Vitaland

HealthStatistics

Ambulatory Care

France, Federal

Republic of Germany,

and United States,

1981-83

Series 5

Comparative International Vital and

Health Statistics Report

No, 5

Data are presented comparing ambulatory medical care in France,

Republic of Germany, and United States, Analysis focuses on office-based

ambulatory care provided by general practice physicians and selected

medical specialists, Data were derived from independent sample surveys

conducted in the three countries, Survey methods and the characteristics

of the health services systems are also described and compared,

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

PublicHealthService

Centers for Disease Control

National Center for Health Statistics

Hyattsvllle, Maryland

June 1989

DHHS Publication No. (PHS) 89-1481
Copyright information

All material appearing In this report IS (n the publlc doma!n and mav

be reproduced or copied without permlsslon; cltatlon as to source,

however, IS appreciated.

Suggested citation

DeLozler J, Kerek-Bodden E, Lecomte T, et al Ambulatory care

France, Federal Republlc of Germany, and Umted States, 1981–83

Nat!onal Center for Health Statlstlcs. Vital Health Stat 5(5) 1989

Library of Congress Cataloging-in-Publication Data

Ambulatory care: France, Federal Republic of

Germany, and UnNed States—1 981 –83 / author, James De Loz[er

p. cm. — (Vital & health statlst(cs. Series 5, Comparative

International vital and health statistics reports ; no. 5) (DHHS

publ,catlon ; no. (PHS) 89–1481 )

By J. De Loz!er and others.

Bibliography: p.

Supt. of Dots. no.. HE 20.6209:5/5

ISBN 0-8406-041&6

1. Ambulatory medical care—United States— Statlstlcs.

2. Ambulatory medical care— France— StatLst!cs. 3. Ambulatory

medical care—Germany, West— Stat Lstlcs. 1. De Lozier, James E.

II. Series. Ill. Series: Vital and health statlst!cs. Series 5,

Comparatwe !nternat!onal wtal and health statistics reports ; no.

5.

[DNLM: 1. Ambulatory Care—France—statistics. 2 Ambulatory

Care—Germany, West—stat\st(cs. 3. Ambulatory Care—

Umted States—

statistics. W2 A N148ve no. 5]

RA407.3.A63 1989

362.1 ‘2’0973021 —dcl 9

DNLM/DLC

for Library of Congress 88–607936

CIP
National Center for Health Statistics

Manning Feinleib, M.D., Dr.P.H., Director

Robert A. Israel, Deputy Director

Jacob J. Feldman, Ph.D., Associate Director for Analysis

and Epidemiology

Gail F. Fisher, Ph.D., Associate Director for Planning and

Extramural Programs

Peter L. Hurley, Associate Director for Vital and Health

Statistics Systems

Stephen E. Nieberdm& Associate Director for Management

Charles J. Rothwell, Associate Director for Data Processing

and Services

Monroe G. Sirken, Ph.D., Associate Director for Research

and Methodology

Division of Health Care Statistics

W. Edward Bacon, Ph.D., Director

James E. DeLozier, ChieJ Ambulato~ Care Statistics

Branch

Manoochehr K. Nozary, ChieJ Technical Services Branch
Preface

Hktorically, the provision of medical care has been associated with institutions alms houses, rest homes, and, more

recently, hospitals. The hospital sector has come to dominate

the health services systems of all developed countries and most

developing countries. As efficacious treatments and preventive

measures emerged, ambulatory care, particularly at the earliest

stages of the natural history of disease, became a practical

alternative to hospital care and expanded rapidly. More and

more patients took their health problems, and even their social

problems, to physicians at earlier stages. Today the great bulk

of medical care throughout the world is given in ambulatory

settings.

Accompanying the advent of unequivocally useful treatments was a proliferation of diagnostic and other therapeutic

maneuvers, many of which now, as in the past are of dubious

benefit. This proliferation was largely confiied to hospital

inpatient care which as it expanded in size, scope, and specialization, consumed an ever greater proportion of health services

expenditures, The imbalances between the hospital and ambulatory sectors, between general and specialty care, between

early and late treatment, between prevention and palliation all

contributed to escalating costs and growing public disenchantment with the management of health services systems. Above

all came the recognition that the first physician to see the

patient is the principal arbiter of how the patient’s problem is to

be managed and, consequently, of how much is to be spent.

The decision to continue treating the patient’s problem on an

ambulatory basis or to have the patient admitted to a hospital,

especially for care by a specialist or super-specialist, is critical

for the nature and quality of the care and for the total costs.

In most countries (France is an exception), specialists

tend to prefer inpatient hospital carq general practitioners and

family physicians tend to choose ambulatory care settings in

their own ofllces or in health centers, clinics, or outpatient departments of hospitals. In some countries there are statutory or

professional limitations on who can practice where. The ratios

and mixes of physicians, equipmen~ and facilities vary widely

within and among countries.

What then, should be the optimum balance between general

and specialty care, among specialists of different types, between ambulatory and inpatient hospital care and among hospitals of different types, and between prevention and treatment? One approach to resolving these issues is to generate

better information about the characteristics of health services

systems, their activities, and eventually, their relative outcomes or benefits, For the most p~ countries have emphasized

vital statistics as the basis for understanding their health prob

lems and health services. A few countries have started to

develop statistics on hospital activities, and a still smaller

number are generating data about ambulatory care. Although

international comparisons of vital statistics have been conducted for decades, and a few comparisons of hospital care

have been undertaken, there have been virtually no organized

international comparisons of ambulatory care. Accordingly,

this initial descriptive analysis of ambulatory care statistics

from three western industrialized countries was undertaken to

assess the dimensions of the similarities and differences and to

stimulate further study.

A larger prospective study involving more countries, larger

samples, and identical data collection methods for core minimum

data sets eventually may be desirable, but this exploratory

study seemed a reasonable beginning. The participants in the

study share common concerns about the overall problems

addressed as well as expertise about the statistical, operational,

and clinical aspects of the data sets compared. From larger

universes of physicians and of patient encounter data from the

three countries, subsets of essentially comparable physician

groups and patient encounter data were selected for common

analysis. The latter was limited to oflice-based, face-t~face

encounters that constitute the major component of ambulatory

care in all three countries. It is this component of care that

offers the major alternative to inpatient hospital care and,

hence, presents the greatest opportunity for prevention, early

treatmen~ and containment of health services costs.

The emphasis on the data selection process was on functional equivalence and realistic comparability, rather than on

excessive precision with respect to classifications, working

arrangements, clinical traditions, and reimbursement schemes.

The comparisons are based on best estimates augmented where

possible by standard errory they are designed more to illustrate relationships and orders of magnitude than to measure

exact differences. This study was not designed to suggest that

one pattern of resources, organization, or reimbursement is

better or worse than another. The main purpose is to suggest

where the search might be started for creating health information systems designed to assist in organizing balanced health

services arrangements that can provide equitable access to

efficacious services, which will improve health status and will

moderate costs.

Kerr L. White, M.D.

ill
Acknowledgments

This study was supported by the Wemer-Reimers Foundation, Bad Homburg v.d.H,, and the Zentralinstitut fiir die

kasseniirztliche Versorgung in der Bundesrepublik Deutschlan&

Federal Republic of Germany the Rockefeller Foundation,

New York N.Y., and the National Center for Health Statistics,

Hyattsville, Md., United States; and the Centre de Recherche

d’Etude et de Documentation en Economic de la Sante, le

Cornmissariat G.5neral au Plan, and 1aCaisse Nationale d’Assurance Maladie et la Federation de la Mutualit6 fraqaise,

Paris, France.

The work was made possible by the cooperation of colleagues in France, the Federal Republic of Germany, and the

United States who provided advice, technical assistance, published and unpublished dat~ and moral support. In particular,

the authors wish to express their gratitude to Ph. Le Fur, C.

Serme~ and J. C. Poulier, in Francq F. W. Schwartz and P,

Wagner in the Federal Republic of Germany and R O. Gagnon

and N. J, Peyton in the United States.
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 ...

Acknowledgments . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Selected results , , , . . . . !, . . . . . . . , . . . . . . . . . . . . . . . . . . . . , !. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Chapter l—Heak.hs ervicessystems in France, the Federal Republicof Germany, and the United States... . . . . . . . . . . . . 5

Demography, health status, and economic indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Health services systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Tables

A. Selected demographic data France, the Federal Republic of Germany, and the United States, 1981 . . . . . . . . . . . . . . .

B, Number and rate per 100,000 population of active physicians in patient care, by type of practice and physician specialty

France, the Federal Republic ofGermany, and the United States, 1981 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

C, Total and per capita heakhexpenditurex France, the Federal Republic ofGermany, sndthe United States, 1981 . . .

D. Access to physicians and payment and reimbursement mechanismsin ambulatory care France, the FederalRepublic

of Germsny, and the United States, 1981–83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chapter2—Survey methods and analytical approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Data sources—general . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sample design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Scope ofcoverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Data collection procedures .,.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Survey instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Data processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Reference populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Definitions ofselected terms..,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tables

E. Summary of ambulatory care survey methods France, the Federal Republic of Germany, and the United States . . . . .

F, Number of physicians, physician response rates, and patient encounters for the ambulatory care surveys used in this

report France, the Federal Republic of Germany, and the United States, 1981–83 ! . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chapter 3—Results—Comparison of ambulatory care in France, the Federal Republic of Germany, and the United

States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . .

Selected characteristics of ambulatory care physicians . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . !. . . . . . . . . . . . . . . . . .

Volume andrateof ambulatory physician-patient contacts and encounters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Characteristics ofambulatory care encounters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Reasons for physician encounters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

7

8

9

11

12

12

13

14

14

15

.15

15

15

11

13

16

16

17

20

24

v
Figures

1. Number of annual ambulatory contacts and encounters per person by type of contacti France, the Federal Republic of

Gemwy, mdthe United States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...!.... . . . ... . . . . . . . . . . . . . . . .

2. Annual rate of encounters per person by patient age France, the Federal Republic of Germany, and the United

States. 1981.83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Rate per 100 population of encounters of patients known to the physician by patient age France, the Federal Republic of

Germany, and the United States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Percent of diagnostic entries in major International Classification of Diseases, 9th Revision, categories France, the

Federal Republic of Germany, and the United States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ,,, ,

5. Number of diagnostic entries per 100 encounters for selected diagnoses France, the Federal Republic of Germany, and

the United States, 198 1–83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6. Percent of diagnostic entries for selected diagnoses France, the Federal Republic of Germany, and the United States,

1981-83.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tebles

G. Percent distribution of encounters and study physicians by physician specialty group France, the Federal Republic of

Germany, and the United States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

H. Number and rate per 1,000 population of physicians, by specialty France, the Federal Republic of Germany, and the

United States, 1981 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

J. Number and percent distribution of office-based physicians by age and sex France, the Federal Republic of Germany,

and the United States, 198 1–83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

K. Number and percent distribution of ofilce-based physicians by type of practice and specialty group France, the Federal

Republic of Germany, and the United States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

L. Rate of nonphysician medical personnel in the offices of solo practice physicians by specialty group France, the Federal

Republic of Germany, and the United States, 1981–83.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

M. Annual rate per person of ambulatory contacts and encounters and number of encounters with study physicians: France,

the Federal Republic of Germany, and the United States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

N. Number and crude and standardized annual rates per 1,000 population of physician-patient contacts: France,

the Federal Republic of Germany, and the United States, 1981–83. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0. Number and crude and standardized annual rates per 1,000 population of physician-patient encounters: France, the

Federal Republic of Germany, and the United States, 1981–83. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

P. Number and crude and standardized annual rates per 1,000 population of physician-patient encounters with study

physician~ France, the Federal Republic of Germany, and the United States, 198 1–83 . . . . . . . . . . . . . . . . . . . . . . . . . .

Q. Number, crude and standardized annual rate per 1,000 population of encounters, and percent distribution of encounters

by visit status, and by patient sex, according to visit status: France, the Federal Republic of Germany, and the United

States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

R Percent distribution of encounters with study physicians by patient status France, the Federal Republic of Germany, and

the United States, 1981-83., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

S. Rate of encounters by new patients per 100 total encounters by patient age and sex France, the Federal Republic of

Germany, and the United States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

T. Percent distribution of diagnostic entries by International Classification of Diseases, 9th Revision, categories: France,

the Federal Republic of Germany, and the United States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

U. Speciilc (index) diagnoses and preventive care categories used in analysis and the corresponding International Classificationof Diseases codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

W. Number of diagnostic entries per 100 encounters for selected index medical and preventive care categories: France, the

Federal Republic of Germany, and the United States, 1981-83... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Y. Percent distribution of diagnostic entries for selected index medical and preventive care categories by type of physician

France, the Federal Republic of Germany, and the United States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

21

22

26

28

29

16

17

18

18

19

19

20

20

20

23

23

23

25

27

27

30

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

List of detailed tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Appendixes

I. Survey instmments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

II. Reference populations by country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

VI
Symbols

. . . Data not available

,,, Category not applicable

. Quantity zero

0.0 Quantity more than zero but less than

0.05

z Quantity more than zero but less than

500 where numbers are rounded to

thousands

*

Figure does not meet atandard of

reliability or precision (more than 30

percent relative standard error)

# Figure suppressed to comply with confidentiality requirements

Vll
Ambulatory Care:

Francq Federal Republic of

Germany, and

United States

by J. DeLozier, Division of Health Care Statistics, National

Center for Health Statistics; H. E. Kerek-Bodden, Zentralinstitut ftir die kassenarztliche Versorgung in der Bundesrepublik Deutschland; T. Lecomte, An. Mizrahi, and Ar.

Mizrahi, and S. Sandie~, Centre de Recherche d’~tude et

de Documentation en Economic de la Sant6; and E.

Schach, Universitat Dortmund

Summary

This study describes the results of a comparison of ambula

tory medical care data for France, the Federal Republic of

Germany (FRG), and the United States of America (U.S.).

Data for this comparison were derived from independent national sample surveys in ambulatory care systems of the three

countries in 1981-83. The French data set resulted from a

sample of physicians who had been asked to document all

patient-physician contacts for a specified 3-day period during

1982-83. The FRG survey of patient-physician contacts was

performed in the fourth quarter of 1981 and the first quarter of

1982, Sample physicians reported for a sample of patientphysician contacts during two consecutive weekdays, the reporting periods being spread across the tsvo calendar quarters in a

balanced fashion. Survey physicians had been drawn at random

from almost all ambulatory care specialties. U.S. survey data

were obtained through a random sample of physicians reprdng

for a sample of their patient-physician contacts for a whole

week with the reporting weeks being spread across the whole

year of 1981. Because regular oflice hours generally do not

take place on weekends, Sundays were excluded in the French

survey, in the FRG survey Saturdays &d Sundays were excluded as reporting days. Although the French and the U.S.

study universes consisted of almost all physicians practicing

ambulatory medical care in the respective countries, the FRG

physicians were drawn from five regions of the country systematically selected to represent the Federal Republic of Germany with respect to demographic population characteristics

and physician specialty distribution. The universes of physicians

and patient-physician encounters of the three national studies

varied according to the ambulatory medical care systems of the

respective countries.

Data sets for this international comparison were derived

from the respective national studies by selecting personal

patient-physician contacts (in the physician’s office or in the

patient’s home—referred to as “encountm”) with eight physician

specialties (general practitioners, pediatricians, obstetricians/

gynecologists, internists, psychiatrists/neurologists, dermatol~

gists, ophthalmologists, and otorhinolaryngologists). Patient

variables used in the international comparison are patient age,

sex, visit status, reason for encounter, and disposition. Yearly

rates of personal patient-physician encounters in ambulatory

medical care were estimated. Crude and age-sex standardized

rates were computed for selected patient and physician

characteristics.

1
Selected results

All three countries are among the group of western industrialized nations with high gross national products per capita

(above U.S. $10,000 per year), moderate economic growth

(2-4 percent), and relatively low unemployment rates (range

4.4 percent for the Federal Republic of Germany to 7.5 percent for the United States in 1981).

The health services systems of the three countries are described by the following structural and access characteristics

●

●

●

●

●

●

Higher physician per population ratios in the two European countries compared with the United States

H@er proportions of physicians in ambulatory care among

all practicing physicians in France and the United States

compared with the Federal Republic of Germany

Higher hospital bed ratios per 1,000 population in the

Federal Republic of Germany than in the other two countries

Higher specialist to generalist ratios in ambulatory care in

the United States compared with the European countries

The majority of the French and German populations being

covered by comprehensive health insurance, compared

with 80 percent of the U.S. population with coverage

mostly for hospital care.

The patients’ paying a varying proportion of the ambulato~

medical care bill out of pocket (in the United States, 30

percenc in France, 20-25 percent and in the Federal

Republic of Germany, less than 10 percent on the average

of the ambulatory medical care bill)

Characteristics of the ambulatory medical care systems are

as follows

. Free choice of physicians for patients in ambulatory medical

care in the three countries

. Independent self-employed, ollice-based physicians as

the major providers of care

● Ambulatory care mostly delivered in oftlce settings, even

though in all three systems ambulatory care physicians are

permitted to supervise patients in hospitals

● Physicians being remunerated on a fee-for-service basis,

with the fee schedules either being freely set or negotiated

between carrier and physicians

With respect to direct encounters between patients and

physicians in ambulatory care it is observed that annual agesex standardized rates of personal patient-physician encounters per person ranged from 10.4 (Federal Republic of Germany) to 6,8 (France) to 2.7 (United States). All three countries

2

report relatively high proportions of total direct physician encounters as being associated with the eight study physician

specialty groups (88 percent for France, 92 percent for the

Federal Republic of Germany, and81 percent for the United

States). Ambulatory physician densities do not explain the

observed variabiMy in rates because they are highest in France,

intermediate in the United States, and lowest for the Federal

Republic of Germany. One explanation for the relatively high

FRG encounter rates may be the higher frequency of physicians’ recommendations to their patients to return (more than

50 percent of encounters) and relatively high referral rates (7,5

percent of encounters).

Almost two-thirds of personal patient-physician encounters in ambulatory medical care in France are accounted for by

generalists. This compares with a little more than 50 percent in

the Federal Republic of Germany and less than one-third in the

United States, Therefore, the degree of generalist responsibility for total ambulatory care is highest in France, intermediate in the Federal Republic of Germany, and lowest in the

United States. However, this international study did not examine

the content of care delivered in a typical ambulatory care contact of each of the three countries. Such comparisons might

provide explanations for the different encounter volumes ob

served or might determine whether there is possible substitution of high encounter rates combined with short contact times

by lower encounter rates combmed with longer contact times.

In the framework of this international comparison, it is of

interest to examine whether the different levels of personal

patient-physician encounter rates per population of the three

countries were related to similar relative distributions across

patient or physician characteristics. It was hypothesized that

observing similar distributions of encounters by patient characteristics might be interpreted as suggesting similar need distributions of patients seeking ambulatory care across countries,

Examining rates of encounters by patient age and sex

yields almost identical distributions for the three countries

though at different levels of magnitude. Furthermore, when

examining diagnostic entries by major International Classification of Diseases (ICD) category and selected specific medical

diagnoses, it is found that these distributions also agree fairly

well, Thus, despite substantial differences in the overall level

of use of ambulatory medical care services in the three countries, the relative distributions of encounters agree by patient

age and diagnostic categov of patient reason for contact.

Estimates of Pearson-product moment correlation coefficients

among the relative frequencies of the fwst 17 major ICD diag-
nostic categories confirm this finding

Pearson-product moment correlation

coefficients

Federal Republic

Country of Germany United States

France . . . . . . . . . . . 0.80 0.78

Federal Republic of

Germany . . . . . . . . . . . 0.86

Even though personal patient-physician encounter rates among

the three countries are related as 1:2.44 (United States France

Federal Republic of Germany), the relative distributions of

these encounters among diagnostic categories and patient age

agree relatively well, However, the responsibility of physician

specialty groups for these encounters varies among countries.

Because this international comparison did not investigate the

severity of morbidity presented in the course of encounters between patients and their physicians, it is uncertain whether

conditions treated in ambulatory care settings of the United

States (a country with a low encounter rate) are more severe on

the average than those in the two European countries.

The study results are of interest because they seem to suggest that similar encounter distributions by patient demographic

and illness characteristics may be the result of similar morbidity distributions in the three countries’ populations despite

substantial differences in the respective health services systems

characteristics.

On the basis of the results of this study, it may be concluded that patient demographic and morbidity characteristics

are more important in determining the structure of encounters

in ambulatory care (shape of relative distributions), while health

services systems characteristics appear to be more important in

determining the volume of services delivered.

3
Introduction

The data presented in this report are derived from surveys

conducted in France, the Federal Republic of Germany (FRG),

and the United States of America (U.S.).

The French data are from the Enqu&e Morbidite et Therapeutique M&-licale(Survey of Morbidity and Medical Care)

conducted by the Centre de Recherche d’Etude et de Documentation en Economic de la Sant&(1981) (Health Economy

Research Study and Documentation Center, formerly the Division d’Economic M&licale du Centre de Recherche pour l’Etude

et l’Observation des Conditions de Vie), The FRG data were

collected by the Zentralinstitut fir dle kasseniirztliche Versorgung in der Bundesrepublik Deutschland (1988) (Central

Research Institute of Health Insurance Physicians) in its survey

entitled Erhebung tiber die Versorgung im ambulanten Sektor

durch niedergelassene &zte (Survey Among Ambulatory

Care Physicians). The U.S, data come horn the National

Ambulatory Medical Care Survey (NCHS, 1983a) conducted by the National Center for Health Statistics,

The surveys were conducted independently in each country,

The agency responsible for each survey developed its design

and materials taking into consideration its particular data needs,

health services system, available resources, and relationship

with its medical community. As a resulg the survey designs

varied among the three countries, and each survey included

data items, terms, and design features not found in the others.

There are, however, many aspects of the designs and data

items that are common to the three surveys and that enable

selective comparisons to be made concerning ambulatory medical care in the three countries. As a consequence, the principal

participants from each of the surveys have collaborated to

develop and analyze a limited but informative common set of

ambulatory medical care data for France, the Federal Republic

of Germany, and the United States. The results of that effort

are presented in chapter 3 of this report.

In chapter 1, a summary comparison of the health services

systems in the three countries is presentet and significant

economic and social factors affecting the use of health services

are described. Differences and similarities that have a direct

bearing on the data used in the analysis are discussed,

In chapter 2, the methods, definitions, and instruments for

each of the three surveys are described and compared, In addition, the manipulations and adjustments needed to derive comparable data from the three surveys are explained. An understanding of this information is necessary for proper interpretation

of the data presented in the results section, The data analysis

and resuits are presented in chapter 3 and in detailed tabulations

after chapter 3,

Survey instruments for all three surveys are displayed in

appendix I, including English translations of the French and

FRG forms. Reference population figures are provided in ap

pendix II.
Chapter 1

Health services systems in

France, the Federal Republic

of Germany, and the

United States

In France, the Federal Republic of Germany (FRG), and

the United States (U.S.) the behavior of the different factors in

the health services system depends on general demographic

and economic characteristics of the population as well as on

the organization, financing, and structure of health services.

The relative importance of each of these factors has not yet

been measured definitively, However, each must be taken into

account in any comparative study, In this repo~ where ambulatory medical care services provided in France, the Federal

Republic of Germany, and the United States are compared, it

is clear that understanding the comparative analysis requires

an understanding of related information for the three countries.

For example, information must be available on such factors as

the age structure of the populatio~ the respective roles of

hospital-based and office-basedphysicians, physicians in salaried

practice, and physicians in fee-for-service practicq and the

scope of medical services provided by generalists and spe

cialists,

In this chapter, the common characteristics and the main

differences among these three countries are reviewed briefly.

Demography, health status, and

economic indicators

France, the Federal Republic of Germany, and the United

States are all western democracies that share a common cultural

heritage and societal valuev all three rank among the most

industrialized countries in the world. Despite these general

similarities, closer examination reveals important demographic

and economic differences.

Estimated in 1981 at nearly 224 million people, the pop

ulation of the United States is roughly four times larger than

that of either of the two European countries (France, 54 milliom

the Federal Republic of Germany, 62 million). Other differences in demographic characteristics that influence the pr~

vision of health services are the geographic distribution and the

age structure of the population (table A).

● In the United States, where the population density of 25

persons per square kilometer is very low, easy access to

health services facilities for everyone tends to be more difficult to achieve than in the European countries where

there are much higher population densities (France, 98

persons per square kilomete~ the Federal Republic of

Germany, 248 persons per square kilometer).

●

●

It is well known that morbidity increases rapidly with age

after 50 yeary therefore, medical needs are probably greater

in the Federal Republic of Germany where the proportion

of population aged 65 years and over (15.2 percent) is

higher than in France (13.5 percent) or the United States

(11,1 percent).

Two major demographic changes during the past decade

have probably exerted opposite effects on the growth of

the health care services field. First, the slowdown in the

rate of population growth that took place in all three countries could have acted to moderate utilizatiorq but, on the

other hand, the growth of the elderly portion of the population has certainly been a factor tending to increase health

services utilization,

Not enough relevant indicators exist to allow a global

comparison of the health status of the three populations. However, in 1981 the commonly cited mortality indicators show

that France had the lowest infant moitality rate, 9.7 deaths per

1,000 live births, compared with 11.6 in the Federal Republic

of Germany and 11.9 in the United Sates. The ranking of the

countries according to life expectancies varies according to the

age or sex considered (table A).

Some quantitative parameters provide general insight into

the economic situation in each country. A comparison of gross

national product (GNP) per capit% expressed in U.S. dollars

or in purchasing power parity, shows that U.S. residents are

more affluent than their European counterparts. In 1981, the

GNP per capita in the United States ($ 12,647) was 14 percent

higher than in the Federal Republic of Germany ($11,076 (in

U.S. dollars) and 20 percent higher than in France ($10,552

(in U.S. dollars)) (Organization for Economic C@Operation

and Development, 1985).

Despite the oil crisis of 1973, all three countries have

experienced economic growth characterized by an average

annual rate of increase in the GNP per capita of 3.5percent in

the Federal Republic of Germany, 3.2 percent in France, and

3.4 percent in the United States (1975–1 980). However, in

recent years unemployment has increasingly become a major

concern in all three countries. In 1981, the percent of unemployed adults among the civilian active population was 5.5 percent in the Federal Republic of Germany, 7.3 percent in France,

and 7.5 percent in the United States.

These general economic clifflculties, which tend to limit

5
Table A. Selected demographic data: France, tha Fedaral Republic of Germany, and the United States, 1981

Country

Federal Republic

Characteristic France of Germany United States

Population:

Total in thousands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Per square kilometer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Average annual increase, 1970-80. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Aga structure:

Alleges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Under 15 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years............,,,,,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sex structure:

Alleges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Under 15 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15–44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

65 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Birth rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .’. , .

Crude mortality rata . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Infant mortality rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Life expectancy

Male:

At birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Atage40 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Atage60 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female:

At birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., .,,

Atage40 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Atage60 years . . . . . . . . . . . . . . , .,.....,,,.,,....,,,...,,,, . . . . . . . . . . . . . . . . .

53,966

98

0.56

100.0

21,9

43.1

21.4

13.5

51.3

48.8

49.5

51.2

61.3

14,9

10.3

9.7

70.4

33.4

17.3

78.5

40.4

22.3

Numbar

61.713 223,688

248

-—

Percant

0.11

Percent distribution

100.0

17.2

44.8

22.6

15.2

Percent female

52.2

48.7

48.6

53.6

64.7

Number per 1,000 population

10.1

11.0

Number par 1,000 live births

11,6

Years

70.5

33.2

16,6

77.1

38.9

20.8

25

1.05

100.0

22.7

46.5

19.7

11.1

51.7

48.9

51.1

52.6

59.1

15.8

8.6

11.9

70.4

33,9

17.5

77,9

40.1

22,5

SOURCES: France: Inatitut National de la Statistique et des kales ~conomiques, D Q C~i and ~. Guignon. 1982. Le situation d~mographique en 1981. Les

Co//ectiorrs de /’/NSEE. S6rie D, No, 94, Paris. Institut National da la Statistique et des Etudes Economiques, B. Faure. 1985. La situation d6mographiqua an 1983—

Mouvement de la population. Les Co//ections de /’/NSEE. S6rie D, No. 109. Paris.

Federal Republic of Germany Bundesministerium fur Jugend, Familie und Gesundheit. 1984. Daterr des Gesurrdheitswesens. Schriftenreihe Band 154. pp. 17, 18, 28,

snd 31, Stuttgart.

United States: U.S. Bureau of the Census. .Statistic8/ Abstract of the United States—7987. 1981.105th Edition. Washingtort U.S. Government Printing Off!ce.

the level of financial resources available for health services,

combined with the rapid rise of health services costs in the

three countries, have confronted policymaker8 with the problem of finding more eflicient means of financing and providing

care.

Health setvices systems

During the past 30 year8, the health services systems of

France, the Federal Republic of Germany, and the United

States have developed at a rapid pace. In all three countries a

broad array of services is available to the population, and dif6

ferent health insurance systems have been introduced to facilitate financial access to health services. Despite fundamental

similarities, the health services system in each country ha8

unique characteristics with respect to size, composition and

organization of resources, patterns of use, and flow of funds.

Health services resources

Personnel constitutes a major component of the resources

used to produce health services. The three countries do not

gather data on the same personnel categories, or on the same

institutions. Therefore, comparisons of the total number of persons employed in the health sector can lead to erroneous conclusions. When analysis is restricted to physicians (table B),
Table B. Number and rata per 100,000 population of activa physicians in patient care, by type of practice and physician specialty: France,

the Federal Republic of Germany, and the United States, 1981

Country

Federal Republic

Type of physicien practice and specialty France of Germany United States

Patient care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Genemlp ractitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Office-based practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gcmeral practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pwient care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Office-based practice, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Number

108,054 144,224 389,369

66,024 75,936 58,897

42,030 68,288 330,472

73,295 60,652 288,038

45,206 26,793 49,947

28,089 33,859 238,091

Number perl OO,OOO population

201 234 174

123 123 26

78 111 148

136 98 129

84 43 22

52 55 106

NOTE “Off[cs-based practics” corresponds to “m6decins lib6raux.” Thoaa physicians may have this practice on afull-time or part-time basia.

SOURCES: Francct Lesprofessions desant6et daction sociala. Situation au l/1/83. Evolution entre 1971 et 1983. SOLIDARIT~-SANT~ Etudes Statistiquea

Nos. 5-6, 1984.

Fed@r,llR~public of Germany: Statistic der Bundes;rztekanrrner. Tatigkeitsbericht 1982. Table3, pp. 19 and 20.

Unitwl Stotes: Department of Physician Data Services. 1983. Physician Characterktics and Distribution in the U.S., 1982 Edition. American Medical Association.

Chicago: Division of Survey and Data Reaourcea.

the following relationships may be seen

. The physician-to-population ratio is higher in the two

European countries (more than 200 physicians in patient

care per 100,000 population) than in the United States

(174 in 1981); but in each country, regional and urbanrural differences continue to exist.

. The specialist-t~general-practitioner ratio was much higher

in the United States where pediatricians and internists also

deliver semices that in France are mainly delivered by

general practitioners.

. The ratio of office-based physicians to total physicians in

patient care was higher in the United States (0.74) and in

France (0,68) than in the Federal Republic of Germany

(0.42); this is in accordance with the Federal Republic of

Germany’s relatively strict division between physicians in

the ambulatory and the inpatient sectors.

In all three countries the hospital sector mainly serves inpatients and includes general as well as specialized hospitals

(psychiatric, for example). The number of beds available per

1,000 inhabitants appears to be higher in the Federal Republic

of Germany (11.3) and in France (10.6) than in the United

States (6.0); however, when nursing home beds in the United

States are included in the comparison, the differences between

the ratios of institutional beds to population in the United

States and the Europeancountriesnarrow.Hospitals also provide care to ambulatory patients, though much more often in

the United States than in France and in the Federal Republic

of Germany,

The rates of admissions to general short-term hospitals per

1,000 population are very similar in the three countries 157 in

the Federal Republic of Germany (Bundesministerium fir

Jugend Familie und Gesundheit, 1985), 166 in France (Ministere des Affaires Sociales et de la Solidarit6 National, 1982-

83), agd 169 in the United States (U.S. Bureau of the Census,

198l),” but the length of stay is longer in the two European

countries (14.7 days in the Federal Republic of Germany, 13.2

days in France, and 7.9 days in the United States). Thus, the

average number of days per hospital episode spent in general

hospitals is higher in the European countries,

Health insurance

The major health services difference between the United

States and the two European countries is that in France and

the Federal Republic “ofGermany virtually the entire population (99 percent in France &d 92 percent in the Federal

Republic of Germany) is covered by compulsory health insurance in the United States only a relatively small part (about

20 percent) of the population is covered by the two major

public progranm Medicare for persons aged 65 years and over

and the disabled, and Medicaid for individuals and families

with incomes below specified levels. The rest of the population

may subscribe to a nonprofit (Blue Cross/Blue Shield) or a forprofit commercial insurance plan to get some financial coverage

for their herdth care expenditures. Nongovernmental health

insurance plans covered about 80 percent of the total civilian

population in 1981; much of this insurance, however, is primarily for inpatient hospital care and includes significant deductibles and copayments for ambulatory care.

In each country, the contributions of the insurance plans to

the medical care expenses vary according to the type of care.

Generally speaking, hospital care is better covered than ambulatory care or chugs.

● In the U.S. system, nearly all plans require that the patient

pay some part of the cost through the practice of annual

7
deductibles and copayment. However, the variety of situations ranges ffom total coverage (for example, Medicaid

hospital patients) to total patient payment without reimbursement (generally the case for nonprescribed drugs).

In France the patient generally pays the provider directly

and afterward seeks reimbursement for a part of his expenses. The copayment rate varies according to the type of

care (25 percent for ambulatory care, 20 percent for hospitalization). However, there are many exceptions to the

rule. For most hospital care the patient does not pay at all

and in other special cases the copayment is waived.

In the Federal Republic of Germany, except in the case of

most prescribed drugs for which the patient bears a minor

part of the cost, the users of services generally do not pay

the provider (physicians, hospitals, and so forth) directly

out of pocket nor do they know the cost of the care they

receive because providers are paid directly by the health

insurance fired.

Health expenditures

The distribution of health expenditures by type of care and

source of funds in the three countries is influenced by dhTerent

health insurance programs, the percents of the population covered by them, and the mix of services used,

To compare health expenditures among the three countries, it is essential to make sure that the health expenditure

data to be compared cover the same array of services. Therefore,

the definition adopted by the Organization for European Community Development for the evaluation of total health

expendhures (Organization for Economic Co-Operation and

Developmen~ 1985) (table C) has been used. From these

estimates it can be seen that the share of health expenditures

in the GNP was higher in the United States (9.7 percent in

1981) than in France (8.9 percent) and in the Federal

Republic of Germany (8,3 percent).

To compare the average per capita expenditure for health

services, exchange rates or purchasing power parities can be

used. In both cases, the per capita expenses in the United

States appear to be higher than in the two European countries.

Although comparing the structure of expenses by source of

financing cannot be done precisely because financing mechanisms vary, the Organization for Economic Co-Operation

and Development (1985) indicates that the share of health

expenditures financed by the public sector in 1981 was

much higher in the Federal Republic of Germany (69.8 percent) and France (71.8 percent) than in the United States

(49.6 percent). Direct payments by the consumers represent

a larger share of the personal health expenditures in the

United States (32 percent) (Health Care Financing Administration, 1982) than in France (Centre de Recherche d’Etude

et de Documentation en Economic de la Sante, 1986) (21

percent) and the Federal Republic of Germany (10 percent)

(Bundesministerium fir Jugend, Familie und Gesundheit,

1983).

Characteristics of ambulatory care systems

In the case of general practitioners as well as specialists,

the great majority of patients in the three countries enjoy free

choice of physicians for ambulatory care, and most medical

services are provided to ambulatory patients by independent,

self-employe~ ofilce-based physicians. The contribution of

hospital-based or other salaried physicians to ambulatory care

accounts for less than 15 percent of total visits in France and

the United States and much less in the Federal Republic of

Germany.

Patients of the FRG statuto~ health insurance scheme are

required to present a voucher to the physician each quarter of

the year for which they wish ambulatory care. In case of

referral, a referral voucher usually is issued by the referring

physician. This does not prevent the patient from going to the

physician of his or her choice.

In all three countries, office-based physicians may continue to supervise patients during their hospital stays. In France,

however, this possibility applies only to patients in rural hospitals and sometimes in private hospitals. In the United States,

it applies to physicians with hospital privileges, held by most

Table C. Total and par capita haalth expenditures France, the Federal Republic of Germany, and the Unitad Statea, 1981

Country

Federal Republic

Expenditure France of Germany United States

Total haalth expenditure

106 national currency! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278,206 128,670 285,828

Asapercent of GNP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.9 8.3 9.7

Per capita health expenditure

National currencyl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,155 2,086 1,243

Exchange rate dollars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 949 923

Purchasing power parity dollars.,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,243

883 851 1,243

1National currency ia tha franc in France; the mark in the Federal Republic of Germany; and the dollar in the United Statea.

NOTE GNP = gross national product.

SOURCE Computations basad on aatimates of GNP and haa[th axpanditures by the Organization of European Community Davalopment. 1985. La Sant6 en Chiffres—

7960-1983. D6penaaa, Cofits, Rdaultata. Paris: Organization of European Community Development, p.12.

8
physicians, In the Federal Republic of Germany, the separation between the ambulatory sector and the hospital sector is

relatively strict. Very few office-based physicians in the Federal

Republic of Germany have hospital privileges (about 9 percent

of ambulatory care physicians). In the United States, out of a

total of 45 hours per week devoted to patient care, general

practitioners spend 11.2 hours in hospitals and specialists

spend 16 hours. In France, activity in hospitals is less important, with 2.8 hours for general practitioners and 11.5 hours for

specialists (Centre de Recherche, pour l’Etude et l’Observation des Conditions de Vie, 1983).

In all three countries, most ambulatory services provided

by private otllce-based physicians are compensated on a feefor-service basis. There are differences among the countries,

however, in the process by which the monetary amount per unit

of service is determined and in the extent of the patients’ direct

involvement in the physician’s compensation (table D):

. In France and the Federal Republic of Germany, most

physicians are constrained by fees negotiated between

doctors’ associations and health insurance funds; in the

United States, in general, physicians are free to set their

fees on a procedure-by-procedure basis subject only to the

limit imposed by market forces.

. In France and the Federal Republic of Germany, remuneration of physicians is based on fee schedules and relative

value scales. In the Federal Republic of Germany, the

Official Schedule (GOA) and the Substitute-HealthInsurance-Fund Schedule of Medical Fees (E-GO) contain monetary fees, whereas the Assessment-Schedule of

Statutory-Fund Medical Services (BMA) is a point-rating

schedule. In the BMA and the fee schedule used in France,

the prices of medical procedures are determined by two

components the relative value scale (number of points

(Punkte) in the Federal Republic of Germany, or lettrecles in France) on the fee schedule and the value of the

basic unit. In the Federal Republic of Germany a service

such as a blood pressure measurement is associated with a

fixed number of basic units (points). Over time the monetary value of the basic unit is moved up and down more

often than the fee schedule is changed, In the United

States, although they may choose to use one of the existing

relative value scales, generrdly the physicians are free to

fix the price of their services.

● In the Federal Republic of Germany, for services provided

to the members of the statutory health funds, the physicians

are paid directly by their organization, which acts as an

intermediary between the health insurance funds and the

physician thus the patient does not know the cost of the

treatment received. In the United States and in France,

the general situation is quite different not only does the

patient usually pay the physician when the services are

received, but the patient also has to bear a copayment

amount because reimbursement from insurance generally

does not correspond to the total price of the services.

When the results of the surveys of ambulato~ care in

France, the Federal Republic of Germany, and the United

States are compared later in this report, it may be usefid to

refer to the data presented in this short comparative summary

of the health services systems in all three countries to suggest

possible explanations for the observed differences or similarities

among the countries.

The usefulness of this background information can be

illustrated by these examples and by the questions they pose:

● It has been shown from the health services utilization house

hold surveys in different countries that demographic, morbidity, and socioeconomic factors exert definite influences

on the utilization of different types of services. It is also

thought that the severity of morbidity presented to physicians could vary with these factors (Kohn and White,

1976). It will doubtless be interesting to examine the

extent to which differences in the demographic, morbidity,

and socioeconomic structures of France, the Federal Republic of Germany, and the United States may be considered responsible for observed differences in the volume

and pattern of use of ambulatory services.

● Health services systems in different countries may differ

with respect to the distribution of responsibility for patient

care among the ambulatory and hospital sectors. The fact

that hospital and ambulatory care sectors may be organized

differently within and across countries will influence the

volume and structure of encounters in each. UncoorTable D, Access to physicians and payment and reimbursement mechanisms in ambulatory care France, the Federal Rapublic of Germany,

and the United States, 1981-83

Country

Item France Federal Republic of Germany United States

Access to physicians . . . . . . . . . . . . . . Free access to general Frea access to general Free access to general

practitioners or specialists practitioner or specialists; 4 practitioners or specialist

vouchers/year; referral voucher

Compensation of physicians

Method . . . . . . . . . . . . . . . . . . . . . . . . Fee for service Fee for service Fee for service

Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . Negotiated Negotiated Market forces

Physician payment . . . . . . . . . . . . . . Patient Health insurance funda

Patient reimbursement , . . . , ., , , . .

Patient or health insurance

Health insurance funds with Compulsory insurance with Health insurance with deductible

copayment small copayment and copayment

Population covered (in percent). . . . . . 99 92 80

NOTE The information in this table applies to the most common occurrences, but a variety of exceptions exists in each country.

9
dinated ambulatory and hospital components might affect

the volume and nature of services performed. Another

area of difference could be the amount of high technology

medical equipment located in the offices of private praticing physicians. Another might be the locale where the

care of the elderly takes place: in hospitals, in nursing

homes, or in ambulatory settings close to the patient’s

home. Such varying distributions of responsibility will be

reflected in the data compare~ in particular, the specific

tasks of the ambulatory care sector will be affected. The

sharing of responsibility between ambulatory and hospital

sectors will reflect in other ways on the specific sets of

observed ambulatory care data. In a country where traditional oflice-based ambulatory medical care is extended

by home health services or support for home care of the

severely il~ thk will be part of the volume of services

observed. On the other hand, ambulatory encounter data

will vary depending on whether services such as surgical

aftercare or drug dependency treatment are provided predominantly in ambulatory settings or in specialized institutional settings.

c The scope of the physician’s activities as well as the physician/population ratio are factors that can intluence the use

of health services. It is generally agreed that increased

numbers of physicians made available to a given population result in higher utilization of medical services by the

populatio~ leading to lower output per physician (in number

of patients). Can the differences in the quantity and mix of

visits per physician be related to the availability of physicians and to different ratios between general practitioners

and specialists?

● Physicians as well as patients face incentives related to

different factors including rules for access, method of compensation for services, and nature of financial coverage by

the sick finds or insurance plans. Comparison of the three

national systems may be useful to test the influence of outof-pocket payment, copaymen~ and free services on the

behavior of physicians as producers and prescribers of

diagnostic procedures and pharmaceutical goods as well

as on the behavior of patients as consumers of health services. To the extent that the three countries differ with respectto the percent of the population covered for ambulatory

medical services and the amount of the average medical

bill covere~ differences in volume and structure of services are expected.

● In social systems with much similarity in population characteristics, as in the three countries comparedj and differences in ambulatory medical care systems, it is of interest

to investigate the volume and nature of physician-patient

encounters to better understand which factors (physician,

patient, or health system) most influenced the actual encounters observed.

10
Survey methods and

analytical approach

The data presented in chapter 3 are derived from three independent surveys conducted in France, the Federal Republic

of Germany (FRG), and the United States of America (U.S.).

To properly understand and interpret the data analysis presented in this report, it is necessary to understand the methods

and instruments of the three surveys and how they relate to one

another. A summary comparison of the survey methods is

shown in table E. Definitions of key terms used in this report

are provided as the last section in this chapter. In the discussion that follows, the major design features of the three surveys

are compared and contrasted. Emphasis is given to similarities

and differences in design that may affect data comparability. A

more detailed description of each survey is available from the

individual sponsors (Centre de Recherche d’Etude et de Documentation en Economic de la Sante, 1981; NCHS, 1983 w

Zentralinstitut fir die kassenarztliche Versorgung in der Bundesrepublik Deutschland, 1988).

It is important to note that the analysis presented in this

report involves subsets of the data produced by the three

original surveys. This has been necessary to develop comparable data bases for the three countries. Explanations of how

these subsets are derived and how data adjustments were made

to develop comparable data bases’ are discussed in the following sections.

Table E, Summary of ambulatory care survey methods: France, the Federal Republic of Germany, and the United States

Country

Item France Federal Republic of Germany United States

Responsible organization . . . . . . . . .

Study titla . . . . . . . . . . . . . . . . . . . . . .

Abbreviation of study title. ., . . . . . .

General type of survey. . . . . . . . . . . .

Purpose . . . . . . . . . . . . . . . . . . . . . . . .

Contact universa. . . . . . . . . . . . . . . . .

Physician universe..,,..,,,.,,,. ,

Units of observation. , , . . . . . . , , , .,

Type of patient contact sample . . . .

Geographic coverage, . . . . . . . . . . . .

Data collation pariod. . . . . . . . . . . .

Length of physician observation. . . .

Method of physician induction. . . . .

Centre de Recherche d’~tude et Zentralinstitut fur die U.S. Public Health Service (PHS)

de Documentation en Economic kasaenarztliche Versorgung in National Center for Health

de la Sant6 (CREDES) der Bundesrepublik Deutschland Statistics (NCHS)

1 rue Paul-Cezanne Herbert- Lewin Str. 5 3700 East-West Highway

Paria, France 75008 D–5000 Koln 41 Hyattsville, Md. 20782

Federal Republic of Germany

Enqu6te Morbidit6 et Erhebung uber die Versorgung National Ambulatory Medical

Therapeutique M6dicale im am bulanten Sektor durch Care Survey

niedergelassene Arzte

EMTM EVaS NAMCS

Probability sample survey of office-based physicians and their patient contacts

Collection of general purpose data describing the public’s use of ambulatory medical care services, the

characteristics of ambulatory patients, and the characteristics of physicians practicing ambulato~ care for

multipla applications

Face-to-face patient contacts Face-to-face and telephone Face-to-face contacts with

with office-based physicians in contacts with office-based office- basad physicians and

office and home settings physicians and their staffs in their staffs in office setting

office setting

All office-based physicians Ambulatory care, office-based All office-based physicians

except general surgeons, physicians entitled to serve axcluding radiologists,

neurosurgeons, urologists, compulsory heslth insurance anesthesiologists, pathologists,

anesthesiologists, and patients excluding anesthesi- and those employed by the

radiologists ologists, radiologists, child Federal Government

psychiatrists, oral surgeons,

neurosurgeone, and selected

smsll specialties

Office-based physicians and Offica-based physicians and Offica-based physicians and

patient contacts patient contacts patient contacts

Multistage, probability, cluster Multistage, probability, cluster Multistage, probability, cluster

Continental France Bremen, Hessen, Pfalz, All States except Alaska and

Nordbaden, and Stidbaden Hawaii

May 1982 through April 1983 Nov. 9 through Dec. 21, 1981, January through December 1981

and Feb. 22 through April 2,

1982

3 consecutive activity days 2 consecutive activity days 7 consecutive days

(Monday through Friday)

Mail and telephone Mail Personal interview

11
Data sources—general

TheFrench data used in this anrdysis are tlom the Enqu&e

Morbidite et Therapeutique Medicale (EMTM) conducted by

the Centre de Recherche d’Etude et de Documentation en

Economic de la Sante, a private, nonprofit research center.

The EMTM, conducted from May 1982 through April 1983,

involved a probability sample of oftlce-based (private practice)

physicians representative of the entire country of France. The

sample physicians provided information for each patient encounter during an assigned 3-activity-day period The purpose

of the EMTM was to collect and analyze detailed data concerning the patients and medical practices of private physicians.

The data were to serve multiple purposes and, generally, to

improve the knowledge and understanding of the structure and

distribution of ambulato~ medical care in France.

The FRG data are from the Erhebung uber die Versorgung

im ambulanten Sektor durch niedergelassene Arzte (EVaS)

(Survey Among Ambulatory Care Physicians) conducted by

the Zentralinstitut fur die kasseniirztliche Versorgung in der

Bundesrepublik Deutschland (Central Research Institute of

Health Insurance Physicians in the Federal Republic of Germany), a private, nonprofit foundation in the Federal Republic

of Germany. The EVaS was conducted in the winter of 1981

and the spring of 1982, and involved a probability sample of

oftlce-based physicians in five geographic subareas of the Federal Republic of Germany. Sample physicians provided information for a systematic random sample of patient contacts

during an assigned 2-activity-day period. This survey was

designed to provide multipurpose data concerning the contents

of ambulatory care and the diagnostic and therapeutic behavior

of major groups of ambulatory medical care physicians.

The U.S. data used in this analysis are from the National

Ambulatory Medical Care Survey (NAMCS) “conducted by

the National Center for Health Statistics of the U.S. Public

Health Service, a Federal Government agency. NAMCS was

conducted throughout 1981 among a probability sample of

otlice-based physicians representative of the total United States

exclusive of Alaska and Hawaii, Physicians in the sample pr~

vialed information concerning a systematic random sample of

patient encounters during an assigned 7-day period. The purpose of NAMCS was to provide a multipurpose data base describing the demographic and medical characteristics of patients

using the services of ofllce-based physicians.

The specitic purposes of the French FRG, and U.S. surveys are related to their individual health services systems and

particular data needs. In reviewing the purposes stated by the

sponsoring agency for each study, however, it is apparent that

all three surveys had a common underlying purpose, namely to

provide general purpose data that describe the use of ambulatory

medical care services by the population and the provision and

prescription of health services by physicians. This includes

data describing selected demographic and medical characteristics of the patients, the nature of the medical services ordered

and provided, and the characteristics of the physicians prcviding the services. Each survey provides data that are intended to serve multiple purposes relating to health services research, epidemiology, health care services, medical education,

and health manpower, with implications for health services

planning, priority setting, resource allocation, and costs.

Sample design

The basic sample design and approach to data collection

were similar for the three surveys, although the specific methods

and procedures varied. The three sample designs all involved

multiple stages of sample selection. Most important, all three

designs had the same elementary sampling unit—an ambulatory

patient encounter with a physician.

The French survey used a two-stage sample. The first

stage of selection involved a stratified random sample of 1,837

physicians selected from a list of all physicians in France

having a private practice, excluding radiologists and surgeons,

In the second stage, patient encounters were sampled by assigning each sample physician to a 3-day reporting period (3

activity days) during the l-year survey period-May 1982

through April 1983. Patient encounter data then were obtained

for every encounter during each physician’s 3-day periodj a

total sample of 72,426 encounters for the year. Reporting

periods were assigned so that approximately the same number

of physicians were reporting each day of the year (Sundays

were excluded). The specialty distribution of the physician

sample was adjusted to assure proper representation within

major geographic regions.

The FRG and U.S. surveys involved multistage cluster

samples. In both, the first stage was the selection of geographic

areas. For the second stage, physicians were randomly selected

within these areas with the specialty dktribution of the sample

approximating the distribution of all physicians in the areas. In

the third stage, patient encounters were sampled by assigning

physicians to reporting periods and systematically sampling

encounters within the reporting periods.

In the Federal Republic of Germany, five geographic

areas were selected in a nonrandom, controlled manner to

approximate the national distribution with respect to physician

specialty and population characteristics. The five areas selected

were Breme~ Hesseu Pfalz, Nordbaden, and Sudbaden. Within these areas, a sample of 893 physicians was randomly selected

from a list of nearly all oftice-based physicians. Each was randomly assigned to a 2-day reporting period either during November-December 1981 or Februa~-March 1982 (Saturdays

and Sundays were excluded from the sample). Physician specialties were uniformly distributed across the reporting periods.

During the 2-day reporting period, encounter forms were completed for a systematic sample of encounters. The individual

encounter sampling rate per physician varied from 10 to 50

percent depending on the expected number of encounters per

day. The total sample of encounters numbered 13,571.

The first stage of the U.S. sample included 87 geographic

areas (counties or standard metropolitan statistical areas) randomly selected with probabilities proportional to their pop

ulations. A sample of 2,333 physicians was randomly selected

within these areas from a list of all ofllce-based physicians.

Each was randomly assigned to a l-week reporting period

during 1981, so that about equal numbers of doctors were

12
reporting each week. Within the assigned week patient visits

were sampled at a rate that varied from 20 to 100 percent

depending on the expected number of encounters. All days of

the week were included, and the sample of encounters totaled

43,366 for the year.

Sample sizes for physicians and patient encounters and

physician universe information are summarized in table F for

the three surveys, Note that sample sizes are presented for the

Ml survey in each country as well as for the data subsets used

in the international comparative analysis presented in chap

ter 3.

The physician universes used for sample selection differed

somewhat among the surveys because of differences in the

health services systems. Each physician sample, however, was

representative of the private, ofllce-based physicians providing

ambulatory medical care. The definitions of “physician,” “private,” and “office-based” are, of course, not entirely synonymous in France, the Federal Republic of Germany, and the

United States, but the functional component of the ambulatory

medical care systems involved in these surveys is essentially

the same in the three countries.

Scope of coverage

The scope of the three surveys differed with respect to

such factors as geographic coverage, time period for data collection, physician specialties sampled, and type of physicianpatient encounters included in the sample. Therefore, as noted

previously, data from each survey were adjusted to produce

comparable statistics from each country for the present analysis.

Ground rules were established to assure comparability among

the three data sets. In summary, these roles were as follows:

1, All data tabulations are weighted estimates that represent

the particular survey universe—Encounter data from each

survey were inflated using appropriate statistical methods,

to produce estimates of encounter volume representative

of its sampling universe. In general, this was done by using

the reciprocals of the probabilities of selection for the respective sample designs.

2. All data are atiusted to reflect annual estimates—Annualized estimates were generated by inflating each reporting

3.

4.

5.

period by the appropriate factor. For example, the U.S.

data were collected during a l-week reporting period. All

U.S. data were, therefore, inflated by a factor of 52 to prcrduce amual estimates. The French and U.S. data represent annual estimates for the whole of France and the 48

contiguous States, respectively. The FRG data represent

the five subregions of the Federal Republic of Germany in

which the survey was conducted. These regions were selected because they reflect the whole of the Federal Republic of Germany with respect to population and physician specialty characteristics.

All data represent all days of the week when office-based

care is regularly available—Although the U.S. data include

all days of the week, Saturday and Sunday were not rep

resented in the FRG data. Ambulato~ medical services

are available in the Federal Republic of Germany through

an emergency service arrangement on these days but are

quite rare, so that their exclusion is considered appropriate

and of negligible consequence. For similar reasons, Sundays are not included in the French data.

Patient encounters are defined to include only personal

~aceteface) contacts with physicians in the physician’s

oflce or patient’s residence—The types of ambulatory

patient contacts included in the samples differed somewhat among the three original surveys. For example, telephone contacts and contacts with physicians’ statl members are included in some but not all of the surveys. To

assure comparability in the data presented in this report,

however, all tabulations used in the comparative analysis

include only encounters in the patient’s residence and

physician’s ofice in which direc~ personal contact with

the physician occurred. (Encounters in the patient’s residence are not included in the U.S. data. Because home

encounters are rare in the United States (less than 1 percent of all contacts), their exclusion should have a negligible impact on the U.S. data (NCHS, 1983b)).

The data represent only those physician specialties common to all studies— The physician specialties included in

the three surveys varied, the major difference being the

exclusion of general surgeons, orthopedists, and urologists

ftom the French survey. This difference and other minor

Table F. Number of physicians, physician response rates, and patient encounters for the ambulatory care surveys used in this repofi France,

the Federel Republic of Germany, and the United states, 1981–83

Country

Federal Republic

Item France of Germany United States

Number ofphysicians in country’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118,000 171,569 485,123

Number ofphysiciana inpatient cere inccuntry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82,779 144,224 389,369

Number ofphysicians in ambulatory care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81,838 60,652 288,038

Number ofphysicians in sample universe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70,697 211,180 247,216

Number ofeligible physicians ensample. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,837 893 2,333

Number cf physicians responding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,350 551 1,807

Response rate ofphyaicians (in percent). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 62 78

Number ofpatient contacts ensample. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72,426 13,571 43,366

Number ofsample physicians usedin current analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,300 466 1,175

Number ofpatient encounters usedin current analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69,517 12,375 33,913

lTotal of all physicians in ccuntty including pstient care, sdministrative, research, and so forth.

25 regions only: 11,605 physicians in ambulatory cars in these 5 regions.

13
specialty differences were resolved in the data tabulation

process for the comparative analysis in this report by

includlng only those physician specialties common to all

three surveys. The common data items and specialties

included in this analysis are as follows:

Data item

Patient

Age

Sex

Diagnoses/problem/

reason for encounter

Visit status

Disposition

Physician

Age and sex

Specialty

Type of practice

Nonphysician office

personnel

Category/comments

Age in years obtained directly

or calculated from date of birth

a. Male

b. Female

Recorded by physician best assessment at time of encounter

New patient (to the physician’s ofilce)

Known patient

Return visit scheduled

Refer to another physician

Admit to hospital

Return to referring physician

General and family medicine

Internal medicine and its sub

specialties(including cardiology, gastroenterology, pneumology, and rheumatology)

Pediatrics

Obstetrics and gynecology

Psychiatry and neurology

Dermatology

Ophthalmology

Otorhinolaryngology

solo

Group

Medically trained

Data collection procedures

The French survey was conducted by telephone and mail.

After a letter of introductio~ physicians on the survey staff

telephoned the sample physicians to solicit their participation.

Those who agreed to cooperate were sent survey materials to

complete and return according to written instruction. Further

telephone contacts were made to assure that respondents understood their task and completed the survey forms on schedule.

The FRG survey was clone primarily by mail. An initial

mailing contained introductory materials, a physician questionnaire, and telephone numbers of persons available to answer

technical questions about the survey. A second mailing included

copies of the patient encounter form, instructions for completing and returning the survey materials, and a final physician data form.

The U.S. survey involved an introductory letter to each

sample physician followed by a telephone call for an appointment and a personal visit by a survey representative. All

survey materials were delivered by the representative, and

instructions were given in verbal and written form. Further

visits and telephone calls were made as needed to assure the

physician’s complete participation.

Each physician in each of the surveys received a physician

questionnaire and patient encounter forms. The process of

completing these forms and their general content are similar for

all three surveys. The physician questionnaire was self-administered (except in the United States where it was completed

during the personal interview) and obtained basic information

about the physician and the practice. The encounter forms,

used to record information about physician-patient encounters,

were completed by the physician or the oftlce staff during the

assigned reporting period for the designated sample of encounters. These forms generally were completed near the time of

the encounter, so that most information was recorded from

knowledge of the events which had just occurred. Retrospective completion of materials by reference to medical records

was discouraged. The patients were not directly involved in

data collection and normally were not aware of the survey. All

three surveys used methods to assure the confidentiality of the

patient and physician data.

Physician participation was entirely voluntary in all surveys. In the FRG and the United States, no remuneration was

offered for participation. In the French survey, participating

physicians were offered payment of approximately $40( U.S.)

or their choice from a selection of books. In all surveys, copies

of that country’s study results were provided to participating

physicians.

Survey instruments

As noted above, there were two basic survey instruments

used in the surveys-the physician questionnaire and patient

encounter form These forms for the three surveys (with English

translations of the French and FRG forms) are reproduced in

appendix I. The physician questionnaire was used to obtain

information about the sample physician and the physician’s

practice. The amount and content of data requested in this

form varied among the three surveys. For this repo~ however,

only three data items from these forms concerning the physician are used, and these items are essentially the same for all

three surveys. These items are (1) age, sex, and specialty of

physicians (2) the physician’s type of practice (solo or group);

and (3) ofilce staff information.

The secon& and most importan~ survey instrument was

the patient encounter form. Again, the data items vary somewhat among the three surveys, but a number of encounter data

items are common to all three and have similar definitions and

response categories. A description of the common data items is

shown in rule 5 in the preceding section. It is this set of data

items that forms the basis for the comparative analysis of ambulatory care in France, the Federal Republic of Germany,

and the United States that is presented in chapter 3.

Some of the common data items require additional explanation. Patient age is available from all surveys, though date

of birth was actually collected in the FRG and U.S. surveys. This

information, along with patient sex, is identical in all studies.

14
Diagnosis was recorded in all surveys, but in a slightly different manner in the French survey, The FRG and U.S. surveys instmcted the physician to record first a principal diagnosis

related to the reason for visi~ and then to record other diagnoses

in order of importance, In the French survey, there was no

order suggested for listing of the diagnoses. In all three surveys,

the diagnostic label recorded on the form was the physician’s

best assessment at the time of the encounter, This label mayor

may not have been expressed in conventional medical terms,

and it mayor may not have been made on the basis of diagnostic

test results or other definitive information.

For purposes of this repom diagnostic tabulations are

based on all listed diagnoses. That is, in tabulating the number

of encounters for a given diagnosis, all encounters with that

diagnosis are counted regardless of the order in which the diagnosis was listed. Encounters with multiple diagnoses, therefore, are counted multiple times.

Visit status refers to whether the patient is new to the

physician’s practice, or had been seen before (new or known

patient). Other explanations for particular data items are pro

vialed in the analysis section of this report as the data are compared for the three countries.

Data processing

In the French, FRG, and U. S. surveys, completed survey

materials were mailed by participating physicians to the respective survey organizations, After routine clerical review and

edit checks, data items not preceded were manually coded and

verified. Of particular interest is the coding of diagnoses that

were recorded in written form by the physicians. In France,

coding of diagnoses was done by physicians employed by the

Centre de Recherche d’Etude et de Documentation en ficonomie

de la Sant6 for that purpose using a specially designed software

package. In the Federal Republic of Germany and the United

States, coding was done by nonphysician personnel instructed

and experienced in the coding of medical data. In the Federal

Republic of Germany, physicians were available to resolve difficult coding problems. The Manual of the International Statistical Classification of Diseases, Injuries, and Causes of

Death (ICD-9) (World Health Organization, 1977) was used

in the French survey and the International Classz@cation of

Diseases, 9th RevisioG Clinical Modzjication (Public Health

Service and Health Care Financing Administration, 1980) in

the U,S. survey. In the Federal Republic of Germany, a modification and German translation of the “Reason for visit classification” (Wagner, Schach, and Schwartz, 1984) was used.

These categories then were assigned to an ICD–9 category by

a physician familiar with the data and expert in the ICD–9

classification system. The FRG and French diagnostic codes

were verified by a second coder. The U.S. data were coded by

two independent coders and differences were resolved by a

third coder. In the United States and the Federal Republic of

Germany, the data for each study were converted to machinereadable form for additional edit checks by computer.

Reference populations

The rates shown in this report are based on the population

estimates shown in table I of appendix II. For France, thk rep

resents the total civilian population as of December31, 1981.

The FRG figures represent the December 31, 1981, civilian

population in the five subareas of the Federal Republic of Germany in which the EVaS was conducted. The U.S. figures rep

resent the civilian population exclusive of Alaska and Hawaii

as of December 31, 1981.

As may be noted in appendix II, the age and sex distributions vary for the three countries, Because health status

and use of the health services system are related to age, selected

data in this report were adjusted to compensate for the age-sex

variability. This was done using the direct method to calculate

age-sex standardized encounter rates. The January 1, 1980,

French population (shown in table II of appendix II) was used

as the standard population.

Standard errors

Estimates of standard errors are provided for selected

statistics to enable the reader to judge precision and to test differences. Differences tested in this report were done using the t

test. Design-specific estimates of standard errors were calculated for each of the three surveys. Detailed methods and formulas may be obtained from the original research (Centre de

Recherche d’Etude et de Documentation en Economic de la

Sante, 1981; NCHS, 1983 q Zentralinstitut tlir die kasseniirztliche Versorgung in der Bundesrepublik Deutschland, 1988).

Definitions of selected terms

Patient contact—Any contact between patient and physician or physician’s staff for professional reasons; includes telephone consultations and excludes, for example, contacts exclusively to make an appointment, drop off a specimen, or pay

a bill.

Patient encounter—A face-t~face contact, for professional reasons, between a physician and a patient in the

physician’s office or the patient’s residence. (Telephone consultations are excluded.)

Physician—A person who is licensed or otherwise entitled

to practice medicine according to the laws and customs of the

individual’s locality.

Study physicians—Physicians included in the detailed

data analysis presented in this report. Includes physicians in

the EMTM, EVaS, and NAMCS surveys who are in selected

specialties common to all three surveys.

Ambulatory patient—Person making a patient-physician

contact who is not hospitalized at the time of the contact.

EMTM—Enqu&te Morbidite et Therapeutique Medicale

(Survey of Morbidity and Medical Care): French survey of

physicians in ofilce practice and their patient encounters conducted in 1982 and 1983.

EVaS—Erhebung uber die Versorgung im ambulanten

Sektor durch niedergelassene Arzte (Survey Among Ambulatory Care Physicians): Federal Republic of Germany survey of

physicians in of~ce practice and their patient contacts conducted in the fourth quarter of 1981 and the first quarter of

1982.

NAit4CS-National Ambulatory Medical Care Survey

U.S. survey of physicians in oflice practice and their patient

contacts conducted in 1981.

15
Chapter 3

Results—Comparison of

ambulatory care in France, the

Federal Republic of Germany,

and the United States

Selected characteristics of ambulatory care

physicians

Although physicians have the major responsibility inFrance,

the Federal Republic of Germany (FRG), and the United

States (U.S.) for the provision of ambulatory medical care services, the characteristics of the physicians and their practices

differ in the three countries.

Physician specialty

Generalists (general and family practice physicians) constitute the largest specialty group in all three countries, but

their relative contribution to the provision of ambulatory care

varies greatly. Among study physicians, generalists account for

68 percent of physicians in France, and in the Federal Republic

of Germany they are 51 percent. In the United States, however,

only 28 percent of study physicians are generalists. Combining

all primary care physicians (generalists, internists, pediatricians, and obstetricians/gynecologists) brings the figures to 86

percent for France and 84 percent for the Federal Republic of

Germany, but still accounts for only 76 percent of the U.S.

ambulatory care study physicians (table G). (In this study,

“internist” for France includes the specialties of internal medicine, cardiology, gastroenterology, pneumology, and rheumatology.)

From another perspective, it maybe seen in table H that

the number of physicians per 1,000 persons also varies considerably among the three countries, particularly within specialties. The density of generalists is four times higher in France

than in the United States and twice as high as in the Federal

Republic of Germany. This major difference is only partly

offset by a higher density of specialists in the United States.

For the specialists covered by the study (internists, pediatricians, obstetricians/gynecologists, psychiatrists, dermatologists,

ophthalmologists, and otorhinolaryngologists), the density in

the United States is31 percent higher than in France and the

Federal Republic of Germany. The density of internists, pediatricians, psychiatrists, and obstetricians/gynecologists is higher

in the United States than in the Federal Republic of Germany

and France. The density is identical in all three countries for

ophthahnologists and slightly lower in the United States for

dermatologists and otorhinolaryngologists. The density in the

Federal Republic of Germany is higher than in France only for

internists end obstetricians/gynecologists, and is exceptionally

low for psychiatrists.

These structural differences by specialty may well reflect a

different allocation of tasks among physicians and as a consequence, a different case mix of patient complaints and treatment regimens by specialty for each country.

Physician age and sex

Physicians practicing in the Federal Republic of Germany

are by far the oldest with 28 percent .ofthem aged 60 years and

over, compared with 18 percent in the United States and only 9

percent in France. Conversely, the highest percent of physicians

under 40 years is found in France, with 48 percent, compared

with 34 percent in the United States and only 24 percent in the

Federal Republic of Germany.

Women represent 20 percent of the medical profession in

the Federal Republic of Germany, 13 percent in France, and 8

percent in the United States. Female physicians are clearly

younger on average than male physicians in France and the

United States, where more than half of female physicians are

under age 40 years. The Federal Republic of Germany, on the

Table G. Parcent distribution of encounters and study physicians by physician specialty group France, the Federal Republic of Germany, and

the United States, 1981-83

country

Federal Republic

France of Germany United States

Physician specialty group Encounters Physicians Encounters Physicians Encounters Physicians

Percent distribution

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 100 100 100 100 100

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 68 59 51 39 28

Primary care specia[istsl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 18 29 33 43 48

Othar ambulatov care specialists. . . . . . . . . . . . . . . . . . . . . . . 13 15 12 16 18 24

1Internists, pediatricians, and obstetricians/gy necologists.

2psy~hiatrists/neurologists, darmatologists, ophthalmclogista, and otorhinolawngdogiats.

16
Table H. Number and rate per 1,000 population of physicians, by specialty France, the Federal Republic of Germany, and the United States,

1981

Country

Federal Republic of

France GermanyJ United States

Number Number Number

per 1,000 per 1,000 per 1,000

Physician specialty Number population Number population Number population

Total ambulatory care physicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81,838 1.513 11,605 0.977 286,526 1.273

All study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70,697 1.307 10,211 0.860 174,461 0.775

Genaral and family practitioners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47,748 0.883 5,212 0.439 49,416 0.220

All study specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22,949 0.424 4,999 0.421 125,045 0.555

Allprimary care specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12,617 0.233 3,349 0.282 83,148 0.369

Intern ists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6,256 0.121 1,780 0.150 43,845 0.195

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,556 0.047 562 0.047 18,464 0.082

Gynecologists/obstetriciana...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,535 0.065 1,007 0.085 20,839 0.093

Other ambulatory care specialists:

Psychiatrists/neurologists........... . . . . . . . . . . . . . . . . . . . . . . . . . 3,807 0.070 326 0.027 20,605 0.092

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,631 0.030 333 0.028 4,708 0.021

Ophthalmologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,882 0.053 591 0.050 11,241 0.050

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,012 0.037 400 0.034 5,343 0.024

Specialists outside ofstudy3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411,141 0.206 57,394 0.117 5112,065 0.498

15 regions only.

‘General internal medicins, cardiology, gastmentercdow, pneumologv. and rheumatology.

3Surgeons and surgical specialties. - -

41ncludes radiologists and anesthesiologists.

‘Includes urologists and orthopedists.

Glncludes doctors of osteopathy.

other hand, shows similar age distributions for males and

females (table J).

Type of practice and personnel support

Just as the organization of the health services systems in

France, the Federal Republic of Germany, and the United

States differs, so too does the organization of each physician’s

ofilce practice. The methods for providing health services to

ambulatory or home-care patients vary greatly from one country

to another, especially for services delivered by private practice physicians.

In France, 62 percent of physicians are in solo practices.

In addition, French physicians employ very few nonphysician,

medically trained personnek only 13 staff per 100 physicians

in solo practice. Medical practice in France, therefore, is generally organized on the basis of physicians working alone in

their ofllces. In the Federal Republic of Germany, on the other

hand, nearly 90 percent of the physicians are in solo practice,

and they are assisted by numerous trained medical stafF 277

staff per 100 physicians in solo practice, The United States has

the lowest percent of solo practice physicians (55 percent) and

occupies a middle point in number of stti members: 90 staff

per 100 physicians in solo practice (see tables K and L).

In France and the Federal Republic of Germany, specialists employ relatively more trained medical personnel than

generalists; however, in the United States the reverse is true.

Volume and rate of ambulatory physicianpatient contacts and encounters

All physician-patient contacts

The encounter rates with ambulatory physicians are quite

different for the populations of France, the Federal Republic of

Germany, and the United States. Table M and figure 1 show

rates per person for all ambulatory contacts, for ambulatory

encounters (face-tc-face contacts) with all office-based physicians, and for encounters with the generalists and specialists

included in this study. In all three groups, the rates are highest

for the Federal Republic of Germany and lowest for the

United States. When all contacts are considered (including

telephone consultations), the rate in the United States is 4.6

contacts per person per year, and in the Federal Republic of

Germany is 14.3 contacts per person per year. The FRG rate

is more than three times greater than the U.S. rate and twice

the French rate (table N).

Encounters with study physicians

As noted previously, the analysis presented here is based

only on direct encounters with study physicians. This restriction results in the exclusion from the analysis of all telephone

contacts, patient encounters in hospital outpatient departments,

and encounters with certain surgical specialties. Encounter

rates based only on encounters with study physicians, therefore,

are lower than those given in the preceding paragraph, but the

reduction is quite different for the three countries. This restricted definition of “encounter” produces a particularly large

reduction in the U.S. rate (54 percent) because a large proportion of physician-patient contacts are in hospital ambulatory

clinics and through telephone consultation, The reduction in

the Federal Republic of Germany is 32 percen~ largely due to

the elimination of telephone consultations. The rate in France

is reduced only about 15 percent because telephone consultations and hospital ambulatory encounters are infrequent. Therefore, most ambulatory care in France is accounted for by the

physicians included in the study,

17
Tabla J. Number and parcent distribution of offica-baaed phyaiciana by aga and sex: Franca, tha Fedaral Republic of Germany, snd the

United States, 1981-83

Country

Federal Republic Federal Republic

Physician age and sex Francel of Germany2 United States3 Francel of Germany2 United States3

All physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SEX

Famala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AGE

All physicians

Under 30 years,.,,,.........,,. , .,,,..,..

30-39 years, . . . . . .. d. . . . . . . . . . . . . . . . . . . .

40-49 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50-59 years, ., . . . . . . . . . . . . . . . . . . . . . . . . . .

60 years and over........,,.. . . . . . . . . . . . .

Femalea

Under 30yaars, . . . . . . . . . . . . . . . . . . . . . . . . . .

30-39 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50-59 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60 years and over . . . . . . . . . . . . . . . . . . . . . . . .

Males

Under 30 years . . . . . . . . . . . . . . . . . . . . . . . . . . .

30-39 years . ., . . . . . . . . . . . . . . . . . ,,, ...,,,

40-49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50-59 yaars. ., . .,, ,,, ,. ..,,... . . . . . . . . . .

60years andovar . . . . . . . . . . . . . . . .,, ..,,,,

Numbar of”physicians Percant distribution

70,697 11,605 286,526 100.00 100.00 100.00

9,353 2,270 24,181 13.23 19.56 8,44

61,344 9,335 262,345 86.77 80.44 91.56

926

33,122

16,529

14,033

6,087

326

4,514

2,447

1,359

707

595

28,605

14,084

12,674

5,386

40

2,687

3,487

2,196

3,195

19

479

732

498

542

21

2,208

2,755

1,698

2,653

10,163

86,248

74,979

63,012

52,124

2,106

10,343

5,643

3,577

2,512

8,057

75,905

69,336

59,435

49,612

1.31

46,85

23.38

19.85

8.61

3.49

48.26

26,16

14.53

7.56

0.97

46.63

22.96

20.66

8.78

0.35

23.15

30.05

18,92

27.53

0.84

21.10

32.25

21.94

23.88

0.23

23.65

29.51

18.19

28,42

3,55

30.10

26,17

21.99

18.19

8.71

42.77

23.34

14.79

10.39

3.07

28.93

26.43

22.66

18.91

I Privsta prsctice physicians eligible for study,

zoffice.bs~ed, heslth insuranca physicians in 5 study re9iOnsc

aNOn. Fed,gral, office-based phYaiciens.

Tabla K, Number and parcent distribution of office-baaed physicians by typa of practica and spacialty group: Franca, the Faderal Republic of

Germeny, and the United Statas, 1981-83

Country

Federal Republic Federal Republic

Physician specialty and type of practice France~ of Germany2 United States3 Francel of Germany2 United Statesa

Number Percent distribution

All physicians,..,,,,.,,,..,,,,., ,,, ,., ,,, 70,697 11,605 286,526 100.00 100.00 100,00

solo . . . ...0!... . . . ...00... ., ...,,.,,, ,.. 44,073 10,301 158,439 62,34 88,76

Other . ., . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26,624

55.30

1,304 128,087 37,66 11,24 44.70

Generalists . . . . . . . . . . . ! . . . . . . . . . . ,,, ,, ... 47,748 5,212 49,416 100,00 100,00 100,00

solo . . ..!! (.. . . . . . . . . . ,,, ,. .,,, ,,, ,,, .,, 29,909 4,600 32,239

Other

62,64 88.26 65,24

. . . . . . . . . . . . . . . . . . . . . . . . . . . ... ,., ., 17,839 612 17,177 37.36 11.74 34.76

Specialists. , ., ., ., . . . . . . . . . . . . . . . . . . . . . . . 22,949 6,393 237,110 100.00 100,00 100.00

solo. ., . .,, . .,, ., . ., ...,..., . . . . . . . . . . . . 14,164 5,701

Other

126,200 61.72 89.18

8,785

53.22

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. 692 110,910 38,28 10,82 46.78

1Private practice physician eligible for study.

2office.bssed, health insurance physicians in 5 study re9iOns.

3NOn. Federa[, Office-based physicians.

Encounters with the study physician, however, do repre- physicians resulted in 2.1 encounters per person per year in the

sent the great majority of all direct ofilce and home encounters United States, followed by France with 6 encounters per person

with ambulatory patients, including 88 percent of French, 92 per year; the FRG rate is the highest at 9.7 encounters per

percent of FRG, and 81 percent of U.S. direct encounters person per year, The FRG rate is 4,6 times greater than the

(tables O and P), In particular, encounters with the study U,S. rate and 1.6 times greater than the French rate, When

18
Table L. Rate of nonphysician medical personnel in the offices of

solo practice physicians by specialty group France, the Federal

Republic of Germany, and the United Statea, 1981 –83

Country

Federal Republic

Physician specialty France of Germanyx United Statesl

Rate per 100 physicians

All physicians. . . . . . 13 277 90

Generalists. . . . . . . . 10 267 101

Specialists . . . . . . . . 20 289 85

I Full-time equivalents estimated from suwey results.

specialty is considered, the FRG rates are highest for generalists

and all specialists except psychiatrists (table 1). The French

rates are higher than the U.S. rates for generalists and all

specialists, except internists and pediatricians.

As noted in chapter 1, the age structure of the population

is different in the three countries with the FRG population

being oldest on the average and the U.S. population being

youngest. Given the substantial influence of age on health services utilization, it is important to consider age in any comparison of utilization rates. Standardized rates have been calculated, therefore, using the 1980 French population by age

groups as the base population. This standardization produces a

slight reduction in the FRG rate and a slight increase in the

U.S. rate.

As noted in the first section of this chapter, the distributions of generalist and specialist physicians differ in the

three countries, Similarly, the distributions of encounters with

generalists and specialists differ for the three countries as seen

in table G.

Although generalists account for 74 percent of encounters

in France, they account for 59 percent of encounters in the

Federal Republic of Germany and only 39 percent in the

United States. In all three countries generalists account for a

higher proportion of patient encounters than the proportion

❑~~ Total ambulatoy contacts

R

Total ambulatory encounters

•!l!l

Encounters with study

physicians

15

$?

a

E. 3QOa

::10

$:

~c

~g

gg

v

5

L

~al

JR

2

a

o

France Federal Republic United

of Germany States

Figure 1. Number of annual ambulatory contacts and encounters

per person by type of contact France, the Federal Republic of

Germany, and the United States, 1981-83

they represent of all physicians. For the two specialist groups

in table G the reverse is true. In particular, generalists account

for 39 percent more encounters in the United States, 16 percent more encounters in the Federal Republic of Germany, and

9 percent more encounters in France than would correspond to

their share of physicians.

Although fkee choice of physician maybe exercised in all

three countries, patients use primary care specialists (internists, pediatricians, and obstetriciadgynecologists) more often

in the United States and the Federal Republic of Germany

than in France. Consequently, the combined total of encounters for generalists and primary care specialists represents

about the same percent of total encounters in all three countries, 82 to 88 percent of total encounters. It would seem that

ambulatory patient services provided by generalists in France

Table M. Annual rate per person of ambulatory contacts and encounters and number of encounters with study physicians France, the

Federal Republic of Germany, and the United States, 1981 –83

Country

Federal Republic

Type of contact France of Germany United States

Rate per person per year

All ambulatory contacts’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1 14.3 4.6

Ambulatory encounters with allphysiciansz. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.8 10.6 2.6

Ambulatory encounters with study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.0

Standard error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(0.080) (0.1:; (0.1::)

Ambulatory encounters with study physicians (standardized). . . . . . . . . . . . . . . . . . . . . 6.0 9.5 2.2

Number in thousands

Encounters with study physicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326,470 115,741 473,618

Reference population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54,085 11,874 223,688

I Contacts are all contacts for medical care including telephone, hospital outpatient, doctor”s office, patient’s home, and other noninstitutional settings.

2~nCoun@rs are contacts in Ofice and hOme, e~cluding te[ephone, hospital outpatient department, and so forth.

NOTE Sttmdard error values are in parentheses.

19
Table N, Number and crude and standardized annual rates per 1,000 population of physician-patient contacts: France, the Federal Republic

of Germany, and the United States, 1981-83-

Country

Federal Republic

Item Francet of Germanyl United States2

Total numbarof contacts in thousands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384,000

Crude rate ofcontacts perl,OOO population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

169,279 1,038,616

7,100

Reference population in thousands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14,256 4,643

54,085

Standardized rata of contacts per 1,000 population . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11,874 223,688

7,100 13,795 4,761

1Includes office and telsphone contacta by patienta.

‘Includes office, telephone, and hospital ambulato~ contacts by patients.

Table O. Number and crude and standardized annual rates per 1,000 population of physician-patient encounters: France, the Federal

Republic of Germany, and the United States, 1981-83

Country

Federal Republic

Item Franca of Garmany United States

Total number ofencounterslin thousands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369,109 126,363

Crude rate ofencounters par 1,000 population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

585,177

6,825 10,642

Standard error of crude rate..,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2,616

81 109

Standardized rate of encounters per 1,000 population. . . . . . . ., , . . . . . , . . . . . . . . . . , .

144

6,825 10,388 2,677

1Includes direct encounters with patienta in physician’a office or patient’s residence.

Table P. Number and crude and standardized annual ratea per 1,000 population of physician-patient encounters with study physicians:

France, the Federal Republic of Germany, and the United States, 1981-83

Country

Item

Federal Rapublic

France of Garmany United States

Total numbarof encountersl in thousands. . .,,,...,,,,,,,,,...,,,.,,.. ,,, ,, ..., 326,470 115,741

Crude rata ofencounters parl,OOO population, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,,

473,618

6,037 9,747

Standard error ofcrude rata.,,,., ,, . .,, ,,, , . .,, , . .,, , . . . . . . . . . . , ;..,.....,,,.

2,117

80

Standardized rate of ancountars per 1,000 population. , , , ., , , , ., , , , , ., , . . . . ., , . . .

125 116

6,037 9,522 2,162

1Includes only direct encounters with study physician included in data used in this report.

are provided by generalists and primary care specialists in the

Federal Republic of Germany and the United States,

Encounter rates are thought to be linked to physician density, akhou& as noted earlier, utilization of health services

depends on many factora such as the organization of health services and the division of labor between the ambulato~ and

hospital sectors. In the data presented here, however, the

physician density and encounter rates for ambulatory patients

do not necessarily vary in the same direction. For example, the

physician density is highest in France and the encounter rate is

highest in the Federal Republic of Germany. This holds true

for generalists and practically all specialists,

Characteristics of ambulatoy care

encounters

Although there are significant differences in the encounter

rates for ambulatory care in France, the Federal Republic of

Germany, and the United States, a closer examination of the

20

encounters with generalists

some striking similarities,

Patient age and sex

and specialists in this study shows

Percent distributions of encounters by age and sex are

similar for the three countries, particularly for France and the

Federal Republic of Germany. The small differences that are

seen are attributable largely to differences in the age distributions of the populations. This becomes clear in table 2

which shows the percent distribution and the encounter rate by

age and sex.

Patterns of encounter are similar when patient’s sex is

considered. In all three countries, about 60 percent of the

encounters are with female patients. The rate of encounter per

1,000 population is about 40 percent higher for females than

males in France and the Federal Republic of Germany, and

about 55 percent higher in the United States. In all three countries, encounter rates for females are considerably higher in the
middle age groupy male and female rates are similar for the

young and the elderly.

As previously observed, the encounter rate for the Federal

Republic of Germany is considerably higher than the rate in

France and the United States, with the U.S. rate being the

lowest. This order holds true for each age and sex group shown

in table 2. However, despite the actual values of the rates for

the three countries, the highest rates of encounter for each

country are for the very young and very old and the rate

increases with age for all other age groups (fi@res 2 and 3).

These same patterns are seen within each sex group, except for

males in the age group 2–14 years where the encounter rate is

higher than the next older age group. The fact that this anomaly

in the encounter rate distribution appears for all three countries

is further indication that the patterns of use of health services

by age and sex are similar in the three countries, at least

proportionally.

Visit status

Data concerning the use of physician office services by

new and known patients are shown in tables Q and 3. New

patients are those who have never been seen before for medical

reasons by the solo physician or by any of the physicians in a

group practice setting, Known patients are those who have

been seen previously in the practice either for their current condition or for a previous problem.

The majority of ambulatory care encounters in all three

countries are with known patients (table R), The proportion of

new encounters is similar for France and the United States, but

the Federal Republic of Germany (18.5 percent) had a proportion of new encounters about 30 percent higher than the 13- to

14-percent encounters with new patients found in France and

the United States (table R). Males in all three countries are

slightly more likely’to make new encounters than females. The

widest difference is in France where 16 percent of male encounters are new compared with 13 percent for females (table S).

Some portion of the difference in the percent of new and

known encounters between the Federal Republic of Germany

and the other two countries is thought to be due to differences

in survey methods. The French and U.S. surveys used separate

and discrete items concerned only with establishing whether

the patient was new or known to the physician’s practice. The

FRG survey, on the other hand obtained this information in a

subpart of a larger question that likely tended to result in an

underreporting of known patients. (This information is derived

from item 8 in the French survey, item 30 in the FRG survey,

and item 10 in the U.S. survey encounter forms displayed in

appendix I.)

The proportions of new and known patient encounters

vary by age of patient in a similar manner in allthree countries.

The age group 25–44 years accounts for the highest percent of

new encounters, making about 30 percent of all new encounters (table 3). However, within age groups, the highest proportion of new encounters is made by patients age 15–24 years

(table S). Nearly one-fourth of the encounters in this age group

are new encounters in France and the Federal Republic of

Germany, and nearly one-fii are new in the United States.

This might be expected because this age group is the most

mobile and includes emerging adults who may visit an “adult

care physician” for the first time. The two younger age groups

have slightly lower proportions of new encounters and after age

24 years the proportions of new encounters decrease steadily

with increasing age in each country. When new encounters are

examined by age within each sex group, this same pattern is

observed for females and males, with one exception. For males,

20

/+~

~~”~

— France

z

0°

g 15 J

\

- = - United States ,0’

G

n

\

- = Federal Republic

c

o

of Germany

t? \

:

& 10

a

~

~

c

Y

5

\,

.- .0-0” um -

_=.l ---- --=-

.---” ---

L.-m -.---”

0

I I I I I I I

Under 2-14 15-24 25-44 45-64 65-79 80 yeara

2 yeara yeara years years years yeers and over

Age of patient

Figure 2, Annual rate of encounters per person by patient age France, the Federal Republic of Garmany, and the United States, 1981-83

21
u

s

Under 2-14 15-24 25-44 45-64 65-79 Over 79

2 years years years years yeers years years

Age of patient

Figure 3. Rate per 100 population of encounters of patients known to the physician by patient age France, the Federal Republic of

this was defined differently. There the recommendation was to

Germany, and the United States, 1981-83

relatively high proportions of new encounters are found in the

age groups 25–44 years as well as in the groups 15–24 years.

Visit rates also show similar patterns. This is graphically

illustrated in figure 3 which shows rates per 100 population of

known patient encounters by patient age. Though the rates are

highest in the Federal Republic of Germany and lowest in the

United States for each age group, the patterns by age are

similar.

Disposition

Information concerning the physician’s disposition decision was obtained in item 10 in the French encounter form,

items 87–96 in the FRG study, and item 14 of the U.S. questionnaire. The U.S, and FRG data were collected in similar

fashion, each using a separate question dealing exclusively

with disposition and having comparable disposition categories

for selection by the respondent, The French form, on the other

hand, included selected disposition categories with categories

of therapy prescribed. This is likely to have affected the comparability of results in the studies, particularly with the disposition of return visit planned, and may account in large part for

the low percent of encounters in this category for France. The

categories of disposition compared among the three countries

are return visit planned, referral to other physician, admit to

hospital, and return to referring physician. These data are contained in tables 4–7.

The physician’s disposition Return visit planned in the

French survey meant that the physician gave the recommendation to return soow however, in the FRG and the U.S. studies

return at specified time, which would include long-term arrangements as well as short-ten-nfollowup appointments. The United

States had the highest percent of Return visit planned (60 percent of all encounters) dispositions, with the Federal Republic

of Germany having a slightly lower percent (56 percent),

According to the French study, only 19 percent of the encounters resulted in this disposition, As noted previously, a significant portion of this difference is thought to be due to the survey

design. In addition, it seems probable that in France the ambulatory care provided during one consultation constitutes a wider

range of diagnostic and therapeutic services by the doctor and

his personne~ compared with the United States and the Federal

Republic of Germany where the same services may be performed in the course of several consultations, leading to the

higher rate of return visit planned. This assumption is partly

conl%med by the duration of the patient-physician encounter,

which is 15 minutes in France, about 12 minutes in the United

States, and about 10 minutes in the Federal Republic of Germany. On the other han~ one might expect a high rate of

Return visit planned to lead to an increased number of encounters per person. However, the highest rate of Return visit planned

is for the United States (table 4), which has the lowest encounter

rate. Only the Federal Republic of Germany has a relatively

high value for both rates. Thus, the meaning of Return visit

plamed seems to vary among the three countries in the data

collection process and with respect to the patient’s interpretation of the physician’s instruction.

22
Table Q, Number, crude and standardized annual rate per 1,000 population of encounters, and percant distribution of encounters by visit

status, and by patient sax, according to visit status: France, tha Federal Republic of Germany, and tha United Statea, 1981-83

Country

Encounters with known patients Encounters with new patients

Federal Rapublic Federal Republic

Item France of Germany United States France of Germany United States

Number of encounters per year in thousands

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

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Encounters in percent of total encounters

Total ,,, ..,,..,. . . . . . . . . . . . . . . . . ... ,., !.. .

Crude rates of encounters per 1,000 population

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

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standardized rates of encounters per 1,000

population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Encounters in parcent

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

279,457

168,932

110,526

94,293

56,938

37,355

411,650

257,819

153,831

47,058

25,739

21,273

21,452

12,515

8,937

61,967

37,417

24,550

85.60 81.47 66.92 14.41 18.53 13.08

1,840

2,227

1,426

670

927

806

1,607

2,024

1,570

277

323

228

5,167

6,087

4,197

7,941

9,209

6,564

274

60.38

39.62

5,167

60.45

39.55

7,736

60.36

39.62

1,668

62.63

37.37

869

54.74

45.25

1,786

58.34

41.66

Table R. Percent distribution of encounters with study physicians

by patient statua: Franca, the Faderal Rapublic of Germany, and the

United Stetas, 1981-83

Country

Federal Republic

Patient status France of Germany United States

Percent distribution

All patients . . . . . . . . 100.0 100.0 100.0

Known patients, ., . . 85.6 61.5 86.9

Naw patients, , , . . . . 14,4 18.5 13.1

When the physician’s specialty is considered psychiatrists/

neurologists and dermatologists are among the specialists with

the highest rate of Return visit planned per 100 encounters in all

three countries—an indication of the long-term therapy common

in these practices (table 4).

Referral to other physician generally is a formal document

or referral recommendation to a particular physician or physician group, although in all three countries a formal referral is

not necessary to see another physician.

As might be expectedj Referralto other physician was most

frequent in the Federal Republic of Germany with about 8 percent of encounters resulting in that disposition category (table

5), In contras$ the corresponding figures are about 5 percent

for France and 3 percent for the United States. The higher

FRG rate is probably due to the policies of the FRG health

insurance system. In the Federal Republic of Germany, patients

may see a specialist without a previous referral, In spite of this,

most of them ask their family doctor (usually a general praTabia S. Rata of encounters by naw patienta per 100 total

encounters by patient age and aex France, the Faderal Republic of

Germany, and tha Unitad States, 1981-83

Country

Federal Republic

Age and sax France of Germany United States

All patients

Allagaa . . . . . . . . . . .

Under 2 years . . . . . .

2-14 years . . . . . . . .

15-24 years, . . . . . .

25-44 years . . . . . . .

45-64 yeara . . . . . . .

65-79 years . . . . . . .

SO years and cvar. . .

Female

All agea . . . . . . . . . . .

Under 2 years. . . . . .

2-14 yeara . . . . . . . .

15-24 yeara . . . . . . .

25-44 yaara . . . . . . .

45-64 years . . . . . . .

65-79 years . . . . . . .

80 years and over. . .

Male

All ages . . . . . . . . . . .

Undar 2 years. . . . . .

2-14 yeara . . . . . . . .

15-24 years . . . . . . .

25-44 years . . . . . . .

45-64 years . . . . . . .

65-79 years . . . . . . .

80 years and over. . .

Rate per 100 encounters

18.53 13,08

21,19 10.77

23,06 14.31

24.14 19,47

21.74 16.00

16.61 9.92

13.42 8.17

14.00 7.36

14.47

18.74

18.72

23.20

16.72

11.38

7.89

6,04

13.22

19.16

16.94

21,07

13.95

10.98

7.94

.5.79

16.16

16.37

18.52

26.94

21.88

11.94

7.82

6.61

18,02 12.67

12,26

14,79

18.78

13.84

9.63

8.15

6.33

25.23

20,62

25.63

19,39

16.64

13,48

15,72

19.31

17,15

25.40

21,96

26,64

16.57

13,30

10.05

13.76

9.32

13.86

21.04

21.08

10.34

8,20

5.24

23
titioner or internist) to provide a referral that entitles them to

see a specialist The compulsory sickness funds do not require

this procedure, but recommend that referrals be handled in that

way.

In all three countries, these referrals include referrals for

treatmen~ for specialized care, and for second opinions. In the

Federal Republic of Germany, referrals to hospital ambulatory

services are also included because these services may only be

used on a regular basis with a formal referral document.

Generalists in France and the Federal Republic of Germany had the highest rate of referral to other physicians (about

5 and 9 referrals per 100 encounters, respectively). In the

United States, however, the highest rate was for internists

(about 4 referrals per 100 encounters). Generalists, internists,

and pediatricians accounted for nearly all referrals to other

physicians (85 to 91 percent) in all three countries.

During physician oflice encounters, the disposition decision to admit to hospital (for inpatient care) was rare in all

three countries, being less than 2 per 100 ambulatory encounters in each country (table 6). The rates in the Federal Republic

of Germany and the United States were the same ( 1.7 per 100

encounters), and the French figure was slightly lower (1.4). In

all three countries, the specialty (among the specialties included

in this study) with the highest rate of encounters resulting in an

admit to hospital disposition is otolaryngology. In total volume,

generalists account for the majority of visits with an admit to

hospital disposition-about tw~thirds of such visits in France

and the Federal Republic of Germany and about one-third in

the United States.

Return to referring physician is also a rare disposition

decision in ambulatory care, particularly in the United States

(0.6 per 100 encounters, table 7). The FRG and French

figures are somewhat higher (2.0 and 2.7, respectively). However, there is wide variation by specialty. Internists account for

a substantial portion of encounters resulting in this disposition.

About 60 percent of such encounters in France and about 35

percent in the Federal Republic of Germany and the United

States were attributed to internists. In France, about 30 percent of internist encounters resulted in a return of the patient to

the referring physician. Psychiatrists and neurologists had the

highest such percent in the Federal Republic of Germany and

the United States (13.0 percent and 2.8 percent respectively).

Reasons for physician encounters

In all three surveys, physicians recorded the reason(s) for

each patient encounter, generally as a medical problem or diagnosis. For France a single, simple question was asked “Diagnoses or reasons for the encounter.” The physician accordingly

noted one or more diagnoses or reasons without specifying

which was the most important in motivating the patient to seek

health services. On the other hand, the FRG and U.S. survey

forms contained two types of questions (1) “reason for visit in

patient’s words” and (2) “diagnosis or problem” as determined

by the physician. In both items, multiple entries were to be

recorded in order of significance with the most important listed

first. Data from the second question are used in this analysis

even though the phrase “reason for encounter” is sometimes

used to describe the information.

There are two other conditions that must be described to

understand these data, Firs~ in France all entries in the diagnosis question were coded according to the ICD-9 (World

Health Organizatio~ 1977). In the Federal Republic of Germany, as many as nine entries were coded according to a modification of the “Reason for visit classification” (Wagner, Schach

and Schwartz, 1984) and subsequently recoded into the ICD

categories. In the United States, a maximum of three entries

could be coded according to the ICP9–CM (Public Health

Service and Health Care Financing Administration, 1980). As

a result in all three countries, there often was more than one

diagnostic entry for an encounter: an average of 1.4 for the

United States, 1.8 for France, and 2.5 for the Federal Republic

of Germany.

The lower figure for the United States is probably the

result of coding no more than three entries for any encounter.

The higher figure for the Federal Republic of Germany is

partly the result of coding up to nine entries for each encounter

and possibly due in part to insurance procedures. In spite of the

fact that data collection for this study and the FRG insurance

administrative processes in ambulatory care were completely

separate, it is possible that data collection for the study was

affected by the insurance process. In particular, FRG ambulatory care physicians accumulate diagnostic entries over the 3-

month life of each insurance find voucher for each patien~

This habit may have affected the number of survey diagnoses

entered during the FRG survey.

Second the diagnosis data used in this study were tabulated

on the basis of all coded entries. Therefore, the data reflect the

total of all diagnoses that exist for patients making ambulatory

encounters to generalists and selected specialists included in

this study. The data do not reflect the incidence or prevalence

of disease in the population. Chronic conditions, for example,

which motivate more encounters per person or time period than

acute conditions, will probably have a higher proportion of

encounters in the study than would correspond to their prevalence in the population. Similarly, as the number of existing

conditions increases with age, older patients and their often

chronic conditions will also be disproportionately represented

in the data. Because of these known limitations, this analysis

primarily considers encounter rates and relative distributions

when comparing data from the three countries.

Major ICD categories

In table T, the diagnostic entries are aggregated according

to the ICP9 major chapter groupings and are expressed as

percent distributions for each country.

Comparisons between the countries are most meaningful

when percent distributions are examined because of the differences among the countries in the numbers of coded diagnoses,

and the disparity in the proportion of diagnoses in three somewhat amorphous categories special condition% symptoms,

signs, and ill-defined condition and other and unknown. If the

above categories are eliminated, the relative distributions in

table T show that encounters related to mental disorders and

conditions in the perinatal period are relatively more frequent

in France. Encounters associated with endocrine, nutritional,

and metabolic diseases and immunity disorders diseases of the

blood and the blood-forming organs diseases of the circulatory

24
Tabla T, Percent distribution of diagnostic entries by international Classification of Diseases, 9th Revision, categories: France, the Federal

Republic of Germany, and the United States, 1981-83

Country

Federal Republic

International Classification of Diseases category France of Garmany United States

Percent distribution

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.00 100.00 100.00

Infectious andparasitic diseasea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Endocrine, nutritional, and metabolic diseasea and immunity disorders . . . . . . . . . . . . . . .

Diseaaea of the blood and blood-forming organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mental disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Disorders of thenervous system and aenae organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diseases of the circulatory system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dlseaaea of the respiratory system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diseases of the digestive system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diseases of thegenitourinary system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Complications of pregnancy, childbirth, and puerperium. . . . . . . . . . . . . . . . . . . . . . . . .

Diseasea of theskin andsubcutaneoua tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dlseasea of the musculoskeletal system end connective tissue. . . . . . . . . . . . . . . . . . . . . .

Congenital anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Certain conditions originating in the perinatal period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Symptoms, signs, andill-defined conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Injuries and poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Special conditions, other and unknown codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

systew and diseases of the musculoskeletal system are relatively

more frequent in the Federal Republic of Germany. Encounters in the categories of infectious and parasitic disease~ disorders of the nervous system and sense organ% diseases of the

respiratory system, diseases of the skin and subcutaneous

tissues and injuries and poisonings are relatively more fre

quent in the United States, compared with the respective relative frequencies (percents) of the other two countries. There is,

however, considerable similarity in the general distribution of

diagnostic entries in the three countries. This is apparent in

figure 4, which illustrates that the distributions of diagnoses by

major ICD-9 categories have similar shapes for the three

countries.

Selected index diagnoses and reasons

for encounter

A comparison of the diagnoses and reasons for seeking

medical care services was performed at a more specific level

for 15 commonly encountered (index) medical problems and

for 6 types of preventive and administrative health problems

(table U).

The differences observed in table W and figure 5 are

related to previously noted dtierences in the number of diagnoses per encounter in the three countries, and probably also to

differences in the probabilities of seeking health care services

for various health problems in the three countries, Because

these two factors are confounde~ it is not possible to determine the contribution of each.

As with the broad diagnostic categories, an examination of

the percent distributions for these specific diagnoses provides a

more revealing comparison among the three countries (table 8

and figure 6). Of the 15 medical problems selectet arthritis,

depressio~ and insomnia are relatively more frequent inFrance.

Diagnoses occurring relatively more frequently in the Federal

Republic of Germany are ischemic heart disease, diabetes

2.45

1.30

3.58

0.37

6.89

7.72

16.22

11.84

6.94

3.80

0.42

3.47

8.47

0.24

0.09

14.18

2.70

9.32

2.54

2.03

6.18

0.94

4.47

8.54

24.21

11.34

6.40

5.56

0.23

3.57

10.88

0.27

0.02

3.33

2.78

6.71

3.10

1.86

4.60

0.59

4.62

10,99

13.58

13.76

4.69

5.10

0.30

5.44

6.11

0.25

0.04

3.77

5.38

15.83

mellitus, bronchitis, and contact dermatitis. In the United States,

upper respiratory disease, otitis medi~ and diseases of the

sebaceous glands are relatively more frequently reported in

encounters with the study physicians. While there seem to be

more entries with respect to chronic problems in the Federal

Republic of Germany, acute problems in the United States are

more dominant among the selected medical problems. The 15

selected medical problems represent about one-third of total

diagnostic entries in each of the 3 countries. The relatively low

figures observed in the United States for insomni% depression,

and back pain can be partly explained by the fact that these diseases are frequently treated by psychologists and osteopathic

physicians, two types of medical care practitioners not within

the scope of this study.

The six preventive and administrative health problems

selected accounted for 6.6 percent of diagnostic entries in

France, 9.7 percent in the United States, and only 1.3 percent

in the Federal Republic of Germany. The low FRG figure may

be partly due to methods of diagnostic coding.

Monitoring of normal pregnancy accounted for about 4

percent of physicians’ female diagnoses in the United States

but less than 1 percent in France and in the Federal Republic

of Germany. The monitoring of well children under age 3 years

accounted for about 3 percent of diagnoses in the United

States, about 1 percent in France, and only 0.07 percent in the

Federal Republic of Germany, As noted previously, the low

FRG numbers maybe the result of diagnostic coding methods.

The low frequency of inoculation or vaccination diagnoses in

the United States and the Federal Republic of Germany is

probably related to the fact that these are often performed

during well-child visits or in public clinics. Also, inoculations

usually would not be recorded on the U.S. or FRG encounter

forms as a diagnosis or reason for the encounter.

Encounters for contraception are much more frequent in

France than in the United States and the Federal Republic of

25
Infectious and paraaitic diseaaes

Neoplasma

Endocrine, nutritional, and metabolic

diseaaes and immunity disorders

Mental disorders

Disorders of the nervous ayatem and

sense organs

Diseases of the circulatory system

2

0

01

# Diseasea of the respiratory system

v

y

~

Diseases of the digestive system

Diseases of the genitourinary system

Diseases of the akin and subcutaneous

tissue

Diseaaea of the musculoskeletal system

and connective tissues

Symptoms, signs, and ill-defined

conditions

Injuries, poisonings, snd violence

o 5 10 15 20 25

Percent of diagnostic entries

. . .- —

Figure 4. Percent of diagnostic entries in major International Classification of Diseases, 9th Revision, categorlas France, the Federsl

Republic of Germany, and the Unitad States, 1981-83

Germany; this service is often performed in the United States

in special clinic settings or may take place in institutional settings in the Federal Republic of Germany. These facilities are

not included in this study.

Physician specialty

As noted earlier, generalists accounted for 74 percent of

encounters in France, 59 percent in the Federal Republic of

Germany, and only 39 percent in the United States. Most of

the index diagnoses follow a similar pattern (table Y). In

France, all of the index diagnoses are associated with generalists’ encounters much more frequently than specialists’ encounters except refractive error and diseases of the sebaceous glands.

Similarly, in the Federal Republic of Germany, all but three of

the index diagnoses are associated with generalists’ encounters

more frequently than specialists’ encounters. In the United

26
Table U. Spacific (index) diagnosaa and preventive care categories used in analysis and the corresponding International Classification of

Diseases codes

International Classification of Diseases International Classification of Diseases

category Code category Code

Medical problem

Essential hypertension . . . . . . . . . . . . .

Efack pain . . . . . . . . . . . . . . . . . . . . . . . .

Nauroaia . . . . . . . . . . . . . . . . . . . . . . . . .

Ischemic haart disease. . . . . . . . . . . . .

Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . .

Uppar reapirato~ diseases (pharyngitia,

tonsillitis, laryngitis, sinusitis, acute

respiratory infections) . . . . . . . . . . . . .

Diabetes mellitus . . . . . . . . . . . . . . . . . .

Bronchitis . . . . . . . . . . . . . . . . . . . . . . . .

Refractive snd accommodation

errors . . . . . . . . . . . . . . . . . . . . . . . . . .

Depression . . . . . . . . . . . . . . . . . . . . . . .

Otitis media . . . . . . . . . . . . . . . . . . . . . .

401

720-724

300-301

410-414

725-729

460, 461, 463, 465, 472, 477

250

466, 499

367

309.0, 309.1, 311

309.1, 381, 381.4

Medical problem—Con.

Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . 780.5

Diseases of the sebaceous glands. . . . 706

Contact dermatitis . . . . . . . . . . . . . . . . . 692

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . 493

Preventive care

Normal pregnancy . . . . . . . . . . . . . . . . . V22

Well-child visit . . . . . . . . . . . . . . . . . . . . V20

General medical examination. . . . . . . . V70

lnocuistion/vaccination. . . . . . . . . . . . . V03–V06

Contrscaption, family planning. , . . . . . V25

Administrative visit (examination for

work, school or insursnce . . . . . . . . . V68

Tabla W. Number of diagnostic entries par 100 encounters for selected index medical and preventive cara categories: France, the Federal

Republic of Germany, and the Unitad States, 1981 –83

Country

Federal Republic

Diagnostic category France of Germany United States

Rate per 100 encounters

Total antries for study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.24 -.. 142.84

Medical problem

Total ofselectad problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62.87 82.37 51.73

Essential hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13ack pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ischemic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Upper respiratory disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Refmctivee rror . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otitis media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9.59

6.04

5.06

3.89

6.17

1.48

2.29

2.99

1.96

3.81

1.79

15.60

9.85

1.55

9.22

5.50

8.17

7.78

9.17

4.12

2.23

0.48

9.07

1.97

3.54

3.95

3.94

10.69

3.82

2.81

2.31

0.77

4.28

Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.97 0.60 0.03

Diseases of the sebaceous glands. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.67 1.93 2.12

Contact dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.17 3.30 1.37

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.83 2.26 1.08

Preventive care

Total ofselected preventive care visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.04 3.13 13.87

Normal pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.65 2.10 9.04

Well-child visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.17 0.18 4.42

General medical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.85 0.05 1.66

Inoculation/vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.08 0.33 0.12

Contraception, family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.30 1.21 0.55

Administrative visit (examination for work, school, or insurance). . . . . . . . . . . . . . . . . . . . . 2.06 0.40 1.49

States, on the other han~ only three of the diagnoses are ffom the Federal Republic of Germany and the United States

associated more frequently with generalists’ than specialists’ (French data for these categories are unavailable). Encounters

encounters. with specialists account for the majority of these diagnoses for

The six health and administrative problems selected for four of the six categories in the United States and the Federal

comparison (table Y) show quite similar patterns by specialty Republic of Germany.

27
Essential hypertension

Back pain

Neurosis

Ischemic heart disease

Arthritis

‘Upper respiratory disease

Diabetes mellitus

.:

0 Bronchitis

c

0)

,-

:

Refractive error

Otitis media

Insomnia

Diseases of the sebaceous glands

Contact dermatitis

Asthma

~ France

❑ Federal Republic of Germany

~ United Sates

I

I I I

I

o 5 10 15 20

Number per 100 encounters

‘igure 5. Number of diagnostic entries per 100 encounters for selected diagnoses: France, the Federal Republic of Germany, and the United

;tatea, 1981-83

28
Essential hypertension

Back pain

Neurosis

Ischemic heart disease

Arthritis

Upper respirator disease

Diabetea mellitus

v)

.-

: Bronchitis

E

,-

:

Refractive error

Depression

Otitia media

............................. .............................

.......................................................... .............................

P

.

Insomnia

❑ France

❑ Federal Republic of Germany

❑ United States

Diseases of the sebeceous glands

Contact dermatitis

Asthma

I

I I I I I I 1 !

o 1 2 3 4 5 6 7 8

Percent of diagnostic entries

Figure 6. Percent of diagnostic entries for selected diagnoses: Frenca, the Federal Republic of Germany, and the United States, 1981-83

29
Table Y. Percent distribution of diagnostic entries for selected index medical end preventive care categories by type of physicien: France, the

Federal Republic of Germany, and the United Stetes, 1981-83

Country

Federal Republic of

France Germany United States

Diagnostic catego~ Generalists Specialists Generalists Specialists Generalists Specialists

Medicel problem

Total of selected problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Essential hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bsck pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ischemic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Upper respiratory disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Refractive error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otitis media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diseases of theaebaceoua glands. . . . . . . . . . . . . . . . . . . . . .

Contact dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Preventive care

Total cf selected preventive care visita. . . . . . . . . . . . . . . . . . .

Normal pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Well-child visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General medical examination . . . . . . . . . . . . . . . . . . . . . . . . . . .

Inoculation/vaccination . . . . . . . . . ..c . . . . . . . . . . . . . . . . . . . .

Contraception, family planning . . . . . . . . . . . . . . . . . . . . . . . . .

Administrative visit (examination for work, school, or

insurance) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

82.06

93.63

84.20

65.68

86.75

88.64

84.56

91.29

91.86

2.11

83.71

59.11

94.46

36.94

73.76

83.19

-..

. . .

..-

.-.

. . .

..-

. . .

17.94

6,37

15.80

34.32

13.25

11,36

15.44

8.71

8.14

97.89

16.29

40.89

5.54

63.06

26,24

16.81

. . .

. . .

---

-..

. . .

. . .

. . .

65.36

75.08

76.66

63.60

66.04

81.04

50.54

74.21

69.31

1.93

66.38

10.36

74.86

48.93

56.01

67.72

33.33

22.94

8.02

41.07

60.90

14.84

62.50

34.64

24.92

23.34

36.40

33.96

18.96

49.46

25.79

30.69

98.07

33.62

89.64

25.14

51.07

43.99

32.28

66.67

77.06

91.98

58.93

39.10

85.16

37.50

42.0

52.4

48.6

20.6

32.4

56.6

51.4

47.9

61.3

2.9

41.6

27.2

25.3

12.6

38.7

33.8

28.0

20.1

16.9

35.5

61.8

19.4

67.1

68.1

47.6

51.4

79.4

67.6

43.4

48.6

52.1

38.7

97.1

58.4

72.B

74.7

87.4

61.3

66.2

72,0

79.9

83.1

64,5

38.2

80.6

32.9

30
References

Bundesministerium fir Jugen~ Familie und Gesundheit. 1983. Daten

des Gesundlzeitsweserzs. Schriftenreihe Band 153. Kohlhrnnmec Stuttgart, Federal Republic of Germany.

Bundesministerium fiirJugend, Familie und Gesundheit. 1985. Daten

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Centre de Recherche d’Etude et de Documentation en Economic de la

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National Center for Health Statistics, B. K. Cypress. 1983a. Patterns

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Ambulatory Medicrd Care Survey United States, January 1980-

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visits, volume and interval since last visi~ United States, 1980. Vital

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Le Sante en Chlfies, 1960–83, pp. 31, 33, 161, 166. Paris, France.

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U.S. Bureau of the Census. 1981. Statistical Abstract of the United

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schema fur Kontaktanlasse in der ambulanten Versorgung. Zentralinstitut fir die kasseniirztliche Versorgung in der Bundesrepublik

Deutschland Koln, Federal Republic of Germany.

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Koln Deutscher &zte-Verlag.

31
List of detailed tables

1. Number, percent distribution crude and standardized ammrd

rates per 1,000 population, and standard error of crude rates

of encounters by physician specialty France, the Federal

Republic of Germany, and the United States, 1981-83 . . .

2. Number, percent distribution annual rate per 1,000 population, and standard error of rates of encounters by patient

age and sex France, the Federal Republic of Germany, and

the United States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Number, percent distribution and crude rate per 1,000 population of new patient encounters by age and sex France, the

Federal Republic of Germany, and the United States,

1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Number, percent distribution, rate per 1,000 population,

and rate per 100 encounters of encounters with Disposition

of return visit planned, by physician specialty France, the

Federal Republic of Germany, and the United States,

1981-83 . . ..0...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Number, percent distribution, rate per 1,000 population,

and rate per 100 encounters of encounters with Disposition

of referral to another physician, by physician specialty

France, the Federal Republic of Germany, and the United

States, 1981-83 . . !...,..., . . . . . . . . . . . . . . . . . . . . . . ,., 41

33 6. Number, percent distribution, rate per 1,000 population,

and rate per 100 encounters of encounters with Disposition

of admit to hospital, by physician specialty France the

Federal Republic of Germany, and the United States,

35 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

7. Number, percent distribution, rate per 1,000 population,

and rate per 100 encounters of encounters with Disposition

of return to referring physician, by physician specialty

38 France, the Federal Republic of Germany, and the United

States, 1981-83 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

8. Number, percent distribution, and rate per 1,000 population

of diagnostic entries for selected index medical and preventive care categories France, the Federal Republic of Ger40 many, and the United States, 1981-83 ., ,.. , ,,, ,., ., ,. 44

32
Table 1. Number, percent distribution, crude and standardized annual rates per 1,000 population, and standard error of crude rates of

encounters by physician specialty: France, the Federal Republic of Germany, and the United States, 1981–83

Country

Federal Republic

Physician specialty France of Germeny United States

Number of encounters in thousands

Total ambulatory care physicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allprimaty care specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gy necologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Another atudy group specialists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other specialists in ambulatory care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total ambulatory care physicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allprima~ care specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intern ists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gy necologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Another study group specialists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists. , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other specialists in ambulatory care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total ambulatory care physicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists ..,...,.,,.......,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allprimary care specialists. .,... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetriciana/gy necologistsl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allnther study group specialists .,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists.,...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologiats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Othwspecialiats in ambulatory care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total ambulatory care physicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allprimaty care specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gy necologistsl. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Another study group specialists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists........., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other specialists inambulato~ care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

369,109

326,470

242,657

42,889

17,944

10,170

14,775

40,924

9,312

7,596

14,995

9,021

42,639

100.00

88.45

65.74

11.62

4.86

2.76

4.00

11.09

2.52

2.06

4.06

2.44

11.55

126,363

115,741

68,801

33,238

18,093

6,472

8,673

13,702

1,696

3,455

4,956

3,593

10,622

Percent distribution

100.00

91.59

54.45

26,30

14.32

5.12

6.86

10.84

1.34

2,73

3.92

2.84

8.41

585,177

473,618

183,669

202,945

86,651

62,991

53,303

87,004

19,681

23,262

31,608

12,453

111,559

100.00

80.94

31.39

34.68

14.81

10.76

9.11

14.87

3.36

3.98

5.40

2.13

19.06

Rate of encounters per 1,000 population

6,825 10,642 2,616

6,037 9,747 2,117

4,467 5,794 821

793 2,799 902

332 1,524 387

188 545 282

532 1,403 460

757 1,154 387

172 143 88

140 291 104

277 418 141

167 303 56

788 895 499

6,825

6,036

4,487

793

332

188

532

757

172

140

277

167

788

Standardized rate of encounters per

1,000 population

10,388 2.677

9,522 2,163

5,566 844

2,838 900

1,435 425

720 276

1,337 420

1,118 402

133 87

282 103

402 155

301 57

866 514

lBased on female population only.

33
Table 1. Number, percent distribution, crude and standardized annual rates per 1,000 population, and standard error of crude rates of

encounters by physician special~ France, the Federal Republic of Germany, and the United States, 1981-83—Con.

Country

Federal Republic

Physician specialty France of Germany United States

Total ambulatory care physicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allprimary care specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gy necologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Another study group specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other specialists in ambulatory care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard error of crude rates of encounters per

1,000 population

. . . 140 144

. . . 136 116

. . . 118 49

. . . 54 53

-.. 46 23

--- 13 18

. . . 26 15

. . . 42 23

. . . 9 7

. . . 31 8

. . . 13 11

. . . 23 5

. . . 33 30

34
Table2. Number, percent distribution, annual rate perl,OOO population, andstandard error of rates of encounters bypatientage and sex

Franca, the Federal Republic of Germany, and the United States, 1981-83

Country

Federal Republic

Age and sex France of Germany United States

Allpatients. . t, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SEX

AGE

All patienta

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years, hi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years.,...,......,...,,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 yeara, .,,.,,,.,.,...,,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-79 yeers, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80yeara and over.,.,,.,..,,..,,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

Undar2yaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years. . i . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . ., . .,, ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years.,...,.,,...,,..,,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-79 Vears. ,,. ., . . .. i . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80 years and over. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mele

Under 2 years .,, , . .,, .,..,..., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 yaars, .,. .,. ,,. of, ..,,.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 yeara . . . . . . . . . . . , . ..0....0. . ..0....!., . . . . . . . . . . . ,, .,,,..,,. . ..!...

25-44 years, , a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 yaars .,, . ., . .,, .,......, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

66-79 years . ., . .,, , . ...,...,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80yeers and over,.,,....,,..,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SEX

AGE

All patients

Undar 2 years ,,, ,., ,., . . . . . . . . . . . . . . . . . . . . . . . . .,, .,,,,,,, ! . . . . . . . . . . .,, . . .

2-14 years. ,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years .,, .,,,,,,. ,, ..,.,,,., , . ...!,.... .,, ,., ,, .,, . . . . . . . . . . . . . . . . . .

26-44 yeara, ,oon, .,n. ,., .n. ,.. n,. . 88 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..8..

46-64 years,,..,,,,...,,,,,,,,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-79 yeers, ,, . .,, , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80years andovar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

Under 2 years, ., .,, , . .,, ...,...., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 yeara. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 yesrs ,.!. !, ..0.. . . . . . ...!.. , ! ..,,,..,, . . . . . . . . . . . , .,.,,..,,! ... ,.. .

26-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years ,, ...,,,.., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-79 yaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

,

Male

Under 2yaars .,..,,........,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years ,,, ,., ,,, . . ,,, ,, .,,,., ,,, ,,, ,,, ., , .,,,,,,,., , .,,,,,,,,. . . . . . . . . .

326,533

194,770

131,763

17,079

41,678

34,517

82,129

78,109

54,639

18,382

7,978

19,652

21,987

53,508

45,531

33,272

12,842

9,101

22,026

12,530

28,621

32,578

21,367

5,540

100.00

59.65

40.35

5.23

12.76

10.57

25.15

23.92

16.73

5.63

4.10

10.09

11.29

27.47

23.38

17.08

6.59

6.91

16.72

Number of encounters in thousands

115,741

69,452

46,289

3,619

10,110

13,165

26,813

31,026

24,779

6,229

1,811

4,952

7,820

16,768

17,378

16,404

4,319

1,808

5,158

5,345

10,045

13,648

8,375

1,910

Percent distribution

100.00

60.01

39,99

3.13

8.74

11.37

23.17

26.81

21.41

5.38

2.61

7.13

11.26

24.14

25.02

23.62

6.22

3.91

11,14

473,617

295,236

178,381

33,759

60,175

65,698

122,420

104,894

69,119

17,552

16,736

29,463

45,844

85,829

63,120

42,246

11,998

17,023

30,712

19,854

36,591

41,774

26,873

5,554

100.00

62.34

37.66

7.13

12.71

13.67

25.85

22.15

14.59

3.71

5.67

9.98

15.53

29.07

21.38

14.31

4.06

9.54

17.22

35
Table 2. Number, percent distribution, annual rate per 1,000 population, and standard error of ratea of encounters by patient age and sex

France, the Federal Republic of Garmany, and the United States, 1981-83—Con.

Country

Federal Republic

Age and sex France of Germany United States

Male—Con.

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

80 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All patienta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SEX

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AGE

All patients

Under 2 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years.................,,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 yaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

80yaars and over, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

80years andovar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2–14years . . . . . . . 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

80 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SEX

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AGE

All patienta

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2–14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

65-79 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80 years and over. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2–14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

80years andovar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent distribution

9.51 11.55 11.13

21.72 21.70 20.51

24.72 29.48 23.42

16.22 18.09 15.06

4.20 4.13 3.11

Rate of encounters per 1,000 population

6,037 9,747 2,117

7,018 11,233 2,550

5,004 8,134 1,653

10,752 15,400 4,870

4,048 5,739 1,370

4,060 6,677 1,622

5,546 7,872 1,924

6,744 11,441 2,386

9,604 16,950 3,414

11,360 19,119 3,899

10,293 15,803 4,938

3,908 5,768 1,372

5,079 8,161 2,233

7,418 10,107 2,629

7,685 12,004 2,731

9,978 17,912 3,596

11,204 18,844 4,175

11,190 15;01 7 4,803

4,182 5,712 1,368

3,003 5,274 994

3,767 5,750 1,182

5,758 10,796 2,004

9,075 15,336 3,124

11,740 19,772 3,635

Standard error of rates of encounters per

1,000 population

101 70 92

72 60 61

391

95

78

88

112

194

252

328

85

113

173

137

205

232

92

39

65

74

137

221

244

137

52

91

114

159

318

320

234

59

68

73

93

140

234

296

66

94

105

112

151

283

36
Table 2, Number, parcant distribution, annual rata par 1,000 population, and standard error of rates of encounters by patient age and sex

Franca, the Federal Rapublicof Garmany, andthe United Statas, 1981-83—Con.

Country

Federal Republic

Age and sex France of Germany United States

Male

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

80yaars and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard error of rates of encounters

1,000 population

362 123

97 59

55 93

67 96

101 184

177 258

223 317

per

279

66

56

54

90

156

309

37
Table 3. Numbar, percent distribution, endcrude rata perl,OOO population of newpatient encountera byageandaex France, the Federal

Rapublic of Garmany, end the Unitad States, 1981-83

Country

Federal Republic

Age and sex France of Germany Unitad States

All ages

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

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 yaars, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

80 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

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

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8.. . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

65-79 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

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

Under,2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 yeara . . . . . . . . . . . . . . . . . . . . . . , ., ...,,.,, . . . . . . . . . . . ., .,,,..,,, ,,, .,,,..

65-79 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,, .,,,.,,.. . . . . . . . . . . .

80 years and over . . . . . . . . . . . .,, ,. .,,,.. ,,, .,,..,,. , . .,,.,,.,, . . . . . . . . . . . . . . .

All eges

Total . . . . . . . . . . . . . . . . . . . . . . ,,, ,. .,.,,. . . . . . . . . . . . . .,.,,,.,,, , .,,,,..,.. . . . .

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 yeara. .c . . . . . . . . . . . .. l.... . . . . . . . . . . . . . .. O. . . . . . . . .. O.... . . . . . . . . . . . . .

15-24 yaars . . . . . . . . . . . .. c...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . .. o... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . ,,, ..,,.,,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

66-79 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

Total . . . . . . . . ...!...,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...0.... . . . . . . . .

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 yeara . . . . . . . . . . . . . . .. l... , ,, .,,,....! ,, .,,..,.., ,, !,...,..! . . . . . . . . . .

25-44 yaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-79 yaars. , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80 yaara and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , ., .,,.,.,. . . . .

Male

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

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years . . . . . . . . . . . . . . . . . . . . . . . . +. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

65-79 years....,.......,...,,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80 yaare and over. . . . . . . . . . . . . . . . ,,, ,., ,. .,, ,,, ,., .,,,, ,,, ,,, ,,, ,. , .,,,..,,,

47,058

3,201

7,802

8,009

13,730

8,893

4,313

1,110

25,742

1,529

3,722

4,633

7,467

5,004

2,643

744

21,316

1,672

4,080

3,376

6,263

3,889

1,670

366

100.00

6.80

16.58

17.02

29.18

18.90

9.17

2.36

100,00

5.94

14,46

18.00

29.01

19.44

10.27

2.89

100,00

7.84

19.14

15.84

29.38

18.24

7.83

1.72

Number in thousands per year

21,452

767

2,331

3,178

5,628

5,152

3,325

871

12,515

457

1,021

2,004

3,252

2,891

2,211

679

8,937

310

1,310

1,174

2,576

2,261

1,114

192

Percent distribution

100.00

3.58

10.87

14.81

27.17

24,02

15.50

4.06

100.00

3.65

8.16

16.01

25.98

23.10

17.67

5.43

100.00

3,47

14.66

13.14

28.82

25.30

12.47

2.15

61,967

3,636

8,613

12,787

19,591

10,401

5,648

1,291

37,417

2,051

4,357

8,811

11,877

6,079

3,443

999

24,550

1,586

4,256

4,177

7,714

4,321

2,204

291

100.00

5,87

13.90

20.64

31.62

16.78

9.11

2.08

100,00

5,48

11.64

23.01

31.74

16.25

9,20

2.67

100,00

6.46

17.34

17,01

31.42

17.60

8,98

1.19

38
Tabla 3, Number, percent distribution, end crude rate per 1,000 population of new patient encounters by age and sex France, the Federal

Republic of Germany, and the United States, 1981 -83—Con.

County

Federal Republic

Age and sex France of Germany United States

All ages

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

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-79 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

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

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years,...,..,.,.,...,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years, . ., . .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years, , .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years, .,, .,, ,,, , .,,,.,.,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-79 years . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80years andovar ..,..,,,..,,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mala

Total, ...,..,,,...............,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Under 2 years .,, ., ., ...,...,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years ., ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years. ., .,, ,,, .,, ,., ,, .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years, , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years, .,, ,,, , . .,, ,., ,. .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .

66-79 years,,..,...,.,,,..,,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80yeara and over .,, , ., ...,...,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

870

2,016

758

942

927

768

758

686

928

1,973

740

1,070

1,035

845

793

649

809

2,057

775

809

824

687

709

775

Rate per 1,000 population

1,807

3,264

1,323

1,612

1,711

1,900

2,274

2,672

2,024

3,974

1,139

2,092

1,960

1,997

2,414

2,965

1,570

2,583

1,451

1,158

1,475

1,789

2,040

1,979

277

525

196

316

308

237

279

287

323

605

203

419

364

.263

293

348

228

447

190

209

249

207

256

190

39
Table 4. Number, percent distribution, rate perl,fMO population, andrateper 100 encounteraof encounters with Disposition of return visit

planned, by physician specialty France, the Faderal Republic of Germany, and the United States, 1981-83

Federal Republic

Physician specialty France of Germany United States

All specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gy necologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gynecologists...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gynecologists....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists.....,... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinola~ngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

63,135

100.00

68.25

4.65

1.73

3.43

9.60

4.98

4.26

3.10

1,167

797

54

20

40

112

58

50

36

19.34

17.76

16.36

10.74

14.66

65.11

41.36

17.92

21.73

Number in thousands

64,874 286,246

Percent distribution

100.00

58.80

16.82

4.55

6.91

1.87

4.15

3.34

3.55

Rate per 1,000 population

5,464

3,213

919

248

378

102

227

182

194

Rate per lOO encounters

56,05

55.44

60.32

45.58

51.71

71.70

77.97

43.96

64.10

100.00

33.36

20.93

10.87

14.21

5.76

5.53

6.91

2.42

1,280

427

268

139

182

74

71

88

31

60.44

52.00

69.16

49.42

76.29

83.77

68.11

62.54

55.63

40
Table5, Number, percent distribution, rata per 1,000 population, andrata per lOO ancountersof encounters with Disposition of referral to

another physician, by phyeician special~ Franca, the Faderal Republic of Germany. and the United Statas, 1981-83

Country

Federal Republic

Physician specialty Franca of Germany United States

Allspacialiats. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians.......,..,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ganaraliata, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians, ., . .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gy necologists ..,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists..,...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists, , .,, ,, .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists. , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhlnolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allstudy physiciana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians. , ..,..,..,,.,,.,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obetatriciana/gy necologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Paychlatrists/neurologists,..,.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologiats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...!..... . . . . . . . . . . . .,

Allstudy physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ganeraliats , ..,..,.,,, .,, .,,,.,,. . . . . . . . . . . . . .,, .,!.... . . . . . . . . . . . . . . . . . . . . .

Interniate . . . . . ..c . . . . . . . . .. c.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Padiatriclans ,, .,,..,,,, ,,, ,,, ,,, ,, , .,,,.,,,., . .,, ,, .,.,, .,, .,.,,.,, . . . . . . . . .

Obatatriclans/gy necologists ..,.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Paychlatrists/neurclogista.,..,.., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists , .,..,,.,,, $.,,....,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologiata, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologiets . . ...0....0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15,205

100.00

82.46

5.83

2.78

1.79

1.97

1.66

1.35

2.16

261

232

16

6

5

6

5

4

6

4.66

5.17

4.94

4.15

1.84

3.22

3.33

1.37

3.64

Number in thousands

9,082

Percent distribution

100.00

70.91

15.40

3,78

4.79

0.95

1.39

1.43

1.35

Rate per 1,000 population

765

542

118

29

37

7

11

11

10

Rata par 100 encounters

7.85

9.36

7.73

5.30

5.02

5.07

3.65

2.62

.3.42

12,137

100.00

42.06

30.46

12.69

7.82

2.22

1.40

2.10

1.04

54

23

17

7

4

1

1

1

1

2.56

2.78

4.27

2,48

1.78

1.37

0.73

0,81

1.01

41
Table 6. Number, percent distribution, rate per 1,000 population, and rate per 100 encounters of encounters with Disposition of admit to hospital,

by physician specialty: France, the Federal Republic of Germany, and the United States, 1981-83

Country

Federal Republic

Physician specialty France of Germany United States

All specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gy necologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allatudy physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gy necologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allatudy physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gy necologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4,651

100.00

67.23

7.46

1.51

4.54

4.24

1.12

2.32

11.59

86

58

6

1

4

4

1

2

10

1.42

1.29

1.93

0.69

1.43

2.12

0.68

0.72

5.97

Number in thousands

1,990

Percent distribution

100.00

66.68

10.85

2.96

8.34

1.61

0.00

3.82

5.73

Rate per 1,000 population

168

112

18

5

14

3

6

10

Rete per 100 encounters

1.72

1.93

1.19

0.91

1.91

1.89

0.00

1.53

3.17

8,005

100.00

31.37

22.05

5.61

19.00

2.99

0,31

7.55

11.13

36

11

8

2

7

1

3

4

1.69

1.37

2.04

0.71

2.85

1.21

0.11

1.91

7.15

42
Table 7. Number, percent distribution, rate per 1,000 population, and rate per 100 encounters with Disposition of return to referring

physician, by physician apecialw France, tha Faderal Republic of Germany, and the United States, 1981-83

Country

Federal Republic

Physician specialty France of Germany United States

All specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gy necologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetricians/gy necologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists,....,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologist., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All study physicians, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Generalists, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internists. .,, , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .

Obstetricians/gy necologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatrists/neurologists....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dermatologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ophthalmologists, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otorhinolaryngologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8,864

I 00.00

10.15

59.53

3.44

2.28

7.93

2.59

7.30

6.77

184

17

98

6

4

13

4

12

11

2.72

0.37

29.41

3.00

1.37

7.55

3.03

4.31

6.65

Number in thousands

2,310

Percent distribution

100.00

26.71

35.45

0.39

4.07

9.52

1.30

17.23

5.32

Rate per 1,000 population

195

52

69

1

8

19

3

34

10

Rate per lOO encounters

2.00

0.90

4.53

0.14

1.08

12.97

0.87

8.03

3.42

3,054

100.00

15.00

35.07

7.43

15.03

17.71

0.65

7.63

1.47

14

2

5

1

2

2

1

0.64

0.25

1.24

0.36

0.86

2.75

0.09

0.74

0.36

43
Table 8. Numbar, percent distribution, and rate per 1,000 population of diagnostic antriea for selected index medical end praventiva cere

categcrias: France, the Federal Republic of Germany, and the United States, 1981-83

Country

Federal Republic

Diagnostic catego~ France of Germany United States

Alldiagnostic entries ...,.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All diagnostic entries.......,,, . .,, ,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical problem

Total ofselectad problems,..,,,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Essential hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Back pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurosis .,,....,.,..,.....,,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ischemic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,, , ...,...,,,

Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...!.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Upper respiratory disease, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes mellitus. ., ..,..,... . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .

Bronchitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Refractive error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otitis media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diseases of the sebaceous glands. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Contact dermatitis...,..,..,,,. . .,, , . . . . . . . . . . . . . . . . . . . . . . . . .,,.....:...,,..

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Preventive care

Total ofselected preventive care visits, . .,, ,,, ,, .,, ,,, .,, .,, . . . . . . . . . . . . . . . . . . .

Normal pregnancy..,,,,,,..,,,.. .,, ,,, ,,, ...,,, . . . . . . . . . . . . .,, . . ...!. . . . . . .

Well-child visit. , .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Genaral medical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Inoculation/vaccination, ,, ...,,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,, . .,, ,, . . . . . . . . .

Contraceptionr family planning, . . . ,,, , . ., . .,, ,, .,, ,, .,, ., ..,,,.,, ,, ., ...,,..,

Administrative visit ., . ., ..,,,.,, ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Another diagnostic entries .,.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical problem

Total of selected problems, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Essential hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Back pain.....,...........,,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neurosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ischemic heart disease. , , , . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. !,,,.

Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Upper respiratory disease, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., .,...!,.. . . . . . . . . . . . . .

Bronchitis, ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Refractive error ., ., . ., .,....,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Depression ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otitis media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Insomnia. ..e . . . . ..c. ” . . .. c...”. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diseases of the sebaceous glands. , . . . . , . . . . . . , . . . . . . . . . . . . ! . . . . . . . . . . . ...,,.,

Contact dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Preventive care

Total ofselected preventive care visits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Normal pregnancyl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Well-child viait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General medical examination, ..,, , . .,, ., . .,, ,, . .,, ,, . . . . . . . . . . . . . . . . . . . . . . . . .

Inoculation/vaccination . ...,...,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Contraception, family planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Administrative visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

598,923

100.00

34,69

5.29

3.33

2.79

2.15

3.40

6.33

1.26

1.65

1.08

2.11

0.99

2.19

0.37

0.65

1.01

6.64

0.87

1,20

0.47

1,15

1.62

1.14

58.67

3,795

579

364

305

235

372

693

136

181

118

230

108

239

41

71

110

727

186

131

51

125

199

124

Numbar in thousands

285,975

Percent distribution

100,00

33.34

6.32

3,99

0,63

3.73

2,22

3.31

3,15

3.71

1.67

0.90

0.20

0.24

0.78

1.34

0.91

1.27

0,53

0.07

0.02

0.13

0.49

0.02

65.39

Rate per 1,000 population

8,029

1,521

960

151

899

536

796

758

894

401

217

47

59

188

322

220

305

247

18

5

32

118

4

676,532

100.00

36.22

6.36

1,38

2,48

2,77

2.76

7.49

2.67

1.97

1.61

0.54

3.00

0.02

1,48

0.96

0.75

9.77

3.94

3.10

1.16

0.08

0.39

1,04

54,07

1,095

192

42

75

84

83

226

81

59

49

16

91

1

45

29

23

293

230

84

35

3

12

32

1Female population only.

44
Appendixes

Contents

I. Surwy instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

France. ., ., .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Federal Republic ofGermany. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

II. Reference populations by country. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Tables

I. Reference populations by age andsex France, theFederal Republic ofGermany, and the United States, December31,

1!2S1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

H. Population data byageand sex France, January l,1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

45
Appendix I

Survey instruments

France

EMTM encounter form and English translation

O PATlENT NOI I I [ QUESTIONNAIRE SEANCE @ DATE

@ SEXE @ AGE @ OCCUPATION I •l actif ~ PROFESSION @ LIEU @ Cepatient

ans sinon 2 ❑ femme au foyer actuelle ou ancienne

❑ masculin

Vous-t-i!

3❑ eleve, etudiant I •l au cabinet dijaconwlte?

si nourrisson 4 ❑ retraite z❑ au domicile

❑ feminin F,❑ ch6meur 3 ❑ autre, preciser ❑ oui

mois 6 ❑ Aut re, preciser ❑ non

Cette affectrm est-elle en tours de

NO d’ordre Iraitement ou aous surveillance m6dcale’

du ou des nonet non

medicament (s) ne I’a mais I’a ne

prescrit (s) oui jamais dbja

~ DIAGNOSTICS ou motifs de la seance

salt

ete ete pas

A

B

c

D

E

F

@ SUITES si rrecessaire cocher p/usieurs cases ~ ACTES DE SOIN, DE DIAGNOSTK ou DE PREVENTION

effectues au tours de cette seance par vous-m6me ou un

I ❑ aucune assistant, en dehors de I’examen clinique habituel.

z ❑ pharmacie

3 El analyses

4 ❑ examens radiologiques

5 ❑ envoi au medecin traitant

6 ❑ envoi au specialist, /eque/

70s0’ins ”infiMiers” ””””””’’””” ““’”””’’”””””

a •l kirresitherapie

9 ❑ hospitalisation

10 ❑ patient a revoir prochainement

II ❑ arr~t de travail ou scolaire

,2 ❑ autre, preciser

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

@ EFFETS THkRAPEUTIQUES RECHERCHI% pour chaque medicament, clans Ibrdre de la prescription

1 4

2 5

3 6

46
VISIT QUESTIONNAIRE

(En~ish translation)

O PATlENT NO1~ Q DATE

Q SEX ~ AGE 0 OCCUPATION ~ PROFESSION @ SITE @ Thepatient

_ years 10 currently emptoyed current or former (wherephysiciansees

❑ male

Hasthispatient

patient) consultedyou

zIZ housewife

for infants

before?

sO student

•! female 40 retired

,0 office ❑ yes

_ months ,0 unemployed

20 home ❑ no

SD other, specify

6❑ other, specify

Is conditioncurrentlybeingtreated

Prescription or undermedicalsurveillance?

number(s) of NO NO

prescribed never but Oon’t

medications YES has was in know

@ DIAGNOSES or reasons for visit been past

A

B

c

D

E

F

@ ACTIONS (check all that apply) @ THERAPEUTIC, DIAGNOSTIC, OR PREVENTIVE SERVICES

I ❑ none

performed this visit by doctor or assistant in addition to usual

examination.

2 ❑ pharmacy

, ❑ lab tests

4 ❑ x-ray

s •l return to treating physician

E ❑ sent to specialist (specify specialty)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7 ❑ nursing care

E ❑ physiotherapy

B ❑ hospitalization

o ❑ patient scheduled forearly return visit

, ❑ nowork orschool

* R other (specify)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

@ Therapeutic effect desired foreach medication inorder ofprescriptions (number istoagree with prescription number

in item 9)

1 4

2 5

3 6

47
EMTM physician induction form and English translation

CREDOC ENQUETE MORBIDITE THERAPEUTIQUE MEDICALE

Division d“Econom\e M@dicrde

ANNEXE 2

QUESTIONNAIREANONYME

MEDECIN

cmher la ou Ies case(s) cotrespondante(s)

1. SEXE : 0 Masculin O F@minin

2. ANNEE DE NAISSANCE : 1 1,9, I ~

3. ANNEE DETHESE:

[1,9, I J

4. ANNEE DE 1“ INSTALLATION: l_!J_ 9 I

I J

5. ETES-VOUS : 0 G@n&-aliste

O Sp&ialiste pn+ciser

Par ailleurs @tes-vous:

O comp@tent fJ,pci.w

O comp&mt exdusif pd.w

6. AVEZ-VOUSUNE ORIENTATION OU UNE

(ex. hom~opathie, acupuncture. g&-iatrie)

DISCIPLINE PARTICULIERE :

0 oui

Si oui, Iaquelle:

7. AVEZ-VOUS DES TITRES

O oui

Si oui, Iesquels:

O non

HOSPITALIERS OU UNIVERSITAIRES :

~ non
8. DANSQUELLEREGION13%S-VOUS INSTALLE :

‘o

‘o

so

‘0

‘o

‘o

‘o

“o

lkde-’Francew,.n. ra91 m. m w w to Lonaine w. 55.57.em

Champagmwkienne Im.Io.s. sa @ Alsace167.66)

Pbde la,.@. ml t,o Fnmche&rrnt@ m. m m.WI

Haute-N6rrnwdie rzr.76) td_J Paysde b Loirew 49.s. z as

CerrtreIm.z3.3637.41.451 ,,(J BretagneIZ2.s.%.s61

Bas2e-NOmranche(14w.61) M(J PcNou-Charerrte2m 17. w. as

Bourgsgrie 121.s. 71.691 Isa Aquitabe t24. m. 40.47. MI

Nerd-Pas-de-CalaisIS 6zI

Midi-- m. n 31.= w a u a

Lk370dn I 19.22. 67)

Rh&3e-fupes 101.07.2A 15. efn. 73.741

Auvergne(co.IS.43.ax

Lmguedoc-RowsiUomII .mxQw

Pwm+d&effAluc4 imMu. Q441

come 12UI

9. TYPE DE LA COMMUNE D’INSTALLATION :

‘o

?0

‘o

‘o

‘o

rurale

bourg ou vine isoke

baniieue

vine, centre d’une agglomeration

autre prdcrser

10. NOMBRE DHABITANTS DE L’AGGLOMERATION DANS IAQUELLE VOUS EXERCEZ :

(OUde la commune si celle-ci est isolde)

‘o ‘ 999

,0 Id; 4999

!(-J 5oooa 9999

.(-J looooa49999

11. L’ESSENTIEL DE VOTRE CLIENTELE

,0 agricole

d’une zone

,0 industrielle

,(J r&identielle

,0 mixte prtkker

,0 50000ii99999

,0 100000a299999

,0 300000et plus, hors agglomdrat.ion Palisienne

sfJ agglomf&ation pansienne

EST-ELLE ISSUE:

12. EXISTE-T-IL DES FACTEURS DE RISQUE PARTICULIERS LIESA L’ENVIRONNEMENT

DANS LA ZONE OU VOUS RECRUTEZ VOTRE CLIENTELE:

0 oui O non

Si oui, Iesquels:

49
13. QUELLE DISTANCE SEPARE VOTRE LIEU D’EXERCICE: (en kilomWes)

- du Centre Hospitalier Universitaire ou R@gionalle plus proche, ,.. :

-du Centre Hospitalier leplusproche ........ . .. . . .. . . ....... :

-de1’h6pital pubfic!eplusproche ............. ........... ... . ................................... :

-del’dtablksement privdd’hospitaiiition Ie plus proche ............... ................. :

14.QUEL EST VOTRE MODE DACTMTE :

,fJ Iibdral int6gral

,(J lib&al ~ temps partiel avec activitd .saIaride hospitaii&e

,0 Iib%ai ~ temps partiel avec activitd saiaride autre qu’hospitaih?re

,fJ autre P*,

15. S1 VOUS EFFECTUEZ UNE ACTIVITE SAlJ4R1EE :

combien d’heures y consacrez-vous par semaine: ~ heures

- clans quel cadre I’exercez-vous:

16. EXERCEZ-VOUS VOTRE ACTMTE LIBERALE :

,(J de faqon individuelle

,0 en cabinet de groupe d’une m~me sp~cialit~

prt%iser Ie nombre de mddecins du grape (y compris vous-m~me): ~

,(J en dinet pluridiscipfinaire

prti?a”%vIe nombre de mt!decins du groupe (y compris vous-mGme): ~

.0 autre W*

17. EMPLOYEZ-VOUS DANS VOTRE CAE31NETUN PERSONNELPARA-MEDKAL:.

(infinni@re, kim%ittx%apeute, ... )

O oui O non

Si oui, quelle est sa qualification:

18. DISPOSEZ-VOUS AU CABINET DE L’UN DES APPAREILS SUIVANTS :

,(J dlectrocardiogmphe ,0 fibroscope ,,(J audiomdre

,0 4chographe ,0 phonomdcanographe ,,0 imp4dancemWe

,(J microscope “a appareil de Helter ,,(_J mat&iel Cl’assistance respkatoke

.0 appareil de radiographic *O 41ectroenc&phalographe ,,0 podoscope

,0 appareil de mdioscopie ,.O dlectror&kmgraphe ,$0 autres pr4dser

19. EIWSAGEZ-WUS DANS L’ANNEE A VENIR L’ACQUISITION DE NOUVEALJXMATERIELS :

0 oui O non

Si oui, Iesquels:

50
20. PENSEZ-VOUS UTILE DE TENIRUN FICI-fIERMEDICALPOUR CHACUN DE VOS PATIENTS:

(J oui, mais je n’ai pas Ie temps de Ie faire

,0 oui, mais je ne peux Ie faire par insuffisance de secretariat ou manque de place

lo oui, mais je ne Ie fais pas, n’ayant pas trouve de fiches de rekk bien adapt&s

lo oui et je m’astreins &le faire

,0 non, cela me parait inutile, je connais suffisamment bien mes patients.

,0 autre CWWr

21. S1 VOUS TENEZUN FICHIER PAR MALADE, QUAND REPORTEZ-VOUS

LES RENSEIGNEMENTS SUR iA FICHE :

,(J pendant la consultation

,0 immediatement apn?s la consultation

,0 en cas de visite pendant ia visite

,0 en cas de visite au retour a votie cabinet

,0 en fin de joumde

.0 en fin de semaine

f_J autre prd.kr

22. VEUILLEZ NOUS FAiRE PART DE VOS OBSERVATIONS SUR LA PRESENTATION,

L’UTILISATION OU LA FORMULATION DU PRESENT QUESTIONNAIRE

ET DES DOSSiERS PATIENTS:

23. AU VU DES QUELQUES RESULTATS PRESENTES DANS LE “DEPLIANT CREDOC” JOiNT,

QUEL.5SONT LES POINTSDE RECHERCHEQUE VOUS SOUHAiTERiEZ VOiR DEVELOPPER

A PARTIR DE CEITE ENQUETE :

51
1.

2.

3.

4.

5.

6.

7.

PHYSICIAN QUESTIONNAIRE

(English translation)

SEX : l_l Male l_l Female

YEAR OF BIRTH: l_LJ_J_l

YEAROF THESIS: l_l_l_l_I

= OF~sT pRA~lcE : l_l_l-l_l

ARE YOU : IJ General Practitioner

l_l Specialist please speci&

l_[ “Competent”*

DO YOU WORK IN A PARTICULAR FIELD : l_l Yes

l~yes,state which:

(% Homeopath~ Acupuncture, Geriatrics)

DO YOU HOLD A PARTICULAR POST IN A HOSPITAL OR UNIVERSITY:

l_l Yes lJ No

if yes, state which:

1 A physician is ‘competent”or erclusive “competent”:

– whether he practices both his own speciality and general medicine or another speciality (recognized or not)

– or he practices a particular medical quall~cation not recognized as a specialiv.

52
S. PLACE OF PRACTICE :

l_l

L—1

l—l

L_l

l–l

l—l

l—l

L.-l

l_l

L—l

l_l

Ile-de-France (75,77,78,91,$ZZ93,M,%)

Champagne-Ardeme (08,10,51,52)

Picardie (U 60,80)

Haute-Normandie (27,76)

Centre (18,28,36,37,41,45)

Basse-Normandie (14,50,61)

Bourgogne (21,58,71,89)

Nord-Pas-de-Calais (59,62)

Lorraine (54,55,57,88)

Alsace (67,68)

Franche-Comt6 (2s,39,70,90)

9. KIND OF AREA :

l_l rural

l_l village or isolated town

l_l suburbs

I_] town or ci~ center

l_l other, please specify

u

kl

u

u

u

u

l_l

L—J

H

10. NUMBERS OF INHABITANTSIN PLACE OF PRACTICE:

1–1 1 to 999

l—l 1,000 to 4,999

II

1:!

I__! 5,000 to 9,999

I_! 10,000 to 49,999 !1/

11. THE MAJORITY OF YOUR PATIENTS COME FROM:

[_l agricultural

l_l industrial

I

Zone

l_l residential

l_l mixed, please specify

Paysde la Loire(44,49,53,72, 85)

Bretagne (2z 29,35,56)

Poitou-Charentes (16,17,79,?@

Aquitaine (M,33,40,47,64)

Midi-Pyrenkes (09,K+31,32,46,65,81,82)

Limousin (19,23,87)

Rh6nes-A1pes (01,07,26,38,42,69,73,74)

Auvergne (03,15,43,63)

Languedoc-Roussillon (11,30,34,48,66)

Provence-Alpes-Ci5te d’Azur (04,05,06,13,83,84)

Corse (20)

50,000 to 99,999

100,000 to 299,999

300,000 and more, except Paris’ district

Paris’ district

12, ARE THERE ANY p~~cu~ E~RoNMENTAL RISK FACTORS WERE YOUR PATIENTS L~~ ,

l_l Yes l_l No

l~yes,please specl>:

53
13. DISTANCE FROM PLACE OF PRACTICE TO THE NEAREST: (in kilometers)

- Central teaching or regional hospital .... ... ........ ..... . .. ... ....... ..................... ... ...... ............

- Hospital center ... ..... ... ...... . .. . . . . . .... . . . ......... ................. ....... ....... . ................. ....... :

- Public hospital ..... ...... .......... .... ... .. . .. .. .. ....... ................... ..... .................... ......................... :

- Private hospital ........ ...... ..... ..... .. ........ . .............. ............ ............................... ....... ................. :

14. MANNER OF PRACTICE:

l_l Private practice only

l_l Private and hospital activity

I_] Private and nonhospital activity

l_\ Other, please speci&

15. IF YOU ARE AN EMPLOYEE :

- how many hours a week: I I ] hours

- type of work :

16. IN YOUR PRNATE PRACTICE ARE YOU:

l_l alone

l_l with partners practicing the same specialty

state number of partners (including yourself): I I j

l_l multidisciplinary practice

state number of partners (including yourself) : l_l_l

l_l other, please specify

17. DOES YOUR PRACTICE EMPLOY AUXILIARY STAFF:

l_l Yes l_l NO

zfyes, please specl@ their quallzcations:

18. DOES YOUR PRACTICE POSSESS ANY OF THE FOLLOWING APPARATUS:

l_l electrocardiograph l_l fibroscope l_l audiometer

l_l ultrasonograph l_l phonomechanograph i_/ impedancemeter

I_! microscope l_l Helter’s recording Id respiratory monitor

]_l radiography apparatus l_l electroencephalograph l_l podoscope

\_l radioscopy apparatus l_l electroretinograph l_l others, please speci&

19. IN THE NEXT YEAR DO YOU INTEND TO ACQUIRE NEW EQUIPMENT:

l_l Yes l_l No

z~yes, which:

54
20, DO YOU THINK IT USEFUL TO KEEP A MEDICAL FILE ON EACH OF YOUR PATIENTS:

l_l yes, but I have no time to do so

l_l ye% but I ean not do it due to lack of space or heavy secretarial schedule

l_l Yes but I do not do it beeausc of the lack of adequately adapted medical files

l_\ yes, by requirement

l_l no, as I know my patients well enough it seems useless

l_l other, please specify

21. IF YOU KEEP A FILE ON EACH PATIENT, WHEN DO YOU FILL IN YOUR FILE:

l_l during the office visit

l_l immediately after office visit

l_l during a home visit

l_l on arrival at your office after medical visit

l_l at the end of the day

l_l at the end of the week

l_l other, please specify

22. PLEASE STATEYOUR COMMENTS ON THE PRESENTATION, THE USE OR THE FORMULATION OF THIS

QUESTIONNAIRE AND OF THE PATIENT’ S FORM :

23. IN RELATION TO THE RESULTS IN THE ATTACHED“DEPLIANT CREDOC” WHATRESEARCH WOULD

YOU LIKE TO SEE DEVELOPED :

55
Federal Republic of Germany

EVaS encounter form and English translation

56
m

u

m Nummer

201205 “:

Bitte filrjeden driiten

Patienten den Erhebungs

bogen ausfillen und

danach ein neues Blatt

beginnen.

Namen der Patienten

(als Ged~chtnisstiltze)

1.—

2.

3.

(ErhebungsbogenauslOUen)

Dieser Teil verbleibt beim

AM. Wir bitten urn

Aufbewahnmg.

Erhebung iJberdie

ambulante Versorgung

durch niedergelassene

Atzte.

Zentralinstitut ftir die

kasserkhztliche

Versorgung in der

Bundesrepublik

Deutschland

HaedenkampstraBe 5

5000 Kt)ln41

Tel. 0221/402001

Nummer

m

Zentralinstitut fijr die kassenarztliche Versorgung in der Bundesrepublik Deutschland

201205 * Erhebung uber die ambulante Versorgung durch niedergelassene kte E V3

I Diese TeiIe konnen von der Arztfrelferin ausgefiillt w

Geschlecht

krankenversichert

IDmtinnlich

,U bei AOK, BKK, IKK, LKK,

29 weiblich

Knappschaft, o. ~.

2D bei Ersatzkasse

— 39 privat

Geburtsjahr

I I I 1

Form der Konsultrdion

!5 - 18 ~ Patient kommt selbat

Bei SalJgfingen ~Patient hat Atzt gesprochen

~:;n ~ ❑ Patientschicktanderen

19 - 20 ~ Arztgespr~ch mit Angehdrigen

Nationalitit

IDdeutsch

2D t(irkisch

3D italienisch

~njugoslawisch

5D spanisch

&lsonstige

Utelefonischer Kontakt

~ Hausbesuch - Besuch im Heim

..

I❑ Arzt wurde gerufen

29 Routinebesuch

~ Patient in der Praxis bekannt

~ Patient war wiedereinbes!ellt

U-EL-J

❑ patient von au13en(iberwiesen

32

to zur Mit-/Weiterbehandlung

2D zur Konsiliar-/

Auftragsbehandlung

3Jlzur Unfallvorstellung

Tag der Konsuitation

,DMo 2CI Di ,g M

d~ Do s~ Fr

Grund der Konaultation

Q Vorsorge ~ Krankheit

$1 Unfall ~ Notfall

~ Patient will Bescheinigung ffir

AWKrankengeld

❑ Patient will ~berweisung

~ Patient will Rezept

~ anderes, was?

I

Behandlung rrnd Leistuhgen I

I anldllich dieser Consultation

Sitte geben Sie das jetzige Anfiegen des Patienten

(Beschwerden, Probleme, such nichtmedizinische Anliegen)

moglichst in seinen Worten wieder.

Wichtigates Anliegen:

I

I

Problemschwere aus der Sicht des

~ Patient kommt deswegen

Patienten I13geringfugig

zum ersten Mal 2H mittel

s~gravierend

sonstige Anliegen:

I

I

I

Hauptdisgnose [nur zum wichtigsten Anliegen

des Patienten)

I Vorsorge

~ ❑ Schwangerschaff

~ sonstige diagnostische Diagnose:

Leistungen, welche? ~ aku~ und zwar seit

,,

1I ~ Krankheitsfrijherkennung bei

I Kindern

/ ~ Jugendarbeitsachutz

I ❑ Krebsfrliherkennung

/ $1 Impfung

I

: PrWentive Leistungen im

, folgenden bitte nicht noch

I einmal angeben.

I

I

I Diagnoatik -

~ ~ Anamnese

\ ❑ kbrperliche Untersuchung

, ~ EKG

I ❑ Blutdruckmessung

/ ~ Rbntgen

; ❑ Entnahme von Untersuchungsmaterial

; ~ Labor

Therapie

~ Rezept

❑ Medikamentenmuster

~Arztl. Gespr~ch, Beratung

❑ Therapeutiaches Zuhdren

~ Psychotherapies

❑ Physikalische Therapie

~ Injektion, excl. Impfung

❑ Chirurgische Leistung

~ Verband

~sonstige therapeufische

Leistungen, wetche?

I#erstmals 2D ver[tingert

,3

~ heute ~~

75 76

Tag en W;ch?n

Wieviele Kontakte

seither deswegen?

m

Problemschwere aus der ~ chronisch, und zwar seit

Sicht des Arztes ID weniger ala einem Jahr

!Ilgeringf(igig 29 mehr als einem Jahr

20 mittel

39 gravierend

Wieviele Kontakte deswegen ungef~hr im Quarfal?

w

~ postoperative Nachbehandlung

andere Diagnosen in der Reihenfolge ihrer Wichtigkeit:

Behandlungsplan

~ weitere Consultation

Q unndtig

~ wiederbestellt

~ telefonischer Kontakt

~ bei Bedarf

~ ~berweisung an a~deren Arzt

ID Mit-/Weiterbehandlung

2H Konsiliar-/

Auftragsbehandlung

39 Unfallvorstellung

~ ROckkehr zum uberweisenden A,rzt

~ Einweisung ins Krankenhaus

~ sonstiges (z. B. Kur, Beratungsstelle), was?

Dauer des personlichen

Arzt-Patienten-Kontaktes m

in Minuten: 97 98
Cn

m

El Number !

207J98 $

Please complete thi

form for every thir

patient and the~-

please use a new

form.

Patients’ names

(as memory aid)

1.

2.

3.

(com~lete form)

This part remains

with the physician.

Please keep

Survey among

ambulatory care

physicians

Central Research

Institute of Health

Insurance Physicians

in the Federal

Republic of Germany

Haedenkampstr. 5

D-5000 Koln 41

Phone: (0221) 402001

Number

El

Central Research Institute of the Health Insurance Physicians in the

207398 ,,* Federal Republic of Germany

SURVEY AHD?KJWBULAT(RY CARE PtlYSICIUtlfilS (English translation)

;[Theseparts may be filled in b.vthe_cJ &oT’s_a&sistantl

SEX HEALTH INSURANCE

,0 male ,U G&&3ry insurance

2P female .D Substitute Fund

,~ Privately insured

DATE OF BIRTH

TYPE OF CONSULTATION

I I I

15 - 18 ❑ Patient comes to office

23~ =o~t~;ient-phy.iAge of

b&biesth~ ❑ P.tientsendsotherperson

1$- 20

!7 WWve

“ ian spoke to a

7-” NATIONALITY ❑ Telephone contact

$1 I&nt.r institutional

,D German

,D Turkish

,D Physician was called

,D Italian

,H Routine visit

29

40 Jugoslav

~n Spanish ~ Pa%w,ttis known in the

tinother ❑ Patient was asked to

31 return

❑ patient was referredin

....

,~or treatment

,Dor second opinion or

consultation

,~or treatment after an

33on-the-job accident

DAY OF CONSULTATION

,D Mon ,U Tue ,9 Wed

,9 Thu ,9 Fri

—

REASON FOR CONSULTATION

❑ prevention ❑ illness

u accident B emergency

tient w”sh& ce tifica-

~ ~~gf$~r ~i.abili!y sick.

m patient wishes referral

9 F%.

tient wishes prescrip-

~ ather, specify

MEOICAL TREATMENT AND SERVICES

(this consultation)

PREVENTIVE Services ❑ other di.gnastic

U prenatal “ services, spscify

U preventive examination of

children

❑ lW?iWa%WcG s

❑ cancer-screening ‘ ‘“plOy-TH~~A~UTIC-SirViX~---

‘19

U inoculation Qpreecription

. ❑ drug-.ample

~medical counseling Please do not enter

preventive services ❑ therapeutic listening

again. ~psychother.py

❑ physiotherapy

DIAGNOSTIC Services !7 W!%on

ction, excl. inOcu-

~ history •loffice su,rgery

~ bandage, dressing

~ physical examination

❑ EKG ❑ other therapeutic

w services, specify

~ blood-pressure check

Q X-ray

❑ removal of tissue for

examination

❑ lab services

W

DISABILITY-certificate

,Df irst ,Dprolonged

?0

P1.aee fill in the putientis reasans (complaints,

problems, alsa non-medical reasons) far this visit,

if possible in patient’s own words.

MOST IMPORTANT REASON:

I .— —-l

~

Seriousness of patienVs problem

Other reasons for contact

PRINCIPAL DIAGNOSIS (corresponding

to the most important reason)

Diagnosis

❑ acute, since when

“Qtda’l[.IL] 1,,.L]

;ayst” week):

How many visit:

for this reasm

, , ~p to now<

Seriousness of patientts I19 .U

prablem evaluated by ~ chronic, since when

physician ,0 less than a year

,D light Q more than . year

,0 medium 8“

,D serious Abcut how many visits

/2 quarterly for this

~lyl -

reason?

84

❑ post-operative

85treatment

Other diagnosss by order of importance:

DISPOSITION THIS VISIT

Qfollow-up

❑ unnecessary

~ return at specified time

❑ telephone follow-up planned

!!0

❑ return if needed

31

~ref erred ta other physician

,H for treatmsnt

,D for second opinion or

consultation

,0 for treatment after ..

‘3 on-the-job accident

~returned to referring physician

~.dmit ta hospital

❑ other (e.

w ci.” comiw~{a~%j )“~;W~-

—

OURATION OF PERSONAL

DOCTOR-PATI~CT r“- ,i; .,MI

in minutes
EVaS physician induction form and English translation

KASSEN~RZTLICHE VEREINIGUNG S~DBADEN 78 FREIBURG L BIL,

K5rperscbaft des offentlichen Recbts kdg..i&t 27

~@n 0761/82075

Izl

Zentralinstitut Hacdmkampstra& ;

fur die kassenarztliche Versorgung 5000Koin41

Telefon (0221)402001

in der Bundesrepublik Deutschland TelexM83242K& d

Rochtsfiihigo SWhmg

EINF~RUNGSFRAGEBOGEN

Erhebung ilber die anbulante Versorgung

durch niedergelas sene Xrzte

Fur die Erhebung Uber die ambulante Versorgung durch niedergelassene Arzte bitten wir Sic, uns die nachfolqenden Fragen

zu beantworten.

Arztstempel:

Datum:--------------------------

(1) Wir haben Sie in Ihrer Eigenschaft als niedergelassenen

Arzt fiirRVO- und Ersatzkassen ausgewtilt.

Sind Sie noch niedergelassener Arzt fur alle Kassen?

ja ()

nein ()

._-=_-=====_-=----- -------======_-=----=--.----===----=---.=------ .=-===.===--===

Wenn Sie mit “nein” geantwortet haben, bitten wir Sic, den

Fragebogen nicht weiter auszufullen. Senden Sie den Bogen

bitte im beiliegenden Fzeiumschlag aa die KV zuriick, da wir

im Rahmen unserez Studie such ciiese Anqa3e~ auswerten wollen.

Vielen Dank fiir Ihre Mitarbeit!

======____ ---- =_____ ----- =----- --—----—-__— - _________________________ __________________________ ___ ===== ==S

59
(2) Sie sind

Ist das richtig?

ja ()

nein ()

Wenn nein, fur welches Fachgebiet sind Sie zugelassen?

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

(bitte Gebietsbezeichnunq eintragen)

(3) Praktizieren Sie allein oder mit anderen Arzten

zusammen?

Welchen Fachgebieten gehoren

Ihre Kollegen an?

Gebietsbezeichnunu Anzahl

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

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

allein ()

in Gemeinschaftspraxis

(gemeinsame Abrechnung) ()

in Praxisgemeinschaft

(getrennte Abrechnung) ()

mit wieviel Arzten auger

Ihnen selbst?

--------

(Anzahl)

60
(4) Wieviele nicht~rztliche Personen einschlief31ichnicht

bezahlter Personen (ohne Reinigungspersonal) sind in

Ihrer Praxis t~tig?

(Bitte Zahl der und deren

Personen Positionen eintragen)

ganztags -------- --------------,-------------_

------ ------ _- , ------ ----_- __

halbtags -------- ----------_---,--------------

------ ------ -- , ------ ------ --

stundenweise -------- --------------,----------_-_-

------- ------- , --------------

(5) Gehoren Sie einer Laborgemeinschaft an?

ja ()

nein ()

(6) Nennen Sie bitte die beiden wichtigsten apparativen

Einrichtungen in Ihrer Praxis:

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

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

(7) Im Rahmen der geplanten Erhebung mochten wir Sie bitten,

an zwei aufeinanderfolgenden Wochentagen iibereine Auswahl von Kontakten in Ihrer Praxis zu berichten.

Wir nennen Ihnen nun die fur Sie ausgewahlten 2 BerichtsS

--------------—----, das sind die

Wochentage Mo------ Di Mi------ Do Fr--:

Sind Sie an mindestens einem dieser Tage ambulant tatig?

ja ()

nein ()

61
(8)

(9)

Wenn Sie Frage (7)’mit “nein” beantworten muBten, dann

sind $tirSie der , das sind Mo Di Mi ---------------- --------

----- Do Fr alternative Erhebungstage.

Sind Sie mindestens an einem dieser Tage ambulant t~tig?

ja ()

nein ()

Wenn nein, dann wahlen Sie bitte eines der

folgenden Tagespaare:

------------ -------- MO Di ~>-~g~g ( )

-------------------- gQQ&QQ-q: ( )

-------------------- @-D~ Mi Do-~z ( )

Bitte geben Sie fur eine typische Woche Ihrer Praxis die

Anzahl aller Patienten und Ihre Arbeitszeit fur Sprechstunde

und Hausbesuche (ohne Zeitaufwand fur Verwaltungsarbeiten)

pro Tag an.

- Gemsinschaftspraxen: Beziehen Sie bitte Ihre Anga.benauf Patientenzahl und Arbeitszeit aller Kollegen zusammen.

- Belegiirzte:Berficksichtigen Sie bitte nur Ihre ambulanten F~lle. --- ----------

Wochentag Anzahl der

Patienten Arbeitszeit

Montag ------------__

Dienstag --------------

Mittwoch --------------

Donnerstag ------------ --

Freitag

Samstag

Sonntag

Wieviele

tung pro

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

------ -----_ --

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

Stunden benotigen

Woche?

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

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

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

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

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

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

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

Sic zusatzlich fur Praxisverwalca. ------ Stunden

.===-- ==..= ====. .==== ==... ===.. =.=== ==..= . . . . . . . . . . ..==. ==..= =.

Wir danken Ihnen fiir Ihre Nitarbeit und versichern Ihnen, dafl

Ihre Auskiinfte nur dieser Studie dienen und von uns streng vertraul ‘ch behandelt werden.

1

Qk. ~ <.< ~

(Dr. 8. J. Ballstaedt) (Dr. med. +-.W. Schwartz)

1. Vorsitzender der KV SLidbaden Geschaft~fuhrer des ZI

.=============..=.=. ..=.==========..=.=== .=..=======.======. ..
Induction Interview

(Englishtranslation)

We ask you to please answer the following questions for the survey

among ambulatory care physicians (EVaS)

Stamp of physician

Date

You were chosen for the survey since you are entitled to physician

services for RVO1) and Ersatzkassen*)-patients.

1. Are you a physician entitled to treat RVO and Ersatzkassen (compulsory health insurance)patients?

Yes

No (Please stop here and return form to the ZI)

2. You are (Physicianspecialty was listed) ?

Is this correct?

Yes

No - which specialty do you practice?

3. Do you practice in a group or solo practice?

solo, gro!lp

How many physicians are you, except for yourself?

Number

Which specialty do your colleagues belong to?

Specialty Number

Specialty Number

4. How many non-physicianpersonnel work in your office (including

non-salariedpersons, but excluding cleaning personnel)?

Number of

persons Position

Full time

Half time

Hourly presence

‘JRVO Reichsversicherungsordnung- Reich insurance regulations - Law

~st~blishing sickness funds/compulsoryhealth insurance

2)EK, Ersatzkasse - Substitute health insurance fund

63
5. Do you participate in a cooperative laboratory organization (Laborgemeinschaft)?

Yes

No

6. Please name the two most important pieces of equipment in your

practice

7. In the framework of the planned investigation we wish to ask you

to report about a sample of contacts to your office during two

consecutive week-days. These are your reporting days.

9

Dates Week-days marked

Will you be delivering ambulatory medical care on at least one

of these days?

Yes

No

8. If you had to answer ’no’to question 7, then your a’

days are

s

Dates Week-days marked

Will you be delivering ambulatory medical care on

of these days?

Yes

ternate reporting

at least one

No (Please choose one the following pairs of reporting days)

9

Dates Week-days marked

3

Dates Week-days marked

9

Dates Week-days marked

64
9* Please list the number of patients and the time spent in patient

contact (without administrative activities) for a typical week.

- Group practices: Please give total number of patients and

total contact time for all ‘partners

Physicians who also care for hospital patients: Please include

only ambulatory care patients

Week day Number of Time in patient

patients care (hours)

Monday

Tuesday ,

Wednesday —

Thursday —

Friday

Saturday

Sunday

How many hours do you need in addition for administrative tasks

in the office?

We thank you for your cooperation and assure that your responses will

solely be used for this study. All data will be kept confidential.

Signature of the president Signature of the Director

of the respective physicians’ of the ZI

organization

65
EVaS evaluation intarviaw form and English translation

PI Zentralinstitut fur die kassenarztiiche Versorgung

in der Bundesrepublik Deutschland — Rechtsfahige Stiftung —

5000 K51n 41, Haedenkampstr. 5, Telefon (02 21) 40 200 I

Arztstempel :

01 1. Erhebungstag

Datum: .. . .. . .. ... . .. .

Wieviele Praxiskontakte fanden insgesamt statt?

. . . . . . . . . . . . . . .

(Anzahl)

o2 Zeitaufwand

Wieviel Zeit brauchten Sie etwa, urn einen Erhebungsbogen auszufullen?

,, .,,... .. 00.,.,

(Minuten)

o3 2. Erhebungstag

Datum: ,,,.,,

Wieviele Prax

.. . .. . .. ... . .

(Anzahl)

.,, . . . . .

skontakte fanden insgesamt statt?

o4 Auswertungsergebni sse

Glauben Sic, da13 Arztbefragungen einen Einb

in die Probleme der Arztpraxis gestatten?

.,, ,,,,. . . .. ... . ,0 ..,.., . .. . ... .. . .. . .. ... . .

ick

.,.

. . . . . . . . ., ..,..0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.. 0,.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..0...

Wunschen Sie die Zusendung eines Ergebnisberichts?

❑ ja

IJ nein

FUR IHRE MITARBEIT BEDANKEN WIR UNS SEHR

66
—

B

Zentralinstitut fur die kassenarztliche Versorgung

in der Bundesrepublik Deutschland — Rechtsfahige Stiftung

5000 Koln 41, Haedenkampatr. 5, Telefon (02 21) 40 2001

(English translation)

Physician’s stamp:

o1 1

St Reporting Day

Date: ................

How many office contact took place in total this

day?

. . . . . . . . . . . . . . . .

(Number)

o2 Time Requirement

Required time to complete one encounter record

form:

. . . . . . . . . . . . . . . .

(Minutes)

o3

04

~nd Reporting Day

Date: .................

How many office contacts took place in total this

day?

..............

.. (Number)

Study in physicians’ offices

Do you believe that studies in physicians’ offices

adequately reflect activities there?

....................................................

....................................................

....................................................

Do you wish to receive a report about the study?

❑ yes

l_Jno

THANK YOU VERY MUCH FOR YOUR COOPERATION

67
United Stetes

NAMCS encounter form

68
,

i

%! 382831 [

PATIENT ~LOG

As each patient arrives, re ord name and

J

time of visit on the lo9 elow. For the

patient entered on line #2, also complete the btient record tb the right.

I

PATlENT’S NAME TIME OF

VISIT

t--

...

Reco,d ,lems 1-15 I

10, rho,Palm. t.

.—

1

I

I

1

i

1

CONTINUE LISTING +TIENTS

ON NEXT PAGE

!

, ❑ am PROBLEM

2 ❑ cHRONIC PROBLEM. ROUTINE

3 ❑cHRONIc PROBLEM, FLAREUP

4 ❑ws”mmwmsr 1NJUR%

5 ❑ NON ILLNESS CARE IROUTINE

PRENATAL. GENERAL ExAM,

WELL BABY, ETC )

10, HAVE YOU SEEN

PATIENT BEFORE?

,UYE, ,DNO

i

IF YES. FOR THE

CON Dill ON IN

ITEM 9.1~

NATIONAL AMBULATORY MEDICAL CARE SURVEY

~. COLOR OR RACE I 5. ETHNICITY

1❑ WHITE

2 ❑ BLACK I ❑ HISPANIC

ORIGIN

3 l--JA&lANAN:Flc 2 ❑ NEIT

HISPANIC

4 ❑AMERICANINCW41I

ALASKAN NATIVE

& DIAGNOSTIC SERVICES THIS VISIT

\Check all ordered or providcdi

I l_JNONE . ❑ ,ICG

2 ❑ LIMITEDHISORY/EXAhI . ❑ VISIONTEST3 ❑ GENERAL HISTORYIEX.WA 10 ❑ EN.13SC13W

. ❑,.,,,s7 ,, ❑ M&;LSTATUS

5 ❑ CL,NICALIAB TEST

.DXF7AY

,. HOTHER,SprCJf.,

7 ❑ Bu30Dm-s”FtE CHECK

11= MEDICATION THERAPY THIS VISIT

,(-JNONE

—

, ~F’HYsIOTHE”A@Y

3DOF,ICE SURGERY

4❑ ,AMIL, PLANNING

& PATIENT’S COMPLAINT(S), SYMPTOM(S), OR OTHER

REASON(S) FOR ~ VISIT [In parienr k o wn words/

a. MOST IMPORTANT

b. OTHER

[ Ming brand or Xeneric names, recwd all new and con tim,ed medico ricms ordwcd, Inlet wd, adminisrert’d, or (,thernvsc

provtded a I tlris visf. Include immuniziw and dtxensitiz ;Irg oxen CSI

a. FOti PRINCIPAL DIAGNOSES IN :TEM9-4 t). FOR ALL OTHER RLASONS

1 1

.— ---------

2 2

3. 3,

4 4

5&C HOTH,RAFW,

THERAPEUTIC LISTENING

9. PHYSICI ANS OIAGNOSES

a. PRINCIPAL DIAGNOSIS/PROBLEM ASSOCIATED WITH ITEM Ed

b OTHER SIGNIFICANT CURRENT DIAGNOSES

L,JNONE

12. NON-MEDICATION THERAPY

[Check 41/ st’,rict’s ,,rdered w provided fl,is visit/

6DCJ,ETCO”NSELING

8❑ M6DICAL COUNSELING

=HS-61 05-B (9/79)

13.:;g:;~

FOR THIS VISIT

BY A~HER

PHYSICIAN?

, ❑ ,,s

,DNO

14 DISPOSITION THIS VISIT

- /Check .11 thdt IIPPf?/

3 flNo F”LmwwP!ANNEo

2 URCTURNATSPEC,FIED TIME

3 ❑ RETLIFIN IF NEEDED, PR N

4 LqTELEPHONE FOLLU\V.UP PI ANNED

5 ❑ REFERRED TDOTHEN PHYSICIAN

6 ❑ RET”RNE(,TO 8EPERR,NG PHYSICIAN

7 ❑ ADF.IT TD HosPITAL

8 ❑ OTHER /,,,(,,),

15. g:%y

VISIT

[Time acmall.r

spen r wi rlt

physician \

Mm.t,,

~ U.S GOVERNMENT PRINTING OFFICE 1960-721-S02 3.1 OMB No. 68-R1498
NAMCS physicianinductionform

COP?FIDENTIAL*

NORC-4284

BEGIN DECK 3

ns Aniwovf?d

I

FOR OFFICE USE

ONLY:

m

5-6/

m

7-10/

r

m- ..==.

OMB No- 6a~1498

NATIONALAMBULATORYMXDICALCARE SURVEY

INDUCTIONINTERVIEN

BEFORE STARTINGINTERVIEW

~m

1. ENTER PNYSICIAN1.D. NUMEER IN BOX TO 1-4/

RIGRT. I

2. ENi’ERDATES OF ASSIGNEDREPORTING WEEK IN~ .~

Q. 2, P. .2.

.W

Doctor, before I begins let me take a minute to give you a littlebackgroundabout

this survey.

Although ambulatorymedical care accountsfor nearly90 percentof all medical care

receivedin the United States,there ia nO sYst~tic info~tion about the characteristicsand problemsof peoplewho consultphysiciansin their offices. This kind

of informationhas been badly needed by medical educatorsand othersconcernedwith

the medicalmanpowersituation.

In responseto increasingdemands.forthis kind”ofinformation,the National Center

for Realth Statisticsj.in close consultati~ with representativesof the msdical

profession,has developedthe National~ulatoW~dical Care Su~eY=

your own task in the su~ey iS sqlej carefuW d-@+ @ 8@uld not t~~

of your time. Essentially,it consistsof your perticipatim during a specified

7-day period. “Duri.izgthis period,YOU simply check off a ~1 ~t’of ~o~-

tion concerningpatients that you see.

Now, before we get into the

your practice. The answers

analysia,and of course all

actualprocedures,I have a few questi~s to ask about

you give mewill be used only for classificationand *

informationyou provideis held in strictconfidence.

1. First,YOU are a

(ENTERSPECIALTYFROM CODE ON FACE SEEET LABEL.)”

Is that right? Yes . . . . . . . . .

No. . . . (ASKA) . .

A, IF NO: What is your specialty.(includinggeneral practice)?

(Nameof Specialty)

. . x

. . Y

Hll

11-13/

*

The National Ambulatory Medical Care Survey is authorized by

Congress in PublicLaw 93-353,section308. It is a voluntary

study and there are no penalties fcr refusiag to answer any

question. All informationcollectedia confidentialand will

be used only to preparestatisticalsummaries. No information

which will identify an individual or a physician’s praccice

will be released.

..

70
2. Now, doctor, thLs study will be concerned with the ambulatory patients you will

see in your office during the week of (READ REPORTING DATES ENTERED BEIW).

(that’s a (that’s a

.— I Monday) through I Sunday)

month date month date

Are you likely to see ~ ambulatory patients in your office during that week?

Yes. . . . . . (@~Q.3). .x

No . . . . . .(ASKA) . . ..y

A. IF NO: Why is that? RECORD VERBAT~ THEN READ PARAGRAPH BXKW

Since it’s very important, doctor, that we include any ambulatory patients

that you ~ happen to see in your office during that week, I’d like to

leave these forms with you anyway--just in case your plans change. 1’11

plan to check back with your office just before (STARTING. DATB) to make

sure, and I can explain them in detail then, if necessary.

GIVE DOCTOR THE ~ PATIENT RECORD FORMS AND GO TO Q. 9, P. 6.

71
3. A. AZ what office locationwill you be seeing ambulatorypatientsduring that

7-dayperiod? RECORDUNDER A BELW AND THEN CODE B.

B. FOR EACH OFFICE LOCATIONENTERED IN A, CODE YES ORNO TO “IN SCOPE.”

]IN SCOPE (Yes) 10UT OF SCOPE (No) I

Privateoffices Hospitalemergencyrooms

Free-standingclinics Hospitaloutpatientdepartments

(non-hospitalbased) College or universityinfirmaries

Groups,partnerships Industrialoutpatientfacilities

Kaiser,HIP, Mayo Clinic Familyplanning CliIIiCS

NeighborhoodHealth Centers Government-operatedclinics

Privatelyoperatedclinics (VD,maternal& childhealth, etc.)

(exceptfamilyplanning)

IN CASE OF DOUBT, ASK: Is that (clinic/facility/institution) hospitalbased?

Is that (clinic/facility/institution) gwernment

operated?

c. Is that all of the office locationsat which you expect to see ambulatory

patient=uring that week?

Yes. . . . . . . . . . . X

No . . . . . . . . . ..Y

IF NO: OBTAIN ADDITIONALOFFICE LOCATION(S),ENI!ERIN “A” BELOW,AND REPEAT.

A. B.

Office Location In Scope?

Yes

I

MO

(1) 1 0

(2) 1 0

(3) 1 0

(4) 1 0

TOTAL INJSCOPELOCATIONS: I I 14/

IF ALL LOCATIONSARE OUT OF SCOPE, THANK TKE”DOCTORAND LEAVE.

72
4. A.

B.

DECK 3

During t!latweek (REPEAT 3ATES), ‘nowmany ambulatory patients do you expect

to see in your office practice? (DO NOT COUNT PATIENTS SEEN AT [OUT-OF-SCOPE

LOCATIONS] CODED IN 3-B.)

ENTER TI)T& UNDER “A” BELOW AND CIRCLE NUMBER CATEGORY ON .APFR~

And during thosesevendays (REPEAT DATES IF NECESSARY), on how many @%_ do

you expec~ to see any ambulatory patients? COUNT EACH DAY IN WHICH DOCTOR

EXPECTS TO SEE .ANYPATIENTS AT AN IN-SCOPE OFFICE LOCATION.

CIRCLE NLX23ERCF DAYS IN APPROPRIATE COLUMN UNDER “B” BELOW.

13ETERMTNEPROPER ’PATIENTLOG FORM FROM CHART BELOW. READ ACROSS

ON “TOTAL PATIENTS” LINE ‘UNDER“A” AND CIRCLE LETTZR IN APPROPRIATE

“D.YZS”CCXI!N UNDER “B.”

T.iiIS‘JT!2ZXTELLS YOU WIIICXOF THE FOUR PATIENT LOG FORMS (A, B, C, D)

SHOULD BE USED BY THIS DOCTOR.

LOG FORM DESCRIPTION

A--Patient Record is to be

completed for ALL

patientsliste~m Log.

B--PatientRecordis to be

completedfor every

SECONDpatientlisted

on Log.

C--PatientRecordis to be

completedfor every

THIRD patientlisted

on Log.

*J).-pa~ient Record is to be

completedfor every

FIFTH patient listed

on Log.

15-17/

A. B.

Expected total Total ~ in practice

patients during during week.

surveyweek.

ENTER TOTAL FROM

Q. 4-A.

m“ :11213 T:151617

1- 12 PATIENTS AAAAAAA

13- 25 “ B AAAAAA

I

26- 39 “ CBAAAAA

40- 52 “ I CBBAAAA

I 53-65 “ ID CB BA AA

I

66- 79 “ tDC BB BAA

80- 92 “ DDCBBBB

93-105 “ I DDCBBBB

106-118 “ DDCCBBB

119-131 “ DDCCBBB

132-145 “ DDDCCBB

146-158 “ DDDCCBB

159-171 “ ID DD. CCCC

172-184 “ ID DDCCCC

185-197 “ DDDDDDD

198-210 “ I DDDDDDD

211+ 11 ID DDDDDD

*

In the rare izstance the physician will see more than 500 ~atients during

.IiJzssigned rsporc<ag week, give him two D Patient L~olios and instruct him

to completea patientrecord form for only every tenth patient. Then you are

to draw ail::LArJug>.zh~ ?atient Record on every other page of the two folio pads,

starting with Page 1 of the pad. The physician then completes the Patient Log

on every ~agey but completes the Patient Record on every second page.

73
DECK 3

5. FIND LOG FOLIOWITH APPROPRIATELETTEB ~ CIRCLE LETTER,ENTER FIRST FOUR NUMBERS

OF THE FORM AND NUMBER OF LINES STAMPED“BEGINON NEXT LINE” FOR THE B-C-D LOG

FORMS (if no linesare stamped,enter “O”) BELOW.

k

FOLIO No. Lines FOR OFFICE USE ONLY

Stamped“BEGIN Number patient record

Letter

19-23/

A 24-26/

B

c

D

6. HAND DOCTOR HIS FOLIO AND EXPLAINHW FORMS AREXO BE FILIJZDOUT. SHOW DOCTOR

INSTRUCTIONSON THE POC~.OF FOLIO,-ITEMS8 and 12 ON CARD IN POCKET

OF FOLIO AND ITEMDEFINITIONSON THE BACK OF FOLIO, TO WHICH NE CAN REFER AFTER

YOU LEAVE.

EMPHASIZETHAT EVERY PATIENTVISIT ExCEPT ADMINISTRATIVEPURPOSEONLY IS TO BE

RECORDEDON THE LOG FOR ENTIRB REPOKI!INGPERIOD. FOR EKAMPIJi,IF A MEDICAL

ASSISTANTGAVE THE PATIENTAN INOCULATION,OR AmCBNICIAN ADMINISTEREDAN

ELECTROCARDIOGRAMAND THE PATmN’J!DID Nm SEE ~ DOCTOR,T~S VISIT MUST STILL BE

LISTED ON THE LOG.

RECORDVERBATIMBELCW7ANY CONCERN,PROBLEMSOR QiJESTIONSTHE DOCTOR RAISES.

7. IF DOCTOR EKPECTSTO SEE AMBULATORYPATIENTSAT MURE TKkN ONE IN-SCOPELOCATION

DURING ASSIGNEDWEEK, TELL HIM YOU WILL DELIVERTHE FORMS TO THE ~HER LOCATION(S).

ENTER THE FORM LBTTERAND NUMBER{S)AND NUMBEROF LINES STAMPED“BEGINON NEKT

LINE” FOR THE B-C-D LOG FOR,THOSELOCATIONS BELOW, BEFORE DELIVERING FORM(S).

FOLIO No. Lines vFOR OFFICEUSE ONLY:

Location Stqed ~lBEGINNumber patientrecord

Letter ,Number ON NEKT LINE” forms completed

-

27-31/

32-34/

35-391

40-42/

43-47/

48-50/

74
51/

DECK 3

8. During the survey weeK (U?EAT UACT DAI’ES),will anyone be available to help

you in filling out these records (at eachIN-SCOPE location)?

Yea . . . . (ASKA) . . . 1

No , , , ● ,.. . . . .2

A. IF YSS: Who would that be?

SECORD NAME, POSITION”ANDLOCATION.

I I POSITION I

LOCATION J

52/

PERSO~Y BRIEF EACH PERSON LISTED ABOVE.

EMPNASIZE TEAT EVERY PATIENI!VISIT DURING TEE ENTIRE WEEK IS TO BE SECORDEDONTNE

LOG EXCEPT “ADMI??ISTRATXVEPUFWSE ONLY.”

9. Do you have a 801o practice, or are you amociated with other phyaiciem in a

partnership, in a group practice, or in some other way?

solo. . . . . (GO TO.Q. 10) . . 1 !

Partnership . . (ASK A-C) . . . 2

Group . . . ..(ASKA-C) . ..3

<--- Other (SPECIFYAND ASKA-C) . . 4

IF PARTNERSNIP,GROUP.OR OTNER:

A. 18 this a prepaid group practice? Yea . . (ASK[l]) . . . 1

[1] IF YES TO A: What per cent

No . . . . . . . . . .2

of patients are

prepaid? per cent

B. Now many other phyaiciana are

amociated with you? NUMSER OF PHYSICIANS:

c. What are the specialties of the other physicians aasoci.atedwlth you?

(How many of these are there?)

Specialty Number of Phyaiciana

(1)

(2)

(3)

(4)

(5)

D. CIRCLE ONE:

All physicians in this partnership/group practice

have the same specialty . . . . . . . . . . . . . . . . . . 1

l-fore than one specialty in this partnership/group practice . . 2

53/

54-56/

57-59/

60/

75
BEGIN DECK 4

10. Now I have just one more question about your practice. @OTE, IF DocToR p~~IcEs

IN ‘LARGEGROUP,THE FOLLOWINGINFORMATIONCAN BE OBTAINEDFROM SOMEONEELSE.)

A. What is the total number of full-time (35 hours or more per week) employees of your (P@mership/

group) practice? Include persons regularly employed who are n~ on vacation, teWorarilY ill,

etc. Do not include other physicians. RECORD ON BOTTOM LINE OF COLlJFf4A BELCW.

(1) HW—myof these full-time employees are a . . . (mOCA~GOR~SBELCJJAS NECESSARy

AND RECORD NV?5ER OF EACH IN COLVMN A.)

B. And what is the total number of part-time (less than 35 hours per week) ●mployees of your

(partnership/group)practice? Again, include persons regularly e~loyed who are n~ on Vacati%

ill, etc. Do not include other physicians. RECORD ON BOTTOM LINS OF COLUMN B BEUYJ.

(1) HOW WY of these part-time emplmyees are a . . . (READ CATEGORIES BELCW AS .NSCESSARY

AND REC6R0 NUKBER”OF EACH IN COLVi4NB.)

Y

A.

E+oyeea Full-time

(35 or more hours/week)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Regiaterad Nurse . . . . . . . . . . . 11-13/

Llcenaed Ractical liurae . . . . . . . 14-161

NuraiogAide. . . . . . . . . . . . . 17-19/

PhyakianAeaiatant* . . . . . . . . . 20-22/

Xechnicien. . . . . . . . . . . . . . 23-251

Secretary or Racepticdat . . . . . . 26-281

Other (S?CCIFY) 29-311

b

rorAL:I I 32-34/

B. I

Part-time

Less than 35 hours/week) I

35-37/

38-40/

41-43/

44-46/

47-49/

50-52/

53-55/

* d

*

physician Aeaiataot mat be a graduate of an accredited trainiog program for Fhyaician

Aesiateate (?hyaician Exteodera, Medex, etc.) or certified by the Natiooxl Board of Msdical

I!xmiaers through the Catificatiop Ex~ for Aeaistant to the Primery Care physician.

BEFORE YOU LEAVE, AGAIN STRESSTHAT EACH AND EYERY AMBUL&CORYPATIENT SEEN BY THE

Doc’roROR HIS sTAFFDUMNG m 7-DAY~loD AT ALL IN-SCOPEOFFICELOCATIONS (mEAT

THEM) IS TO BE INCLUDEDIN THE SURVEY, THAT EAC~ATIENT IS TO BE RECORDED ON THE LOG,

AND ONLY THE APPROPRIATE NUMBER OF PATIENT RECORDS COMPIET.ED.

Thank you for your time, Dr. . If you have any (more)Westionsj

please feel free to call me. MY phone number is written in the folio. I’ll

call

11.

12.

~ on Monday morning of

TIME I~ERVIEW ENDED . .

DATE OF INTERVI?ZW . . .

your survey

. . . . . .

. . . . . .

week just to remind

AM.

PM

you.

. . . . . .

I II H I 1

(Month) (Day) (Year)

76
DECK 4

COMMENTS:

INl!ERVIEWERNUMBER INTERVIEWER’S SIGNA+NJRE

[11111

FOR OFFICE USE ONLY:

No. of Patients Seen: ml 59-61/

L I I J

ToCal Days in Practice during Week: c1

62/

77
Appendix 11

Reference populations by count~

Table 1. Refarence populations by age and sax: France, the Fedaral Republic of Germany, and the United Statea, December 31, 1981

Country

Federal Republic

Age and sax France~ of Germany2 United States3

All persons

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

Under 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 yesrs, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

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

80 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

Total . . . . . . . . . . . . . . ..!0 . . . . ...!. . . ..(. .#. . . . . . . . . . ... .!..., . . . . . . . . . . .

Undar2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 years...,..,.,.........,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years . .,, , . . . . . . . . . . . . . . . . ., ..,...,,,,....,,...,.8,,,.,,.. ,,, ,..

45-64 yeers .,,.,.,,,,.,,..,,,,,, ,, . . :,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-79 yaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

Total . . . . . . . . . . . ...0... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,.

Under 2 yeara. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2-14 yeara .,, .,, , ., . . . ...,,..., . . . ..!! 000. . . . . . . . . . . . , .,, ,,, ..,, ,., ,,,

15-24 years, , . ., .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-44 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

80yeara And over .,...,.., . . . . . . . . . . . . . . . . . . . . . . . . . . . ,, .,,..., ,,, ,,, .,.

54,085,000

1,588,383

10,295,638

8,501,217

14,809,857

11,582,714

5,689,084

1,618,107

27,751,933

775,089

5,029,234

4,329,275

7,212,848

5,924,718

3,334,530

1,146,229

26,333,067

813,284

!5,266,404

4,171,942

7,597,009

5,657,996

2,354,554

471,878

11,874,000

235,000

1,761,500

1,971,700

3,406,200

2,711,900

41,461,900

4325.800

6,183,100

114,600

858,500

958,200

1,659,100

7,447,700

4915,800

4229,200

5,690,900

120,400

903,000

1,013,500

1,747,100

1,264,200

4546,100

496,600

223,688,000

6,932,000

43,920,000

40,505,000

63,623,000

43,958,000

20,248,000

4,502,000

115,781,000

3,389,000

21,475,000

20,528,000

32,653,000

23,115,000

11,747,000

2,874,000

107,906,000

3,544,000

22,444,000

19,977,000

30,969,000

20,843,000

8,601,000

1,528,000

‘Civilian population.

2T,3ts[ population fOr regionsof Bremsn, Hessen, Pfalz, Nwdbadam and s~dbaden.

Scivilian population exclusive of Alaska and Hawaii.

4Eatimate.

Table II. Population data by age and aex Frence, January 1, 1980

[Data wad to calculate standardized rates included in this rapoti]

Sex

Age Total Female Male

Number in thousands

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $. . . . . . . . . . . . . . . . . 53,587 27,340 26,247

Under 15 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12,002 5,862

15-24 years.....,......,....,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6,140

8,499 4,176

25-44 years.,....,......,...,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4,323

14,413 7,006

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

7,407

11,138 5,701 5,438

65 years And over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,535 4,596 2,940

78
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Vital and Health Statistics

series descriptions

SERIES 1.

SERIES 2.

SERIES 3.

SERIES 4.

SERIES 5,

SERIES 6.

SERIES 10.

SERIES 11.

SERIES

SERIES

2

3.

SERIES 14.

Programs and Collection Procedural—Reports describing

the generel programs of the National Center for Health

Statistics and its offices and divisions and the data COI.

Iection methods used. They also include definitions and

other material necessa~ for understanding the data.

Data Evaluation and Mathods Research—Studies of new

statistical methodology including experimental tests of

new survey methods, studies of vital statistics collection

methods, new analytical techniques, objective evaluations

of reliability of collected data, and contributions to

statistical theory. Studies also include comparison of

U.S. methodology with those of other countries.

Analytical and Epidamiological Studies—Reports presenting analytical or interpretive studies based on vital

and health statistics, carrying the analysis further than

the expository types of reports in the other series.

Documants and Committee Reports-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.

Comparative International Vital and Health Statistics

Raporta-Analytical and descriptive reports comparing

U.S. vital and health statistics with those of other countries.

Cognition and Survey Measurement—Reports from the

National Laboratory for Collaborative Research in Cognition and Survey Measurement using methods of cognitive

science to design, evaluate, and test survey instruments.

Data From the National Health Interview Survay-Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other

health-related topics, all based on data collected in the

continuing national household interview survey.

Data From the National Health Examination Suwey and

the National Health and Nutrition Examination Suwey—

Data from direct examination, testing, and measurement

Of national samples of the civilian noninstitutiona lized

population provide the basis for (1) estimates of the

medically defined prevalence of specific diseases in the

United States and the distributions 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 tha Institutionalized Population Suways—Discontinued in 1975. Repons from these sutveys are included in Series 13.

Data on Health Rasourcas Utilization—Statistics on the

utilization of health manpower and facilities providing

long-term care, ambulatory care, hospital care, and family

planning services.

Deta on Health Rasourcas: Menpowar and Facilities—

Statistics on the numbers, geographic distribution, and

characteristics of health resources including physicians,

dentists, nurses, other health occupations, hospitals,

nursing homes, and outpatient facilities,

SERIES

SERIES

5.

6.

SERIES 20.

SERIES 21.

SERIES 22.

SERIES 23.

SERIES 24.

Data From Special Surveys-Statistics on health and

health-related topics collected in special surveys that

are not a part of the continuing data systems of the

National Center for Health Statistics.

Compilations of Advance Data From Vital and Health

Statistics—These reports provide early release of data

from the National Center for Health Statistics’ health and

demographic surveys. Many of these releases are followed

by detailed reports in the Vital and Health Statistics

Series.

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; geographic and time series analyses;

and statistics on characteristics of deaths not available

from the vital records based on sample surveys of those

records.

Data on Natality, Marriage, and Divorce—Various statistics on natality, marriage, and divorce other than as

included in regular annual or monthly reports. Special

analyses by demographic variables; geographic and time

series analyses; studies of fertility; and statistics on

characteristics of births not available from the vital

records based on sample surveys of those records.

Data From the National Mortality and Natality Suweys—

Discontinued in 1975. Reports from these sample surveys

based on vital records are included in Series 20 and 21,

respectively.

Data From the National Suwey of Family Growth—

Statistics on fertility, family formation and dissolution,

family planning, and related maternal and infant health

topics derived from a periodic survey of a nationwide

probability sample of women 15-44 years of age.

Compilations of Data on Natality, Mortality, Marriage,

Divorce, and Induced Terminations of Pregnancy—Advance reports of births, daaths, marriages, and divorces

are based on final data from the National Vital Statistics

System and are published annually as supplements to the

Monthly Vital Statistics Report ( MVSR). These reports are

followed by the publication of detailed data in Vhal Statistics of the United States annual volumes. Other reports

including induced terminations of pregnancy issued periodically as supplements to the MVSR provide selected findings based on data from the National Vital Statistics

System and may be followed by detailed reports in Vital

and Health Statistics Series.

For answers to questions about this report or for a list of titles of

reports published in these series, contact

Scientific and Technical Information Branch

National Center for Health Statistics

Centers for Disease Control

Public Health Service

Hyattsville, Md. 20782

301 -436–8500
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HUMAN SERVICES

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National Center for Health Statistics

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