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?%?OPERTY OF~~ *


PUBLICATION:
 3RAMN & 7

%y EDITORIALLIBRARY 

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

U.S. DEPARTMENT OF HEALTH, . Public Health Service


EDUCATION, AND WELFARE Office of Health Research, Statistics, and Technology Number 49 � April 16, 1979


Office Visits for Family~Planning, National Ambulatory 

Medical Care Survey: United States, 19771 

According to data collected in the National 

Ambulatory Medical Care Survey (NAMCS), an 

estimated 11 million visits to office-based physicians included a family planning service, either 

as one of the stated purposes of the visit or as an 

adjunct service when patients visited for other 

problems. 

The NAMCS is a sample survey conducted annually by the Division of Health Resources Utilization Statistics in the National Center for Health 

Statistics. The estimates in this report are based on 

information recorded by participating physicians 

on brief encounter forms (Patient Record, see Advance Data No. 48, April 13, 197 9) during sample 

office visits. A brief description of the sample design and an explanation of the sampling errors 

associated with selected aggregate statistics may 

be found in the Technical Notes of this report. 

Data on family planning services are also reported from the National Survey of Family 

Growth (NS FG), based on a sample of currently 

married women between the ages of 15 to 44 

years, with a family planning visit in the List 3 

years; and by the NationaI Reporting System for 

Family Planning Services (NRSFPS), based on 

reports by a sample of organized family planning 

service sites. *Y3Because of the differences in the 

lThis report was prepared by Beulah K. Cypress, 

Ph.D., Division of Health Resources Utilization Statistics. 

2National Center for Health Statistics: Use of 

family planning services by currently married women 

15-44 years of age, United States, 1973 and 1976, by 

G.E. Hendershot. Advance Data j?om Vital and Health 

Statistics, No. 45. DHEW Pub. No. (PHS) 79-1250. 

Public Health Service. Hyattsville, Md. Feb. 7, 1979. 

3National Center for Health Statistics, Provisional 

Data from the National Reporting System for Family 

pkmning Services, January 1976-December 1976, 

(mimeo). 

populations sampled, and differences in the 

definitions and collection procedures, statistics 

on family planning visits from these several data 

systems differ. According to NSFG statistics for 

1976, an estimated 11,153,000 women in the 

a~: range 1544 years had visited their own phy ­

slcmn within the last 3 years for family planning 

services. Provisional data from NRSFPS for 

1976 indicated about 5,427,000 visits by 

women of all ages to organized family planning 

clinics. 

In NAMCS, patients’ principaI problems, 

complaints, or other reasons for visit, expressed 

as nearly as possible in the patient’s own words, 

are recorded by the physician on the Patient Record. From 1973 to 1976 these reasons for visit 

were coded according to a symptom classification developed for use at the inception of the 

survey! However, this ckssification scheme did 

not provide much detail in the area of family 

pkmning. The opportunity to obtain more complete information was presented by the 1977 

revision of the c1assification,5 The new taxonomy delineated, among other presenting 

patient problems and complaints, the most 

commonly presented types of family planning 

reasons for visiting physicians -given by patients. 

4National Center for Health Statistics: The National Ambulatory Medical Care Survey: Symptom 

classification, by S. Meads and T. McLemore. Vital and 

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

(HRA) 74-1337. Health Resources Administration. 

Washington. U.S. Government Printing Office, May 

1974. 

5National Center for Health Statistics: A reason 

for visit classification for ambulatory care, by D. 

Schneider, L. AppIeton, and T. hlcLemore. Vital and 

Health Statistics. Series 2-No. 78. DHEW Pub. No. 

(PHS) 79-1352. Public Health Service. Washington. 

U.S. Government Printing Office. In press. 
2 

This permitted a clearer identification of fandy 

planning visits than was possible in earlier national surveys of ambulatory care in physicians’ 

offices. Also in 1977 for the first time, “family 

planning” was included in the therapeutic 

services listed on the Patient Record. 

In NAMCS, a family planning therapeutic 

service is defined as services, counseling, or 

advice which might enable patients to determine 

the number and spacing of their children. It includes both contraception and infertility services. Information from this item was used to 

estimate the number of visits which included 

family planning services even thou<gh the physician did not record that as the patient’s reason 

for visiting the physician. 

In about half of the 11 million family phmning visits patients expressed a reason for visiting 

the physician which was related to family pkmning. In the other half, reasons other than family 

planning were given but, in addition to other 

medical care, some kind of family planning 

therapeutic service was rendered during the visit 

(table 1). It is not known whether some patients 

were reluctant to say that family planning was 

their reason for the visit or whether the subject, 

Table 1. Number and parcent distribution of office visits for 

family planning with a family planning reason for visit or with 

a family planning therapeutic service included, by patient age 

and sex: United States, 1977 

Family planning visits 

Age and sex Reason for Therapeutic 

visit service 

stated included 

Total . . . . . . . 5,662 I 5,341 

& Percent distribution 

Alleges . . . . . 100.0 I 100.0 

15-19 years . . . . . 11.6 10.1 

20-34 years . . . . . 76.3 68.8 

354~ yaars . . . . . 10.0 10.2 

45 years and over . . “2.0 10.8 

— Sex

Female . . . . . . . . 

Male . . . . . . . . . 

possibly related to the presenting problem, arose 

during the course of the visit. But for the purpose of estimating the extent of utilization of 

private physicians for family planning services, 

these encounters were considered “family planning” visits. 

It was postulated that teenagers might be 

less inclined than older patients to cite family 

planning as a reason for going to the physician’s 

office. Apparently this was not the case since 

differences between the proportions of teenagers’ visits in which they cited a reason and 

those in which they simply received a service 

were not statistically significant. On the other 

hand, patients 45 years and over were less likely 

to give than not give family planning as a reason 

when they received a family planning service 

during the visit. This may or may not indicate 

that for this group of patients family planning 

was probably incidental to their purpose in 

visiting the physician. 

PATl ENT SEX, RACE, AND AGE 

The ratio of about 13 visits by women to 

one visit by men was not unexpected (table 2). 

However, the fact that about 791,000 family 

planning visits to physicians were made by men 

provides a new perspective on the traditionally 

female-oriented approach to discussion of family 

planning visits. Because of the paucity of data 

on family plmning visits by men, most published reports have dealt exclusively with visits 

by women. Unpublished data from NRSFPS 

reveal only about 39,000 visits by men in some 

4,800 organized family planning service sites 

during 1976.3 While the NAMCS visit rate of 

about 10 visits by men for each 1,000 males 

over 15 years in the population is quite low 

compared to that of females (about 122 per 

1,000), this may mark the beginning of a trend 

and bears scrutiny in the future. 

Available data sources indicate that white 

patients tend to visit private physicians for family planning services at a higher rate than black 

patients, while black patients visit organized 

family planning clinics at a higher rate than 

white patients do. Of the white female respondents in NS FG with a family planning visit 

in the last 3 years, 86 percent reported visiting 

a private physician; but only 63 percent of the 
9 admdata3 

Table 2. Number, percent distribution, and rate of office visits are higher when calculated for women only. A 

for family planning, by patient sex, race, and a9e: United forthcoming series report on “Office Visits by States, 1977 -

Women” wiIl include family planning data for 

Number 

I these groups.) 

Percent Visit rate in distri- per Sex, race, and age thou- bution 1,0001 

sands 

I 

GEOGRAPHIC DISTRIBUTION 

Total . . . . . . . 68:9 

Proportions of famiIy planning visits did not 

Sex differ significantly among the four geographic — 

regions when sampling variability was taken into 

Female . . . . . . . . 

Male . . . . . . . . . 

10,213 

791 

92.8 

7.2 

121.6 

10.5 account (tabIe 3), approximating the regional 

proportions of all NAMCS visits. Similarly, visits 

Race in metropolitan areas exceeded those in nonWhite . . . . . . . . . 

Black and all 

9,998 90.9 71.3 metropoIitan areas, reflecting the high concentration of physicians’ offices in metropolitan 

other . . . . . . . . 1,006 9.1 51.9 areas. 

Age 

15-19 years . . . . . 1,199 10.9 57.1 Table 3. Number, percent distribution, and rate of office visits 

35-44 years . . . . . 1,110 10.1 48.4 or nonmetropolitan area: United States, 1977 

45 years and over. . 695 6.3 10.6 

@ 1 Based on the civilian noninstitutionalized POPUkIthI 15 

Number 

in 

Percent Rate 

years and over. Region and area thou- distri- per 

20-34 years . . . . . 8,000 72.7 158.9 for family planning, by geographic region and metropolitan 

sands bution 1,000 

black respondents reported the location as the Total . . . . . . . 11,003 100.0 68.9 

physician’s office.z On the other hand, organized family planning clinics which reported to Region 

NRSFPS showed an enrollment rate of roughly 

144 per 1,000 black women 15-44 years of age 

in the population, compared ~vith only about 44 

Northeast . . . . . . 

North Central . . . . 

South . . . . . . . . . 

2589 

2,485 

3,553 

23.5 

22.6 

32.3 

70.6 

58.0 

68.1 

per 1,000 white women of the same age.3 The West . . . . . . . . . 2,377 21.6 85.0 

NAMCS data also discIosed a differing utiliza- Area 

tion pattern by race with white women visiting 

at a rate of 71 per 1,000, compared with 52 per Metropolitan. . . . . 9,019 82.0 82.7 

1,000 black and other women. The reader Nonmetropolitan . . 1,984 18.0 39.2 

should note that the NAMCS visit rate includes 

initial and return visits, some of which may be 

by the same patient; but the NRSFPS enrollment rate is based on an undupIicated count of PHYSICIAN SPECIALITY 

patients. 

Most family planning visits to office-based Most family planning visits (65 percent) ocphysicians were made by patients of both sexes curred in the offices of obstetrician+-ynecolin the age range 20-34 years (73 percent), rep- ogists, with an additional 26 percent made to 

resenting an average of about 159 visits for each general and family practitioners (GFP) (table 4). 

1,000 persons of that age in the United States Male patients chiefly visited GFP’s and urol9( table 2 ) . Patients aged 15-19 years accounted ogists. The patient’s age did not appear to make 

for about 11 percent of the total with a visit rate a difference in the choice of physician by speof about 57 per 1,000. (Visit rates by age groups cialt y. 

~ 
4 adwlncedata o 

Table 4. Number and percent distribution of office visits for family planning by most visited physician specialty, according to patient 

age and sex: United States, 1977 

Age and sex Number 

in Total 

thousands 

Alleges . . . . . 11,003 100.0 

Age

— 

15-19 years . . . . . 1,199 100.0 

20-34 years . . . . . 8,000 100.0 

35-44 years . . . . . 1,110 100.0 

45 years and 

over . . . . . . . . . 695 100.0 

Sex 

Female . . . . . . . . 10,213 100.0 

Male . . . . . . . . . 791 100.0 

PATI ENT’S R EASON 

FOR VISIT 

About 93 percent of the 5.7 million visits 

by patients who specifically stated they were 

visiting for family planning or related reasons 

fell chiefly in three major groups: those who 

visited for counseling, examinations, and general 

advice; those who required insertion, removal, 

or checkup of contraceptive devices; and those 

who visited for the prescription or renewal of 

contraceptive medication (table 5). (PredictPhysician specialty 

General 

and Obstetrics Urological All 

family and surgery other 

practice gynecology specialities 

25.8 I 64.8 3.1 6.3 

Percent distribution 

37.5 58.5 0.0 * 4.0 

23.1 69.3 *3.5 * 3.0 

‘28.0 *58.8 *4.6 8.6 

*32.7 �32.6 *I-.6 *33.1 

24.8 69.8 * 0.1 * 5.3 

*38.3 *42.O *19.7 

ably, it was observed that teenagers were proportionately more likely to visit for contra- � 

ceptive medication than they were for a contraceptive device.) 

Surgical sterilization of patients of both 

sexes was performed during the visits for a relatively smalI number of patients. Of the estimated 240,000 such visits, about 80 percent 

were for vasectomies. Patients electing sterilization ranged from 20 to 44 years of age. 

Patients who visited seeking abortions or 

for whom abortions were performed during 

Table 5. Number and percent distribution of office visits with a family planning reason for visit by reason category: United States, 1977 

Number in Percent 

Reason category and NAMCS codel I thousands I distribution 

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,662 100.0 

Family planning, N.0.S.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X500 2,085 36.8 

Contraceptive device3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. X510 1,604 28.3 

Contraceptive medication . . . . . . . . . . . . . . . . . . . . . . . . .. . . . ..X505 1,569 27.7 

Other reasons forvisit4. . . . . . . . . . . . . . . . . . . X515, X520, X525, X530 405 7.1 

l~ased on a reason for visit ~las.qification developed for use in NAMCS(seereference 5).


21ncludes counseling, examinations, and generaladviceregarding; birth control, N.O.S.; unwanted weWMICY; Contraceptive> N-o-s.;


sterilization; infertility y; genetics; contraception followup, N.O.S. 

31nc]u&s IUD insertion, removal, or checkup; diaphragm insertion, removal, or checkup. a 

41nchsdes evaluation for and arrangement for abortion, wants abortion, sterilization (this visit), abortion (this visit), and artificial 

insemination. 

NOTE:N.O.S.= not otherwise specified. ?4 
� 

Table 6. Number and percent distribution of office visits which included a family planning therapeutic sewice but not a family planning 

reason for visit, by most common principal reason for visit: United States, 1977 

I 

Principal reason for visit and NAMCS codel Number in 

thousands 

Percent 

distribution 

I I 

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 5,341 I 100.0 

I 

I 

Gynecological examination.. . . . . . . . . . . . . . . . . . . . . . . . . ..X225 864 18.1 

Postpartum examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..X215 902 16.9 

Prenatal examination, routine. . . . . . . . . . . . . . . . . . . . . . . . . ..X205 787 14.7 

Symptoms referable tothegenitourinary system. . . . . . . . . . . . . S640-S829 668 12.5 

Pap smear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. X365 � 336 6.3 

Another reasons forvisit . . . . . . . . . . . . . . . . . . . . . . . . . . . residual 1,684 31.5 

lBased on a reason for visit classification developed for use in NAMCS (see reference 5). 

the visit were relatively rare in physicians’ The rate of Pap tests performed during famoffices. ily pkuming visits in physicians’ offices (about 

It was posited that for the 5.3 million visits 46 percent) was simik.r to that of the organized 

in which patients received a family planning family planning clinics measured by NRSFPS.3 

therapeutic service without having directly However, blood pressure checks were proexpressed family planning as their reason for portionately more frequent during clinic visits


visit, the primary reasons would cover the (about 78 percent) than they were during


broad array of problems usually found in office physician visits estimated in NAMCS (about 58


medical practice (e.g., respiratory or circulatory percent).


problems). However, those visits were more Patient age was apparently not a determining


likely to be associated with reasons involvbk factor in the physician’s provision of services,


certain examinations and care of genitourinary since for each service shown in table 7 the differ-


problems than they were with reasons related


to other problems. The types of care sought by
 Table 7. Number of NAMCS visits and number and percent of

patients who also received family pkmning thera- family planning office visits for patients 15 years and over, 

peutic services are listed in tabIe 6. It is of in- by most common diagnostic and therapeutic service: United 

terest to note that 15 percent of these visits States, 1977 

were for routine prenatal examinations and 17 I t 

All I

Family

that family planning was likely to be a consider- therapeutic service visits visits 

ation both during pregnancy and following 

delivery. Total . . . . . . . . . . . . . . . . . . 466,296 11,003 

Percent of visits 

DIAGNOSTIC AND Limited examination and/or history . . 57.6 49.5 

THERAPEUTIC SERVICES General examination and/or history . . 20.2 36.2 

Pap test . . . . . . . . . . . . . . . . . . . 6.5 45.8 

Compared to NAMCS visits for all reasons, 

patients visiting for family pkmning received 

Clinical laboratory test. . . . . . . . . . 

8100d pressure check. . . . . . . . . . . 

Drugs (prescription and 

22.4 

40.0 

33.9 

58.2 

percent for postpartum examinations, indicating Most common diagnotic and NAMCS planning 

proportionately more Pap tests, blood pressure nonprescription). . . . . . . . . . . . . 54.5 42.8 

Diet counseling . . . . . . . . . . . . . . 7.2 7.7 checks, clinical laboratory tests, and general Medical counseling . . . . . . . . . . . . 20.9 22.1 

examinations (tabIe 7). 
---

-------

ences in the proportions by age were not statistically significant. However, the patient’s reason 

for visit may have influenced the use of some 

services during some visits. General examinations, Pap tests , and cIinical Laboratory tests 

were proportionately more frequent when 

patients visited for contraceptive medication 

than when a contraceptive device was involved 

(table 8). However, Pap tests are usually performed at a visit prior to the insertion of a contraceptive device and, thus, such tests may have 

been included in a visit with a different reason. 

Differences in the proportions of other services 

were not statistically significant. 

Table 8. Number and percent of visits for contraceptive medication and for contraceptive device, by selected diagnostic services: United 

States, 1977 

I I 

Diagnostic sewice Contraceptive Contraception 

medication device 

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Limited examination and/or historv . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

General examination and/or history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Paptest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Clinical laboratory test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Blood pressure check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

1,569 1,604 

Percent of visits 

49.1 66.3 

37.4 *14.6 

66.9 *24.O 

36.0 *14.4 

57.9 36.6 

SYMBOLS 

Data not available-------–----–---–—---------

Category not applicable ----------------------

Quantity zero----—-—----------— 

Quantity more than Obut less than 0.05-—-

Figure does not meet standards of 

“reliability or precision---—----------—--—­

. . . 

-

0.0 

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~7 

TECHNICAL NOTES 

SOURCE OF DATA: The information presented 

in this report is based on data colIected in the 

NationaI Ambulatory Medics.I Care Survey 

(NAMCS) during 1977. The target population of 

NAMCS encompasses office visits within the 

conterminous United States made by ambulatory patients to physicians who are principality 

engaged in office practice. The National Opinion 

Research Center, under contract to the NationaI 

Center for HeaJth Statistics, was the organization responsible for the survey’s fieId operations. 

SAMPLE DESIGN: NAMCS utilizes a multistage 

probability design that involves samples of primary sampling units (PSU’S), physician practices 

within PSU’S, and patient visits within practices. 

For 1977 a sample of 3,000 non-Federal officebased physicians was selected from master files 

maintained by the American Medical Association and American Osteopathic Association. The 

physician response rate for 1977 was 77.5 percent. Sample physicians were requested to complete Patient Records (brief encounter forms) 

for a systematic random sample of office visits 

taking place within their practice during a 

randomly assi<gned weekly reporting period. 

During 1977, 51,044 Patient Records were compIeted by sample physicians. 

SAMPLING ERRORS: The standard error is’ 

primarily a measure of the sampling variability 

that occurs by chance because onIy a sample, 

rather than the entire universe is surveyed. 

The relative standard error of an estimate is 

obtained by dividing the standard error of the 

estimate by the estimate itself and is e:ipressed 

as a percent of the estimate. Relative standard 

errors of selected aggregate statistics are shown 

in table I. The standard errors appropriate for 

estimates percentages of visits are shown in 

table II. 

DEFINITIONS: An ambulahxy patient is an 

individual presenting himseIf for personal health 

services who is neither bedridden nor currently 

admitted to any health care institution on the 

premises. 

An office is a place that the physician 

identifies as a lo~ation for his ambulatory practice. Responsibihty over time for patient care 

and professional services rendered there generally resides with the individual physician, rather 

than an institution. 

Table 1. Approximate relative standard error of estimated number of office visits, NAMCS 1977 

Estimated number of office Relative standard 

visits in thousends error in percent 

500. . . . . 29.0 

600 . . 26.5 

1.ooo . . 20.7 

2.000 . . . 14.9 

5.000 . 9.9 

1o.ooo. . . 7.6 

20.000 . . . 6.1 

50.000 . . . 4.9 

1oo.ooo . 4.5 

5oo.ooo . . 4.1 

Example of use of table: An aggregate estimate of 75,000,000 

visits has a relative standard error of 4.7 percent or a standard 

error of 3,525,000 visits (4.7 percent of 75,000,000). 

Table 11.Approximate standard errors of percentages of estimated 

number of office visits, NAMCS 1977 

Base of percentage 

number of visits 

in thousands 

m 

Standard error in percentage points 

500 . 2.9 6.3 8.6 11.5 13.2 14.4 

600 . 2.6 5.7 7.9 10.5 12.0 13.1 

1,000 . 2.0 4.4 6.1 8.1 9.3 10.2 

2,000 . . 1.4 3.1 4.3 5.7 6.6 7.2 

5,000 .. . 0.9 20 2.7 3.6 4.2 4.5 

10,000. . . 0.6 1.4 1.9 2.6 2.9 3.2 

20,000 . . 0.5 1.0 I.4 1.8 2.1 2.3 

50,000. . .. 0:3 0.6 0.9 1.1 1.3 I.4 

100,000 . . 0.2 0.4 0.6 O.B 0.9 1.0 

500,000 . . ().1 0.2 0.3 0.4 0.4 0.5


Example of use of table: An estimate of 30 percent based on 

an aggregate of 15,000,000 visits has a standard error of 2.5 percent. The relative standard error of 30 percent is 8.3 percent (2.5 

percent + 30 percent). 

A visit is a direct personal exchange between 

an ambulatory patient and a physician or a staff 

member working under the physician’s supervision for the purpose of seeking care and rendering heaJth services. 

A physician is a duly licensed doctor of 

medicine (M.D.) or doctor of ostepathy (D. O.) 

currently in office-based practice who spends 

time in caring for ambulatory patients. Excluded 

from NAMCS are physicians who are hospital 

based; physicians who specialize in anesthesiology, patholoCgy, or radiology; physicians who are 

federaIIy employed; physicians who treat only 

institutionalized patients; physicians empIoyed 

full time by an institution; and physicians who 

spend no time seeing ambulatory patients. 
Recent Issues of Advance Data From Vital and Health Statistics 

No. 48.1977 Summary: National Ambulatory Medical No. 45. Use of Family Planning Services by Currently 

Care Survey (Issued: April 13, 1979) Married Women 15-44 Years of Age: United 

States, 1973 and 1976 (Issued: 

No. 47. Prevalence, Dkability, and Health Care for 

Psoriasis Among Persons 1-74 Years: United No. 44. Health Care Coverage: United States, 1976 (In 

States (Issued: April 3, 1979) preparation) 

No. 46.	 Hemoglobin and Selected Iron-Related Findings of Persons 1-74 Years of Age: United 

States, 1971-74 (Issued: January 26, 1979) 

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

Information Branch. 

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