Daia Evaluation and Methods Research Series 2

Number 22

Three Views of

Iiypertemsion and

Heart Disease

Examination diagnoses t)f hypertension and heart disease made

in the first cycle of the Health Examination Survey are compared with reports of these diseases on a self-administered

medical history and on an inquiry completed by the person’s

own physician.

DHEW Publication No. (H RA) 74-1289

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

Public Health Service

Health ResourcesAdministration

National Center for Health Statistics

Rockville, Maryland
NATIONAL CENTER FOR HEALTH STATISTICS

EDWARD B. PERRIN, Ph. D., Director

PHILIP S. LAWRENCE, SC.D., Deputy Director

DEAN E. KRUEGER, Acting Associate Director for Analysis

GAIL F. FISHER, Associate Director for the Cooperative Health Statistics System

ELIJAH L. WHITE, Associate Director for Data Systems

IWAO M. MORIYAMA, Ph. D., Associate Director for Internatiowd Statistical Programs

EDWARD E. MINTY, Associate Director for Management

ROBERT A. ISRAEL, Associate Director for Operations

QUENTIN R. REMEIN, Associate Director for Program Development

PHILIP S. LAWRENCE, SC.D., Acting Associate Director for Research

ALICE HAYWOOD, Information Officer

Vital and Health Statitics-Series 2-No. 22

DHEW Publication No. (HSM) 74-1289

.
CONTENTS

Page

Sources of Information -------------------------------------------------

Major Comparisons ---------------------------------------------------

Total Prevalence ---------------------------------------------------

Certainty of Diagnosis ------- ------- ------- ------- ------- -------- ---

KtidofHeart Disease -----------------------------------------------

Conceptual BasisofComparisons ----------------------------------------

~eMedicd History ---------------------------------------------------

Examination Cases by Medical History --------------------------------

Demographic Fideli~-----------------------------------------------

Age and Sex--------------------------------------------------------

Other Demographic Variables ----------------------------------------

Symptoms as aDia~ostic Tml-----------------------------------------

~e PhysicianInquiry --------------------------------------------------

‘l%e Physician Inquiry as a SurveyInstrument --------------------------

Nonres~nse -------------------------------------------------------

Other Variables ----------------------------------------------------

lhe Medical History From the Viewpoint ofthe Physician Inquiry --------

Conclusion -----------------------------------------------------------

SomeQualifications of theData ---------------------------------------

Last ~oughts ------------------------------------------------------

References -----------------------------------------------------------

Detailed Tables -------------------------------------------------------

Appendix I.

A. Medical History Questions Related to Cardiovascular Disease --------

B. Forms Used in Recording Findings on the Physical Examination ------

C. Physicia Inqtiy Fore ------------------------------------------

1

2

2

2

4

4

5

6

7

7

7

9

10

10

11

12

12

12

12

13

14

15

32

36

43
IN THIS REPORT compam”son is made between diagnoses of hypertension and heart disease made by the HeaJth Examination Survey and those

vepovted on a self-administered medical history and by the personal physician.

DuYi?ig 1960-62 the U.S. Health Examination Suvvey examined 6,6?2

adults-a sample of the population of the Um”tedStates between ages 18

and 79 yeavs. This yielded careful medical diagnoses of heart disease

and hypertension, For the same pevsons and the same diagnoses, information is also available from a self-administered medical history.

In addition, for a small group of these examinees, reports were obtained

from theiv personal physicians.

The examination yielded more cases of heart disease and hypertension

than eithev the self-administered medical history OYthe reports by the

personalphysician. If a case was veported as definite by the examination

or the personul physician, the likelihood that another vepovting system

would agvee with this diagnosis was greater than if the case was veported as suspect or bo~derline.

Diqyzoses veported on the self-admim”stered medical history were

likely to be covrobovated by the survey examination when they indicated

a physicians diagnosis but not when they indicated self-diagnosis. Hypertension symptoms reported on the medical histovy weve fwnd not to

be associated with the subsequent hypertension diagnosis onexamination.

Repovts of heavt disease and hypertension by a pevsonalphysim”an, while

move conservative than the diagnoses by the .sWvey examination, weve

likely to be corroborated by it.

I

Category nonapplicable ------------------ . . .

I

Quantity zero -------------------------- -

I

1

Quantity more than Obut less than 0.05---- 0.0 I

Figure does not meet standards of

reliability or precision -----------------

*
THREE VIEWS OF

HYPERTENSION AND HEART DISEASE

Tavia Gordon, Division of Health Examination Statistics

Who has heart disease? Who has hypertension?

There are no unique answers to these questions. The questions themselves are complex and

difficult to define. If they are phrased differently,

if a different set of instruments are used, or if

a different informant is approached, different

answers can be expected. Where different answers

are given, however, it is not ordinarily easy to

explain why the variances take exactly the form

they do, and agreement may be equally puzzlin~.

In the first cycle of the U.S. Health Examination Survey (HES), 6,672 adults—a sample of

the civilian, noninstitutionalized population of the

United States between ages 18 and 79 years—

were given an extensive, standardized examination which included, among other things, a careful medical evaluation for heart disease and

hypertension. 1-7 For the same persons and the

same diagnoses information is also available

from a self-administered medicaI history and,

for some of these persons, from their personal

physician. In this report the agreements and

disagreements in diagnoses from these various

sources will be considered from several points

of view. Other points of view would, no doubt, be

of interest to investigators and might well yield

a different picture. This is inevitable, and no claim

to an exhaustive analysis of the data is made.

The data themselves are limited by the nature

of their collection. They were collected and processed for the purpse of characterizing the population of the United States, not for methodological

uses. Some information which could have been

coded and subsequently analyzed for methodolog-

.

ical studies cannot now be retrieved. Some

information which might have been collected if the

primary interest had been methodological was not

collected in order to minimize interference with

the conduct of the survey.

On the other hand, the data have strengths

which data from conventional methodological

studies do not have. For one thing they pertain not

to some particular group specially chosen for the

purposes of a methodological inquiry but to an

actual population which has been surveyed. All.of

the variety, all of the complication and confusion

encountered in a general population are preserved

intact. Conclusions may be harder to reach, but

those that can be reached are likely to be stronger

and of more general utility than conclusions drawn

from specially designed, artificially formulated

inquiries on what are usually the peculiar groups

chosen for methodological investigations.

SOURCES OF INFORMATION

In the process of seIecting the sample, an

inter~iewer supplied by the U.S. Bureau of the

Census visited a set of preselected sample homes

and interviewed a responsible adult in each household. The interview was similar to the one conducted by the Health Interview Survey. s

A seIf-administered medical history was

completed by the sample person when he came to

the HES trailer for an examination. One of the

questions he was asked was whether he had heart

disease. He was also asked whether he had hypertension.
Tbe sample person was then given a medical

examination. Survey diagnoses of heart disease

and hypertension were systematically arrived at

—according to an explicit set of criteria—on the

basis of the medical history, the description of

findings made on the physical examination, the

diagnostic impression of the examining physician,

and expert interpretations of the electrocardiogram and the chest X-ray.

For a sample of the examined persons, information was obtained from the person’s own physician. 9 The request for information was brief,

simple, and categorical. No criteria were offered

to, or requested from, the physician for any

diagnosis. Replies were tabulated as received,

with no followup to clarify obscure entries or to

complete forms that were incomplete. Inquiries

were sent to the physicians of 762 of the 6,672

examinees in the survey; essentially complete replies were received for 488.

The forms used for recording these different

sets of information are presented in Appendix I.

MAJOR COMPARISONS

Total Prevalence

Different estimates of Uotal prevalence came

from the different sources. The largest number of

cases of heart disease and hypertension came

from the examination.

Before turning to the data it is important to

emphasize that they derive from specific instruments. The survey examination was not just any

examination, but the specific one used in the first

cycle of the Health Examination Survey. Changes

in that examination might well have altered the

prevalence reported, just as a change in the method

of obtaining the medical history or the physician

inquiry might have altered the prevalence figures

obtained by these mechanisms. It is important

to remember this historical particularity in considering the data to be presented and also to

remember that what is true for heart disease

and hypertension is not true for all other diseases.

Some 1,600 cases of heart disease were

diagnosed by the survey examination (table 1).

There were 834 cases reported on the medical

history. For the subgroup of examinees included

in the physician inquiry, 154 cases of heart

disease were diagnosed by the survey msmination, but only 92 cases were reported by the

personal physician (table 2). On the same subgroup of examinees, 82 cases of heart disease were

reported on the self-administered medical history.

The situation was similar for hypertension.

The survey examination resulted in the disgnosis

of 1,943 cases. The medical history yielded 1,175

cases (table 3). In the physician inquiry group the

survey examination diagnosed 164 cases as against

98 cases reported by the personal physician, with

102 cases reported on the medical history (table 4).

The difference in levels is portrayed graphically in figure 1. Data from the physician fiquiry

are adjusted to the same level as the examination

counts by the following procedure: Let ri he the

ratio of the number of cases reported by the

personal physician to the number of cases reported by survey examination forage-sex group L.

Let ni be the number of all examinees in t&t

age-sex group with the specified disease. Then

~ riniis the age-sex adjusted prevalence for the

disease. For heart disease this yields a count

of 892 cases; for hypertension, a count of 975.

While this procedure does not necessarily preserve the correct relationships to the medical

history reports, in this instance it works reasonably well.

Certainty of Diagnosis

In the foregoing discussion all reported cases

of heart disease and hypertension were counted.

The various sources, however, distinguished

between definite diagnoses and uncertain or

borderline diagnoses, and this distinction will be

important in subsequent analysis.

In reporting heart disease, the survey examination and the personal physician tended to divide

cases about evenly between definite and suspect

cases. The survey examination yielded 855 cases

of definite heart disease and 745 of suspect.

The physician inquiry indicated that the personal

physicians of the examinees tended to divide heart

disease in about the same fashion as did the

examination diagnosis: On the subgroup of examinees covered by the physician inquiry, the personal

physician reported 58 definite cases c~fheart

2
2poo

r

I

Sursr.y

WPXnhYtion

PwsonOl

physician

Medicol

history

Surv*y

.xominaiion

Hypertension

Personal

PhysicIan

Medical

history

Figure 1. Number of cases of heart disease and hypertension as determined by survey examination, personal physician, and medical history.

disease and 34 suspect, as compared with 94and

60, respectively, reported by the survey examination (table 2). In contrast with physicians, the

examinees themselves almost always reported

heart disease on their medical history either

as present or absent, rarely indicating anyuncertaimy. (Oftheexaminees, 796 reported “yes”

and 38 “?” In the physician inquiry group, 79

reported “yes” and 3 “?”)

‘l%e same contrast between medical diagnosis

and the person’s own report was observed for

hypertension. l%e survey examimtion assigned a

diagnosis of definite hypertension to 1,016 cases

and a diagnosis of borderline hypertension to 927

cases (table 3). ‘Ihe personal physician was much

more likely to characterize a diagnosis of hypertension as definite than was the examination (65

of the 98 cases were diagnosed hypertension by

the personal physician as against 84 of the 164

cases so diagnosed by the examination for the

same examinees), but there was still a strong

.

contrast with self-reporting (table 4). Cases

were seldom reported on the medical history

as suspect but almost always as definite. (On

the medical history, 1,140 persons reported “yes”

and 35 “?” Of the persons in the physician inquiry

group, 100 reported “yes” and 2 “?”)

As might be anticipated, if a case of heart

disease or hypertension was reported as definite

by any reporting system, the likelihood that

another reporting system would agree on that

diagnosis was greater than if the case was reported suspect (tables 5-8). For example, of the

855 cases diagnosed as having definite heart

disease on the examination, 30.1 percent (257

cases) were considered to have a definite heart

disease on the medical history. On the other hand,

of the 1,600 cases diagnosed on the examination

as either definite or suspect heart disease, 396

(24.8 percent) reported on their medical history

that they had heart disease. When more doubtful

diagnoses were added, the percent of agreement

3
was reduced. On the other hand, of course, the

absolute number of cases on which agreement was

noted increased.

The tendency for greater agreement among

the various reporting systems as the diagnosis

became more definite was especially clear with

a grackd characteristic such as blood pressure

(table 9). The higher the blood pressure the more

likely was hypertension to be reported by any of

the mechanisms under consideration; ipso facto,

the more likely were they to be in agreement. At

lower blood pressure levels disagreement is not

unreasonable, especially if it is assumed that

treatment has reduced the blood pressure level

in some instances—a fact which the survey

examination could not evaluate at all and which

the personal physician could evaluate better than

his patient.

Kind of Heart Disease

Preferences among the specific heart disease

diagnoses varied. The survey examination and

criteria led to a heavy repxting of hypertensive heart disease. Of the three major types of

heart disease—coronary, hypertensive, and rheumatic—317 cases were assigned to the first

category, 881 to the second, and 75 to the third.

The physician’s diagnosis of his own patient

tended to differ from the survey examination

diagnosis in that he specified a larger proportion

of the reported heart disease as coronary than

did the survey (table 10). The personal physicians

reported 41 cases of coronary heart disease, 55

cases of hypertensive heart disease, and 15 cases

of rheumatic heart disease, while on the same

examinees the survey examination diagnosed 38,

86, and 11 cases, respectively. The comparative

neglect of hypertensive heart disease is understandable; the examination diagnosis was dependent on a routine cardiovascular reading of the

chest X-ray and a routine electrocardiographic

reading. Even with moderate blood pressure

elevations, ordinary medical practice would not

routinely call for a chest X-ray or electrocardiogram.

The medical history did not distinguish among

the various categories of heart disease, and while

more specific information was elicited in followup questioning, this information was not coded.

CONCEPTUAL BASIS OF

COMPARISONS

Having given some data indicative of the

scope of differences among the three sources,

it may be desirable to pause here and (discuss

the conceptual basis for such comfiarisons.

The viewpoint is taken in this repc~rt that

heart disease—or hypertension—means the same

thing, whether it is reported by the perscm himself, by the person’s physician, or by the survey

examination.

Obviously this formulation represents a simplified picture, whether the physician’s standpoint

is taken or the patient’s, quite aside from complexities introduced by other parties to medical

experience.

It is probably true that this formulation is

closer to the physician’s viewpoint than the

patient’s. Still, it can never be strictly true that

diagnoses of heart disease or hypertension made

by different physicians mean exactly the same

thing. Even if two physicians with similar training

and outlook made the diagnosis, there would be

at least some shade of difference in their findings

and their interpretation of the findings,, If the

diagnosis were a simple one such as hypertension,

their blood pressure measurements would almost

surely differ, if only a trifle; their diagnostic

criteria would differ, and their prognosis and

proposed treatment (which are really part of a

physician’s diagnostic criteria) would alsc~differ.

This is, of course, the most optimistic view of

diagnostic reliability. Medical literature, including reports of the Health Examination Survey,

cites many instances of” large variations in

medical diagnosis.

In many instances, agreement on a IIabel of

heart disease or hypertension conceals differences which are far from insignificant. The findings on which the diagnosis was made msy have

been quite different—in one case a history or

physical finding, say; in another, an X-ray finding or an electrocardiographic abnormality. If

it is agreement on heart disease, the specific

heart disease diagnosis may differ.

Nonetheless, it is agreement. The point where

disagreements pass from trivial to substantive

depends entirely on the object in view, and this

4
should be reflected in the fineness of the classification used. If it is important to distinguish

heart disease diagnosed on the basis of X-ray

from heart disease diagnosed by electrocardiogram, then the classification should reflect this

distinction. If it is felt that the disease is the

same whether one view or another is reported,

then the distinctions in viewpoint should not be

carried in the classification.

The differences between the survey examination and an examination by the person’s own

physician have two roots. The first is the fact

that a personal physician is responsible for the

medical care of the person while the survey was

not. The second is the fact that a personal physician ordinarily varies the scope and content of

his examination from one patient to another,

whereas the survey examination was essentially

the same for all persons. The first fact has consequences in diagnosis which are real enough

but which for heart disease and hypertension are

surprisingly small. 1° The second fact is by no

means trivial. A person who has consulted his

physician only for trauma or acute illness may

never have had an evaluation for cardiovascular

disease. If he has had such an evaluation it may

have been superficial. On the other hand, if he

has had some cardiovascular illness he may have

had a more extensive medical examination than

was provided by the survey. In intention and in

design, however, the survey examination was

planned to parallel a clinical examination and to

be conceptually monistic.

When the self-administered medical history

is considered, a much greater diversity is

apparent. In the first place, access to medical

diagnosis is highly variable from person to person. Some people receive regular, thorough

medical care; some people never receive medical

care; most range somewhere between. Both

medical attention and diagnosis are more likely

to occur if there is some medical complaint. If

the person feels in good health or is inclined

to minimize pain or discomfort he is less likely

to receive a thorough medical examination than

if the opposite is true.

In addition, not all diagnoses are made by

physicians. A good deal of self-diagnosis and

diagnosis by nonmedical per~ons takes place. This

may occur even when the person routinely receives thorough medical attention. Sometimes the

patient, after having received medical attention,

discounts the phy~ician’s statement of illness or

of health and substitutes his own or someone

else’s. Much self-diagnosis arises without any

medical attention.

The fact that the medical history obtains

the person’s own picture of his health leads to

further diversily. The complexities of communication are well recognized, and added to these are

problems of individual attitude. What does the

person see as the purposeof the history, its value,

and its risks to him? Wes he feel that only serious

or severe iIlness should be reported? Clearly,

his attitude is influenced by the knowledge that

the medical history is part of a medical examination. He may feel impelled to report his fears

or suspicions of disease to alert the examining

physician. Alternatively, he may screen out welldefined but minor illnesses from his account. If

he has a mild form of heart disease with no

treatment prescribed, no limitation of function,

or only minor limitation, he may not report this,

or, indeed, he may doubt or disbelieve the diagnosis.

The preceding discussion is not intended as

a systematic account of the problems of diagnosis

and reporting, nor is it argued that the issues

referred to are all substantial. What is being

suggested is that there are reasons for anticipating variances between reports from different

sources. It could be argued that these sources are

simply reporting different phenomena. For the

purposes of this paper the view is taken, instead,

that they are reporting the same phenomena but

at different levels of sensitivity. In a sense, of

course, a statement that only heart disease with

a specified impact is re~rted could be interchanged with a statement that heart disease is

reported only if it has a specified impact. The

choice between the two statements is a matter of

taste. Their consequences, however, differ.

5

246-9s9 0 -67-2
THE MEDICAL HISTORY

This section deals with the relationship between the self-administered medical history and

the examination.

It was shown that the medical history yielded

52.1 percent as many cases “ofheart disease as

the examination and 60.5 percent as many cases

of hypertension. To what extent did the survey

examination corroborate these reports?

Fewer than half of the persons who declared

they had heart disease on the medical history were

found to have heart disease on the examination

(47.5 percent—396 out of 834), and the percentage

of agreement on hypertension, while better, was

only 61.8 (726 of 1,175). This is not an impressive

level of agreement.

On the other hand, the deficiencies of the

,, medical history information were not as great

as they might seem (tables 11 and 12). Where

the person reported that the diagnosis had been

made by a physician, the agreement with the

examination diagnosis was better. Of the 510

cases where the examinee reported a physiciandiagnosed heart disease on his medical history,

there were 301 cases of heart disease (59.0

percent) diagnosed on examination, the majority

of the diagnoses (216) being definite. Of the 954

persons reporting high blood pressure diagnosed

by a physician on ‘tieir medical history, 644 (67.5

percent) were found to be hypertensive on examination, 458 of these were definitely hypertensive.

For both diseases, then, a medical history report

of a physician’s diagnosis was fairly reliable,

although it fell far short of yielding the amount

of diagnosed heart disease or hypertension obtained from the survey examination.

On the other hand, where the examinee reported heart disease or hypertension that was

not medically diagnosed, agreement was much

lower. In fact, the likelihood that the disease

would then be found by examination was little

greater than if no heart disease or hypertension

had been reported on the history.

Without considering all aspects of the replies to the medical history questions on heart

disease and high blood pressure, it might be

noted that persons reporting that they took medicine for these diseases were more likely to be

diagnosed as having the disease than persons

simply reporting a physician’s diagnosis— 170

of the 246 for heart disease (69.1 percent) and

310 of the 434 for hypertension (71.4 percent)—

but this modest gain in corroboration was more

than balanced by the substantial loss in yield.

Examination Cases by Medical History

No procedure can be considered to produce

certain diagnoses; hence, it is reasonable to

discuss disagreements without deciding which

source is in error. The survey emphasis on objective and well-defined evidence for disgnosis

would rule out some cases that might reasonably

be regarded as disease. On the other hand., some

cases of disease which have never manifested

by symptom or which have never been subject

to a careful medical scrutiny would be uncovered

by a thorough examination such as the survey

provided.

But relativity must have some boundaries.

The survey examination was a more trustworthy

source of diagnostic information than the medical

history. That granted, it makes sense to consider the set of examination diagnoses as the feal

universe and the cases of heart disease and hypertension reported by the medical history as a

sample from that universe.

Obviously, the medical history was not likely

to select an unbiased sample of the “real” cases.

The 834 cases of heart disease reported by

the medical history and the 510 reported as

physician-diagnosed heart disease were assigned

the following diagnoses by the survey examination:

Examination

diagnosis w

I

Def i.nite heart

disease -------------- 264 216

Suspect heart disease- 132

No heart disease ------ 438 2% ,

Similarly, for hypertension, the 1,17’5 cases

reported on the medical history (954 of them re6
ported as physician-diagnosed)

fallowing diagnoses:

were assigned the

Examination

diagnosis

Number of medics 1

history reports

of hypertension

Definite hypertensionBorderline hypertension--.=----------

Normotension ----------

496 458

230 186

449 310

In short, themedical history wasmorelikely

to sample definite cases ofheart disease orhypertension than suspect or borderline cases.

If the medical history is now consideredas

a case-finding instrument, the question can be

asked, Whatpercentageofcoronary, hypertensive,

and rheumatic heart disease diagnosed by the

survey examination was reportedasheart disease

on the medical history?

Heart disease,

total --------- 24.8 24.0

Coronary heart

disease --------- 58.9 49.2

Hypertensive

heart disease--- 22.4 16.9

Rheumatic heart

disease --------- 36.0 32.0

A person diagnosed on examination ashaving

coronary heart disease was more Iikely to report

that hehadheart disease than aperson diagnosed

as having hypertensiveheartdiseaseorrhewatic

heart disease. This doesnotnecessarily meanthat

hereportedthis specific diagnosis onthemedical

history, only that he reported some form ofheart

disease.

Demographic Fidelity

Although the number of persons reporting

heart disease or hypertension on their medical

history was substantially less than the number

for whom these diseases were diagnosed on the

survey examination and the “mix” of cases was

not an unbiased one, were the proportions constant from one subgroup of the population to

another? To the extent that they were, the medical

history can be said to give the same picture as

the survey examination but on a reduced scale. To

the extent they were not, the pictures will differ,

and the answers to the question Who? will diverge.

Age and Sex

Consider the various age-sex groups, since

prevalence varied markedly by age and sex. Was

the reduction in scale constant from one age group

to another? Was it the same for men and women?

It was not. The number of cases reported

on the medical history expressed as a percentage

of cases diagnosed on examination decreased with

age for heart disease, while for hypertension the

comparable percentages described a slightly Ushaped curve with the lowest pint roughly in the

middle of the age span. Percentages were generally higher for women than for men (tables 13 and

14).

Other Demographic Variables

These age-sex differentials complicate the

analysis of data for other demographic variables

since these other variables are all correlated

with age and sex. To allow for this we will revert

to the technique used in other reports and compute actual and expected values for each population

.th subgroup. Suppose, for example, that in the ~

age group, there are ~i persons with less than

$2,000 income (sum of ni =~). Let ~iailn. Suppose

the percentage of persons with heart disease in

this age group (regardless of income) is ri . Then

the expected percentage for all age groups combined is the sum of pi ri. We can express the

actual rate as a ratio of the expected rate and

compare the ratios for the various reporting

systems.

—
In tables 15-19 the ratios are computed using

ppulation estimates derived from the sample

rather than counts of examinees. (Ratios using

counts alone were also calculated and are similar

to those presented.)

These ratios of relative prevalence may be

viewed as giving a series of cross-sectional

mappings or profiles of the population. The question is, Did the medical hist6ry give the same profile as the examination? The answer is, It did not.

Figure 2 compares the profiles of heart

disease prevalence by race for each sex. The

medical history depressed the relative prevalence

for Negro women. For Negro men this distortion

was even more marked.

Figure 3 compares the profiles of hypertension prevalence by race for each sex. For men

the medical history yielded a profile almost

identical to the examination. For women this was

not the case. The medical history exaggerated

the relative prevalence of hypertension for Negro

women.

Because of these race differentials the discussion of other demographic variables should

be race-specific, and since the number of Negroes

in the sample was small, discussion is restricted

to the white population.

2.00 Men Women I

.%rwey ypc;l

●xamlnatoon Surve

examina !Ion

m White ~ Neqro

I

Fiqure 2. Rat io of actual to expected prevalence

of heart d isease on survey exami nat ion and medi -

cal history, by race and sex.

2.00 Men Women

0,00

Survey

examinotlon

a White ~ Negro

I

Figure 3. Rat io of actual to expected prevalence

of hypertens ion on survey exami nat ion and med ical h istory, by race and sex.

For nearly every major demographic variable

in the white population the picture presented by

examination findings emerged from the medical

history only in a distorted version (tables 16-

19).

Consider the profiles for hypertension. The

examination showed almost no variation in hypertension prevalence by income. The medical history showed a distinctly elevated hypertension

prevalence in the lowest income group. The examination showed an inverse relationship between

education and hypertension prevalence. The medical history showed the same relation but exaggerated it substantially. The examination showed

about the same hypertension prevalence in the

South and West Regions and a higher prevalence

in, the Northeast, while on the basis of the medical

history the Northeast appeared to have the lowest

prevalence. On the examination rural farm and

rural nonfarm areas had average prevalence,

but on the medical history they had a greatly

elevated hypertension prevalence.

Thus the medical history gave a substantially

different picture of the distribution of hypertension

in the U.S. population than did the examination.

8
For heart disease, similar differences were

found between the examination and the medical

history, although these differences were less

marked.

The examination showed higher heart disease

prevalence at lower incomes. This differential

was slightly exaggerated by the medical history.

An inverse relationship between education and

heart disease prevalence was apparent on the

examination; this, too, was slightly exaggerated

by the medical history. On the basis of the

examination, the South appeared to have the

lowest heart disease prevalence, but it had the

highest prevalence on the medical history.

SYMPTOMS AS

A DIAGNOSTIC TOOL

The exact relationship between symptoms

and disease in the general population is not

precisely known. It is recognized that illness may

appear without pathognomic symptoms, but it

is nonetheless possible that appropriate symptom

complexes may constitute effective screening

devices for some diseases. Certainly they provide the only hope of identifying cases of unknown disease short of an actual medical examination.

The medical history included a number of

questions directed to symptoms thought to be related to the cardiovascular diseases. In this section we will consider those questions which, on a

priori grounds, are believed associated with

hypertension. Each question will first be treated

separately; then the questions will be treated as

a group. The analysis will have to take age and

sex into account, but hopefully, if diagnostic

symptom complexes are uncovered they will

prove to be diagnostic for adults in a number of

age groups.

Before examining the specific data it may be

useful to explore some general issues.

By and large, diagnosis is seldom arrived

at by a direct route. Rarely is a communicable

disease diagnosed by isolating the known etiological agent or even by measuring some specific

trace of the agent, such as a rise in antibodies.

The symptoms described by the patient, the physical signs manifest on examination (seldom pathognomic in themselves), and current experience in

the patient’s community are ordinarily relied on

instead. In diagnosing chronic disease, similar indirect tests are used. The electrocardiogram replaces a direct examination of the heart, since

direct examination is always limited and dangerous at best, and signs and symptoms are collected,

assembled, and evaluated against the general

background of medicaI experience.

In principle, indirect diagnosis can be carried

beyond current practice. Any characteristics may

be examined for their relation with any specified

disease, and there is something to be said for

expanding the range of foqrnal inquiry beyond

the characteristics traditionally associated with

the disease. However, as the number of characteristics under study increases, the number of permutations rapidly multiplies, pressing on the t~tal

available information and the computational resources.

It therefore seems the better part of wisdom,

in investigating hypertension, to begin with the

traditionally suspect symptoms. After all, the

relevant queries were included in the medical

history questionnaire to test their relation to

this disease. What is more, the symptoms are

suspect because a large body of observation has

attested to their relevance.

The symptoms discussed are headaches,

nosebleeds, tinnitus, dizziness, and fainting. ‘he

specific questions are reproduced in Appendix 1.

The results are easily summarized: There

was no association whatever between any of these

symptoms individually and the occurrence of

hypertension, no matter how frequently the symptom occurred or how severe it was. Selected

data are shown for the age group 45-64 (table

20).

It is nonetheless possible that some combination of these symptoms is indicative of hypertension. To test this, two approaches were used.

The first was to categorize responses to each of

the symptom questions (except the question on

fainting) into one of four categories.

1. Yes, I had the symptom as often as every

few days, and it Mhered me quite a bit.

2. Yes, I had the symptom as often as every

few days, but it lmthered me just a little.

3. Yes, I had the symptom less often than

every few days, but it bothered me quite

a bit.

4. All other replies (essentially negative).

9
Answers to the question on fainting were

placed in one of two categories, “yes” or “other”

(essentially negative).

All combinations of these symptoms were

considered separately for each age-sex group.

For each combination a count was obtained of

the total number of cases as well as the proportion of these cases reporting hypertension.

Hypertension was first defined as definite or

borderline, and then it was redefined as definite

only. The results were the same using either

definition. For each age-sex group a cutoff was

made using the percentage of cases that were

hypertensive of those negative on all five symptoms. It was felt that any symptom combination

that did not identify a larger proportion of hypertensive than was found in completely asymptomatic individuals was not worth consideration.

The next step was to look at successive agesex groups to see if the same “discriminatory”

combination appeared in a succession of agesex groups. No such combinations of symptoms

with a persistently higher than expected prevalence of hypertension were found. The specific

tables were not included here, since they were

rather bulky.

The second approach was to count the number

of positive symptoms reported and to determine

whether hypertension prevalence varied with the

number of such symptoms. For this purpose all

responses except essentially negative ones were

counted as positive. One would expect that as

the number of positive symptoms increased from

none to five the prevalence of hypertension would

rise. It did not. Table 21 presents tabulations for

the age groups 35-64 years.

The failure of any combination of symptoms

to predict hypertension is not unexpected, given

the negative results for the individual symptoms.

Clearly if one wishes to obtain information about

hypertension by use of a questiomaire, the direct

question, inadequate as it is, is the only usable

procedure. Symptom ‘information is totally noncontributory.

THE PHYSICIAN INQUIRY

The purpose of the physician inquiry was to

evaluate ‘@ssible differences in medical status

between sample persons who came in for exa~-

ination and sample persons who did not. l%e

results of the comparison of physicians’ reports

for examined and nonexamined persons have already been described,g and it is umecessary to

restate them here.

In addition to serving ita primary purpose

the physician inquiry yielded information on examined persons as such. Inquiries were sent to

the personal physicians of 762 examined persons.

Essentially complete reports were received for

488 persons. What we ‘propose to consider now is

the relationship between medical information for

examined persons reported by their own physicians and medical information for the same

persons available from other sources. Because

the viewpoint here is different from that in the

earlier report on the physician inquiry, the data

are tabulated differently and will vary slightly

from those previously published.

A number of possible insights are available

from such comparisons, but only two will be

considered.

The Physician Inquiry as a Survey Instrument

If the diagnostic information given by the

personal physician and by the standardized,, uniformly applied examination performed by the

Health Examination Survey are in reasonable

accord, it is conceivable that an examination

survey could be rendered more efficient by a

supplementary physician inquiry, using available

medical records. The design of such a program

will not be proposed in specific terms, but in

general it might take the following form. A

large sample would be drawn and an inquiry would

be sent to the individuals’ physicians. The sample

would then be divided into two parts, persons for

whom a usable physician reply was received

and those for whom a usable reply was not received. A sample from each group would be

examined.

The utility of such a procedure would depend on the degree of correspondence between

information from these two sources. How closely

did the survey examination and the personal

physician agree?

It has already been shown that the personal

physician reported 6 cases of heart disease or of

hypertension for every 10 cases diagnosed in the

10
same persons by the survey examination. Agreement on specific individuals was relatively high

(table 10).

9

I I I

Exand -

PhysiDiagnosis nation ~:~u;ry

Both

H~:ldisease, 9

---------- 154 92 70

Coronary heart

disease ---------- 38

Hypertensive

heart disease---- 86

Rheumatic heart

disease ---------- 10

41 17

55 34

15 6

Hypertension---- 164 I 981 73

I I

Thus 76.1 percent of all cases reportedby

the personal physician as having heart disease

were similarly diagnosed by the survey examination, although agreement on specific heart

disease diagnoses was at a lower level. In

addition, 74.5 percent of all cases reported as

hypertensive were so diagnosed by the survey.

Agreement, however ,varied with age andsex

(tables 22 and 23). Generally speaking, the ratio

of cases reported by the personal physician to

cases diagnosed by the survey increased with

age and was higher for womenthanmen.

Nonresponse

Up to this point wehavebeen discussing the

physician inquiries which yielded a usable reply.

What about the one inquiry in three for which a

usable reply was not received? How did nonresymse distort the picture?

The first thing to notice is that response

to the inquiry was not unbiased. Replies for

women were more likely to be usable than replies for men. Among men the likelihood of a

usable reply was less if the man was under 45

than if he was over 45; among women there

were no strong age differentials in response

rate. These age and sex differentials (table 24)

somewhat complicate comparisons between usable

and nonusable inquiries. There was a strong

gradient in the probability of a usable reply

with income. The lower the family income the

less likely it was that a usable reply would be

received from the personal physician (table 25).

The percentage of usable replies rose from 56.6

for persons with family incomes under $2,000

to 71.6 for persons with family incomes over

$10,000. There was also a distinction between

replies for persons with a college education and

persons without a college education, the response

to physician inquiry being greater for those with

a college education. Apparently there were no

response differences associated with urban and

rural residence or with residence in the central

city of standard metropolitan statistical areas

(SMSA’S), outside the centraI city, or in urban

areas outside SMSA‘s. On the other hand, slight

regional differences did exist, with the percentage of usable replies being greatest in the Northeast Region and least in the Wesq however, this

differential was not strongly marked.

There was some indication that the probabili~

of receiving a usable reply from the physician

was related to the medical status of the individual (table 26). The amount of heart disease and

hypertension found on examination was less

among persons for whom no usable reply was

received than among the group for whom a

usable reply was received. This seems to lx!

true in general for all age-sex groups with

the exception of women under 45 years.

(Why this group should ke an exception

is difficult to say, but we may speculate on it.

Let us assume that for other age-sex groups the

likelihood that a person will regularly visit a

physician or have a thorough physical examination

is related to his health status; if he has an illness

he is more likely to have a physician who knows

him well than if he does not have an illness. On

the other hand, for women in the childbearing

ages let us suppose the likelihood of having

medical care on a routine basis is unrelated to

illness unless pregnancy and minor irregularities

related to the reproductive system are to ke

designated as illness. Hence the likelihood of a

physician’s knowing their medical status would be

largely unrelated to their health.)

All in all, the large proportion of nonusable

replies to physician inquiry and the differences

between the population subgroups in this pro11
portion make it hazardous to rely exclusively

on a physician inquiry to define the medical

status of the population. However, as an adjunct

to an examination survey, this is a promising

resource.

Other Variables

The sample chosen for the physician inquiry

was IxXh qualitatively ancl quantitatively too

limited to make analysis by other demographic

variablea worthwhile. For that matter, it is

possible that a more extensive investigation would

present a somewhat different picture than has

been presented by the data collected.

While the discussion has considered the

possible utility of a physician inquiry in defining

the prevalence of heart disease and hypertension,

this instrument may also be applicable for other

purposes. For example, the physicians were also

asked to report the examinees’ blood pressure,

height, and weight. These measurements were

less frequently reported than the information

on disease, but when they were reported there

was close average agreement with the examination findings.

Measurement I

Physician Examinquiry inat ion

‘===t=h

Distributions of blood pressure, height, and

weight as reported by the personal physician

and the examination on the same persons are

given in tables 27-29.

The Medical History From the Viewpoint

of the Physician Inquiry

Presumably, some cases where the physician

had diagnosed the disease were not reported on

the self-administered

because the physician

veyed this information

medical histor y—either

had not adequately conto his patient or because

the patient simply did not report it. The physician

inquiry bore out this possibility.

Heart Hyperdisease tens ion

Number reported by

physician ------------

Number reported on

medical history as

physician- diagnosed> -

Number reported by

both -----------------

92

60

40

98

93

60

In shor., the medical history reports of physiciandiagnosed heart disease or hypertension understated the amount of physician-diagnosed disease.

Where the examinee indicated a physiciandiagnosed disease and the physician did not report

this, it cannot be concluded that the examinee

was misstating the facts, since the diagmosis

may have been made by another physician. The

true level of reporting should be approximated

by the positive replies which were in agreement

with the report by the personal physician-for

hear’ disease 43 percent and for hypertension

61 percent.

CONCLUSION

Some Qualifications of the Data

While the sources of information have already

been described briefly, some special considerations might be noted at this point.

The survey examination was designed tc~place

special emphasis on the findings made at the time

of examination. With two significant exceptions,

the diagnosis of heart disease was almost entirely

independent of the medical history inform~ation.

The two exceptions were angina pectoris, which

required an appropriate description by the examinee as well as the judgment of the examining

physician, and hypertensive heart disease, which

(in a small proportion of cases) relied on a history of treated hypertension when the examination

blood pressures were normal but the heart findings were not. Except for angina pectoris, how12
ever, a heart disease diagnosis always required

an abnormal finding on the chest X-ray or the

electrocardiogram, each of which was interpreted

without access to any other information about the

examinee. Hypertension as such was always defined on the basis of blood pressure as measured

on the examination.

The information from the personal physician

was also qualified in some resp&cts. For an inquiry

to be sent, a personal physician must have been

designated by the examinee and his address given.

Permission to consult the physician had to be

obtained. What is more, there had to be indication

on the household interview that a personal physician (not necessarily the specific physician reported) had been consulted by the examinee within

the past 2 years. However, almost all persons

examined gave a physician’s name and a current

address, and relatively few replacements had to

be made either because the person had not seen a

physician within the last 2 years or because he

failed to give permission to consult his physician.

On the other hand, the physician was more

accurately identified on the medical history

than he would ordinarily have been in a household interview. This no doubt improved the

chances of obtaining usable information from

the physician. It might be noted that unwillingness to sign a permission form is one of the

best indicators of reluctance to be examined,

so this unwillingness would not constitute a

spcial disadvantage to the use of a physician

inquiry as compared with an examination survey.

l%e plan and execution of the physician

inquiry led to including in the inquiry an examinee

group that had more women, more older persons,

and fewer nonwhite persons than the Health

Examination Survey sample as a whole. The age

and sex biases occurred kcause the examinees

included in the inquiry were matched to the nonexamined group on the basis of age and sex, and

the nonexamined group had those biases. ‘Ihe

bias with res~ct to race arose despite an effort

to match on face because in attempting to match

unexamined nonwhite persons on sex and age (the

more important variables) it was often inqmssible

to find examined nonwhite persons of the same

sex and nearly the same

while they should be noted,

age. These biases,

do not mmduce anv

difficulties in comparing reports by the various

instruments. They do, however, lead to prevalence rates for the inquiry group which are

higher than those for the sample as a whole.

LQSt Thoughts

This paper hcludes a wide variety of topics

and, perhaps, some variation in viewpoint. It would

probably be unwise to attempt to summarize it;

however, some final observations may be in

place.

The analysis was largely impressionistic;

that is, the conclusions are not to be taken as

“statistically significant” in any formal sense.

While statistical tests were sometimes applied to

help decide what the data meant, the tests were

never rigorous in the sense that they were based

on exact probabilities concerning population estimates obtainable by the different techniques.

Repeated measurement aIways tends to

variant results. Where the measurements are

repeated with different instruments, the variation is likely to be greater. Hence there is

nothing surprising in the fact that the medical

examination given by the HES yielded different

results from the medical evaluation supplied

by the examinee’s physician and from the selfadministered medical history.

The magnitude of these discrepancies, however, was so great as to raise the question

whether, in fact, these various instruments were

measuring the same thing. This is an entirely

reasonable query. In this report, however, the

question is put this way: Assuming that the instruments were measuring the same thing, how

great was the disagreement among them? From

this relatively simple point of view the final

test for these various mechanisms for counting

cases of heart disease or hypertension is how

well they count and whether they count the same

way in every population subgroup. These questions

have not been finally answered here, but a number

of facts and viewpoints leading to an answer have

been presented. If nothing else these may be

useful as a touchstone of opinion.

13
lNationrd Center for Health Statistics: Blood pressure of

adults, by age and sex, United States, 1960-1962. Vitat and

Health Statistics. PHS Pub. No. 1000-Series 11-No. 4. Public

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

June 1964.

2National Center for Heafth Statistics: Blood pressure of

adults, by race and area, United States, 1960-1962. Vita2 and

ffea2th Statistics. PHS Pub. No. 1000-Series 11-No. 5. Public

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

Juiy 1964.

3Natjonal Center for Health Statistics: Heart disease in

adults, United States, 1960-1962. Vital and He olth Statistics.

PHS Pub. No. 1000-Series 11-No. 6. Public Health Service.

Wasbin@m. U.S. Government Printing Office, Sept. 1964.

%ational Center for Health Statistics: Coronary heart

disease in adults, United States, 1960-1962. Vital and Health

Statistics. PHS Pub. No. 1000-Series 11-No. 10. Public Health

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

1965.

5National Center for Health Stati sties: Hypertension and

hypertensive heart disease in adults, United States, 1960-1962.

Vita2 and Heolth Statistics. PHS Pub. No. 1000-Series 11-No.

13. Public Health Service. Washington. U.S. Government

Printing Office, May 1966.

6Gordon, T., McDowell, A. J., and Waterhouse, A. M.:

Defining the prevalence of heart disease in an examination

survey. Am.J. Pwb. HeoZ.$h 55879, June 1965.

7Gordon, T., and Waterhouse, A. M.: Hypertension and hypertensive heart dieease. Journa2 of Chronic Disease 19:1089,

Oct. 1966.

8National Center for Health Statistics: Hesltb survey procedure, concepts, questionnaire development, and definitions

in the Health Interview Survey. vital and He aith Statistics.

PHS Pub. No. 1000-Series l-No. 2. Public Health Ser.tice.

Washington. U.S. Government Printing Office, May 1964.

‘National Center for Health Statistics: Cycle I of the

Health Examination Survey, sample and response, United

States, 1960-1962. Vital and Health Statistics. PHS Pub. No.

1000-Seriee 11-No. 1. Public Health Service. Washingtnrr. U.S.

Government Printing Office, Apr. 1964.

10National Center for HeaIth Statistic: Evaluation of a

single-visit cardiovrtscular examination. lieaZth ISto-$i8~CS.

PHS Pub. No. 584-D7. Public Health Service. Washington.

U.S. Government Printing Office, Dec. 1961.

—000

14
DETAILED TABLES

Page

Table 1. Number of persons reported as having heart disease, by examination and medical

history: Health Examination Survey, 1960-62---------------------------------------- 17

2. Number of persona in physician inquiry group reported as having heart disease, by

;~;o~zl physician, examination, and medical history: Health Examination Survey,

---------------------------------------------------------------------------- 17

3. Number of persons reported as havin~ h$pertensi.on by examination and medical history: Health Examination Survey, 19 0-6

>

---------------------------------------.--- 17

4. Number of persons in physician inquiry group reported as having hypertension, by

~;o~zl physician, examination, and medical history: Health Examination Survey,

--------------------------------------------.------------------- ------------ 17

5. Number of persons reported as having heart disease, cross-classified by examination

and medical history: Health Examination Survey, 1960-62---------------------------- 17

6. Number of persons reported as having hypertension, cross-classified by examination

and medical history: Health Examination Survey, 1960-62---------------------------- 17

7. Number of persons in physician inquiry group reported as having heart disease,

cross-classified by personal.physician and medical history: Health Examination Survey, 1960-62------------------ --------------------------- -------------------------- 18

8. Number of persons in physician inquiry group reported as having hypertenshn,crossclasslfied by personal physician and medical history: Health Examination

1960-62

Survey,

---------------------------------------------------.--------------------- ---- 18

9. Percent of persons reported as having h ertension on examination, medical history,

and ph sician inquiry, by examination brood pressure level: Health Examination Survey, 1$6O-62----------------------------------------------------------------------- 18

10. Number of persons in physician inquiry group reported as having hypertension or

specified heart disease, cross-classified by personal physician and examination:

Health Examination Survey, l96O-62------------------------------------------------- 19

11. Responses to medical history questions on heart disease, by final examination diagnosis of heart disease: Health Examination Survey, 1960-62------------------------- 20

12. Responses to medical history questions on high blood pressure, by final examination

diagnosis of hypertension: Health Examination Survey, 1960-62---------------------- 21

13. Number of persons reported as having heart disease on examination and medical history, by sex and age: Health Examination Survey, 1960-62--------------------------- 22

14. Number of perks reported as having hypertension on examination and medical history, by sex and age: Health Examination Survey, 1960-62--------------------------- 22

15. Ratio of actual to expected prevalence of hypertension and heart disease on examination and medical history, by aex and race: Health Examination Survey, 1960-62-- 23

16. Ratio of actual to expected prevalence of h pertension and heart disease on examination and medical history, by income for t{e white population: Health Examination

Survey, 1960-62------------------------------.------------------------------------- 23

17. Ratio of actual to expected prevalence of hypertension and heart disease on examination and medical history, by education for the white population: Health Examination Survey, l96O-62--------------------------------------------------------------- 24

15
Detailed Tables—Con.

Page

Table 18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29,

Ratio of actual to expected prevalenceof hypertensionand heart disease on examination and medical history, by geographicregion for the white population:Health

Examination Survey, l96O-62-------------------------------------------------------

Ratio of actual to expected prevalenceof hypertensionand heart diseaseon examination and medical history, by place description for the white population:Health

Examination Survey, l96O-62-------------------------------------------------------

Number of men and women aged 45-64 years, by h pertensive status and symptoms on

medical history: Health ExaminationSurvey, 1968-62-------------------------------

Prevalenceof hypertensionaccording to

ported by sex for specifiedage groups:

Number of persons in physician inquiry

examination and by personal physician,

the number of hypertension symptoms reHealth Examination Survey, 1960-62--------

group reported as having heart disease on

by sex and age: Health ExaminationSurvey,

1960-62.-----"--------------------------------------------------------------------

Number of persons in physician inquiry group reported as having hypertension on

examination and by personal physician,by sex and age: Health ExaminationSurvey,

l96O-62---------------------------------------------------------------------------

Response to physician inquiry,by sex and age: Health ExaminationSurvey,1960-62--

Response to physician inquiry,by specified demographic characteristics: Health

ExaminationSurvey, l96O-62-------------------------------------------------------

Number of persons with examinationdiagnosis of heart disease, by whether response

to physician inquirywas usable or not usable: Health Examination Survey, 19601-62-

and as repbrted by

Number of persons,

and as reported by

Number of persons,

and as reported by

Number of Persons according to their blood pressure as determined on examination

persoml physician:Health Examination Survey, 1960-62---------

by sex according to their heizht as determined on examination

personal physician:

by sex according to

personal physician:

Health ExaminationSurvey,

their weight as determined

Health Examination Survey,

1960-62---------

on examination

L960-62---------

24

24

25

27

27

28

28

29

29

30

31

31

16
Table 1. Number of persons reported as having

heart disease, by examination and medical

history: Health Examination Survey, 1960-62

I I

Table 4. Number of persons in physician inquiry group reported as having hypertension,

by personal physicia~ examination,and medical history: Health Examination Survey,1960- C9

Diagnosis I

Examina- Medical

tion history

Total--------------

Definite-----------------

. Number of persons

Suspect------------------ 745 38

Negative----------------- 5,072 5,838

Table 2. Number of persons in physician inquiry group reported as’ havhg heart disease, by personal physician,examination,

and medical history: Health Examination Survey, 1960-62

I I

Diagnosis Personal Examina- Medical

physician tion history

I

Number of persons

Total---- 488 488 488

Definite------- 58 94 79

Suspect-------- 34 60 3

Negative------- 396 334 406

Table 3. Number of persons reported as having

hypertension,by examination and

history:

medics1

Health Examination Survey, 1960-62

Diagnosis

Total--------------

Definite-----------------

Borderline---------------

Negative-----------------

==I==

Number of persons

6,672

1,016

927

4,729

6,672

1,140

35

5,497

Diagnosis I

Personal Exa~- Medical

physician history

I

Number of p~rsons

Total---

l=====-

Definite------- 65

Borderline----- 33

Negative------- 390

488

84

80

324

488

100

2

386

Table 5. Number of persons reported as having

heart disease, cross-classified by examina-

.‘tionand medical history: Health Examination

Survey, 1960-62

I

Number of persons

rTotal-- 6,672 855 745 5,072

Definite- 796 257 127 412

Suspect-- 38 7 5 26

Negative- 5,838 591 613 4,634

Table 6. Number of persons reported as having

hypertension,cross-classifiedby examination

and medical history: Health ExaminationSurvey, 1960-62

1

Total-- 6,672

Definite- 1,140

Suspect-- 35

Negative- 5,497

Number of persons

m

17
Table 7. Number of persons in physician inquiry group reportedaahaving heart disease,

cross-classified by personal physicianand

~e; history: Health ExaminationSurvey,

Personalphysician

Medical

history

Total Defhite Suspect Negative

I

Number of persons

Total--

n

488 58 34 396

Definite- 79 35 8 36

Suspect-- 3 1 1 1

Negative- 406 22 25 359

Table 8. Number of persons in physicianinquiry group reportedas having h ertension,

cross-classified by personal prysician and

medical history: Health ExaminationSurvey,

1960-62

Personalphysician

I

Number of persons

Total---- 488 65 33 390

Definite--- 100 50 12 38

Suspect---- 2 2

Negative--- 386 15 21 350

I u I 1

Table 9. Percent of persons reported as having-hypertensionon examination,medical history, and

physician inquiry,by examinationblood pressure level: Health ExaminationSurvey, 1960-62

systolic

pressure

(mm. hg.)

Less than 90-------

90-----------------

1oo----------------

no--------J-------

120----------------

130----------------

140----------------

150----------------

160----------------

170----------------

180----------------

190----------------

2oo----------------

210----------------

220----------------

230----------------

240----------------

250----------------

260 and over-------

EzIEi@z

Percent of persons

0.5

4.7

16.8

95.6

95.3

95.8

96.6

93.6

98.7

100.0

91.3

100.0

100.0

100.0

100.0

100.0

4.9

6.2

6.6

9.6

15.1

23.6

33,.7

42.6

56.7

65.5

74.0

59.1

69.6

80.0

66.7

100.0

66.7

100.0

1.7

8.9

25.4

13.0

46.3

44.0

57.1

88.9

75.0

80.0

100.0

100.0

Diastolic

pressure

(mm. hg.)

Less than 50-----

50---------------

55---------------

60---------------

65---------------

70---------------

75---------------

80---------------

85---------------

90---------------

95---------------

1oo--------------

1o5--------------

11o--------------

115--------------

120--------------

125--------------

130--------------

135 and over-----

=?

Percent of persons

8.8

1.4

2.5

3.3

5.3

6.6

12.2

20,4

36.7

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

10.5

5.5

1.3

7.8

8.9

7.6

11.7

14.9

22.8

32.5

34.6

44.7

59.5

50.0

74.4

68.4

55.6

83.3

90.0

0.0

0.0

9.1

0.0

9.8

4.6

12.2

21.8

25.0

43.6

41.7

57.1

57.1

100.0

66.7

100.0

100.0

——

18
Table 10. Number of persons in physician inquiry group reported as havin h

fied heart disease, cross-classifiedby personal physician and examinat on:

Survey, 1960-62

f ype;:~;msz:;

.

Personal physician’sdiagnosis

Total.......----------------------------

Definite-----------------------------------

Suspect or borderline------------------------

Negative-------------------------------------

Examination

diagnosis

TotalDefinite----

Suspect or

borderlineNegative----

TotalDefinite----

Suspect or

borderlineNegative----

TotalDefinite----

Suspect or

borderlineNegative----

TotalDefinite----

Suspect or

borderlineNegative----

488

84

80

324

65

38

14

13

33

12

9

12

390

34

57

299

Number of persons

488

94

60

334

58

36

10

12

34

20

4

10

396

38

46

312

488 ! 488

22 65

16 21

450 402

18 33

6 u

4 3

8 13

23 22

I

6 12

1 2

16 8

447 433

10 36

--L11 16

426 381

19
Table 11. Responses to medical history questionson heart disease, by final examinationdiagnosis of heart disease:Health ExaminationSurvey, 1960-62

Medical histc.ryquestion and response

Have you ever had any reason

to think you may have heart

trouble?

Yes-------------”....---------------------

y ---.”......................-------------

-“-------.--...-”------------------------

If “yes” or “?” did a doctor

tell you that you had heart

trouble?

Yes, total---------------------------------

Yes, diagnosis specified------------------

No--------------------------------m-.-----

How long ago did you first

start having it?

1 year-------------------------------------

1-5 years---------------------------------

More than 5 years--------------------------

Have you had it in the past

12 months?

Yes-.-------------------------------------

No----------------------------------------

Do you take any pills or

medicine for it?

Yes, total--------------------------------

Y#, medicine named----------------.--.---

--.------------------------------.------

Number of responses

All

responses

796

5,83(?

38

510

393

286

125

267

397

538

235

246

133

541

With examination

diagnosis of

heart disease

Definite Suspect

127

613

5

40

23

86

Percent of

responses

with examination diagnosis

of heart

disease

48.2

20.6

*

59.0

55.7

29.o

40.8

47.9

51.1

49.1

48.5

69.1

71.4

38.3

NOTE: Various subtotalsare not reconciled.

\

20
Table -—-—- 12. ——. Resnonses ..——=. ..—.— to——medical .—. historv auestions on hiszhblood uressure. by final examination

diagnosis of hyperten~i;n: Health Exam%ation S~rvey, 1960-~2

Medical history question and response

Have you ever had any reason.

to think you may have high blood

pressure?

Yes ------------------------------------- --

p...-.-...-...- ...................-----m.

.......-------------------- --------------

If “yes” or “?” did a doctor

tell you it was high blooa

pressure?

Yes-------------------------------- -------

No------------------------ ----------------

How long ago did you first

start having it?

1 year---------------- -----p---------- ----

1-5 years--------------------------- ------

More than 5 years-------------------------

Have you had it in the past

12 months?

Yes----------------------------------------

No --------------------------- -------------

Do you take any pills or

medicine for it?

Yes, total.......-------------------- -----

Yea, mdicine named -----------------------

No------------------------ ----------------

Number of responses

All

responses

954

187

233

420

468

704

349

434

149

701

With examination

diagnosis of

hypertension

Definite

485

520

11

458

27

81

166

228

331

116

Borderline

226

697

4

186

40

47

87

89

136

70

74

20

151

Percent

-of responses

with examination diagnosis

of hypertension

62.3

22.1

*

67.5

35.8

54*9

60.2

67.7

66.3

53.3

71.4

72.5

56.3

NOTE : Various subtotals are not reconciled.

246-9600-67-4
Table 13. Number of persons reported as having heart disease on examination and medical history,

by sex and age: Health Examination Survey, 1960-62

I 1

Men Women

Age

Medics 1 Medics 1

Examination history Examination history

I

Number of persons

18-24

25-34

35-44

45-54

55-64

;;-;;

Total, 18-79 years---------------------------- 806 I 355 I 794

I I

years-----------------------------------------

years----------------------------------------- % :: %

years----------------------------------------- 139 69 105

years----------------------------------------- 177 183

years----------------------------------------- 187 :: 205

years----------------------------------------- 154 53 1;;

yeara----------------------------------------- 49 17

NOTE : Medical history counts omit 38 caaes reported aa ? heart disease.

Table 14. Number of persons reported as having hypertension on examination and medical history,

by sex and age: Health Examination Survey, 1960-62

Men I

Women

Age

Examination Medics history 1 Examination Medical

history

I

Number of persons

Total, 18-79 years---------------------------- 966 431 977 709

18-24 years---------------------&------------------- 25

25-34 years----------------------------------------- 1% ;: %

35-44 years----------------------------------------- 201 ;: 145 109

45-54 years----------------------------------------- 208 86 251 150

55-64 years----------------------------------------- 212 84 247 152

65-74 years----------------------------------------- 139 76 216 148

75-79 years----------------------------------------- 45 18 51 31

NOTE: Medical history counts omit 35 cases reported as ? high blood pressure.

22
Table 15. Ratio of actual to expected prevalence of hypertensionand heart disease on examination and medical history, by sex and race: Health ExaminationSurvey, 1960-62

Hypertension Heart disease

Ratio of actual

to expected

Number of cases

reported

Number of cases

reported

Ratio of actual

Sex and race to expected

Examination

0.97

1.34

0.96

1.49

Examination

804

148

791

178

Medical

history

355

72

541

160

Medical

history

0.97

1.36

0.91

1.83

Exemination

646

149

608

177

Medical

history

Examination

0.94

1.60

0.92

1.81

Medical

history

Men

white-----------------------

Negro-----------------------

319

33

1.03

0.79

Women

376

65

0.99

1.02

~ite-..- .........----------

Negro-----------------------

Table 16. Ratio of actual to expectedprevalence of hypertensionand heart disease on examination and medical history,by income for the white population:Health Examination Survey, 1960-62

Hypertension

I

Heart disease

I

I

Number of cases Mtio of actual

reported to expected

Number of cases Ratio of actual

Income reported to expected

Exami- Medical

nation history I

Exami- Medical

nation history

Examination

Medical

history

Examination

Medical

history

1.21 264

1.03 254

0.99 317

0.83 147

0.99 153

129

143

174

1%

1.07 1.12

1.07 1.07

0.95 0.92

0.92 0.92

0.99 1.12

LWS than $2,000------------ 291

$2,000-$3,999--------------- 298

$4,000-$6,999---------------

!

425

7,000-$9,999--------------- 214

10,000 and over------------ 206

192

187

235

105

101

1.00

1.01

1.00

0.95

1.00

23
Table 17. Ratio of actual to expected prevalence of hypertension and heart disease on examination

and medical history, by education for the white population: Health Examination Survey, 1960-62

I

Hypertension

I

Heart disease

Number of cases

reported

Ratio of actual

to expected

Number of cases

reported

I

Ratio of actual

to expected

~—

Education

ExaminationMedical

history

Examination

Medical

history

Exami- lmami- Medical

nation history

I 1

Less than 5 years------------

5-8 years--------------------

9-12 years -------------------

13 years and over------------

1.16 1.29

1.06 1.13

0.96 0.92

0.87 0.85

1.12 1.16

1.07 1.06

0.98 1.02

0.84 0.77

Table 18. Ratio of actual to expected prevalence of hypertension and heart disease on examination

and medical history, by geographic region

1960-62

for the white population: Health Examinati~ Survey,

Ragion

-

Hypertension Heart disease

I

Number of cases Ratio of actual

reported to expected

Number of cases

reported

-

Ratio of actual

to expecited

TExami- Medical

nation history

Exami- Medical Exami- Medical

nation history nation history

T

627 277

426 282

542 337 ---L 443 207

34s 208

466 280

1.03 0.86

0.94 1.10

1.01 1.08

Northeast --------------------

South------------------------

West -------------------------

1.13

0.91

0.93

0.92

1.04

1.06

Table 19. Ratio of actual to expected prevalence of hypertension and heart disease on examinationand medical history, by place description for the white population: Health Examination Survey,

1960-62

> -

Hypertension Heart dLsease

Ratio of actual

to expected

Number oi cases

reported

Number of cases

reported

Ratio of actual

Place description to expected

I

a=Exami- Medical

nation history

ExaminationMedical

history

Exami- Medical

nation history

SMSA-in central city---------

SMSA-outside central city----

Urban-not SMSA---------------

Rural farm-------------------

Rural nonfarm----------------

459

510

n:

273

255

228

1;;

175

0.98

1.04

0.92

1.03

1.00

0.98 391 194

0.86 ;;; . 196

1.08 103

1.33 125

1.15 211 1;!

1.05 0.97

0.96 0.94

0.97 1.04

1.22 1.19

0.92 1.09 ~

1

24
Table 20. Number of men and women aged 45-64 years, by hypertensive status and symptoms on mdical history: Health Examination Survey, 1960-62

Symptoms on medical history

Every

~very

HEADACNES

In the past few years, have you had any

headaches?-------------------.------------

~

few days, bothers quite a bit--------------

~ewdays,-bothers just a little------------

Less omen, bothers quite a bit------------------

Essentiallynegative

Yes, less often, bothers just a little-----------

No-----------------------------------=--------.

Other------------------------------------------

NOSEBLEEDS

In the past few years have you had any

nosebleeds?-------------------------------

Yes

Every few days, bothers quite a bit--------------

Every few da s, bothers just a little------------

Leas often, ;others quite a bit------------------

Essentiallynegative

Yes, less often, bothers just a little-----------

No---------------------------------------------

Other-------------------------------------.------

TINNITUS

At any time in wer the past few years,

have you ever noticed ringing in your ears

or have you been bothered by other funny

noises in your ears?----------------------

Every few days, bothers quite a bit--------------

E~~yo~~da s, bothers just a little------------

s ~others quite a bit------------------

Essentiallynegative

Yes, less often, bothers just a little-----------

No-----------------------------------------------

Other--------------------------------------------

Men I

Wonen

965

:;

51

401

401

3

965 —

:

10

8%

3

965

z

20

206

637

5

21(

1

i

26

178

210

—

1!

3

12

Number of persons

21( 1.148

136

52

145

539

271

5

1.148

1

:

100

1,034

2

l,lia

68

50

23

292

710

5

285

15

z

70.

188

1

213

19

2:

10)

213

i

1;:

2

213

14

11

4

1:

1

25
Table 20. Number of men and women aged 45-64 yeara, by hypertensive status

cal history: Health Examination Survey, 1960-62—COn.

and symptoms m medi1

Symptoms on medical history

DIZZINESS

Have you ever had spells of dizziness?-----

Every few days, bothera quite a bit--------------

Every few days, bothers just a little------------

Less often, bothers quite a bit------------------

Essentially negative

YeS, less often, bothers just a little-----------

No ---------------------------------------- -------

Other---------------- ----------------------------

FAINTING

Have you ever fainted or blacked out?------

Yes ---,----- -------- -------- -------- -------- ------

No---------------- -------- -----------------------

Other--------------------------------------------

Men I Women

‘G7==l’’+

965

36

25

31

280

587

6

96$

168

797

210

Number of persong

210

10

4

9

58

128

1

210

1%

1,148

62

19

71

490

496

10

1,148

314

832

2

285

T

21

1;

126

121

1

285 —

2:;

1

213

-—

14

1;

:3

3

213

26
Table 21. Prevalenceof hypertension according to the number of hypertension symptoms reported,

by sex for specifiedage groups: Health ExaminationSurvey, 1960-62

Age group and number

positive symptoms

o

1

2

3

0

1

2

3

0

1

2

3

35-44 years

of

s~t~-.-..........-.-.--.

,

s~tm ---------------------

symptoms--------------------

symptomsand over-----------

45-54 years

symptoms--------------------

symptom---------------------

symptoms--------------------

symptomsand over-----------

55-64 years

Symptoms--------------------

Synlptom---------------------

symptoms--------------------

symptomsand over-----------

Number

of

persons

456

188

48

11

344

139

45

19

250

105

38

25

Men

Percent with:

Definite

hypertension

13.6

13.8

16.7

9.1

22.4

14.4

13.3

15.8

23.2

27.6

28.9

24.0

Definite or

borderline

hypertension

28.7

27.1

33.3

27.3

40.7

30.2

40.0

42.1

51.6

50.5

47.4

48.0

Number

of

persons

367

263

120

34

333

220

107

45

215

130

68

30

women

Percent with:

=

11.2

7.2

6.7

8.8

21.3

20.5

19.6

17.8

33.5

30.8

26.5

33.3

18.5

16.7

22.5

17.6

36.9

35.0

34.6

31.1

58.6

55.4

47.1

56.7

: The 5 symptoms being counted are specified in the text section’’Symptmaas a Diagnostic

Too!?

Table 22. Number of persons in physician inquiry group reported as having heart disease on examination and by personal physician,by sex and age: Health ExaminationSurvey; 1960-62

—

1

I

Men Iwomen

Age

Total, 18-79 years----------------------------------

18-44 years-----------------------------------------------

45-64 years---------------------------------------------

65-79 years-----------------------------------------------

--------------------------Eland.-

1

Personal Examiphysician nation

Number of persons

55 I 31 I 99 I 61

I I I

27
Table 23. Nnnber of persons in physician inquiry group reported as having hypertensionon,examination end by personal physician,by sex and age: Health ExaminationSurvey; 1960-62

Men Women

Age

Examination

Personal

physician

ExamiNumber of persons

Total, “18-79years---------------------------------- 601 .241 104 I 74

18-44 years-----------------------------------------------

45-64 years-----------------------------------------------

65-79 years-----------------------------------------------

Table 24. Response to physician inquiry, by sex and age: Health ExaminationSurvey, 1960-62

,

Number of responses

Percent,of

Lnquirieayielding

usable respcnses

Sex and age

All

responses

Usable

responses

Yo usable

responses

64.0 ..-—.,

18-44

~~=a~------------------------------- 762 488 274

110

120

40

52.7

61.7

62.5

years-------------------------------

years-------------------------------

years-------------------------------

Women

18-44

45-64

65-79

225

186

81

153

123

55

68.0

66.1

67.9

years---------.-.---................

years-------------------------------

years-------------------------------

28
Table 25. Response to physician inquiry, by

nation

specifieddemographic

Survey, 1960-62

characteristics:Health ExamiCharacteristic

Income

Lass than $2,000--------------------------

$2,000-$3,999-----------------------------

$4,000-$6,999-----------------------------

$7,000-$9,999-----------------------------

$10,000 and over--------------------------

Unknown-----------------------------------

Education

kss than 5 years-------------------------

5-8 years---------------------------------

9-12 years--------------------------------

13 years and over-------------------------

Unknown-----------------------------------

Place description

SMSA-in central city----------------------

SMSA-outsidecentral city-----------------

Urban-not SMSA----------------------------

Rural farm--------------------------------

Rural nonfarm-----------------------------

Geographicregion

Northeast---------------------------------

South-------------------------------------

West--------------------------------------

Number of responses

All

responses

99

144

250

115

88

66

45

193

378

124

22

301

278

;:

80

Usable

responses

1?!

240

88

13

188

183

54

i;

234

110

144

No usable

responses

43

25

25

31

1:$

107

Percent of

inquiriesyielding

usable responses

56.6

61.1

65.6

66.1

71.6

62.1

62.2

61.7

63.5

71.0

59.1

62.5

65.8

68.4

58.3

61.3

69.2

63.6

57.4

Table 26. Number of persons with examinationdiagnosis of heart disease, by whether response to

physician inquiry was usable or not usable: Health Examination Survey, 1960-62

Examination

Response I All t

Heart disease

perSol?s Definite Suspect

Hypertension

~

Number of persons

All responses----------------------------- 762 133 87 128 122

Usable response--------------------------------- 488 94 60 84

No usable response------------------------------ 274

80

39 27 44 42

29
Table 27. Number of persons according to their

reported by personal physician:

blood pressure as determinedon examinationand as

Health Examination Survey, 1960-62

Systolic blood ressure

(mm hg.Y

Total-----------------

Less than 90----------------

90-99-----------------------

100-109---------------------

110-119---------------------

120-129---------------------

130-139---------------------

140-149---------------------

150-159-----------------’----

160-169---------------------

170-179---------------------

180-189---------------------

190-199---------------------

200-209---------------------

210-219---------------------

220-229---------------------

230-239---------------------

240-------------------------

EEl!E!3

Number of persons

448

—

1

13

56

67

88

63

53

39

23

20

9

8

5

2

1

448

1

1

24

74

116

82

41

38

28

20

10

3

5

3

1

1

Diastolic blood ressure

(m. hg.Y

Total------------------

50-54------------------------

55-59------------------------

50-64------------------------

55-69------------------------

70-74------------------------

75-79--:---------------------

65-89------------------------

90-94------------------------

95-99------------------------

100-104----------------------

105-109----------------------

110-114----------------------

115-119----------------------

120-124----------------------

125-129----------------------

130-134----------------------

135-139----------------------

xamiationPersona1

physician

umber of persons

448

—

5

11

18

58

59

80

80

50

39

23

12

7

1

2

2

1

448

1

3

26

12

93

39

156

24

44

9

30

2

5

1

2

1

–.

30
Table 28. Number of persons, by sex according to their height as determined on examinationand

as reported by personal physician:Health Examination Survey, 1960-62

I

Men Women

Height

Exami- Persona1 Exami- Persona1

nation physician nation physician

.

Number of persons

All persons-----------------------------------------

Less than 150 centimeters--------------------------------.

150-154 centtiters---------------------------------------

155-159 centimeters---------------------------------------

160-164 centimeters---------------------------------------

165-169 centimeters---------------------------------------

170-174 centimeters---------------------------------------

175-179 centtieters---------------------------------------

180-184 centimeters--------------------------------------.

185 centimateraand over----------------------------------

77 I 77

L

6 5

:? :;

45 51

18 36

14 21

3 1

2

Table 29. Number of persons, by sex according to their weight as determined on examinationand

as reported by.- personal physician: . . Health Examination Survev. 1960-62

Weight

All persons-----------------------------------------

GSS than 100 pounds--------------------------------------

100-109 powds --------------------------------------------

110-119 pomds --------------------------------------------

120-129 pomds --------------------------------------------

130-139 pomds --------------------------------------------

140-149 pouds --------------------------------------------

150-159 pomds --------------------------------------------

160-169 pouds --------------------------------------------

170-179 pounds------------------------------------------

180-189 pomds --------------------------------------------

190-199 pounds--------------.-----------------------------

200 pounds and over-------------------------------------

,

Men I

Women

,

I I

Exami- Peraona1

nation physician

Exami- Personal

nation physician

Number of persons

98 I 98 [ 249 I 249

31
APPENDIX I

A. MEDICAL HISTORY QUESTIONS RELATED TO CARDIOVASCULAR’ DISEASE

(Excerpts From HES-204, Medical History-Self Administered)

1. a.

‘?.

3.

4.

5.

6.

7.

9.

16.

a.

a.

a.

In the past few years have you had any headaches? HIxZlm

If YES b. How often? Every few days _J~ Probes A,B

c. Do they bother you

~

in the past few years have you had any nosebleeds? IINxZIm

If YES b. How often? Every few days l___-J~

c. Do they bother you

~

Probe A

At any time over the past few years, have you ever noticed rinqinq

in your ears or have you been bothered by other funny noises

mmm

In your ears? Probes A,@

If YES b. How often? ] Every few days

c. Do they bother you -[

~

just a little

Have you ever had spells of dizziness?

If YES b. How often? Every few days

c. Do they bother you

~

Have you ever fainted or blacked out?

a. Have you ever had a stroke?

Elmm

m

just a little

If YES b. Have you had a stroke in the past 12 months?

c. Have you ever seen a doctor about it?

Has any part of your body ever been paralyzed?

Was there anytime in your life when you had a lot of bad sore

throats?

DEHmzl

JEmIHzl

EElimllzl

ElmlEl

mlmm

Em!zIlzl

a. Have you ever been bothered by shortness of breath

stai rs?

If YES b. How often? Almost everytime

c. Does it bother you 1-1

Probe A

Probes A.D

32
Probe A

Probe A

Probes A,B

17. a.

18. a.

19. a.

20. a.

21. a.

Have you ever been bothered by

physical work or exercising?

If YES b. How often?

c. Does it bother you

shortness of breath when doing

DElmlm

Almost everytime [~

quitea bit[ Ijust a littlel

Have you ever been bothered by shortness of breath when You were not —

doing physical work or exercising? m mm

If YES b. How often? Every few days ~

c. Does it bother you -[ just a little

Have you ever been bothered by shortness of breath when You are

excited or upset about something?

mmm

If YES b. How often? Almost everytime l_-__-1~

co Does “ bother you ~

Have you ever waked up at night because you were short of

breath? mmm

If YES b. How often? lEvery few niqhtsl lLess often[

c. Does

In the east few

or tightness in

I I , E

it bother you quite a bit I

just a little

years, have you ever had any pain, discomfort,

your chest? EIEiizlEl

IF YES, please answer questions b through j ~elm.

b. How often? Every few days 1~

c. Does it bother you

~

just a little I

d: Where does it bother you? (Check every place it bothers you.)

12Eml Dal EiEEl IEml -

I Somewhere else[ State where

e. Does it usually I

stay in one place ~m

f. How long does the pain usually last?

Just a few minutes Few minutes to an hour I lMore than an hour

I

0. Cbes it usually come When you take a lot of exercise or

when you are quiet [

or

is there no difference

h. Does it usually come when you are upset or

doesn’t this make any difference

I

j. Do you take any ~illsorrredicine for it?

33
z a. In the past few years, have you ever had any pain, discomfort,

or trouble in or around your heart? Hmm

IF YES, please answer questions b through j below.

b. How often? Every few days ~

c. Does it bother you

~~r

d. Where does it bother you? (Check every place it bothers you.)

Eml m ImiiEm m -

Somewhere else State where I

e. Does it usually stay in one place I ~lzl

f. How long does the pain usually last?

More than an hour

g. Does it usually come When you take a lot of exercise or

when you are quiet or

is there no difference

h. Does it usually come when you are upset or

doesn’t this make any difference

1

I

23. a.

24. a.

25. a.

26. a.

62. a.

j. Do you take any pills or medicine for it?

Sometimes, our hearts

or beating real fast,

noticed your heart do

If YES b. How often?

“act funny” (odd) like missing a beat,

or seem to turn over. Have you ever

anything like that?

Every few days [

c. Does it bother you -1

EIEIEI

El mm ~

just a little

Have you ever been bothered by your heart beating hard? HIXNIl

If YES b. How often? Every few days L-----J~

c. Does this bother you ~[

Are your ankles ever swollen at bedtime? B

If YES b. Is the swelling gone by morning? m

When you walk, do you have pains or cramps in your legs? B

If YES b. How often? Evkry few days

~

c. Does it bother you -1

~

Has a doctor ever said you ‘lad rheumatic fever (inflammatory

mm

EmI

IIElm

.—

rheumatism) MM

If YES b. Have You had it in the past 12 months? l--]~ ~’

c. Are you taking any pills or medicine for it? mm

Probes A,B

d

Probes A,B

Probes A,B

Probe A

Probe A

If YES d. ‘What is it?

34

..
&j. Has a doctor ever said You had chores or St. Vitus’ Dance? EIEzI

65.. a.

Probe C

66. a.

Probe C

Probe C

Has a doctor ever told you that you have hardening of the

arteries? mm

If YES b. Have You had this condition in the past 12months?l=l~~l

Have You ever had any reason tcthink You maY have high blood

pressure? Emm

If YESor ? b. Did a doctor tell you it was high blood

pressure? mm

c. How long ago did you first start having it?

1 year J~l over 5 years I

d. Have you had it in the past 12 months? HEm

e. Do you take any pills or medicine for it? mmlzl

If YES f. Give name of the medicine

67a. Have you ever had any reason to think you may have heart

trouble? EEm

lfYES or ? b. Did a doctor tell you that you had heart

trouble? mm

If YES, what did he call it?

If YES

c. How long ago did you first start having it?

m ~ Ioversy-1

d. Have you had it in the past 12 months? lYES\lNOll?

e. 00 you take any pills or medicine for it?

EHEHII

f. Give name of the medicine

Probes: A. Do you have any idea what causes your ?

B. Tell me how it feels.

c. In what way does it bother or a“

O. How many flights?

These questions were used, where indicated,

answered either “yes” or “?”

feet you?

f the exam nee

35
B. FORMS USED IN RECORDING FINDINGS

ON THE PHYSICAL EXAMINATION

Confidentiality has been assured the individual as set forth in 22 FR 1687

PIIS-3034 iiealth Exxaination Survey

REV. 4-61 PNYSICAL EXAMINATl~

19ES-205

<

BLOOD PRESSURE - LEFT ARM

TIWE SYSTOLIC DIASTOLIC 1 DIASTOLIC 2

1.

2.

3.

OCULAR FUND I RlallY LEFT . REMARKS COOE

4. Normal

5. Fundus not Visual ized

6. Globe Absent

7. Increased Light Reflex

8. Narrow Arterioles

9. Tortuous Arterioles

0. AV Compress ion

1. Hemorrhage

b

.2. Exudate

3. Venous Engorgement

$. papilledema

5. Oisc Abnormal

6. Lens o:ac ities

..:_ ..:_

7. Iritis

8. other (Specify]

#

“-”’’ad’ III El El El ❑ El

I

,~.,.—- . -.. =.-.

36
4

EARS R lair LEFT REHARKS CODE

20. normal

21. Drum not Visualized

22. Malformation

23. Exudate

2u. perforated Drum

25. Scarred Orum

●

NECK

26. Venous Enooraement [Uori~ht) IWFl m

PERIPHERAL ARTERIES - lnsDect ion and palpation 1

27. All Normal ❑

RIWT SIDE NORMAL SCLEROTIC TORTUOUS NOT DONE* CODE

28. Superficial Temporal

29. Brachial

30. Radial

LEFT SIOE NORMAL SCLEROTIC TDRTUOUS IIOT DOSE” CODE

31. Superficial Temporal

32. Brachial

t

33. Radial

,

●WT OWE (Specify which item number and why not done) \

37 ‘
s DUALITY .-. .—.. . OF ARTERIAL PULSATIONS 1

~134. All Normal ❑

RIGHT SIDE HoRnAL DDIMD111~ DINIHISHED PA:&E IIOT’ DOHE” CODE

35. Rad’ial

,

36. Dorsal is Pedis

37. Post-t ibial

LEFT SIDE NORMAL WtMolm DIMINISHED PA:% IIOT DOHE* CODE

1

38. Radial

k

39. Dorsalis Pedis

40. Post-t ibial

LOWER EXTREMITIES RIWIT LEFT REMARKS CODE

1

41’. Normal

42. Not Done”

,

43. Varicos ities

44. Dependent Edema

45. ulcers

●

●WIT DONE (Specify which item number and why not done)

38
HEART

U6. Tbrlllo Hone ❑

IF present, Sp+2Cify: Lccat ion ●

Timing

47. AsIcal Imwloo .— Not FeTta

MCL At or inside EE!Ezl @

Interspace ElmElam I

48. Hawt Sounds .—

Normal ❑

Accentuated Diminished

‘2 c1 •1

‘2 •1 ❑

‘1 ❑ •1

Third Heart Soundn Splitting of second sound abnormaln

Other (Specify) I

49. Hurmur8 If present, specify (in order): location, intensity (grades I through V), pitch,

quality, duration, timing, transmission, and whether significant or non-significant.

Systolic None •1

.

Diastolic None u

MUSCULOSKELETAL SYSTEM

i

50. Arthritis .●nd Rhouutlsm No Positive Findings c1

If positive findings are present, fi?l out Suamtry ——of Joint lnvolvomont

on next page. I

39
StMARY OF JOIIIT IIIVOLVEIIEHT

I MS WESTATMW

ilolnts

Tender Swelllng Do formlty

II. Shoulder

2. Elbow

3. Wrist

U. NetacarpOphalangeal

5. Proximel -

interphalangeal

6. Distalinterphalangea.1

17. Hip

i8. Knee

i9. Ankle

\O. Feet

M. Cervical

spine

\2. LUMbar

spine

$3. other’ I I I

.Imltatlon Oth*rl C049

I

1

1 m

tacord positiva findings as R for right, L for loft, RL for both, .xempt for pin* (Items 61 ●nd

621 wklch should bc ch*ck ●arked.

Fingars (ltam~ SQ, 55, ●md 56J: Record totml rmmbar of joints Involwad en ri$ht or left.

1

‘Otho.rm ●anifastattons imoldo Mabard*n18 nodos, subcutaneous nodulos, ulnar dowiatlonf

ti on, heat, ●trophy, ●nd funmcl fist.

●

Wothcr’ joints Imcludo t*mPOrO=andlbul*r, stornoclavtcwlar, sacroiliac, and 8 ~clflc

f*et.

pain on ● oolnts of tho

/’-’

40

,
ADDITIONAL FNWl@S Ill TM FINS4CAL EIWJIIATIOII f

Ilals ❑ catE

B. Head

5. Meek

.

6. Chest

7. Extremities

Ioarsmuocular Syotoa

8. Gait

9. Cf30rd inat ion

,

&

O. Strength . 4

I. Tremor &

lntAIRmlTs

a-•

swain?

Ister Illnosa -s

Dlrtb or *JW C4K

T2. Cleft palate

T3. Club foot

74. Paralysis (Specify site)

75. uissing digits (Specify)

76. other (SpeCifY)

77. Additional Remarks

r

/’”
EXAIUHlll@ PHYSICIAIIW lMFRESSlti

Cardlevascular 01s068.s tiEGATIvE POSITIVE SUSPECT

Hypertension ................................................................ •1 ❑ ❑

Peripheral arteriosclerosis .......................................... •1 •1 •1

Organic heart disease ................................................... ❑ •1 ❑

Angina pectoris ........................................................... •1 •1 •1

If positive or suspect,

Etiology

Anatomy

Physiology

Functional capacity

Other

Comments

Arthrltts ●nd Rhoumatlsm

NO arthritis

Classical arthritis (give specific diagnosis)

Definite arthritis

Rheumatic complaints

Questionable complaints

Othsr Olsoasos ●nd Condlt Ion8

M.D.

Signature

42
C. PHYSICIAN INQUIRY FORM

(

Co. fidcntiality has kmr assur.d ttm individual .s .ct forth in 22 FR 1637

PHS35Q4 PHYSICIAN INQUIRY Form Approved Bureau of the

8-60

Budget No. 68-R621LS4

HES-21I Eqires 6-30-63

SERIAL NUMBER

~

PATI ENT’S NAME, ADDRESS, AGE, AND SEX

1. WhsrI did you last se- this patient?

2. What did you traat him for at that tire.?

3. In gcntml, vrwld you dcscrib* the patient’s h.olth at that time as:

❑ Excollsnt ❑ Good ❑ Fair ❑ Poor

4. Did tfm potimt have any of the following conditions? (PI...* .hcck th* appmpriat* block)

Y9S, Don-t know

Y*%, passibl. (Hav. no infomotion

CONDITION dcfinito ‘r N. b-ring on rhis

trntativ* condition)

a. Hypcrtansion

b. Poriphcral vascular dizcasc

c. Coronary heart disease

d. Hypcrtensiv@ heart disease

●. Rh~umatic heart dis~ose

f. Other hurrt diseaso (PlcrJsc specify)

.

j. Ofmbmtm

t. Arthritis or rhaumoti sm

5. If in your record, plsaso spaeify the following mcasummmrts and the dat* Iatast mcasur*mant was takmr:

a. Blood pressure

(oat.)

k. Haight

(oat.)

c. Weight

(oat.)

(S@mwm of physician) (Dsto)

Ot*: PIwse use otfmr side ~r additional inkmation or comm.nts

43

u.aoovmwuEwr FTLmTmGoFmcE: 19s70- 24s-90s
t

Series 1.

Series 2.

Sm”es 3.

Sm”es 4.

Sert”es10.

Sm”es 11.

Sw”es 12.

Serz”es 13.

Sw”es 14.

Series 20,

Sm”es 21.

Sm”es 22.

VITAL AND HEALTH STATISTICS PUBLICATION SERIES

Originally Public Health Service Publication No. 1000

Progmms and collection &ocedures.— Reports which describe the general programs of the National

Center for Health Statistics and its offices and divisions, data collection methods used, definitions,

and other material necessary for understanding the data.

Lkata etxalt@ion and methods resewch. —Studies of new statistical methodology inclu~ experimental tests of new survey methods, studies of vital statistics collection methods, new analytical

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

Atmlvtical studies. —Reports presenting analytical or interpretive studfea basedon vital and health

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

Documents and committee r@Orts.- Final reports of major committees concerned with vital and

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

birth and death certificates.

DMZ Jrom the ‘Health Intm”ew .%rvev. —Statistics on ijlness, accidental injuries, disabfli~, use

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

collected in a. continuing national household interview survey.

Dab from the Health Examination Survey. —Data from dfrect examination, testing, and measurement of national samples of the civilian, noninstitutional population provide the basis for two types

of reports: (1) estimates of the medically defined prevalence of specific diseases in the Unfted

States and the distrilmtions of the population with respect to physical, physiological, and psychological characteristics; and (2) analysis of relationships among the various measurements without

reference to an explicit finite universe of persons.

Data from the Institutional Population Surveys. —Statistics relating to the health characteristics of

persons in institutions, and their medical, nursing, and personal care received, based on national

samples of establishments providing these services and samples of the residents or patients.

Data from the Hospital Discharge Survey. —Statistics relating to discharged patients in short-stay

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

Data on health resources: ?nm@ower and facilities. —Statistics on the numbers, geographic distribution, and characteristics of heslth resources including physicians, dentists, nurses, other health

occupations, hospitals, nursing homes, and outpatient facilities.

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

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

geographic and time series analyses.

Data on natality, nuarriage, and divorce. —Vsrious stadstics on natality, marriage, and divorce

other than as included in regular annual or monthly reports-pecial analyses by demographic

variables, also geographic and time series analyses, studies of fertility.

LMta from the National Natality and .Mortality Surveys. — Statistics on characteristics of births

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

records, including such topics as mortality by socioeconomic class, hospital experience in the

last year of life, medical care during pregnancy, health insurance coverage, etc.

of titles of reports published in these series, write to: Office of Information

/’”

Nat ional Center for Health Statistics

Public Health Service,

Rockville, Md. 20852

HRA