

the present tie, even by people who were aware

of tie risks involved in using it, is of itself a

smong indication that morbidiry statistics are in

great demand.

Advances in Sampling

and Survey Techniques

No survey of national scope undertaking to

obtain more dmn a few very limited items on ill-

. . negs and its consequences has been made since

the National Health Survey. However, public healrh

and sampling statisticians are now in a much better posiuon to say how a comprehensive survey

or surveys should be planned in order to produce

useful and accurate data. The following areas of

advance are illustrative:

1. From the uses to which the results of the

National HeaI~h Survey and other studies have

been put we have learned more about the types of

data it is necessary to have in a well-rounded

program of collection.

2. Much has been learned from research

done in Census work and in non-Gove~ental

data by means of questionnaires and interviews.

In the design of schedules there have been some

marked improvements.

3. The developments in mass X-ray surveys

and the use of multiphasic screening techniques

have taught us a great deal about the problems of

detecting nomnanifest disease. Experiments with

the use of symptom schedules have had some success in picking out persons who are in need of

medical care but who for one reason or another

have not sought medical assistance.

4. Longitudinal and cohort-type studies have

provided new information about the characteristics of illness, particularly chronic illness, the

frequency of disabling attacks, the clustering

within households, and similar data. The experience in these intensive studies will prove useful

in designing the more exrensive type of survey.

5. The very rapid advances that have been

made in the development of applied sampling

theory have “showed how it is possible to design

probability samples of human populations that provide much greater sampling precision per dollar

expended, and during this development of theory

there has been a wholesome emphasis on making

the theory and the field application coincide. The

growing realization that aU sources of error, and

not alone that which is due to sampling, must be

considered in planning and kept under con~ol is

particularly important for illness surveys.

Other Recent Studies

Several srudies recently completed, in planning, or under way will add “some rather specific

methodological results in the field of the measurement of illness. Among these studies are:

1. The Baltimore Eastern Health Dis&ict

= in which the white population of a sample of

35 blocks in the health dis&ict was studied for

periods up to 5 years (1938-1943). Actually 17 of

the blocks were included in the study for 5 years,

another 17 were included for 3 years, and one

block was dropped early in the third year of study.

A small corps of well-trained interviewers made

monthly visits to all families residing in the

blocks at the time of the visits. Information was

obtained on illnesses or injuries that had occurred

since the previous visit and on all medical care

including preventive services received in the interval. hy responsible member of the family who

happened to be present was accepted as the respondent. Diagnostic information on cases of illness that had been artended by a physician was

checked with the physician or with hospital or

.1 

d 

d

.

26
,niques

sms of

;s with

le .sucleed of

nother

!s have

:teris3s, the

tering

xperiuseful

=vey.

s been

npling

iesign

It prodollar

fieory

latig

?. The

jr, and

ust be

rol is

planecific

neas-

: are:

~

ple of

?d for

17 of

rears,

i one

.tudy.

made

n the

i was

mred

care

e inY who

E ref illI was

,al or

g 

our knowledge of how to make more accurate surveys of the less intensive type in the future. It was

found, for example, that many of the chronic diseases present in the population at the time of the

first visit were not brought ~o the attention of tie

interviewer until the family had been visited six

or more times. It was probably the occurrence of

a disabling attack that led to the first reporting of

many of these diseases, but because of tie length

of time that the families were followed it is likely

rhat nearly all serious chronic diseases present

were eventually picked up. To mention only one

other of the numerous varieties of investigation

That has been made, it has been ~ssible to study

the course of chronic illness in terms of frequency

and dismibunon of disabling attacks. New studies

of these Eastern Health District data will continue to smear for manv vears.

2, tie California M&bidity Research Prol-

~ is being conducted by the State Health Department with the assistance of the Bureau of the Census and under a grant from the PubIic Healfi

Service. The objectives of the project are the

srudy ofi (a) methods of obtaining data on illness

and disability from population surveys based on

objective sampling methods, and (b) methods of

using data arising from administrative programs,

in conjunction with population sample surveys, for

specjal purpose studies or statistics. In San Jose,

California, an intensive pilot study has been carried out in which the interview method and the

diary merhod of collecting illness data have been

compared, a number of aspects of diary-keeping

have been investigated, and the effects of the interviewer and the respondent upon the data have

been evaluated. Making use of the findings of the

San Jose study a statewide survey is soon to be

undertaken, both as a demonstration of the methods and also for the purpose of making further

methodological tesm.

3. ‘l%e Special Research Project of the

Health Insurance Plan of Greater New York will

provide as a by-product some useful comparisons

of illness data horn an interview and from the

records of a broad-coverage medical care plan.

This project is financed by grants &om the

Commonwealth Fund and horn rhe Rockefeller

Foundation. It includes: (a) a household interview

with each of a sample of 5,000 families insured

under the plan; (b) an identical household interview with each of a sample of 5,000 househohis

pg

interview can be compared with records 

plan, and a similar comparison can be mad

rates of utilization of medical services, thu

viding a basis for calibration of ~he results 

tained in household surveys. Variation amon

terviewers can be studied, and aLso the eff

memory failure of the respondent can be 

ured for illnesses attended by a physician. 

thermore, since the cost of the service has 

removed as a determining factor, the utiliz

rates for persons covered by the plan will 

great value in helping to determine what m

care is required for persons with specific 

tions.

4. Surveys sponsored by the Commission 

Chronic Illness will make use of all metho

measuring chronic illness in the population

Hunterdon County, New Jersey, a symptom 

tionnaire was provided for each adult to be 

out by himself, a sample of families has bee

terviewed, and subsamples of those with and 

out manifest chronic disease will be screene

means of diagnostic tests. Thorough ph~sical 

aminations will also be given and histories 

These should supply some particularly usefu

perience on the measurement of needs for 

cal care. A similar study to be conducte

Baltimore, Maryland, is now getting under 

5. ml 

Studies, being carried on by the Graduate 

of Public Healrh of the University of Pittsbu

till concentrate upon the familial aspecm 

ness but will also investigate methodolog

problems in household illness surveys. The 

work for the first of these surveys, involv

sample of several thousand households fr

section of the Arsenal Health Dismict and a 

percent sample of the remainder of the c

Pittsburgh, has now been completed and ana

of some of the results have begun to ap

6. Other studies that conmibute to the 

odology of morbidity surveys are: (a) the s

of small experiments being conducted by th

vision of Public Health Methods on memory 

illness, respondent bias, interviewer varia

accuracy of household report of diagnosis, 

existence or nonexistence of records carryin

diagnosis in the offices of general practitione

(b) the very intensive study of home injuries 

ried out by the School of Public Health of the 

versity of Michigan in Washtenaw County; (
g 

the incidence of attended illness horn a countrywide sample of physicians, which is being undertaken by the Research Depsrunent of Modern

Medicine Publications, Inc.; and (d) the surveys

of unmet medical care needs in rural areas of

Michigan, Ohio, and other areas, making use of

the symptom schedule developed by Hoffer,

Schuler, and others.

When the results of the above-mentioned

studies and projects become available we should

know a great deal more than we do now almut tie

relative value of” various procedures for the

measurement of illness.

Morbidity Statistics Applicable to

Large Segments of the Population

Before considering the types of additionaldata that should be collected to meet the needs for

national statistics described in Pam III of this report, ir is essential to review the present sources

and to determine the extent to which these sources

are capable of filling the needs. The National

Health Survey of 1935-1936 has already been mentioned. 1[ has a number of inadequacies for current use. In tie first place, tie survey was based

almost entirely on urban populations. Hence, national estimates may be quite far in error because of the failure to take into account differences between urban and rural morbidity. In rhe

second place, many important changes have taken

place in the dismibution and characterisucs of the

ppulation since 1936, and there have been alterations in tie parterns of provision of medical care

and in medmds of prevention and ~eanmentofillness. These alone would be sufficient to make the

results of the National Heakh Survey out of date,

buc in addition a world war has intervened leaving

in its wake not only a large number of serviceconnecmd disabilities but also other less obvious

scars which may not even be detected for a number of years. Finally, current needs for statistics

are different and data horn the National Health

Survey are not available in the proper form to

answer today’s questions. To suggest rhaz tie

country continue to base important decisions on

statistics that are over 15 years old would be a

poor recommendation, even if the statistics were

well suited in other respects to tie problems at

hand.

One other source of national statistics has

also been mentioned briefly-the Modern Medicine Physicians Panel on Medical Treatment(see

“Other Studies” above). This must be considered

anism which may turn out to be capable of providing national estimates (andpossiblysomeregiona.l

estiates as well) of the incidenceofattendedillness by diagnosis in some detail. It may also

supply useful information on the types of attending

physician, and the types of drugs and other treatment prescribed. Whether it will show rates for 

population characteristics other than age and sex 

is not yet lmown. The statistics are based upon a 

report of the practice of a national sample of phy- 

sicians for one full week in each three-month period.

Despite their vintage, mention should be made .:

of the studies conducted by the Committee on the 

Costs of MedicaI Care in 1928-1931. The detailed 

information on morbidity and utilization of medi- 

cal services horn the survey of 9,000 families, 

and the estimates of medical care needs made by 

Lee and Jones were not duplicated in the later and 

larger National Health Survey. Consequently, the

studies of the Committee on the Costs of LMedical 

Care conti.ue to provide the only source of cer- 

tain very useful types of statistics. The 23 papers ‘

by S. D. Collins on morbidity and medical care 

utilization rates born the househoId survey have

been widely used. The Lee-Jones estimates are

still consulted although their inapplicability to

present conditions is obvious.

Other significant sources or potential sources

of morbidity statistics may be classified as follows :

A. The notifiable disease reporting system

(including industrial diseases, cancer, rheumatic

fever, and other diseases in some Scares).

B, Data accumulated as a by-product of insurance and prepaid medical care plans.

1.

2.

3.

Sick benefit associations, group health and

accident insurance.

Prepayment medical care plans (Health m

Insurance Plan of Greater New York, Permanence Health Plan, indusmial plans,

union plans, and others).

State disability insurance plans (Rhode

4.

5.

6.

Island, California, New Jersey, New York,

and Washington).

Life insurance companies (results ofphysical examinations).

Hospitalization insurance plans (Blue

Cross, etc.).

Railroad Retiement Board plan.

L. Tax-financed public assistance andmedical care plans.

1. Programs providing all or a part of the

medical services required by recipients

oh old-age assistance, aid to dependent

28

.
provid.

i egional

nded ilIay also

ttending

r treatates for

and sex

1 upon a

of phy -

mth pe-

‘~emade

s on the

~etailed

f medi-

‘milies,

nade by

wer and

?tly,” the

~iedical

of cer -

papers

‘al care

q have

(es are

,ility to

sources

as folsystem

wm atic

‘t of inllrh and

{Health

-k, Perplans,

. .

(Rhode

vYork,

f phys-

(Blue

cimedit of the

cipients

:pendem

.

L.

3.

D,

children, aid to the blind, aid IO the permanently and totally disabled, and general

public assistance (whetier by cavitation or

fee-for-service).

Armed Services sickness and medical care

statistics.

Admission or discharge or other hospital

statistics for Veterans Adminismation,

Public Health Service, and Indian Service

hospitals.

Other hospital and clinic admission and

discharge records ~New York City Hospital Morbidity Reporting Project).

E. Absenteeism records

1. In indusmy

2. In schools

F. Routine physical examinations

1. In industry

2. In schcds

G. Records of physical examinations of Selective Service registrants.

H. Case-finding programs, multitest screening programs, case registers.

I. National surveys using tie schedule of the

Census Bureau’s Current Population Survey.

J. Local surveys.

K. Miscellaneous sources (data on the back

of birth certificates, motor-vehicle accident reports, industrial injury reports).

This list may not be complete, but it does include the major sources now producing records

hat are or might be usable for statistical purposes. It would be impossible to discuss each one

of them here, but certain characteristics of these

sources can be considered from the s~andpoint of

their usefulness for serving national needs.

The nature and scope of the data supplied by

the notifiable disease reporting system are well

known; hence, this source may be passed over

here with the comment that, though the reporting

system is indispensable, the diseases reported

constitute only a small fraction of the total illness

experienced by the general population, no matter

which of the common utits of measurement is used

for the comparison.

Turning to the sources in Caregory B, it must

first be stated that, with the possible exception of

State disability insurance plans, all of these have

a common limitation. This is the factor of self

selection in the coverage. In some of the plans, by

virtue of tie fact that coverage is automatic for

large groups, tiis facror is less important, but one

still cannot use the data to make probability estimates for the general population.

In the State disability insurance phns, coverage is complete for c~tain legally defined classes

of the population.

Anotier more serious limitation o

sources in Category B arises horn the re

tions in the type of illness covered by the 

ance and the termination of benefirs under 

plans after a certain number of weeks 

elapsed or a certain number of dollars have 

paid. Only the broad-coverage prepayment 

of which the Health Insurance Plan of G

New York and Permanence Health Plan are 

as examples, do not suffer from this limit

For the most par~ ,data from these insu

plans relate to artended illness. Despite the 

tations, however, some sources in this cat

have proved very valuable. As an example w

cite the Public Health Service statistics on 

trial sickness absenteeism in a group of repo

organizations made up of mutual sick benef

sociations, group health insurance plans, 

company relief deparunents. The data are l

to sickness and nonindusmial injuries c

absence from work for 8 consecutive cal

days or longer. With the exception of the re

of illness in the armed services, these repre

the longest series of comparable illness stati

published in the United States, going back a

do 101920.

The value of the records of broad-cover

prepayment plans for special studies of att

illness and the utilization of medical car

been referred to previously.

Sources in Category C are limited to s

groups of che population which are entitled 

nancial assistance or free inedical care be

of special legislation. The Army and Navy 

ness and medical care statistics are tie 

comprehensive statistics of the sort availab

any group in the United States. Many s

studies of importance have originated from 

sources, bm, in general, the lack of repres

anveness of the groups included in Category 

a major limitation 10 rheir use for most 

purposes we have listed in Part 111.

When hospital admission or discharge 

ords are collected for all of the hospitals 

large city (as was done in New York Ciry 

Welfare Council in 1933) so that it is possib

relate hospitalization to a population-at-risk, 

statistics can be useful in indicating differen

in frequency of hospitalization in different 

ments of the population. While hospitalized 

represents only a small h action of all illne 

ceiving medical care and there is undoub

great variation from one economic or 

stratum to another in the types and sever

cases that are hospitalized, nevertheless, 

pitaliza~on rares by diagnosis, age, sex

other characteristics of the population are 
-.

p

It should be remembered, however, thachospital admission or discharge races reflect only

usage of hospital facilities and must be supplemented by some kind of independent estimates of

demand in order to be helpful in planning.

hlemal hospital starisdcs are currently providing our only national data on the magnitude of

the problem of mental illness. Strenuous efforts

are now being made by hospital adminismators

and statisticians under the leadership of the National Institme of Mental Health to improve the

statistics. Only a grea~er number of beds and

more medical personnel will remove one basic

limitation which is fiat the rates are Iargely determined by the availability or lack of availability

of hospital care.

bother use of hospitalization statistics related 10 a Imown population base is for obtaining

rough rates of “incidence for diseases that are

rare and severe. Recent titerest in aplastic anemia, for example, has led to a search for hospitalized case data in a Imown population.

Absenteeism records and routine physical

examinations vary greatly in quality and usefulness. Only a few studies of school absemeeism

could be said to have conmibuted to the kinds of

needs for statistics mentioned in this report. The

pirfalls are: inaccurate diagnostic information,

lack of complete seasonal coverage, difficulty in

distinguishing berween absence for illness and absence for other reasons, peculiar distiibucions by

days of tie week, and the interruptions caused by

week ends and holidays. It should be possible,

however, to use absenteeism on a day-to-day basis as an early index of epidemics, though tie necessary degree of cooperation has in the past

proven difficult to maintain. (The cause of the epidemic would probably have to be determined by

independent investigation.)

School physical examinations are usually a

poor source of information on the health of children. Here and there one hears of communities

that have improved the examination procedure and

made real use of the resuIts, but recent efforts to

use tie records from the routine examinations

for statistical purposes are rare.

Physical examinations in some indusmies and

also in other programs, such as that of the Farm

Security Administration, have been the basis of a

large number of special studies. When the examinations are uniformly and thoroughly carried out,

and when there is not tw great a factor of selectivity determining which individuals come for examination, the compilation of statisucs from the.

pgpy

are resmicted to the employees of a particular

plant or indusmy, and here is no basis for generalization of the results. Furthermore, the rype

of information that is obtained horn the usual

physical examinauon is not particularly valuable

for the uses listed above. This is because the

examination identifies various conditions that may

be indicative of the existence of disease, conditions such as hypertension, anemia, overweight,

refrac~ve errors, and so forth, but the resuks

of followup to determine diagnoses are only

rarely available. Nor is it usually possible to determine from the records what medical care has

been received for the conditions discovered.

The same can be said for the Selective Service examination records. The interpretation of the

voluminous data from this source has been a subject of contiovers y. To what extent do they reflect

poor healzh in the age groups of the regismants ?

What is the effect of changing standards for admission on tie recorded information? What is the

effect of differing practice from one induction center to another? The consensus of statisticians

seems to be that onIy the most limited generalizations are possible.

Category H is intended to cover the programs

which have case-fhding and case-following as

their objective. Some of these, such as the mass

chest X-ray screening, have reached millions of

people. In all of them the use of the results for

purposes of measurement is plagued by one great

question: What almut the people who chose not to

be examined? Recently there have been several

studies aimed at determinirig the characteristics

of those who did not appear for screening. There

had not been any instance prior to 1952 of an integration for measurement purposes of multitest

screening with other measuring techniques. Before long, however, we shall have the results of

the surveys of the Commission of Chronic Illness.

(See almve.) It seems likely that the combination

in one survey or series of surveys of multitest

screening with physical examinations and interviewing (i. e., disease detection examinations) offer the greates~ promise for providing morbidity

data of the breadth required to meet the national

needs. Such studies as are now under way are local in nature, but they will teach us a great deal

about tie feasibility of applying the same methods

in more extensive surveys.

The number of diseases for which there

exists a screening test that can be carried out on

a mass scale is still small, and the efficiency of

the screening tests now in use (their ability to

30
nations

:ticular

or genfie type

? usual

aluable

use the

lat may

condiweight,

r esulrs

‘e only

? to deme has

,vered.

>Servnofthe

I a subreflect

rants 7’

or adr is the

m centicians

leraligrams

ing as

? mass

ions of

~LS for

? great

nor to

everal

ristics

‘here

i inteIlutesr

s. BeUlts of

,lness.

nation

ltitest

interns) of-

:bidity

]tional

re loN deal

:thods

there

out on

,ncy of

ity to

pp gppg 

out too many false positives and false negatives)

is no~ accura~ely known. Much work is yet to be

done in this field, but the technique of mass

screening, devised for case-finding, may eventually extend greatly the usefulness of morbidity

statistics.

Surveys remain the most useful, flexible, and

in many ways the most reliable source of statistics on morbidity and utilization of medical services. T%ey are also, unfortunately, the most ex -

per,sive source in cost per case of illness discovered. Nevertheless, there is one survey based

on an accurately representative national sample

which can provide estimates for a limited number

of items at a very reasonable cost. This is tie

Census Bureau’s Current Population Survey

(C. P.S.). The monthly visiting of a sample of approximately 25,000 households, carried on by the

Bureau, is primarily for the purpose of collecting

economic and demographic data on the laimr force,

such as unemployment, movement in and out of the

laker force, hours of work, and so forth. It is

possible to add to the schedule of this interview,

by arrangement with the Census Bureau, a maXimum of, perhaps, six to ten questions on any subject of importance to the Government, providing,

of course, that the questions only require information that the household respondent, usually the

housewife, can supply. On several occasions this

means has been employed to obtain some limited

data on morbidity. Over a period of tirm the

C.P.S. could be used to accumulate a fair volume

of morbidity statistics relating to the noninstitutional populauon of the United States. The source

has, however, the following drawbacks: (1) the

sample was designed to produce only national esIirnates whereas morbidity statistics are needed

at least on a regional basis; (2) the amount of information that can be collec~ed in any one survey

is very small and the calls upon the C.P .S. by

various agencies of the Government are so numerous that the monthly survey is usually booked

up well in advance; (3) the population of resident

institutions is not covered in the surveys, but it

should be possible to sample such institutions

separately; (4) the Census Bureau would have dif -

ficulty mairdng and maintaining a staff of the

specialized coders who code causes of illness

and, consequently, the studies conducted so far

have had to be designed to avoid this coding. (If a

regular program of surveys were conducted, this

last difficulty could probably be overcome by detailing coders to the Census Bureau.)

The outstanding advantage of the morbidity

estimates supplied by the C.P.S. is that an esti

ing to the fact that tie 25,000 households 

tute a probability sample. Furthermore, 

viewers are carefully mained, and the 

field offices provide good supervision. 

are available relatively promptly.

In conclusion, one opinion sometimes 

is that it should be possible to combine d

these many existing souces, including 

fiable disease reports, to make a compre

body of statistics on disease incidence a

alence in tie United States. A little study 

that this cannot be done. Not only are the

ous gaps (particularly in information 

populations), but also t!he difficulties inpu

gether statistics born such a wide va

sources with differing definitions, comple~

coverage, sysrems of classification, and 

are overwhelming.

Nevertheless, if the tiagmentary 

listed almve are Iooked upon as supplemen

formation to be used for improving the 

and scope of data obtatied from national 

they offer many pcmsibilities. Some of th

tialities of the use of existing records as 

to a survey are being explored in the C

Morbidity Research Project. (See above.)

We must conclude, however, that 

possible to fill the urgent needs for natio

tistics on the incidence and prevalence 

eases, injuries, and imphents and on 

zation of medical services by relying sol

records now being collected or data c

available.

How Other Countries

Have Met This problem

Three orher coun~ies are now engag

collection of national morbidity data by m

surveys. These counmies are: Canada, D

and Great Britain. In the case of the 

countries the surveys have a limited 

while the survey of Siclmess in Engla

Wales is a cominuing program.

The Canadian Siclmess Survey, for w

field work is now complete, involved the 

at intervals of a month of some 10,000 hou

scattered throughout Canada. The survey 

full year and was expectedto costinthe ne

hood of $500,000. The following quo~ation

an article in the bulleti of the Canadian 

ment of Health and Welfare (December 1

scribe the type of data to be obtained and 

eral objectives of the survey:
tie amount and dismibution of acute illness

for the survey year in various sections of our

population-how much tie is lost and how

much it costs. Much information on the extent

and nature of chronic illness such as arthri -

tis, diabetes, and cancer will also be determined along with the amount of disability

and cost involved in treating and caring for

such conditions.

“As well as learning much almur various

communicable diseases (measles, influenza,

etc.) and noncommunicable disease such as

arthritts, cancer, and high blood pressure,

the groundwork will be laid for more detailed

research projects imo various aspects of the

diseases . . . .

“Public health amhorities have realized for

many yearn tie shortcomings “of our current

Imowledge of acute and chronic sicImess and

disability, so that a need for such a survey

has existed for some time. Some statistics on

illness have been available for years in tie

form of communicable disease reports, indusmial sickness reports, and hospital records, bur these figures have often been far

from complete. ‘They have not, in any case,

represented an accurate total of Canadian

illness. Health authorities feel that a more

accurate Imowledge of the health and siclaess

of Canadians is indispensable for mapping

public health plans Imth for present and for

future needs. The present survey is designed

to produce this knowledge. It is also realized

that the present project is not a survey to end

all surveys and that other applications of

similar methods may be used in the future to

provide health indices in provinces and communities. ”

The objectives of the 3-year survey being

conducted by the National Health Service of Denmark are very simikr to those stated for the

-, Canadian survey. The Danish project began in

June 1951 and it, too, involves monthly visits to a

sample of households. A manslation of a s~atement by the National Health Service gives the following types of data that will be produced for the

population of the coun~y:

1:

2.

3.

32

Diseases not trea~ed by a doctor with the

patient’s own unverified diagnoses.

Diseases treated by a doctor with diagnoses verified by the doctors themselves.

Hospitalized diseases reported not only

according to the usual exiracts from hospital records, but specified in regard to

4. The relation between patient’s diagnoses

and doctorts diagnoses in cases t~eated

and verified by doctors.

IIIring the course of tie survey, information

on the illnesses of approximately 100,000 different persons over 15 years of age will be obtained.

In addition to this survey there will be a special

study of hospitalized cases in Denmark for one

year beginning in 1952.

In Great Britain periodic surveys of illness

among persons over 16 years of age are being

made by a government social survey organization

on behalf of r~e Minismy of Health. They were

initiated in October 1943 and with a few interruptions have provided statistics for every month

since that tie. Although the Sickness Survey was

originally set up to meet the emergency needs of

a counay in the depths of total war, it was found

to be so useful that it was not abandoned at the

end of the war. So far as can be ascertained it is

a permanent fixture.

The questions on the scheduJe relate ro all

illness and injuries experienced during a twomonth period whether a doctor was consulted or

not, the amount of time the person was confined

to bed and unable to go to work, the number of

visits of or visits to the doctor or dentist, and the

Iengrh of stay in the hospital. The cause of illness

is coded in some detail.

In reply to a Ietter from a member of this

Subcommittee regarding possible gaps in the data

now being collected in the survey of Sichess, Dr.

Percy Stocks, Medical Statistician, in the General

Register Office of England and Wales, referred

ro his paper, “Measurement of the Public Health”

(British Medical Bulletin, 1951, Vol. 7, No. 4, pp.

312-316) and stated as follows:

“The major gaps, and how they can be filled,

are mentioned in the paper. ‘The diagnostic

detail is of course inadequate for many purposes such as srudies of neoplasms, but for

large fields of siclmess which cannoc be assessed berter at present in any other way it

is adequate. Geographic detail can be obtained

by aggregating records of one or more

years; it would be useful of course if that

could be done more quickly for short periods,

but that would involve a sample size which

would be too costly; and in England and Wales

it may be possible to meet that need partly

by National Insurance certicauons of unfitness for work. I do not know of any imms

which could be profitably added to the schedule for regular use, but from time to time
5 social

,agno6es

treated

rrn ation

I differbtained.

special

for one

illness

e betig

lization

y Were

‘ intery month

vey was

eeds of

s found

d atthe

ed it is

3 to all

a twodted or

xulned

nber of

and the

illness

of this

hedata

55, Dr.

eneral

‘ferred

ieakh”

4,pp.

filled,

.nostic

y pur-

>qt for

be asway ir

tained

more

.f rhat

riods,

which

Wales

Partly

unfittems

ched.

I time

special questions are appended over a limired

period for research purposes as the occasion

arises (e. g., concerning deafnessto assess

the need for provision of hearing aids).

“The only n~ed for earlier diagnosis and

medical attention which I think to be im -

portam with the present arrangemems for

medical care relares to malignant neoplasms,

but I am not of the opinion that a Survey of

Sickness should be used to attempt~o improve

that posiuon.”

Statistics on sickness and injury claims Wnder tie National Insurance Acts are also being

obtained in Great Britain. “The Minismy of National Insurance has arranged for a 10-percent

random sample to be taken of all claims to a

sictiess benefit, a 20-percent random sample of

industrial injury benefit claims, and a 100-percent

analysis to be made of tie industrial disease

claims. In the sample for sickness benefit the

diagnosis is associated with age, sex, marital

PART

, py, y, 

tion, locality, and other relevant fac~ors; for 

jury benefit cases the circumstances in which 

accident or disease arose is also associated

(“Note on Morbidity Statistics in England 

Wales ,“ World Health Organization Morbid

Conference, WHO/HS/Morb. Conf./3, 3 Octo

1951.)

To provide a population-at-risk for th

statistics from claims there will also be a 3-p

cent sampling of the records on all persons r

istered under the National Insurance Acrs.

Other developments in Great Britain inclu

(1) a pilot study for what may become a natio

sample of discharge or death records for h

piral inpatients; and (2) a pilot study to expl

the possibility of collecting information a

parients and illnesses meated by general pr

titioners, based on records maintained by th

practitioners.

VI

Recommendations:

Types of Data to be Collected in Order to Meet U. S. Needs

As the discussion in Part V indicates, there

exists a multiplicity of possible sources of data,

each dealing more or less adequately with some

segment of tie population and with some diseases. For tie reasons stated, however, these

sources cannot be brought rogether TOprovide the

material for an objective picture of the amount

of disease, disability, or medical needs at thenational, regional, or local level.

Function of National Morbidity Surveys

We recommend tha~ a continutig national

survey be conducted, adequate to provide regional esttiates at intervals of two years and

estimates for the nation as a whole at quarterly

intervaIs. Its purpose would be to obtain data on

the prevalence and incidence of disease, injuries,

and impairments, on the nature and duration of

the resulting disability, and on the amount and

type of medical care received. The data would be

obtained from a probability sample of households

(with special provision for the sampling of institutions including hotels).

The suggested maximum interval of 2 years

between publications of results from tie continuing national survey seems adequate to us at 

present tie to serve the major needs outined 

Part III. However, we recommend that the f

work be organized in such a way that more 

quent summarizations may be made for the nat

as a whole if the need should arise. We fur 

recommend the use of a relatively small corps 

interviewers for the field work with interviewin

conducted during a part of each month, rath

than a larger corps of interviewers working 

less frequent intervals. This will have rhe 

vantage of permitting more intensive training 

interviewers at no exma cost. It also should m

possible closer supervision of the field wo

Furthermore, the special studies will require 

establishment of a permanem government unit 

effective planning and administration. Instead 

expanding and conmacdng this staff before 

after large intermittent national surveys, it wo

be better ro have continuous field work under 

charge of a small staff of fixed size and h

competency.

Current interests center in chronic diseas

rather than in acute diseases with a marked s

sonal patiern. Nevertheless, seasonal chang

make it desirable to have survey results wh
years. Field work conducted during a partof each

month can be planned in such a way that resulrs

may be summarized ac the end of a year or two

years. With slight modifications quarterly changes

may also be watched if necessary. Experience indicates that two visits to each household will improve the completeness of repordlg of chronic

diseases present. ‘The panel of households can be

changed several times during a year in order to

give a better sample coverage for annual or

biennial averages.

In a survey of national scope, it will presumably be necessary to employ part-time lay interviewers for ~he most part. For diagnosed illnesses, experience in previous morbidity surveys

indicates that lay interviewers, if competently

trained, can obrain data which permit a classification into meaningful diagnostic categories in the

International Statistical Classification of Diseases, Injuries, and Causes of Death (6th retision). Diagnoses reported by the household respondent will be checked with the medical practitioner if tests now in progress show that this

method is practical and useful.

The importance of providing data that are

usable at the local level has been noted earlier in

this report. From the efisting knowledge about

differentials in morbidity rates and in availability

of medical care in different parts of the counmy,

it is our opinion thar satisfactory data for use at

local levels will be obtained from a survey large

enough so that dara can be published separately

for each of some 50 regions into which the counmy can be divided. Several methods of making

this subdivision have been examined by the Subcommittee. It is sugges~ed that 10 of these regions

be the 10 largest metropolitan areas. For theremaining 40 regions, one of the foIlowing alternatives is suggested:

A geographic subdivision imo 10 areas, and

within each area, a s~atification by city

size into 4 slrata.

A geographic subdivision into 13 areas, and

within each area, a stratification by cicy

size into 3 strata.

A geographic subdivision into 20 areas,

and within each area, a smatification into

2 strata-urban and rural.

The best choice depends on the relative magnitude of geographic differentials in morbidity and

medical care, as compared with differentials that

are associated with size of city. By the use of one

of these pIans, or some combination of them, we

believe that each region will be sufflcientlyhomo

its purposes the survey data for the region in

which the area lies.

Function of Special Studies

Ahhough the general surveys will furnish

basic data not at present available, there will remain numerous important gaps. Not only will diagnostic detail be insufficient for many purposes but

no information will be obtained from these general surveys about nonrnanifest illnesses. Furthermore, accurate data will be obtained only for

diseases of relatively high prevalence and incidenc e.

Undiagnosed disease will appear in ~he schedules either as symptoms, or as diagnoses not accompanied by evidence that they were made by a

physician. It would be desirable to follow through

on cases of this rype by a diagnostic appraisal.

Probably, only a subsample of such cases would

need to be studied.

The identification of nonrnanifest diseases,

i.e., diseases which can be identified by diagnosuc

measures but which have not yet caused symptoms

recognized by the patient as such, is an important

part of modern preventive medicine. This can be

done either by the complete examination method,

by prior application of screening tests, followed

by more definitive diagnostic examinations in

those with positive tests, or by a combination of

these methods, with a short physical examination

serving, in effect, as one of the screening tests.

There is already sufficient experience at hand

(notably in the five pilot srudies which were sponsored by health departments in cooperadon with

the Public Health Service 2) to indicate that such

methods of finding nonmanifest disease are practicable and fruirful. However, up to the present,

it has not been possible to apply these methods to

a representative sample of the adult population.

(School health examinations, in areas where they

are adequately performed, represem, in part,

case-finding of nonmanifest disease in the school

population, but not of the toral population of school

age.) The services requtied to provide &eannent

2m= ~m~== “=r= ~onducc=d in: Richmond, Vtiginia; AdMu,

Ga.; 22 coundcs in AIabsmn; Bosmn, !@ss.; and Indismpolia, Ind.

This is by m mcsns a complete list of the screening scudics hat

have conuibuced m the dcwlopmcnr of the technique.

34
ion in

..

mnish

dlrediages but

2 genFurly for

incizhed-

)t ac-

?bya

rough

tisal.

would

ases,

10SUC

Xorns

mtant

an be

xhod,

owed

sin

.on of

lation

:ests.

hand

+Kmwith

such

mac-

?sent,

ds to

ition.

tiey

part,

:hool

;hool

:ment

,dmm,

is, Id.

Cs dmc

rhe prevalence of nonmanifest disease in the general population is known. If a study of nonmanifest

disease is made, a study of undiagnosed disease

should also be included.

Consequently, it is recommended that a series

of special smdies be conducted in addition to the

general surveys. The principal functions of these

special studies will be as follows:

1. To obtain data on undiagnosed and nonmanifest disease, by means of laboratory screening, detection and physical examinations of subsamples drawn from the general surveys.

2. To obtain necessary data, where it is lacking, on the natural course of a disease or on the

effectiveness of medical care or rehabilitation

programs.

3. To collect statistics on the methods of

payment and costs of medical care and to test the

accuracy of these by making use of ou=ide

sources.

4. To assemble any data from the existing

studies and sources described in Parr V as may

be useful for supplementing rhe findings of the

national survey.

5. To attack methodological problems relating LO tie measurement of morbidity and the

relationship of such measurements to the provision of medical care.

grams and local studies such as the various 

titest programs, the Framingham Project, e

cases where such evaluations will contribu

knowledge of techniques for obtaining desired 

Requests for Date That

are not Feasible to Meei

Needless to say, a combined program o

eral and special smdies will fail to meet nu

ous requests for dara by particular bodies. I

eral, the methods proposed are not suitable 

great diagnostic detail is demanded orwhere 

eases or conditions that are rare are 

studied.

Investigations to determine the extent of 

tal illness, alcoholism, narcotic addiction, 

habit-forming drugs, and special disease en

of rare frequency could not feasibly be inc

in the general morbidity survey or any of the 

cial studies that would be a part of the ge

program. Accordingly, it is recommended 

such investigations be undertaken independently 

those groups and agencies which are prim 

concerned with each specific problem.

PART Vll

Recommendations on Survey Design

Maior Specifications of graphic region should be less than ~ percen

Accurncv and Detail characteristics that occur in more than Ype

The national survey will be conducted on a

continuous basis providing quarter-yearly morbidity statistics for each of 11 metropolitan areas

and 3 population-size classes in 13 regions. The

specifications would provide for rwo interviews

(3 months apart) with each of tie sample households and, when the sample results are cumulared

over a two-year period, they should permit of estimates (for each of the 50 areas) such that the

relative sampling error would be less than 50

percem for characteristics that occur in more

than 1 percent of the population. For characters -

~

tics of greater frequency, the coefficients of variation of estiates in each of the memopolitan

I

areas and population-size classes within each geoof the national population as shown in the foll

table:

—x —Y

50 1

15 10

12 15

9 25

5 50

3 75

2 90

Separate estimates are needed for thes

memopolitan areas: (1) New York, (2) Ch
:gion in

furnish

will re-

,lldiag-

>ses but

se gen5. Furmly for

Id illC~-

schednot acde by a

fmough

]raisal.

; would

seases,

gnostic

nptoms

portant

can be

nethod,

>llowed

ms in

wion of

ination

: tests.

~t hand

= sponn with

at such

e pracresent,

lods 10

Ilalion.

re they

1 part,

school

school

atmem

Atlam,

mlis, Ind.

dies Ltlar

the prevalence of nonmanifest disease in the general population is known. If a srudy of nonmanifesr

disease is made, a study of undiagnosed disease

should also be included.

Consequently, it is recommended that a series

of special srudies be conducted in addition to the

general surveys. The principal functions of these

special studies wilI be as follows:

1. To obtain data on undiagnosed and nonmanifest disease, by means of laboratory screening, detection and physical examinations of subsamples drawn from the general surveys.

2. To obtain necessary data, where iris lacking, on the natural course of a disease or on the

effectiveness of medical care or rehabilitation

programs.

3. To collect statistics on the methods of

payment and costs of medical care and to tesr tie

accuracy of these by making use of outside

sources.

4. To assemble any data from the existing

studies and sources described in Part V as may

be useful for supplementing the findings of the

national survey.

5. To attack methodological problems relating to the measurement of morbidity and the

relationship of such measurements to the provision of medical care.

grams and local studies such as the various m

titest programs, the Framingham Projec~, etc.

cases where such evaluations will contribute 

knowledge of techniques for obtaining desired d

Requests for Date That

are not Feasible to Meet

Needless to say, a combined program of g

eral and special studies will fail to meet num

ous requests for data by particular bodies. In 

eral, the methods proposed are not suitable wh

great diagnostic detail is demanded orwhere 

eases or conditions that are rare are to 

studied.

Investigations to determine the extent of m

tal illness, alcoholism, narcotic addiction,.use 

habit-forming drugs, and special disease entit

of rare tiequency could not feasibly be inclu

in the general morbidity survey or any of the 

cial studies that would be a part of r-he gene

program. Accordingly, it is recommended 

such investigations be undertaken independently 

those groups and agencies which are primari

concerned with each specific problem.

PART Vll

Recommendations on Survey Design

Maior Specifications of

Accuracy and Detail

The national survey will be conducted on a

continuous basis providing quarter-yearly morbidity statistics for each of 11 memopolitan areas

and 3 population-size classes in 13 regions. The

specifications would provide for lwo interviews

(3 months apart) with each of the sample households and, when the sample results are cumulated

over a two-year period, they should permit of estimates (for each of the 50 areas) such that the

relative sampling error would be less than 50

percem for characteristics that occur in more

than 1 percent of the population. For characteristics of greater frequency, the coefficients ofvariation of estimates in each of the memopolitan

areas and population-size classes within each geographic region should be less than ~ percent 

characteristics that occur in more than X per

of the national population as shown in the follow

table:

—x —Y

50 1

15 10

12 15

9 25

5 50

3 75

2 90

Separate estimates are needed for these 

metropolitan areas: (1) New York, (2) Chic
D. C. Separate estimates are needed also for the

following geographic regions: (1) New England,

(2) New York, Pennsylvania, and New Jersey,

(3) Maryland, Virginia, North Carolina, and Delaware, (4) Georgia, Florida, and %uth Carolina,

(5) Alabama, Mississippi, and Louisiana. (6)

Illinois, Indiana, and Ohio, (7) Wisconsin and

Michigan, (8) North and SoUth Dakota, Nebraska,

Kansas, Minnesota, and Iowa, (9) Kenntcky, Tennessee, and West Virginia, (10) Missouri and Arkansas, (11) Oklahoma, Texas, New Mexico, and

Arizona, (12) Montana, Idaho, Wyoming, Nevada,

Utah, and Colorado, (13) Washington, Oregon, and

Califonia. And within each of the geographic regions, estimates are needed for these three population groups: (1) rural, including places under

2,500, (2) cities of from 2,500 up to 50,000, and (3)

cities of 50.000 or over.

Maior Specifications

of the Survey Design

1. General. During a two-year period, 45,000

dwelling units will be sleeted for the sample, and

each sample dwelling unit will be enumerated in

two consecutive quarters resulting in a total of

90,000 enumerations. On tie average, three sample dwelling units will be subsampled from the expected 9 dwelling units within each of the 15,000

sample segments. The sample segments will be

located within 500 primary sampling unim selemed from the approximately 2,000 such primary

sampling unirs in the United States. Within the

sample dwelling unit any responsible adult 18

years of age or older will serve as respondent for

himself and all related persons in the household.

Assuming a questionnaire similar to the one used

in the San Jose Health Survey and tie HIP Survey,

a household enumeration would require almut one

hour-to complete.

2. Metropolitan areas. The 11 metropolitan

areas are primary sampling units selected for the

sample with certainty. About 9,000 separate dwelling units, one-fifth the sample dwelling units, will

be enumerated in metropolitan areas. The enumerations will be approximately equally divided

among the 11 areas so that within a two-year

period about 820 separate dwelling units or 1,640

enumerations will be made in each area. Since

the enumerations will be taken monthly, there will

be about 65-70 enumerations per month in each

area. However, it is specified that during the

earlier for the first time be reinterview, and

an equal number of new sample dwelling units be

enumerated for the first tie.

3. Geographic regions, exclusive of metropolitan

areas. There will be 489 primary sampling units

in the 13 geographic regions. The 200 odd primary

sampling units in the Current Population Survey

will be supplemented by the necessary number of

new primary sampling units. To reduce tie scatter between enumeration units, it is planned that

a given primary sampling unit will be visited only

once a quarter. This will be accomplished by assigning one-third the number of primary sampling

units in each region to sets A ,B, and C, respectively. The enumeration of dwelling units in primary sampling unirs in set A will bemade during

the first, fourth, and seventh months and every

third month thereafter. The enumeration of dwelling units in primary sampling units inset B will be

made during the second, fifth, and eighth months

and every third month thereafter. And, likewise,

the dwelling units in primary sampling units in

set C will be enumerated during the third, sixth,

and ninth months and every third month thereafter.

During a two-year period about 72,000 enumerations will be made in the 36,000 sample

dweHing units in the geographic regions. Therefore, on the average, about 3,000 enumerations

will be made in each month in 163 primary sampling units— or akout 18-20 enumerations per

primary sampling unit per quamer. However, it is

specified that during the initial enumeration in a

primary sampling unit only one half the regular

number of monthly enumerations be made, and

that each quarter thereafter, the dwelling units

enumerated for the first tie a quarter earlier

be reinterviewed, and an equal number of new

sample dwelling units be enumerated for the first

time.

Special Studies

‘The national survey would not meer all of the

most pressing needs for morbidity statistics unless it is supplemented by special studies. The

most impormnt special studies are those designed

to obtain data on undiagnosed and nonmanif esc

diseases by means of physical examinations of a

sample of the U.S. population.

The surveys of undiagnosed and norunanifesc

diseases discussed in Part VI, can best be undertaken as .Parr of the national survey but on a sub

36
. months

.’ed, and

mits be

2PQ!W

ilgunits

mimary

Survey

nber of

le scatned that

ted ordy

i by asampJing

respecin priI during

d every

fdwell.

will be

months

kewise,

units in

i, sixth,

there-

)0 enusample

llererations

T samns per

‘er, itis

;on in a

regular

de, and

g units

earlier

of new

he first

Ilof the

tics unes. The

,esigned

~anifest

ms of a

lanifest

?under1 a mb

p

U.S. national sample. The examinations would require a medical “crew” and equipment, and it

would be necessary to “bring together” the sample cases and the examining facilities. This may

mean either bringing the facilities to the subjects

(i.e., by means of completely mobile examini~

units) or bringing the subject to the facilities. In

the past, screening tests have run into a high

selectivity factor. Even in screening programs

confined to a single industrial or governmental

PART

pgp 

The success of a program calling for the ex

nation of a representative sample of the U .S. 

ulation depends upon the ability to get practica

m (at least 90 percent) of the population to 

in for examination. Experience with methods 

achieving this goal is not yet availabIe and ex

sive experimentation is necessary with m

examining units, publiciry campaigns, sp

transportation for examinees, etc.

Vlll

Suggested Methods for Obtaining Data on Need for Medical Care -

The need for well-founded estimares of the

facilities and services required to furnish good

medical care is generally recognized. Such estimates are indispensable for formulating policy

wirh regard to questions such as the desirable

number of physicians, nurses, dentists, technicians, and related personnel to be mained; the

number of general and special hospitaI beds 10 be

built; the number and rype of other institutions

for the care of the sick to be established, and so

forth. For some purposes interesr centers primarily in the total services and facilities required to provide medical and preventive care to

a specified group of people; for others, separate

estimates are wanted for people known to have a

particular disease or impairment.

The estimation of the amount of medical care

needed in a given situation presents difficult problems. No single method of measurement is ideal.

Needed medical care may be described as

that care (in the broadest sense) which a

person would seek, if it were available, if

he knew it was available, if he were wellinformed as to what was considered desirable medical care, and if there were no

important economic or other barriers 10 his

obtaining it.

The following three methods for obtaining estimates of need for medical care, as distinguished

from ordinarily obtained medical care, may be

considered:

1. By expert appraisal of the needs either of

(a) persons with one or another disease or

group of diseases,1 or of (b) a sampl

persons, boti well and sick, from the 

eral population. In the former proced

the total picture of needs for medical 

would be obtained by studying diseas

group by group, and adding the estima

needs for these groups, incIuding separ

estimates for preventive services and 

care required by persons with la~en

nonmanifest disease, usually chronic. 

horn morbidity surveys would also b

quired. to provide a basis for combin

estimates in tie different groups. 

validity would depend in par~ upon 

representativeness of the samples of 

sons with the various diseases,

In the latter procedure representativ

samples from the general popula

would be srudied by experts to determ

all services needed, including diagnos

SUrnmarizauon might be in terms of 

egories of services rather than diagnos

1~~ would & ~~ilti ~ tie merhod used in *G =-cdkd 

]onea esrimmtes from tbe sndies of tie Committee on rb. C3

Medical -e. See “The Fundamentals of Good Medical Ca

Roger I. Lee and Lewis Webster Jones, assisted by Bubara 

publicnrion No. 22 of die Cnmmitree on the Costs of Medical 

Tbc Uniwrsiry of Chicago Press, Chicago, Illinois, 1933.
7-.

38

needs would actually use facilities provided for those needs.

By study of the services actually obtained

by groups under the most favorable conditions now existing. (a) Insurance covered

groups (such as the Health Insurance Plan

of Greater New York). To this would have

to be added an estimate for the services

not covered by the insurance plan and an

adjustmem for selection of the insured

group (empl~yed, age, etc.). (b) Physician’s

families. (c) Highest income group. Study

of services could be secured either from

the recipients by the journal method or by

periodic visirs, or by studying a record of

services from vendors of such services,

e.g., physicians, hospitals, ourpatientclinics, etc., classified by economic status of

the recipient. The last named method requires, of course, that the population served by the vendors be known and that all

sources of medical service to that population be included.

obtained are (a) psychia~ists; (b) public

health physicians; (c) nurses; (d) hospital

beds (general and chronic): (e) dentists.

It should-be noted that these-&e methods

differ in their assumptions. Metiod 1 is dependent

upon expert opinion as to what care is needed.

Method 2 assumes that the best care now obtained

by favored groups is a reasonable approximation

of the care which would actually be sought and

needed by all groups, if economic and other barriers were minimized. Method 3 would probably

yield the most conservative estimates of unmet

needs, since it would be based for the most part

on those unmet needs already manifest as a resulr of existing demand, rather than on demand

that would exist if economic and other barriers

were at a minimum.

A combination of a morbidity survey with

method 1 would seem to be the most convincing

and feasible method. From the standpoint of

methodology, however, it would seem desirable

that all rhree methods be studied. It may very

weIl appear that each method would supply information not obtainable from any of the others.
)rtages

uld be

public

xspital

,ntists.

Iethods

endent

leeded.

xained

nation

Thtand

r bar-

]bably

unmet

st part

a rexnand

rriers

v with

incing

int of

irable

T very

infer -

‘fiers.

-.

Subcommittee on National Morbidity Survey

Dr. W. Thurber FaIcs, atirman ---------- Baltimom City Health &,artmcnt

(Deceased) Baltimore, MaryInnd

Dr. Genrgc F. Bndger -------

---------- Western Reserve university

Clewclmnd, Ohio

Mr. William G. ~chran -------------- - The Johns Hopkins Universi~

Bdr.imore, Maryland

Dr. Edward Holmes -------- ---------- Cicy HcaIch Dcpartmenc

Richmond, Virginia

Dr. MormnI. Lcvin --------- ---------- New York State Dcparcmcnc of Healcb

Albany, New York

Dr. Eli Mm.rks-- . -------------------National Opinion Research Ccntcz

Universim of Chicago

&icago, ‘Illinois

Mr. Tbeodore Woolsey ------- --------- Division of Public Hcalch Me*ads

Public Hcafch Service

u. s.

Dr. Lowell J.

Washington, D. C.

National Committee on Vital and Health Statistics

Reed, chairman ------------ The Johns Hopkins UnivcrsiW

.,

Dr. Halbert L. Dunn, Vice Chairman -------- Nar.ionaf &ffic; of Viral Statistics

Dr. I. M. Moriyama, S=crctary ----------- -

Dr. George Baehr ------------ --------

Dr. Edwin L. Crosby --------- ---------

h. Edwin F. Daily ---------- ---------

Dr. Paul M. Densen ------------- . . . . . .

Dr. Harold F. Dam ----------- --------

Dr. W’. Thurber FaIes (Deceased) ----------

Mr. Eugene L. Hamilton --------- -------

-.——.

Public Healfi .%rvicc

Washington, D. C.

National Office of Vital statistics

Public Health Service

Washington, D. C.

Hcalfn Insurance Plan of Greater New York

New York,New York

Joint Commission on Accreditation of Hospitals

Chicago, Illinois

HeaIfi Insurance Plan of Greater New- York

New York, New York

Un iversi~ of Pittsburgh

Pittsburgh, Pennsylvania

National Institutes of Health

Public Health Service

Washington, D. C.

Balrimore C&Y Healrh Deparzmcnr

Baltimore, M-land

Offi Ce of Surgeon General

rlcparu-nenr of the Army

Washington, D. C.

Dr. Philip M. Hauser ------------------ University of Chicago

Dr. Rohm H. Hu[chesan ------- --------

Sir. P. K. Wb@mu ---------- ---------

Chicago, illinois

Scare Deparcrnenr of Public Health

Nashville, Tennessee

Scripps Foundation for

Research in Population pmblcms

Miami Universi w

oxford, Ohio
APPENDIX II

NATIONAL HEALTH SURVEY ACT

PUBLIC LAW 652- 84TH CONGRESS

CHAPTER 510- 2D SESSION-S. 3076

AN ACT

To provide for a continuing sumcy and special studies of sickness and disability in tie United .%ares, and

for periodic qarts of the results chercof, and for ocher purposes.

Be it enacted by the Senate and House of Representatives of the United

States of America in Congr ess assembled, That this Act may be cited as the

“National Health Survey Act”.

Sec. 2. (a) The Congress hereby finds and declares—

(1) that the latest information on the number and relevant characteristics of persons in the countiy suffering from heart disease, cancer,

diabetes, ardmitis and rheumatism, and other diseases, injuries, and handicapping conditions is now senousIy out of date; and

(2) that periodic invemories providing reasonably current informs.

tion on these matters are urgently needed for purposes such as (A) appraisal of the true state of health of our population (including bah adults and

children), (B) adequate planning of any programs to improve their health,

(C) research in the field of chronic diseases, and (D) measurement of the

numbers of persons in the working ages so disabled as to be unable to perform gainful work.

(b) It is, tierefore, the purpose of this Act to provide (1) for a continuing

survey and special studies to secure on a non-compulsory basis accurate and

current statistical information on the amount, dismibution, and effects of illness

and disability in tie United States and the services received for or because of

such conditions; and (2) for studying methods and survey techniques for securing

such statistical information, with a view toward tieti continuing improvement.

Sec. 3. Part A of title ILI of the Public Health Service Act (42 U. S. C. ch.

6A) is amended by adding after section 304 the following new section:

40
Sec. 305. (a) The Surgeon General is authorized (1) to make, by sampling

or other appropriate means, surveys and special studies of the population of the

United States to determine the extent of illness and disability and related information such as: (A) tie number, age, sex, ability to work or engage in other

activities. and occuDaaon or activities of Dersons afflicred with chronic or other

disease or injury o; handicapping cohditi~n; (B) the rype of disease or injury or 

handicapping condition of each person so afflicted; (C) tie length of time that

each such person has been prevented from carrying on his occupation or activities; (D) the amounts and types of services received for or because of such conditions; and (E) the economic and other impacts of such conditions; and (2) in

connection therewith, to develop and test new or improved methods for obtaining

current data on ilIness and disability and related information.

“(b) The Surgeon General is authorized, at appropriate intervals, 10 make

available, through publications and otherwise, to any interested governmental or

other public or private agencies, organizations, or groups, or to tie public, the

results of surveys or studies made pursuant to subsection (a).

“(c) For each fiscal year beginning after June 30, 1956, there are authorized

to be appropriated such sums as the Congress may determine for carrying out

the provisions of this section.

“(d) To assist in carrying out the provisions of this section the Surgeon

General is authorized and directed to cooperate and consult with the Depart- 

ments of Commerce and Labor and any other imerested Federal Deparmnents

or agencies and with State health depamnents. For such puqmse he shall utilize 

insofar as possible the services or facilities of any agency of the Federal Government and, without regard to section 3709 of the Revised Statutes, as

amended, of any appropriate State or other public agency, and may, without regard to section 3709 of the Revised Statutes, as amended, utilize the services or

facilities of any private agency, organization, group, or individual, in accordance with written agreements benveen the head of such agent y, organization, or

group, or such individual, and the Secretary of Health, Education, and Welfare.

Payment, if any, for such services or facilities shall be made in such amounts

as may be provided in such agreement. ”

Sec. 4. Section 301 of the Public Health Service Act (42 IJ. S. C. 241) is

amended by smiking out the word “and” ac tie end of paragraph (f), redesignating paragraph (g) as paragraph (h). and inserung immediately following paragraph (f) the following new paragraph:

“(g) Make available, to health officials, scientists, and appropriate public

and other nonprofit instimtions and organizations, technical advice and assistance on the application of statistical methods to experiments, studies, and surveys in health and medical fields: and”.

Approved July 3, 1956. . . I

* us. aavunu[n’r mlmlma OFFK1 : 1- 0-aM-ua
. .

OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS

Public Health service Publication No. 1000

SERIES 1-4. GEN13RAL sERIES. Pmgrem descriptions, mathodologiml rmsmrch, sod smslyiicnl studies of vital nd health sutistics.

Ewlism repds or this kind htve ~ppesred in “ViUl ~’jsfics-Special Reports” snd in “Heslth Statistics frum the Nnticmal Pleslth survey,” 

A smd D, PHS Publication No. 5S4.

series1:

series 2,

series 3:

series 4:

Pmmsms mrd collection procedures. -Reper& which deimnba the geneml pmgrsms CJ tie NationBl Center for Health Ststi9tic9 

ib o[ficcs snd divisions, dats callsction methods used, definitias, snd other mttenal necess~ for understanding or the te

cnl cbsmcteristics of published dints.

fhf.s avslumtion md me~ods rsse~rch. -Studies of new stdistical methodolo~ inchding rnxperim~tsl tests of new suwey 

ads, studies of vitsl statistics collection methods, new SCIdfi-Cd tmhniques, objective evstuations of relimbili~y or collected 

contributions to etatiw,ical thency.

Anslyticsl Studies. -Tbia series comprises mp presenting mnlyticsl or intacpmtive studies bmcd on vitsl and health statis~

Documents snd committse m- ts.- Finsl reports of nmjor committees mncsrned with vital and henlth etsti.eticg snd docum

nuch -S remmmended mndel rid registmtion laws snd revised bhth md death ccrtificmtcs.

SERIRS 10-12. D.4T.4 FROM TFIE NATIONAL HEALTH SURVEY

Etrlier repo~ of the kind sppeming in Series 10 have been issued m “Health SUtistics frnm the Nm.ionsf Health Survey,” Series B snd C, 

Publication No. 5B4.

Series 10: Statistics on illness, mccidnntsl injuries, disability, use of bospitcl, medical, dental, tnd other services, md -her health-;elm

tnpics, bsscd on datm collecvsd in the continuing Nationnl Herdth Interview Survey.

Series 11: Dscs [corn the HerJth Exsminhtion 5urvey bsssd on the direcl examinr.tion, testing, snd measurement of nstional scmples o

population of the United Shtas, including the medically definsd prevalence of spscific disecses, snd distributions of the Pp

tion with rasped ta vsrious pbysicnl snd physiological messurmrents..

Series 12: Ds~ from the Health Records Survey relsting to the hetlth chtmcteristics of persons in institution, snd cm hospiml, mf=

nursing, and personsl cam rsceived, bmsd on nntiarnl scnrples of estsblishmen~ prnviding these semices snd r$cmples or 

rssidsn~ of patients, or of mmrds of Lhe eskblishments.

SERIES 20-23. DATA FROM THF NATIONAL VITAL STATT5TICS SYSTEM

Emrlier reprts of this Kind hmve been iasusd in ‘Vitsl .Statistics-Specid Repnti. ”

Series 20:

Ssries 21:

~~:

%rics 23:

Vmious repnti on motility, tabulations by cause or death, ” ige, ccc., time series of mtes, data for g-gcsphic srems, SU

cities, etc. -oLher lbmr M included in mntml m rnmthly repnrr.%

D~L- on rdslity such AS bid by nga of moLhsr, birth order, geogr~phic sre~, StAtes, cities, time series of rates, e&-compila

tions or d-te not includsd in the mgulsr mrnusl volumes or monthly reperk

Dtti on mmriage md divorce hy vsriou9 demo~phic [nc@rs, geographic nreas, etc.-other I.hmi tlmt included in mnuml or mo

reports.

Dau frnm Lhe pmgmm or ssmple suneys cclmted tn vitsl recmds. The suhjec~ being cmmmd in these surveys are vmicd in

ing tnpics such m mortslity by cocioecmomic clmsse.s, hospitalization in the last yesr d life, X-my exposure during pre.gnm

mLc.

Catalag Card

U. 1. Nanand Cmt,r @ Hedib ~1411,sf,cS

Origin, prngmm, and npemtion or the U.S. National Henlth Survey. + description or

Lhe developments Iemding ta enaconent or the Nsrionnl Health Survey Act, md n summmy of the policies, initinl pmgrsm, md opcmtion or the Suwey. Wmshingtan, L1.S.

Depertmmrt or Hedtb, Education. md Welfare. Public HealtJ Service, 1963.

41 p. Z7cm. (IIS Viul md HcddI .%cimics. .Smim 1, no. 1)

U.S. Public Hmkh %micc. Publicmion no. 1000, Smies 1, ❑ . 1

I

I

L U-S Nsrionml Hemlrh 51mT - Adminimmtian. L U.S. - SC&tics, !kdicml.

1. Tide. I

I

Orslnled by Dcpumcnc O( Hmlrh, E&cmuB., mndWlfUc Libruy.

I