DOCUMENTS AND COMMITTEE REPORTS

The Analytical Potential

of NCHS Data for

Health Care Systems

A Report of the United States National

Committee on Vital and Health Statistics

DHEW Publication No. (HRA) 76-1454

Series 4

Number 17

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

Public Health Service

Health Resources Administration

National Center for Health Statistics

Rockville, Md. September 1975
i

Library of Congress Cataloging in Publication Data

United States. National Committee on Vital and Health Statistics.

The analytical potential of NCHS data for health care systems.

(Documents and committee reports-National Center for Health Statistics; series 4, no. 17)

(DHEW publication; no. (HRA) 75-1454)

Supt. of Dots. no.: HE 20.6209:4/17

1. Hygiene, Public–Statistical ser~ces–united States. 2. United States. National Center for Health Statistics. I. Title. II. Series: United States. National Center for Health Statistics. Vital and health statistics. Series 4: Documents and committee reports; no. 17.

III. Series: United States. Dept. of Health, Education, and Welfare. DHEW publication;

no. (HRA) 75-1454.

HA37.u1693 no. 17 [RA407.3] 312’.0973s [312’.0973]

ISBN 0-8406 -0044-5 75-619171

For sale by the Superintendent of Docmnents, U.S. Government Printing Office, Washington, D .C. 20402-Price 8CIcents

U.S. NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS

Chairman

PETERSON, Osler L., M.D. 1975

Center for Advanced Study in the Behavioral

Sciences

202 Junipero Serra Boulevard

Stanford, California 94305

Executive Secretary

MORIYAMA, I. M., Ph.D.

Acting Associate Director for International

Statistics

National Center for Health Statistics

Health Resources Administration, PHS, DHEW

Rockville, Maryland 20852

Members

BAUERSCHMIDT, Alan D., Ph.D. 1978

Associate Professor of Management

College of Business Administration

University of South Carolina

Columbia, S.C, 29208

COOPER, E. Leon, M.D. 1976

Executive Director

National Medical Association Foundation, Inc.

1150 17th Street, N.W.

Washington, D.C. 20036

FRAZIER, Todd M., Mr. 1975

Assistant Director

Harvard Center for Community Health and Medical

Care

643 Huntington Avenue

Boston, Massachusetts 02115

GOLDSMITH, John R., M.D. 1977

Head, Epidemiological Unit

California State Department of Public Health

2151 Berkeley Way

B~rkeley, California 94704

KJELSBERG, Marcus O., Ph.D. 1977

Associate Professor

Director, Division of Biometry

School of Public Health

University of Minnesota

1226 Mayo Memorial Building

Minneapolis, Minnesota 55455

LUDDEN, Forest E., Ed.D. 1978

Director

Special Services Administration

State Department of Public Health

State Office Building

Montgomery, Alabama 36104

PERRIN, Edward B., Ph. D., ex officio

Director

National Center for Health Statistics

Health Resources Administration, PHS, DHEW

Rockville, Maryland 20852

POWERS, Mary G., Ph.D. 1976

Chairman, Department of Sociology and

Anthropology

Fordham University

E. For&am Road

Bronx, New York 10458

RICE, Dorothy, Mrs. 1975

Deputy Assistant Commissioner

Office of Research and Statistics

Social Security Administration, DHEW

Universal North Building

1875 Connecticut Avenue, N.W.

Washington, D. C. 20009

TAYLOR, William F., Ph.D. 1976

Head, Medical Statistics Section

Mayo Clinic

200 First Street, S.W.

Rochester, Minnesota 55901

Iii
CONSULTANTS ON ANALYTICAL POTENTIAL OF NATIONAL CENTER

FOR HEALTH CARE SYSTEMS

ANDERSEN, Ronald, Ph.D.

Research Associate and Associate Professor

Center for Health Administration Studies

5720 Woodlawn Avenue S.

Chicago, Illinois 60637

DAVIS, Karen, Ph.D. (Mrs.)

Research Associate

Economic Studies

Brookings Institution

1775 Massachusetts Ave., N.W.

Washington, D.C. 20036

FRAZIER, Todd M.

Assistant Director

REINKE, William A., Ph.D.

Professor

Department of International Health

School of Hygiene and Public Health

615 North Wolfe Street

Baltimore, Maryland 21205

STAFF:

KRUEGER, Dean E.

Biostatistics Center

George Washington University

Bethesda, Maryland 20014

Formerlv:

Harvard Center for Community Health and Medical Deputy D-irector

Care Office of Health Statistics Analysis

643 Huntington Avenue National Center for Health Statistics, HRA, PHS,

Boston, Massachusetts 02115 DHEW

Rockville, Maryland 20852

LAURIAT, Patience

Division of Retirement and Survivor Studies

Office of Research and Statistics

Social Security Administration, DHEW

Universal North Building, Rme 1123A

1875 Connecticut Avenue, N.W.

Washington, D.C. 20009
CONTENTS

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

General Recommendations ........................................................................

Background ................................................................................................

Charge to the Technical Consulting Panel ..............................................

Approach Used by the Techinal Consulting Panel .....................................

Section I. Users and PotentiaJ Users ............................................................

Section II. User Needs as Assessed by the Technical Consulting Panel ........

Subject Matter Issues and Related Methodological Problems ..................

Issues That are Primarily Methodological in Nature ................................

Section III. Specific Recommendations ......................................................

Subject Matter ........................................................................................

Methodological .......................................................................................

Additional Resources Needed .................................................................

Section IV. Conclusions ..............................................................................

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

Appendix I. Excerpts ................................................................................

Appendix II. Inconsistencies of NCHS Data ..............................................

Appendix 111.Previous and Planned Activities of the Health Interview

Survey ................................................................................................

Year Collected ........................................... . . . . ..0...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendix IV. ..............................................................................................

Vital and Health Statistics Publications Series ........................................

Periodicals .............................................................................................

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v
THE ANALYTICAL POTENTIAL OF

NCHS DATA FOR HEALTH CARE SYSTEMS

A REPORT OF THE UNITED STATES NATIONAL COMMITTEE

ON VITAL AND HEALTH STATISTICS

INTRODUCTION

At their October 19-20, 1972 meeting the U.S.

National Committee on Vital and Health Statistics established a Technical Consulting Panel

charged with investigating ways in which the analytical potential of data produced by the National

Center for Health Statistics (NCHS) could be more

fully realized. The Panel was organized in the

spring of 1973 and held its first meeting September 17, 1973.

Following a brief account of background factors related to the charges given to this Panel, the

report deals with four main topics—users, their

information needs, specific recommendations, and

conclusions.

GENERAL RECOMMENDATIONS

The Technical Consulting Panel recommends

that NCHS explore the possibilities of increasing

the analytical potential of data related to health

care subject matter issues and methodological

problems concerned with:

1.

2.

3.

4.

The estimation of costs of alternative

types of national health insurance. These

estimates would be based on data showing

the frequency distribution of medical care

expenditures.

The effed of nonfinancial bavrieys on the

accessibility of medical care.

The development of measures of population health levels and change over time.

The further development of “synthetic estitnatesf~ for local area health planning.

5. The development of collaborative publications (NCHS staff and other investigators)

to be published in journals read by members of the medical community.

6. The development of incveased consultative

capacity within NCHS.

Specific recommendations deveIoped by

members of the Panel appear in Section III. A

final recommendation is concerned with the need to

provide NCHS with resources for implementing the

subject matter and methodological recommendations made by this panel.

BACKGROUND

“Unlike most other large organizations, bureaus are economically one-faced rather than

two-faced. They face input markets where

they buy the scarce resources they need to

produce their outputs. But they face no economic markets whatever on the output side.

Therefore, they have no direct way of evaluating their outputs in relation to the costs

of the inputs used to make them.l

The National Center for Health Statistics, one

of the several semi-independent governmental

agencies producing general purpose statistics, is

in the sense of Downs* comment economically onefaced. In its mission to:

11

. . . develop and maintain systems capable of

providing reliable, general purpose, national,

descriptive health statistics. . . for the use of

the health industry and related industries both

public and private.” 2
traditional performance measures have been related more to the technical quality of statistics

produced than to the other face of the problem, that

is, to an assessment of the extent to which the Center’s product meets the consumer’s needs.3

This does not imply, however, that efforts

have not been made to evaluate the NCHS output.

Several methods have been used. These include:

user surveys conducted by NCHS, surveillance of

legislative and health program proposals as they

relate to NCHS activities, consultation with NCHS

advisors representing a wide range of interests,

representation on informal committees within

government, input from State statistical offices

through the Public Health Conference on Records

and Statistics, and advice from the U.S. National

Committee on Vital and Health Statistics. (See

appendix I for illustrations of the type of input

made by the U.S. National Committee on Vital and

Health Statistics to the National Center for Health

Statisticso) In addition, NCHS was recently reviewed by an expert committee whose report concerned itself with an assessment of present NCHS

activity and with an overall evaluation of the

11

.,. extent to which the statistical output meets

present and anticipated national health needs.;’ 4

Both the former and present director of

NCHS are well aware of the one-faced dilemma of

their organization. They spoke to this point at the

WHO sponsored Second International Conference

of National Committees on Vital and Health Statistics, and pointed out not only the elusive nature

of the problem but also the perils of not being

sufficiently concerned with user needs:

“TOO often statistical systems are designed

and operated by statisticians who have no

established channel for real communication

with the planners, policymakers, and program managers expected to use the statistical

results. The table of results from the systems

become an end in themselves. They may be

timely; they may be reliable; but they are

simply not fully providing the kinds of information the potential users need or, perhaps,

the needed information is obtainable in the

system but is not being presented properly at

all.

“The most important need, we feel, is for the

statistician to come out of his ivory tower and

-.

study what is being done, or perhaps, what is

not being done, with the statistics already

produced.

“Statistical systems of this sort (not responsive to consumer’s needs) are created and

may operate year after year through the

inertia of governmental process, until, perhaps, a serious fiscal situation arises. It is

discovered that little use is being made of the

tables turned out by the statistical system,

and the budget office wields its axe.” 5

Limited resources, changing health service

needs, and the competition for funds among important governmental programs have resulted in

increased pressures for relevant and timely information that can be used in planning and allocating resources to national health programs. 6

It is reasonable to expect NCHS to provide a significant share of the quantitative information

used by decision makers in establishing national

health priorities and in the allocation of funds to

implement or strengthen indicated programs. It

is the responsibility of NCHS to meet these expectations by the timely production of relevant

information in a format that enhances its use by

decision makers.

It is also reasonable to recognize that these

increased pressures for an improved information

base cannot be met unless adequate budgetary

support and sufficient staff are provided to NCHS.

In working with NCHS staff in the exploration of

numerous problems identified later in this report,

it became obvious to Panel members that a large

part of the problem was not the insensitivity to

users’ needs but rather the inability of NCHS,

under severe fiscal constraints, to meet the rapidly increasing demand for health statistics.

With these considerations in mind, members

of a Technical Consulting Panel (TCP), established in October 1972 by the U.S. National Committee on Vital and Health Statistics, responded to

the request to explore ways of increasing the analytical potentialities of NCHS data.

Charge to the Technical

Consulting Panel

Specifically, the charge to the Panel was as

follows :

2
“Most presentations and analyses of NCHS

data are limited to statistics produced by a

single data collection mechanism. Rarely, a

particular health problem is examined in

terms of all of the data from various

sources pertaining to that problem, The analytic potential of NCHS data has been only

partially realized.

“The Technical Consult ing Panel will identify health and demographic statistical problems which warrant intensive analytical

studies, These may be of two types:

“a. Subject matter-oriented analyses, in

which the focus is on the health or

demographic problem;

“b. Methodology-oriented analyses, in

which the focus is on the statistical

problem of relationships between sets

of data collected by different mechanisms or on evaluation of the utility of

the sets of data.

“The Panel*s judgment as to priorities

among the various problem- oriented analyses will be useful, along with identification

of particular types of data required for the

analyses but not presently available. ”

As the Panel began to consider its charge two

problems soon became clear, First, the charge as

stated was too broad to be dealt with adequately by

the interests represented by members of the

Panel. For this reason we have restricted oJrselves to a consideration of ways to increase the

analytical potential of NCHS data for health care

and suggest that other TCP’S should be formed to

look into other important areas, such as the demographic and epidemiological uses of NCHS data.

Secondly, within the broad area of data for

health care we observed that the subject matter

and methodology issues had to be viewed from the

perspective of both fi~esent and potential users of

NCHS data. The Center is able in a limited way to

appraise present user requirements through specific requests that it receives and more generally

through formal and informal contacts with numerous agencies and individuals. In the short run this

interorganizational assessment of present user

needs is supplemented by the Panel members who

reflect an important, though not complete or necessarily representative, source of external insight. It is apparent that in the long run a more

formal mechanism must be established for effective representative and continuing external input

from both present and potential users of NCHS

data. This is necessary if the Center is to move

from its essentially one-faced orientation to

serve its clientele more adequately.

Admitting the somewhat limited horizons of

the Panel, it has been possible nevertheless to subdivide further the two basic elements of the Panel’s

charge (subject matter and methodology) and to

list specific topics of concern (section HI) within

the expanded set of categories.

Within the subject matter area the Panel has

found it useful to distinguish between problems

which have broad policy implications and those

which relate to more specific analytical questions.

With respect to policy matters the Panel recognizes, for example, that NCHS data have the potential for analysis of the effects which alternative

proposals for national health insurance might be

expected to have on the utilization and cost of

selected services for specified segments of the

population. The question of how NCHS data might

be utilized to determine the distribution of preventable, in contrast with currently nonpreventable, disease within particular subgroups is illustrative of more distinct problems.

In the methodological realm, the Panel has

found it convenient to delineate four aspects of the

problem. First, consideration must be given to

existing data gaps which present obstacles to potential users of NCHS data. Several types of data

gaps identified previously by working groups of

the U.S. National Committee on Vital and Health

Statistics are summarized in appendix I.

Secondiy, attention must be directed to limitations in the value of existing data due to the incompatibility of data from multiple sources. In

part such incompatibility might arise from differences in units of measurement. (See appendix

II for a summary of an NCHS staff study of “Inconsistencies of NCHS Data.”) Data on the supply of

health manpower, for example, might not be organized geographically to be compatible with the primary sampling units of the Health Interview Survey supplying morbidity information. The second

3
aspect of incompatibility concerns the dynamics of

health and health care, for example, data do not

relate episodes of illness to the care seeking patterns of individual patients.

The third aspect of methodology relates to the

“packaging” of information in forms that are most

meaningful to users. Such packaging includes the

preparation of integrated basic data sets, descrip.

tive compilations of summary statistics, publication of analyses of general interest, and the provision of consultative services to users with specialized analytical needs.

The fourth aspect is concerned with an exploration of new distribution channels for NCHS

data. The existing channels, mainly published series, represent one mode. The further development of additional channels of distribution, e.g.,

tape transcripts, may be indicated in order to

maximize the impact of methodological changes

that could result from a consideration of data gaps,

compatibility of data sets, and improved “packaging. ”

In addition to the classes of subject matter

and methodological issues that were considered

by the TCP in an effort to explore ways of increasing the analytical potential of NCHS data,

there is another dimension of the problem that

needs to be considered. This involves setting up

review mechanisms that will assure that the needs

of data users are known to information specialists

within NCHS.

Approach Used by the

Technical Consulting Panel

Three factors have influenced the approach

taken by the TCP in addressing its assignment.

The first was “The Report of the Committee to

Evaluate the National Center for Health Statistics”4

and their view that:

“An effective system of health statistics

must, then, provide those responsible for

health services with necessary information

to help understand the situation, identify

problems, set priorities, define policy, plan

programs, manage services efficiently, and

evaluate effect iveness. ”

Second, were the implications of Downs! description of the problems of an economically onefaced organization in sensing the extent to which

the organization is maintaining a reasonable

quid Pvo quo relationship with both those who control the agency’s appropriations and budget (executive and legislative branches) and other users of

NCHS output.

The third influencing factor is the recognition

that NCHS, like many other nonprofit organizations, has a complex marketing mission to perform. Marketing in the nonprofit sector involves

assessment of: (1) the marketing task, with emphasis on the identification of consumers and the

importance of satisfying their needs; (2) the marketing mix, which includes the ideas of product

policy and distribution channels; and (3) distinctive competence, which in this instance involves the unique characteristics and the mandate

of the National Center for Health Statistics.8

The following approach evolved from the

TCP’S consideration of these factors:

Section I.

Section II.

Identification of users and potential users of NCHS data.

Assessment of the inf orrnation

needs of users and potential

users and the relationship of

these needs to data produced by

NCHS.

Section III. Specific recommendations.

Section IV. Conclusions.

In pursuing this plan over the past 6 months

the TCP formulated several specific recommendations for improving the analytical potential of

NCHS data only to discover that NCHSstaff members had already initiated plans to implement

similiar recommendations. This is important for

at least three reasons. First, it is satisfying to

discover that the TCP and NCHSstaff independently

arrived at similar conclusions. Second, it reinforces our belief that as an organization NCHS is

aware of and is adapting to user needs. Third, the

shared interest between TCP members and NCHS

staff in problem areas provides a framework for

continuing jointly a work program that enhances

implementation of recommendations. With this as

background we can now begin to focus on the first

section of the TCP report.
SECTION 1.USERS

AND POTENTIAL USERS

The National Center for Health Statistics has

a variety of formal and informal methods of

alerting itself to users’ needs for data. These include: the U.S. National Committee on Vital and

Health Statistics, the Advisory Committee for the

Cooperative Health Statistics System (CHSS) (and

its predecessor, the “Standing Committee of the

Public Health Conference on Records and Statistics, PHCRS), the Panel of NCHS advisors, relationships with officials in other parts of the U.S.

Departments of Health, Education, and Welfare

(DHEW), and other governmental agencies, participantion in activities of professional organizations

and academic institutions, and ad hoc surveys of

user needs.

Formal reports of the U.S. National Committee and the Advisory Committee for CHSS9

provide a record of the expert opinion and advice

received.lo-lz These are usually specific with respect to types of data, methods of data collection,

and purposes to be served. Information on users’

needs which is received through other organizational relationships is not as well documented

and has not been reviewed systematically.

Two types of ad hoc studies of users’ needs

have been made by NCHS. The first type was

based on a sampling of requests made to NCHS

for publications, other data, and other information,

Such a survey throws light only on overly expressed needs, cannot measure unexpressed

needs, provides little insight on the uses to which

the data are put, and yields no knowledge of the

kinds of changes in data systems and publications

which users would favor.

A second type of survey is illustrated by a

study conducted in 1968 in which NCHS attempted

to get some of this additional information through

a two-stage sample survey of present and potential users. The first stage consisted of building

lists of potential users from NCHS mailing lists,

directories of public and private health organizations, and authors of health and demographic literature. Interviews with small numbers of people

in the 11 categories which were established for

sampling purposes were used to construct a questionnaire, to identify users of health and vital statistics from other sources, to inquire about knowledge and use of NCHS data, and to determine the

individual users’ occupational responsibilities. In

this first stage the questionnaire was sent to

5,200 persons with an 80 percent response rate.

All but 5 percent of those who had used any health

statistical data had used data from NCHS.

Of the 2,400 respondents who had used NCHS

data within the last 6 months 40 percent were from

a university, a hospital, or a clinic; State and

local governments including health departments

comprised 17 percent; agencies of the Federal

Government’s executive branch made up 15 percent; and private industry, particularly insurance

companies, 12 percent. These 2,400 recent

users— 58 percent of all stage 1 respondents—

were in the universe of significant users from

which a sample of 952 would receive an indepth

questionnaire.

In this second stage 78 percent responded,

but an early analysis based on 73 percent was

allowed to stand when the late respondents were

found to have characteristics similar to the earlier

respondents.

Five classes of respondents were established

for analytical purposes, and important differences

were observed in types of uses made of NCHS

data. The five classes are (1) Federal Government, (2) State and local government, (3) planning

group and nonprofit agencies, (4) universities and

hospitals, and (5) other private enterprises.

●

●

●

●

More than one-third (36 percent) found it

necessary to manipulate the data in some

way rather than use them in the form in

which they were received.

Fifty-five percent found comparison of two

or more figures more important than magnitude of a single figure (20 percent).

Geographic, time, and other comparisons

were made in descending order of frequency

(32, 27, and 19 percent, respectively).

More than half of the respondents used NCHS

data along with data from other sources (55

percent) while one-fourth used NCHS data

directly.

The users in this second stage felt that (1)

measures of health was the subject matter area

needing the greatest additional emphasis, followed

by (2) medical economic data (costs of services,
insurance coverage, etc.), (3) utilization semices,

and (4)demographic diu%oStatistics on existing resources, facilities and ?n@owe?’, were thought

in least need of additional emphasis.

The respondents were also asked to rank

their present and projected needs for the following

items in order of importance:

Demographic, social, and economic detail

Longitudinal data (sequential observations

on the same individual)

Comparison of change over time

Diagnostic detail

Geographic detail

Given these choices, half (49 percent) of all

users ranked demographic, social, and economic

detail first. Time comparisons were ranked first

by 16 percent. Geographic detail was ranked first

by only 3 percent, but this may reflect the users’

awareness that detailed geographic data are not

available from surveys conducted by NCHS.

Three important limitations of this study are

apparent and have implications for an assessment

of the analytical potential of NCHS data. First,

this users survey was not designed to get information on the nature, impact, and relative importance of various use.% The study does not distinguish, for example, between the value of a statistic on the average number of physician visits

per person per year as used in a speech by a

Federal official and an analysis of socioeconomic

and geographic differences in those rates for the

purpose of proposing or establishing national

policy.

Second, this type of stwdy does not systemat.

ically explore potential user segments. For

example, although users in the executive branch

of the Federal Government constituted 15 percent

of significant users in the first-stage survey,

there is not evidence of use by the legislative

branch of the Federal Government. It is hardly

likely that all 14 national health insurance bills

now before Congress were developed without some

use of NCHS data, but it is also significant that

this important group is not identified as a user

segment.

The third limitation of this users study concerns consumev attitudes about the balance between descriptive statistics and the analysis of

NCHS data. For reasons related to maintenance of

a reputation for objectivity, NCHS has avoided analytical studies related to policy decision areas.

There are, however, options and user preferences

in the direction of more analytical work that have

not been explored fully by means of user surveys. a

Implications from NCHS user studies along with

an awareness of these three types of limitations

will be reflected in following sections of this report.

SECTION Il. USER NEEDS

AS ASSESSED BY THE

TECHNICAL CONSULTING PANEL

The Technical Consulting Panel as constituted makes no claim of being representative

of users and potential users of NCHS data. The

Panel is mainly discipline oriented (an economist,

sociologist, demographer, health planner, former

State and local health statistician and ex officio,

and a member of the NCHS staff). The limited view

of the Panel has been offset somewhat by consultations with users and potential users from other

fields. Even so there is good reason to introduce

this section of the TCP report with a disclaimer

with regard to the representativeness of our views.

In considering means for enhancing the analytic potential of NCHS data, certain issues arise

which can be classified as essentially methodological in nature. In contrast, issues which are on

the surface subject matter oriented (i.e., statements of important questions to be answered by

NCHS data) frequently contain methodological implications and therefore cannot be uniquely classified. For example, questions concerning the

aOn the occasion of its 50th anniversary the Office of

Business Economics (OBE), Department of Commerce

presented in Part H of the Survey of Current Business, a series

of invited papers written by a wide range of data users, In a

review article, the Director of OBE, Jaszi, reacted to numerous

points raised in the contributed papers. One point concerned

user requests for increased analysis and interpretation of data.

The position taken by the Dwector of OBE recognized the

dangers of analytical involvement and stated OBE policy, The

impression one gets from this sampling of OBE’S user views and

the Diiector’s response is that there are mutually acceptable

compromises on the balance of descriptive and analytical

studies. A similar compromise might be found for the activities

of NCHS. Survey of Current Business, OBE: vol. 57, 7, Part H,

Ju]y 1971.
costs of specified services provided to different

population groups in varied organizational settings

may be answered only through analysis of Medicare, Social Security Administration, American

Hospital Association, and other data sets and may

consequently raise major methodological questions concerning data compatibility.

The following list begins with subject matter

issues related to methodological problems. The

second group of issues is primarily methodological in nature. Specific recommendations related to

selected problem areas are given in the next

section of the TCP report.

Subject Matter Issues and Related

Methodological Problems

~. Estimation of costs of alternative @@ of

national health kwwnce plans. In part these estimates would need to be based on data showing the

frequency distribution of medical expenditures.

Related methodological problems include:

1.1

1.2

1.3

1.4

Studies involving health insurance

coverage and verification of medical

expenditures linked to social and

demographic characteristics.

Studies of distributional consequences of catastrophic health insurance

coverage.

Expenditure studies using imputed

value techniques,

Employer/employee sharing of health

insurance premium coverage.

2. Effect of nonfinancial bwriws on accessibility of medical ca~e. Policy research on this

key question is hampered by the absence of adequate data bringing together all facets of demand

and supply determinants. Related methodological

problems include:

2.1

2.2

..

Studies of the determinants of medical

care utilization for geographic areas

linked to the availability of medical

service resources (m;dical manpower, facilities, modes of delivery

of health services).

Comparisons of medical care utilization patterns among those eligible for

benefits provided by public programs

with persons not covered by these

programs.

2.3 Determinants of medical specialization and choice of geographic location

(physicians and dentists).

Issues That Are Primarily

Methodological in Nature

1. Development of measures of population

health levels and change over time. This issue

generates the need for an integrated data base, a

system of health accounts which would permit

meaningful association to be made between the

health needs of various population groups, the

provision and utilization of services in response

to these needs, and the outcome of such service

utilization. This would require the organization

and maintenance of a body of timely, reliable, computerized data relating to health status, services,

facilities, and manpower acquired from multiple

sources and accessible to a wide range of users.

The emphasis here is on access of compatible sets

of basic data rather than access to published analyses. Because some data sets are compiled from

secondary sources, the degree of accuracy and

completeness is variable. Moreover, the capability of linkage to a particular geographical area,

population group, or time period is frequently inadequate. Finally, since the concern here is with

the development of a repository of varied data

subjected to minimal processing and interpretation, the elapsed time between data collection and

accessibility should be minimized.

2. Further development of “synthetic estimates” for local area health planning. Local areas

especially need help in developing utilization estimates. At present such estimates are frequently

based upon data that are grossly inadequate if they

exist at all.

3. Increased attention to the routine analysis

and reporting of findings, conclusions, and recommendations of general interest to users possibly

through a collaborative (NCHS staff and non-NCHS

investigators) publication series. The emphasis

here is on the analysis and dissemination of information in scientific journals rather than on “inhouse” publications of general purpose descriptive

statistics. Through joint efforts NCHS staff may

7
gain a better understanding of potential user data

needs.

4. Provision for increased consultative capacity within NCHS. Recognizing that user requirements are varied and in many respects specialized, NCHS should increase its capacity to respond to these specialized needs. Through this

consultative service users could gain abetter appreciation of the range of existing NCHS data

sources, their analytic potential, and their limitations.

5. The publication series of NCHS are well

known to selected segments of the health sector.

There are, however, other segments, possibly

potential users, who are either not aware of the

data available or not able to make use of it in the

format in which it is presented. Other governmental agencies, e.g., SSA (examples include SSA’S

Health Insurance Series, Current Medicare Survey Series, and National Health Insurance Proposals publications) and the Census Bureau

(see for example the series - “We the American

People,” Series 1-15, U.S. Department of Commerce, Bureau of the Census, 1972), face a similar packaging/distribution channel problem and

have developed methods aimed at a broad range

of data users. Their techniques for assembling

and disseminating information through publications should be considered by NCHS.

6. The Census Bureau through its summary

tape processing network has opened another distribution channel that may also be useful to NCHS.

Efforts in this direction could be related to the

consultative service mentioned in 4. above, to the

evolving Cooperative Health Statistics System and

to educational institutions where many potential

users of NCHS data receive their professional

training,

In the preceding listing of user needs as

viewed by Panel members it is useful to distinguish

between the high priority problem areas that can

be met by new uses of existing NCHS data and

those that imply a modification of NCHSdatas ys -

tems or methods.

The following classification was used by the

TCP for stratifying identified subject matter and

methodological issues with respect to present

capabilities of NCHS data sets.

Class 1. Utilizing Existing NCHS Data

● From publications and unpublished data

● By manipulation of existing

data

● Combination of NCHSdata with

other data sets.

Class 2. Within Current Survey Framework

● New questions on surveys

. Merger of existing data files,

e.g., Health Interview Survey

and Master Facility Inventory.

Class 3. New Survey Methods

● Cohort followed for a period of

time

● Coordinated samples, e.g.,

Health Interview Survey,

Health Examination Survey,

and Hospital Discharge Survey

. Sample of above followed for a

period of time.

Class 4. New Surveys, e.g., prepaid group

practice enrollees.

In developing specific recommendations, the

TCP made an effort to consider both the importance of identified issues and the implications of

recommendations on the work program of NCHS.

Thus, the issues highlighted in the next section represent a mix of those in which the importance of

the issue and/or the feasibility of the recommendations is favorable to the objective of increasing

the analytical potential of NCHS data.

SECTION Ill.

SPECIFIC RECOMMENDATIONS

Each member of the TCP was asked to develop more fully one or more of the issues he or

she had identified, keeping in mind the capability

of NCHS to respond. Several of these recommendations were developed jointly with NCHS staff.
s ublect Mamer

. . . . . . . .

financial burden of illness relative to the amount

1. General issue area: Estimation of costs of

alternative types of

national health insurance plans.

Specific issue: Frequency distribution of

medical care expenditures.

The following recommendations are divided

into those which might be carried out with data

that are currently available (Class 1) and those

which would require alteration in data collection

methods (Classes 2, 3, and 4).

Possible with cument data (Class 1): Of the

data available from NCHSat the time of this study,

those based on the annual Health Interview Study

offer the greatest potential for analysis of estimation of costs of alternative types of health insurance plans.

The 1970 survey offers some fine opportunities to look at the relationships between health

insurance coverage and utilization patterns and

illness. Of particular interest would be use of

hospitals and doctor visits for chronic conditions

by the presence and type of health insurance coverage. This is the type of information being sought

to estimate the impact of various national health

insurance proposals on the population as a whole

and on various subgroups within it.

One problem in cross -classif ying the expense

information collected in 1971 with other variables

is that the expense information is the only data

which applies explicitly to calendar year 1970.

However, one could examine the relative burden

for those with activity and mobility limitation

since inmost cases these conditions would beret -

$ospective and, thus, would be present in 1970 as

well. Also, since the main import of out-of-pocket

expenditures is to measure the financial burden of

health services, a measure of family outlay relative to family income would be an interesting dependent variable to examine according to the

demographic data collected. Finally, it might be

possible to do some analyses on an aggregate

basis using both 1970 and 1971 data. For example,

if an analyst wanted to know something about the

of disability experienced for different income

groups, the data would be available as long as information on the demographic variable (income) is

collected in both years. The process would be to

compare the ratios of aggregate disability days

from the 1970 survey to the 1970 expenditure information collected in 1971 for each income group.

With the health insurance data collected in

1972, analyses similar to those suggested for the

1970 study might be performed. Perhaps of special interest, given the Health Maintenance Organization (HMO) legislation, would be the behavior of

people covered under prepaid group practice, although sample size will be a problem, The 1972

data also allows for the direct examination of the

relationship between hospital and physician utilization and type of health insurance coverage. The

more detailed nature of the questions provide more

opportunity than was true for the 1970 data.

Analyses of drug expendit,ures and utilization

by source of payment using the 1973 data will be

particularly relevant to the debate as to whether

drugs should be included under Medicare and possibly under national health insurance. One problem

here is, how are payments under major medical

coverage to be treated since the question has only

a 2-week recall period on the HIS questionnaire.

More analyses might be attempted linking

manpower and facilities data by area to individual

observations. The availability of information on

the supply factors might considerably enhance

analysis of the determinants of utilization and expenditure behavior.

Design changes necessary (Classes 2-4):

Given the concern about validity of respondent

reporting of out-of-pocket costs and insurance

coverage, one suggestion would be to do verification studies through providers and carriers. Such

verifications on national samples have proven

feasible (Ronald Andersen and Odin W. Anderson,

A Decade of Health Services, University of Chicago Press, 1967; and Ronald Andersen, et al.,

Health Services Use, DHEW Publication No. (HSM)

73-3004, October 1973). One problem is that the

National Health Survey sample is much bigger than

the samples in the above studies. If total verification were attempted, the demands made on a particular provider or carrier would be much greater.

It might be possible to verify only a proportion of
the total sample and adjust the estimates on the

basis of the partial verification (Class 2).

Verifications might also be used to estimate

total expenditures for services received in addition to improving the estimates for out-of-pocket

costs. Analyses of total expenditures emphasize

total costs to the system rather than financial burden to the individual. While other sources such as

the Social Security Administration (SSA) provide

aggregate data on the total costs of health services, there would still seem to be some value for

NCHS to provide such estimates from time to

time. For one thing the data sources are different,

SSA stresses producer data while NCHSestimates

would originate from the consumer. “rhe possibility of the different sources validating each other

would be useful. Probably of more importance

would be the ability of NCHS to monitor total expenditures for various subgroups in the population

defined by various demographic variables, illness

variables, and utilization variables not available

from aggregate sources. For example, analyses

of total expenditures might be done for groups of

different income, education, or disability levels

(Classes 3 and 4).

Another approach for getting at total medical

care expenditures for a sample of consumers is to

estimate expenditures according to the units for

service consumed. The advantage of this approach

is that independent information collected from

providers and third-party payers is not necessary.

Assuming that enough detail is collected on the

units, (i.e., number of hospital days, number of

doctor visits, type of hospital, and doctor) health

service estimates on the cost of these services

might be made on the basis of cost information

available from such sources as the AMA Periodic

Survey, the AHA records on per diem charges from

individual hospitals, and the California Relative

Value Scale. An initial attempt using this approach

on a national survey has been done and is briefly

described in Ronald Andersen, et al., Ex@nditwes

for. Personal Health Services, DHEW Publication

No. (HRA) 74-3105.

Preliminary analyses comparing these estimates with verified information show relatively

small discrepancies for mean estimates of hospital expenditures. The variability for individual estimates has not yet been examined. More detailed

information of the procedure and methodological

analyses of this approach will be provided in

later publications. One major drawback of this approach currently is the necessity for intensive involvement of a relatively, highly trained coding

staff and the probable difficulty of replicating some

of the estimates by independent coders. Hopefully,

the magnitude of these problems might be reduced

by more refined and sophisticated decisionmaking

procedures with a greater proportion of the decisions being made by computer rather than individual coders (Class 1).

A special problem, particularly for estimating hospital and some physician expenditures,

results from high expenditure individuals. The

highly skewed nature of some expenditure distributions results in inordinately high standard errors. One solution is to rely more heavily on analyses of distributional and median estimates than

has been done in the past. Increasing the sample

size is another option which maybe open to NCHS.

Another possible way to deal with the problem is

to use a screening procedure to enrich the sample

with high expenditure families and individuals. The

latter procedure has been employed in one national

survey (Patricia Collette, Odin W. Anderson, and

Jacob J. Feldman, Changes in Family Medical

Care Expenditures and Volunikwy Health Insurance, Cambridge, Harvard University Press,

1963), (Class 3).

A study of the feasibility of another approach

for obtaining information on medical care expenditures is now being carried out by the Division of

Health Interview Statistics (HIS) of the Center in

response to persistent demands for medical eco.

nomic data regarding the relationship between

health care expenditures, utilization of health

services, 7 and health insurance coverage. The

Medical Economics Research Study is being implemented through a contract with Johns Hopkins

Medical Institution. Johns Hopkins has in turn subcontracted the data collection and data processing

activities associated with this study to a consulting

firm, Westat, Inc.

The contractors are working with the Division

of Health Interview Statistics in developing and

field testing procedures for a panel survey. The

plan calls for interviewers to conduct a series of

interviews at each sample household either in person or via the telephone to obtain the required information. To aid the respondents to recall and

10
report the event accurately, they will be asked to

record the health services received and the associated expenditures in diaries. This information, regarding health services and health expenditures obtained in the household interviews, will be

supplemented by data obtained from record sources such as health care providers and health insurance organizations. Through the linkage of the

household interview data and the record source information, it is anticipated that the most accurate

estimates can be derived.

If the tested procedures prove to be feasible,

they will be used in a national data collection effort as soon as the resources are available}

In conclusion, the TCP member feels that the

current analyses of NCHS with respect to health

insurance and expenditures are most useful. In

addition, the data being collected lend themselves

to important additional analyses. Finally, there

are numerous opportunities to increase the scope

of the data which are collected and the type of analyses which are done on them.

2. General issue area: Effect of supply

factors on accessibility of medical care.

Specific issues: Utilization and availability of medical service resources (manpower, facilities, mode of delivery).

Utilizat ion and health

status of Medicaid beneficiaries.

As part of an effort to curtail Federal expenditures, the administration has proposed phasing out Federal support for many health programs

which provide direct medical care services (such

as community mental health centers) or which

subsidize the creation of health resources (HillBurton, training fellowships). The major new

initiative proposed is national health insurance.

bpcr~onal~ommunication from Mr.Garrk J. Los=, Acting

Deputy Associate Director for Data Systems, NCHS, November

2.5, 1974.

This switch in emphasis away from programs

which intervene directly on the supply side of the

medical care market raises one crucial question:

are financing programs sufficient to assure adequate access to medical care for all individuals?

Or are supplementary programs necessary to

overcome nonfinancial barriers to medical care?

Research on this key question is hampered

by the absence of adequate data bringing together all facets of demand and supply determinants. There are a number of data tasks that

NCHS could undertake which would permit substantial research programs on this issue:

● Merger of facilities data from the Master

●

●

●

Facility Inventory with the Health Interview

Survey.

Additional questions on the Health Interview

Survey relating to the availability of Health

Maintenance Organizations, prepaid group

practices, neighborhood health centers, and

other free clinics.

Additional questions on the closest available

medical resources.

Design of enrollment based surveys to determine how various modes of health service

delivery affect utilization of services.

Merger of facilities data from the Master Facility Inventory with theHealth Interview Survey is

fairly straightforward. For each sample person

questionnaire in HIS survey, the medical resources in his area should be added to his person

record. For persons residing in standard metropolitan statistical areas (SMSA), resources would

be measured relative to the population in the SMSA.

For other persons the county would be an appropriate geographical unit.

Another geographic stratification of analytical interest would be the Professional Standards

Review Organization (PSRO) areas. Measures of

medical resources which should be included at a

minimum are: patient care physicians per capita,

general practitioners per capita, primary care

physicians per capita (general practitioners, pediatricians, and internists), hospital-based physicians per capita, surgical specialist physicians

per capita, beds in short-term hospitals per

capita, beds in extended-care facilities per capita

(or per person aged 65 and over in the area), and

11
beds in other nursing home facilities. Other measures such as physician extenders, nurses, allied

health workers, pharmacists, etc., might be added

over time. Other dimensions that might be added

eventually include State and local government

hospital beds, hospital beds for training purposes,

home health agencies, independent laboratories,

organized outpatient departments, etc. These data

on availability of medical resources should be

added directly to the HIS data base and be distributed via standardized tapes to researchers.

(Class 1.)

While merging availability of medical resources data with the Health Interview Survey is

a fairly simple extension which should provide

some valuable insights, supplementary questions

added to HIS would be of even greater value.

Families could be asked if they received any services from such organizations as health maintenance organizations, neighborhood health centers,

prepaid group practices, maternal and infant

clinics, child and youth clinics, or other clinics.

In addition to knowing whether services were obtained from such organizations, it would be desirable to know whether the option of care in such

organizations was available. To determine this the

interviewer might enter data on the existence of

such organizations in the Primary Sampling Unit

or surrounding area in collecting the data. A determination would have to be made of the maximum

distance a facility could be within to be considered

“available.” (Class 2.)

A related tactic would be to inquire of the individual as to the closest available medical resources. This would include not only organizations

but also individual physicians. Questions to be

pursued could include: how far is the nearest doctor; why don’t you go there instead of to — (He’s

too expensive, he doesn’t take new patients, the

waiting time is too long, etc.); why don’t you go to

a nearby private hospital? This would permit an

examination of what alternatives were available to

the individual and why closer alternatives weren’t

pursued. (Class 2.)

While the above suggestions could be incorporated within the framework of existing NCHS

surveys, thorough examination of the effect of

supply on utilization of medical services is impeded without the more detailed type of data which

would be forthcoming from specially designed surveys. Of particular interest would be two surveys

concentrating on the importance of supply availability in rural areas and in central city areas. To

illustrate, several delivery models have been proposed for rural areas. These include (1) integrated service strategy (combining medical care,

nutrition, counseling, sanitation, improved housing, and other social services); (2) medical care

service organization strategy (neighborhood

health centers, rural clinics, hospital outpatient

outreach programs, and HMO’s); (3) medical manpower strategy (National Health Services Corps,

loan forgiveness, recruitment of medical students

from rural areas, and rural preceptorship); (4)

paramedical personnel strategy (physician extenders, nurse practitioners, and allied health

personnel); (5) technology (telecommunications,

use of computers, and greater dispersal of laboratory and X-ray equipment to physicians); and

(6) transportation (emergency transportation systems, mobile vans, etc.). A carefully designed

survey might make it possible to compare utilization of medical services and perhaps impact on

health status for rural areas according to the

availability of these alternative delivery programs. A similar type survey for strategies that

have been pursued in central city areas should

also be designed. (Class 4.)

Impact of Medicaid on the poor: Existing data

with which to analyze the impact of public medical

care financing programs are limited because some

programs, such as Medicaid, have not developed

adequate statistical reporting systems, and because program data inherently do not permit comparisons of those covered and those ineligible for

benefits. Surveys of NCHS could help remedy both

of these deficiencies, in part through expansion of

questions on current surveys but also, perhaps,

through the development of new survey populations. The HIS and HANES (Health and Nutrition

Examination Survey) provide excellent opportunities for comparing medical care utilization with

health status patterns of persons not covered by

such programs. By systematically including questions on Medicaid eligibility, important gaps in information about this program could be eliminated.

For example, it is currently difficult to obtain

counts of poor persons who are not covered by

Medicaid, counts of the proportion of Medicaid recipients falling below the poverty line, counts of

12
poor persons who are not covered by either Medicaid or private insurance, etc. These very basic

data could be estimated if care were taken to obtain accurate information on Medicaid eligibility.

Estimates from the U.S. Budget indicate that approximately 27 million persons received Medicaid

benefits in 1974. This is sizable enough that it

should be possible to pick up some essential program information by simply adding questions on

Medicaid eligibility. (Class 2.)

In addition to supplying much needed information on counts of poor persons eligible or ineligible for Medicaid, HIS could be used to compare

whether Medicaid beneficiaries are sicker than

other poor persons, whether they use more hospital care, or whether they see physicians more

frequently than other poor persons. If the sample

of persons covered by Medicaid were sufficiently

large, some investigation of sociodemographic

characteristics of recipients of Medicaid services

could also be made. Currently no one knows how

many persons are eligible for Medicaid, or how

eligibles or enrollees are distributed ‘by income,

race, or residence. This type of information is

essential in determining whether all groups have

adequate access to medical care services under

extensive financing programs.

While systematically including questions on

Medicaid enrollment and indicators of possible

eligibility for Medicaid on such surveys as HIS

and HANES could help remedy important deficiencies in knowledge about the effectiveness of the

program, a more detailed survey restricted to the

poor would undoubtedly bean even superior instrument for pursuing further such questions as State

variations in Medicaid benefits. Such a special

survey might also concentrate on the effect of physicians and hospitals participant ing in Medicaid on

the utilization of medical services. (Class 4.)

Methodological

1. General issue area: Measures of population health levels and

change over time.

Specific issue: The need for an integrated

data base for health care

system appraisal.

Apart from information of varying detail obtained relative to the many individual elements of

the health care system (manpower, facilities, financing mechanisms, health status, utilization,

etc.) it seems desirable to develop an integrated

data base which would permit an overview of the

system in operation as a whole. While some of the

aspects and purposes of the systems approach are

outlined below, the single overriding concern is to

gain insight into the general question: Who cent?+

butes to the health cave of whom at what cost in response to what health needs?

The “who” part of the question relates to manpower, facilities, and technology utilization and

organization. The “whom” part relates to population characteristics and location. The “cost” factor includes both the economic costs of providing

services and payment mechanisms reflecting the

burden of such costs on the various sectors of the

economy. Finally, the assessment of health needs

requires a determination of the services appropriate for and utilized in relation to the care of illness

as well as the protection and promotion of health.

A functional framework, as outlined in table A,

appears to afford the best basis for such an assessment of the health care system. Each of the

functional areas could be separately analyzed as

a subsystem, and in addition, interrelationships

could be conveniently appraised. For example,

one could clearly ascertain the balance between

ambulatory and inpatient care. Similarly, the role

of preventive services could be examined relative

to the potential for reducing the curative load for

care.

Within the functional categories a rough determination could be made of levels of need in relation to services actually provided. Thus, critical

areas of imbalance could be highlighted. Along

with the measure of services provided, it would be

possible to ascertain the mix of providers (by institution and by staff category) and the cost of

providing such services.

While some of the existing national data could

be useful in the functional analysis, it would also

be necessary to obtain interrelated elements of

information from a sample of local areas. Thus,

for example, health needs in a community would

be related to the availability of manpower and

services and to patterns of care within the same

13
Table A Conceptual format of functional information system

Effort by

Units inst. and

Function Need of personnel cost service type

Ambulatory care of acute illness

and accidents

Ambulatory care of chronoc illness

4cute hospital care

2hronic hospitaJ care

2ommunity mental health care

~are for drug abuse Care for afcohotkm

Institutional mental health care

ilaternal and child health

Family planning

4duIt preventive care

communicable disease control

ztc.

community. It would also be desirable to obtain inputs of health services, the output in terms of

cohort information on a longitudinal basis in order

to establish, among other things, the incidence and

impact of catastrophic illness and existing profiles

of care received in the course of an entire episode

of illness.

An illustrative, though not exhaustive, list of

benefits of the proposed information system follows. First, the functional breakdown would facilitate the analysis of cost and resource utilization implications of discreet service packages

contemplated in various health insurance programs and in various patterns of organization of

services.

Secondly, classification of illnesses by diagnosis, duration, and severity would permit quantification of the need for medical care relative to

utilization and the preventability y of the illness relative to the amount of money and effort expended

on prevention.

Finally, a better understanding could be acquired concerning the cost-effectiveness of various service programs. In particular, by means of

the Kessner tracer approach, attention could be

focused upon the analysis of selected health problems for which care is known to be potentially effective.

The overall objective of such a “system of

health accounts” is to identify and describe the

changed health status, and the relationships between inputs and outputs. The last is the most

difficult to achieve both because of the detailed

data requirements and because of the need to demonstrate a cause and effect relationship or have

reasonable assurance that a particular effect is

not clearly due to some cause other than the input

of services. In controlled experiments this is accomplished through formulation of specific hypotheses, selection of suitable subjects, their

allocation to treatment and control groups, administration of treatment, and observation of outcomes for the various groups.

Experimental conditions cannot be established in health care programs for the general

population but some aspects can be incorporated

in a system of health accounts. Inputs of health

services should be classified according to age

groups or other population subgroups to which they

are directed, Outcomes in terms of change in

health status can be classified in the same way so

that changes in health of target groups can be related to levels of input for the same groups.

The development of an integrated data base

generally implies the need for new statistical

components or systems (Class 2-4) and for the

coordination of this effort with the evolving Cooperative Health Statistics System. There are, how14
ever, some input/output relationships that can be

studied with existing data.

Using available data (Class 1) it should be

possible to determine the expected effect on health

status of at least certain types of inputs of health

services. To the extent that some services have

no effect, the ability to detect changes associated

with those that do is limited if the two types are

not identified and accounted for separately. Two

axes on which it is important to classify inputs

are (1) whether the service is expected to prevent

ill health, by type of event (occurrence of disease,

disability, mortality); and (2) the time interval after which the effect on health status should become

evident. Outcomes should be classified in the same

ways (type of event, and time) so that relationships

between inputs and outputs can be observed.

It may be advisable to begin by identifying

those diseases that are currently preventable, and

observing whether levels of input for various geographic or other demographic subgroups are related to outcomes. If they are, low levels of inputs

should be increased. If they are not, it could be

concluded that extraneous factors were intervening, that services were not being applied w“ith

equal effectiveness, or that the assumption of

preventability was in error.

2. General issue area: Methods to increase

accessibility of NCHS

data through modification of distribution

channels.

Publications: The publications of NCHS are

made available to the public in several ways:

Mailing List Request (see appendix IV), Catalogue

of Publications 13; Current Listing and Topical Index to the Vital and Health Statistics 14; Monthly

Vital Statistics Report: Vital and Health Statistics Publication Series (the Rainbow Series); and

Vital Statistics of the U.S. This distribution network is effective for those who know about NCHS.

The problem is one of getting to potential users

m,~re effectively.

Murnaghan’s 15description of health-services

information systems is an example of how to acquaint potential users with the product of NCHS.

Her emphasis on alerting newcomers to information sources should be followed up aggressively by

NCHS.

There are several ways by which this could

be accomplished, some of which necessitate structuring the message in a way that will convey more

explicit ideas of information utility than presently

exists in the traditional announcements of publications. Other methods could be attuned to the

levels of statistical sophistication of potential

users.

The Department of Commerce through its

National Technical Information Service (NTIS) is

attempting to develop new distribution channels by

using market segmentation techniques based on:

(1) Areas of interest (by using an information request card that allows the respondent to identify specific interest

areas, e.g., administrators, biomedical

technology and engineering, business

economics, environmental pollution and

control, and library and information

sciences) and

(2) by economic status (making credit card

purchase of government funded reports

available through NTIS).

Although a listing of some NCHSpublications

now appear in NTIS announcements it is recommended that a working group explore with NCHS

the possibility of promoting more aggressively the

availability y of NCHS publications and developing

new formats aimed at the particular needs of

potential users, e.g., Health Maintenance Organizations, foundations for medical care, and Professional Standards Review Organizations.

Tapes: For users familiar with the system

and its constraints, certain NCHS data tapes are

available7 (figure 1). The problems involved in

increasing the availability of tapes, e.g., confidentiality,l 6control of use, requests for consultation on tape use, etc., need to be weighed against

the possible benefits of increasing the analytical

potential of NCHS data.

The restriction on identification of geographic

location for data files from localities having less

than 250,000 population may impose a barrier to

the utilization of tape file data for comprehensive

health planning and for studies based on the newly

designated Professional Standards Review Organi15
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16

This page may be used for ordering data sets.

Simply detach from publication (or copy), indicate those data sets you want, put yo w n&e and

address at bottom of page, enclose payment and

sent to the following address.

ORDER FORM

No. Data Sets available

from NCHS in 1975

la Master Facility Inventory Data,

hospital, 1971-73, (Specify

year) ......................................

lb Master Facility Inventory Data,

nursing home, 1971 ...............

lC Master Facility Inventory Data,

other health facilities, 1971 ...

ld Master Facility Inventory Data,

nursing homes and other

health facWies, 1973 .............

2a Data on Family Planning Service

Sites, 1973 .............................

2b National Reporting System for

Family Pkmning Services Data,

1971-73, (Specify year) ..........

3a Hospital Discharge Survey Data,

1969-72, (Specify year) ..........

4a Vita.IStatistics Natality, detail,

1968-73, (Specify year) .........

4b Vital Statistics Natality, local

area summary, 1968-73,

(Specify year) ........................

4C Vital Statistics Natality, State

summary, 1968-73, (Specify

year) ......................................

5a VitaI Statistics Mortality, detail,

1968-73, (Specify year) ........

5b Vital Statistics Mortality, local

area summary, 1968-73,

(Specify year) ........................

5C Vhal Statistics Mortality, causeof-death summary, 1968-73,

(Specify year) ........................

6a Vital Statistics Marriage, detail,

1968-73, (Specify year) .........

Density desired: ❑80,0 bpi

cost of

Data Set

$200.00

200.00

200.00

200.00

200.00

450.00

200.00

395.00

70.00

70.00

395.00

70.00

11,5.00

70.00

Scientific and Technical Information Branch

National Center for Health Statistics

5600 Fishers Lane

Parklawn Building, Room 8-20

Rockville, Maryland 20852

1975

No.

7a

8a

9a

10a

1la

12a

13a

14a

15a

16a

17a

18a

19a

Data Sets available

Porn NCHS in 1975

Vital Statistics Divorce, detail,

1968-73, (Specify year) ..........

Followback Survey, Natality,

196466 .................................

Followback Survey, Natality,

1967-69, (Specify year) ..........

Followback Survey, Infant

Mortality, 1964-66 ................

Followback Survey, Mortality

1966-68 .................................

Health Interview Survey, 1969-71,

(Specify year) ........................

Health Examination Survey,

Cycle I, demography .............

Healt,h Examination Survey,

Cycle I, psychological ...........

Health Examination Survey,

Cycle I, physical ...................

Health Examination Survey,

Cycle I, cardiovascular ..........

Health Examination Survey,

Cycle I, arthritis ...................

Health Examination Survey,

Cycle 1, dental ........................

Health Examination Survey,

Cycle 11 (aII) ........................

U 1600 bpi

cost of

Data Set

70.00

60.00

60.00

60.00

60.00

600.00

100.00

150.00

150.00

150.00

150.00

150.00

300.00

Send indicated data sets to:

Figure 1
zation (PSRO). A study of the methods used by the

U.S. Bureau of Census summary tapes and data

profile packets designed specifically for user segmentsl 7may help resolve some of the constraints

now imposed to safeguard the confidentiality of

data,

Exploration of NCHS summary tape centers

located at schools of public health and at universit y

business schools which are showing an increasing

interest in the health sector offer a twofold benefit. First, for those who are likely to become producers of data, the access to NCHS data files

would provide an opportunity to gain proficiency

with the computer as it is applied to large data

files and possibly the development of analytical

skills. Second, for those who are likely to become

users? the data centers could be used as a method

of introducing potential users during their educational experience, to the range of data available

through NCHS.

An alternative model might be to establish

summary tape centers at each of the PHS regional

offices in a manner consistent with the current effort to regionalize some of the NCHSactivity. Staff

detailed to the regional offices, supported when

necessary by central office staff, could make the

product of NCHS available to a wider range of

users, e.g., States participating in the evolving

Cooperative Health Statistics System.

It is recommended that a working group explore with NCHSthe possibility of establishing tape

processing centers that would increase accessibility and the analytic use of NCHS data.

Additional Resources Needed

In this study Panel members have identified a

number of approaches that may be useful in increasing the analytical potential of NCHS data in

one important data use area—Health Care, Some

of the recommended approaches can be implemented within the present structure of information

collected by NCHS, others will require the development of new information system components.

Some recommendations are addressed to the need

for increasing the availability of the information

specialists from NCHS to work with Federal, regional, State, and local officials and with the educational institutions that train both producers and

users of information. These

cannot be implemented without

resources available to NCHS,

recommendations

making additional

The TCP has identified important subject

matter issues and methodological problems. It has

recommended further development of information

and consultative capacity for Federal, regional,

State, and local health planning. It has proposed

new communication channels to existing and potential users along with the development of data

access techniques designed to increase the effectiveness of linkages between NCHS and educational institutions. All of these activities will require additional funds and personnel. The specification of the nature, magnitude, and timing of requests for additional resources is a task for NCHS.

The Panel’s responsibility, however, is to point out

that in our opinion there is little likelihood that

significant progress will be made toward increasing analytical potential of NCHS data unless this

support is forthcoming.

SECTION IV. CONCLUSIONS

The nature of the activities carried out by

NCHS and the rapidly changing information needs

generated by a health care delivery system characterized by some to be in a period of crises,

makes it necessary to monitor the effectiveness

of the Center’s role in the national health intelligence system. The work of the TCP during the past

6 months and earlier studies initiated by the U.S.

National Committee on Vital and Health Statistics

constitute efforts in this direction. In-house

evaluation by the Center staff constitutes another

approach. Collectively these efforts make a case

for developing a continuing assessment procedure

that assures user input.

The current study, based on a nonrepresentative set of NCHS data users brought together as a

Technical Consulting Panel identified subject matter and methodological problem areas considered

to be important in increasing the analytical potential of NCHS data. These are shown in table B

according to a classification that indicates existin~

or new data systems.

Related to these recommendations are two

additional conditions. First, in order to implement

17
Table B Summary of selected recommendations

Subject matter

MedicaI care

Demand and

supply

determinants

h4ethodological

problems

Data gaps

Data compilations

Distribution

channels

class 1 class 2 class 3 Class 4

Utilizing Within current New survey New surveys,

existing survey framc- methods e.g., special

NCHS data work needed groups

[Ilness, income, health

insurance,

and utilization patterns

Utilization

data merszed

Health expenditure

verification studies

Determinants

for selection

with man}owcr of health

and facility providers

data forgeo-

&wdphic areas

catastrophic

illness expenditures

using enriched

samples

Supply availability in

selected geographic areas,

e.g., rural and

central city

areas

synthetic

estimates

_ Integrated data base for health care system appraisal _

Publication series promotion

Rcgiorud Summary Tape Centers

these efforts to increase the analytical potential to secure continuity in assessing the extent to

of data, NCHS will need additional funds and staff. which the information systems of NCHS are in fact

Second, more emphasis needs to be given to efforts meeting user needs.

18
REFERENCES

.

‘Downs, Anthony: Inside Bureaucracy. Little Brown and

Co., 1967, p. 29.

.

‘National Center for Health Statistics: The Mission and

Policies of the National Center for Health Statistics.

HSM-72-1201, 12 pp. 1971.

3

Fertility Statistics: Report of the President’s Commission,

Vol. IL Washington. U.S. Government Printing Office, 1971.

4

National Center for Health Statistics: Heakh Statistics

Today and Tomorrow. A report of the Committee to Evakate

the NCHS. J’itdand Health Statistics. Series 4-No. 15. DHEW

Pub. No. (HRA)74-1452. Health Resources Administration.

U.S. Government Printing Office, Sept. 1973.

5

Wook.cy, T., and Perrin, E.: Assuring the Usefulness of

Nutiomd Hetsklt Statistics System. A paper presented at the

Second International Conference of National Committees on

Vital and Heakh Statistics. Copenhagen. Oct. 1-5, 1973.

6

Brothcrston, J. H, F.: Health Planning and Statistics: An

Ovciview, WHO Working Paper 70.10. Geneva, Dec. 1970.

7

Nat ion al Center for Health Statistics: Standardized

Aficro-Data Tape Transcripts, DHEW Pub. No. (HRA) 74-1213

(Revised). Washington. U.S. Government Printing Office, June

1974.

8

Shapiro, B. P,: Marketing for Nonprofit Organizations.

Hwwrrd Business Review, Sept.-Ott. 1973.

9

Cooperative Health Statistics System: The Cooperative

Federal-State Local Statistical Systems authorized by P. L.

91-515.

10

National Center for Health Statistics: United States

St~tistics on Afcdical Economics. PHS Pub. No. 1125. Public

Health Service, Washington. U.S. Government Printing Office,

1964.

11

National Center for Health Statistics: The 1970 Census

and Health Statistics. Vital and Health Statistics. PHS pub. No.

1000-Series 4-No. 10. public Health Service. Washington. U.S.

Government Printing Office, Apr. 1969.

12

National Center for Health Statistics: Migration, Vital,

~d Health Statistics. Vital and Health Statistics. PHS pub. No.

1000-Series 4-No. 9. public Health Service. Washington. U.S.

Government Printing Office, Nov. 1968.

13

National Center for Health Statistics: Catalogue of

publications of the National Center for Health Statistics.

DHEW Pub. No. (HRA) 74-1300. Public Health Service.

Washington. U.S. Government Printing Office, Nov. 1973.

14

National Center for Health Statistics: Current Listing and

Topical Index to the Vital and Health Statistics Series,

1962-1972. DHEW pub, No. (HSM) 73-1301 (Revised). Public

Health Service, Washington. U.S. Government Printing Office,

May 1973.

15

Murnaghan, J. H.: Health-Services Information Systems in

the United States Today. NE-W 290:11, Mar. 14, 1974.

16

National Center for Health Statistics: Policy Statement on

Release of Data for Individual Elementary Units and Related

Afatters. DHEW Pub. No. (HSM) 73-1212. Washington. U.S.

Government Printing Office, Ju]y 1972.

17

U.S. Department of Commerce, Bureau of Census: Data

Profile Packets for Community Health Centers in Small Area

Data Notes. Vo]. 5, No. 9, Sept. 1970.

19
APPENDIX I

EXCERPTS

Excerpts from minutes of the U.S. National Committee on Vital and Health Statistics related to statistical

needs of the future.

Meeting of March 7-8, 1968.

“Demography

“There are increasing requirements for vital and

health statistics because of the marked fall in the

birth rate, continuing urbanization, continuing depopulation of rural areas, and intensification of

health problems of Negroes and other minority

groups. Small area data are needed for study of

and planning to solve these problems. Basic problems of under enumeration of the population and

incomplete reporting of some vital events (especially marriages and births) remain. Data which

cannot be supplied by vital records alone include

information on illegitimacy and conception before

marriage; on dissolution of cohorts of marriages;

and on minority groups such as Mexican-American, Puerto Rican, and migrant worker families.

“Some progress has been made on needs listed at

the fifteenth Anniversary Conference, including

study of internal migration, plans for quinquennial

censuses, an increasing role for private research

groups in the statistical activities of government,

and studies of family planning. Additional data are

needed on child spacing, the relationship of

socioeconomic status to age at marriage and to

fertility, concentration of aged persons in some

geographic areas, disability of the aged, and gross

as opposed to net migration.

“Public health

“Many of the statistical needs in public health are

shared with the fields of demography and economics. Planning must be carried on both in small

areas and for minority groups as well as for the

whole population and at long range. General indices

of health are needed as well as measurements of

the effectiveness of specific health programs and

methods of relating benefits to costs.

“Comprehensive statistics on health hazards in the

environment (air pollution, radiation, noise, chemicals) are lacking. Gaps between knowledge and its

application are wide though there is little descriptive information available on care being provided

through private practice and in hospitals and

clinics. International comparisons are essentially

limited to mortality. There is need to introduce

order into the rapid and diverse development of

hospital data systems; to improve manpower statistics, to modernize the roles of the Federal,

State and local statistics programs. Critical needs

in methodology include ways of measuring the extent of mental illness, alcoholism and drug use;

and ways of dealing with the ‘long-range effects’

which pervade the epidemiology of chronic diseases.

“’The several phases of health care and the organization necessary to provide them being merged.

Prevention, detection, care, and rehabilitation may

be carried on under the same auspices. Nevertheless, the ‘service gap’ is increasing, due inpart to

shortages of personnel. Provisions for financing

are changing rapidly. Data are needed on the cost

and effectiveness of service provided under various arrangements.

“Health resources and services and health economics

“There have been major improvements in economic and manpower statistics during the past decade. Data on expenditures are now available on object of expenditure by source of funds. Better data

on prices of health care will be available from the

Bureau of Labor Statistics this year. Information

on manpower in 35 categories of health professions

has been published by the National Center for

Health Statistics and the time series on supply of

physicians reported by the American Medical

Association covers a number of years.

“Problems in definitions include the point at which

an individual enters the profession (e.g., before or

20
after graduation; house staff as students or providers of service). The loss of physicians to the

practice of medicine suggests that their training

may not be suited to their functions. Measurement

of nurse manpower is difficult. Trend data on professions other than physicians are needed.

I!Because income of an individual or family is

affected by illness expenditure data would reflect

socioeconomic status more accurately. Survey

sample sizes adequate to permit cross-classification of income and education with health variables

would be useful. Subdivisions of the age category

65 and over is essential in health statistics. Many

problems in availability and classifications of expenditure and price data remain to be solved. No

useful subnational data are available.

“Judgments on levels of hospital costs cannot be

made without measures of quality of care. More

generally, estimates of economic benefits are dependent on measures of effect of programs on survival and health. Too frequently the practicing physician does not know whether a patient follows a

prescribed regimen, let alone its effect on his

health. The economist should deal with marginal

costs (the cost of an additional unit), whereas only

average cost data are usually available. ”

Meeting of November 3-4, 1969.

“Health services statistics

“There are many gaps and deficiencies in available

data. Remedies will not come easily, and some may

require expensive field studies. The obligation to

plan health services may be helpful as a framework for organizing data needs, particularly if

conceptualization of problems is emphasized. . .“

The minutes highlighted the need for solid baseline

financial data of all types for a single year. This data

base would include financial data in the areas of expenditures, sources of funds, price indexes, and data obtained

from respondents in household surveys.

“Demographic status

“Another high priority need is for continuing study

of family growth . . and a fuller exploitation of data

presently available; examples are systematic analyses of data from various sources which bear on a

particular question such as racial differences in

health; and cohort measures which can be constructed for fertility, mortality, etc., through reorganization or retabulation of data. . .

“Health statistics

“Gaps in the array of national statistics on health

status include: (1) identification of certain groups

with special problems such as alcoholism and drug

abuse; and (2) data which relate health status to

receipt of health care. As a means of identifying

health statistical needs of the future, it may be

useful to classify health-related phenomena ac -

cording to different axes and judge whether the

statistical system provides the necessary data.

Two axes of classification were proposed:

A. Problem axis

1. Population

2. Environment

3. Iatrogenic disease

4. Manpower

5. Urbanization

B. Functional axis

1. Warning system

2. Protection

3. Service (action)

4. Training

5. Planning

6. Legislation’ r

Several of these comments formed the basis for the

establishment of other technical consulting panels which

are working toward more detailed recommendations.

21
APPENDIX II

INCONSISTENCIES OF NCHS DATA

Inresponse toarequest made January 24, 1972an

NCHS staff study was made for the purpose of identifying inconsistencies in NCHS statistics. The results

indicate:

1. Data from the Health Interview Survey (HIS) and the

Health Examination Survey (HES) have produced

more apparent inconsistent estimates of the same or

similar parameters than any other pair of data collection systems. These inconsistencies can largely

be attributed to differences in universes, operational

definitions, measuring devices, and observers.

2. Apparent discrepancies between the Health Interview

Survey and the lIospital Discharge Survey (HDS) apply

3.

to estimates of discharges, surgical operations, and

the average length of stay in ,short-stay hospitals. In

part these differences can be attributed to the inclusion of the experience of deceased persons in the

HDS, technical admissions, and other inclusions in

HDS estimates that were excluded from HIS estimates.

Inconsistencies in vital statistics reports occurred

as a result of different class ificat ions of fetal deaths

(2o weeks or more gestation in the NCHS Series 20

reports VS. 28 weeks or more in Series 3 reports) or

to the use of provisional data in one series VS. final

data in another series.

22
APPENDIX Ill

PREVIOUS AND PLANNED ACTIVITIES OF THE HEALTH INTERVIEW SURVEY

Year Collected

1970: Information was collected on insurance coverage for hospital, surgical, and doctor visit services.

Coverage has been analyzed with respect to age, sex,

income, region, and race (Monthly Vital Statistics Report, Vol. 21, No. 9, Supplement 2, December 18, 1972).

1971: Information was collected on out-of-pocket

expenditures for the year 1970. Included were expenditures for health insurance premiums, nonfamily members, dentists, doctors, hospitals, prescribed medicines, and eye care. This information has been analyzed

according to age, sex, race, income, and region (Monthly

Vital Statistics Report, Vol. 22, No. 1, Supplement, April

2, 1973). Further analyses emphasizing the family as the

unit of analysis and type of expense are forthcoming.

1972; Data were collected on all health insurance

items collected in 1970 and in addition on coverage under

supplementary extra cash indemnity plans and under

prepaid group practice. These data will be presented in

a report about to be published which will largely parallel

NCHS Series 10, No. 66, “Hospital and Surgical Insurance

Coverage in the United States- 1968,” January 1972. In

addition, questions were included on sources of payment

for hospital bills, fraction of the bill paid by insurance,

and out-of-pocket payments by the family. For doctor

visits, the source of payment was also determined.

1973: Information was collected on the sources of

payment for prescribed medicine, and the out-of-pocket

and total costs for these medicines.

1974: Health insurance coverage information is

currently being collected but not in the same detail as in

1972.

1975: Out-of-pocket information similar to that

collected in 1971 will again be collected from one-fourth

of the national sample. In addition, for hospital admissions and physician visits third-party payers and out-ofpocket costs will be elicited. Also, a methodological

study concerning how to design a panel study to collect

consumer expenditure data will be conducted.

1976: Preliminary plans are to begin a panel study

on consumer expenditures which will include a minimum

of 5,000 households.

23
APPENDIX IV”

Vital and Health Statistics Publications Series

Series 1, Proqams and collection proceduves.— 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 for understanding the data.

Series 2. Data evaluation and methods research. —Studies of new statistical methodology including: experimental tests of new survey methods, studies of vital statistics collection methods, new analytical

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

Series 3. Analytical stzufies. -Repcmts presenting analytical or interpretive studies based on vital and health

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

Series 4. Documents and committee repovts.— Final reports of major committees concerned with vital and

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

birth and death certificates.

Sevies 10. Data from the Health Interview Survev.— Statistics on illness, accidental injuries, disability, use

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

collected in a continuing national household interview survey.

Series 11. Data from the Health Examination Suvvey. —Data from direct examination, testing, and measurement of national samples of the civilian, noninstitutional population provide the basis for two types

of reports: (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.

Series 12. Data 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.

Series 13. Data j?om the Hospital Discharge Survey. —Statistics relating to discharged patients in short-stay

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

Series 14. Data on health vesources: manpower and facilities. —Statistics on the numbers, geographic distribution, and characteristics of health resources including physicians, dentists, nurses, other health

occupations, hospitals, nursing homes, and outpatient facilities.

Series 20. Data on mortality. —Various statistics on mortality other than as included in regular annual or

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

geographic and time series analyses.

Sm”es 21. Data on naikzlity, marriage, and divoyce. —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.

Series 22. Data from the National Natality and Mortality Surveys.— Statistics on characteristics of births

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

24
Vital and Health Statistics Publication Series—Con.

This listing permits you to choose only the topics of interest to you. For example, beginning with

Series 10, you can select the publications on disability by checking only this box. If you wish to

receive all reports for this series, or any other series, check all boxes.

•1

•1

•1

•1

•1

Series 1. Programsand collection procedures

Series 2. Data evaluation and methods research

Series 3. Analytical studies

Series 4. Documents and committee reports

Series 10. Data from the Health Interview Survey

Disability

Illness

Use of health services

Series 11. Data from the Health Examination Survey

❑ Nutrition

Cycle I. Adults, aged 18-79 years (No additional

reports from this cycle are planned. For

available reports, see Current Listing of the

VITAL AND HEALTH STATISTICS

SERIES)

Cycle 1!. Children, aged 6-11 years

❑ Vision and hearing

❑ Body measurements

❑ Psychometric

❑ Dental

❑ Other

Cycle III. Youth, aged 12-17 years

❑ Vision and hearing

❑ Body measurements

❑ Psychometric

❑ Dental

Other

Series 12. Data from the Institutional Population

Surveys

•1

•1

•1

•1

❑

In nursing homes

In other institutions

In physicians’ offices

In family planning clinics

In outpatient facilities, NES

Series 13. Data from the Hospital Discharge Survey

❑ Norunedical characteristics

H Diagnoses and surgical procedures

❑ Charges and sources of payment for care

Series 14. Data on health resources manpower and

facilities

❑ Selected health occupations

❑ Short-range forecasts of the supply of selected

health occupations

❑ Staffing of health facilities

❑ Inpatient facilities

❑ Outpatient facilities

❑ Nonpatient facilities

Series 20. Data on mortality

D General mortality, including causes of death

❑ Infant mortality

Series 21. Data on natality, marriage, and divorce

Q NataIity

❑ Marriage

❑ Divorce

Series 22. Data from the National Natality and

Mortality Surveys

❑ Natality followback surveys

❑ Mortality followback surveys

❑ Data from the National Ambulatory Medical Care Survey

❑ Data from the National Survey of Family Growth

25
Periodicals

•1

•1

❑

•1

•1

Lktings and announcements of publications.

Life Tables

Data on life expectancy in the United States, by sex, color, and age. Issued annually.

Monthly Vital Statistics Report

Contains monthly and cumulative provisional data on births, natural increase, marriages (or

marriage licenses issued), deaths, and infant deaths for States, certain cities, Puerto Rico and

Virgin Islands (U.S.); and on divorces for specified States and V&@ Islands (U.S.) with

brief analysis of these vital statistics. It also presents death rates by cause, age, color, and

sex, estimated from the returns of a 10-percent sample of death certificates filed in State

and independent city vital statistics offices.

Nosology Guidelines

Issued periodically, discusses causes-of-death coding problems and related matters. It

supplements the Eighth Revision, International Classification of Diseases, Adapted for Use

in the United States, PHS Pub. No. 1693, and Vital Statistics Instruction Manual Part 2;

Cause oflleath Coding, issued by the National Center for Health Statistics.

News of the Cooperative Health Statistics System

Issued hi-monthly, presents short articles and news on the development of the Cooperative

Health Statistics System and on related activities in NCHS.

Print name, organizational affiliation, and address below and return to:

National Center for Health Statistics

ATTENTION: Mr. James L. Brent

Public Health Service, HRA

5600 Fishers Lane

Rockville, Maryland 20852

* U. S.GOVERNMENT PRl??TJNGOFFICE :1975210-’3Sl/3

26
VITAL AND HEALTH STATISTICS PUBLICATION SERIES

Formerly Public Health Service Publication No, 1000

Series 1. l+o~ams 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 for understanding the data.

Series 2. Data evaluation and methods reseavch. — 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.

S&cs 3. Analytical studies .-Reports presenting analytical or interpretive studies based on vital and health

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

Series 4. Documents and committee ~epo~ts.— Final reports of major committees concerned with vital and

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

birth and death certificates.

Series 1(2. Dakt porn the Health Interview Swvev.— Statistics on illness, accidental injuries, disability, use

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

collected in a continuing national household interview survey.

Sc?ries 11. Data from the Health Examination Suvvey. —Data from direct examination, testing, and measttrement of national samples of the civilian, noninstitutional population provide the basis for two types

of reports: (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.

SLW?S 12. Data fkom the Institutional Population .Wweys —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.

Series 13. Data from the Hospital Dischavge Swvey. —Statistics relating to discharged patients in short-stay

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

Seric!s 14. Data on health vesowces: manpowev and facilities. —Statistics on the numbers, geographic distribution, “ad characteristics of health resources including physicians, dentists, nurses, other health

occupations, hospitals, nursing homes, and outpatient facilities.

Swim 20. Data on movWity.-Variotts statistics on mortality other than as included in regular annual or

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

geographic and time series analyses.

Sm”es 21. Data on rtatality, mawiage, 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.

Sevies 22. Data porn the National Natality and Motctality Suvveys.— 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 to: Scientific and Technical Information Branch

Nat ional Center for Health Statistics

Public Health Service, HRA

Rockville, Md. 20852
U.S. DEPARTMENT OF

HEALTH, EDUCATION, AND WELFARE

Public Health Service

Health Resources Administration

5600 Fishers Lane

Rockville, Md. 20852

OFFICIAL BUSINESS

Penalty for Private Use, $300

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