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EDJTOF#AL LIBRARY/Ha 

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FROM VITAL & HEALTH STATISTICS OF THE NATIONAL CENTER FOR HEALTH STATISTICS 

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE � Public Health Service I Number 33 � July 18,1978 

Office Visits to Orthopedic Surgeons, National Ambulatory 

Medical Care Survey: United States, 1975-19761 

Using data from the National Ambulatory 

Medical Care Survey (NAMCS), this report 

describes an estimated 47,152,000 visits made to 

the offices of orthopedic surgeons over the 

2-year span from January 1975 through December 1976. NAMCS is a sample survey designed to 

explore the provision and utilization of ambulatory care in the physician’s office, the setting 

where most Americans seek health care. The 

survey is conducted yearly throughout the 

coterminous United States by the Division of 

Health Resources Utilization Statistics of the 

NaticmaI Center for Health Statistics. The survey 

sample is selected from doctors of medicine and 

osteopath y who are principally engaged in 

o f fice-based, patient-care practice. Excluded 

from the sample are an indeterminate number of 

physicians who render some office-based ambulatory care but whose patient-care activities are 

secondary to another primary roIe such as 

teaching, research, or administration. AISO excluded from the NAMCS scope are physicians 

who are hospital based; those whose speciaIty is 

anesthesiology, pathology, or radioIogy; and 

physicians in Federal Service. 

Because the estimates presented in this 

report are based on a sample rather than on the 

en t ire universe of office-based, patient-care 

physicians, they are subject to sampling variability. See the Technical Notes for an explanation and for guidelines in judging the relative 

precision of estimates presented in this report. 

1This report was prepared by Hugo Koch, Division of 

Ilealth Resources Utilization Statistics. 

The directions offered there also provide the 

basis for judging the statistical significance of 

differences between estimates. 

DATA HIGHLIGHTS 

With an estimated 47,152,000 office visits 

during the 2-year span 1975-76, orthopedic 

surgeons occupied a position of middIe prominence in the provision of office-based ambulatory care. This is evident from the listing in 

tabIe 1. 

Understandably heading the list are the five 

primary care and/or more generaked practitioners. Among the other office-based providers 

of ambulatory care-those generalIy characterized by a more focused cIinicaI speciaIization— 

orthopedic surgeons were second only to 

ophthalmologists in volume of wisits. 

Table 1. Number of office visits to the 13 most visited specialists, 

by type of specialty and rank order: United States, 1975-76 

Number of visits Rank Type of specialty in thouwrrds 

General and family practice ....... 

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

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

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

General surgary ... ....................... 

Ophthalnmlogy ....... ................... 

Orthopedic surgery..................... 

Dermatology .... .......................... 

Psychiatry ................................... 

Otolaryngology .......................... 

Urology ........................... ........... 

Cardiovascular disease ................ 

Neurology ...................... ............ 

460,297 

130,367 

107,085 

97,070 

77,259 

53,969 

47,152 

35,721 

30,616 

27,192 

20,728 

13,517 

3,784 

I 
2 

* 

Compared with the entire universe of officebased physicians, orthopedic surgeons reversed 

the overall preference for solo over multiplemember practice (table 2); more than one-half 

of visits to orthopedic surgeons (55 percent) 

were made to physicians in multiple-member 

practice arrangements. 

Table 2, Number and percent distribution of office visits to 

orthopedic surgeons, and percent distribution of office visits 

to all specialists, by characteristics of physician: United 

States, 1975-76 

Visits to Visits to 

Physician orthopedic surgeons all specialists 

characteristic Number in Percent Percent 

thousands distribution distribution 

All visits ........... 47,152 100.0 100.0 

Location of practice 

Metropolitan area2...,. 36,585 77.6 73.3 

Non metropo iitan 

area ... . . ....... .. .. .... .. ... . 10,567 22.4 26.7 

Type of practice 

solo . ... .. ..... ... . ..... .. .. .... 21,401 45.4 60.0 

Other . .. .... ... .. .. .... . .. .... . 25,751 54.6 4aa 

l~a~ed on an ~~timated I.I55.900.000 visits made to all 

office-based physicians in 1975 and 1’976.’ 

2~o~ati~n within a standard metropolitan statistical area 

(SMSA). Composition of SMSA’S does not reflect 1974 adjustment. 

A majority of visits to orthopedic surgeons 

(58 percent) were made by patients in the age 

group 25-64 years (table 3). Median age for visits 

was about 35 years. 

An estimated 53 percent of visits to 

orthopedic surgeons were made by male patients 

(table 3), a proportion that substantially exceeded the average proportion of male visits 

found in overall office-based practice (40 percent). Indeed, orthopedic surgery is one of the 

few specialties where visits by males equaled or 

exceeded visits by females; the other notable 

examples were pediatrics, urology, and cardiovascular disease. 

The 23 percent of visits to orthopedic surgeons made by new patients is relatively high 

Table 3. Number and percent distribution of office visits to 

orthopedic surgeons, and percent distribution of office visits 

to all specialists, by characteristics of the patient: United 

States, 1975-76 

Visits to Visits to 

Pat ient orthopedic surgeons all specialists 

characteristic 

Number in Percent Percent 

thousands distribution distribution 

All visits ........... 47,152 100.0 1Ott.o 

— 

Age

+= 

Under 15 years ........... 7,747 16.4 18.1 

15-24 years ................. 7,663 16,3 15.1 

25-44 years ................. 14,313 30,4 25.5 

46-64 years ................. 12,911 27,4 25.1 

65 years and over ....... 4,519 9.6 16.2 

— sex

Female .. .. .. .. .... .. ... .. .. .. . 22<248 47.2 60.4 

Male . ...... . .. .... .. ... ... ... .. . 24,904 52.8 39.6 

Prior visit status 

New patient ... .. .. .. ... .. .. 10,620 22.5 14.6 

Old patient, new 

problem . .. ...... . .. ... .. .. 3,258 

Old patient, old 

problem .. ... ... . ... .. . .. .. . 33,274 -QG 

lBased on an estimated 1,155,900,000 visits made to al! 

office-based physicians in 1975 and 1976. 

NOTE: Figures may not add to totals due to rwnding, 

compared with ‘the. average 15 percent found in 

overall office-based practice (table 3). Contributing in large degree to this increased 

presence of new patients is the finding that 7.1 

percent of all visits to orthopedic surgeons were 

referrals from other physicians or agencies —lte., 

almost one-third of the visits by new patients 

were referred visits. This referral rate is considerably larger than the average rate of 2.6 percent 

found for all office-based physicians; indeed, it 

is exceeded by only two other most visited 

specialties—urology &d neurology. 

For every visit at which a new problem was 

presented to the orthopedic surgeon (i.e., any 

visit by a new patient or a visit by an old patient 

with a new problem) there were an average of 

2.4 return visits per year, a return-visit rate that 

0 
o admce&a3 

Table 4. Number, percent, and cumulative percent of office visits to orthopedic surgeons, by the 10 principal diagnoses most commonly 

rendered by the orthopedic surgeon: United States, 1975-76 

Visits to orthopedic surgeons 

Principal diagnosis and ICDA code 

Number in Percent Cumulative 

thousands percent 

Medical and surgical aftercare .............................. ................................. YI o 8,925 18.9 18.9 

Synovitis, bursitis, and tenosynovitis ................................................... . 731 3,179 6.7 25.6 

Sprains, strains of other and unspecified parts of back ........................ 847 2,364 5.0 30.6 

Osteoarthritis and allied conditions ...................................................... 713 1,989 4.2 34.8 

Displacement of intervertebral disc ...................................................... 725 1,829 3.9 38.7 

Sprainsi strains of sacroiliac region .............4....... ................................. 846 1,663 3.5 42.2 

Fracture of radius and ulna ........................................................ .......... 813 1,358 2.9 45.1 

Dislocation of knee ............................. ................................................. 836 1,064 2.3 47.4 

Other diseases of musculoskeletal system, othar deformities ................ 738 1,061 2.3 49.7 

Vertebrogenic painsyndrome............................................................... 728 1,031 2.2 51,9 

substantially exceeded the average of 1.6 return 

visits found in overalI office practice.2 

Some problem of the musculoskeletal system (e.g., pain, swelling, injury, etc.) was the 

reason most frequently given by patients for 

� visiting the orthopedic surgeon. The largest 

proportion of these complaints or symptoms 

centered on the hip and lower extremity (reported in 28 percent of visits); second in order 

of frequency were problems of the shoulder and 

upper extremity (reported in 25 percent of 

visits); next in frequency were back problems 

(reported in 20 percent of visits); and finally 

were complaints about problems with the face 

and neck (reported in 13 percent of visits). 

Table 4 presents data on the principal 

diagnoses frequently rendered by the orthopedic 

surgeon. The principal diagnosis was the firstIisted diagnosis on a survey form that permitted 

up to three diagnostic entries. Diagnostic terms 

and codes are those established by the Eighth 

Revision International Classification of Diseases, 

Adapted for Use in the United States, 1968 

(ICDA). Two major diagnostic groups accounted 

for two-thirds of all the principal diagnoses 

made by the orthopedic surgeon; these were 

“Accidents, . . .. and violence” (36 percent of all 

diagnoses) and “Diseases of the musculoskeletal 

system and connective tissue” (30 percent ). 

*To obtain this return-visit rate, divide all visits clas­

*.	 sified as “old patient, old problem” by visits representing new-problem encounters (i.e., visits by “new 

patient” plus visits by “old patient, new problem”). 

To establish or, more typically, to confirm 

and limit a diagnosis, orthopedic surgeons pIaced 

chief reliance on two diagnostic procedures–the 

Iimited examination and the X-ray (tabIe 5). In 

keeping with the nature of their specialty, they 

used X-ray about five times more frequently 

than the average office-based physician. In 

Table 5. Number and percent of office visits to orthopedic’ 

surgeons, and percent of visits to all speciiilists; by selacted 

diagnositc and therapeutic services ordered or provided: 

United States, 1975-76 

Visits to Visits to 

SsIcteq ]services orthopedic surgeons III special ists 

ordered or provided Number in Percent Percent 

of visits of visitsl 

Diagnostic service 

Limited history and 

examination .. . ... .. .. ... . 26,019’ 55.2 51.6 

General history and 

examination ... ... .. . ... .. 5,142 10.9 16.3 

Clinical laboratory 

test .. .. . ... ... .. .. ... . .. ... .. . 745 1.6 22.8 

X-ray .. .. . .... .. .. .. .. .. . .. .. . . 17,096 36.3 7.6 

Blood pressure check.. 690 1.5 33.2 

Therapeutic service 

Drug prescribed ..... .. ... 8,030 17.0 43.6 

Injection . .. . ... .. . .... . .. .... 2,998 6.4 13.1 

Office surgery . ..... .. .... . 6,748 14.3 6.9 

Physiotherapy . ... .. . .... . 4,477 9.5 2.6 

Madical counseling ... . . 7,766 16.5 13.0 

1Based on an estimated 1,155,900,000 Vkits made to all 

office-basedphysicians in 1975 and 1976. 
4 admdata o 

Table 6. Number and percent distribution of office visits to further contrast with the average experience, ‘ 

orthopedic surgeons, and percent distribution of office visits 

to all specialists. bv characteristics of the visit: United States, 

1975-76 

orthopedic surgeons made relatively less use of 

drugs and injections and relatively more of 

manipulative and surgical forms of treatment 

Visits to Visits to 

orthopedic surgeons III specialists 

(e.g., physiotherapy and such surgical procedures as wound suture, fracture reduction, and 

Visit characteristic the application or removal of supportive mateNumber in Percent Percent 

thousands distribution ~istributionl 

rials for fractures and sprains). 

Table 6 presents data on the severity of the 

patient problems presented to the orthopedic 

All visits ... ....!... 47,152 100.0 100.0 surgeon. These data express the doctor’s judgment of the extent of impairment that might 

Seriousness result if no care were available. In keeping with 

of problem the average tendency among office-based practiSerious and very tioners, orthopedic surgeons judged most of 

serious,..., ... . ..... ...d.... 11,203 23.8 19.2 their patients’ probIems (3 of every 4) to range 

Slightly serious.,, .. .. . ... 18,137 38.5 32.3 

Not serious,, . ... .. .... .. .. . 17,813 37.8 48.5 

from slightly serious to not serious in prognosis. 

Data on disposition (table 6) show that 

Disposition scheduled followup-directed after 2 of every 3 

(selected actions) visits—is the rule with office-based orthopedic 

No followup ... . ..... ... .. . 4,969 10.5 12.3 surgeons as it is with all office-based practiReturn at specified tioners. Admission to the hospital, though sometime .... .. ... ..... . .. . ... ... . 31,261 66.3 60.2 

Return if needed., ... .. . 7,695 16.3 21.9 

Referred to other 

what more common in the office-based practice 

of the orthopedic surgeon than it is in overall � 

physician or agency.. 1,064 2<3 2.8 office-based practice , is still a rare event (3.5 

Admit to hospital ..,.... 1,646 3,5 2.1 percent of visits). 

The duration of visit (the portion of an 

office visit that involves face-to-face contact 

O minutes (no faceto-face contact with 

physician) .... ... ... ... ... . 517 1.1 1.8 

between patient and orthopedic surgeon) was 

under 16 minutes for about 70 percent of office 

1-5 minutes., .... ... .. .... . 7,801 16.6 15.1 visits (table 6). Agreeing closely with the finding 

6-10 minutes . .... .. .. ..... 13,672 29,0 31.5 

11-15 minutes ..... .. .. ... 11,650 24.7 26.6 

16-30 minutes . ..... .. . ... 11,132 23,6 19,5 

for all office-b ased practitioners, the average 

face-to-face encounter between patient and 

31 minutes or more ... . 2,378 5.0 5.5 orthopedic surgeon was probably about 15 

minutes in duration. 

113ased on an estimated 1.155.900.000 visits made to all 

uffice-based physicians in 1975 and 1“976.” 

NOTE: Figures may not add to totals due to rounding. 
dwmcdda5 

TECHNICAL NOTES 

q 

SOURCE OF DATA: The information presented 

in this report is based on data collected in the 

Nat ional Ambulatory Medical Care Survey 

(NAMCS) during 1975 and 1976. The target 

population of NAMCS encompasses office visits 

within the coterminous United States made by 

ambulatory patients to physicians not in Federal 

Service who are principally engaged in office 

practice and not in the specialties of anesthesiology, pathology, or radiology. 

SAMPLE DESIGN: NAMCS utilizes a multistage 

probability design that invoIves samples of 

primary sampling units (PSU’S), physician practices within PSU’S, and patient visits within 

practices. Each year a sample of practicing 

physicians is selected from master files maintained by the American Medical Association and 

the American Osteopathic Association. (This 

sample included 136 orthopedic surgeons in 

1975 and 140 in 1976.) These physicians are 

requested to compIete Patient Records (brief 

encounter forms) for a systematic random 

sample of office visits taking place within their 

practice during a randomly assigned weekly 

reporting period. A facsimile of the Patient 

Record used during 1975-76 is shown in a 

previous issue of Advance Data From Vital and 

Health Statistics, No. 12, October 12, 1977. 

Characteristics of the physician’s practice, such 

as primary specialty and type of practice, are 

obtained during an induction interview. A detailed description of the NAMCS design and 

procedures has been published in Series 13-No. 

33, Vital and Health Stat&ics, DHEW Pub. No. 

(PHS) 78-1784, Public Health Service, Washington, U.S. Government Printing Office, Dec. 

1977. 

SAMPLING ERRORS: Because the estimates 

for this report are based on a sample rather than 

on the entire universe, they are subject to sampling variability. The standard error is pnmm-ily 

a measure of sampling variability. The reIative 

standard error of an estimate is obtained by 

dividing the standard error of the estimate by 

the estimate itself and is expressed as a percent 

of the estimate. Relative standard errors of 

selected aggregate statistics are shown in tabIe 1. 

The standard errors appropriate for estimated 

percentages of visits are shown in table II. 

Table 1. Approximate relative standard errors of estimated number of office visits: United States, 1975-76 

Estimated number Relative 

of office visits standard error 

in thousands in percent 

600 ....................................... .................. 30.2 

1,000 ...................................................... 23.5 

2,000 ...................................................... 16.7 

4,000 ...................................................... 12.0 

10,000 .................................................... 8.0 

40,000 .................................................... 4.8 

200,000 .................................................. 3.4 

1,000,000 ............................................... 3.1 

.Example of use of table: An aggregate estimate of 25,000,000 

visits has a relative standard error of 6.4 percent or a standard 

error of 1,600,000 visits (6.4 percent of 25,000,000). 

Table II. Approximate standard errors of percentages of estimated 

number of office visits: United States, 1975-76 

Estimated percent 

Base of percent 

(number of visits 

in thousands) 

error in percentage points 

600 .. ... .. .. ... .. . .... . .. 3.0 6.5 9.0 12.0 13.8 15.0 

1,000 ................... 2.3 5.1 7.0 9.3 10.7 11.6 

2,000 ................... 1.6 3.6 4.9 6.6 7.5 8.2 

4,000 ................... 1.2 2.5 3.5 4.7 5.3 5.8 

10,000 ................. 0.7 1.6 2.2 2.9 3.4 3.7 

40,000 ................. 0.4 0.8 1.1 1.8 

200,000 ............... 13.2 0.4 0.5 ;:: ;:: o.8 

1,000,000 .... ........ ().1 0.2 0.2 0.3 0.3 0.4 

I Standard

Example of use of table: An estimate of 20 percent based on 

an aggregate estimate of 80,000,000 visits has a standard error of 

1.3 percent. The relative standard error of 20 percent is 6.5 percent (1.3 percent + 20 percent). 

DEFINITIONS: An ambulatoy patient is an 

individual presenting himself for personal health 

services who is neither bedridden nor currently 

admitted to any health care institution. 

An office is a place that the physician identifies as a location for his ambulatory practice. 

ResponsibiIit y over time for patient care and 

professional services rendered there generally 

resides with the individual physician, rather than 

an institution. 

A ZXMtis a direct personal exchange between 

an ambulatory patient and a physician or a staff 

member working, under the physician’s super-
6 ad?ancedata o 

vision for the purpose of seeking care and ren- based; physicians who specialize in anesthesidering health services. ology, pathology, or radiology; physiciarw who 

A physician is a duly licensed doctor of are federally employed; physicians who treat 

medicine (M.D.) or doctor of osteopathy (D. O.) only institutionalized patients; physicians 

currently in office-based practice who spends employed full time by an institution; and 

time in caring for ambulatory patients. Excluded physicians who spend no time seeing ambulatory 

from NAMCS are physicians who are hospital patients. 
---

o dmcedab7 

Recent Issues of Advance Data .Frorn Vital and Health Statistics 

No. 32. Sociodemographic and Health Characteristics Na. 29. A Compr@on of Nursing Home Residents and 

of Persons by Private Health Insurance f20ver- Discharges from the 1977 NationaI Nursing 

age and Type of Plan, United States, 1975 Home Survey: United States (Issued: May 17, 

(Issued: 1978) 

‘ No. 31,	 Office Vkits to Ophthalmologists: National 

Ambulatory Medical Care Survey, United 

States, 1976 (Issuedi No. 28. Office Visits for Hypertension: Nationaf Ambulatory Medicaf Care Survey, United States, No. 30.1976 Summary: National Ambulatory Medical January 1975-December 1976 (Issued: April Care Survey, United Skates (Issued: 28, 1978) I 

I A complete list of Advance Data From Vita/ and Health Statistics is available from the Scientific and Technical 

Information Branch. ~ 

I SYMBOLS 

I Rata not available----—––--------—---—-. 

I Category not applicable———---—–––- .,. 

Quantity zero---—--——–-–-—--—- -

Qwmtity more than Obut less than 0.05——— 0.0 

Figure does rmt meet standards of * reliability or precisian —--—-

I Data suppressed to comply with 

confidentiality requirements— —-...———. # 

GPo 931 398