DOCUMENTS AND COMMITTEE REPORTS

Health Statistics

Today and Tomorrow

A Report of the Committee to Evaluate

the National Center for Health Statistics

The report of a’ committee established by the Administratorr

Health Services and Mental Health Administration, as submitted September 1972.

DHEW Publication No. (HRA) 75-1452

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

Public Health Service

Series 4

Number 15

Health Resources Administration

National Center for Health Statistics

Rockville, Maryland
*

Vital and Health Statistics-Series 4-No. 15

First issued as DHEW Publication No. (HRA) 75-1452

September 1973

For sale by the Superintendent of Documents, U.S. Governnle[.1 l’rinting (Jllim

Washington, D .C. 2c402 - Price 65 cents
NATIONAL CENTER FOR HEALTH STATISTICS

EDWARD B. PERRIN, Ph. D., Director

PHILIP S. LAWRENCE, SC.D., Deputy Director

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

GAIL F. FISHER, Associate Director for the Cooperative Health Statistics System

ELIJAH L. WHITE, Associate Director for Data Systems

IWAO M. MORIYAMA, Ph. D., Associate Director for International Statistics

EDWARD E. MINTY, Associate Director for Management

ROBERT A. ISRAEL, Associate Director for Operations

QUENTIN R. REMEIN, Associate Director for Program Development

PHILIP S. LAWRENCE, SC.D., Acting Associate Directorfor Reseurck

ALICE HAYWOOD, Itzformatzon Officer

COOPERATION OF THE BUREAU OF THE CENSUS

Under the legislation establishing the National Health Survey,

the Public Health Service is authorized to use, insofar as possible,

the services or facilities of other Federal, State, or private agencies.

In accordance with speci~cations established by the National

Center for Health Statistics, the Bureau of the Census, under a

contractual arrangement, participated in planning the survey and

collecting the data.

Vital and Health Statistics-Series 4-No. 15

DHEW Publication No. (HRA) 75-1452

Library of Congress Catalog Card Number 73-600252
In this report the Committee to Evaluate the National Center for

Health Statistics, under the auspices of the Office of Program Planning

and Evaluation of the Health Services and Mental Health Administration,

undertook to determine not only the extent to which the Center

is achieving its stated mission as a Federal statistical agency but also

the extent to which health statistics generated by many agencies and at

many governmental levels meet national health requirements as currently perceived.

Because of the broad scope of this document and ~cause of the

significant recommendations it contains for the future course of the

statistical activities of the National Center for Health Statistics, I felt

it of great importance to reproduce it in the Vital and Health Statistics

Documents and Committee Reports Series.

Edward B. Perrin. Ph.D

Acting Director, NCHS

...

Ill
LETTER OF TRANSMITTAL

September 25, 1972

Dr. Vernon E. Wilson

Administrator

Health Services and Mental

Health Administration

Department of Health,

Education, and Welfare

Rockville, Maryland 20852

Dear Dr. Wilson:

Transmitted herewith is the report of your Committee to Evaluate the National Center for Health Statistics. In accordance with your charge, this working

group came together to examine and evaluate the National Center for Health Statistics and to prepare a written report. We saw our mission as requiring examination not only of th”e activities of the National Center for Health Statistics but also

of other related statistical operations, to evalute the extent to which the statistical

output meets present and anticipated national health needs. We have been guided by

our previous experience and by information that we have acquired with the help of

the staff resources you have provided.

The Committee found itself in complete accord with your view that timely statistics of high quality constitute “the framework upon which a rational and effective

health care system can be made available to all Americans.” The Committee defined the role of health statistics as (1)to provide a comprehensive picture of the

nature and magnitude of the Nationls health problems, (2) to assess how well health

services are meeting these problems, at what cost, and with what gain, and (3) to

serve basic health research needs.

In order that health statistics may best serve the Nation’s health needs, the

Committee recommends that a system of health accounts be developed to serve as

a guide to’ establish program priorities and to identify data gaps, and that a closer

relationship be established between general purpose and programmatic statistics.

The Committee’s recommendations are presented in two categories: “general recommendations” and “technical recommendations. ” The latter, more specific in

character, are considered as no less important than the former.

Members of the working group have been engaged for more than a year in

considering the issues and achieving consensus on the recommendations. The

group is mindful of the budgetary and personnel implications of its recommenda-
.

tions, the implementation of which will require substantial increase in resources.

Any evaluation of budgetary and personnel increases required, however, should

be judged in relation to the more than $80 billion a year now being expended for

health care in the Nation, with the prospect of substantial increases in such expenditures in the years ahead.

The Committee is convinced that improvement in health statistics would

greatly facilitate improvement in health care both in the private and public sectors.

For that reason the group was dismayed to learn, as it was concluding its assignment, that the Senate-House Conference Committee considering the 1973 HEW

appropriation had singled out health statistics as the only budget item reduced

from the President’s request; and to learn that personnel ceilings were preventing

the full utilization of appropriations already made. The Committee cannot emphasize too strongly its conviction that failure to provide adequate statistical intelligence for formulation of health care policy may be costly in dollars and in

human health and life to an extent completely incommensurate with the relatively

small budgetary savings that may be effected.

The Committee wishes to take this opportunity to express its gratitude to

you and your colleagues in HEW and HSMHA for the cooperation and assistance

provided in the conduct of our task. It wishes also to express its appreciation of

the proficient staff services given by the contractor, Moshman Associates, Inc.,

without which its mission could not have been accomplished.

P.M. Hauser

Chairman
FOREWORD

This Report sets forth the major findings and recommendations of

the Committee to Evaluate the National Center for Health Statistics

(NCHS). It presents the Committee’s view bf today’s health statistics and

tomorrow’s needs and uses this frame of reference as a basis for its

recommendations.

Supplementing the Report is a series of 19 Special Reports which

are specific to some aspect of health statistics and activities of the

Center and which detail or support many of the findings and recommendations here presented.

Prepared as subcommittee or staff documents, not all of these

Special Reports have been reviewed by all members of the Committee.

Therefore, they should not be construed as having full Committee endorsement.

For working purposes the Committee established five subcommittees: Vital Statistics and Health Status, Health Resources and Services,

Statistical Methodology, Federal-State- Local Systems, and User Inquiry

and International Act ivites. Most of the committee members served on

two of these subcommittees; members of the staff were assigned to each,

with a different key individual for each subcommittee. These subcommittees were responsible for detailed reports of major program aspects

and prepared recommendations which were presented to the entire Committee.

Special mention should be made of the undertakings of the subcommittee on the User Inquiry. This subcommittee developed a listing of

users of National Center for Health Statistics material including governmental, university, industrial, and other groups. In response to an invitation to comment on the NCHS programs, a great volume of valuable

information was received from these users. This material was drawn

upon in many of the subcommittee reports on particular program components. The Committee wishes to make special note of its gratitude to

these contributors.

It is impractical, if not impossible, to give proper acknowledgment to the many individuals who have been generous in making their

views and experience known to the Committee. In particular, the staff

of NCHS under Mr. Theodore D. Woolsey have been most cooperative

and pat ient in providing information to the Committee. Special acknowledgment is due to Mr. Stanley Glaser, HSMHA Project Officer, and to

Mrs. Gail Fisher, NCHS Liaison Officer to the Committee, for their

many helpful suggestions and their assistance to the Committee and

staff during the 15 months of the Committee’s tenure.

vii
THE COMMITTEE TO EVALUATE THE

NATIONAL CENTER FOR HEALTH STATISTICS

Philip M. Hauser

Chairman

Theodore R, Ervin

Vice Chairman

WilburJ. Cohen

Paul M. Densen

Merwyn R. Greenlick

Thomas B. Jabine

Hyman B. Kaitz

IrvingJ. Lewis

SelrnaJ. Mushkin

Robert E. Patton

Dorothy P. Rice

Margaret D, West

Jack Moshman

Executive Secretary

THE STAFF

Jack Moshman

Director

Professional Consultants

David G. Abraham

Charles F. Kiefer

Elaine M. Kokiko

James L. Lewis

Nathaniel Macon

Steven T. Polyak

Martin E. Silverstein

B. Ralph Stauber

Lillian B. Kharasch (Editor)

Helen Abbey

Helen Chase

Jerome Cornfield

Charles R. Dean

Jean Mayer

Carl E. Ortmeyer

Robert Reed

Clerical

Mary G. Laeske

Esther S. Moshman

Patricia S. Redmond

1See page 22 for bio~aphies of the members of the Committee.

viii
CONTENTS

Page

Foreword ------------------------------------------------------------

I. Introduction: ANew Look At Old Problems ---------------------------

II. Health StatisticsToday ---------------------------------------------

Population --------------------------------------------------------

Health Status -----------------------------------------------------

Health Manpower --------------------------------------------------

Health Care Facilities ---------------------------------------------

Health Services Utilization and Financtig---------------J~-----------

Todayts Problems ------ ------ --------------------------------- ----

1. Timeliness ---------------------------------------------------

2. Analysis -----------------------------------------------------

3. Quality ofData ------------------------------------------------

4. Standardization of Records and Definitions -----------------------

5. Comprehensive Reports ---------------------------------------

6. More Adequatehdexhg ----------------------------------------

7. Machhe-Readable Data----------------------------------------

III. Health StatisticsTomorrow -----------------------------------------

A System of National Health Accounts --------------------------------

Cooperative Federal-State-Local Health Statistics System -------------

Training Activities ------------------------------------------------

Data Needs -------------------------------------------------------

1. Population ---------------------------------------------------

Birth and Death Statistics ------------------------------------

Marriage and Divorce Statistics ------------------------------

2. Health Status -------------------------------------------------

3. Health Manpower ---------------------------------------------

4. Health Care Facilities -----------------------------------------

5. Health Services Utilization and Financing ------------------------

6. Environment -------------------------------------------------

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CONTENTS—Con.

Page

IV. Recommendations: Shape Of Things To Come -------------------------

General Recommendations of theCommittee --------------------------

Technical Recommendations of the Committee ----------------------- -

1. Program Development -----------------------------------------

A. Vital Statistics--------:----------------------------------

B. Health Care Resource Data --------------------------------

C. Health hterview Survey -----------------------------------

D. hdexesof Health Status -----------------------------------

2. Methdolog --------------------------------------------------

A. Vital Statistics -------------------------------------------

B. Health kterview and Health andNutritionExaminationSurveysC. Qher Survey Mechanisms ---------------------------------

D. Research and Development --------------------------------

3. Management and Operations ------------------------------------

A. Vital Statistics -------------------------------------------

B. Health hterview and Health andNutritionExaminationSurveysC. Data Processtig ------------------------------------------

D. Working with Other Agencies and Data Users ----------------

E. Cooperative Federal-State-Local Health StatisticsSystem -----

F. Training Activities ---------------------------------------

4. Publications and Other Data Access -----------------------------

Biographical Data on Committee Members -------------------------------

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HEALTH STATISTICS TODAY AND TOMORROW

1. INTRODUCTION: A NEW LOOK AT OLD PROBLEMS

Upon this gifted age, in its dark hour,

Rains from the sky a meteoric showe-r

Of Facts . . . they lie unquestioned, uncombined.

Wisdom enough to leech us of our ill

Is daily spun, but there exists no loom

To weave it into fatwic;. . .

“Huntsman, What Quarry?”

Edna St. Vincent Millay

Miss MiHay’s verse expresses eloquently the

more prosaic complaint of health administrators

ihm they have a superfluity of statistics but little

information.

The primary role of health statistics in the

I_lllitpd st~t~s should be

1. to provide a comprehensive picture of the

naturu and magnitude of the Nation’s health

problems;

2. to assess how well health services are

meeting these problems, at what cost, and

with what gain; and

3. to serve basic health research needs.

An effective system of health statistics must,

tlwn, provide those responsible for health services

with necessary information to help understand the

sit uat ion, identify problems, set priorities, define

policy, plan programs, manage services efficicmtly, and evaluate effectiveness.

These objectives require a mutually enh:.iricing or symbiotic relationship among the various parts of tlk health statistics system. The staI iSKical system must serve the common needs of

the users as well as the unique requirements of

policymaking, planning, managing, evaluating,

teaching, and research. The system, while maintaining” continuity, must be sensitive to changing

policies and priorities. It must be comprehensive.

It must be timely. It must provide interpretations

of the statistics in terms relevant to policy questions. It must also include the wide dissemination

of information to the scientific community, the

decision-makers, and to the population as a whole.

The charge to the Committee to Evaluate the

National Center for Health Statistics was to assess

the activities and functions of the NCHS within the

broad framework of the role of health statistics.

This need for a comprehensive statistical basis

for dealing with the health needs of the Nation was

emphasized in the initial briefing of the committee

by Dr. Vernon E. Wilson. He not only stressed the

broad social purpose to be served by the NCHS but

also underscored the importance of forging a proper linkage between the Center and other statistical activities of HSMHA and other agencies concerned with health- related matters.

1
The stated mission of the NCHS is

. . . to develop and maintain systems capable

of providing reliable general purpose national

descriptive health statistics on a continuous

basis and to publish these statistics for . . .

widespread use. . .

This statement emphasizes thegeneralpurpose nature of the activities of the NCHS. The

Committee agrees completely with the need for

such general purpose data. In the context of the

essential broad social scope of health statistics,

however, one must relate the general purpose

character of the NCHSactivities to program policy

needs.

Programmatic data yield information. only

about those who are served by the program. From

the social policy point of view, it is important to

know how those who are served by the program

differ from those who are eligible but do not receive services, or from the general population.

Data on the latter group are obtained through the

general purpose statistical agency.

A need exists for continuing discussion and

coordination between the general purpose and

programmatic statistical units. To provide a

mutually beneficial relationship requires a continuous communication channel. An administrative

mechanism is needed to foster this communication

so that identification of problems, classifications

and definitions of data elements, and general

methods of data collection can be agreed upon

jointly.

As the President’s Commission on Federal

Statistics suggested (Vol. 1, chapter 3, pages 109-

111), when new statistical series are generated

in response to each newly perceived “need,” substantial expenditures of resources can result without commensurate return. The Committee proposes the development of a system of health accounts as a framework which can serve as a guide

to help determine which statistics are most urgently needed. Such a framework would systematically relate the inputs of services, manpower,

facilities, and expenditures to output measures of

health status such as rates of mortality, morbidity, and disability. Chapter 111of this Report

sets forth the concept of such a framework in

more detail. Unless some such system is developed, there exists a continued danger of generating statistics that are of less than optimum

usefulness.

An important consideration in the collection,

processing, analysis, and use of health-related

statistics is that of the relationship among the

participants of the emerging Cooperative FederalState- Local Health Statistics System being implemented by the NCHS. The Committee has reviewed

the development of this cooperative concept and

offers several recommendations directed towards

expanding the support and scope of this system,

thereby maximizing the results to be realized by

all partners of this system.

In keeping with the Committee’s charter, this

Report begins with a review of the current status

of health statistics and the problems existing today. It continues with the future needs in health

statistics. Forecasting the shape of things to come,

the Committee’s recommendations are presented

in Chapter IV. Certain general recommendations

are followed by technical recommendat ions, more

specific in nature. The latter are grouped in four

broad categories: Program Development. Methodology, Management and Operation, and Publications and Other Data Access.

In assessing the Committee’s recommendations, there should be a recognition of the large

and increasing expenditure on health care in this

country, now running at an annual rate of more

than $80 billion. All evidence coming before the

Committee indicates that the level of financial

support for the statistical intelligence for such

a large investment in the health services system

is not commensurate with the investment itself.

The Committee’s recommendations have substantial implications for future requirements for

increased money and manpower in the development of a comprehensive, flexible, and useful

health statistics system.
Il. HEALTH STATISTICS TODAY

What sloes this Nation know today about the

health of its population, and from where does

this lmowled~e come? We know most—and have

known for the longest time—about death. Since

1’1:1:3,all States have comprised a death reporting mea. So our first comprehensive health

status data cam e from knowledge of the ages at

which people died and causes of death.

Through the death reporting program, we

htive followed the decline in communicable dis -

mse and the rise in chronic diseases. T~e birth

mud death reporting systems have provided vital

data and a number of important indexes of health

status. In prcwiciing guides to the changing pattern of diseases of public health importance,

these systems have had great influence on decis ions relating to new directions in medical

care snd in research.

Death, birth, marriage, and divorce statistics constitute the Vital Statistics Program”ofthe

National Center for Health Statistics. These,

together with the decennial population enumeration conducted by the Bureau of the Census and

immigration and emigration data, provide the

basis of knowledge of the size, distribution,

characteristics, and growth of our national population.

But essential as are these data, they do not

give information about the health of people

throughout their lives—information needed to

indicate medical care needs, to determine causes

of disability, and to provide a picture of the health

status of the American people. Ambitious attempts

at such measurements were first made by the

Public Health Service in the early 1920’s in

Hagerstown, Maryland, and again by the Public

IHealth Service’s first National Health Survey in

1Q~~, made with WpA funding. The National

Opinion Research Center began in 1953 a series

of periodic surveys on the use of and expenditures for medical care. The passage of the National Health Survey Act of 1956 made it possible

to undertake a continuing national health survey

using a probability sample of the entire population of the LTnited States. This mechanism has

produced first the Health Interview Survey and

then the Health Examination Survey. It has enabled the development of a unique body of knowledge about the health of our population. Further,

these surveys have provided a wealth ofinformation about the utilization of and expenditures for

health services. The NCHS has also undertaken record surveys which add further dimensions to knowledge of health status.

These national general purpose health statistics are complemented by many programs,

public and private, which gather and publish data

about subgroups of the population. The latter

data are primarily for health program purposes,

such as the control of a particular disease or the

beneficiaries of a particular health service program.

Health statistics today encompass health

service resources as well as health status and

health care utilization. For many years professional organizations were the sole collectors

of such data, and today they will maintain primary responsibility. But with the growing need

for comprehensive data and the increasing role

of the Federal government in the financing of

health facilities and services and the education

and training of health manpower, the NCHS has

assumed greater responsibility in the area of

health resources statistics. Today publications

of the NCHS, based on data from many sources,

bring together the widest available range of data

on health manpower and facilities.

Health statistics today were considered by

the Committee in five major categories: population, health status, health manpower, health

care facilities, and health services utilization

and financing.

Population

Information about the size, composition,

and growth of the population of the United States

comes mainly, from two sources, the Bureau of

the Census and the NCHS.

The decennial census has for almost 200

years provided counts of the population, together

with enumeration of a wide variety of demographic

characteristics, thus providing basic descrip3
tions of the population of the United States. These

censuses are now supplemented by the Census

Bureau’s Current Population Surveys.

These data are complemented by the Vital

Statistics Program of the NCHS, which has three

major components: natality statistics, mortality

statistics, and marriage and divorce statistics.

These provide the information about the dynamics

of population, its growth, and changes in its com -

position. They furnish the information, basic to

making population projections, for fertility analysis, for mortality analysis, for the appraisal of

health status, for planning needed health services, for projecting school needs, and for other

purposes. They are essential materials in the

teaching of demography, sociology, medicine,

and public health. In addition, these data are inputs to industrial marketing analysis, actuarial

investigations, and insurance financing generally.

These reporting programs are based on legal

documents: birth, death, marriage, and divorce

records. All States and other reporting jurisdictions belong to the birth and death reporting

areas, which have a very high degree of completeness of reporting. Marriage statistics, however, are reported by only 41 States and Washington, D.C., and divorce statistics by only 29,

with summaries from the remaining jurisdictions.

Birth and death records and derived statistics include a wide array of data. Thestandard

birth certificate includes anumber ofitems about

the child, his parents, and the receipt of health

services. The death certificate similarly includes

considerable detail about the deceased and the

cause of death. Data from these legal records

are supplemented from time to time by followback studies of births and deaths.

The NCHS presents vital statistics in a variety of publications. The first published national

data, Monthly Vital Statistics Reports —PvovL

sional Statistics, BiYths, Mawiuges, Divorces

and Death, appear within 2 months after the close

of the reporting period. Final figures are published some 2 years after the end of the reporting year, with a narrow range of tabulations.

The definitive volumes, Vital Statistics of the

United States, appearing some 3 years after the

close of the reporting period, contain a very wide

range of data.

In general, except for the important matter

of timeliness, these reports do an excellent job

of meeting the demands of users, within the limits

of available data.

Health Status

The most important sources of information

on health status of the population of the United

States are two major activities of the NCHS: The

Health Interview Survey (HIS) and the Health Examination Survey (HES). Complementary data

come from the NCHS Hospital Discharge Survey

(HDS). Birth and death reports, as have been

noted, also contribute to knowledge of health

status.

The Health Interview Survey is a household

survey designed to obtain, on a continuing basis,

information on acute and chronic illness, im.

pairments, injuries, disability, utilization of

health services, and related topics. The survey

uses a stratified, probability sample, with interviews each year of some 42,000 households,

providing data on about 134,000 persons. Findings

of these surveys, which have been conducted

since 1957, have been published in a large num -

ber of reports. These include the annual Current

Estimates from the Health Interview Survey published soon after the end of each survey ye.~r,

as well as annual reports of acute conditions and

associated disability, chronic conditions, dis -

ability and injuries, and hospitalizations. Less

frequent reports deal with physician and dent.11

visits, use of other health services, and persnnul

health expenditures and insurance.

The Health Examination Surveys are studies

of the health of the population using direct physical examinations, clinical and laboratory tests,

and other measurements. This survey provides

the best data obtainable about the physical and

physiological characteristics of the American

people and about such health characteristics as

the prevalence of certain chronic diseases. Three

survey cycles have been completed. They have

covered (1) the adult population (l%W-62), (2)

children, ages 6-11 (1963-65), and (3) youths,

ages 12-17 (1966-70). The Health and Nutrition

Examination Survey (HANES), the cycle now in

progress, covers the population 1-74 years of

4
;lg~ and gives special emphasis

needs and nutritional status.

to unmet health

Each of these cycles has utilized a probability sample. For the first three, the samples included 6,000 to S,000 persons; in the current

cycle, it is planned to examine some 30,000 individuals.

The schedule of publications based on data

from the first cycle is essentially completed.

For the second, the first few reports have been

puhlishecl, and for the third, none. As with the

1-11S,each publication is directed to a fairly narrow sector of survey findings; there are no reports dealing with findings in a comprehensive

m mmer,

The Hospital Discharge Survey provides data

cm characteristics of patient utilization of hospitals. The survey has been taken continuously beginning in 1964. While the HIS and HES draw from

th~’ universe of the civilian, noninstitutionalized

population, the HDS draws from the universe of

putic$nts discharged from short-stay hospitals,

including those who die in the hospital. The sample institutions include some 700 of the 7,000

hospita~s in the hfaster Facility Inventory; of

th~v+~’,patient records of 395 hospitals have been

irwluckd in the survey.

Health Manpower

The primary sources of health manpower

d.ltii today are professional organizations. These,

in a variety of ways and at varying levels, assem -

l-il~ m-d publish data on licensed members of

their professions or on professional organization

membership, These efforts may be supported

entirely by the professional organization itself,

;W is the case with the listings and publications

d the American Medical Association; they may

he ussistwd by the NIH Bureau of Health Manpower Education, as are the American Dental

Association and the American Nurses Associ-

.~tinn; or may be supported by the NCHS, as have

hw-’n recent collections of data on pharmacists,

opticii ms, and optometrists. A number of other

~l!I~mcies supply complementary information —for

cs,imple, the Council on Foreign Medical Gradu,ttes :mcl the U.S. Immigration and Naturalizatlnn Service, which give information on the international movement

the Internal Revenue

of health workers, and

Service, which makes

available certain data on professionals’ income.

These undertakings supply totals for individual professions. The one source for overall

data is the Bureau of the Census which provides

decennial counts of workers in health occupations and in the health services industry. The

usefulness of Census data, however, is limited

because (1) occupations are recorded as reported

by the person enumerated, resulting in totals

and distributions often quite different from those

reported by the professions, and (2) these data

are not available on a current basis.

For reference purposes today, the most important comprehensive sources of health manpower data are the NCHS annual Healtk Resource

Statistics and its companion, Health Manpowen

A County and Metropolitan Avea Data Book, and

the Health Manpower Souvce Book series and

related publications of the NJH Bureau of Health

Manpower Education.

Health Care Facilities

The most comprehensive listing of health

care facilities is the L4aster Facility Inventory

(MFI) of the NCHS. This listing, which was compiled as a sampling frame for such studies as

the Hospital Discharge Survey and the Nursing

Home Survey, includes the names and addresses

of all known inpatient health facilities in the United

States.

With data from the MFI and the studies which

it has made possible, the NCHS has published

information on institutional distribution and char -

acteristics in Hospitals-A County and Metropolitan Avea Data Book, Nuvsi~ Homes—A

County and Metropolitan Avea Data Book, and in

the annual Health Resouvce Statistics.

The Health Care Facilities Service of HSMHA

compiles and publishes data on the supply of and

need for health care facilities, a responsibility

growing out of the construction funding authority

originally granted to the Public Health Service

under the Hill-Burton Act of 1946. Statistics on

the volume, status, and costs of construction

under this authority are provided by the Facil -

ity Engineering

HSMHA.

and Construction Agency of

5
Data on facilities for a variety of categorical programs are compiled and published by

the Maternal and Child Health Service, the National Institute of Mental Health, the Center for

Disease Control, and the Community Health

Services, all in HSMHA, and by the National Cancer Institute of NIH. Data on facilities participating in the Medicare program are assembled and

published by the Social Security Administration.

The Department of Defense, the Veterans Administration, and DHEW publish reports on clinical facilities under their jurisdictions.

The annual survey of the American Hospital

Association, published in August of each year

in Hospitals, is unique in that it provides a complete listing of registered hospitals, together

with patient load data for each institution.

Health Services Utilization and Financing

The Health Interview Survey, since 1959, has

regularly collected and published data on the use

of hospitals, physicians, and dental services, by

geographic area, age, sex, income, and other

demographic factors. This survey has also collected, at less frequent intervals, data on individual and family expenditures for health services.

Other survey mechanisms of the NCHS that

yield data on health care financing and the use

of health services include the Hospital Discharge

Survey, the Nursing Home Survey, the planned

Ambulatory Care Survey, and the National Reporting System for Family Planning Services.

Many other agencies have responsibilities

for assembling data in this field. HSMHA’S National Center for Health Services Research and

Development, concerned with the improvement

of the quality and availability of health services,

has undertaken a variety of utilization studies,

directly or under grant. The Social Security

Administration has a broad mandate with respect to the operation of the hfledicare Program,

while the Social and Rehabilitation Service is

responsible for Medicaid.

Those Federal agencies which provide direct medical care, the Department of Defense,

the Veterans Administration, and several HSMHA

components, provide utilization data for the populations they serve.

Important information on costs of he~llth

services comes from publications of a num her

of Federal agencies, among them the Monthly

Consume7 IWice Index from the Bureau of Lakmr

Statistics, Skn%stics of Income from the internal Revenue Service and Gouemment Finances

and the Su?wey of Cuwent Business fr(nm the

Bureau of the Census.

Information on hospital utilization is :1s.

sembled and published by the American Hospit;ll

Association in a survey now financed l~lrgely by

the NCHS, the Commission an Profession:ll and -

Hospital Activities, and the Blue Cross .~ndoth~,r

insurance carriers.

Today’s Problems

In all of these fields the NCHS has mde

unique contributions. Its statistical designs and

the conduct of its major surveys have been exemplary models. It has done a generally excellent job of meeting the demands of its users

within the limits of available data, but a numlm’r

of problems still exist. These are urges-it, and

they should be noted before consider otinn is

given to tomorrow’s needs. These problems cim

be grouped under seven major subjects: (I)

timeliness of publication, (2) analysis of dnt:l

collected, (3) quality of data, (4) stanclarcliz~[-

tion of records and definitions, (5) development

of comprehensive reports which bring togethti’r

material gathered through the several and corn -

elementary data gathering programs, (6) indexing of available publications and unpuhlishml

data, and (7) accessibility of basic data in computer-readable format.

1, Timeliness

Among the complaints of the users lnf tht~

NCHS data, that of the delays in pub] icaticm is

overriding. Users of vital statistics data and cl:~to

from the HIS, HES, and HEM all cite l;~ck (,f

timeliness as an urgent problem. The usefulnesfi

of reports from the data systems is greatly

enhanced as the timeliness is increased. A cnm -

plex and rapidly changing society cannot :~ff,-,rd

the luxury of long gaps between collection and

release of health data.

6
2, Analysis

The quality of the analytical studies published by the NCHS in the fields of vital statistics

and health statistics has been consistently high

and has been praised by a wide range of users.

But many areas have received too little analytical attention. Important among the current analytical needs are trend analysis, socioeconomic

analysis of demographic and health status data

relating to the utilization and financing of health

services, linkages of HIS and HES findings, linking of birth and infant mortality records, and

patterns of marriage and divorce.

Analyses in these areas are needed for a

variety of reasons. Trend analysis, for instance,

helps to assess progress and establish priorities.

The socioeconomic analyses which have so far

been undertaken strongly indicate that future

gains in the health of the population are at least

as likely to come from improvements in socioeconomic status as from biomedical advances.

Changing value systems are reflected in marriage and divorce patterns which have great implications for future population growth and its

economic consequences.

3. Quality of Data

The President’s Commission “onFederal Statistics has stated that improvement of the quality

of Federal statistics in the decade ahead is “.. .

the single most urgent need facing the federal

statistical system.”

NC”HShas made and continues to make commendable efforts to maintain and improve the

quality of its own major statistical series. But

problems still exist. Among problems of current

concern are the quality of cause-of-death data

reported on certificates and the effect of obtaining data from proxy respondents in HIS. Inadequate attention has been given to the quality

of data obtained and compiled from other sources,

especially in the health manpower and facilities

areas.

4. Standardization of Records and Definitions

In the vital records field, lack of uniformity

of content of birth, marriage, and divorce records

makes it impossible to secure national data on

some items of importance. In the areas of health

manpower, facilities, utilization, and financing,

the lack of consistent terminology and definitions

greatly limits the usefulness of collected data.

There is often great difficulty in comparing

various programs because units of measurement are different among and within programs

both at the national level and at State and local

levels. Such terms as enrollee, registrant, encounter, service, person, and patient may be

used interchangeably in reports. In these circumstances an administrator has great difficulty

in assessing program achievement. The problem

arises both in comparing operating program statistics with each other and comparing the accomplishment of a given program with the situation in the country generally. To achieve the

necessary agreements on definitions and classifications, there must be close collaboration

between those responsible for programmatic

statistics and those responsible for general purpose statistics.

5. Comprehensive Reports

The NCHS produces little in the way of publications which cover a broad range of subjects

drawing from the several statistical operations

of the Center. With its wealth of material on which

to draw, the NCHS has an opportunity to make an

unparalleled contribution to a wide audience, including key decision-makers for the health field,

by preparing “overview” publications covering

the broad aspects of health trends and health service utilization trends.

6. More Adequate Indexing

The NCHS produces a great volume of valuable data. But it fails in one related job which,

if fulfilled, would be of enormous benefit to users

and which should ease its own burdens. It is very

hard for users to know just what information is

available and how to retrieve it. The need here

is for:

a. An index of the content of each series, including forthcoming publications.

b. Information about the types of unpublished

data available and how to get them.
7. Machine-Readable Data

It would be most helpful to many users if

NCHS would make available basic data files in

machine-readable format at the earliest possible

date after collection and editing of the data. Availability implies complete documentation of record

formats and appropriate publicity as to their

availability at a nominal cost. It is suggested

that NCHS consider adopting the procedure of

the Bureau of the Census in designating private

firms which satisfy reasonable criteria as clepositories and processors of the tapes. Naturally, the confidentiality of the files must be

maintained with respect to individuals and individual families.

Omitted from the foregoing discussion has

been reference to needs for types of data not now

collected or available. That subject we will now

consider in Chapter 111,Health Statistics Tomorrow.

Ill. HEALTH STATISTICS TOMORROW

We have great need for an expanded program

of health statistics for the strengthening and improvement of health services. Health care is a

pressing social, political, and economic issue in

the United States today. Issues of special concern

are the financing of care, the availability of resources, factors affecting use of services, and the

evaluation of health services provided.

Health status and conditions are influenced

not only by the availability and quantity of health

services but also by many other factors. It is

generally recognized that the problems of health

in America are closely related to and ‘often reflect general social and economic problems such

as poverty, urban deterioration, and poor education. Today we have no effective way of measuring the relative importance of these.

The NCHS has made significant contributions

to the development of “reliable, general purpose,

national, descriptive health statistics” in accordance with its stated mission. Substantial progress

has been made in the gathering, processing, and

dissemination of health statistics as well as in the

refinement of methodological and statistical techniques in this area. But present statistical techniques and the data now collected and published

on health status, health care resources, health

service utilization, financing and organization of

health care services are not adequate for planning

to meet the health problems faced by the Nation.

To answer already pressing problems, to

cope with the health problems of tomorrow, and

to provide a basis for the formulation of public

policy in the health area, there is a need for the

systematic development of accurate and comprehensive data for plaming, administering, and

evaluating health care in the United States. These

data should be developed within a framework of a

health accounts system which would relate the

inputs into the system and the outputs frnm the

system, combining and synthesizing gener~ll

purpose and programmatic statistics.

A System of National Health Accounts

A system of health accounts, consisting of

inputs of resources, measured in dollars, manpower, facilities, and services, and outputs of

health status, measured by mortality, morbidity,

disability and ability to function, is a necessary

tool for the administrator who must make the

decisions concerning deployment of the resources

at his disposal.

The input and output data must be sufficiently

comprehensive and detailed to permit analysis of

the relationship between various resource inputs

and benefit outputs, and between general purpose

and programmatic statistics.

General purpose statistics, such as those

collected by the National Center for Health Statistics, provide an overview of the mortality,

morbidity, and disability of the population and

of the general pattern of utilization of the health

care system. The statistics provide information

about the nature and magnitude of the

country’s health problems. At the same time, the

several health care programs under the aegis of

the Health Services and Mental Health Administration are producing a considerable volume of

program statistics. The health accounts system

8
Figure 1. A prototype framework for a system of health accounts.

INPUTS’

MANPC IER

Nurses

Physician

Services

Dental

Services

Nursing

Visits

Hospital

Admissions

Demographic

Characteristics Etc. Physicians Dentists

.

No. Rate

—

No.

.

Rate

.

No.

—

—

Rate

—

No.

—

Rate

.

No. Rate

—

No,

.

Rate TNo. Rate

Age

Sex

Race

Education

Etc.

INPUTS’

FACILITIES – Beds EXPENDITURES

Hospitals Nursing Homes

Homes for Aged

Etc. Total Public Private

No. Rate No. Rate No. Rate Federal State Local Insurance Out-of-Pocket

Demographic

Characteristics

I

Age

Sex

Race

Education

Etc.

OUTPUTS

MORTALITY

1

MORBIDITY,

by cause DISABILITYI PERSONS WITH lMPAIRED–

t

Days Lost Etc. Hearing Eyesight Mobility

Feeding

Capacity ‘t=”

(

No. Rate No. Rate No. Rate No. Rate No. Rate

4

I

Demographic

Characteristics

No. of

Deaths Rate Incidence Prevalence

Cases Rate Cases Rate

Age

Sex

Race

Education

Etc.

1

Some Inputs may be difficult to cross-classify against certain demographic variablas. Such classification problems must be resolved

further development of the basic concept.

9
will help the administrator to assess the extent

to which the programs for which he is responsible

are meeting the Nation’s health care needs, and

at what cost.

A prototype framework in terms of”input and

output measures related to demographic characteristics of the population is presented in figure

1. This represents a beginning, to catalyze thought

and, hopefully, action. Even this first display

makes apparent some of the most important data

gaps, both from the viewpoint of the administrator

and the statistician. In further development, a

number of matrices will be required, each depicting subparts of the health service system.

The main purpose of a system of health accounts is to aid in visualizing the relation of inputs to outputs, both for the Nation and for specific programs. To the degree that the health accounts system clarifies relationships, it should

serve as a managerial tool to help set program

priorities, allocate resources, and identify gaps

in the available statistical information.

Cooperative Federal-State-Local

Health Statistics System

The recognized goal of the Cooperative Federal-State-Local Health Statistics System is to

achieve data comparability in health statistics

activities at all levels of government and the private sector by developing standard definitions,

classifications, and collection procedures, so that

elemental data units could flow to all levels of the

health community. This would insure that data

secured from source documents at each level of

the system were comparable from State to State

and could be aggregated at any level for program

planning, management, evaluation and research

purposes. A system of national health accounts

could serve as a useful guide to State and local

areas participating in the system.

A successful Cooperative Federal-StateLocal Health Statistics System will receive fiscal

and administrative support only as it meets the

needs of the administrators, particularly at the

State and local levels. Its viability will depend in

large part on the ability of the statistical staff to

understand and foster the intimate and mutually

dependent relationship between programmatic and

general purpose statistics.

The NCHS must develop an adequate field

staff cognizant of Federal, State, and local data

resources and needs, to provide consultation and

substantive technical assistance to State and

local personnel. At present, there is a marked

lack of trained personnel knowledgeable in this

area.

Training Activities

The Committee supports the NCHS plans to

meet such needs by several training activities,

The development of a Data Use and Analysis

Laboratory within NCHS, expansion and enrichment of the Applied Statistics Training Institute

(ASTI) training programs, and university-level

long-term training programs in health statistics

are activities directed to these ends.

Currently, ASTI’S program is technical

rather than issue-related. There is a continuing

need for such technically oriented activities as

medical coding, sample design, and analytical

techniques. However, increasing attention should

be given to professional training within a conceptual framework and related to the general

purpose programmatic issue. Consider, for example, the problem of developing a record system

which can effectively monitor and evaluate a

Health Maintenance Organization (HMO) system—

certainly a problem of considerable concern at

the present time.

Data Needs

The system of health- accounts must evolve

out of the give and take of ideas in the work process rather than from a blueprint drafted in advance. Some of the data that will be needed within

this framework are described in the following

pages. This discussion, clearly, cannot pretend

to provide a comprehensive listing of requirements for each area.

1. Population

The Vital Statistics Program of the NCHS is

a strong one, and one which meets most of the

subject-matter demands of its users. But as we

look at the problems with which the health community is now beginning to grapple, we find major

10
questicms which cannot be answered with available data. As we have noted earlier, part of the

prnblern is the inadequate analysis and linkage of

information from vital records, part of the lack of

standardization of record forms, and part incompleteness of reporting. Important areas remain in

which basic information is not collected.

Meeting these needs will require changes in

the content of the birth, death, marriage, or divorce registration forms. Such changes in most

c;wes require modification of the State laws under

which initial vital registration is conducted.

Achieving such changes will require increased

effectiveness by NCHS in working directly with

the representatives of official State agencies concerned with vital statistics, and imagination and

resourcefulness in working with appropriate professional organizations.

Birth and Death Statistics

In the field of population statistics, the present and future growth of the population are of

overriding concern. But for the basic question:

“What factors are affecting fertility?”, we deal

with conjecture as much as with facts. To meet

the needs in this area we support the undertaking

of the planned Family Growth Survey and urge

the establishment of an abortion reporting progrmn.

NCHShas commenced plans for a major Family

Growth Survey to provide new data on natality, fer -

ti lity, family planning, and health. Field work for

this survey will be conducted during the period

November 1Q72 through May 1973, including the

pretest, and biennially thereafter. This survey

will be similar to the Growth of American Families Surveys of 1955 and 1970, conducted by the

Survey Research Center of the University of

Mich@an and the Scripps Foundation for Research in Population Problems, and to the National Fertility Studies of 1965 and 1970, conducted by Princeton University with funding from

the National Institute of Child Health and Human

]Icvelopment.

Data will be obtained every 2 years by interviewing probability samples of the Nation’s

women in the reproductive ages who have ever

been married, with questions including marital

and pre~mancy history, attitudes about family

size, contraceptive practices, and socioeconomic

background. The development and funding of this

program can be considered a major step forward

not only for NCHS but for population research

throughout the world. The plans, however, do not

call for interviews of never-married women. As

a significant number of births occur to such women, some attempt should be made to include

them in the survey despite the problems which

such inclusion might create.

A serious gap in the vital statistics reporting

system is the lack of reporting of the abortion

component of fetal deaths. The policy of the NCHS

has been to collect and publish data only on fetal

deaths with a gestation age of 20 weeks or more.

In the United Nations’ Principles fw a Vital

Statistics System (Statistical Papers, Series M,

No. 19, August 1953), fetal death .is defined as

r‘death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy.” That report recommends with respect

to fetal deaths “, . . the registration of all fetal

deaths irrespective of the period of gestation is

a desirable goal to be attained as soon as possible. . .“

The growing importance of legal or therapeutic abortion as a determinant of fertility and

the recent sharp changes in laws covering this

area reinforce the need for collection and analysis

of the vital records for such pregnancy terminations. The NCHS has lagged behind New York

City and those other jurisdictions which have

taken leadership in reporting in this field, analyzing the social and demographic characteristics of the women and reporting their receipt

of medical care.

As improved abortion reporting through the

vital event registration system will require the

solution of difficult problems involving confidentiality and differences in legal reporting requirements by States and other jurisdictions, the

path to adequate data will be difficult and lengthy.

NCHS should continue to work with State and local

vital registration officials to obtain implementation of necessary changes in the legal registration systems. Meanwhile, a way to produce better

nationwide data is to develop supplemental national sample reporting programs by hospitals

and other health service providers. The Center

for Disease Control is experimenting with a

11
system based on service reports from hospitals,

which may serve as a basis for further NCHS

development.

An important problem for users of death

data has been the identification of the diseases

present at death and, of these, which is the

underlying cause. Mortality statistics have

generally dealt with the single condition identified

as the underlying cause of death, and only rarely

with the multiple conditions present. Although

the underlying cause concept served public health

purposes reasonably well when major concern

centered on communicable diseases, the concept

is becoming increasingly inadequate as chronic

diseases have increased in importance as causes

of death; as accidents, injuries, and occupational

diseases have become subject to increased study;

as the role of psychiatric disorders has received

more emphasis; as medical research has sought

a clearer picture of the natural history of diseases;

and as related problems are emerging with changing meaning and definition of death.

Death reports do not supply adequate socio-

‘ economic data, and there are few national statistics by socioeconomic indicators. Better data

in this area, related to causes of death, medical

care received, and illness history, would help to

determine the impact of governmental and private

efforts on the incidence and prevalence of illness,

as well as to reduce excess mortality. For example, the addition of years of schooling on the

death certificate would provide, at relatively

small increase in data collection cost, a highly

significant measurement of socioeconomic status

for mortality analysis.

Some of these data, particularly those related

to socioeconomic status, should be provided

through appropriate changes in the vital statistics

records. Others are best obtained through special

studies of various kinds. such as followback surveys and different types of linkage mechanisms

relating the birth and death certificates to each

other or to other types of “documents such as the

Census schedules and medical records.

In recent years there has been considerable

interest in the development of a National Death

Index, an index useful to individuals conducting

epidemiological investigations. This has been supported by the U.S. National Committee on Vital

and Health Statistics and more recently by the

President’s Commission on Federal Statistics.

In view of the importance and usefulness of a

National Death Index, NCHS should devise a plan

to meet the various problems attendant on the

establishment of such an index.

Marnhge and Divorce Statistics

Statistics on marriage and divorce are particularly deficient despite their importance in our

society. The first need for marriage and divorce

reports, as has been noted, is the completion of

the reporting areas. Turning to data reported,

marriage and divorce records are found to be

much less standardized and to include much less

information than those for births and deaths.

Marriage statistics by race or color are

seriously limited bylaws prohibiting the collection

of such data on the certificates. Data about rates

of first marriages and remarriages, about ages

at marriage, and about remarriages of widowed

and divorced persons are not available for whites

and persons other than white or for specific

groups such as Negroes, American Indians or

persons of Chinese or Japanese descent, for

approximately one-third of all marriages in the

marriage reporting area. The Public Health

Conference on Records and Statistics strongly

endorses the placing of items such as race or

color in a confidential section of the certificate

in order to permit legitimate statistical uses

but bar other uses. Just as school and other

systems have found that data on race or color

were needed and have reinstituted their reporting,

so family service and other public programs need

such data to plan and to evaluate their impact.

Suppressing the basic data on race or color

creates an additional barrier to understanding

and planning related to these problems. Additional

data of value would include remarriage statistics

for both widows and widowers by age, income

status prior to widowhood, and other socioeconomic variables. There is also need for statistics on the distribution of children by age for

various kinds of families, by age of family head,

and by type of family, and for more comprehensive

cohort analysis.

2. Health Status

Surveys of the NCHS—the Health Interview

Survey, the Health Examination Survey, and the

12
I#ospital Discharge Survey-have produced awide

range of valuable information about manyaspects

of the health of the American people. Data have

been assembled and published for such characteristics as disability, illness in bed, and hospitalization, all in relation to age, sex, family income,

and certain other socioeconomic characteristics.

Major chronic diseases have received careful

study, and their prevalence has been documented.

Much attention has been given to the growth and

development, physical and mental, of young people.

The current Health and Nutrition Examination

Survey will provide an overview of the nutritional

status of the entire population.

There are data gaps, of course. Preschool

children have not been examined, although they

:UX included in the current HANES. Data on

industry and school, injuries and on environmentally stimulated diseases are not satis -

factory. Too much time elapses before tests for

conditions of new concern, such as sickle cell

anemia, lead poisoning, and other conditions associated with environmental hazards, are included

in the surveys.

But a more basic question must be addressed.

What is meant by health status? There are a vari cty of partial indexes, including disability days,

hospital days, physician visits, and the incidence

:md prevalence of key diseases. Mortality statistics provide other indexes.

Mortality was a sensitive indicator of health

status when the infectious diseases were a major

health problem. It is still of value in certain

situations. 13ut indexes of morbidity are greatly

needed today for program planning and evalu-

.ttion, particularly for assessing the effectiveness of prob~ams aimed at primary prevention.

Further, measures of disability and functional

status are needed to assess the impact of health

programs on ~atients with chronic disease and of

programs to improve the lot of the elderly.

SUCIIindexes would provide the means for relating health to medical care, to age, to income,

to occupation, to place of residence. In view of

the increasing importance of socioeconomic

fwxors, indexes sensitive to changes in life

style and the quality of life will become increasingly significant. A great deal of methodological research needs to be undertaken in this

connection.

How can health status information be put

into a meaningful and useful form? The NCHS

has given this problem some attention. In 1965

the Center published An Index of Health: Mathematical Models. This took into account the num -

ber and duration of illnesses and the occurrence

of death. The next year the Center published

Conceptual Problems in Developing an Index of

Health; this focused on the goal of developing a

comprehensive index of changing health status,

one which would use both mortality and morbidity

data. This report recommended that the nonfatal

consequences of illness be measured in terms of

the total annual volume of disability days.

Further work on this latter component was

then undertaken by the NCHS and documented in

a 1972 publication, Disability Comfionents fovan

Index of Health. This report considered three

components, disability days of(1) institutionalized

persons with long-term disability, (2) noninstitutionalized persons with long-term disability,

and (3) persons with short-term disability. Data

for the latter two are available from the HIS, but

adequate data for the long-term institutional population are not available on a regular basis.

Another effort to develop a general index of

health was made by the Human Population Laboratory of Alameda County. The goal was to

measure health along the three dimensions specified in the WHO concept (physica I,mental, and

social) and ultimately seek a composite index.

The physical health index developed by this group

used a spectrum ranging from severe disability

through presence of chronic conditions and presence of symptoms to “no complaints,” with a

measure of central tendency termed a ‘‘riclit” for

each component population group. The usefulness

of this index was then tested in relation to age,

income, and other characteristics and then in

relation to health practices. A measurement of

mental health, developed from an eight-item Index of Psychological Well-Being, was also tested.

Other investigators are exploring other approaches. Further work is needed, so that some

such measures can be agreed upon and used more

widely.

3. Health Manpowar

Health manpower data today are generally

limited to counts of persons, with some deline -

13
ation of personal characteristics and of geographic distribution. Definitions even of the persons to be included in a total count are far from

precise. New occupations are emerging rapidly in

response to new medical technology, but there is

little information available about the locations or

extent of these developments. Studies of changing

functions have been fragmentary. The staffing

patterns of health service units and the productivity and effectiveness of professional and allied

workers under varying patterns of setting, organizat ion, and payment, for varying population

groups, have hardly been touched on.

Health manpower shortages and costs, both

direct and indirect, are considered today to be the

major barriers to the adequate availability of

health services. While the primary role of the

NCHS in the collection and dissemination of vital

and health status statistics is fairly clear, the

position with respect to health manpower statistics

is not. The NIH Bureau of Health Manpower Education and NCHShave overlapping responsibilities

for the collection and analysis of manpower data.

Although the two agencies have been trying to coordinate plans, much of the needed work remains

undone.

Looking to the future, then, are needs for

statistics which give more meaningful information

about the supply, distribution, and characteristics

of health manpower, in relation to functions and to

organizational or institutional settings in which

they function. Data adequate for cohort analysis

and for projections of future supplies must be

developed.

These needs will in turn require a careful

evaluation of the quality and usefulness of data

now available and the development of new mechanisms for the collection of more meaningful data.

Important among these will be the development

of methods and procedures for States and communities to make complementary or parallel

studies of their own manpower resources, within

the context of a Cooperative Federal-State-Local

Health Statistics System.

4. Heekh Care Facilities

What kinds of medical care delivery systems

will be developed in the future, and what will be

their impact on traditional facilities used in health

care? What new facility patterns are likely to

emerge? What about care, for example, for such

population groups as the mentally ill, criminals,

drug addicts and alcoholics? How will care for

these groups alter present institutional facility

concepts? The use of income maintenance plans

and other methods of financing such programs

will probably accelerate the creation of new types

of facilities for the provision of health care.

As the institutional framework within which

medical care is provided has changed and as the

supportive technologies have increased in com -

plexity and cost, the Nation faces a lack of adequate care facilities in some areas and unnecessary proliferation and duplication of ex.

tremely costly services and equipment in others.

Needs for the future include, then, resolution

of problems of classification and definition, and

evaluation and improvement of the quality of data

obtained. Concern for confident ialit y of data has

hampered administrative and other use of available material. The problem of reconciling confidentiality while still permitting effective use of

the data must be resolved.

Much better and more detailed information

must be collected on the services and facilities

available so that these, in turn, can be related to

data from the Hospital Discharge Survey and

other sources on the utilization of the services

and facilities provided. Cost data must be developed in relation to characteristics of the facilities, their staffing, and their utilization.

Here again it will be important to develop

methods and procedures for States and communities to make complementary or parallel studies

of their own facilities resources, within the context of the Cooperative System.

5. Health Services Utilization and Finencing

Patterns of utilization of health services are

changing. Important among them are developments

in the potential of medicine itself, education of the

public as to the value of services, increased availability of resources of manpower and facilities,

and new mechanisms for payment for* service.

The questions are many: What groups use health

care when they are well? What determines their

demand? Who uses care when ill and under what

conditions? What causes underuse of health care?

What causes overuse? What is optimal use of

health care services for different population

14
hvoups? What determines the behavior of providers and consumers of health care services?

Another range of questions concerns national

policies on medical care. Does medical care make

a difference in health status? Does medical care

affect the outcome of pregnancy? What choices of

medical care have an impact on avoidance of

added medical care? On avoidance of premature

death? Which financial patterns provide incentives for the use of different types of health care?

What types of health care organization promote

optimum USe of resources? What is the effect of

method of payment on level and type of use?

To provide answers to these questions will,

in many instances, require carefully planned and

org;lniz~d reseal-ch studies. But the general purptxip clam collected by the NCHS and the data

arising from operating programs should aid in

p,ming the research questions and should clarify

research desihm requirements.

The statistical base for answering such

questions is rather thin, but a start has been

m;lde for securing such information. The Federal

~i~encies with medical care financing responsibilities, particularly the Social Security Adminis -

tration and the Social and Rehabilitation Service,

have assembled and analyzed a considerable body

of information on the financing and utilization of

services by their beneficiaries. In HSMHA, the

NCHSR&D has supported a variety of studies dealing with the organization and financing of services

and their utilization. In the NCHS a variety of

mechanisms, HIS, HIZS, and HDS in particular,

have developed important information on the utilization of, and payment for, health services.

Looking to the future, this area of health

service use and cost should receive much more

.Ittention. Measurement of utilization of services

must be more comprehensive. The HIS findings

must be supplemented by data on care in the last

year of life. Account must also be taken of the

popul~~tions h long-term care facilities so that

a truly comprehensive picture of health services

used by the entire population can be developed.

Here, too, State and local. data must be collected

to complement the national data.

There are major gaps in cost data. There is

the need for better information on total and on

out -of -pocket expenditures in relation to family

composition, socioeconomic characteristics, and

insurance coverage. Another gap is the lack of

information on costs of courses of treatment and

costs of hospital episodes in relation to diagnosis

and outcome.

As new types of health service organizations

are emerging, such as group practices and health

maintenance organizations, and as new payment

mechanisms are proposed and debated, there is

an urgent need for data on the organization, utilization, and costs of services in relation to organization, staffing, and methods of payment.

These types of information must be tied to

information on the health status of the population

served. For this, in the last analysis, is our

primary concern.

6. Environment

Air, water, land, and noise pollution have

emerged as serious threats to health. Measurements of these forms of poHution are not necessarily within the province of the NCHS. However,

there are data collection and analysis tasks that

must be carried out in order to relate specific

environmental measurements to the health status

of the population.

The special statistical tasks include development of measures of population at risk to various

types and levels of pollutants, determination of

risk of mortality and morbidi~ by type and level

of pollutant, quantification of the effects of changes

in population distribution, review of sampling

procedures to increase the efficiency of observations on pollutants for purposes of identifying

health hazards, application of data on environmental pollutants to estimate annual and probilities, particularly the Social Security Administration and the Social and Rehabilitation Service;

risk of exposure to specific pollutants.

Carrying out these tasks will require use of

the data collected by such general purpose statistics agencies as NCHS and the Bureau of the

Census in order to delineate more effectively

the populations at risk and the magnitude of the

hazards encountered.

The Committee has tried to forecast the needs

in health statistics and to outline the problems.

Recommendations for both today’s and tomorrow’s

problems will be made in the following chapter.

15
IV. RECOMMENDATIONS: SHAPE OF THINGS TO COME

The general recommendations cut across the

entire range of programmatic and general purpose statistics. Technical recommendations are

more specific in nature, pointing to changes and

improvements needed.

General Recommendations of the Committee

(1)

(2)

(3)

(4)

(5)

(6)

A health accounts system should be developed

by HSMHA with the objective of coordinating

programmatic and general purpose statistics

to provide a comprehensive basis for planning,

administering, and evaluating health care in

the United States, in both the public and private

sectors. However, present health statistics

activities should not be curtailed or new ones

delayed pending the development of the health

accounts system.

An administrative structure should be created

in HSMHA in which line authority is provided

for coordinating programmatic and general

purpose statistics for the development and administration of the health accounts system.

Primary responsibility should be fixed for

coordinating HSMHA‘s statistical activities

with the statistical activities of other HEW

components and other health statistics produced by government agencies.

A major effort should be made to improve the

timeliness of publication and other release of

health statistics. Specific measures to this

end are included among the technical recoin -

mendations.

Data now being collected and compiled should

be analyzed in a comprehensive context and

interpreted with special attention to current

and emerging health needs.

More effective provision should be made for

the widespread dissemination of health statistics by means of more adequate indexing

of publications, making available summary

computer tapes, and the preparation of summary and interpretive pub~ications which

draw on data from diverse sources.

(7)

(s)

(9)

Continuing emphasis should be placed cm the

evaluation and improvement of the quality of

data and a systematic and periodic review of

the statistical programs should be made, with

the goal of redesigning, modifying in the

interest of efficiency, and eliminating those

programs for which the usefulness does not

justify the cost. The Committee endorses the

similar recommendation of the President’s

Commission on Federal Statistics and recommends the use of the Commission’s guidelines for program review.

Resources for research and development

should be materially increased, with special

attention to achieving improved methods for

ccd~ection, processing and analysis of data,

and the development of measurement techniques adequate to meet anticipated future

needs.

The Cooperative Federal-State-Local Health

Statistics System should be developed on a

comprehensive basis fully utilizing the existing framework of State and Federal st atistical operations, minimizing duplication.

and increasing and accelerating financial

support by means of a project Srant m contract funding rather than by formula grants.

(Messrs. Ervin and Patton, the two State

government members of the Committee, and

Dr. Mushkin wish to disassociate themselves

from the funding mechanism in the foregoin~~

paragraph and substitute the following statement: The Nation’s health statistics system

should be a truly cooperative Federal-StateLocal system. One of the most important elements in developing such a system is to assure the collection of data over time. If State

and local governments are to make essential,

long-term commitments to such a system,

they must be assured a continuity of financing,

if they meet their obligations. We urge that a

formula grant system be instituted to provide

a sound basis for this type of continuity, after

a reasonable R&D period financed by project

grants or contract funding. The desired Fed16
eral-State-Local system cannot be achieved

by project grants orcontract funding alone.)

(10) Intensive effort should be made to expand and

broaden the training of personnel with particular emphasis upon the relationship between theconceptualization ofhealthstatistics

and the data recording andcollectionmechanisms, giving special attention to the Cooperative Federal-State-Local Health’Statistics

System.

(11) Technical assistance services should be established and maintained for users and producers of all types of health statistics, with

special attention to the Cooperative FederalState-Local Health Statistics System.

(1?) Budget, personnel, and average grade level

should be increased as necessary to implement the recommendations, bearing in mind

that what is required is a statistical intelligence system for health activities which already involve an outlay of more than $80

billion per year. A specific measure which

would increase NCHSIS capability to provide special purpose data requested by other

Federal agencies and nongovernmental

groups would be to exempt positions needed

for reimbursable work from current ceiling

restrictions. -

(13) Responsibility should be assigned to an appropriate unit for the analysis of data relating to the impact of environmental hazards

on health.

To these general recommendations we add

the following technical recommendations with

respect to Program Development, Methodology,

Management and Operations, Publications and

Other Data Access.

Technical Recommendations of the Committee

1. Program Development

.4* vital statistics

To meet present and emerging needs for vital

statistics, data on the dynamics of population

growth, and on the socioeconomic factors

related to these phenomena, the Committee

recommends that:

(a)

(b)

(c)

(d)

Death certificates be revised to include

data on level of educational achievement.

NCHS actively develop a plan for meeting

the problems of cost and confidentiality,

and make recommendations to the Administrator for establishing a National

Death Index, in accordance with prior

committees’ support of the development

of such an index.

NCHS make greater efforts to extend the

marriage and divorce reporting areas

to provide coverage of the United States.

NCHS establish an abortion reporting

program as part of the Vital Statistics

Program.

B. Health Cave Resouvce Datu

(1) To meet present and emerging needs for

data on the availability, utilization and economics of health care resources, the Committee recommends that the NCHS expand

its program to collect, compile, analyze,

and publish, on a timely basis, data on the

utilization and cost of health services and

on health manpower. Emphasis should be

given to:

(a)

(b)

(c)

(d)

(e)

Services of physicians in various institutional settings, including home, offices, hospitals, group medical practices, health maintenance organizations

and other institutional-based settings.

The relationship between disease and use

and cost of services by episode and by

course of treatment.

Total, rather than out-of-pocket expenditures, by families and by individuals.

Number, distribution and characteristics

of established and emerging occupational

groups, including analysis of race, ethnicity and other significant subgroupings

of the manpower poll and institutional

settings in which they function.

The development of working life tables

for specific occupations.

17
Much of the data necessary for these tasks

will come from primary sources of the NCHS and

from data collected by other agencies, particularly

the Social Security Administration and the NIH

Bureau of Health Manpower Education. Therefore,

the Committee recommends that NCHS establish

agreements and work closely with these agencies

in developing the NCHS programs for the next

several years, and that the NCHS expand its

staff of professionals substantively qualified in the

areas of health manpower, health services, and

health economics to strengthen the Center’s contribution to knowledge and understanding of health

care phenomena in the United States.

(2)

c.

D.

To improve the collection and analysis of

health resource data, the Committee recommends that the NCHS:

(a)

(b)

(c)

Increase the components of the Master

Facility Inventory to include such facilities as group medical practice, health

maintenance organizations, and family

planning service facilities.

Code, process, and analyze the medical

data from the 1970 Hospital Discharge

Survey.

Develop plans to collect health manpower

data necessary to supplement or replace

data from existing sources.

Health Interview Survey

To increase the usefulness of HIS data, the

Committee recommends that the NCHSmeet

the need for HIS data for States and large

metropolitan areas either by:

(a) Increasing and redesigning the annual

sample, or

(b) Providing assistance to States, through

the Cooperative Federal-State- Local

Health Statistics System, so that they

can make the necessary supplementary

surveys, More work is needed in the

evaluation of synthetic State estimates

as a possible means of supplementing

estimates obtained directly from sample

surveys.

Indexes of Health Status

To help understand health needs, the Committee recommends that the NCHSvigorously

pursue methodological research in the develop2.

A.

B.

co

ment of indexes of health status, in cooperation with ot~er programs within HSMHA and

with other appropriate agencies and consultants concerned with health matters.

Methodology

Vital Statistics

To improve the quality of data collected, the

Colnmittee recommends that the NCHS:

(a)

(b)

Conducr studies to provide current estimates, on a national basis, of the effects

of reporting and processing errors on

cause-of-death data.

Devote more effort to new techniques of

data transcription and conversion to

machine-readable form.

Health Interview and Health and Nutiition

Examination Surveys

To improve the quality of data collected, the

Committee recommends that the NCHS:

(a)

(b)

Conduct continuing evaluation studies and

measures designed to control and reduce

nonsampling error for both HIS and

HANES. Among such studies should be

the evaluation of potential biases introduced into the HANES by the nonrandom seasonal pattern used to sequence stands.

Act, before undertaking the next cycle of

HANES, to reduce the collection of material of marginal value in histories,

examinations, laboratory tests, and supplemental questionnaires. The present

cycle is imposing too great a burden of

time and effort on individuals examined

and is producing more data for each

examinee than can be properly processed

within available resources,

Othet’ Swrvey Mechanisms

To improve the quality of data collected

through other survey mechanisms, the Corn -

mittee recommends that the NCHS:

(a) For health manpower data, (i) develop

and institute measures for evaluation of

comdeteness and accuracv. and (ii) de18
D,

3.

A.

(b)

velop methodology for identifying and inventorying emerging and unlicensed occupations.

For health care facility data, develop and

institute measures for evaluation of the

quality of data obtained from professional

and trade associations.

Research and Development

To meet the increasing burdens being placed

on its programs, the Committee recommends

that the NCHS undertake an expanded program

of research and development and some

specific guidelines as follows:

(a)

(b)

Substantial efforts should continue to

be devoted to experimental studies to

measure the error and cost components

of statistics produced in the major data

systems by currently used and by alternative methods.

Several surveys are moving into the areas

of health attitudes, perceptions, knowledge, and behavior. Complex constructs

are involved, and a substantial developmental effort is needed explicitly to

define the objectives of these inquiries

and to develop valid operational messures of the constructs selected for investigation.

Managementand Operations

Vitil Statistics

To improve the quality of data collected and

the timeliness of publication of vital statistics data, the Committee recommends

that ~he NCHS:

(a) Review the vital statistics program in an

effort to achieve a better balance among

the requirements of timeliness, level of

detail, and precision. Some consideration

should be given to increased use of sampling outside of the 3-year period centering on the decennial census, that is,

beginning with 1972 or 1973.

(b) Take drastic measures to improve the

timeliness of its reports. We note par-

(c)

(d)

titularly that these measures must not

include omission of reports for 1970 or

1971, as these are critical years for

analytical use in connection with the

1970 census data.

Reinstate production and quality standards in data preparation with provision

for incentive awards.

Make increased efforts to stimulate the

development of stronger national policies

regarding uniform standards of record

content and data preparation.

B. Health Inte-vview and Health and Nutrition

Examination Surveys

To improve the quality of data collected and

the timeliness of publications from the HIS

and the HANES, the Committei! recommends

that the NCHS:

(a)

(b)

(c)

(d)

Undertake, preferably through an outside group, a thorough-going analysis of

HANES data preparation and data processing system, giving special attention

to simplification of the overall structure

and flow of materials, and to greater use

of the computer to identify and make adjustment of defective data.

Prepare specifications for data preparation operations, computer edits and

related steps for the HANES at a much

earlier stage, to reduce the time lag

between completion of field work and the

availability of clean data tapes for tabulation and analysis.

Review the data preparation phase for the

HIS, looking to the elimination of manual

transcription of data from questionnaires

to worksheets prior to keying.

Develop, in accordance with the recommendations of its 1970 internal study

group: “. . . a closer coordination of the

HIS and HANES programs which would

lead to better estimates of certain health

phenomena in the population and also a

better delineation of strengths and weaknesses of each approach. ”

19
c.

D.

E.

Data Processing

To improve the timeliness of data collected,

the Committee recommends that NCHS develop and apply reporting and production

control techniques to the data preparation

operations for the purpose of maintaining

work flow, identifying delays, and assuring

that schedules are met.

Working With Othe-rAgencies and Data Users

To become more responsive to the needs of

the present and potential users of its findings,

the Committee recommends that the NCHS

develop active advisory panels representing

a variety of groups of data users to help to

identify areas of timely and emerging interest

and to assist in planning the incorporation of

these data needs info existing NCHS program

components or into new survey mechanisms

as these may prove to be necessary.

Cooperative Federal-State-Local Health Statistics System

In its relations with the States and local communities, the Committee recommends tha~

(a) An advisory committee on health statistics policy be established by the HSMHA

Administrator to facilitate a better

understanding of the proposed cooperative system, to provide for strong representation of the States and localities at

the policy level, and to provide assistance

to NCHSin problems of definitions, standards of performance, quality control, and

systems planning.

(b) Every avenue should be explored to advance the implementation phases of the

Cooperative Federal-State-Local Health

Statistics System and the allocation of

evaluation and. research and demonstration grant funds be considered for improving the present vital statistics

system and other components of the

system.

(c) The average grade level of NCHS should

be increased in order to provide for necessary staff competency to man the ad-

(d)

(e)

ditional key positions and technical assistance positions necessary to effective

implementation of the Cooperative System. A staff study shows that the NCHS

average grade level is now lower than

that of other comparable Federal statistical agencies.

NCHSprovide more consultant service to

the States, particularly in the fields of

nosology, health interview survey design,

execution and analysis, data processing,

and in the development and use of data

on health manpower and facilities, and

on health care utilization and financing.

NCHS improve its collection procedures

by the promotion of a cooperative program in which the States would, to the

fullest extent practicable, supply data in

machine-readable form.

F. Tvaining Activities

To provide the Nation with statistical personnel qualified to make effective contributions to the health care system, the Committee recommends that:

(a)

(b)

Regional programs in statistics training

and mutual assitance, possibly in affiliation with schools of public health or

universities having departments of biostatistics, should be established byNCHS

to: (i) facilitate field training; (ii) minimize travel restrictions on potential

participants, thus allowing students to

fully exploit the career development offered through sequentia~ attendance of

courses in a core curriculum; (iii) enhance responsiveness and communication

between the partners in the cooperative

program regarding their training needs;

and (iv) help meet State, local, and Federal staff requirements.

The provisions for the exchange of personnel among the Federal, State, and

local parmers be fully exploited and a

continuing personnel interchange program be incorporated into the NCHS

20
(c)

training programs in order to effectuate

the timely implementation of the Federal-State-Local Cooperative Health

Statistics Sys~m.

The focus of NCHS training activities

be broadened to accommodate varying

levels of need for training and continuing

education as the budget and staff of the

spectrum of NCHStraining programs are

increased. The dimension of these activities should include; (i) the shortterm, applied training programs of ASTI;

(ii) academically-oriented training programs outside of and beyond ASTI through

which participants would receive university-equivalent credit; (iii) long-term

career development programs which

would be an incentive to State and local

employees to pursue higher career opportunities in health statistics; and (iv)

continuing education programs oriented

toward keeping Federal, State, and local

employees in health statistics current in

their areas of work.

4. Publications and Other Data Access

To increase the usefulness of the data collected through the several surveys and programs of the NCHS, and to bring the findings

to a wider audience, the Committee recommends that:

(a)

(b)

(c)

The NCHS prepare and publish one or

more comprehensive reports drawing on

the wide range of material available from

vital statistics reports, health interview

surveys, health examination surveys, and

other data sources to provide a wider

audience with more understanding of the

health status and health service utilization of the Nation.

The NCHS publish and give wide circulation to frequently updated indexes of

the contents of all of its publications,

including those forthcoming, together

with information on the availability of

computer tapes and unpublished data.

The NCHS make computer tapes with data

from the several programs more readily

available to potential users.

21
MEMBERS OF THE COMMITTEE TO EVALUATE THE

NATIONAL CENTER FOR HEALTH STATISTICS

PHILIP M. HAUSER, Chui?’man

Professor of Sociology and Director of the Population Research Center at the

University of Chicago. He served formerly as Acting Director (1949-50) of the U.S.

Bureau of the Census and as U.S. Representative to the Population Commission of

the United Nations (1947-51). He is a former President of the American Statistical

Association, the Population Association of America, and the American Sociological

Association. He is President-Elect of the National Conference on Social Welfare

(1972-73).

THEODORE R. ERVIN, Vice Ckxzimn

Chief of the Bureau of Administrative Services for the Michigan Department

of Public Health. He has also served as Assistant to the Commissioner of Public

Health in Michigan and as a public health information officer in both voluntary and

public agencies.

WILBUR J. COHEN

Professor of Education and Dean of the School of Education at The University

of Michigan in Ann Arbor. He was Secretary of Health, Education, and Welfare

during 1968. He has been associated with the broad fields related to human wellbeing during his entire professional career —as teacher, administrator, and policymaker at the national level.

PAUL DENSEN

Director of Harvard’s Center for Community Health and Medical Care and

Professor of Community Health at the Harvard School of Public Health. He has

also served as Deputy Commissioner of Health for the City of New York, and Director of the Division of Research and Statistics of the Health Insurance Plan of

Greater New York.

MERWYN R. GREENLICK

Director of the Health Services Research Center of the Kaiser Foundation

Hospitals in Portland, Oregon, and Adjunct Professor of Sociology at Portland State

University. He is a member of the National Academy of Science’s Institute of

Medicine and is Secretary-Elect of the Medical Care Section of the American Public Health Association.

22
THOMAS B, JABINE

Chief of the Statistical Research Division, Bureau of the Census. Fellow of the

American Statistical Association and constituent member of the Inter-American

Statistical Institute.

HYMAN B. KAITZ

Assistant Commissioner for Current Employment Analysis, Bureau of Labor

Statistics, U.S. Department of Labor. Formerly Director, Office of Statistical

Standards, BLS)and Director, Industrial Growth and Research Staff, Business and

Defense Services Administration, U.S. Department of Commerce.

IRVING J. LEWIS

Professor, Department of Community Health at the Albert Einstein College of

h[edicine. He was formerly Deputy Administrator, Health Services and Mental

Health Administration, Department of HEW, and also served as Deputy Assistant

Director for Human Resources Programs of the U.S. Bureau of the Budget.

SELMA J. MUSHKIN

Director of Public Services Laboratory of Georgetown University and Professor

of Economics. She has also served as economist with the U.S. Public Health Service

and as a resea?ch professor at the Johns Hopkins School of Public Health. A member of the Science Committee on Medicare for Armed Forces Dependents and of

the President’s .Commission on Scientific Personnel. Staff member to the President’s Commission on the Health Needs of the Nation and Consultant to the Pan

American Health Organization and UNESCO.

ROBERT E. PATTON

Deputy Commissioner of the New York Department of Mental Hygiene. He also

has been Associate Commissioner for Program Planning and Director of Statistics

and Data Processing for the Department.

DOROTHY P, RICE

Deputy Assistant Commissioner for Research and Statistics, Social Security

Administration. She formerly served as Chief of the Health Insurance Research

Branch in the same organization and as a Medical Economist in the Division of

Community Health Services, Public Health Service.

MARGARET D. WEST

Consultant, Department of Health and Population Dynamics, Pan American

Health Organization. Formerly Director, Office of Program Planning and Evaluation, Bureau of Health Manpower Education, NIH! DHEW.

23
JACK MOSHMAN, Executive Secvefu?’y

President of Moshman Associates, Inc., and Adjunct Professor, Eagleton Institute of Politics, Rutgers University. Fellow of the American Statistical Association, formerly Vice President of the Association for Computing Machinery and

Chairman of the National Academy of Science-National Research Council Panel to

Evaluate the Center for Computer Sciences and Technology, National Bureau of

Standards.

* U. S.GOVERNMENT PRINTING OFFICE : 1973 643-87t3/h

24
VITAL AND HEALTH STATISTICS PUBLICATION SERIES

Originally Public Health Service Publication No. 1000

Sm”es 1.

Series 2.

Sm”es 3.

Sevies 4.

Series 10.

Sem”es 11.

Sevies 12.

Series 13.

Series 14.

Series 20,

Sm”es 21.

Series 22.

Prognxms and collection procedures, — Reports which describe the general programs of the National

Center for Health Statistics and its offices and divisions, data collection methods used, definitions,

and other material necessary ‘x understanding the data.

Data evaluation and methods reseurch. — Studies of new statistical methodology including: experimental tests of new survey methods, studies of vital statistics collection methods, new analytical

techniques, objective evaluations of reliability of collected data, contributions to statistical theory.

Analytical studies .—Reports presenting analytical or interpretive studfes based on vital and health

statistics, carrying the analysis further than the expository types of reports in the other series.

Documents and committee reports.— Final reports of major committees concerned with vital anc

health statistics, and documents such as recommended model vital registration laws and revised

birth and death certificates.

Da h fvom the Health Interview Survev. —Statistics on illness, accidental injuries, disabilit~ use

of hospital, medical, dental, and other services, and other health-related topics, based on data

collected in a continuing national household interview survey.

Data J%om the Health Examination Survey. —Data from direct examination, testing, and measurement of national samples of the civilian, noninstitutional population provide the basis for two types”

of re~rts: (1) estimates of the medically defined prevalence of specific diseases in the United

States and the distributions of the population with respect to physical, physiological, and psychological characteristics; and (2) analysis of relationships among the various measurements without

reference to an explicit finite universe of persons.

Da h from the Institutional Population Surveys — Statistics relating to the health characteristics of

persons in institutions, and their medical, nursing, and personal care received, based on national

samples of establishments providing these services and samples of the residents or patients.

Data @om the Hospital Discharge Suvvey. —Statistics relating to discharged patients in short-stay

hospitals, based on a sample of patient records in a national sample of hospitals.

Data on health resources: nuznpowev and facilities. —Statistics on the numbers, geographic distribution, and characteristics of health resources including physicians, dentists, nurses, other health

occupations, hospitals, nursing homes, and outpatient facilities.

Data on movfality. -Various statistics on mortality other than as included in regular annual or

montttly reports —special analyses by cause of death, age, and other demographic variables, also

geographic and time series analyses.

Data on natality, marriage, and divorce. —Various statistics on natality, marriage, and divorce

other than as included in regular annual or monthly reports +pecial analyses by demographic

variables, also geographic and time series analyses, studies of fertility.

Data .fvom the National Natality and Mortulity Surveys. — Statistics on characteristics of births

and deaths not available from the vital records, based on sample surveys stemming from these

records, including such topics as mortality by socioeconomic class, hospital experience in the

last year of life, medical care during pregnancy, health insurance coverage, etc.

For a list of titles of reports published in these series, write KO: Of ficc of Information

National Center for IIealth Statistics

Publi( IIealth Service,

Rockville, MA 20852
PUBLIC HEALTH SERVICE

Health Resources Administration

5600 F*rs Lane ?08TA@C AND F=S

●AID

u

*

Rockville, Maryland 20852

U.S. ~ARTM- Of HEW

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