PROPERW OF THE 

NATIONAL CENTER Series 2

PUBLICATION: ;RA(i6~ For HEALTH STATISTICS INumber 10 

‘ EDIT(IRIA ~i~~~~ 

VITAL and HEALTH STATISTICS 

DATA EVALUATION AND METHODS RESEARCH 

Hospital Utilization


in the last year of life 

Development and test of a method of measuring the 

effect of omitting decedents from a survey of hospitalization. 

Washington, D.C. hty 1965 

U.S. DEPARTMENT OF 

HEALTH, EDUCATION, AND WELFARE Public Health Service 

Anthony J. Celebrezze Luther L. Terry 

Secretary Surgeon Generol 
This report was originally published in the series “Health Statistics 

from the U.S. National Health Survey,” which has since been replaced 

by the “Vital and Health Statistics” series. The method described in 

this report is being used currently by the Health Records Statistics 

Division to obtain estimates of the hospital experience of decedents 

not covered in the Health Interview Survey. It is, therefore, being 

reprinted in its present form. 

Public Health Service Publication No. 1000-Series 2-No. 10 

For sale by the Superintendent of Documents, U.S. Government Printing Office 

Washington, D.C. 20402- Price 30 cents. 
NATIONAL CENTER FOR HEALTH STATISTICS 

FORREST E. LINDER, PH. D., ~i?7C~O?’ 

THEODORE D.WOOLSEY,Deputy Director 

OSWALD K.SAGEN,PH.D.,zlni~ta?zt Director 

WALT R.SIMMONS,M.A.,Statistical ~dvi~or 

ALICEM.WATERHOUSE, M.D.,Mtdical Advi-ror 

JAMES E.KELLY,D.D.S.,Dental tidvi~or 

LOUISR.STOLCIS, M.A.,
Executive ojicer

OFFICE OF HEALTH STATISTICS ANALYSIS 

IWAOM. MORIYAMA,PH. D., Cltief 

DIVISION OF VITAL STATISTICS 

ROBERTD. GROVE,PH. D., (3&f 

DIVISIONOF HEALTH INTERVIEWSTATISTICS 

PHILIP S. LAWRENCE,Sc. D., Chief 

DIVISIONOF HEALTH RECORDSSTATISTICS 

MONROEG. SIRKEN,PH. D., Chief 

DIVIS1ONOF HEALTH EXAMINATIONSTATISTICS 

ARTHURJ. MCDOWELL, Chief 

D1VIS1ONOF DATA PROCESSING 

SIDNEYBINDER, Ckiej 

COOPERATION OF THE NATIONAL OFFICE OF VITAL STATISTICS 

Under legislation establishing the National Health Survey, the 

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

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

The methodological study in this report was performed under a reimbursement agreement with the National Office of Vital Statistics, Public Health Service. 

Public Health Service Publication No. 1000-Series 2-No. 10 
PREFACE


A major phase of the U. S. National Health Survey is 

the collection of data by means of family interviews on health 

matters. This interviewing is carried on each week of the 

year throughout the Nation in a sample of households. Each 

household is interviewed only once and the interview questions relate only to the household members who are alive 

at the time of interview. A number of the questions are 

concerned with the family members’ illness and medical 

care experience over a period of time ending with the Sunday 

before the interview, i.e., over a reference or recall periodj 

A recall period as short as the past 2 weeks is used for questions on acute illness, but for hospitalization the questions seek 

to elicit information on every episode in the past 12 months. 

When the 12-months’ data are collected only for living 

persons, the estimates of hospitalizations and associated 

hospital stays relate only to persons who have survived until 

the interview. These persons constitute the major part of but 

not the entire population exposed to the risk of being hospitalized during the 12 months in question. The persons who 

have died during the 12-month reference period will have 

accounted for a significant part of the total hospital utilization during that time. Therefore, their experience needs 

to be included to estimate properly the amount of hospitalization associated with specific conditions, as well as the 

total amount of hospital utilization during a year. 

For a number of reasons, household interviews are not 

satisfactory for collecting data concerning persons who have 

died. Therefore, the National Health Survey arranged for a 

study by the National Office of Vital Statistics to develop 

and test a method of data collection and estimation to fill 

this gap in hospitalization data. The method to be explored 

was based on follow-back inquiries starting from death certificates. As a result there has been developed and demonstrated a practical method for obtaining the data and estimating the specific portion of decedent experience which 

must be added to the data on the living population so as to 

produce estimates of total hospital utilization over any specified reference period. This method is described in the following 

report prepared by the National Office of Vital Statistics. 

IFO= an explanation of the time references in the household


interview see U.S. National Health Survey, Concepts and Defini­


tions in the Health Household-Interview Survey, Health Statis -


tics, Series A3, PHS Publication no. 584-A3. public Health Serv­


ice, Washington, D.C. Sept, 1958.

The report presents a theoretical formulation of the 

problem under study. A method of data collection and a test 

of it are described, the data are presented, and the theory is 

applied to them. For the sake of economy, the data collected 

were confined to deaths during a single month. This necessitated the adoption of certain assumptions that would become unnecessary if deaths over an entire 12-month period 

were to be used. The formulation also advantageously utilizes 

the entire experience during the last year of life in the estimation process, and consequently a small sample of decedents will suffice. 

The data in this study were derived from a sample of 

one month’s deaths in the 3 Middle Atlantic States. They 

are presented only to illustrate the method. ‘The reader is, 

therefore, cautioned against using any of the numerical estimates as indicative of actual experience even for the Middle 

Atlantic region. 

***** 

For the special studies which are carried out at its expense but are not directly conducted by the National Health 

Survey, a staff member is assigned for liaison with the research organization doing the study. In addition to keeping 

closely informed on the study progress and conveying the 

National Health Survey’s viewpoint in decisions on study 

methodology, the liaison person edits the final research report for publication in Health Statistics, Series D. For this 

study, Mr. Earl Bryant of the Special Studies staff discharged 

these responsibilities. 
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CONTENTS


Preface


~e Research Problem


~eMe&od of Study ----------------------------------------------


Hospital Utilization Not Covered in Household Surveys


Adjustments Derived From Other Studies


The Mortality Survey


Sample Design and Suney Procedures


Survey of Funeral Directors


Survey of Itiormants


Survey of Medical Institutions


Editing Procedures


Experimental Findings From the Mortality Survey


Comparison of Reports From Hospitals and Family Informants


Data Collection Procedures for Deaths Occurring in Hospitals


Data Collection Procedures for Deaths Occurring Optsideof Hos­


pitals


Conclusions on Experimental Findings


Hospital Utilization in the Middle Atlantic States


Estimates Derived From the National Health Survey


Estimates Derived From the Mortality Survey


Adjustment of the Health Survey Estimates


Hospital Utilization by the Population That Died Inside and Outside


of Hospitals


Conclusions Regarding Hospital Utilization in the Middle Atlantic


States


Deriving Estimates From the Mortalit~ Survey


Estimating Process


Daily Variation in Hospital Utilization Within the Last Year of Life--- -


Effect of the Length of the Reference Period in the Health Survey


Sampling Variability of Estimates Derived From the Mortality Survey----


Variability of Hospital Utilization by Decedents


Sampling Errors


Sample Design for a National Mortality Survey


Optimum Stratification by Place of Death ---------------------------


SamplingErrors of National Estimates


Summary and Conclusions


Appendix I. Glossary of Terms Used in This Report


Terms Relating to Hospitalization in the Mortality Survey


Terms Relating to the Mortality Survey


Appendix II. Derivation of Formulas


Hospital Utilization Not Covered in the National Health Survey


Variance of the Estimate


Terminal Hospitalization Not Covered in the Health Survey


Page 

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30

HOSPITAL UTILIZATION


in the last year of life 

(The following research report was prepared in the Nationa Office of Vital Statistics, U.S. Public


Health Service, by Monroe G. Sirken, who directed the research project. Acknowledgment is due Morton L.


Brown, who gave valuable assistance in the Mortality Survey, a so to Karol Walsh and Gustav Carlson, who


assisted in computationsof sampling error, and to Ruth Crockel who assisted in the Mortality Survey.


The National Office of Vital Statistics conducted the project ‘under a contract with the U.S. National


Health Survey.)


THE RESEARCH PROBLEM 

This report presents the results of a research project undertakenfor the purpose ofdeveloping and testing a procedure for obtaining 

estimates of hospital utilization by decedents. 

The U. S. National HeaRhSurveycovers only the 

experience of persons living at the time that 

household interviews are conducted. consequently, to obtain estimates of total hospital utilization by the population, it is necessary to supplement the hospital data collected inthe health 

surveywith similar data for decedents. 

The .Method of Study 

A specific survey method for collecting the 

needed data was investigated. It was a survey 

“anchored to the death record”l inwhich infermation on hospital utilization during the lastyear 

oflife was collected byfollowing back to sources 

of information identified on the death certificate 

and to others identified by these sources. The 

essentials of this survey method as applied to 

this problem are: 

(a)


(b)


(c)


(d)


selecting a probability sample of deaths


from the files of registered death cer­


tificates.


conducting surveys of the death certif­


icate informant andthehospital inwhich


death occurred, both of which are iden­


tified on the death certificate, and of


other potential sources identified by the


death certificate sources.


collecting information on the episodes


of hospital utilization during the l-year


period prior to death for the decedents


in the sample.


deriving unbiased estimates of thevol­


ume of general hospital utilization by


decedents not covered in the household 

interviews of the U. S. National Health 

Survey, and the variance of these estimates. 

There were two distinct but interrelated 

problems of the research project. First it was 

necessary to develop an appropriate stochastic 

model and to derive a formula which would provide efficient and unbiased estimates of hospital 

utilization by decedents which is not covered in 

the household interviews of the National Health 

Survey. Also, it was necessary to develop and 

test a design for a mortality survey that would, 

at the lowest cost, provide accurate data for estimating the parameters specified by the stochastic model. 

The stochastic model specified the process 

for obtaining, from the Mortality Survey, unbiased estimates of hospital utilization by decedents not covered in the health survey and the 

sampling variability of the estimates. 

The design of a mortality survey was tested 

in a survey conducted in the Middle Atlantic 

States involving several hundred deaths. Tle 

pilot study provided information for comparing 

the accuracy and costs of estimates of hospital 

utilization by decedents based on (a) different 

sampling designs, (b) different data collection 

methods, and (c) different sources of information. 

Hospital Utilization Not Covered 

in Household Surveys 

A discussion in a National Health Survey 

publication of the limitations of national estimates of hospital utilization derived from the 

U.. S. National Health Survey, 2 cautions that 

“Since the survey data refer only to persons who 

I 
were alive at the time of interview, the hospital 

experience of persons who died in the year prior 

to the interview period is not counted. ” In view 

of the objectives of this report it is appropriate, 

if not essential, to clearly define the hospital 

utilization by decedents which is not covered in 

the health survey. This will require a brief summary of the statistical design of the U. S. National 

Health Survey. 3 

The National Health Survey Program conducts a weekly survey of a national sample of 

households that is representative of the civilian 

noninstitutional population. For each person residing in sample households on the enumeration 

date, the interviewers collect information on 

hospital utilization during the preceding 12-month 

period. (The 12-month period preceding the week 

of interview is called the reference year in this 

report. The estimates of hospital utilization by 

both decedents and by persons interviewed in the 

National Health Survey refer to utilization during 

the reference year.) Two recall questions elicit 

information on the number of times each person 

in the household had been hospitalized “during 

the past 12 months.” For each hospital episode, 

a series of questions are asked including those 

which establish the month of admission and the 

length of stay. Estimates of hospital utilization 

during the reference year are derived from the 

survey reports collected from a series of consecutive weekly samples. 

The reports collected in each interviewing 

week provide estimates of the hospital utilization during the preceding 12-month period by 

persons who were alive at the time of interview. 

The health survey does not cover the experience 

of persons who had died prior to the interview. 

Specifically, the estimates of hospital utilization 

derived from the health survey exclude the hosmates deriv-ed from the health survey will be 

referred to as the volume of hospital utilization 

by decedents during the reference year. For example, national estimates of hospital utilization 

referring to the 12-month period, July 1957-

June 1958, derived from the household interviews 

of the National Health Survey would not include 

the volume of hospital utilization during this 

period by persons who died between July 1957 

and June 1958. The factors needed to adjust these 

data to include the utilization by decedents and 

thereby obtain estimates of total hospital utilization are unknown. Preliminary estimates of 

these adjustment factors based on the Mortality 

Survey conducted in the Middle Atlantic States 

will be presented subsequently in this report. 

Adjustments Derived From Other Studies 

Two reports of independent research dealing with the problem of undercoverage of hospital utilization by persons prior to death in estimates derived from health surveys have been 

published. 4Js Both reports were concerned with 

the results of health surveys in which information on hospital utilization was collected retrospectively for a 12-month period prior to the 

enumeration date for the living population. Both 

reports indicated that adjustment of the estimates 

derived from the health survey to include the 

hospital utilization of decedents was substantial, 

particularly for the population at the older ages. 

To adjust the estimates of the national volume of hospital care based on a survey of hospitalization which had been conducted in March 

1952, as a supplement to the Current Population 

Survey by the Bureau of the Census, Falk and 

Brewster 4 made crude estimates of the volume 

of hospital care received by decedents 65 years 

of age and over. First, they estimated the proportion of deaths at ages 65 years and over which 

occurred inside and outside hospitals. Then they 

assumed specified hospital admission rates and 

lengths of stay per admission for deaths which 

occurred inside and outside hospitals. The addition of this volume of care received by decedents 

to the estimates for persons 65 years and over 

based on the household survey increased the volume of admissions and days in the hospital by 

approximately one fourth. 

Siegel, Belloc, and Hesse s estimated the 

volume of hospital care received by decedents 

who died between July 1, 1951 and June 30, 1952, 

in order to adjust the estimates of the volume of 

hospital care based on a household survey in San 

Jose, Calif. They estimated the volume of hospital care received by decedents by a procedure 

which involved matching the death records for 

deaths that occurred between July 1, 1951 and 

June 30, 1952, with the hospital records of persons who received care during the same period 

in four general hospitals serving the population 

of San Jose. Their adjustments of the estimates 

based on the health survey of the San Jose population for the experience of persons who died 

increased hospital admissions by 6 percent and 

hospital days by 10 percent (table 1). For persons 65 years of age and over, the adjustment 

increased both the rate of admissions and the 

rate of days in the hospital by approximately 

one third. 

Compared with statistics on hospital utilization, other health statistics derived from the 

household survey would in all likelihood be considerably less affected by the omission of the experience of decedents. This point is worth mentioning since the findings to be reported subse2 
----------

Table 1. Annual rates of admissions and days in general hospitals per 1,000 population 

by sex and age, unadjusted and adjusted to include the experience of decedents not 

counted in the California Health Survey: San Jose, May 1954-April 1955 

Admissions Days 

Sex and age Rate per 1,000 Percent 

Rate per 1,000 

per sons persons Percent 

increase increase 

Unadjusted Adjusted Unadjusted Adjusted 

Both sexes---- 93 99 6 881 969 10 

0-44---------------- 91 685 705 3 

45-64--------------- R 106 i 1,151 1,272 10 

65+----------------- 109 146 34 1,900 2,493 31 

Male ------------ 70 76 9 968 1,050 8 

0-44---------------- 56 57 3 709 725 

45-64--------------- 101 111 10 1,451 1,563 : 

65+----------------- 121 162 34 2,018 2,609 29 

Female 114 119 4 798 892 12 

0-44---------------- 121 122 1 662 685 3 

45-64--------------- 94 101 7 862 991 15 

65+------------------ 98 131 34 1,792 2,386 33 

SOIJrce: Siegel, B. M.; Belloc, N. B.; and Hesse, F.E. Household surveys for hospital planning: Adjustment for decedents missed. Pub. Health Rep. 72: 993, NOV. 1957. 

quently deal entirely with hospital utilization. 

In the household interview ofthe National Health 

Survey, information concerning hospital utilization is collected fora 12-month period preceding 

the week ofenumeration ,whereas, formost other 

health characteristics collected in thehousehold 

THE MORTALITY 

A mortality survey was conducted in the 

Middle Atlantic States to develop and to test a 

survey method for collecting information onhospital utilization during the last 12 months of life. 

The information was collected retrospectively 

for a sample of persons whose death occurred 

in the Middle Atlantic States during April 1957. 

These data would be used to derive esthnatesof 

the volume of general hospital utilizationby decedents during aspecific l-year referenceperiod. (That is, the volume of hospital utilization 

interview, the information is collected for a prior 

2-week period. Additionally, compsredwithmost 

other health characteristics collected inhousehold interviews, hospital utilization is probably 

more strongly linkedtothesubsequentoccurrence 

of death. 

SURVEY 

during a specified 12-month period by persons 

who died during that period.) It should be noted 

that only part of the utilization during the last 

12 months of life occurs during the reference 

year. In considering a specific reference period, for example, a calendar year, only the utilization during the last week of life falls into the 

reference period for those dying atthe endofthe 

first week of the reference period, only theutilization during the last two weeks forthosedytig 

at the end of the second week, and soon. 

3 
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SAMPLE DESIGN


AND SURVEY PROCEDURES


A sample of 695 death certificates was selected from the shipments of death certificates 

in the Current Mortality Sample which arrived 

in the National Office of Vital Statistics during 

May 1957.* A systematic sample of every fourth 

certificate in this shipment from the registration 

areas in the Middle Atlantic States was selected. 

Thus, the sample consisted of about 2!4percent 

of deaths for which April 1957 was the principal 

*The Current Mortality sample is a lo-percent


sample of death certificates which is transmitted


monthly to the National Office of Vital Statistics


(NOVS) by each of the 54 independent areas for


registering deaths. The certificates are selected


systematically from the files of death certifi­


cates registered in the central office of the reg­


istration area. The shipments of certificates in


the Current Mortality Sample which arrive in NOVS


toward the end of each month relate to deaths for


which the previous month is the principal month of


occurrence.


month of occurrence. The distribution of the 

deaths by place of occurrence is shown below 

Number of 

Registration sample deaths 

Total . . . . . . . . . . . . . 695 

NewYorkCity . . . . . . . . . . I 72 

New York (excluding New york City) 177 

Pennsylvania . . . . . . . . . . . 

New Jersey. . . . . . . . . . . . H 

area


The principal sources of information were 

persons whoprovided personal information almut 

the decedents for the death certificate (informants) and the hospital in which they received 

medical care. The informant is generally some 

close relative ofthe decedent. In someinstances, 

the address of an informant couldnotbeidentified. For such cases, the funeral director was 

asked to identify some close relative ofthe decedent. By and large this “relative’’h adbeenthe 

death-certificate informant, Surveys of these 

sources were conducted during the 6-monthperiod, June-November 1957 (table 2). 

Table 2. Schedule of data collection by source of information and type of survey 

Period during 1957 

June ------------------------

July-August 

September-October 

November --------------------

Survey of Funeral Directors 

Principal sources of 

information 

Type of 

survey 

Sample size 

Funeral directors Mail 208 

Relatives of decedents Mail 643 

(informants) 

Medical institutions in 

which deaths occurred


Referral hospitals


Nonresponding


informants to the mail


Mail 423 

Mail 196 

Personal


interview 86


survey


the death certificate because this information 

was not entirely legible or complete. Consequently, amailsurvey wasconducted with funeral directors to obtain this information. On completion of a regular and certified mail followup, the response rate was about 97 percent. (The 

interval between original and followup mailing 

was 2 weeks for each of the sources of information surveyed in this study.) 

Space is provided on the stahdarddeat.hcertificate (fig. l) for the signature and the address 

of the informant (item 17) and for the name and 

address of the funeral director (item 24). For 

about 30 percent of the deaths in this study, 

however, it was not possible to establish the 

name and mailing address oft,he informant from 

4 
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Survey of Informants 

A mail survey was conducted wifi informants for 643 of the 695 deaths in the sample. 

For 35 deaths, the informants could not be identified. For 17 deaths, the age at death was 1 

week or less and it had been decided for policy reasons that informants for these infants 

would not be surveyed. The initial response 

rate was about 43 percent and followup by certified mail increased the response rate to about 

87 percent. Personal interviews were attempted 

with nonrespondents in Standard Metropolitan 

Areas (about 90 percent of the deaths occurred 

in SMA’S in the Middle Atlantic States), and as 

a result the response rate was increased to about 

95 percent.* 

The informant was asked two screening questions to establish whether the decedent had been 

in a medical institution. 

A. 

B. 

the 

Since January 1, 19562 was the deceased a patient In a hospital, nursing home, or sanitarium overnight or longer? 

1. � Yes 2. � No (if no, skip to page 3) 

How many times was the deceased a patient i n a 

hospital, nursing home, or sanitarium? 

number of times [ Please complete a 

sect ion below for each of these 

times beginning with his last hospital stay. ) 

*The household survey was subcontracted to 

Bureau of the Census and the interviews were 

conducted by enumerators who regularly conduct the 

Current Population Survey, but who received special training to conduct health interview for 

this study, 

For each hospital episode that he reported, 

the informant was asked the series of questions listed below: 

A. When did he enter the hospital? 

_Month _Day —Year 

B. What is the name and address of the hospital 

he was in? 

Name 

City or Place 

State 

c. How many nights was he in the hospital? 

number of nights 

D. For what condition(s) was he hospitalized? 

E.	 Were any operations performed on him during 

this stay in the hospital? 

1. � Yes 2. � No 

F. Please list all operations performed. 

Survey of Medical Institutions 

For about three fifths of the deaths in the 

sample, a medical institution was reported as 

the place of death on the death certificate (item 

1 on the standard death certificate). Amailsurvey was conducted with these institutions concurrently with the mail survey of family informants. Abut 65 percent responded to the 

initial mailing and the response rate was virtually 100 percent after a certified mail followup. 

The screening questionon the form mailed 

to the institution established the number oftimes 

the person had been admitted to the institution. 

A.	 How many times was the person whose name appears above admitted to your institution since 

January 1, i956? 

number of separate admissions between 

January 1, 1956, and date of death. 

5 
For each reported admission, the following 

information was requested: 

Periods Ad- Dis- Diag- Operations 

of care mitted charged nosis performed 

I Month I Month I I 

Period Day Day 

Year Year 

l—l I I � None 

The institution of death was also asked if it had 

knowledge of other medical institutions in which 

the decedent had received care. 

A. According to your records or to your personal 

knowledge, was the deceased a patient in any 

other hospital, nursing home, or sanitarium 

between January 1,1956, and the date of death? 

1. � Yes 2. � No 3. � Don!t know 

For each other institution reported, the following information was requested: 

Name 

City or place 

County 

Approximate admission date 

The returns from the family informants 

and institutions in which death occurred were 

EXPERIMENTAL 

screened for information identifying institutions 

in which the decedent was reported to have 

received nonterminal care during a period between January 1, 1956 and death. A mail survey, involving essentially the same form mailed 

to institutions providing terminal care, was conducted with these institutions as well as with the 

additional institutions which they in turn identified. 

In this manner, the mail survey of referral 

institutions included every institution which was 

reported by any source to have provided nonterminal hospital care to the decedent. The response rate for general hospitals (exclusive 

of the hospitals providing terminal care) was 

about 65 percent after the initial mailing and 

almut 97 percent after a certified mail followup. 

Editing Procedures 

Editing procedures comprised an essential 

step in processing the returned forms. When the 

form from a funeral director or hospital or family informant was returned, it was edited for 

completeness and consistency. If the form was 

evaluated as providing inconsistent or incomplete information a special letter was mailed to 

collect further information. In the event that it 

was felt that the family informant whose form 

failed edit would be unable to supply the supplementary information, queries were sent to another relative of the decedent if one had been 

identified either by the funeral director or the 

informant himself. 

FINDINGS 

FROM THE MORTALITY SURVEY


In the Mortality Survey conducted in the 

Middle Atlantic States, reports of hospital utilization by decedents were collected from both 

family informants and from each of the hospitals 

which provided the care. This double collection 

procedure was a deliberate feature of the design of the pilot study even though it added to 

the cost of conducting the pilot study. It was 

anticipated, however, that the duplicate reports 

from hospitals and family informants would provide valuable data for purposes of deriving efficient survey procedures for the proposed extension of the pilot study to a national mortality 

survey. 

Comparison of Reports From 

Hospitals and Family Informants 

First, the possibility was explored of collecting the hospital utilization information from 

the family informants only without any recourse 

to hospital records. In this connection, the admissions to general hospitals reported by informants 

and hospitals were compared and the findings are 

summarized below. 

A total of 687 admissions to general hospitals during the year before death was reported either by informants or by the hospitals 

for the 695 decedents in this study. The hos-
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Table 3. Comparison of the number of admissions to general hospitals reported by informants and hospitals by sex and age of the decedent 

Number of admissions Per cent 

Sex and age 

All deaths-­

Male$ under 65 

years 

Female, under 65 

years 

Male, 65 years 

and over 

Female, 65 years 

and over 

difference 

Reported by Reported b Reported Reported (Hospi_tal 

either the both the by by in- informant) 

informant informant hospital f ormant Gross Net 

and only only cliff er - differhos~ital hospital ence ence 

687 475 I 170 42 I 31 I 19 

207 123 74 10 41 31 

128 88 32 8 31 19 

202 148 39 15 27 12 

150 116 25 9 22 11 

pital and informant reports agreedon about two 

thirds of the admissions. About 6 percent of the 

admissions were reported by the informant only 

and about 25 percent were reported bythehospitals only. Thus, the net difference inthenumber of admissions reported by hospitals andinformants was about 19 percent more admissions reported by hospitals. The gross and net 

differences in reporting of admissions were 

greater at ages under 65 years than at older 

ages and they were greater for males than 

for females (table 3), 

0fthe42 admissions reported by informants 

that were presumed not to be reported byhospitals, 26 refer to decedents for whom at least one 

admission was reportedly ahospital, butnotreported by informants. It seems likely that most 

of these 26 admissions were in fact reportedly 

hospitals, but, because ofreporting errors made 

by the informants, a match could not beestabIished. The hospital reports refuted a few admissions reported by informants such as those 

for persons dead onarrival atthe hospitaland for 

persons who received outpatient care only. Nine 

admissions reported by informants were notconfirmed either because the hospital did not return 

the survey form or because thehospital was not 

queried owing to the cutoff date of the survey. 

0fthe170 admissions that were notreported 

by the informants, about one third represented 

deaths for which no report was obtained from the 

informant and two thirds represented deaths for 

which a report was received from the informant 

but the particular admission was not reported. An 

informant report was not obtained for 78 deaths 

oraboutll percent of the695deaths inthe aample. 

Twenty six of these deaths represented casesin 

which-the informants didnotrespondto the survey 

and 52 were deaths in which the respondent was 

not queried, either because theywereinfantdeaths 

1 week or less of age(17deaths) or because an 

informant was never identified (35 deaths). 

The large net underreporting of admissions 

by informants as compared with thenumberreported by hospitals makes it apparent that a survey of informants alone would not have provided 

satisfactory data, and that a survey of hospitals 

is indicated in order to obtain accurate data. As 

a matter of fact, the estimates of hospital u= 

lization by decedents that will be presented in 

this report are based entirely on the episodes of 

hospitalization reported by the hospitals themselves which provided the care. 

Having established the need for collecting reports dir;ctly from the hospitals that pro;ided 

care, the possibilities were explored of eliminating entirely or reducing the extent of the survey 

of informants. Since these possibilities differed 

according to whether or not death occurred in a 

hospital, - separate explorations were made on 

this basis. 

Data Collection Procedures for 

Deaths Occurring in Hospitals 

For deaths occurring in hospitals, there were 

3 sources from which information was collected 

7 
----------

--

almut the hospital experience of the decedent . . during the 12-month - period prior to death: 

(a) Hospitals reported on the death certificate in which death occurred. * 

(b)	 Family informants reported on the death 

certificate or identified by the funeral 

director. 

(c)	 Other hospitals in which the decedent 

received care prior to death which had 

been identified by the institution of 

death, family informant, or another 

hospital. 

Of the hospital utilization during the reference yesz by persons who died in hospitals, about 

87 percent of the discharges and about 84 percent 

of the nights of care in general hospitals were 

provided and reported by the hospitals in which 

death occurred (table 4). Thus a survey of the 

hospitals in which death occurred would by itself 

have provided most of the data pertaining to genTable 4. Discharges and nights in general 

hospitals during the reference year for 

persons who died in hospitals, based on 

reports from hospitals queried in the 

prescribed order 

Order of querying 

hospitals =F= 

Percent 

Total 100 100 

1.	 General hospitals in which 

death occurred- 87 84 

2.	 General hospitals reported 

by the institution of death---- 8 9 

3.	 General hospitals reported 

by the family infonnant---------- 5 7 

*A hospital is defined to include all medical


institutions listed either in the Directory of the


American Hospital Association (AHA) or in the


State hospital plans prepared under the Hill-Bur-


ton Act. About 56 percent (389) of the deaths in


the sample occurred in these hospitals—372 deaths


Occurred in AHA-listed hospitals. Deaths in gen­


eral hospitals accounted for about 290 out of the


372 deaths in AHA hospitals.


eral hospital care for these decedents. Abut 8 

percent of the hospital utilizationwasin general 

hospitals referred to by the institution ofdeath. 

Only about 5 percent of the hospital care during 

the reference year of persons dying inhospitals 

was based on reports from hospitals which no 

other source except the family informant identified. Less than lpercentofthe care wasinhospitals reportedin personal interviews withinformants who did not reply to the mail survey. 

In this study, almut 63 percent of all discharges from general hospitals during theyear of 

reference were discharges by death; This is a 

notable fact because theplaceofdeath isrecorded 

on the death certificate and there would be no 

needto conduct a special mortality surveyto 

Iearnof such hospital discharges. 

Data Collection Procedures for 

Deaths Occurring Outside of Hospitals 

For deaths that occurred outsideofhospitals, 

the family inforniant was the only source identifiable from the death record from which tocolIect information on decedent’s episodes ofhospital carepriortodeath. ’Ihus,unlikethedeaths 

for which the death record identified ahospital 

as the place ofoccurrence, there is nopractical 

way of eliminating the survey offsmilyinformants. Also there would be a needto conduct a 

survey of each of the hospitals reported by the 

informants in order to obtain accurate informationonthe number and dates ofhospital episodes. 

A vital question is: Howcompletely arethehospitals which were utilized prior to death reported 

in the survey of informants? Although an unequivocal answer is not available from the Mortality 

Survey conducted in the Middle Atlantic States, 

the following results are illuminating. 

Of the utilization of general hospitals during 

the reference year by persons dying outside of 

hospitals during that year, over 90 percent of the 

discharges and nights of care was reported by 

hospitals identified by informants who responded 

to the mail survey (table 5). The remaining hospital utilization was reported by hospitals which 

were either identified bv informants who resoonded to the personal inter~iew or by other hospitals. 

Unfortunately, queries were not mailed to 

some of the hospitals that were identified in the 

personal interview with family informants because the interviews were completed after the 

cutoff date of the hospital survey. Since the es. 

timates derived from the Mortality Survey were 

based entirely on reports of hospitals that provided the hospital care, the estimates do not reflect the care received by these few cases. Assuming the informant reports of hospital utilization by these cases, the volume of hospital utili8 
---------------

---------

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

Table 5. Estimates of discharges and 

nights in general hospitals during the 

reference year for persons who died 

outside of hospitals, “based on reports 

of hospitals queried in the prescribed 

order


Order of querying


hospitals
 * 

Percent


Total 100 100 

1.	 Hospitals reported 

in mail survey of 

informants 91(83) 94(85) 

2.	 Hospitals reported


by other hospitals- 2(2) 2(2)


3.	 Hospitals reported


by personal inter-


view survey of non­


responding inform­


ants to the mail


survey 7(15) 4(13)


NOTE: The numbers in parentheses have been 

adjusted for the hospital care provided by a 

smal I number of hospitals which were not included 

In the estimates because the hospitals were not 

queried. 

zationby persons who died outsidehospitals


wouldhave been increasedby about10-15per-


Conclusions on Experimental Findings 

About 19 percent more hospital discharges 

were reported by hospitals than were reported 

by family informants. Actually, it appears that 

very few hospital discharges would have been 

missed if those reported by family informants 

onlyhad been excluded.This findinghasimportant 

implications concerning the design of efficient 

survey procedures to collect data on hospital 

utilization for agroup ofdecedents. 

For deaths occurring in hospitals, thereis 

no needto conducta survey of familyinformants. 

Based on this Mortality Survey it is estimated 

that about 95 percent ofthe utilization of general 

hospitals that would not recovered inthe health 

survey was reported by the hospital identifiedas 

the place of death on the death certificate andby 

other hospitals referred by this source. About5 

percent oftheutilization wasreportedbyhospitals 

that would not have been identified except for the 

surveyoffamily informants. 

For deaths occurring outside ofhospitals, it 

is necessary to conduct a survey of the family 

informants in order to identify the hospitals utiIized bypersons prior todeath. It is subsequentlynecessaryto conduct asurvey ofeach ofthese 

hospitals inorder to obtain accurate data onepisodes ofhospitalization. Itappears,however,that 

amail survey of informants without provisionfor 

followup by personal interview with nonrespondents would be sufficient. The utilization reported 

by hospitals that were identified in the interviews 

accounted for less than 2 percent of theestimated 

hospital utilization by the decedents during the 

reference year. 

MIDDLE ATLANTIC STATES 

by persons whose usual place of residence is 

other than in institutions such as penal institutions, 

tuberculosis sanitariums, mental hospitals, etc.) 

by sex and 3 broad age groupings are shown in 

table 6. They are based on data collected in the 

regular household interviews conducted in the 

Middle Atlantic States by the National Health 

Survey during July 1957-June 1958. For convenience, the reference year is considered to be 

calendar year 1957. The amounts of hospital utilization are largest for the age group under 45 

years and smallest for the age group 65 years and 

over. Variation in the population sizes among the 

various age groups is the factor most responsible for the noted differences in the frequency 

of hospital utilization by age. The total population 

size and frequency of hospital utilization were 

greater for females than for males. For the 

middle age group, the frequency of utilization of 

general hospitals was slightly greater by males 

9 

cent.The estimate of thevoltuhe of hospital utilization by alldeathswotid have been increased 

by less than 2 percent. 

HOSPITAL UTILIZATION IN 

The frequency of total utilization of general 

hospitals in the Middle Atlantic States during 1957 

is equal to the sum of two quantities: 

(a) thehospital utilization bytheppulation 

that was alive at the beginning of 1958, 

(b) %’~hospital utilization bythe population 

that died during 1957. 

Estimates of hospital utilization by the population alive at the end of the reference year (i.e., 

alive at the end of calendar year 1957) were derived from the National Health Survey and estimates of hospital utilization by the population that 

died during 1957 were derived from the Mortality 

Survey. 

Estimates Derived From the 

National Health Survey 

Estimates of utilization of general hospitals 

by the civilian noninstitutional population (i.e., 

THE

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

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

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

Table 6. Estimates of the uti.13-zation 

household interviews conducted during 

vey: Middle Atlantic States 

Sex and age 

Both sexes 

o-44--------------------------------

45-64-------------------------------

65+---------------------------------

Male ----------------------------

o-44--------------------------------

45-64-------------------------------

65+ 

Female 

0-44--------------------------------

45-64-------------------------------

65+---------------------------------

* 

Population figures by broad age groups for 

of general hospitals by sex and age based on 

July 1957-June 1958 in the National Health SurCivilian population* Hospital uti.li,zation 

size (in thousands) (in thousands) 

in 1957 Discharges Nights 

32,660 2,951 29,227 

22,215 1,934 14,108 

7,445 723 10,098 

3,000 294 5,021 

15,909 1,105 12,809 

10,900 625 5,665 

3,632 366 5,466 

1,377 114 1,678 

16,751 1,846 16,418 

11,315 1,309 8,443 

3,813 357 4,632 

1,623 180 3,343 

combined sex groups were taken from Bureau of the Census, 

cUt_f_ei)t Population Reports, Series P–25, No. [94, Table [. Figures by sex and age were computed assuming 

the sex ratios in 1959 for the U. S. civilian population. 

than by females but for the younger and older 

age groups, the utilization was substantially 

greater by females. 

Estimates Derived From 

the Mortality Survey 

Estimates of hospitaI utilization during 1957 

by sex and broad age groupings by the population 

that died during 1957 in the Middle Atlantic States 

(table 7) were derived from theMortality Survey. 

(Again, for convenience and for the purpose of 

comparison with National Health Survey household interview data the calendar year 1957 is 

taken as the reference year, even though theestimates are based on hospital experience ofpersons dying during April 1957.) On the average, 

about 658 discharges and 11,336 nights of care 

per 1,000 deaths were omitted from the estimates of utilization of general hospitals derived 

from the health survey. It is estimated that the 

349,147 persons who died during 1957 in the 

Middle Atlantic States had 230,000 discharges 

and 3,958,000 nights of care during 1957. Consequently, this amount of hospital utilization was 

not covered in the National Healt.h Survey household interviews. 

The preponderance of deaths at the older 

ages is responsible for the fact that t.he number 

10 

of discharges and nights ofcare are 3 to 4 times 

greater for the group 65 years of age andover 

than for the groups under 45 years ofage. Actually, the rate of utilization of general hospitals 

per 1,000 deaths is lower for the group 65years 

and over than for the younger groups.* There 

were more male than female deaths andthefrequency of utilization of general hospitals was 

greater for males than for females. Except for 

the younger age group, lmth the frequency and 

rates of hospital utilization by males exceed 

those for females. 

Estimates of total utilization of general hospitals during 1957 in the Middle Atlantic States 

bysex andbroad age groupings may recomputed 

by adding the respective frequenciesofutilization 

for the living population (table 6) to those of the 

population that died (table 7). 

*It should be emphasized that the trend downward with advancing age in the rates of discharges 

and nights of care per 1,000 deathe reported here 

covers utilization of general hospitals only, Inclusion of utilization of long-term hospitals and 

nursing homes would probably affect the trend in 

rates of discharges and nights of care by age, 
--------

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

--------

Table 7. Utilization of general hospitals during 1957 by decedents by sex and age:


Middle Atlantic States


Number of Hospital utilization by decedents during 1957


Sex and age deaths in
 Rate per 1,000 deaths Frequency (in thousands)
 1957*


Discharges Nights Discharges Nights


Both sexes


0-44--------------------


45-64-------------------


65+---------------------


Male----------------


0-44--------------------


45-64-------------------


65+---------------------


Female


0-44--------------------


45-64-------------------


65+---------------------


349,147 658 11,336 230 

I I 

47,173 847 10,277 40 

95,398 794 15,670 76 

206,576 554 9>567 114 

193,790] 690 I 12,312 I 134 

27,784 693 9,346 19 

60,005 853 15,315 52 

106,001 598 11,384 63 

155,357 616 10,044 96 

I I I 

19,389 1,090 11,740 21 

35,393 691 16,298 24 

100,575 504 7,526 51 

3,958


485


1,495


1,976


2,387


260


919


1,207


1,560


228


577


757


National Office of Vital Statisticsr Vital Statistics of the United States, 1957, Volume II, Table 

60, pp. 15-16 

Table 8. Annual rates of discharge and nights of care in general hospitals per 1,000


persons: National Health Survey estimates,unadjusted and adjusted to include expe­


rience of decedents by sex and age: Middle Atlantic States


Sex and age


Both sexes---


0-44------------


45-64-----------


65+-------------


Male----------


0-44------------


45-64-----------


65+-------------


Female


0-44------------


45-64-----------


65+-------------


Discharges Nights of care


Rate per 1,000 persons percent .Rate per 1,ooo Persons Percent


Unadjusted Adjusted increase Unadjusted Adjusted increase


90 98 9 895 1,016 14 

87 89 2 635 657 3 

97 107 10 1,356 1,559 

98 139 42 1,674 2,373 :: 

69 78 13 805 955 19 

57 59 4 520 544 5 

101 115 14 1,505 1,758 17 

83 129 55 1,219 2,090 71 

110 116 5 980 1,073 9 

116 117 1 746 766 3 

94 100 6 1,215 1,368 13 

111 147 32 2,060 2,525 23 

II


x 
--------------------

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

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

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

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

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

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

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

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

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

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

Adjustment of the 

Health Survey Estimates 

The health survey estimates of rates of discharges and nights in general hospitals during 

1957 per 1,000 midyear population by age and 

sex, unadjusted and adjusted, to include the hospital utilization of the population that died during 

1957 are presented in table 8. The adjustments 

of the health survey estimates for the omission 

of hospital utilization of decedents are greater 

for males than for females, and for both sexet~ 

the adjustments increase markedly with advancing 

age. The adjustment for deaths had minimal effect, at ages under 45 where the rates of hospital 

utilization, based on the health survey, are increased by less than 5 percent. At ages 65 and 

over, however, the increases in the hospital rates 

due to the adjustment are very substantial. The 

hospital rates at these ages are increased by 20 

to 30 percent for females and by more than 50 

percent for males. 

Table 9. Percentage of discharges and nights in general hospitals not covered in the 

National Health Survey by sex, age, and place of death 

Percent Volume not 

covered Deaths oc- Deaths not 

Sex and age in survey Total curring in occurring . 

Both sexes 

o-44 

45-64 . -------

65+--------------------------------* 

Male --------

0-44--------------------------------

45-64 

65+---------------------------------

Female 

0-44--------------------------------

45-64-------------------------------

65+---------------------------------

Both sexes 

o-44--------------------------------

45-64-------------------------------

65+ 

Male ----------------------------

0-44 

45-64-------------------------------

65+---------------------------------

Female 

0-44--------------------------------

45-64 -

65+----------------------------------

hospitals hosp~als 

Discharges 

230,000 100 88 12 

40,000 100 95 5 

76,000 100 92 8 

114,000 100 83 17 

134,000 100 87 13 

19,000 100 92 8 

52,000 100 92 8 

63,000 100 82 18 

96,000 100 89 11 

21,000 100 97 3 

24,000 100 90 10 

51>000 100 85 15 

Nights 

3,958,000 100 

488,000 100 

1,496,000 100 

1,974,000 100 

2,398 100 

260,000 100 

919,000 100 

1,219,000 100 

1,560,000 100 

228,000 100 

577,000 100 

755,000 100 

87 I 13 

92 8 

88 12 

84 16 

88 I 12 

90 10 

90 10 

85 15 

85 15 

95 5 

85 15 

82 I 18 

12 
-----------

-----------

--------

-----------

Hospital Utilization by the Population 

That Died Inside and Outside of Hospitals 

It was hypothesized that of the hospital utilization by decedents during 1957 considerably 

more would be utilized by the persons dying in 

hospitals than by the persons dying elsewhere. 

The hypothesis was confirmed by the results of 

the Mortality Survey (table 9). About 88 percent 

of the discharges and nights of care utilized by 

decedents and not counted in’ the health survey 

were accounted for by persons who died in hospitals. In contrast, only about 56 percent of the 

deaths occurred in hospitals. For discharges the 

percentage varies with the age of the decedent, 

ranging from 83 percent for the age group 65 

years and over to 95 percent for those under 45. 

This variation is due largely to the fact that the 

percentage of deaths occurring in general hospitals decreases with advancing age. This trend 

probably reflects greater utilization of specialized long-term hospitals and nursing homes by 

the ill and infirm at the older ages. 

The rates of discharges and nights of care 

in general hospitals per 1,000 deaths occurring 

in hospitals was roughly five times greater than 

those per 1,000 deaths occurring outside of hbspitals (table 10). It will be noted that the rates of 

discharges per 1,000 deaths occurring in hospitals 

is less than 1,000 for the older age groups. The 

explanation is that utilization of general hospitals 

only was counted in computing these estimates. 

Thus, there were a number of persons dying in 

hospitals, particularly at the older ages, for 

whom terminal discharges were not counted because death occurred in nongeneral hospitals. 

Table 10. Annual rate per 1,000 deaths of discharges and nights in general hospitals 

during the reference year for persons dying during the year by sex, age, and whether 

or not the death 

Sex and age 

Both sexes---

o-44------------

45-64 

65+-------------

Male ----------

o-44------------

45-64 

65+-------------

Female 

o-44------------

45-64 

65+-------------

Conclusions Regarding 

in the Middle Atlantic 

occurred in a hospital: Middle Atlantic States 

Deaths in hospitals I Deaths outside hospitals 

Estimated 

number per 1,000 

deaths 

per 1,000 

deaths number per 1,000 

deaths 

per 1,000 

deaths 

196,093 1,036 16>921 153,054 186 3,448 

33,244 1,127 13,556 13,929 185 2,667 

57,023 1,228 23,263 38,375 156 4,468 

105,826 906 15,627 100,750 198 3,163 

105,580 1,102 19,764 87,960 206 3,361 

17,171 1,000 13,676 10,613 190 2,381 

34,442 1,386 24,157 25,563 154 3,462 

54,217 955 18,866 51,784 234 3,505 

90,263 954 14,740 65,094 159 3,571 

16,073 1,276 13,414 3,316 167 3>667 

22,581 977 21,841 12,812 160 6,560 

51,609 850 12,000 48,966 158 2,779 

Discharges Nights Estimated Discharges Nights 

Haspital Utilization estimates of utilization of general hospitals deStates	 rived from the household interviews of the National Health Survey. For the 350,000 deaths that 

occurred in the Middle Atlantic States during 

According to the Mortality Survey, there 1957, it isestimatedthat about 230,000 discharges 

were 658discharges and 11,336 nights of care and ahnost 4 million nights of hospital utilization 

per 1,000 deaths that were not included in the were not covered in the estimates derived from 

13 
the health survey. When the National Health Survey estimates of utilization of general hospitals 

during 1957 are adjusted to include the experience 

of decedents, discharges were increased by abut 

9 percent and nights of care by about 14 percent.* 

By age, the size of the adjustment was greater for the older group; by sex, the size of the 

adjustment was greater for males. The reason 

for this is largely due to the fact that the death 

rate increases with advancing age and it is larger 

for males than for females. 

Place of occurrence of death is another variable correlated with the frequency of utilization 

of general hospitals by the decedents, Deaths occurring in hospitals represented only slightly 

more than half the total number of deaths but they 

accounted for more than four fifths of the hospital 

utilization not covered in the health survey. 

DERIVING ESTIMATES FROM THE MORTALITY SURVEY


As already indicated, data on hospital utilization during a 12-month period prior to death 

were obtained for a sample of about 2%percent of 

the deaths that were registered in the vital statistics offices of the Middle Atlantic States during 

April 1957. Estimates of hospital utilization 

during 1957 by the population that died during 

that year were derived from these data. Since the 

sample was not selected from all deaths occurring throughout the year, it was necessary to 

assume that hospital utilization during the 12 

months preceding death for persons dying in April 

was representative of the utilization by persons 

dying during the other months of the year. Specifically, it was assumed that the probability that 

a person received hospital care on the ith day 

(i=O, 1,....364) preceding death was the same for 

persons dying in every month during 1957 regardless of whether the hospital utilization occurred in calendar year 1957 or 1956. 

This assumption would have been unneces-, 

sary had the estimates been derived from an alternative survey design involving (a) the selection 

of a sample of deaths from those occurring 

throughout the calendar year 1957, and (b) the 

‘There is a definitional difference between a


discharge as used in the Mortality Survey and that


used in the National Health Survey. The National


Health Survey does not define an event as a hos.


pital episode or discharge unless the person


spends at least one night in the hospital, Thirty-


eight discharges were counted in the Mortality Sur­


vey that by definition would not have been count­


ed in the health survey because the admission and


discharge occurred on the same day. One of these


discharges occurred on the day before death and


37 were discharges by death. Had these discharges


been excluded in the Mortality Survey, the esti­


mate of discharges per 1,000 deaths not covered


in the health survey would be 603. The adjustment


factor would be about 8 percent. The revised es­


timates per 1,000 deaths occurring within and


outside of medical institutions would be 941 and


183, respectively


14 

exclusion of hospital utilization during the period prior to calendar year 1957. However, this 

alternative survey design had two disadvantages. 

It would have increased the duration of the period 

required to collect the data by almost a full year 

and it would have provided information onhospital utilization foraperiod prior to death averaging only about 6 months. The former disadvantage by itself contraindicated the alternative 

design because results were needed as quickly 

as possible. The latter disadvantage would have 

had the effect of increasing thesampling errorof 

the estimate. 

Estimating Process 

Define pi as the probability that a person 

who died during some specific preference year 

had utilized a general hospital (i.e., receiveda 

night of care or was discharged) on theiQ day 

preceding death (i = O, 1,...,364Th enu, thehe 

average hospital utilization during the reference 

year per death that occurred during that year is 

364 364 

(l)ii=	 “ z pi– 

5

i= 3:5 Pi 

i=o 

The first term of the formula,~ pi, represents the expected number of times that a person dying during the reference year utilized a 

general hospital during the full 12-month period 

preceding death. Thesecond term of the formula, 

I J- P.1. represents the expected number of QLC 

tim%”that- the utilization during the 12-month 

period prior to death was made prior to the reference year. 

Hence, the difference between the two terms 

is the expected number of times that a person 

dying during the reference year utilized general 

hospitals during the same year. In other words, 

the difference is the expected utilization of hospitals per death during the reference year that is 

not covered by the health survey. 
Estimates of the pi ‘s were derived from the 

information collected for the 695 deaths in the 

sample. For example, the probability of discharge on each of the i days preceding death was 

estimated as follows. Discharges within a 12-

month period prior to death that were reported 

by hospitals for the deaths in the sample were 

distributed by days prior to death on which the 

discharge occurred and each of these frequencies 

was divided by 695. In a similar manner the 

probabilities of nights of hospital utilization on 

successive days preceding death were estim~ted 

from the sample. The estimated values, Pi 1s, 

were substituted for pi’s in fcmmula (1) to obtain 

the estimate ii!* 

The estimated volume of hospital utilization 

during 1957 by the persons who died during that 

year was obtained by multiplying the mean estimate ii’ by D, the total number of deaths during 

the reference period. 

(2) U! . DC’ 

The value of D used is the number of deaths that 

occurred in the Middle Atlantic States during 

1957 obtained from Vital Statistics of the United 

States, 19S7, U. S, Department of Health, Education, ‘lind Welfare, Public Health Service, National Office of Vital Statistics, Volume II. 

Daily Variation in Hospital Utilization 

Within the Last Year of Life 

Within the 12-month period prior to death, 

there is a very marked increase in the daily utilization of general hospitals as the day of death 

approaches (table 11). The daily discharge rate 

per 1,000 deaths increases gradually from less 

than 1 during the twelfth month before death to 

*A somewhat simpler method that did not in­


volve deriving estimates of the pi’s was used in


verifying the computations


where d symbolizes the number of deaths in the


sample and where


1 if the Atb death utilized a hospital on the i‘h day


~ti­- 0 if the Ath death did not utilize a hospital on the

{ ith dq 

about 3 on the day before death. However, on the 

day of death the rate is about 400. The daily rates 

for nights of hospital utilization range from about 

15 during the twelfth month before death to more 

than 350 on the day of death. For nights of care, 

the rates are about the same for experiences between 6-12 months before death. The rates increase steadily during the 6 months prior to 

death. 

It will be noted that on the day of death, the 

probability of a discharge is greater than that for 

a night of care in a general hospital. This difference is accounted for by persons who died on the 

same day that they were admitted to the hospital; 

they were counted as having been discharged on 

the day of death, but they were not counted as 

having spent that night in the hospital. 

As shown in table 11, for virtually all periods during the l-year interval before death, the 

level of hospital utilization is greater for deaths 

occurring in hospitals than for other deaths. The 

difference, however, in the level of hospital utilization between the types of deaths is greater 

for nights than for discharges. 

The difference in the daily rates between the 

two types of deaths is obviously greatest on the 

day of death. It will be observed, however, that 

the rate of utilization of general hospitals on the 

day of death is not 100 percent for deaths occurring in hospitals, nor is it zero for deaths 

occurring outside of hospitals. There were a 

number of hospital deaths that did not occur in 

general or short-term hospitals; these were not 

counted as having utilized a general hospital on 

the day of death. On the other hand, there were a 

few deaths that did not occur in the hospital but 

had been discharged on the day of death from a 

general or short-term hospital; these were counted as having utilized a general hospital on the day 

of death. 

Because the probability of hospital utilization increases sharply toward the end of the last 

year of life, the hospital utilization during a specific year of reference for persons who die during 

that year accounts for most of the volume of utilization during the entire 12-month period before death (table 12). For example, considering 

all persons who died in the Middle Atlantic States 

during 1957, 83 percent of all their discharges 

and 74 percent of all their nights of care during 

the 12 months preceding death actually took place 

during 1957. 

15 
----------------

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

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

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

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

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

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

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

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

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

--------

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

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

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

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

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

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

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

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

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

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

Table 11. Daily rates of utilization of general hospitals per 1,000 deaths during se-


lected periods prior to death according to whether or not death occurred in a hos­


pital: Middle Atlantic States, 1957


Daily rates per 1.000 deaths


Discharges Nights of care
 Period prior to death


O-1 days 

1-2 days 

2-3 days 

3-4 days 

4-5 days 

5-6 days 

6-7 days 

O-1 week----------------


1-2 weeks


2-3 weeks


3-4 weeks---------------


O-4 weeks


4 weeks-2 months


2-3 months


3-4 months


4-5 months


5-6 months


6-7 months


7-8 months


8-9 months


9-10 months


10-11 months


11-12 months


Sample size


Deaths


r.otal Deaths in outside Total Deaths in


hospitals hospitals hospitals


417.3 740.4 6.5 366.9 650.4 

2.9 2.6 3.3 328.1 578.4 

1.4 2.6 O*O 300.7 532.1 

1.4 2.6 0.0 271.9 480.7 

0.0 0.0 0.0 256.1 452.4 

0.0 0.0 0.0 236.0 416.5 

2.9 0.0 6.5 211.5 370.2 

60.8 106.9 2.3 281.6 497.2 

3.5 3.3 3.7 185.0 307.4 

2.1 2.9 0.9 156.2 250.5 

2,1 2.9 0.9 121.9 195.0 

17.1 29.0 1:;.; 312.5 

1.9 2.3 ::: 134.8 

1.5 1.5 52:2 77.3 

1.3 1.7 U 37.4 49.0 

1.0 1.2 0.7 33.9 47.0 

1.0 0.9 23.6 27.8 

;:: 0.8 0.2 1509 17.1 

0.7 1.2 0.1 16.7 25.5 

0.8 1.1 0.4 19.1 28.5 

0.5 0.3 0.6 12.0 14.5 

0.6 0.8 0.4 13.0 16.5 

0.6 0.7 0.5 16.3 21.6 

695 389 695 389 

Deaths


outside


hospitals


6.5


9.8


6.5


6.5


6.5


6.5


9.8


7.5 

29.4 

36.4 

28.9 

25.6 

25.6 

20.3 

22.7 

17.2


18.2


14.4


5.5


7.1


8.9


8.7


8.0


306


16

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

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

-------- ---

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

----------

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

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

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

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

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

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

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

Table 12. Discharges and nights in general hospitals within a 12-month period prior to


death by sex, age, and whether or not the care was received during the reference 

year. Deaths during 1957: Middle Atlantic States


Percent


Total (in Sex and age Not received


thousands) Total during refer-


Both sexes


0-44--------------------------

45-64-------------------------

65+---------------------------

Male


0-44--------------------------

45-64-------------------------

65+-------- ---,.----

Female


0-44 -------- -.------

45-64-------------------------

65+---------------------------

Both sexes


0-44 --------

45-64-------------------------

65+---------------------------

Male


0-44 --------

45-64-------------------------

65+--------

Female


0-44--------------------------

45-64-------------------------

65+--------

49 

94 

136 

166


::


77 

112


23


30 

59 

5,379 

712 

2,050 

2,617 

3,313 r 

432 

1>235 

1,648 

2,046


280


817


949


ence year


Discharges


100 17 

100 17 

100 20 

100 15 

100 19 

100 14 

100 21 

100 18 

100 14 

100 14 

100 17 

100 11 

Nights


100 26 

100 32 

100 25 

100 24 

100 28 

100 40 

100 26 

100 27 

100 22 

100 19 

100 15 

100 20 

Received during


reference year


83 

83 

80 

85 

81


86


86 

83 

89 

74 

68 

75 

76 

72 

60 

74 

73 

78


17

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

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

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

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

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

Effect of the Length of the Reference 

Period in the Health Survey 

This study has indicated that the National 

Health Survey estimates of hospital utilization 

in the Middle Atlantic States should be adjusted 

by about 9 percent to include the experience of 

persons who died during the reference period of 

12 months prior to the interview. The following 

shows how the omission of decedent experience 

affects the health survey results when reference 

periods of different lengths are used. 

The average volume of hospital utilization 

during the reference period of R days per person 

dying during the period is 

R-1 R-1 

(3) ‘R = I P.–g I 

P. 1 i=o 1 i=l) 

where pi is the probability of hospital utilization 

on the i& day prior to death. 

Assume that independent estimates of hospital utilization during a time period of kR days 

are derived from two types of health surveys, 

one having reference periods of kR days and the 

other having a reference period of R days’ duration. In the former, a single survey is conducted 

at the end of the reference period of kR days. 

In the latter k surveys are conducted at intervals 

of R days during the period of kR days. The estimate of hospital utilization by the living population during the reference period of kR days 

derived from the k surveys each with a reference 

period of R days’ duration would be larger than 

Table 13. Estimates of hospital utilization 

that derived from the single survey with a reference period of kR days. The reason is that the 

single. survey would cover a smaller portion of 

the hospital utilization during the kR days by the 

deaths that occurred during that period. 

For the survey having a reference period 

of kR days, iikR is the hospital utilization 

per death during the kR-day period that would 

not be covered by the health survey results. 

For the survey having a reference period of 

R days, kiIR is the hospital utilization per 

death that would not be covered. According to 

formula (3) the expected difference between the 

hospital utilization per death during the time 

period of kR days that would not be covered 

in a single health survey with a reference 

period of kR days and k health surveys each 

covering a reference period of R days is 

R-1 kR-1 

(4) ‘kR - kiiR = (k-1)~ ipi + ~ (kR-i)p ; 

i=o i=R i 

From the viewpoint of maximizing the coverage of hospital utilization by decedents, the 

reference period in the health survey, obviously, should be minimized. This gain would, however, have to be weighed against the loss due 

to collecting less information per person in 

the health survey. The effect of the latter would 

be to increase sampling errors of the estimates 

of hospital utilization derived from the health 

survey. 

by decedents not covered in the health 

survey during a reference period of specified duration of less than 1 year compared 

with utilization during a reference period of 1 year’s duration: Middle Atlantic 

States, 1957 

Duration of reference 

period 

1 year 

6 months 

3 months 

1 month 

2 weeks 

1 week --------------------

Hospital utilization by decedents not covered in health 

survey 

Discharges Nights of care 

Per 1,000 deaths Percent Per 1,000 deaths Percent 

658 100 11,336 100 

572 87 8,772 77 

508 6,370 56 

451 U 3,328 29 -

432 66 1,980 17 

422 64 1>226 11 

18 
The duration of the reference period of 

1 year in the National Health Survey is not 

necessarily permanently fixed. It is therefore 

of more than purely theoretical interest to compare the estimates of discharges and nights 

of care presented in this report with those that 

would have been obtained assuming reference 

periods of shorter duration in the health survey 

(table 13). 

AS was to be expected, the rates of discharges and nights of care decrease without 

exception with decreases in the duration of the 

reference period in the health survey from 1 

year to 1 week. It is noteworthy, however, 

that the reductions in discharges are relatively 

small compared with the reductions in the nights 

of care. For a reference period of l-week 

duration, the reduction is less than 40 percent 

for discharges and about 90 percent for nights. 

The explanation is that, within the 12-month 

period prior to death, a very much larger proportion of the discharges than of the nights of 

care occur on the day of death. 

SAMPLING VARIABILITY OF ESTIMATES DERIVED


FROM THE MORTALITY SURVEY


Variability of Hospital Utilization 

by Decedents 

The estimates presented in this report were 

derived from sample data and consequently the 

estimates are subject to errors due to sampling 

variability. 

The previous section contains an exposition 

on the method of deriving estimates of ii the average volume per death of hospital utilization 

that is not covered in the health survey. The 

method assumed that all persons who died dur ­

ing 1957 had the same probability, pi of utiliz ­

th in~ a general hospital on the i day prior to 

death (i=O,1,...364). Under this assumption the 

sampling variance of G* the estimate of ii, was 

found to be 

‘This is equivalent to writing ~J = ~ ~A 

d 

wh, ru u,~ is the derived number of decedent dis. 

chnr~:cs ill the reference year for the Ath of D 

,Iischnrgc. s. \\’hen the experience is restricted to 

t 11t, tcrrninul epi sode only, joint probabilities 

II ru not involved and U2 is simpli fied to 

Uh 

364 U2 . ,~ Pi [(700 -i+l)(i)12 - ii2 ‘A 1-0 4(365)2 

where pi (i=l, ... 363) is the proportion of the


decedents who were admitted to the hospital on the


where p.. is the joint probability that the de­ lJ th th cedent was hospitalized on both the i and j 

days before death.* 

Population variances were estimated from 

the sample by the formula, 

(6) S:A= 35 (1- 365) ~ ‘ pi+ 

i=O 

364 

2 ~>j~’ (1- +5)(1- &5)fiij -T1’2 

where ~.. is the proportion of d deaths in the lJ 

sample h-ospitalized (i.e., discharged or uti ­

th lized a hospital overnight) on both the i and 

.th 

J days before death, and $i is the proportion of the sample hospitalized on the 1

.th day 

before death. The estimates of the standard 

deviations of discharges and nights of care by 

age and sex of the decedent and by whether or 

i ‘h day before death, and p364 is the proportion 

that were admitted 364 days or more prior to


death.


The estimated sampiing variance of the quan­


tity Ii’ becomes then, S$ = : ~2 

d UA “


i“he relative sampling errors (coefficient of variation expressed in percent) , obtained from the 

formula 

v:, = 100 [ s:, /(ij@4 u 

are assembled in table 17. 

19 
--------

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

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

not death occurred in a hospital is presented 

in table 14. Since the utilization of general 

hospitals is about 5 times greater for deaths 

occurring in institutions than for deaths occurring elsewhere, the standard deviations are 

considerably higher for estfmates of the former 

than for estimates of the latter. The standard 

deviations of discharges are about 50 percent 

greater for hospital deaths, and on the average, 

the standard deviations of nights of utilization 

are more than twice as large for hospital deaths 

than for nonhospital deaths. 

The calculation of S~Awas verified directly 

from the distribution of deaths by their hospital 

utilization during the reference year as follows 

. d 9 

(7) S:A= (uA-ii’)A 

I 

X=l ‘-1 

364 where 

‘A= ;0 (1-&5)uAi 

is the hospital utilization durfng the reference 

year of the ~th decedent in the sample. The 

random variable uAi is equal to 1 if the Am de­ .. 

cedent was hospitalized on the im day before 

death. It is equal to O if he was not hospital­

.th ized on the 1 day before death. The distributions of decedents in the sample by their ex-. 

petted number of discharges and nights of utilization during the reference year are presented 

in tables 15 and 16, respectively. 

Sampling Errors 

The percent sampling errors (coefficients 

of variation) of the esthnates of discharges 

and nights of care by age and sex of the decedent and whether or not death occurred fn 

a hospital are presented in table 17. For each of 

these classes of decedents, the relvariance of 

the sample estimate ii’ was computed by the formula 

s?, 

(8) Rel Var (ii’)= V:, = *)2 

The formula assumes simple random samplfng with replacement. 

Table 14. Standard deviations of estimates of hospital utilization during the reference year for decedents by sex and age and whethe; or not death occurred-in a hospital 

Sex and age 

Both sexes 

0-44--------------------

45-64-------------------

65+---------------------

Male ----------------

0-44--------------------

45-64-------------------

65+---------------------

Female 

0-44 

45-64-------------------

65+---------------------

Standard deviation 

Discharges I Nights 

Deaths 

Total Deaths In outs ide Total Deaths in 

hospitals hospitals II hospitals 

0.765 I 0.768 I 0.427 I 21.9 ] 26.0 

I I I I 

0.843 0.817 0.427 22.1 25.5 

0.939 0.957 0.410 26.0 28.5 

0.630 0.597 0.435 19.4 24.3 

0.818 0.831 0.455 23.3 28.3 

0.824 0.854 0.442 25.0 30.9 

1.055 1.082 0.419 24.9 28.5 

0.635 0.564 0.476 21.7 27.2 

0.688 0.675 0.383 19.9 22.5 

0.826 0.760 * 16.8 17.7 

0.685 0.653 0.397 28.0 28.8 

0.622 0.629 0.382 16.2 20.0 

Deaths 

outs ide 

hospitals 

10.9 

6.54 

16.4 

8.53 

8.99 

5.88 

10.9 

8.55 

13.2 

* 

24.2 

8.154 

* 

Sample size too small to estimate standard deviation 

20 
---------------- ---

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

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

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

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

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

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

-----------

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

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

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

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

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

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

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

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

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

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

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

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

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

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

-------- ---

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

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

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

Table 15. Percent distribution of decedents by their derived number of discharges


during the reference year and whether or not death occurred in a hospital: Middle


Atlan;ic States, 1957-


Derived number of discharges during 

the reference year 

Total Deaths in 

hospitals 

Deaths outside 

hospitals 

Total -..------ 100.0 100.0 100.0 

None-------- ----.--- 45.8 19.8 78.8 

1/365 tO 1/2 2.3 0.7 4.2 

183 to 364---.--m-- 7.6 4.4 11.8 

m m 

1-------- --,------ 28.8 50.9 0.7 -.------ 4.0 4.9 2.9 

1 1/2 to 2-------- --.----- 7.9 13.4 1.0 

1 to 1 1/2----..---


2 to 2 1/2---------------------------- 1.2 1.8 0.3


2 1/2 to 3----”-----------., 1.2 1.8 0.3


3 to 3 1/2 0.3 0.5 0.0 

3 1/2 and over 1.0 1.8 0.0 

Sample size 695 389 306 

Mean-------- ‘0.658 1.036 0.186 

Standard deviation 0.765 0.768 0.427 

Coefficient of variation 1.166 0.741 2.296 

Table 16. Percent distribution of decedents by their derived number of nights of hos-


pital care during the reference Year, and whether or not death occurred in a hospitsh


~iddle Atlantic ~tates, 1957 - -


Derived number of nights of care Total Deaths in Deaths outside 

during the reference year hospitals hospitals 

Total-----..,. 100.0 100.0 100,0 

None-------- 49.4 26.2 78.8 

1/365 to 10-------- 22.1 31.9 

10 to 20“------- 9.1 12.6 ::: 

20 to 30 6.6 8.7 4.0 

30 to 40-!------- 3.1 4.9 1.0 

40 to 50--.---------”--- 2.6 4.4 0.3 

50 to 60------------------------------ 4.1 0.6 

60 to 70-“------ ::; 2.3 0.3 

70 to 80------- 0.9 1.5 0.0 

80 and over ----.-----.----- 2.0 3.4 0.3 

Sample size 695 389 306 

Mean--------- 11.3 16.9 3.45 

Standard deviation 21.9 26.0 10.9 

Coefficient of variation 1.93 1.54 3.16 

21

-------

Table 17. Percent sainpling errors of estimates of discharges and nights of care in 

general hospitals during 1957 for persons who died during 1957 by sex, age, and 

whether or not death occurred in a hospital: Middle Atlantic States 

I Total Deaths in hospitals 

Deaths outside I hospitals 

Sex and age 

Num- Percent samber pling error Num- Percent samber pling error 

in in 

sam- Dis- Disple charges Nights samchar ges Nights 

ple 

Both sexes-- 695 I 4.5 I 7.4 389 

I I 

o-44----------- 90 10.5 22.6 63 9.1 23.7 27 45.2 47.2 

45-64---------- 191 8.6 12.0 114 7.4 11.5 77 28.6 41.6 

65+------------ 414 5.6 10.0 212 4.6 10.7 202 15.6 19.0 

Male --------- =-l---b 216 

I 

5.21 

I 

9.8 180 I 

I 

16.8 \ 

I 

20.0 

o-44----------- 55 16.1 26.1 34 14.6 38.8 21 51.8 54 � 1 

45-64---------- 122 11.2 14.7 70 9.5 14.2 52 38.7 43.5! 

65+------------ 219 7.2 12.9 112 5.7 13.6 107 20.0 23.7 

Female 299 6.5 I 11.5 173 I 5.5 I 11.6 

I I 

o-44----------- 12.8 24.2 11.1 24.5 6 * 

45-64---------- :; 12.0 20.7 :: 10.1 19.7 25 41.: 73.8 

65+------------ 195 8.9 15.4 100 7.6 16.6 95 25.0 31.6 

E

3.8 7.5 306 13.1 18.1 

I I 1 I

* 

Sample size too small to compute sampling error. 

The coefficients ofvariationof the estimates the nonhospital deaths are more than twice at~ 

of nights are more than 50 percent larger than large as the estimates of hospital utilizationb!~ 

those for discharges ,and the coefficients ofvar- the deaths occurring inhospitals. 

iation of the estimates of hospital utilization by 

SAMPLE DESIGN FOR 

A NATIONAL MORTALITY SURVEY 

This project was undertaken to develop and 

to test a survey method to collect national statistics of hospital utilization during the l-year 

period prior todeath in order toderive estimates 

of hospital utilization by the decedents that are 

not covered in the National Health Survey. The 

experimentaland substantivefindings ofthe Mortality Survey in the Middle Atlantic States that 

have been presented in this reportprovide abasis 

for designing a national mortality survey that 

would assure stated precision in the estimates 

at minimum cost. 

Optimum Stratification 

by Place of Death 

Whether or not death occurred in aninsti­

‘tution is a fact discernible from thedeathcertificate. It has been shown that there are substantial differences between hospital and nonhospital deaths in data collection costs and il 

the variances of the utilization of general hospitals prior to death that are derived from th~ 

Mortality Survey. Optimum allocation ofthenational sample to two strata according towhether 

22 
or not death occurred in an institution would, in 

this instance, substantially increase the precision of the estimates per dollar costs as compared with estimates derived from a simple random sample. 

The experimental findings of the mortality 

survey conducted in the Middle Atlantic States 

that were presented earlier indicate that it is not 

necessary to conduct a survey of family informants for deaths that occurred in hospitals. As a 

result, the per unit costs of data collection would 

be more than twice as large for nonhospital deaths 

than for hospital deaths because for the former 

it would be necessary to conduct a survey of 

both family informants and of the hospitals utilized by the decedent and for the latter it would 

be necessary only to conduct a survey of the 

hospitals utilized by the decedent. 

On the other hand, the standard deviation of 

the distribution of deaths by hospital utilization 

not covered in the health survey in the Middle 

Atlantic States is about twice as large for hospital deaths as for nonhospital deaths. The ratio 

of the standard deviations of hospital deaths to 

nonhospital deaths is about 1.75 for discharges 

and about 2.5 for nights. 

According to a well known formulaG the optimum allocation of the sample to strata that 

gives the most information per dollar is obtained 

when ~, the number in the sample taken from the 

h th stratum is 

(9) nh = n ‘h ‘h/& 

& (Nh ‘h/&) 

where Nh, Sh, and Ch are the population size, 

standard deviation, and per unit cost in the hm 

stratum and n is the total sample size over all L 

strata. 

Assuming the findings of the Mortality Survey that the per unit data collection cost would 

be about one half as large for hospital deaths as 

for nonhospital deaths and that the standard deviation would be almut twice as large for hospital deaths as for the nonhospitai deaths, then the 

optimum allocation of the national sample decrees 

that about 80 percent of the deaths would be selected from the stratum of hospital deaths. Since 

about 60 percent of the national deaths occur in 

the hospitals, optimum allocation to strata implies that hospital deaths would be selected at 

almost triple the sampling rate of nonhospital 

deaths. 

Additional economies by stratification would 

be realized if hospital deaths were subdivided into two strata according to whether or not death 

occurred in a general hospital. The per unit data 

collection costs for deaths occurring in nongeneral hospitals would be about the same as those 

for deaths occurring in general hospitals, but the 

standard deviation of the distribution of general 

hospital utilization would be considerably smaller 

for the deaths in nongeneral hospitals. 

The utilization of general hospitals by the 

population that died in resident medical institutions in the Middle Atlantic States contributed 

very little to the estimates of utilization by the 

decedents presented in this report. From the 

conceptual viewpoint it is questionable whether 

persons dying in resident institutions should have 

been included in this Mortality Survey. Since estimates of general hospital utilization in the 

Middle Atlantic States derived from the National 

Health Survey covers only the noninstitutional 

population the estimates derived from the Mortality Survey that wer~ used to adjust the health 

survey estimates for hospital utilization by decedents should have excluded the resident institution population also. Similarly, the national estimates of hospital utilization derived from the 

National Health Survey cover only the noninstitutional population. * 

Sampling Errors of 

National Estimates 

Assuming the variances and costs derived 

from the Mortality Survey conducted in the Middle Atlantic States and the optimum allocation of 

the sample stratified by place of death within and 

outside of hospitals, expected sampling errors 

were computed for estimates of hospital utilization by decedents that would be derived from 

national samples ranging in size from 1,000 to 

10,000 deaths. Expected sampling errors are 

shown separately for discharges (table 18) and 

nights of care (table 19). 

*The distribution of national deaths durincj 

1958 by type of institution in which death Occurred is Percent 

Total death s...... . . . . ..Ioo 

Deaths in general hospitals . . . . , . . 48 

Deaths in other nonresident hospitals . . 3 

Deaths in resident hospitals. . . . . . . 10 

Deaths outside of hospitals . . . . . . . 39 

Source : Vital Statistics of the dnitetl States, 

1958. vol. II, i.lat ional Office of Vital Statistics, Department of Health, Education, and Welfare. In print. 

23 
----------

----------

Table 18. Expected sampling errors of estimates of hospital discharges during the rderence year involving decedents by sex and age, that would be derived from a na­


tional mortality survey of specified sample sizes


Total number of deaths in the sample


Sex and age 1,000 2,000 3,000 4,000 5,000 7,500 10,000 

Coefficient of variation


Both sexes---- 3.1 2.2 1.8 1.6 1.4 1.2 1.(I 

0-44---------------- 6.9 4.9 4.0 3.5 3.1 2.6 2.:! 

45-64--------------- 4.0 3.3 2.9 2.6 2.1 1.$ 

65+----------------- ::; 3.0 2.5 2.1 1.9 1.6 1.LL 

Male------------ 4.2 3.0 2.5 2.1 1.9 1.6 1.4 

0-44---------:------ 11.4 8.1 6.6 5.7 5.1 4.2 3.6 

45-64--------------- 7.3 5.2 4.3 3.7 3.3 2.7 2.4 

65+----------------- 5.5 3.9 3.2 2.8 2.5 2.0 l.@ 

Female 4.5 3.2 2.6 2.3 2.0 1.7 1.5 

0-44---------------- 8.2 5.8 4.7 4.1 3.7 3.0 2.:i 

4R$4------------”-- 8.2 4.8 4.1 3.7 3.0 2.6 

65+----------------- 6.5 H 3.8 3.3 2.9 2.4 2.1, . 

Table 19. Expected sampling errors of estimates of nights of hospital care during the


reference year involving decedents by sex and age, that would be derived from a na­


tional mortality survey of specified sample sizes


Total number of deaths in the sample


Sex and age


1,000 2,000 3,000 4,000 5,000 7,500 10,000
 .


I Coefficient of variation


o-44---------------- 15.6 11.0 -3--3-% 5.7 5.(I 

45-64--------------- 9.3 6.6 5.4 4.7 4.2 3.4 3.(I 

65+----------------- 7.6 5.4 4.4 3.8 3.4 2.8 2.!i 

Male------------ 7.0 5.0 4.1 I 3.5 I 3.2 

I 

0-44---------------- 27.0 19.1 15.6 13.5 12.1 9.9 8.(I 

45-64--------------- 10.7 7.6 6.2 5.4 4.8 3.9 3.:1 

65+----------------- 9.7 6.9 5.6 4.9 4.4 3.6 3.1. 

Female 9.2 6.5 5.3 I 4.61 4.2 

0-44---------------- 17.5 12.4 10.1 8.8 7.9 6.4 5.(1 

45-64--------------- 17.3 12.2 10.0 8.7 7.8 6.3 5.!1 

65+----------------- 12.1 8.6 7.0 6.1 5.4 4.5 3.$, 

Both sexes---- I 5.61 4.0 2.1 I 1.11
 .


24

------

---------

It is pertinent to consider, also, the sampling errors to be expected in national estimates 

of total utilization of general hospitals based on 

the sum of (a) estimates of utilization by the 

living population derived from the National Health 

Survey, and (b) estimates of utilization by decedents derived from a national mortality survey. 

The variance of the estimate of total hospital 

utilization is 

where U~ is the estimated volume of hospital 

utilization by the living population and LJ~ is the 

estimated volume of hospital utilization by decedents. 

Standard errors of national estimates of selected statistics on the annual volume of hospital 

utilization based on the household interviews of 

the National Health Survey have been published 

(table 20). They are 5 to 10 times larger than the 

expected standard errors of comparable statistics 

for decedents based on a mortality survey of 

alx)ut 1,000 deaths. Consequently, the sampling 

error of estimates of total utilization of general 

hospitals would be completely dominated by the 

standard errors of the estimates derived from 

the National Health Survey. 

SUMMARY AND 

Estimates of the annual volume of hospital 

utilization by the national population are based 

on data collected in the household interviews of 

the National Health Survey. The interviews obtain information on hospital utilization during a 

reference period of 12 months before the week of 

the interview by each resident in the household. 

The household interviews do not, however, obtain 

information on hospital utilization by the persons 

who would have been residents of the household 

except for the fact that they had died during the 

reference year. Thus, the annual estimates derived from the health survey do not include the 

hospital utilization by the population that died 

during the year. To obtain estimates of the total 

volume of hospital utilization, the estimates derived from the household interviews of the National Health Survey have to be supplemented by 

estimates of hospital utilization by decedents. 

This report presents the results of a research project that was undertaken to develop 

and to test a method for ascertaining the volume 

Table 20. Standard errors of estimates 

of selected statistics on annual utilization of short- stay hospitals derived 

from the National Health Survey 

The statistic Sample 

estimate 

Standard 

error 

Total discharges 

from shortstay hospitals- 16,700,000 270,000 

Total discharges 

from shortstay hospitals 

for persons 65 

years of age 

and older 1,800,000 90,000 

Total number of 

days of hospitalization for 

persons discharged from 

short-stay hos ­

pitals .43,300,000 7,400,000 

Source: U. S. National Health Survey. Hospital ization, Pat i ents Discharged From Short-Stay 

Hospitals, United States, July 1957-June 1958. 

Health Statistics. Series 8-7. Public Health 

Service Publication No. 584-B7. Public Health 

Service, Washington, D. C., December 1958, p. 35. 

CONCLUSIONS 

of hospital utilization during a reference year by 

persons who died during that year. The method 

involved collecting data on utilization of general 

hospitals during a 12-month period prior to death 

for a sample of decedents selected from death 

certificates registered in State Health Departments. There were two distinct phases to the 

project— a theoretical and an applied phase. 

The theoretical phase of the project involved 

a consideration of hospital utilization during the 

last 12 months of life as a stochastic process. 

Formulas were derived for computing unbiased 

estimates of hospital utilization by decedents 

during a reference period of specified length and 

for computing the sampling variability of these 

estimates. The derivations are contained in Appendix II. 

In the applied phase of the project, the Mortality Survey was conducted in the Middle At&mtic States involving 695 deaths that were selected 

from death certificates registered in the State 

Health Departments during April 1957. This sur25 
vey was designed to serve as a pilot study to 

gain experience that would be needed in order to 

design an efficient national mortality survey. In 

the pilot study, information on hospital utilization 

during the 12-month period prior to death was 

collected from family informants and from hospitals utilized by the decedents. ‘The data collection procedures of the piIot study were analyzed with the view to determining a procedure 

to be applied in the proposed national survey that 

would produce accurate national data at minimum 

costs. The data collected in the pilot study were 

used to derive estimates of general hospital utilization during the reference year by decedents 

as well as to derive sampling errors of these estimates. The estimates were then used to adjust 

those based on the National Health Survey household interview data. 

According to the Mortality Survey, there 

were 658 discharges and 11,336 nights of care 

per 1,000 deaths that were omitted from the estimates of utilization of general hospitals derived from the household interviews of the National Health Survey. The health survey estimates 

of utilization of general hospitals during 1957, the 

reference year, were increased by about 9 percent for discharges and by about 14 percent for 

nights of care after adjustment for the 230,000 

discharges and almost 4 million nights involving 

abut 350,000 deaths that occurred in the Middle 

Atlantic States during 1957 (see footnote on p. 

14). 

By age, the size of the adjustment was greater for the older group, by sex, it was greater for 

males. Thus, for the ~pulation 65 years of age 

and older, the adjustment increased the health 

survey estimates by more than 25 percent for females and by more than 50 percent for males. 

Place of death was another variable correlated with the frequency of utilization of general 

hospitals by decedents. Deaths occurring in hospitals represented only slightly more than half 

the total number of deaths but they accounted for 

more than four fifths of the hospital utilization 

not covered in the health survey. The utilization 

of general hospitals during the reference year 

was about 5 times greater for deaths occurring 

in institutions than for deaths occurring elsewhere. 

Place of death was an important variable 

also from the viewpoint of data collection procedures. For deaths occurring in hospitals, it is 

not necessary to conduct a survey of family informants. It was estimated that about 95 percent 

of the utilization of general hospitals during the 

reference year was reported by the hospital iden- “ 

tified on the death certificate as the place of 

death and by other hospitals referred by this 

source. Only about 5 percent of the utilization by 

these terminal cases was reported by hospitals 

that would not have been identified except for the 

survey of family informants. 

For deaths occurring outside of hospitals, 

it is necessary to conduct a survey of the family 

informants in order to identify the hospitals utilized by these decedents. It is necessary subsequently to conduct a survey of each of these 

hospitals in order to obtain accurate data on episodes of hospitalization. It appears, however, that 

a mail survey of informants without provision fop 

followup by personal interview with nonrespondents would be sufficient. The utilization reported 

by hospitals that were identified in the interviews 

with informants accounted for less than 2 percent of the total hospital utilization during the 

reference year. 

Assuming that the per unit data collection 

Costs would be larger and the variability of the 

statistics would be smaller for nonhospital than 

for hospital deaths as found in the Mortality Survey, optimum allocation of the national sample 

indicates that hospital deaths should be selected 

at almost triple the sampling rate of nonhospital 

deaths. 

The expected sampling errors of national 

estimates of utilization of general hospitals during 

the reference year by decedents are surprisingly 

small. The coefficients of variation of the estimates of discharges range from 1 to 3 percent 

and for nights of care from 2 to 6 percent for 

samples based on 1,000 to 10,000 deaths. The 

coefficients of variation are relatively small also for estimates by sex and broad age groups. 

Sampling errors of national estimates of the 

annual volume of hospital utilization derived from 

the National Health Survey are considerably 

larger than the expected sampling errors of 

comparable statistics” for the decedents based on 

a national mortality survey of about 1,000 deaths. 

In fact, the sampling error of estimates of total 

utilization of general hospitals would be dominated by the sampling errors of the estimates 

for the living population derived from the National 

Health Survey. 

In planning for a national mortality survey, 

consideration should be given to a program for 

conducting a continuous national mortality survey in order to collect hospital utilization data 

for a relatively small sample of deaths annually. 

The Mortality Survey in the Middle Atlantic States 

demonstrated the feasibility of a method for estimating total hospital utilization by supplementing the statistics from the National Health Survey 

with estimates of utilization by decedents derived 

from a survey “anchored to the death record. ” 

Since the expected sampling errors of estimates 

to be derived from a national mortality survey 

appear to be negligible compared with the sampling errors of estimates based on the National 

Health Survey, a sample of a few thousand deaths 

26 
* 

or less would be sufficient to assure reliable 

annual national estimates of total hospital utilization. 

There would appear to be several advantages 

to a program for conducting a continuous mor ­

tality survey of hospital utilization of several 

years’ duration. The one-time costs of getting 

the national survey underway during the first year 

would be amortized over several years. Annual 

estimates of total hospital utilization could be 

derived for a series of years, and combining the 

data for 2 or more years would permit greater 

detail in the tabulations. In addition to the need 

for these data in order to supplement health survey data and thereby obtain estimates of total 

hospitalization, the data would appear to be potentially useful also as supplements to the regular 

mortality statistics derived from statistical data 

reported on the death certificate. 

REFERENCES 

1. A general discussion of the main features


of surveys !tanchored to vital records” is pre­


sented in Sirken, M. G. , and Dunn, H. L. : Expand­


inq and Improving Statistics. pub. Health ReP. 73:


537-S40, June 1958.


2. U. S. National Health Survey. Hospitaliza­


tion. Patients Discharged From Short-Stay Hospi­


tals, United States, July 1957-June 1958. Health


Statistics. Series B-7. Public Health Service publication No. 584-B7. Public Health Service, Wash­


ington, D. C., December 1958.


3. For a detailed description see The Statis­


tical Desiqn of the Health Household-Interview


m. Health Statistics, Series A-2. public


Health Service Publication No. 584-A2. Public


Health Servicej Washington, D. C., July 1958.


4. Falk, I. S., and Brewster, A. W.: Hospi.


talization Insurance and HOspital Utilization


Among Aged Persons,. March 1952 Survey, Social Se­


curity Bulletin 15:3-13, Nov. 1952.


5. Siegel, B, M.; Belloc, N. B.; and Hesse,


F. E.: Household surveys for hospital planning:


adjustment for decedents missed. Pub. Health Rep.


72: 989-997, November 1957.


6. Hansen, M. H.: Hurwitz, W. N.; and Madow,


W. G.: Sample Survey Methods and Theory. Vol. I.


John Wiley & Sons, Inc., New york, N.y., 1953.


p. 221.


27 
APPENDIX I 

‘GLOSSARY OF TERMS 

The following are definitions of selected terms relating tohospitalization andtothe survey which havea 

specialized meaning in this report. 

Terms Relating to Hospitalization 

in the Mortality Survey 

Hospital. —A hospital is any medical institution 

listed either in the Directory of the American Hospital 

Association or in the State hospital plans prepared under the Hill-Burton Act. 

General hospital. —A general hospital is one listed 

in the Directory of the American Hospital Association 

as providing a “general” type of service. 

Hospital episode. —A hospital episode is a period 

of stay in a hospital beginning on the day of admission 

and ending on the day of discharge. The period of stay 

of a well, newborn baby is not considered a hospital 

episode. However, an admission and discharge on the 

same day is considered an episode. 

Hospital admission. —A hospital admission is a 

hospital episode that began during a 12-month period 

prior to death. Patients dead on arrival (DOA) in the 

hospital are not counted as hospital admissions. 

Hospital discharge. —A hospital discharge is a hospital episode that ended during a 12-month period prior 

to death. 

Night of care .—A night of care is a night on which 

the decedent had been confined to a hospital during the 

USED IN THIS REPORT 

12-month period prior to death. A hospital episode for 

which the dates of admission and discharge are the 

same is not counted as a night of care. 

Terms Relating to the Mortality Survey 

Referral institution .—A referral institution is an 

institution other than the 

from which the decedent 

the 12-month period prior 

Survey, these institutions 

death certificate informant 

on the death certificate 

occurred. 

one in which death occurred 

had been discharged during 

to death. In the Mortality 

were identified eitner by the 

or by the institution listed 

as the place in which death 

Informant. —The informant is the person whose 

name is recorded on the death certificate as having 

provided the funeral director with the personal information alxmt the decedent for completion of the death 

certificate. The informant is usually some close relative of the decedent who is acquainted with the facts 

required for the death certificate. 

The reference period.—The reference period is a 

calendar time period for which information on hospital 

utilization is collected. The reference period in the 

National Health Survey for hospital data is the 12 months 

prior to the week of interview. This same 12-month 

period is also considered the reference year for the 

Mortality Survey. 

28 
APPENDIX II 

DERIVATION OF FORMULAS 

Hospital Utilization Not covered The size of UR increases as R increases. This may 

in the National Health Survey be seen as follows-:-Consider a survey covering a referAssume that every person intbe household inter- ence period of kR days. According to formula (3) 

view of the National Health Survey is interviewed at the


same instant of time and that information is collected kR-1


retrospectively for a reference period of R days’ dur- ‘kR ~ (kR-i)pi


ation immediately preceding the interview. Then, UR, ‘kR = ~ i=o


the volume of hospital utilization during the reference 

period by persons who died during that time period is, kR- 1 

(1) rJR . ; ad Xd 

kR { i =() i.R } 

d=l 

kDR R-1 D 

The symbol ad represents the average amount of hos- =—.— ~ (R-i)pi+m kR (k-1) ‘~liPi + 

_ ‘kR ‘~l@R - ki +ki _— - i)pi + Z (kR - i)pi

pital utilization (i.e., nights, discharges) during the 

R i=() { i=o 

th 

reference period by the Xd deaths occurring on tie d 

day of the reference period. In other words, formula 

(1) represents the volume of hospital utilization during 

the reference period for persons who died during that 

kR-1 

~ (kR - i)pi 

i.R } 

period, and consequently, not covered in the health 

survey, ‘kR Define pi as the probability that a decedent had =kUR+ — (k - I) ‘~liPi + ‘5-1 O@ - i)pi} 

been hospitalized (i.e., spent a night in a hospital, or kR { i=O i.R 

discharged from a hospital) on the iti day preceding 

death (i = O, l,.,., R ,... ,), Assume that the pi are con- It will be noted that the first term of the almve formula 

is the hospital utilization by decedents that would not 

stant over the reference period. Then 2id is equal to be covered in estimates derived from k weekly health 

Pi. Substituting this expression for ad in formula The expected difference between the hospital utilization 

(l), the expression becomes by decedents not covered in a single health survey 

covering a reference period of kR days and k health 

surveys each covering a reference period of R days is 

R d-1 

(2) UR=~ ‘d ~ Pi R-1 kR-1 

‘4) UkR - kUR ‘kR (k-1) ~ ipi + ~ (kR-i)pi 

surveys each covering a reference period of R days. ~ 

= ~R 

d=l i=() { i=o i=R } 

Assuming that the deaths are uniformly distributed


over the reference period, formula (2) becomes Unbiased Estimate


Estimates of hospital utilization by decedents not 

covered in the health survey were based on a sample 

of d deaths selected from D deaths and were derived 

from the following formula. 

R-1 

where DR is the number of deaths occurring during the (5) u’ .+ $=1 i~ (l--&i 

reference period of R days. 

29 
=

Terminal Hospitalization Nat 

1 if the Xm decedent in the sample utilized 

a hospital (i.e., night or discharge) on the Cavered in the Health Survey 

ith For the decedents, assume that there is a single where uAi = day prior to death discharge during the reference period prior to death 

O if the ~h decedent did not utilize a hospi- and that the discharge is due to death. The number of Ital on the i* day prior to death discharges not covered in the health survey, ~, it; 

This estimate is unbiased, (7) J=D7T 

d R-1 where 7Tis the probability of death occurring in a hosE(U’) = ~ ~=1 i~o (L - ~) E(uAi) pital, among D deaths occurring during the referenc,t 

period. The nights not covered in the health survey~ 

R- 1 is 

=D ~ (l-~)pi =U 

i=l) R-1 

(8)~ = ~ ~. (R-i)pi = K ‘%1 i=o (R-i)r~+lR ‘r 

Variance af the Estimate where pr 1r=l,... (R-1)] represents the probability that

Assume simple random sampling of deaths with re- a decedent was admitted to the hospital on the rthda:f 

placement, then before death. pR is the probability that a decedent wa:; 

admitted to a hospital prior to (R-1) days before death. 

It follows that pi . ~ pr when it is assumed that al 1 

r=i+l 

discharges are due to death; hence, the nights of hoc. 

D2 d R-1 vitalization are clustered during a period of consecutiw, 

.— E 

d2 A=1 

z 

[ i=(J (1-; )26: 

ii + days prior to death. 

Formula (8) may be simplified as follows: 

R-1 R-1 R 

XZ (1 - :)(1 -i)“ ~(uxiu ~j) (9)/4= : i~o (R - i) ~ Pr 

i#j=O 1 r=i+l 

Pr .—

D2 

z

d 

R~l (1 - #/2 Pi(l - Pi) + ~rfl ‘~ol (R -i) 

[ 

R-1 

IX (1 - +)(1 - ~)(Pij - PiPj) 

i#j=O 1 R-r 

=~~pr~i.~i 

r=l [1 

i=l i=l 

After some algebraic simplification, this becomes .:; pr JY+L(wf-r’l 

r.1 [ ! 

d2 x=l j,. O [1 

~2 R-1 . 

(6) 62U, . ~ ~ (l-&pi + 

{ i=l) =~f (r)(2R-r+l)pr 

r.1 

U2 The variance of}; an estimate of~ based on a simple ~~ (1 - +)(1 ‘~)Pij - ~} random sample of d deaths selected with replacemem i#j=O is 

where pij is the probability of the decedent being hospitalized on both the iti and j* days prior to death. 

30 * U.S. GOVERNMENT PRINTING OFFICE : 1965 0-775-581 
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No. 1. 

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%, 0. 1. 

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1