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PROPERIY OF Tl#’ 

FWBLICATKXWB 

EDITORIAL IJBRAF!Y 

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

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE � Public Health Service I Number 16 � February 7, 1978 

Off ice Visits to Internists: 

National Ambulatory Medical 

According to data collected in the National the relative standard errors associated with 

Ambulatory Medical Care Survey (NAMCS), an selected aggregate statistics may be found in the 

estimated 62,117,000 visits were made to the Technical Notes. A copy of the Patient Record 

offices of internists during calendar year 1975. appears in an earlier report. 2


These visits accounted for almost 11 percent of


the estimated total visits made to all office-based


m physicians in 1975. 

The NAMCS is a sample survey designed to DATA HIGHLIGHTS 

explore the provision and utilization of ambulatory care in the physician’s office–the setting Comparison of visits made to office-based 

where most Americans seek health care. The sur- physicians in the five most visited specialties 

vey is conducted yearly over the coterminous shows that visits to internists were exceeded 

United States by the Division of Health Re- only by the number of visits made to general 

sources Utilization Statistics of the National and family practitioners (table 1). 

Center for Health Statistics. The survey sample 

is selected from doctors of medicine and osteopathy who are engaged in office-based, patient 

care practice. In its current scope, the NAMCS Table 1. Number and percent of visits to 

excludes physicians practicing in Alaska and off ice-based physicians, by selected 

physician specialties: Hawaii; physicians whose specialty is anesthesi- January-December 1975 

O1OW, ~atholosw, or radiolo~; and physicians in “.-A 

Government se-~ice. ‘“ “ -

Care Survey, United States, 1975’


Definitions of terms used in the survey and a 

detailed explanation of the sample design and 

1This report was prepared by Beulah K. Cypress, 

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

2Nation~ Center for Health Statktics: Ambulatory 

medical care rendered in physicians’ offices: United 

States, 1975. Advance Data From Vital and Health Sta­

@ tistics, No. 12, DHEW Pub. No. (HRA) 77-1250. Health 

Resources Administration. Hyattsville, Md., Oct. 12,1977-

Selected 

specialty 

General and family 

practice 

Ink?ynal medicine 

Obstetrics and 

gynecology 

Pediatrics 

General surgery 

United States, 

Number 

of Per -

visits cent 

in of 

thou - visits 

sands 

234,660 41.3 

62,117 10.9 

48,076 8.5 

46,684 8.2 

41,292 7.3 
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* 

2 adwlncedata 

Table 2. Number, percent distributions, and annual rate of visits to office-based in­


ternists by type and location of practice, and age, sex, and color of patient:United


States, January-December 1975


Selected physician and


patient characteristics


All visits


Type of practice


solo


Other~----------------------------------


Location of practice3


Metropolitan ----------------------------


Nonmetropolitan -------------------------


A&g


Under 15 years


15-24 years


25-44 years


45-64 years


65 years and over


~


Female


Male


Color


White


All otherl


Number of


visits in


thousands


62,117


33,706


28,411


52,543


9,574


2,047


5,474


13,106


23,565


17,925


36,978


25,139


56,438


5,679


Percent


distributions


of vtsits


100.0 

54.3


45.7


84.6


15.4


ii:: 

21.1


37.9


28.9


59.5


40.5


90.9


9.1


Annual rate


of visits


per 100 in


population


. . . 

. . . 

. . . 

37


14


35


25


31


21


lBased on population estimates for July 1,1975: Bureau of the Census, Current Popu­


lation Reports, Series P-25 and P-26.


‘Includes partnership and group practices. 

3Signifies location within or outside the standard metropolitan statistical areas (34SA’S). 

40f this category about 82 percent are visits by black persons. 
o 

adwme&b3 

Type and Location of Practice 

About 54 percent of visits to internists were 

to those in solo practice (table 2). This is a 

direct reflection o! the fact that about 52 percent of the internists in the NAMCS sample were 

estimated to have been engaged in solo practice. 

Table 2 also shows that 85 percent of the 

visits to internists were to offices located within 

standard metropolitan statistical areas 

(SMSA’S),3 a probable number since about 70 

percent of the population reside within SMSA’S. 

However, the visit rate was more than twice as 

high for visits to offices in metropolitan locations 

(37 visits for each 100 persons in metropolitan 

areas). This may signify an inclination for some 

of the population outside of SMSA’S to visit 

internists within SMSA’S. 

� Age, Sex, and Color of Patient 

Information derived from table 2 indicates 

that the number of office visits to internists increased with advancing age to age 65 years, the 

greatest number occurring in the age interval 

from 45 to 64 years; and a very small number 

(about 3 percent) representing the group under 

15 years of age. The a.rnmd rate of visits also 

shows a steady increase with age across all age 

groups. 

Two of three visits were made by females, as 

shown in table 2. This is partly explained by the 

fact that females (51 percent) outnumbered 

males (49 percent) in the general population. 

However, the tendency of females to visit the 

internist more often is demonstrated by their 

higher rate of annual visits. Fi@re 1 illustrates 

the influence of sex and age on the annual visit 

3An SMSA is defried as a gToup of contiguous 

counties containing at least one city of 50,000 inhabitants 

or more, or two contiguous cities with a combined population of at least 50,000 inhabitants. The distinction 

“metropolitan/nonmetropolitan” should not be confused 

with “urban/suburban” or “urban/rural” since an SMSA 

may contain urban, suburban, and rural sub sect ions. 

rate. The annual rate of female visits exceeded 

the annual rate for males in every age category 

except under 15 years. The difference became 

greater after the age of 44, with the largest difference in annual rate between females and 

males occurring in the age group 65 years and 

over. 

Figure 1. ANNUAL RATE OF VISITS TO INTERNISTS 

PER 100 IN POPULATION BY SEX AND AGE OF 

PATIENT. UNITED STATES, JANUARY-DECEMBER 

1975. 

100 

r 

n Male = Female 

AGE OF PATlENT IN YEARS 

Vkits by white persons (91 percent) outnumbered visits by all others (9 ~ercent) to L 

internists, paralleling to some degree the population ratio. However, the average annual rate of 

office visits was ako higher for white persons—31 

visits for each 100 white persons in the population were made to internists’ offices, whereas 

members of other races visited at a rate of 

21 out of 100. These data are similar to percentages found for general and family practitioners 

and could indicate that members of other races 

avail themselves more often of other means of 

ambulatory medical care since the NAMCS includes only office-based care. 
-------------

4


Table 3. Number and percent of visits to


office-based internists, by sex and


color of patient: United States, Jan-


uary-December 1975


Color of patient Female Male


~& 

The domination of the intemkt’spatient


load by the white female is illustrated
 in the 

matrixshown intable3. 

Patient’s Major Complaint, Symptom, 

or Other Reason for Visit 

The dataintable4arederivedfrom anitem


on the surveyform which elicits
 the reasonfor


visit
recordedby the physicianasnearlyaspos­


sibleinthe patient’s
 own words.The symptoms


presentedby patientscovereda broadspectrum


Table 4. Number, percent, and cumulative percent of visits to office-based internists,


by the 20 most frequent patient problems, complaints, or symptoms: United States,


January-December 1975


20 most frequent patient problems,
 Rank complaints, or symptoms and NAMCS code~


General and required physical


examinations-----------------------9OO,9Ol


Pain in chest---------------------------322


Problems of lower extremity-------------4OO


Fatigue---------------------------------OO4


Abdominal pain--------------------------540


High blood pressure---------------------2O5


Problems of back region-----------------4l5


Cough-----------------------------------311


Problems of upper extremity-------------4O5


Vertigo—dizziness----------------------O69


Shortness of breath---------------------306


Headache--------------------------------056


Throat soreness-------------------------52O


Diabetes mellitus-----------------------991


Cold------------------------------------3l2


Visits for medication-------------------910


Nervousness-----------------------------810


Problems of face, neck -----410


Allergic skin reactions-----------------ll2


Other symptoms referable to cardiovas­


cular system---------------------------220


Number of Percent Cumulative


visits in of percent of


thousands visits visits


3,455 

2,834 ::: 1;:! 

2,724 4.4 14.6 

2,460 4.0 18.6 

2,292 3.7 22.3 

1,823 2.9 25.2 

1,756 2.8 28.0 

1.694 2.7 30.7 

1;500 2.4 33.1 

1.427 2.3 35:4 

1;365 2.2 37.6 

1,262 2.0 39.6 

1,137 1.8 41.4 

1,072 1.7 43.1 

960 1.6 44.7 

884 1.4 46.1 

831 47.4 

749 ::; 48.6 

716 1.2 49.8 

672 1.1 50.9 

lSymptomatic groupings and code number inclusions are based on a symptom classifi­


cation developed for use in the NAMCS.

5


of probIems since the 20 most common reasons 

for visit constituted only about half of all visits. 

Principal Diagnosis4 

Table 5 lists the 20 most common principal 

diagnoses assigned by internists to office visits. 

4Principal diagnosis is the first diagnosis listed by the 

physician on the Patient Record. 

These diagnoses covered about one-half of all 

visits made to office-based internists in 1975. 

Table 6 shows the number of principal diagnoses according to major ICDA groups.5 The 

5National Center for Health Statistics: Eighth Revision International Classification of Diseasm, Adapted for 

Use in the United States (l CDA). PHS Pub. No. 1693. 

Public Health Service. Washington. U.S. Government 

Printing Office, 1967. 

Table 5. Number. percent, and cumulative Percent of visits to office-based internists 

by the 20 most-common-ICDA 3-digit ca~egories containing the principal diagnosis: 

United States, January-December 1975 

� Rank


11 

12


:: 

15


16


17


18


19


20 

20 most common ICDA 3-digit Number of percent Cumulative


visits in of percent
 categories and codel thousands visits of visits


Essential benign hypertension-----------4Ol


Chronic ischemic heart disease----------4l2


Diabetes mellitus-----------------------25O


Medical or special examination----------yOO


Acute upper respiratory infection-------465


Neuroses--------------------------------3OO


Osteoarthritis and allied conditions----7l3


Symptomatic heart disease---------------427


Medical and surgical aftercare----------ylO


Rheumatoid arthritis and allied


conditions-----------------------------712


Obesity---------------------------------277 

Observation, without need for further 

medical care ---------------------------793 

Emphysema-------------------------------492 

Hay fever-------------------------------507


Other eczema and dermatitis-------------692


Other nonarticular rheumatism-----------7l7


Synovitis, bursitis, and tenosynovitis--731


Arthritis, unspecified------------------7l5


Symptoms referable to respiratory


system------.--------------------------783


Bronchitis, unqualified-----------------490


5,781


4,894 17.2


2,777 21.7


2,566 25.8


1,588 28.4


1,430 30.7


1,414 33.0


1,253 35.0


1,101 36.8


1,011 38.4


983 40.0


838 41.3


837 42.6


749 43.8


746 45.0


727 46.2


662 47.3


628 48.3


614 49.3


577 50.2


lDiagnostic groupings and code number inclusions are based on the Eighth Revision


International Classification of Diseases, Adapted for Use in the United States.


9.3 
----------------------------

� 

6 admncedata 

Table 6. Number and psrcent distribution of visits to office-based internists by


P?&ipal diagnosis classified by major ICDA groups: United States,January-December


Principal diagnosis classified by ICDA group and codel


All principal diagnoses


Infective and parasitic diseases -------------- ----000-136 

Neoplasms ---------------- -------------------------140-239 

Endocrine, nutritional , and metabolic diseases----240-279 

Diseases of the blood and blood-forming organs----280-289 

Mental disorders----------------------------------29O-3l5 

Diseases of the nervous system and sense organs---320-389 

Diseases of the circulatory system----------------39O-458 

Diseases of the respiratory system----------------46O-5l9 

Diseases of the digestive system- -----------------52O-577 

Diseases of the genitourinary system--------------58O-629 

Diseases of the skin and subcutaneous tissue------68O-7O9 

Diseases of the musculoskeletal system and 

connective tissue--------------------------------7lO-738


Symptoms and ill-defined conditions---------------78O-796


Accidents, poisonings, and violence---------------8OO-999


Special conditions and examinations without


sickness -----------------------------------------YOO-Y13


Other diagnoses, “none,” and unknownz --------------------


Percent
 Number of
 distribu­
 visits in tion of
 thousands
 visits


62,117 100.0 

1,737 2.8 

2,310 

5,678 ::; 

760 

2,250 M 

2,033 

15,436 2;:: 

7,295 11.7 

3,422 5.5 

2,327 3.8 

1,597 2.6 

5,332 8.6 

4,085 

2,674 ::! 

4,317 7.0 

865 1.4 

lDiagnostic groupings and code number inclusions are based on the Eighth Revision


International Classification of Diseases, Adapted for Use in the United States.


‘630-678, Complications of pregnancy, childbirth, and the puerperium; 740-759, Con-


genital anomalies; blank, noncodable, and illegible diagnoses.


following four diagnostic groups accounted for 

over 54 percent of all principal diagnoses 

rendered, with almost half of these included in 

diseases of the circulatory system: diseases of 

the circulatory system; diseases of the respiratory system ;endocrine, nutritional, and metabolic diseases; and diseases of the musculoskeletal system and connective tissue. 

Diagnostic and Therapeutic Services 

Blood pressurechecks were provided in over 

61 percent of all visits, and EKG’s were performed in 14 percent of visits to the internist 

(table 7). Only 33 percent of visits to all officebased physicians included blood pressure checks, 

with an EKG performed in only 3percent ofall 

visits, reflecting the high degree of diseases of 

the circulatory system diagnosed by internists. 

Almost half of all visits to the internist resulted 

in a drug administered or prescribed. Medical 

counseling was included in almost 18 percentof 

the visits to the internist, about 6 percent more o than to all office-based physicians. 
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ackmdaa7 

Table 7. Number and percent distribution of visits to office-based internists, by diagnostic and therapeutic services ordered or provided: United States, JanuaryDecember 1975 

Number of Diagnostic and therapeutic services ordered visits in_ percent of or providedl thousands visits 

All visits--------------------------------------- 62.117 100.0 

No services provided----------------------------------- 832 1.3 

Diagnostic services


Litnited history or examination ,132 61.4 

General history or examination ,498 20.1 

Clinical lab test-------------------------------------- ,893 38.5 

X-ray------- ,131 13.1 

Blood pressure check----------------------------------- ,156 61.4 

EKG---------------------------------------------------- ,663 14.0 

Hearing test------------------------------------------- 932 1.5 

Vision test-------------------------------------------- ,465 2.4 

Endoscopy. . ---------------------------------------------- ,005 1.6

Therapeutic services 

Drug administered or prescribed2----------------------- 30,761 49.5 

Injection 7,209 11.6 

Immunization or desensitization 1,596 2.6 

Office surgery----------------------------------------- 905 

Physiotherapy 701 ::? 

Medical counseling------------------------------------- 11,078 17.8 

psychotherapy or therapeutic listening----------------- 1,667 2.7 

Other services provided-------------------------------- 1,075 1.7 

lpercentswill not add to 100 because most patient visits required the provision of
 more than one treatment or service.


21ncludes prescription and nonprescription drugs.


Prior Visit Status and Seriousness Tables 8 and 9 also provide data that exof Probiem press the physician’s judgmental to the extent 

of impairment that might result if no care were 

Data from tables 8 and 9 indicate that available for the given problem. They shouIdbe 

about 7 of 8 visits to internists were by re- viewed in the context of the specialist’s practice. 

turning patients, with continuing problems pre- About 71 percent ofallvisits werejudged by 

sented by 6 of 8patients the physician had seen the internist as either not serious or slightly seribefore. The greater the age of the patient, the ous. However, the tendency to judge cases as 

o ,greate rwasthetendency to visit with arecurring belonging in the more serious category increased 

problem. with advancing age ofthepatient. 
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� 

8dmcedda 

Table 8. Number and percent distributions of visits to office-based internists by


prior visit status, seriousness of problem, disposition of visit, and duration of


visit: United States, January-December 1975


Selected visit characteristics


All visits


Prior visit status


Patient seen for the first time


Patient seen before for another problem


Patient seen before for current problem


Seriousness of problem


Serious and very serious


Slightly serious


Not serious


Disposition


No followp


Return at specified time


Return if needed


Telephone followup


Referred to other physician/agency


;~nizto hospital
 -


Duration of visit3


O minute (no face-to-face encounter with physician) --------


1-5 minutes


6-10 minutes


11-15 minutes


16-30 minutes


31 minutes or more


Number of


visits in


thousands


62,117


8,122


12,995


41,000


17,751


20,883


23,484


5,635


42,467


10,248


3,099


2,751


1.037


’890


420


3.504


15;381


22,110


15,293


5,410


Percent of


visits


100,0 

13.1


20.9


66.0


28.6


33.6


37.8


16.5


::.!!


H


24:8


35.6


24.6


8.7


lPercents will not add to 100 because some patient visits had more than one dispo­


sition.


zIncludes return to referring physician.


sSi~ifies time spent in face-to-face encounter between physician and patient.

--------------------- ------------------------

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-----------------------------

a&medaa9 

Table 9. Number and percent distributions of visits to office-based internists by prior visit status and seriousness of ,.rnbh?~.


according to age, sex, and color of patient: LlnitedStates, January-December 197s


IWmber of
 Age, sex, and color of patient visits in
 thousands


All visits------------------- 62>117


Age
 —


Under 15 years 2,047
 15-24 years 5,474
 25-44 years 13,107
 45-64 years 23,565
 65 years and over------------------ 17,925


Sex
 —


Female 36,978
 Male------------------------------- 25,139


color 

fiite------------------------------ 5;,:;:
 All otherl-------------------------


Prior visit status Seriousness of problem 

Percent 

distribu- Patient seen before tion of visits Pa~’chgeer Serious 

or very Slightly Not 

first time ?or another For current serious serious serious 

T problem problem 

20.9 66.0 28.6 33.6 37.8


40.C 31.3 10.6 27.3 62.2
 32.2 36.8 12.0 28.2 59.9
 23.7 56.8 20.6 33.0 46.5
 19.0 71.5 32.5 33.6 34.0
 15.8 78.5 36.5 36.5 27.0


21.2 66.6 26.8 34.9 38.3
 20.5 65.2 31.3 31.7 37.0


20.9 66.6 28.8 33.9 37.3
 21.2 60.6 26.3 31.1 42.7


100.0 28.7
 100.0 31.0
 100.0 19.4
 100.0 9.6
 100.0 5.8


100.0 12.2 100.0 14.3 

100.0 12.6
 100.0 18.2


‘Of this category about 82 percent are visits by black persons.


Disposition and Duration of Visit 

Over two-thirds of the visits to internists’ 

offices resulted in the direction to return at a 

specified time (table 8), highly correlating with 

the fact that 2 of 3 visits were made by returning patients with recurring probIems. Like 

the general and family practitioner, the internist 

admittccl a ve~ small percentage of his patients 

to the h<)spitzd (sIightly less than 2 percent). 

“~hc average visit to the internist’s office 

lasted 18.2 minutes, y~hich exceeded the average of 15.0 minutes for all speciaIties.6 

6see reference cited in footnote Z. 
.....................................

10 acimncedata 

TECHNICAL NOTES 

SOURCE OF DATA: Data presented in this re- mate. Relative standard errors of selected aggreport were obtained during 1975 through the gate statistics are shown in table I. The standard 

Nat ion al Ambulatory Medical Care Survey errors appropriate for the estimated percentages 

(NAMCS). The target population of NAMCS en- of office visits are shown in table II. 

compasses office visits within the coterminous 

United States made by ambulatory patients to 

physicians who are principally engaged in office Table 1. Approximate relative standard errors Of estimated numbers of office visits 

practice. 

SAMPLE DESIGN: The 1975 NAMCS utilized a 

multistage probability design that involved sam- Estimate Relative standard 

in error in 

ples of primary sampling units (PSU’S), physi- thousands percentage points 

cian practices within PSU’S, and patient visits 

within practices. Within the 87 PSU’S co~mposing 500 .......................................... 30.1 

the fii-st stage of selection, a sample of approxi- 1,000 . . 21.4 

mately 3,500 physicians was selected from mas- 2,000....................................... 15.3


ter files maintained by the American Medical 5,000 ...... ................................. 10.0


10,000 .................... ................. 7.5


Association and the American Osteopathic Asso- 30,000..................................... 5.1


ciation. Sampled physicians, randomly assigned 100,000................................... 4.0 

to 1 of the 52 weeks in the survey year, were 550,000................................... 3,5 

requested to complete Patient Records (brief en- Example of use of table: An aggregate of 80,000,000 has a 

counter forms) for a systematic random sample relative standard error of 4.3 percent or a standard error of 

3,440,000 (4.3 percent of 80,000,000). of office visits taking place within their practice


during the assigned reporting period. (A fac­


simile of the Patient Record used is shown in a


rneted numbers of office visits 

Health Statistics, No. 12, October 12, 1977.) 1 

Additional data concerning physician practice 

characteristics such as primary specialty and 

type of practice were obtained during an inducEstimated percentage Base of percentage 

(number of visits 1 or 5 or 10or 20 or )0 or in thousands) 99 95 90 80 70 

50 

tion interview. tl--

A complete description of the survey’s backprevious issue of Advance Data From Vital and Table II. Approximate standard errors of percentages for asti­


ground and development has been presented in 1,000..................... 2.1 4.6 6.3 8.5 9.7 10.6 

an earlier publication in Series 2 of Vital and	 3,000..................... 1.2 2.7 3.7 4.9 5.6 6.1 

5;000..................... 0.9 2.1 2.8 3.8 4,3 4.7 Health Statistics (No. 61. DHEW Pub. No. 10,000 ................... 0.7 1.5 2.0 2.7 3.1 3.3 

(HRA) 76-1335. Health Resources Administra- 50,000 ......... ...... .... 0.3 0.7 0.9 1.2 1.4 1.5 

tion. Washington. U.S. Government Printing 100,000, ........... ..... 0.2 0.5 0.6 0.8 1.0 1.1 

500,000 ... .......... .... 0.1 0.2 0.3 0.4 0.4 0.5 Office, Apr. 1974). A detailed description of the 

1975 NAMCS design and procedures will be Example of use of table: An estimate of 30 percent based on 

presented in future publications. an aggregate of 75,000,000 has a standard erro; of 1.2 percent. 

The relative standard error of 30 percent is 4.0 percent (1.2 per- SAMPLING ERRORS: Since the estimates for cent+30 percent). 

this report are based on a sample rather than the 

entire universe, they are subject to sampling variability. The standard error is primarily a measure ROUNDING: Aggregate estimates of office visits 

of sampling variability. The relative standard er- presented in the tables are rounded to the nearror of an estimate is obtained by dividing the est thousand. The rates and percents, however, 

standard error of the estimate by the estimate were calculated on the basis of original, unitself and is expressed as a percent of the esti- rounded figures. Due to rounding of percents, 
---------- ---

o


admceMa 11 

the sum of percentages may not equal 100.0 per-


cent.


DEFINITIONS: An ambulatory patient is an in­


dividual presenting himself 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 location for his ambulatory practice. 

Responsibility over time for patient care and 

professional services rendered there generally resides with the individual physician rather than 

an institution. 

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 health services. 

A physician is a duly licensed doctor of medicine (N1.D.) or doctor of osteopathy (D. O.) currently in practice who spends time in caring for 

ambr.datory patients at an office location. Excluded from NAMCS are physicians who specialize in anesthesiology, pathcdogy, radiology; 

physicians who are federally employed; physicians who treat only institutionalized patients; 

physicians employed full time by an institution; 

and physicians who spend no time seeing ambulatory patients. 

SYMBOLS 

Data not available—-—--————— 

Category not applicable––--–—--–-–——- . . . 

Quantity zero-------—-----—–----—---––– -

Quantity more than O but less than 0.05—- 0.0 

Figure does not meet standards of * reliability y or precision-———— 

I 

Recent Issues of Advance Data From Vital and Health Statistics 

No. 15.	 National Ambulatory Medical Care Survey of No. 13. ArnbuIatory Medical Care Rendered in PediaVisits to General and Family Practitioners, tricians’ Offices During 1975 (Issued: October 

Januaq-December 1975 (Issued: December 13, 1977) 

14, 1977) 

No. 12. Ambulatory Medical Care Rendered in Physicians’ Offices: United States, 1975 (Issued: 

October 12, 1977) 

No. 14. Weight by Height and Age of Adults 18-74 

Years: United States, 1971-74 (Issued: No- No. 11. Pregnant Workers in the United States (Issued: 

vember 30, 1977) September 15, 1977) 

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

Information Branch. 

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