Hospital Use

by Children

in the

United States

and Canada

The hospital discharge rate of children

under 15 years of age is lower in the

United States than in many other countries.

This comparison of children’s hospital use

in the United States and Canada explores

possible reasons for the relatively low

discharge rate of U.S. children. Discharge

rates are compared by age, sex, diagnosis,

and surgical procedure. Morbidity and

mortality rates are examined for indications

that U.S. children are in better health

than Canadian children and thus are less

likely to need hospitalization. Characteristics

of the health services systems in the two

countries are investigated for evidence

that ambulatory care is substituted for

inpatient care in the treatment of U.S.

children or that U.S. children have greater

problems obtaining access to hospital care

than Canadian children.

Comparative International Vital and

Health Statistics Reports

Series 5, No. 1

DHHS Publication No. (PHS) 84–1477

U.S. Department of Health and

Human Services

Public Health Service

National Center for Health Statistics

Hyattsville, Md.

August 1984
Copyright Information

The National Center for Health Stat! atics has obtained permission from

thecopyright holders to reproduce certain quoted material in this

report. Further reproduction of this material is prohibited without

specific permission of the copyright holders.All other material

contained in the report is in the public domain and maybe used and

reprinted without special permission; citation as to source, however,

is appreciated.

Suggested Citation

National Center for Health Statistics, L. J. Kozakand E. McCarthy:

Hospital uaebychildren inthe United States and Canada. Vita/and

HeaMrStatistics. Series 5, No. l. DHHSPub. No. (PHS) 84-1477.

Public HealthSarvice.Washington, U. S. Government Printing Office,

Aug. 1984,

Library of Congress Cataloging in Publication Data

Kozak, Lola Jean.

Hospital use by children in the United States and

Canada.

(Vital & health statistics. Series 5, Comparative

international vital and health atatiatics reports ;

no. 1) (DHHS publication ; no. (PHS) 84-1 477)

Authora: Lola Jean Kozak and Eilaan McCarthy.

bibliography p.

Supt. of Dots. no.: HE 20.6209:5/1

1. Children— Hoapital cere—United States—fjtatistjcs

2. Children—Hospital care—Canada—Statistics.

3. Hospital utilization—United Statea—Statistics.

4. Hospital utilization—Canada—Statistics. 5, United

States—Statistics, Medical. 6. Canada—Statistics,

Medical. 1. McCarthy, Eileen. Il. National Center

for Health Statistics (U. S.) Ill. Title. IV. Series:

Vital and health statistics. Series 5, Comparative

international vital and health statistics reports ;

no. 1. V. Series: DHHS publication : no. (PHS) 84-1477.

[DNLM: 1. Child, Hospitalized—Canada—statistics.

2. Child, Hospitalized—United States—statistics.

3. Hospitals—utilization—Canada. 4. Hospitala—

utilization—United Statas. 5. Patient Discharge—

Canada—statistics. 6. Patient Discharge—United

States—statistics. W2 A N148ve no.1 ]

RJ242.K69 1984 362.1 ‘1 ‘088054 84-600167

IS8N 0-8406 -0295-2

.
.— -—

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 A nalysis

and Epidemiology

Garrie J. Losee, Associate Director for Data Processing

and Services

Alvan O. Zarate, Ph. D., Associate Director for International

Statistics

E. Earl Bryant. Associate Director for Interview and

Examination Statistics

Robert L. Quave, Acting Associate Director for Management

Gail F. Fisher, Ph. D., Associate Director for Program

Planning, Evaluation, and Coordination

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

and Methodology

Peter L. Hurley, Associate Director for Vital and Health

Care Statistics

Alice Haywood, Information Officer

Vital and Health Care Statistics Program

Peter L. Hurley, Associate Director

Gloria Kapantais, Assistant to the Director for Data Policy,

Planning, and Analysis

Division of Health Care Statistics

W. Edward Bacon, Ph. D., Director

Joan F. Van Nostrand, Deputy Director

Mary A. Moien, Chief Hospital Care Statistics Branch

Manoochehr K. Nozary, Chief Technical Services Branch

OffIce Of International Statistics

n

Alvan O. Zarate, Ph. D., Director

Robert B. Hartford, Ph. D., Director, Comparative

International 1Health Statistics Program
Acknowledgment

The authors wish to thank the Health Division, Statistics

Canada, for contributions to this study. Special thanks are due

to Cyril Nair, Chief, Institutional Care Statistics Section,

Douglas Angus, Chief, and Owen Adams, Analyst, Research

and Analysis Section, for their generous assistance and support.

Thanks are also due to the Comparative International

Health Statistics Program, National Center for Health Statistics, for supporting the study. A substantial portion of the

data analysis was carried out while Lola Jean Kozak was a

statYmember of the Comparative International Health Statistics

Program,
Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Outline ofstudy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Data highlights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Hospitaluse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Health status, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Health services, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Hospital use. ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Age and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Surgical procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Newborn infants, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Hospital fatalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Discussion, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Health status ., . .,, ,,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Cause ofdeath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Supply anddistribution ofresources . , . , . . . . . . . . . . . . . . . . ! !. . . . . . . . . . . . . . . . . . ! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Physician utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Health insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Summary, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

List ofdetailedtables, ...,..,..,,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Appendixes

L Sources ofdata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

II. Definitions ofselectedterms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

List of text figures

1, Rates per 10,000 population for patients, excluding newborn infants, discharged from shofi-stay hospitals, by age:

United States andCanada,1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2. Average lengthof stay in days forpatients, excludingnewbom infants, discharged from short-stay hospitals, byage:

United States and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

3. Rates per 10,000 population for patients under 1 year, excluding newborn infants, discharged from short-stay hospitals,

by diseases ofthe respiratory system: United States andCanada,1978. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

4, Rates per 10,000 population for patients 1–4 years discharged from short-stay hospitals, by diseases of the respiratory

system: United States and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

v
5.

6.

7.

8.

9.

10.

11.

12.

Rates per 10,000 population for patients 5– 14 years discharged from short-stay hospitals, by diseases of the respirato~

system: United States and Canada, 1978, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rates per 10,000 population for patients under 15 years, excluding newborn infants, discharged with tonsillectomy

with orwithout adenoidectomy: United States, 1965–80; Canada, 1966–80. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Deaths per 100,000 population for persons under 15 years ofage, by selected causesof death United States and

Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ratesper lO,OOOpopulation forpatientsunderl 5years,exc1uding newbominfants,discharged fromshort-stayhospitals,

by diagnostic categories: United States and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rates perl0,000 population forpatients under 15 years, excluding newborn infants, discharged from short-stay hospitalsby geographic divisions ranked from lowtohigh onthebasis ofhospital beds: United States, 1978; Canada,

1977 -78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rates per 10,000 population for patients under 15 years, excluding newborn infants, discharged from short-stay hospitals by geographic divisions ranked from low to high on the basis of pediatric hospital beds: United States, 1978;

Canada. 1977.78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rates per 10,000 population for patients under 15 years, excluding newborn infants, discharged from short-stay hospitals by geographic divisions ranked from low to high on the basis of rate of physicians: United States and Canada,

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rates per 10,000 population for patients under 15 years, excluding newborn infants, discharged from short-stay hospitals by geographic divisions ranked from low to high on the basis of rate of pediatricians: Uriited States and Canada$

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

List of text tables

A.

B.

c.

D.

E.

F.

G.

H.

J.

K.

L.

M.

N.

o.

P.

Q.

R.

s.

T.

u.

w.

Y.

z.

vi

Discharge rates and average lengths of stay for patients discharged from short-stay hospitals, by sex and age: United

States and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Discharge rates and average lengths of stay for patients under 15 years of age discharged from short-stay hospitals, by

sexandage: United States and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Discharge rates and average lengths of stay for patients discharged from short-stay hospitals, by age and diagnostic

category :United States and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Discharge rates for patients under 15 years of age discharged from short-stay hospitals, by age and selected diagnostic

conditions: United States and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rates of surgical procedures for patients discharged from short-stay hospitals, by age and surgical category: United

States and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rates ofsurgical procedures forpatients discharged from short-stay hospitals, by ageand selected surgical categories:

United States and Canada, 1978.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent distribution and average lengths ofstayofnewborn infants, by health status: United States, 1978: Canada,

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ! , . . . . . ,

Discharge rates andaverage len~hsof stay forsick newbominfants, by diagnosis: United~States, 1978; Canada,

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent distribution oflivebirths by bitihweight categories: United States and Canada, l978 . . . . . . . . . . . . . . . . . . . .

Hospital fatality rates for patients discharged from short-stay hospitals by age: United States and Canada, 1978 . . . .

Average annual number ofdisability andbed days andpercent ofpersons with limitation ofactivity, byage andsex:

United States, 1978; Canada, 1978–79. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Death rates bysexand age: United States and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Death rates forchildren under 15 yearsby sex andage: United States and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . .

Infant mortality rates byage: United States and Canada, 1978 .,....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Death rates by age and cause of death category: United States and Canada, 1978, . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Infant mortality rates by selected causes of death United States and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Neonatal mortality rates by age andselected causes ofdeath United States and Canada, 1978 . . . . . . . . . . . . . . . . . . .

Death rates forchildren l–14years ofageby age and selected causes ofdeath United States and Canada, 1978 . . .

Rates ofshort-stay hospital beds andphysicians: United States and Canada, 1977–78 . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent of short-stay hospitals with pediatric units by bed size: United States, 1978; Canada, 1977 -78 . . . . . . . . . . . .

Rates of hospital beds, pediatric beds, physicians, pediatricians, and hospital discharges for patients under 15 years of

age, by geographic division: United States, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rates ofhospitalbeds, pediatricbeds, physicians, pediatricians, and hospitaldischarges forpatients under 15 yearsof

age, by geographic division: Canada, 1977–78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ratesofhospital discharges forpatients under 15 years with selecteddiagnoses, by geographicdivision: United States,

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

13

20

21

27

27

28

28

4

6

7

8

11

12

13

14

14

15

17

18

18

19

19

22

23

24

25

25

26

26

28
AA. Rates ofhospital discharges for patients under 15 years with selected diagnoses, by geographic division: Canada,

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

BB. Percent distribution of physician contacts by place of contact, according to age: United States, 1978; Canada,

1978-79 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

CC. Percent ofpopulation withaphysician contact inaye=by age: United States, 197&Cmada, 1978-79 . . . . . . . . . . . 29

DD. Average number ofphysician contacts inayear byage United States, 1978; Canada, 1978-79 . . . . . . . . . . . . . . . . . . 30

EE, Percent distribution ofpopulation byhealth insurance coverage, according toage:United States, 1978 . . . . . . . . . . . . 30

FF. Percentofpopulationwithhealthinsurance by age and family income: United States, 1978 . . . . . . . . . . . . . . . . . . . . . . 31

GG. Rates ofhospital episodes byanual family income, health insurance status, mdage:United States, 1978 . . . . . . . . . 31

vii
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 standards of

reliability or precision

# Figure suppressed to comply with

confidentiality requirements

...

Vlll
Hospital Use

in the United

and Canada

by Children

States

by Lola Jean Kozak and Eileen McCarthy,

Division of Health Care Statistics

Introduction

The United States has a hospital discharge rate higher

than many other Western industrialized countries. In 1980

there were 170 discharges per 1,000 population in the United

States. 1Recent discharge rates reported by other countries include 161 discharges per 1,000 population in Denmark,z’a 149

in Canada,3 129 in New Zealand,4’b 106 in England and

Wales,s.b and 101 in the Netherlands.b’a Australia is one of the

few countries that reports a higher discharge rate than the

United States, 181 per 1,000 population.7 However, the discharge rates of children under 15 years of age are higher in all

of these countries than in the United States. The 1980 discharge rate for U.S. children under 15 years of age was 67 per

1,000 population. In Australia there were 126 discharges of

children under 15 years of age per 1,000 population, in Denmark 92,a in Canada 97, in New Zealand 95, in England and

Wales 77, and in the Netherlands 75a

The high total discharge rate for the United States has

been explored in a number of comparativestudies,8-11 but little

attention has been paid to the low discharge rate of U. S. children. It is not clear whether the low children’s discharge rate

should be considered a positive finding or a subject of concern.

The low rate could be interpreted as an indication that U.S.

children are in better health than children in other countries or

that fewer children are hospitalized unnecessarily in the United

States. However, the low rate could also suggest that some

U.S. children do not receive hospital care when they need it.

This comparison of hospital use by children in the United

States and Canada was undertaken to explore the reasons for

the relatively low discharge rate of U.S. children. Canada was

considered especially appropriate for the comparison because

of the many similarities between the U.S. and Canadian health

services systems. 12Both countries have health care programs

that are the joint concern of the Federal and State or Provincial

governments. While Canada has a national health insurance

program and the United States does not, both countries have

active private sectors within their health care systems. Most

physicians in the two countries are in private practice and are

paid on a fee-for-service basis. Most U.S. and Canadian hospitals are locally controlled nonprofi~ and, unlike most European

hospitals, open staffed: Physicians not employed by the hospitals can admit and follow their private patients.

aPublisheddata were adjustedto exclude newborn infants.

bData exc]ude maternity patients.

Canada was also chosen for the comparison because its hospital data were more comparable with U.S. data than were the

hospitaf data ii-em other countries. While U.S. data were for shortstay hospital discharges, the hospitaf discharge data available

from other countries included patients treated in both long- and

short-stay hospitals. However, for Canada it was possible to

obtain special tabulations of data on short-stay hospital discharges. In addition, the same adaptation of the International

Classification of Diseases (ICD) was used to code discharge

diagnoses and surgical procedures in Canada and the United

States. Other countries used somewhat different versions of the

ICD to code diagnoses and frequently followed a separate coding system for surgical procedures.13JQ

Outline of study

There were three main components to the comparison,

each of which makes up a section of this report. First, children’s

hospital use was examined in detail to determine whether the

U.S.-Canadian difference in children’s discharge rate was pervasive or limited to a few categories of children. Discharge

rates were compared by age, sex, diagnosis, and surgical procedure. Attention was also given to newborn infants, whose

discharges were not included in the discharge rates of children

in either Canada or the United States.

The second component of the study was an exploration of

the health status of U.S. and Canadian children. Mortality and

morbidity rates were compared by age and sex for indications

that U.S. children were in better health than Canadian children

and thus were less likely to need hospitalization. Children’s

mortality rates for selected causes of death were also examined

for evidence that differences in the incidence or severity of

specitlc conditions could account for variations in the discharge rates for the conditions.

The third component of the study was a comparison of aspects of the health services systems in the United States and

Canada to examine two possible explanations of the lower level

of children’s hospital use in the United States. One possible

explanation is that U.S. children rely on ambulatory care for

conditions that are treated on an inpatient basis in Canada.

Because of the costs of hospital care and because hospitalization

can result in emotional problems in children, the treatment of

children on an ambulatory basis whenever possible has frequently been urged in the United States.15-*7 Previous U.S.

1
studies have indicated that increases in the use of ambulatory

care contribute to declines in hospitalization. 18’19A second

possible explanation of U.S. children’s lower discharge rates is

that U.S. children have greater problems obtaining access to

hospital care than Canadian children,20 and, as a result, some

U.S. children do not receive needed inpatient treatment. To

investigate these possible explanations, the supply and distributionof hospital beds andphysicians inthe United States and

Canada were examined. Physician utilization in the two countries was compared, and the health insurance coverage of the

two populations was explored.

Data sources

The data compared in the study were primarily for 1978.

When the study was undertaken, the 1978 hospital discharge

data were the most recent available to the authors for Canada.

More recent discharge data have been published in both countries.1,21

The discharge data for the United States were collected in

the National Hospital Discharge Survey, a continuous voluntary survey conducted by the National Center for Health Statistics since 1965. Information for the survey was obtained

from the medical records of a sample of patients discharged

from a national sample of general and special short-stay hospitals, excluding Federal hospitals. The sample for 1978 included approximately 219,000 medical records from 413 hospitals. A detailed report on the design of the National Hospital

Discharge Survey has been published.zz Appendix I contains a

further description of the survey and each of the other data

sources used in the study. Appendix II presents definitions of

the terms used in this report.

The Canadian discharge data were from the Health Division of Statistics Canada, which has compiled data on discharges from general and allied special hospitals in Canada

since 1960. Except for a small number of patients whose hospitalizations were not paid for by the national insurance program, data were collected on each individual discharge rather

than a sample of discharges. The general and allied special

hospitals include acute care, convalescence, and chronic hospitals, but data used in this study were only for discharges from

the short-stay hospitals, unless otherwise noted. Published reports provide detailed descriptions of the Canadian discharge

data system.13,23

The mortality data for the United States were obtained

from the Division of Vital Statistics, National Center for Health

Statistics, which receives information on all death records from

the States and the District of Columbia. The main source was

Vital Statistics of the United States, 1978,24 but unpublished

tabulations were also consulted.

The U.S. death rates, as well as the discharge rates based

on the National Hospital Discharge Survey, were computed

using estimates of the 1978 population revised in light of the

1980 U.S. census,25 and thus differ from previously published

rates.

Canadian mortality data were obtained from the Health

Division, Statistics Canada, publications Vital Statistics,

197826 and Causes of Death, 1978,21 which were based on

data from all death records collected by the Provinces and Territories. Death rates and discharge rates were computed using

estimates of the 1978 population revised after the 1981 Canadian Census.28

The U.S. National Health Interview Survey was the

source of data on bed and disability days, restricted activity,

physician utilization, and health insurance coverage in the

United States. The survey, conducted by the National Center

for Health Statistics since 1957, covers the civilian noninstitutionalized population of the United States. Data for approximately 110,000 persons in 40,000 households are collected for

the survey each year in interviews conducted throughout the

year. Descriptions of data collection, field procedures, and

questionnaire development in the National Health Interview

Survey have been published,29,30as have detailed discussions

of the sample design and estimation procedures.J 1,32

Data from the Canada Health Survey were compared with

the U.S. data. Statistics Canada and the Department of National Health and Welfare were responsible for the Canada

Health Survey, which was conducted nationally from July

1978 through March 1979. The survey covered approximately 97 percent of the noninstitutionalized population of the

coun~ the 3 percent excluded were persons in the Territories,

on Indian Reservations, and in certain remote areas. Data for a

total of 31,668 persons in 10,571 households were collected

during the survey. A description of the survey has been pubIished.ss

Data on hospital beds in the United States were taken

from the American Hospital Association’s Hospital Statistics.34The Canadian bed data came from the Health Division

of Statistics Canada, both from the Health Division’s publication, Hospital Annual Statistics, 1977– 78,35 and a special

tabulation of data on short-stay hospitals. In both countries,

the data were collected by means of an annual questionnaire

filled out by the individual hospitals. The U.S. data used in the

study were for short-stay non-Fedwal hospitals registered with

the American Hospital Association, but questionnaires were

also completed by the long-stay, Federal, and nonregistered

hospitals. The Canadian questionnaires were sent to all general

and allied special hospitals, but data from the convalescence

and chronic care hospitals were excluded from this study.

The main sources of physician data for the United States

were the American Medical Association’s Physician Distribution and Medical Licensure in the U.S., 197836 and “Medical

Education in the United States, 1977–1978.”37 Canadian

physician data were from the Department of National Health

and Welfare publication Canada Health Manpower In ventoy,

1979.38In both countries, continuously updated computer files

that contain information on physician characteristics were the

basis of the published reports. The information in the computer

files was drawn from a variety of sources, including medical

schools, medical associations, medical specialty organizations,

hospitals, and periodic questionnaires sent to all physicians.

2
Data highlights

Hospital use

●

●

●

●

●

●

●

●

●

For children under 15 years of age, the Canadian discharge rate was 44 percent higher than the U.S. rate.

Canada had a longer average length of stay for every age

group; Canadian children stayed in the hospital approximately 20 percent longer than U.S. children.

The Canadian discharge rate for children under 15 years

of age with respiratory diseases was 71 percent higher

than the U.S. rate.

Canada had a discharge rate more than 2% times the U.S.

rate for children under 15 years of age with upper respiratory infections.

The discharge rate for children under 15 years of age with

hypertrophy of tonsils and adenoids was 67 percent higher

in Canada than in the United States.

The rate of surgical discharges for children under 15 years

of ?ge was 21 percent higher in Canada than in the United

States, but for persons 15 years of age and over, the difference in rates was not statistically significant.

There was no significant difference in U.S. and Canadian

surgical discharge rates for children under 15 years of age

when the category tonsillectomy with or without adenoidectomy was excluded.

The proportion of newborn infants who were not healthy

was 16 percent higher in the United States than in Canada.

Healthy newborn infants stayed in the hospital almost twice

as long in Canada as in the United States.

Health status

●

●

●

●

Children under 15 years of age had 28 percent more disability days and 44 percent more bed days in the United

Statesthan in Canada.

The U.S. death rate was 14 percent higher than the Canadian rate for children under 1 year of age and 8 percent

higher for those 1–4 years of age.

The Canadian death rate was 15 percent higher than the

U.S. rate for children 5–9 years of age and 6 percent higher

for those 10-14 years of age,

Death rates for respiratory diseases did not differ between

●

●

●

●

the United States and Canada for children under 15 years

of age.

For congenital anomalies, Canadian children under 15

years of age had a 26 percent higher death rate than U.S.

children and a 47 percent higher discharge rate.

For certain causes of perinatal mortality and morbidity,

U.S. children under 1 year of age had a higher mortality

rate and a higher discharge rate than Canadian children.

The highest neonatal mortality rates were for anoxic and

hypoxic conditions, for which the U.S. rate was higher,

and congenital anomalies, for which the Canadian rate was

highe~ however, the newborn infant discharge rates did

not differ for either condition.

Accidents accounted for approximately 40 percent of the

deaths of the children in the 1–4 years age group and for

over half of the deaths of those 5– 14 years of age in the

United States and Canada.

Health services

●

●

●

●

●

●

●

Canada had a higher rate of total hospital beds and a rate

of pediatric beds twice that in the United States.

The rate of pediatricians was higher in the United States

than in Canada.

Discharge rates of children under 15 years of age were

related to the rates of total hospital beds in the United

States and to the rates of pediatric beds in Canada.

There were inverse relationships between the rates of physicians and pediatricians and children’s discharge rates in

the United States.

The percent of children under 15 years of age with a physician contact was the same in the United States and Canada, but U.S. children had a higher average number of contacts per person.

While Canadians are virtually all covered by a nationwide

hospital insurance program, no health insurance coverage

was reported for 10 percent of the U.S. population and 12

percent of children under 5 years of age.

Among U.S. children under 15 years of age in families

with an average annual income less than $10,000, those

without insurance coverage had a significantly lower rate

of hospital episodes than those with coverage.

3
Hospital use

A detailed exploration of the patterns of hospital use in the

United States and Canada could suggest possible explanations

for the lower hospital discharge rate of U.S. children. If the

lower U.S. rates were only found for a few categories of children

(that is, for one age group, one sex, or a small number of diagnostic categories), then a specific difference between the United

States and Canada in the incidence of certain diseases or in the

usual medical practices associated with them would be suggested. However, if lower discharge rates were found for U.S.

children across many age, sex, diagnostic, and surgical categories, the explanation would probably be a more general characteristic of the countries, such as the health status of the

children or the accessibility of children’s health services.

Age and sex

The 1978 discharge rates for short-stay hospital patients

in the United States and Canada are shown by age and sex in

table A and by age in figure 1, The total discharge rate was

8 percent higher in the United States, but for children under 15

years of age, the Canadian discharge rate was 44 percent higher.

The Canadian discharge rate was not higher than the U.S. rate

for any other age group, though for two age groups, 25-34

years and 55–64 years, the differences in discharge rates between the two countries were not statistically significant.

Among the age groups for which discharge rates were higher in

the United States, the difference in rates varied from a 9-percent

higher U.S. rate for the 15–24 years age group to a 22-percent

higher U.S. rate for the 35–44 years age group.

The total discharge rates of males and females were higher

in the United States, but the discharge rates of males and females under 15 years of age were higher in Canada. Some

variations in discharge rates also existed for other age groups

by sex. The discharge rates for males 15–24 years of age was

13 percent higher in the United States, and for males 25-34

years of age, the U.S. rate was 29 percent higher. Differences

Table A. Discharge ratas and average lengths of stay for patienta discharged from short-stay hospitals, by sex and age: United States and

Canada, 1978

[Data are for non-Federal hospitals in the United States and for all short-stay hospitals in Canada. Data from both countries exclude newborn infants]

Both sexes Male Female

United United United

Age group States Canada States Canada States Canada

Rate per 10,000 population

Alleges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,615 1,493 1,350 1,248 1,863 1,736

Under 15 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671 965 733 1,073 607 851

15-24 years................,.. . . . . . . . . . . . . . . . . . . . . . . . . 1,358 1,242 782 691 1,922 1,805

25-34 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,678 1,!579 924 717 2,399 2,448

35-44 yaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,521 1,249 1,208 925 1,816 1,581

45-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,735 1,471 1,627 1,391 1,836 1,551

55-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,070 1,923 2,192 2,121 1,962 1,742

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,979 2,719 3,328 3,117 2,712 2,382

75yaars and over...........,.. . . . . . . . . . . . . . . . . . . . . . . . . . 4,461 4,043 5,012 4,765 4,151 3,579

Average length of stay in days

Alleges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4 8.9 7.8 9.4 7.1 8,5

Under 15 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 5.3 4.5 5.3 4.4 5.3

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.7 5.6 6.0 6.5 4.2 5.2

25-34 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 6.0 6.4 7.0 4.7 5.7

35-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.5 7.7 6.8 8.0 6.3 7.4

45–54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.8 9.5 7.8 9.6 7.8 9.5

55-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.1 11.5 8.9 11.3 9.2 11.7

65–74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.4 13.8 10.1 13.4 10.7 14.3

75 years And over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.5 18.4 11.0 17.0 11.9 19.7

NOTE: Data in this table differ slightly from those in the tables that follow. Discharges whose diagnoses were coded in the supplementary classifications, a section of

the Eighth Revision International Classification of Diseasas, Adapted for Use in the United States common Iy referred to as y-codes, are only included in this table.

4
c

0

.-

3

3

n

0

n

0

0

0

0-

k

cl.

In

al

G

a

4,500

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

I

o

I I I I I I I I I

Less 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75

than and

1 over

Age in years

Figure 1. Retes per 10,000 population for patients, excluding newborn infants, discharged from short-stay hospitals, by age: United States

a;d Cenada, 1978

between the two countries in the discharge rates for females in

these two age groups were not statistically significant. Conversely, the U.S.-Canadian differences in discharge rates for

males in the three oldest age groups were not statistically significant. However, the discharge rates for females were higher in

the United States: 13 percent for the 55–64 years age group,

14 percent for the 65-74 years age group, and 16 percent for

the 75 years and over age group. The discharge rates for both

males and females in the age groups 35–44 years and 45–54

years were higher in the United States.

The 1978 average lengths of stay for patients discharged

from short-stay hospitals in the United States and Canada are

shown in table A by age and sex and by age in figure 2. Canada’s total average length of stay was 8.9 days, which was 1.5

days (20 percent) longer than the U.S. total average length of

stay, and Canada had a longer average length of stay for each

individual age group. Unlike the pattern for discharge rates, the

difference in the average lengths of stay of U.S. and Canadian

children under 15 years of age was the same as the difference

for all ages: approximately 20 percent longer in Canada. The

percent differences between the two countries in average

lengths of stay for the age group 15–24 years through 45–54

years were also close to the differences in the total, with Canada’s average length of stay 18–22 percent longer. For the three

oldest age groups, the differences increased up to an average

length of stay 6.9 days (60 percent) longer in Canada for patients 75 years of age and over.

The total average lengths of stay for both males and females were higher in Canada, and for most of the age groups,

the U.S.-Canadian differences between average lengths of

stay were similar for both sexes. One exception was the group

15–24 years of age, for which the average length of stay for

females was 24 percent higher in Canada but the average length

of stay for males was not significantly different between the

two countries. In addition, for the group 25–34 years of age,

the average length of stay in Canada was 21 percent higher for

females but only 9 percent higher for males. A shorter average

length of stay for childbirth in the United States may account

for these contrasts.

Discharge rates and average lengths of stay for three age

groups under 15 years are shown by sex in table B. The statistics

in table B and subsequent tables are slightly different from those

5
/’ /

/

/

19

18

17

16

15

14

13

12

11

10

9

8

7

6

5

4

/-

0

0

0

,0

0

0

0

0

Canada <

0

‘\

United States

3

t

2

1

0

I I I 1 I I I I I J

Less 1–4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75

than and

1 over

Age in years

Figure 2. Average lengths of stay in days for patients, excluding newborn infants, discharged from short-stay hospitals, by age: United States

and Canada, 1978

Table B. Discharge rates and sverage lengths of stay for patients under 15 years of age discharged from short-stay hospitals, by sex snd age:

United States and Canada, 1978

[Data are for non-Faderal hospitala in the United Statas snd for all short-stay hospitals in Canada, Data from both countrias exclude newborn infants]

Both sexes Male Female

United United United

Age group States Canada States Canada States Canada

Rate per 10,000 population

Under 15 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666 953 728 1,061 601 839

Under l year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,051 3,066 2,292 3,464

l-4 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,797

838

2,646

1,342 945 1,545

5-14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

727

480

1,128

627 509 675 449 576

Average length of stay in days

Under 15 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 5.3 4.5 5.3 4.4 5.3

Under l year . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 6.0 7.5 5.7 7.4

l-4 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6.3 7.7

4.0 4.8 4.0

5-14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.7 4.0

4.1

5.0

4.6 4.3 4.7 3.9 4.6

in table A. The reason is that discharges whose diagnoses were With the y-codes diagnoses excluded, the discharge rate

coded in the supplementary classifications, a section of the for children under 15 years of age was 43 percent higher in

Eighth Revision International Classj?cation of Diseases, Canada than in the United States. Higher discharge rates were

Adapted for Use in the United States39 (ICDA-8) commonly found in Canada across all three age groups under 15 years.

referred to as the y-codes, are excluded from all but table A. Canadian children under 1 year of age had a 49-percent higher

6
rate, those I-4 years of age had a 60-percent higher rate, and

those 5-14 years of age had a 3l-percent higher discharge

rate. In each of the three age groups, Canadian males had

higher discharge rates than U.S. males, and Canadian females

had higher discharge rates than U.S. females.

The average lengths of stay were also longer in Canada

than in the United States for each of the three age groups under

15 years of age, Canadian children under 1 year of age stayed

in hospitals 25 percent longer, those 1–4 years of age stayed

20 percent longer, and those 5–14 years of age stayed 12 percent longer. Canadian females in each age group had longer

average lengths of stay than U.S. females. Males under 1 year

of age and 1-4 years of age had longer average lengths of stay

in Canada, but the difference between the two countries in the

average length of stay for males 5– 14 years of age was not

statistically significant.

Diagnosis

Discharge rates

Detailed diagnostic data are presented for the United

States and Canada in tables 1–3. Discharge rates of U.S. and

Canadian patients under 15 years of age are shown for the 17

main diagnostic categories of the ICDA–8 in table C. Canadian

patients under 15 had higher discharge rates for 8 of the 17

diagnostic categories, U.S. patients under 15 years had higher

rates for three categories, and there were no significant differences in the rates for six of the categories. The categories for

which the Canadian discharge rates were higher accounted for

most of the discharges of children under 15 years, 82 percent in

Canada and 74 percent in the United States. The categories in

which U.S. discharge rates were higher accounted for only 3

percent of U.S. children’s discharges and 1 percent of Canadian

children’s discharges.

In both Canada and the United States, the highest discharge rate for children under 15 years of age was for the category diseases of the respiratory system. The Canadian discharge rate for children with respiratory diseases was 71

percent higher than the U.S. rate. The diagnostic category with

the second highest discharge rate for children in both countries

was accidents, poisonings, and violence, for which Canada’s

discharge rate was 21 percent higher than the U.S. rate.

Children’s discharge rates were also higher in Canada for

all but one of the other diagnostic categories that accounted for

sizable numbers of children’s discharges in both countries. For

infective and parasitic diseases, Canada’s rate was 65 percent

higher, The Canadian rate was 14 percent higher for diseases

of the nervous system and sense organs. Canada had a 47 percent higher discharge rate for congenital anomalies, and a rate

more than three times higher than the United States for symp

toms and ill-defined conditions. However, for diseases of the

digestive system, children’s discharge rates in Canada and the

United States were not significantly different.

Among the diagnostic categories that accounted for relatively few discharges of children under 15, the discharge rates

in Canada were Klgher for two: endocrine, nutritional, and metabolic diseases; and diseases of the skin and subcutaneous

tissue. U.S. discharge rates were higher for three: diseases of

the circulatory system; complications of pregnancy, childbirth,

and the puerpenurn, and certain conditions of perinatal morbidity and mortality. For the remaining five categories, neoplasms,

Table C. Discharge rates and average lengths of stay for patients discharged from short-stay hospitals, by age and diagnostic category United

States end Ceneda, 1978

[Far the United Statea, data are for first-listed diagnosis in non-Federal hospitals. For Canada, data are for principal or primary diagnosis in all shorr-stay hospitals. Oata

from both countries exclude newborn infants and are coded using the Eighth Revision International C/assificadon of Disaases, Adapted for Use in the United States

(lCDA-a)]

Under 15 years 15 years and over Under 15 years 15 years and over

United United United United

Diagnostic category and ICDA-8 code States Canada States Canada States Canada States Canada

All conditions . . . . . . . . . . . . . . . ...’. . . . . . . . . . . . . ...000-999

Infective and parasitic disaases . . . . . . . . . . . . . . . . ...000-139

Neoplasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...140-239

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

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

Mental disordera . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...290-319

Diseases of the nervous system and sense orgsns. . ..320-389

Diseases of the circulatory system . . . . . . . . . . . . . . . . . 390–459

Diseases of the respiratory system. . . . . . . . . . . . . . ...460-519

Diseases of the digestive system . . . . . . . . . . . . . . . ...520-579

Diseases of the genitourinary system. . . . . . . . . . . . ...580-629

Complications of pregnancy, childbirth, and the

puerperium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...630-676

Diseases of tha skin and subcutaneous tissue . . . . ...680-709

Diseases of the musculoskeletal system and connective

tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..710–739

Congenital anomalies . . . . . . . . . . . . . . . . . ..’ . . . . . ...740-759

Certain conditions of perinatal morbidity. . . . . . . . . ...760-779

Symptoms and ill-definad conditions. . . . . . . . . . . . ...780-799

Acciden;s, poisonings, and violence . . . . . . . . . . . . ...800-999

Rate per 10,000 population Average length of stay in days

666 953 1,881

57 94 32

13 12 146

12 18 53

13 13 14

9 9 100

59 67 73

8 4 280

210 359 144

68 73 227

34 37 190

4 2 251

13 22 30

14 16 104

30 44 11

9 4

20 65 33”

95 115 193

1,611 4.4

25 3.9

119 6.7

33 7.0

9 5.0

81 13.7

63 3.3

204 10.5

111 3.6

188 4.2

153 3.6

277 2.9

25 4.5

86 6.3

8 5.9

9.6

80 3.5

149 4.8

5.3 7.7 9.7

5.8 6.5 9.0

8.5 10.6 13.8

8.8 9.1 13.0

5.4 8.1 12.2

17.5 11.2 16.2

4.6 6.5 9.6

8.7 10.2 14.5

4.3 7.5 8.5

4.6 7.6 9.0

5.3 5.9 7.0

4.2 3.5 5.0

6.6 8.0 9.3

8.5 8.8 10.5

8.8 6.9 7.8

15.1

4.4 4:3 7:2

5.0 8.2 9.9

7
diseases of the blood and blood-forming organs, mental disorders, diseases of the genitourinary system, and diseases of the

musculoskeletal system and connective tissue, children’s discharge rates in Canada and the United States were not significantly different.

The pattern of discharge rates in diagnostic categories was

considerably different for patients 15 years of age and over

than for those under 15 years of age (table C). The United

States had higher discharge rates for the age group 15 years

and over in 14 of the diagnostic categories. Canada had higher

rates in two categories, and one category, certain causes of

pennatal morbidity and mortality, was not applicable to patients

15 years of age and over. With one exception, discharge rates

for patients 15 years of age and over were higher in the United

States for all of the categories that accounted for sizable numbers of children’s discharges. The exception, symptoms and illdefined conditions, was the only category in which the discharge

rates of both age groups were higher in Canada. Diseases of the

circulatory system was the only disease category in which the

discharge rates of both age groups were higher in the United

States.

Diseases of the circulatory system, along with diseases of

the digestive system, and complications of pregnancy, childbirth, and the puerperium accounted for approximately 40 percent of the discharges of patients 15 years of age and over in

both the United States and Canada. The U.S. discharge rate

was 37 percent higher for diseases of the circulatory system

and 21 percent higher for diseases of the digestive system.

However, Canada had a 10-percent higher discharge rate for

complications of pregnancy, childbirth and the puerperium.

Average length of stay

Canadian patients stayed in the hospital longer than U.S.

patients in the majority of the diagnostic categories, whether

they were under 15 years of age or 15 years of age and over

(table C). Canada had longer average lengths of stay in 13 of

the diagnostic categories for patients under 15 years of age and

in 15 of the categories for patients 15 years of age and over.

The average length of stay for U.S. patients was longer in only

one category, diseases of the circulatory system, and even in

that category, only U.S. children under 15 years of age had

longer average lengths of stay. U.S.-Canadian differences in

the average lengths of stay of children under 15 years of age

were not statistically significant in the categories accidents,

poisonings, and violence; diseases of the digestive system; and

diseases of the blood and blood-forming organs. For patients

15 years of age and over, the difference in the average length of

stay for congenital anomalies was not significant, and the certain

conditions of perinatal morbidity and mortality category did

not apply.

Two of the categories in which the average lengths of stay

for U.S. and Canadian children under 15 years of age did not

differ were major discharge categories for children: accidents,

poisonings, and violence, and diseases of the digestive system.

Among the other important discharge categories, Canada’s

average length of stay for children under 15 years of age was

19 percent higher for diseases of the respiratory system, 49

percent higher for infective and parasitic diseases, 45 percent

higher for diseases of the nervous system and sense organs, and

26percent higher for symptoms and ill-defined conditions. The

Table D. Discharge ratea for patienta under 15 yeara of age discharged from short-stay hospitals, by age and selected diagnostic conditions:

United States and Canada, 1978

[For the United States, data are for first-listed diagnoais in non-Federal hoapitala. For Canada, data are for principal or primary diagnoaia in all short-stay hospitals.

Data from both countries exclude newborn infanta and sre coded using the Eighth Revision /rrtemafiorra/ Classification of Diseasas, Adapted for L/sa in the Urrited

.%eces (ICDA-8)]

Under 15 years Under 1 year 1-4 years 5-14 yaars

United United United United

Diagnostic catego~ and /CDA-8 code States Canada States Canada States Canada States Canada

Rate per 10,000 population

Allconditionsl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...000-999

Infective and parasitic diseases . . . . . . . . . . . . . . . . . . . 000–136

Diarrheal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...009

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

Otitis media without mention of mastoiditis. , . . . . . . . . . . 381

Diseases of the respiratory system. . . . . . . . . . . . . . ...460-519

Upper respirator infections, except influenza. . . ...460-465

Acute bronchitis and bronchiolitis. . . . . . . . . . . . . . . . . ...466

Pneumonia, all forms . . . . . . . . . . . . . . . . . . . . . . . ...480-486

Bronchitis, chronic and unqualified,. . . . . . . . . . . ...490. 491

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...493

Hypertrophy of tonsils and adenoids. . . . . . . . . . . . . . . ...500

Diseases of the digestive system . . . . . . . . . . . . . . . ...520-577

Appendicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..540–543

Inguinal hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...550.552

Gastroenteritis and colitis, except ulcerative, of noninfectious

origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...561

Congenital anomalies . . . . . . . . . . . . . . . . . . . . . . . . ...740-759

Accidents, poisonings, and violence . . . . . . . . . . . . ...800-999

Intracranial injuries, excluding those with skull

fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...850-854

666 953 2,051

57 94 308

26 57 138

59 67 119

30 33 59

210 359 619

30 78 123

20 32 160

47 49 209

13 27 55

12 30 “17

73 122 *

66 73 260

15 19 *

17 16 90

10 4 79

30 44 166

95 115 114

20 24 “19

3,066

599

421

160

99

1,124

382

257

241

145

28

5

213

1

79

34

216

110

25

83B

76

39

97

56

326

62

34

90

25

22

74

70

*

24

14

41

98

21

1,340

146

93

104

57

617

164

51

96

54

58

163

74

3

24

7

51

131

24

480 627

28 30

12 12

40 46

18 19

133 199

10 20

3 5

18 16

5 7

8 20

79 118

50 60

21 27

8 8

3 1

14 26

92 110

19 24

llncludes diagnostic conditions not shown in table.

8
average lengths of stay for patients 15 years and over were 42

percent higher in Canada for diseases of the circulato~ system,

18 percent higher for diseases of the digestive system, and 43

percent higher for pregnancy, childbirth, and the puerperium.

Respiratory diseases

Discharge rates in the United States and Canada for the

age groups under 15 years ofageare presented in tableD by

selected diagnostic categories. It can be seen that diseases of

the respiratory system, the category with the highest discharge

rate for children under 15 years of age as a whole, was also the

category with the highest discharge rates for children in each of

the three age groups, under 1 year, 1–4 years, and 5– 14 years,

in both countries. Three conditions accounted for the majority

of respiratory disease discharges: upper respirato~ infections,

exept influenz+ pneumonia, all forms; hypertrophy of tonsils

and adenoids made up 71 percent of the respiratory disease

discharges for the under 15 years age group in the United States,

and 69 percent in Canada. The importance of the three conditions varied by age.

For the under 1 year age group (figure 3), upper respiratory

infections and pneumonia together were responsible for slightly

over half of all discharges for diseases of the respiratory system

in Canada and the United States. Hypertrophy of tonsils and

adenoids was not a major discharge category, but acute bronchitis and bronchiolitis was important, accounting for approximately one-fourth of the respiratory disease discharges for the

under 1 year age group in both countries.

For children 1–4 years of age (figure 4), upper respiratory

infections, pneumonia, and hypertrophy of tonsils and adenoids

together accounted for 69 percent of the respiratory disease discharges in both the United States and Canada. However, for

children 5– 14 years of age (figure 5), hypertrophy of tonsils

and adenoids alone accounted for 59 percent of respiratory

disease discharges in both countries. Upper respiratory infections and pneumonia were responsible for 22 percent of the

respiratory disease dkcharges for the 5– 14 years age group in

the United States and 18 percent in Canada.

The differences in the U.S. and Canadian discharge rates

for the three respiratory conditions also varied by age. For the

under 15 years age group as a whole, the Canadian discharge

rate in the upper respiratory infections category was more than

2X times the U.S. rate, the differences ranging from 3 times

higher Canadian rates for the under 1 year age group to 2 times

higher Canadian rates for the 5–14 years age group. The discharge rate for hypertrophy of tonsils and adenoids was 67 percent higher in Canada for all children under 15 years, over

8

0-

0

400

350

300

250

200

150

100

50

0

Upper respiratory Pneumonia, Acute bronchitis

infections, except all forms and bronchiolitis

influenza

•l~~. United Ststes

IN

Canada

All other

respiratory

diseases

Figure 3, Retes per 10,000 population for patients under 1 year, excluding newborn infants, discharged from short-stay hospitals, by diseases

of the respiratory system: United States and Canada, 1978

9
200

s.- 150

~

3

Q

o

n

o

0 100

0

0-

:

n

Ill 50

E

a

0

❑~~~~ United States

IN

Canada

Upper respiratory Pneumonia, Hypertrophy of All other

infections, except all forms tonsils and respiratory

influenza adenoids diseases

Figure 4. Rates per 10,000 population for patienta 1-4 vears discharged from short-stay hospitals, by diseases of the respiratory system:

United States and Canada, 1978

150 r

❑::::::: ✎

United Ststes . . . .

EN

Canada

100

50

0

Upper respirator-y Pneumonia, Hypertrophy of All other

infections, except all forms tonsils and respiratory

influenza adenoids diseases

Figure 5. Rates per 10,000 population for patients 5–14 vears discharged from short-stay hospitals, bv diseases of the rest.iratow svstem: .,

United States and Canada, 1978

twice as high for children 1–4 years, and 50 percent higher for

those 5– 14 years of age. However, the U.S. and Canadian

discharge rates for pneumonia were not significantly different

for all children under 15 years of age or for any of the three age

groups.

Other diagnosis

Among diseases of the digestive system, appendicitis accounted for few discharges of children under 1 or 1–4

years ofage, but over40 percent ofthe digestivedisease discharges

ofthose 5– 14years of age in both Canada and the United States.

The Canadian discharge rate for children 5– 14 years of age with

appendicitis was 29 percent higher than the U.S. rate. In both

countries, inguinal hernia was responsible for about one-third of

the digestivedisease discharges of childrenunder 1year of age and

1–4 years of age, but for those 5– 14 years of age it accounted

for only 16 percent of digestive disease discharges in the United

States and 13percentinCanada. The U.S. andCanadian discharge

rates for inguinal hernia did not differ significantly for any of the

three age groups. Gastroenteritis and colitis, except ulcerative,

of noninfectious origin declined in importance with age from the

group under 1 year of age, for which it accounted for 30 percent

of digestive disease discharges in the United States and 16

percent in Canada, to the group 5– 14 years of age for which it

made up only 6 percent of digestive disease discharges in the

United States and 2 percent in Canada. Gastroenteritis was the

one condition for which the U.S. discharge rates were significantly

higher than the Canadian rates in each of the three age groups.

10
In the infective and parasitic diseases category, the discharge

rates for Canadian children under 1 year and 1–4 years of age

were almost twice the U.S. rates, but there was no significant

difference between the countries in the discharge rates for those

5-14 years of age. A similar pattern existed for the subcategory

diarrheal diseases. The Canadian discharge rate for the under 1

year age group was 3 times higher, and for the 1–4 years age

group the Canadian rate was almost 2!4 times higher, but there

was no difference in the U.S. and Canadian rates for children 5–

14 years of age.

For the diseases of the nervous system and sense organs

category and its major subcategory, otitis media, without mention

ofmastoiditis, the only significant differences between U.S. and

Canadian discharge rates were higher Canadian rates for children

under 1 year of age, In contrast, discharge rates for the accidents,

poisonings, and violence category were not significantly different

between the two countries for children under 1 year of age, but

Canadian rates were higher for those 1–4 years and 5–14 years

of age, Discharge rates for intracranial injuries, excluding those

with skull fracture, were significantly different only for the 5– 14

years age group, whose rate was higher in Canada. Discharge

rates for congenital anomalies, though, were consistently higher

in Canada, 30 percent higher for children under 1 year, 24 percent higher for children 1–4 years, and 86 percent higher for

children 5-14 years of age.

Surgical procedures

The U.S. and Canadian rates of discharged patients with a

surgical procedure are shown for the groups under 15 years and

15 years and over by the 17 ICDA-8 procedure categories. The

surgical rates for the United States in tables E and Fare somewhat

lower than the 1978 surgical rates provided in earlier reports

tlom the U.S. National Hospital Discharge Survey. The previous

reports usually refer to all-listed procedures, which may include

up to three procedures per discharge. Because only prima~

surgical procedure data are available for Canada, the U.S. rates

in this report are only for the procedures listed first on the face

sheet of the discharged patients’ medical records.

The total rate of surgical discharges for children under 15

years of age was21 percent higher in Canada than in the United

States, but for persons 15 years of age and over, the difference in

total surgical discharge rates between the two countries was not

statistically significant. Contrary to the numerous U.S.-Canadian

differences in discharge rates for disease categories, surgical

rates did not differ significantly in the majority of procedure

categories for either the groups under 15 years of age or 15 years

of age and over.

Children under 15 years of age had low surgical rates in most

of the procedure categories. The otorhinolaryngology category

had the highest rate in both countries, accounting for 38 percent

of the surgical discharges of the under 15 years age group in the

United States and 44 percent in Canada. The rate of otorhinolaryngology procedures was 39 percent higher in Canada.

Other categories that had relatively large rates of surgical discharges for children under 15 years of age in both countries

included orthopedic surgery, for which the Canadian rate was 23

percent higher, and abdominal and urological surgery, for which

the rates in Canada and the United States did not differ significantly.

Canada’s surgical rate remained higher than the U.S. rate in

the otorhinolaryngology category for persons 15 years of age and

over, although the category was much less important, accounting

for only 5 percent of surgical discharges for the older age group in

Table E. Rataa of surgical procedures for patienta discharged from short-stay hospitals, by aga and surgical category: Unitad States and

Canada, 1978

lFor the United States, dsts sre for first-listed surgicsl procedures in non-Federsl hospitsls. For Canada, data sre for prima~ surgical procedures in all short-stay hospitals.

Datti from both countries exclude newborn infants and are coded using the Eighth Revision International Classification of Diseases, Adapted for Use in the United

States (lCDA-t?)]

Under 15 years 15 years and over

Surgical category and ICDA-8 code United United

States Canada States Canada

Total surgical procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. OI-99. AI-A2

Neurosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..oI-05

Ophthalmology, , .,,.,.,.,,.,,.,,,,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...06-14

Otorhinolaryngology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...16-21

Operations on thyroid, parathyroid, thymus, snd adrenals . . . . . . . . . . . . . . . . . . . . . ...22-23

Vascular and cardiac surgery. .,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...24-30

Thoracic surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...32-35

Abdominal aurgery, , .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...38-48

Proctological surgary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..50–52

Urological aurgety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...54-61

Braast surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...65

Gynecological surgery.....,,..,,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . ...67-72

Obstetrical procedures . ..!! 0..0 . . . . . . . . . . . . . . . . . . ,! ..,,,.. . . . . . . . . . . . . . . . . . 74-78

Orthopedic surge~, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...80-90

Plastic aurgary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...92-94

Oral andmaxillofacial surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..g5-g8

Dantal surgery, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..gg

Biopsy . . . . . . . . . .0 .00..0. . . . . . . . . . . . . . . . . . . . . . . . . . . . ,,, .,,.,, . . . . . . . . . . . . Al -A2

280

4

14

107

*1

9

2

42

*2

25

*

3

“2

39

18

3

4

5

Rate per 10,000 population

338 785

5 16

17 34

149 39

1 5

7 49

1 12

44 106

2 21

27 57

(’) 16

133

~; 81

48 115

20 37

3 7

8 15

3 43

718

13

28

46

3

37

7

108

24

48

13

131

79

107

29

7

13

22

1Quantity mora than zero but less than 0.5.

11
Table F. Rates of surgical procedures for patients discharged from short-stay hospitals, by age and selected surgical categories: United States

and Canada, 1978

[For the United States, data are for first-listed surgical procedures in non-Federal hospitals. For Canada, data are for primav surgical procedures m all short-stay hospl!als,

Data from both countries exclude newborn infants and are coded using the Eighth Revisiorr hrtematiorral Cksificafim of Diseases, Adapted for Use m the L4vred

Stares (ICDA-8)]

Under 15 years Under7 year 1–4 years 5-14 years

United United United United

Surgical category and ICDA–8 code States Canada States Canada States Canada States Canada

Rate per 10,000 population

Total surgicaI proceduresl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 338 429 365 294 384 262 319

Otorhinolaryngology . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...16-21 107 149 *3O 20 127

Myringotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..17.o

193 107 145

15 12 *

11 27 18

Tonsillectomy with orwithout adenoidectomy . ...21.1,21.2 67

11 10

109 * 2 63 143

Abdominal surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...38-48 42

73 107

44 138 131 34 35

Rapairof inguinal hernia, . . . . . . . . . . . . . . . . . . ...38.2.38.3

36

17

40

16 86 74 23 23

Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...41.1

8 8

15 20 *

1

*

Urological surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...54-61

3 21 27

Circumcision . . . . . . . . . . . . . . . . . .

25 27 48 46 33 39 19

61.2

20

. . . . . . . . . . . . . . . . . . . 6 8 *23 29 8 15

Orthopedic surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...80-90 3g

3 4

48 39 43 19 30 46 55

llnclurJes surgical procedures not shown in table.

the United States and 6 percent in Canada. Three surgical

procedure categories, abdominal, gynecological, and orthopedic

surgery were responsible for 45 percent of the surgical discharges

for patients 15 years and over in the United States and48 percent

in Canada. In none of these categories were the differences in

surgical discharge rates between the United States and Canada

statistically significant.

U.S. and Canadian rates for discharges with selected surgical

procedures for children under 15 years of age are shown in table

F. The rate for total surgical discharges in the 1–4 years age

group was 31 percent higher in Canada than in the United States,

and the total Canadian rate for children 5– 14 years of age was 22

percent higher. The total surgical discharge rates for the under 1

year age group were not significantly different. In fact, for none of

the procedure categories listed in table F were the surgical

discharge rates of children under 1 year significantly different

between the two countries,

Tonsillectomy

The surgical procedure category of central importance for

children under 15 years of age was tonsillectomy with or without

adenoidectomy. Although not often performed on children under

1 year, the procedure accounted for over one-third of all surgical

discharges for children 1–4 years and 5– 14 years of age in

Canada, and in the United States,21 percent for those 1–4 years

of age and 28 percent for those 5– 14 years of age. The rate of

discharges for the procedure was more than twice as high in

Canada as in the United States for children 1–4 years of age and

47 percent higher for children 5-14 years of age.

In a fiirther age breakdown not shown in table F, it was

found that the rate of discharges for the procedure for children 5–

9 years of age was 172 in Canada compared with 104 in the

United States, a 65-percent dtierence. For children 10–14 years

of age, though, the Canadian rate, at 50, was not significantly

different from the U.S. rate of 46. It was also discovered that if

tonsillectomy with or without adenoidectomy was excluded, no

significant differences remained in U.S. and Canadian rates for

all other surgical discharges combined for any of the children’s

age groups.

Because of the central importance of tonsillectomy, trends

in the use of the procedure were investigated. The incidence of

tonsillectomy is known to have peaked in the 1930’s.40 However,

the first national data on surgery from hospital discharge records

did not become available until 1965 in United States and 1966 in

Canada.

A graph of tonsillectomy rates for children under 15 years of

age from 1965 to 1980 in the United States and from 1966

to 1980 in Canada is presented in figure 6. The graph shows

a steady decrease in rates for both countries. In fact, the

rates in the United States and Canada decreased at the same

rate, 66 percent from 1966 to 1980. The Canadian rate was 59

percent higher than the U.S. rate both in 1966 and in 1980. In

spite of the sizable decrease in rates, tonsillectomy remains the

most frequently performed surgical procedure on children under

15 years in both countries.

Other procedures

As is shown in table F, there were differences in other

specific surgical procedure categories. The only surgical procedure category for which the U.S. rate was significantly higher

than the Canadian rate was myringotomy, and the U.S. rate

was only higher for children 1–4 years of age. Canadian children in the age group 1–4 years had significantly higher rates

for circumcision and orthopedic surgery. Besides otorhinolaryngology, the only procedure for which discharge rates of

children 5– 14 years of age differed significantly was appendectomy, Canadian children having a 29-percent higher rate.

Newborn infants

Health status

For this report, a newborn infant was a baby born in the

hospital during 1978, The babies who remained continuously

12
300

250

c

.-o

3

200

3

n

0

n

0

g 150

o’

:

n

al 100 G

cc

50

0

--+>

N

/ Data ndawilatde

I I I I I I I I 1 I I I I I I

[

1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980

Year

Figure 6. Rates per 10,000 population for patients under 15 years, excluding newborn infants, discharged with tonsillectomy with or without

adenoidectomy: United States, 1965-80; Canada, 1966–80

in the hospital where they were born were considered newborn

infants, regardless of how long they were hospitalized. However, an infant admitted or transferred to another hospital at

any time after birth was considered a patient under 1 year of

age in the hospital to which admitted or transferred. There was

onc exception to this definition in Canada. A baby admitted to

a Canadian hospital after birth with its mother for maternal

care was counted as a newborn infant.

Generally, data on newborn infants are not included in

hospital utilization rates, but the data can be examined separately. The percent distribution and average length of stay of

newborn infants in the United States and Canada are shown in

table G by health status. In this table newborn infants are

classified as healthy, immature, or sick. A healthy newborn

infant is one whose only diagnosis was that of single or multiple

birth, without mention of immaturity. If immaturity was mentioned, but no specific disease was reported, the infant is considered immature, Sick newborn infants have a diagnosis of a

specific disease, other than or in addition to immaturity and

single or multiple birth. Thus, some immature newborn infants

were included in the sick category rather than the immature

category.

The proportion of newborn infants who were not healthy

was 16 percent higher in the United States than in Canada.

The United States had a much higher proportion of immature

infants. However, there was no significant difference between

the two countries for the sick newborn infant category.

While the average length of stay for all newborn infants

was longer in Canada, the difference was accounted for by the

healthy newborn infants, whose hospital stay was almost twice

as long in Canada. For the immature newborn infant category,

Table G. Percent distribution end average length of stay of

newborn infants, by health status: United States, 1978; Caneda,

1977

[For tha United States, data are for short-stay, non-Fsderal hospitals. For

Canada, data are for general and alliad special hospitals]

United United

Health status States Canada States Canada

Percent

distribution of Average length

newborn infants of stay in days

All newborn infants . . . . . . . 100.0 100.0 4.3 5.8

Healthy infants . . . . . . . . . . . 75.0 78.5 2.6 5.1

Immature infantsl . . . . . . . . . 5.4 2.9 15.3 11.5

Sick infants . . . . . . . . . . . . . . 19.6 18.6 7.7 7.6

lThose with an additional diagnosis ara included in the sick newborn catagorv.

the average length of stay was longer in the United States, and

for the category of sick newborn infants, the difference in U.S.

and Canadian average lengths of stay was not statistically

significant.

Sick newborn diagnoses

Discharge rates and average lengths of stay for newborn

infants are presented by diagnostic categories in table H. Because only the infants in the sick category had a diagnosis of a

specific disease, only they are included in the table. Two of the

categories, maternal conditions and conditions of the placenta

and umbilical cord, were not used in the U.S. National Hospital

Discharge Survey for coding the diagnoses of newborn infants.

These categories accounted for 8 percent of the sick newborn

infant discharges in Canada.

13
Table H. Discharge rates and avarage lengths of stay for sick newborn infanta, by diagnoais: United States, 1978; Canada, 1977

[For the Umted Statea, data are for second-listed diagnosis in short-stay non-Federal hospitals. For Canada, data are for principal or primary diagnosis

in general and alliad special hospitals. Data from both countries are codad using the Eighth Revision International Classification of Diseeses, Adapted for Use m

the United States (ICDA-8)]

United United

Diagnostic category and ICDA-8 code States Canada States Canada

.

Rate per 10,000 Averaga length

newborn infants of stay in days

Total sick newborns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,957 1,860 7.7 7.6

Congenital anomalies. .,....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...740-759 254

Maternal conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4. 760-769 . . .

227 6.6 8.3

72 --- 7.1

Conditions ofplacenta and umbilical cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...770-771 --- 83 ---

Birth inju~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . . . . . . . . . . .. $...... .772

5.5

89 79 4.0

Hemolytic disease of newborn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774-775

6.2

153

Anoxicand hypoxlc conditions not elsewhere classified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 776

97 5.3 7.4

328

Other conditions of newborn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777-778

293 15.5 9.3

800

Conditions other thsn congenital anomalies and certain causes of perinatal morbidity . ..000-738. 780-999

769 5.4 6.8

333 239 8.5 8.9

I First-listed diagnoses tndlcate maturity or immaturity and single or multiple birth.

The largest diagnostic category was other conditions of

newborn, which accounted for 41 percent of sick newborn discharges in both the United States and Canada. Three other

categories also had large rates. Anoxic and hypoxic conditions

made up 17 percent of the discharges for the United States and

16 percent for Canada, the residual category composed

17 percent for the United States and 13 percent for Canada,

and the congenital anomalies percent was 13 for the United

States and 12 for Canada. Together these three categories accounted for 47 percent of U.S. and 41 percent of Canadian

discharges.

The United States had higher rates for two categories. For

hemolytic disease of the newborn, the U.S. rate was58 percent

highe~ and for the residual category, the U.S. rate was

39 percent higher. No significant differences were found between the two countries in ‘the rates for the other sick newborn

categories.

While the total average lengths of stay for sick newborn

infants were not significantly different in the United States and

Canada, dtierences did exist between the countries in theaverage

lengths of stay for specific newborn infant diagnostic categories.

Canadian newborn infants stayed in the hospital 55 percent

longer for birth injuries, 40 percent longer for hemolytic disease,

and 26 percent longer for congenital anomalies and other

conditions of the fetus or newborns. However, newborn infants

in the United States had hospital stays 67 percent longer for

anoxic and hypoxic conditions. The difference between the

United States and Canada in length of stay for the residual

category was not statistically significant.

Reporting practices

The contrast between the higher rate of discharges for sick

newborn infants in the United States and the higher discharge

rate for other chddren under 1 year of age in Canada raises

questions about whether, although the definitions of the two

groups are similar in the United States and Canada, reporting

practices vary between the countries. It is possible that the data

from the National Hospital Discharge Survey are overestimates of the number of sick newborn infants in the United

States. The 1978 estimate of the total number of newborn infants

14

from the survey was 3.68 million while the 1978 estimate of

the total number of live births in the United States was only

3.33 million.41 Although the difference in the estimates is not

statistically significant, it has been a cause for investigation.

Problems were also encountered in the U.S. survey with classification of babies transfen-ed from one hospital to another on

the day of birth. Although after a transfer a baby should have

been classified as a patient under 1 year of age, because of

insufficient documentation on the face sheet of the medical

record, some may have been counted as newborn infants.

However, even if variation in reporting practices results in

an exaggeration of the difference in the rates of sick newborns

between the United States and Canada, examination of other

data suggests that there is likely to be a higher proportion of

sick newborn infants in the United States. Infant mortality data

are discussed in the next section of the report. The percent of

live births by birthweight categories is shown in table J for the

two countries. Low birthweight is associated with health problems

and probably with longer hospitalizations. The United States

has a 50-percent higher proportion of live births in the extremely

low birthweight category of 1,500 grams or less. The percent of

births in the other low birthweight category, 1,501-2,500 grams,

was also higher in the United States. Canada had a higher

percent of births with normal birthweights, 2,501–4,500 grams,

but the United States had a higher percent of births with very

large birthweights, 4,501 grams or more.

Table J. Parcent distribution of live births by birthweight

categories: United States and Canada, 1978

United

Birthweight States Canadal

Percent distribution

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0

l,500grams or less . . . . . . . . . . . . . . . . . . 1.2 0.8

1,501 -2,500 grams . . . . . . . . . . . . . . . . . . 5.9 5.4

2,501 -4,500 grams . . . . . . . . . . . . . . . . . . 91.1 92.2

4,501 grams or more . . . . . . . . . . . . . . . . . 1.8 1.5

1Excludes Newfoundland, which accounted for 3 percant of Canadian live births.

SOURCE: United Nations: Demographic Yaarbook, 1981. New York, 1983,
Hospital fatalities

The fatality rates for hospital patients in the United States

and Canada are presented in table K. For all ages category

(excluding newborn infants), the fatality rates in the two countries

were not signitlcantly different. The similar rates may suggest

that the seriousness of hospital patients’ conditions is about the

same in both countries.

The dit~erence between the United States and Canada in

hospital fatality rates for newborn infants was not statistically

signitlcant; however, the U.S. fatality rates were twice as high

for other children under 1 year of age and 50 percent higher for

children 1–14 years of age. As has already been discussed,

U.S. children at these ages were less likely to be in the hospital

than Canadian children. If the fatality rates are taken as an

indication that hospitalized children were more seriously ill in

the United States than in Canada, the conclusion might be

either that there was less unnecessary hospital use by children

in the United States, or that barriers to health services prevented

U.S. children from reaching the hospital until their conditions had

deteriorated. These issues are explored further in two later

sections—Health Status and Health Services.

The total hospital fatality rates of patients 15 years of age

and cwer in the United States and Canada were not signifiable K. Hospital fatality rates for patients discharged from ahortstay hospitals by age: United States and Canada, 1978

[For tht! United States, data are for non-Federal hoapitala; for Canada, data are

for all short-stay hospitals]

United

Age group States Canada

Rate per 10,000

discharges

All ages (excluding newborn infants) . . . . . . . . . . . 247 240

Newbcwn infants, . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Under 15 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Under l year, . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

l-14 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

15years of age And over . . . . . . . . . . . . . . . . . . . . . 267

15-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

65ymrs and over . . . . . . . . . . . . . . . . . . . . . . . . 702

54

36

89

22

278

30

276

828

cantly different and neither were the rates of patients 15–44

years of age. In Canada, though, patients 45–64 years of age

and 65 years of age and over had higher fatality rates.

Discussion

In each of the three age groups of children under 15 years

of age, both sex groups, and the diagnostic categories that

accounted for the majority of children’s discharges, U.S. children

had lower discharge rates than Canadian children. The lower

discharge rates were accompanied by shorter average lengths

of stay for U.S. children across most age, sex, and diagnostic

categories so that children’s total hospital use was lower in the

United States. These widespread differences in children’s hospital use suggest that general factors, such as children’s health

status or health services, vary between the United States and

Canada.

However, some specific hospital use differences between

the United States and Canada also stood out in the comparison. Most striking was the higher rate of tonsillectomies in

Canada. This surgical procedure, which has been a focus of

controversy in the United States,42 accounted for the higher

total rates of surgical procedures on children in Canada, and

the diagnosis hypertrophy of tonsils and adenoids accounted

for a substantial proportion of Canadian children’s higher

discharge rates for respiratory diseases. Because respiratory

diseases were the most important discharge diagnoses of children

in both countries, the two and three times higher discharge

rates for upper respiratory conditions in Canada also attracted

special attention, particularly since no differences were found

in discharge rate for pneumonia. These and other specific differences indicate that in addition to variations in general factors,

differences may exist in the incidence of certain conditions or

medical practices.

The lower discharge rates of U.S. children were in marked

contrast to the higher rates across most diagnostic categories of

persons 15 years of age and over in the United States. Factors

that might help explain the contrast are explored in the remainder

of the report, including health status indicators and characteristics of the health services systems in the United States and

Canada.

15
Health status

A possible explanation of the differences in hospital use

patterns in the United States and Canada could be that U.S.

children enjoy better health than Canadian children, but that

U.S. adults are less healthy than Canadian adults. Mortality

and morbidity rates in the two countries were compared to

examine this possibility.

Mortality statistics are often used in international research

to indicate health status. However, many more people suffer

illness and injuries than die in a given time period. In addition,

morbidity levels do not necessarily rise and fall with mortality

levels. For instance, advances in the treatment of immature

infants could reduce their death rates but result in a greater

number of children with health problems. On the other hand,

measuring morbidity is more difficult than identifjring deaths.

Morbidity indicators usually rely on self-reports of health status

and behavior, which can be influenced by a variety of factors

other than actual health, such as variations in sick leave or

retirement programs or different expectations about “normal”

levels of health.

Morbidity

Three commonly used morbidity indicators, disability days,

bed days, and percent of persons with limitation of activity, are

presented in table L for the United States and Canada. Disability days refers to the average number of days in a year

persons reduce their usual activities because of illness or injury.

Disability days include days spent in bed, days in which school

or work was missed or housework could not be undertaken, and

days when persons had to cutback but not completely abandon

usual activities. Bed days are a subset of disability days, referring

to the annual average number of days persons spend most or all

of their time in bed because of an illness or injury. All days

spent in a hospital are counted as bed days. Limitation of activity

Table L. Avarage annual numbar of disability and bed days and percent of parsons with limitation of activity. by a9e and sex united state%

1978; Canada, 1978-79

[Data are based on household surveys of the civilian noninstitutionalized population of the United States and the noninatitutionalized population of the Provinces in

Canada. Further information about the surveys ia provided in appendix 1]

United United United

Age group and sex Statas Canada States Canada States Canada

Percent of persons

Disability days Bed days with limitation of

All ages per person per year per person per year activities

Total, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.8 15.7 7.1 5.3 14.2 11.6

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.3 12.5 6.0 4.2 14.3 10.9

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.1 18.9 8.2 6.3 14.1 12.2

Under 15 years

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 8.7 5.2 3.6 3.7 2.8

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.7 8.6 4.9 3.5 4.0 3.4

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.6 8.8 5.5 3.7 3.4 2.2

15-64 yeara

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18.0 15.7 6.6 4.8 13.0 11.2

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.8 11.9 5.3 3.8 13.5 10.6

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.1 19.5 7.9 5.8 12.4 11.9

65 years snd over

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40.3 35.0 14.6 13.2 45.0 38.2

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.1 30.2 14.2 10.6 48.2 38.1

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.9 38.8 14.8 15.3 42.7 38.3

17
refers to an inability to perform all the usual activities of the

population group throughout most of a year period because of

health conditions. For children, the limitations would be in the

amount or kind of school or play activities; for adults, limitations would be in ability to work, do housework, or engage in

social and recreational activities.

The U.S. population was reported to have 20 percent

more disability days and 34 percent more bed days per person

per year than the Canadian population. In addition, the percent

of the population with some degree of ongoing limitation of

activity was 22 percent higher in the United States than in

Canada. In both countries, children under 15 years of age experienced less disruption of their usual activities because of health

problems than did adults. The proportions of children with

yearlong limitations was especially small, and the difference in

the proportion of U.S. and Canadian children with such limitations was not significant. However, U.S. children were reported to have 28 percent more total disability days and 44

percent more bed days than Canadian children.

Interpretation of these morbidity indicators is complicated

by a lack of comparability in the U.S. and Canadian surveys

from which the indicators were taken. While similar definitions

were used in both countries, differences in the survey methodologies were likely to result in higher estimates for the United

States than for Canada. For example, in the Canadian survey

nonresponse was coded as “unknown,” while U.S. data were

adjusted for nonresponse by an imputation procedure. Also,

U.S. survey respondents had more than one opportunity to

report bed and disability days; and, if their answers varied, the

Table M. Death rates by sex and age: United States and Canada, 1978

higher number was used. Canadian survey respondents were

asked about bed and disability days only once. Because of the

survey differences, and the other problems in measuring morbidity, the statistics in table L must be viewed with caution.

Mortality

The U.S. death rate was 21 percent higher than

the Canadian death rate in 1978. As is shown in table M,

higher death rates were found in the United States for each age

group except 75 years and over. The largest difference, 26

percent, was in the death rates for persons 25–34 years of age.

The U.S. death rate was 10 percent higher for children under

15 years.

In both countries males in every age group had a higher

death rate than females. This contrasts with adult hospital discharge rates, which were generally higher for females. The death

rates of both males and females were higher in the United States

than in Canada for each age group under 75 years. For all ages

the U.S. death rate was 18 percent higher for males, 27 percent

higher for females. Among children under 15 years the male

death rate in the United States was 9 percent higher, and the

female death rate 12 percent higher.

A detailed examination of children’s death rates in the

United States and Canada reveals large variations by age

group (table N). The highest death rates, like the highest hospital

discharge rates, were for children in their first year of life. The

U.S. death rate was 14 percent higher than the Canadian rate

for the under 1 year age group, and this excess accounted for

Both sexes Male Female

United United

Age group

United

States Canada States Canada States Canada

Rate per 100,000 population

Alleges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 868 715 977 831 764 601

Under 15yaars. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 116 145 133

15-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

110 98

115 106 169 161

25-34 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60 51

132 105 187 148

35-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

78 62

239 197 312 257 169 135

45-54 years . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610 524 802 691 432

55-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

357

1,387 1,257 1,884 1,7’29

65-74 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

948 823

3,016 2,886 4,182 3,934 2,125

75 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,997

8,642 8,808 10,624 10,780 7,530 7,542

Table N. Death ratas for children under 15 years by sex and age: United States and Canada, 1978

Both sexes Male Female

United United United

Age group States Canada States Canada States Canada

Rate per 100,000 population

Under 15 years,..........,,..,.. . . . . . . . . . . . . . . . . . . . . . . . 128 116 145 133 110 98

Under l year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,381 1,215 1,533 1,352

l-4 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,223

68

1,070

63 77 71

5-9 years . . . . . . . . . . . . . . . . . . . . . . . . . . . .

59

33

55

. . . . . . . . . . . . . . . . . . 38 38

10-14 years, ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45 27

34 36 43 46 24 %

18
the overall higher death rate of U.S. children under 15 years of

age.

In the other three age groups, the differences between U.S.

and Canadian death rates varied, unlike the hospital discharge

rates for these age groups, which were significantly higher in

Canada, The United States had an 8-percent higher death rate

for children 1-4 years of age, but Canada had a 15-percent

higher rate for those 5–9 years and a 6-percent higher rate for

those 10– 14 years of age. The higher death rates of Canadian

children 5 years of age and over indicate that lower health

status may help explain the higher hospital use of these age

groups.

In both countries, male death rates were higher thanfemale

death rates for all the age groups under 15 years of age, which

was consistent with sex patterns in children’s hospital use. For

children under 1 and 1–4 years, the death rates of both males

and females were higher in the United States. For males and

females 5-9 years and males 10– 14 years of age death rates

were higher in Canada. Females 10– 14 years of age had identical

death rates in the two countries.

Infant mortality rates are presented by age in table O. The

first 27 days of life were the most hazardous, accounting for

two-thirds of all first-year deaths in both countries. Mortality

rates for infants under 28 days of age were higher in the United

States than in Canada. The U.S. rates were 16 percent higher

for infants under 24 hours old, 20 percent higher for those 1 to

7 days old, and 19 percent higher for those 7 to 28 days old.

These differences agree with the lower proportion of healthy

newborn infants discharged from U.S. hospitals, However, the

infant mortality rates do not suggest that a lower health level

explains the higher Canadian discharge rate of infants under 1

year of age not classified as newborns. The differences in mortality rates diminished for older infants, but the United States

Tabla O. Infant mortality ratea by aga: Unitad States and Canada,

1978

United

Age group States Canada

Rate per 100,000

live births

Under lyear of age . . . . . . . . . . . . . . . . . . . 1,378 1,195

Under 24 hours . . . . . . . . . . . . . . . . . . . . . . . 511 439

lto7 days . . . . . . . . . . . . . . . . . . . . . . . . . . 287 240

7t028 days . . . . . . . . . . . . . . . . . . . . . . . . . 150 126

28daysto 6 months . . . . . . . . . . . . . . . . . . 335 300

6months tol year . . . . . . . . . . . . . . . . . . . . 95 90

continued to have higher rates for infants at each stage of the

first year of life.

Cause of death

Comparison of death rates by cause may help to explain

differences in hospital use for specific diagnoses. A higher death

rate in one of the countries for a condition may suggest that the

condition is a greater health problem for the country’s population. A higher discharge rate for the condition could then be a

reflection of the greater health problem.

Children under 15 years

Death rates for the 17 main categories of diseases are presented in table P for U.S. and Canadian children under 15

years of age. In figures 7 and 8 the death rates and discharge

rates of children under 15 years for selected disease categories

are compared. Four categories accounted for over threefourths of all children’s deaths in both countries: congenital

Tabla P. Death ratas by age and cauae of death category United States and Canada, 1978

lCauses of death are coded according to the Eigfrth Revision of the /nterrrationa/ Classification of Diseases, Adapted for Use in the United States (ICDA-8)]

Under 15 years 15 years and over

United United

Cause of death category and ICDA-8 code States Canada States Canada

All causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...000-999

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

Neoplasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...140-239

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

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

Mental disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...290-315

Diseases of thenewous system and sense organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...320-389

Diseasea of the circulatory system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...390-458

Diseases of the respiratory system.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...460-519

Diaeases of the digestive system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...520-577

Diseases of thegenitourinary system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...580-629

Complications of pregnancy, childbirth, and the puerperium . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...630-678

Disaasea ofthaskin andsubcutanaoua tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...680-709

Diseases of the musculoskeletal systam and connective tissue. . . . . . . . . . . . . . . . . . . . . . . . . . ...710-738

Congenital anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...740-759

Certain causes of perinatal mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760-769 .2. 769.4-772, 774-778

Symptoms andill-dafined conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...780-796

Accidents, poisonings, and violence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...800-999

Rata per 100,000 population

128 116 1,094 906

6 4 9 4

5 5 235 209

1 2 25 20

3 3

(1’, ~1’, 6 7

5 4 9 9

4 1 576 451

6 6 70 60

2 39 35

~; 15

(“) (1) ;r’,

(’) (l; 1 1

(’) (’) 3 3

19 24 1

42 32 ~;

12 10 15 10

24 25 85 82

‘Quantity more than zero but less than 0.5.

19
Disease category and

[CDA-8 code

Infective and

F

. . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . .

parasitic dmeasea, . . . . . . . . . . .

. . . . . . . . . . .

000-136

Neoplasms,

140-239

Diseases of the

nervous system and

sense organs, 320-389

❑✚❞❊✚❊ ✎✎✎✍✎

United State~

❑ Canada

Diseases of the

circulatory system,

390-459

Diseases of the

respiratory system,

460-519 L

....+...

...#

Diseases of the

B

,...,..

;,:.:.

digestive system, . . .

520-579

Congenital anomalies,

740-759

Certain conditions of perinatal

mortality, 760-779

Symptoms and

ill-defined conditions,

780-799

Accidents, poisonings,

and violence,

800-999

1 I I I I I

o 10 20 30 40 50

Deaths per 100,000 population

Figure 7. Deaths per 100,000 population for persona under 15 years of age, by selected causes of death: United States and Canada, 1978

anomalies; certain causes of perinatal mortality; symptoms and

ill-defined conditions; and accidents, poisonings, and violence.

Canadian children had higher discharge and death rates for

congenital anomalies, and accidents, poisonings, and violence,

but the difference in the rates were considerably greater for

discharges, a 26-percent higher death rate but 47-percent higher

discharge rate for congenital anomalies and only a 4-percent

higher death rate but a 21-percent higher discharge rate for

accidents, poisonings, and violence. U.S. children had higher

death and discharge rates for certain causes of perinatal mortality. However, in the symptoms and ill-defined conditions

category, U.S. children had a higher death rate although the

discharge rate was higher for Canadian children.

The most important discharge category, diseases of the

respiratory system, accounted for only about 5 percent of the

deaths for children under 15 years of age in both countries.

Further, children’s death rates for respirato~ diseases were

identical in the two countries, which contrasted sharply with

the significantly higher discharge rate for this category

in Canada.

Discharge and death rates were also incongruent for two of

the other important discharge categories, infective and parasitic

20
Disease category and

ICDA-8 code

Infective and

parasitic diseases,

000-136

Neoplasms,

140-239

Diseases of the

nervous system and

sense organs, 320-389

Diseases of the

circulatory system,

390-459

Diseases of the

respiratory system,

460-519

Dweases of the

digestive system,

520-579

Congenital anomalies,

740-759

Certain conditions of perinatal

morbidity, 760-779

Symptoms and

Ill-defined conditions,

780-799

Accidents, poisonings,

and violence,

800-999

0 50 100 150 200 250 300 350 400

Discharges per 10,000 population

Figure 8. Rates per 10,000 population for patients under 15 years, excluding newborn infants, discharged from short-stay hospitals, by

diagnostic categories: United States and Canada, 1978

diseases, and diseases of the nervous system and sense organs. esting to note the differences between the United States and

The death rates for children under 15 years of age were small

for both categories, and the U.S. death rates were slightly higher,

though Canada had significantly higher discharge rates for both

categories, Diseases of the digestive system was another relatively important discharge category for persons under 15 years

of age; but this category accounted for few deaths in either

country. Death rates for the category were identical in both

countries, which was consistent with the lack of significant difference in discharge rates.

Though not a major discharge or death category, it is interCanada in diseases of the circulatory system. The children’s

death rate for circulatory diseases was four times higher, and

the discharge rate two times higher, in the United States than in

Canada. On the other hand, children’s death rates for neoplasms were identical in the two countries, and children’s discharge rates for the category were not significantly different.

15 years and over age group

Table P also contains death rates by disease category for

the 15 years and over age group. Four categories accounted for

21
approximately 90 percent of all deaths in both Canada and the

United States. The categories were diseases of the circulatory

system; neoplasms; accidents, poisonings, and violence; and

diseases of the respiratory system. The death rates and the

discharge rates for the four categories were higher in the

United States than in Canada; but for accidents, poisonings,

and violence, the difference in death rates was small. Small

differences in death rates were also the rule in most of the other

13 disease categories, although the U.S. death rates were usually

slightly higher. The Canadian death rate was slightly higher in

one category, mental diseases, but it was a category for which

the U.S. discharge rate was higher.

Infant mortality

Infant mortality rates (deaths in the first year of life divided by live births) are shown for conditions that were leading

causes of infant deaths in table Q. In both the United States

and Canada, three categories accounted for over three-fourths

of all infant deaths: congenital anomalies, certain causes of

perinatal mortality, and symptoms and ill-defined conditions.

For congenital anomalies, Canadian infants had a 3 l-percent higher mortality rate than U.S. infants, which was similar

to the higher discharge rate for Canadian children under 1 year

in the categoty. The higher infant mortality rates held for all

but two of the specific types of anomalies. Particularly striking

was the Canadian rate for spina bifida, which was over 3IA

times the U.S. rate. Congenital anomalies affecting multiple

systems, which include Down’s Syndrome, and congenital

anomalies of the circulatory system other than heart anomalies

were the only anomalies for which the U.S. infant mortality

rates were higher.

U.S. infants had higher mortality rates in the certain

causes of perinatal mortality category. Infants under 1 year of

age in the United States also had a higher discharge rate for the

corresponding category, certain causes of perinatal morbidity.

Within the category, the U.S. infant mortality rates were higher

for each specific condition, except conditions of the placenta.

For the symptoms and ill-defined conditions category,

U.S. infants had a higher mortality rate. However, Canadian

infants under 1 year of age had a higher discharge rate.

Among the other causes of infant deaths, pneumonia and

accidents were the most important in both countries. Pneumonia

accounted for more than two-thirds of all infant deaths from

respiratory diseases in both countries, and accidents accounted

for approximately 85 percent of infant deaths in the accidents,

poisonings, and violence category. The U.S. and Canadian infant mortality rates for pneumonia were almost the same; the

U.S. rate was slightly higher for accidents. U.S. and Canadian

discharge rates for the infants under 1 year of age were not

significantly different for pneumonia or the accidents, poisonings, and violence category.

Diarrheal diseases were among the important causes of

infant deaths and discharge diagnoses in both countries, but

while the infant mortality rate for diarrheal diseases was higher

in the United States, the discharge rate for infants under 1 year

Table 0, infant mortality rates by selected causes of death: United States and Canada, 1979

[Causes of death are coded according to the Eighth Revision International Classification of Diseases, Adapted for Use in the United States (lCDA-E)]

United

Cause of death and ICDA-8 code States Canada

Rate per 100,000

live births

Allcauaesl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..000-999 1,378 1,195

Diarrheal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Septicemia .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,,, . . . . . . . . . . . ...038

. . . . . . . . . . . . . . . . . . . . . . 009 21 12

Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33 13

Diseases of the heart, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..~~~~~~~~~~~;~

... . . . . . . . . . . . 320 16 9

.’390:398;402, 404, 410-429 25

Pneumonia, all forma, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..48r3_486

4

Hernia andinteatinal obstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...550-553.560

45 46

Congenital anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,740_75g

15 14

252 327

Anancephalus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...740

Spinabifida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23 30

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741 9 33

Congenital anomalies of the heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...746 85 98

Other congenital anomalies of the circulatory system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...747

Congenital anomalies of the respiratory system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 748

25 22

21

Congenital anomalies affecting multiple systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 759

31

41 33

Another congenital anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...742-745. 749–758

Certain causes of mortality in early infancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760–769.2, 769.4–772, 774-778

48 80

Maternal conditions related to pregnancy and childbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..762–769

660 504

91 74

Conditiona of placenta......,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...770

Birth injury without mention of cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...772

23 33

Hyaline membrane disease . . . . . . . . . . . . . . . . . . .

56 45

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776.1 80 67

Respirato~ distress syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...776.2

Asphyxia ofnewborn, unspecified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...776.9

100 68

89 69

All other anoxic and hypoxic conditions not elsewhere classifiable . . . . . . . . . . . . . . . . . . . . . . . ...776.0. 776.3 -776.4 18 14

Immaturity, unqualified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...777 110 89

Another conditions of newborn.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760-761, 771, 774, 775, 778 93 43

Symptoms andill-defined conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..780–796

Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. E800–E949

171 148

38 35

1includes causes of death not shown in table.

22
Of age was higher in Canada. For hernia and intestinal obstruction, though, infant mortality rates were similar, as were

the discharge rates of children under 1 year for inguinal hernia.

Septicemia, meningitis, and diseases of the heart were important as causes of infant deaths but were not major discharge

diagnoses of children under 1 year of age. For each, the U.S.

infant mortality rate was higher than the Canadian rate, 78

percent higher for meningitis, 2% times higher for septicemia,

and 6 times higher for diseases of the heart. On the other hand,

several of the major discharge diagnoses of infants under 1 year

were the cause of few infant deaths. These included otitk media,

gastroenteritis and colitis, and all the respiratory diseases except pneumonia.

Neonatal mortality

Neonatal mortality rates (deaths in the first 27 days of life

divided by live births) are presented by cause in table R. To

compare neonatal mortality rates with newborn infant discharge

rates, the causes selected are the same as the diagnoses shown

in table H, with the addition of immaturity. For the neonatal

period as a whole, congenital anomalies and anoxic and hypoxic

conditions not elsewhere classifiable were the most important

causes of death in both the United States and Canada. The

Canadian neonatal mortality rate was higher for congenital

anomalies, but the rate for anoxic and hypoxic conditions was

higher in the United States. The U.S. and Canadian discharge

rates of newborn infants were not signtilcantly different for either

condition,

The neonatal mortality rates were higher in the United

States for five of the other seven cause of death categories.

However, the discharge rates of U.S. newborn infants were

higher only for two of these: immaturity and the residual category, conditions other than congenital anomalies and certain

causes of perinatal mortality. Canada had a higher neonatal

mortality rate for conditions of the placenta and umbilical cord,

for which no U.S. discharge data were available, and a slightly

higher rate for hemolytic disease of the newborn, for which the

newborn infant discharge rate was higher in the United States.

The low neonatal mortality rates for hemolytic disease in

both countries contrasted with the relatively high discharge rates

of newborn infants with the diagnosis. The category, other conditions of the fetus or newborn, also presented a contrast. Though

it was the leading diagnosis of sick newborn infants, it accounted

for only 8 percent of neonatal mortality in the United States

and 3 percent in Canada.

Along with anoxic and hypoxic conditions and congenital

anomalies, immaturity and maternal conditions were important

causes of death during the first day of life in both countries. For

infants 1 to 7 days old, birth injury and the residual category

followed anoxic and hypoxic conditions and congenital anomalies in importance as causes of death. In the 7-to-28 day

period, the residual category had become the most important

cause of death in the United States and the second most important cause in Canada, after congenital anomalies.

‘Mortality of children 1–14 years

The distribution of deaths by cause was different for children 1– 14 years of age than for those under 1 year of age (table

S). After the first year of life, accidents were the most important

cause of children’s deaths, accounting for approximately 40

percent of the deaths of children 1–4 years of age and over half

of the deaths of those 5– 14 years. The accident deaths were

evenly split between motor vehicle and other types of accidents

for children 5–14 years of age, but for those 1–4 years of age

the other types of accidents were more important.

The second most important cause of death for children l–

4 years of age was congenital anomalies. Malignant neoplasms

was the second most important cause for children 5– 14 years.

The U.S. and Canadian death rates for these, and most of the

other causes, were similar, if not identical. Canadian children

1–4 years of age had a higher death rate for leukemia, while the

death rates for U.S. children 1–4 years were higher for diseases

of the heart, accidents, and homicide. The death rates for children 5– 14 years were the same for each of the leading causes

of death, except accidents.

The only conditions important both as causes of death and

discharge diagnoses for the two age groups were accidents,

congenital anomalies, and pneumonia. For children 5– 14 years

of age, the difference between the U.S. and Canadian death

rates for accidents was consistent with the difference in disTable R. Neonetal mortality rates by age and selected causes of death: United States and Canada, 1978

[COUSOSof death are coded according to the Eighth Revision International Classification of Diseases, Adapted for Use in the United States (lCDA-S)]

Under 28 days Under 1 day 1 to 7 days 7 to 28 days

United United United United

Cause of death and ICDA-8 code States Canada States Canada States Canada States Canada

Rate per 100,000 live births

All causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...000-999 949 805 511 439 287 240 150 126

Congenital anomalies . . . . . . . . . . . . . . . . . . . . . . . . ...740-759 178 229 81 104 61 71 36 54

Maternal conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . ..760–769 94 79 74 63 16 12 4 4

Conditions of placenta and umbilical cord. . . . . . . . ...770-771 28 40 25 35 3 5 1 1

Birth injury without mention of cause . . . . . . . . . . . . . . . . ...772 55 45 9 10 33 25 13 9

Hemolytic disease of newborn . . . . . . . . . . . . . . . . . . . . 774-775 6 8 4 4 2 3 1

Armxic and hypoxic conditions not elsewhere classifiable. .. 776 272 217 140 115 101 84 32 18

Immaturity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...777 110 89 101 79 7 7 1 3

Other conditions of fetus or newborn . . . . . . . . . . . . . . . . ...778 77 24 49 11 19 8 8 4

Conditions other than congenital anomalies arid certain causes

of perinatal mortality . . . . . . . . . . . . . . . . . . 000–738, 780-999 128 73 28 18 45 24 55 31

23
Table S. Death rates for children 1-14 yeara of age by age and selected causes of death: United States and Canada, 1978

[Causesof death are coded according to the Eighth Revision International Classification of Diseases, Adapted for Use in the United States (ICDA–8)]

1-4 years 5-14 years

United United

Cause of death and /CDA-8 code States Canada States Canada

Rate par 100,000 population

Allcausesl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 63 33 36

Malignant neoplasms, including neop[asms of Iymphstic and hematopoietic tissue . . . . . . . . . . . . 140–209 5 6

Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..++ ...204-207

4 4

2 3

Another malignant neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..14&203 .208.20g

2 2

3 3

Diseases oftha heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 2

390–398, 402, 404, 410-429 2 1

Pneumonia, all forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480-486

1 1

3

Congenital anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . ...740-759

3 1 1

8

Accidents . .

6 2 2

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...,,.,, . . . . . . . . . . . . . . . . . . . . . . . E800-E949 28 27

Motor vehicle accidents,.....,., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ... ... , . . . . . . ..+ E810-E823 10

17 20

9

All other accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. E800-E807. E825-E949 18

9 10

18

Homicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. E96O-E978

8 10

3 2 1 1

llncludes causes of death not shown in table.

charge rates for the accidents, poisonings, and violence category. The Canadian death rate was 17percent higher, and the

Canadian discharge rate was 18 percent higher for this age

group. For the 1–4 years age group, the U.S. death rate was 4

percent higher for accidents (10 percent higher for the entire

accidents, poisonings, and violence catego~). However, the

discharge rate of children 1–4 years for accidents, poisonings,

and violence was 34 percent higher in Canada. Discharge rates

for congenital anomalies, unlike death rates, were significantly

higher in Canada for both children 1–4 and 5– 14 years of age.

The discharge rates of the countries for pneumonia, like the

death rates, were not significantly different for either age group.

Discussion

Based on mortality and morbidity data, the argument

could be made that U.S. adults had higher hospital discharge

rates because they were less healthy than Canadian adults. For

children under 15 years, though, the relationship between hospital use and health status was not consistent. Despite a lower

discharge rate, the under 15 years age group as a whole had

higher morbidity and mortality rates in the United States.

Within the age group, the lower proportion of healthy newborn

infants discharged from U.S. hospitals could be related to the

higher U.S. neonatal mortality rate, and in Canada the higher

discharge rate of children 5– 14 years could be explained by

their higher death rates. However, the higher infant mortality

rates and death rates of children 1–4 years of age in the United

States do not explain the lower U.S. discharge rates of children

under 5 years, excluding newborn infants.

The relationships between discharge and death rates for

specific conditions also varied. Some conditions, such as septicemia for infants under 1 year of age or malignant neoplasms

for children 1–14 years, were important as causes of death but

not as discharge diagnoses. Conditions that were leading discharge diagnoses often caused few children’s deaths, In particular, respiratory diseases, which were the most important discharge diagnoses of children in both countries, were not, except

for pneumonia, leading causes of children’s deaths. Although

Canadian children were hospitalized more frequently for respiratory diseases, children’s respiratory disease death rates did

not differ between the two countries. For conditions that were

important both as discharge diagnoses and causes of death,

such as accidents, poisonings, and violence, and congenital

anomalies, the findings were mixed. Differences between the

United States and Canada in death rates parallel differences in

discharge rates for some age groups, but not for all.

These findings suggest that factors other than health status

need to be considered to understand the difference in hospital

use by children in the United States and Canada. Accordingly,

characteristics of the U.S. and Canadian health services systems that may affect hospital use are examined in the next

section.

24
Health services

Characteristics of the health services systems in the

United States and Canada are examined in this section for

evidence for two possible explanations for the lower levels of

hospital use by children in the United States. One of the possible explanations is that ambulatory care is “substituted” for

inpatient care in the treatment of U.S. childrex that is, U.S.

children may be treated on an ambulatory basis for conditions

that lead to the hospitalization of children in Canada. The second possible explanation is that U.S. children may have problems obtaining access to hospital care that Canadian children

do not have, Barriers to hospital care could result in some U.S.

children not receiving inpatient care when they need it.

Supply and distribution of resources

The substitution explanation is suggested by the statistics

on supply of hospital beds and physicians in table T. Canada

had a higher rate of total hospital beds and a rate of pediatric

Table T. Rates of short-stay hospital bads and physicians: United

Statas and Canada, 1977-78

[In the United States hospital data are for all non-Federal short-stay hospitals

registered with the American Hospital Association. In Canada hospital data are

for all short-stay hospitals]

United

Health resource States Canada

Rate per 10,000

population

Beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 54

Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . 18 18

Rate per 10,000

population under

15 years

Pediatric beds . . . . . . . . . . . . . . . . . . . . . . . . 211 25

Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . 3.3 2.1

1U.S. data are for active non-Fsderal physicians (MD’s and DOS). Canadian

data are for active civilian physicians (MDs).

2Estimatas of pediatric beds have bean made for nonreporting hospitals. For

details aae appendix Il.

3Data are for phy~iclans certified aa pediatricians bY speciakY boards as of

December 31, 1977.

SOURCES: American Hospital Association: Hospital Statistics, 1979 Edition.

Chicago, 1979; Statistics Canada, Health Division: Unpublished 1978 data from

the Institutional Statistics Section; American Medical Association: Physician

Distribution and Medical Licensure in the U.S., 1978. Chicago, 1979 (Copyright

1979: Used with tha parmiasion of tha American Medical Association); National

Center for Health Statistics: Health, United States, 1982. DHHS Pub. No.

(PHS) 83-1232. Public Health Service. Washington. U.S. Government Printing

Off Ice, Dec. 1982; Medical education in the United States, 1977-1978.

JAMA 240(28), Dec. 22/29, 1978, p. 2841 (Copyright 1978: Used with the

permission of the American Medical Association); Department of National Health

and Welfare: Canada Health Manpower Inventofy. 1978 and 1979. Ottawa,

1978 and 1979.

beds twice that in the United States. The rate of all physicians

did not differ between the two countries, but the United States

had a higher number of physicians certified by specialty boards

as pediatricians per 10,000 population of children under 15

years of age. Pediatricians did not provide all children’s health

services in either country, but previous research indicates that

pediatricians may be more likely than other types of physicians

to treat children on an ambulatory rather than inpatient basis.19

Hospital beds

Slightly over half of all short-stay hospitals in the United

States maintained pediatric units in 1978 (table U). Threefourths of the Canadian shofi-stay hospitals had pediatric units.

The distribution of pediatric units by hospital bed size differed

markedly in the two countries. In the United States, the pro

portion of hospitals with pediatric units increased steadily with

hospital bed size. Only 13 percent of the smallest hospitals had

pediatric units, but over three-fourths of the hospitals with 200

or more beds had the units, and more of the largest hospitals,

86 percent, had pediatric units than any other bed-size category. In Canada, over half of the smallest hospitals had pediatric units, and over 80 percent of the hospitals with 25– 199

beds had the units. The Canadian hospitals most likely to have

pediatric units were those with 50–99 beds, while the proportion

of the largest hospitals with pediatric units was below the average for all sizes of hospitals.

Table U. Percent of short-stay hospitals with pediatric units by

bed size: United Statas, 1978; Canada, 1977–78

[Data are for short-stay non-Federal hospitals registered with the American

Hospital Association in tha United States, and for short-stay hospitals in

Canada]

United

Bed size States Canada

All sizes . . . . . . . . . . . . . . . . . . . . . . . . .

500 beds And over . . . . . . . . . . . . . . . . . . . .

400-499 bede . . . . . . . . . . . . . . . . . . . . . . .

300-399 beds, . . . . . . . . . . . . . . . . . . . . . .

200–299 beds . . . . . . . . . . . . . . . . . . . . . . .

100-199 beds . . . . . . . . . . . . . . . . . . . . . . .

50–89 beds . . . . . . . . . . . . . . . . . . . . . . . . .

25-49 beds . . . . . . . . . . . . . . . . . . . . . . . . .

6-24 beds . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent with

pediatric units

52.2 175.5

85.8 69.8

84.3 88.9

84.0 81.1

77.3 78.8

57.3 84.6

36.5 90.6

23.7 87,4

13.1 ‘53.4

llncludes 58 hospitals with less than 6 beds, one of which has a pediatric unit.

SOURCES: American Hospital Association: Hospita/ Statistics, 1979Edition.

Chicago, 1979; Statistics Canada, Health Division: Unpublished 1978 data from

tha Institutional Statistics Section.

25
The wider distribution of pediatric units in Canadian hospitals could be interpreted as evidence of easier access to inpatient care for Canadian than U.S. children. However, allotting

beds for the exclusive use of children in most Canadian hospitals could also result in admissions of Canadian children for

relatively minor conditions.43

The supply of hospital beds and pediatric hospital beds in

geographic divisions is shown for the United States in table W

and for Canada in table Y. The States making up each U.S. division are listed in appendix II, table VIII. For Canada each

Province is a division, except the two smallest, which are combined to form one division.

In the United States the highest rate of hospital beds was

in the West North Central division. Saskatchewan had the

highest rate in Canada. It is interesting to note that Saskatchewan borders on States in the West North Central division.

Quebec had the lowest hospital bed rate in Canada; and the

two western divisions, Mountain and Pacific, had the lowest

rates in the United States.

The rates by division of pediatric beds per 10,000 population of children under 15 years of age followed a pattern similar

to the total bed rates in Canada. Saskatchewan had the highest

pediatric bed rate, Quebec the lowest, and the divisions in

between ranked much the same on both bed rates. However, in

the United States no relationship was evident between the two

bed rates by division. For example, three divisions had higher

pediatric bed rates than the West North Central division, and

two had lower pediatric bed rates than the Mountain or Pacific

divisions.

The divisions in each country were ranked according to

the discharge rates of children under 15 years, which are

shown in tables W and Y. These rankiigs were compared with

Table W. Rates of hospital beds, pediatric bads, physicians, pediatricians, and hospital discharges for patients under 15 years of age, by

geographic division: Unitad States, 1978

Hospital beds Physicians

Hospital discharges

Division Total? Padiatric2 Tota13 Pediatricians under 15 yearss

Rates per 10,000 population

New England . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Middle Atlantic . . . . . . . . . . . . . . . . . . . . . .

13 22 5.4 540

. . . . . . . . . ... , 46 13 21 5.3

Esst North Central . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

665

47 13 15 3.2

West North Central . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

793

59 12 15 2.7

South Atlantic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,009

43 11 17 4.0

East South Central........,.. . . . . . . . . . . . . . . . . . . . . . .

561

48 8 12 2.6

West South Central . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

790

45 8 14 2.7

Mountain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

709

37 11 15 3.3

Pacific . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

702

36 9 20 4.7 510

l.short-stsy non-Federsl hospitals registered with the American Hospital Association.

2Hoapitals registered with the American Hospital Association,

3Active non-Federal physicians (kfDs).

4Non-Federal physicians (MD’s) in pediatric practice, excluding pediatric residents.

5Non- Federal short-stay hospital discharges excluding newborn infants.

aFor pediatric beds, pediatricians, and hospital discharges under 15 years, rates per 10,000 population under 15 years of age.

SOURCES: American Hospital Association: Hospita/ Statistics, 1979 Edition. Chicago, 1979; American Medical Association: Physician Distribution and Medical

Licensure in tha U.S., 7978. Chicago, 1979 (Copyright 1979; Used with the permission of the American Medical Association); Division of Health Csre Statistics,

National Center for Health Statistics: Unpublished 1978 data from the National Hospital Discharge Survey.

Table Y. Rates of hospital beds, pediatric beds, physicians, pediatricians, and hospital discharges for patients under 15 years of age, by

geographic division: Canada, 1977-78

Hospital bedsl Physicians

Hospital discharges

Division Total Pediatric Tota12 Pediatricians under 15 yaars4

Rates per 10,000 population

Newfoundland and Prince Edward Island . . . . . . . . . . . . . . 55 35 14 1.5

Nova Scotia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,196

67 39 18 1.7

New8runswick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,162

62 31 11 1.0

Quebec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,156

47 18 18 2.5

Ontario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

726

53 23 19 2.3

Manitoba . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

906

64 29 18 2.7

Saskatchewan, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,087

76 43 15 1.4

Alberta . .,, ,,, . .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,775

61 36 16 1.8

British Columbia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1,247

60 25 19 2.4 951

lGeneral and allied special hospitals excluding rehabilitation and extended care hospitals.

‘Active civilian physicians (MD’s).

3Active civilian board cettified pediatricians (MD’s).

4Short-stay hospital discharges sxcluding newborn infants,

5For pediatrjc beds, pediatricians, and hospital discharges under 15 years, ratea per 10,000 population under 15 Years of a9e.

SOURCES: Statistics Canada, Health Division: Hospita/Annua/ Statistics, 7977-78. Ottawa, June 1981; Department of National Health and Welfare: Canada Hea/th

Marrpobver /rwenrory, 7979. Ottawa, 1979; Statiatica Canada, Health Division; Unpublished 1978 data from the Institutional Care Statistics Section.

26
the rankings of the divisions by total bed rates and pediatric

bed rates, using Spearman’s r. as a test of association. Unrounded data were used for the rankings, which resulted in no

cases of tied rankings.

The associations between rankings of the divisions varied

in the United States and Canada, as is illustrated in figures 9

and 10, In the United States a positive, statistically significant

relationship was found between total hospital bed rates and children’s discharge rates (r, = .850), but no relationship existed

between pediatric bed rates and children’s discharge rates

(r$ = –.100). In Canada the relationship between total hospital

bed rates and children’s discharge rates was not statistically

significant (r$ = .667), but a very strong relationship was found

between pediatric bed rates and children’s discharge rates

(r, = .950).

These findings suggest that the supply of pediatric beds is

an important factor in an explanation of Canadian children’s

hospital use. The lower supply and less widespread distribution

of pediatric beds in U.S. hospitals probably does not create a

substantial barrier to children’s hospital use in the United States,

The relationship between the supply of total hospital beds and

children’s discharge rates in the United States implies that U.S.

children are frquently admitted to general hospital beds.

Physicians

The supply of physicians and pediatricians in the geographic divisions of the United States and Canada is also

shown in tables W and Y. In both countries the rankings of the

divisions according to physician and pediatrician rates were

similar. The New England, Middle Atlantic, and Pacific divisions of the United States had the highest rates of physicians

and pediatricians. The East South Central division had the

‘lowest rates. In Canada five Provinces had high rates of physicians, and four of the five also had the highest rates of pediatricians. New Brunswick had the lowest rates of physicians

and pediatricians.

The associations between rankings of the divisions by

physician rates and rankings by children’s discharge are illustrated in figure 11. The relationships were negative and statistically significant in both countries, but the relationship was

stronger in the United States (r~ = —.783) than in Canada

(r, = –.683). The associations between the rankings of the

divisions by rates of pediatricians and those by children’s discharge rates are shown in figure 12. As with physician rates,

the relationships were negative in both countries, but in Canada (r~ = —.667) the relationship was not statistically significant, while in the United States (r~ ‘— .833) it was both significant and stronger than the association between physician

rates and children’s discharge rates.

The inverse relationships between supply of physicians

and children’s hospital use suggest that substitution may take

place between physician and inpatient services for children. In

the United States pediatricians appear more likely to reduce

children’s hospital use than physicians generally. Pediatricians

1,800

1.600

1,400

c

0 1,200

.-

5

3

R

0Q 1,000

0

0

0-

0 800

;

I

I

/

Canada I

lA’+

/p\ ,

/ \,

/

/

4

United States

400

200

I

o~

123.45678 9

Low High

Figure 9. Retes per 10,000 population for patienta under 15 years,

excluding newborn infants, discharged from short-stay hospitals

by geographic divieions ranked from low to high on the baaia of

rates of hospital beds: United States, 1978; Canada, 1977-78

1,800

1,600

1,400

[

1,200

1,000

800

600

I

/

/

I

I

Canada I

400

t

200

t

o~

12345678 9

Low High

Figure 10. Rates per 10,000 population for patients under 15

years, excluding newborn infants, discharged from short-stay

hospitals by geographic divisions ranked from low to high on the

basis of rates of pediatric hospitel beda: United States, 1978;

Canada, 1977-78

27
1,800

1,600

1,400

[

c

0

1,200

.-

;

3

0.

0

a 1,000

0

0

0.

0 800

b

n

al

z

K

600

400

1

United States

20LJ_u—

12345678 9

Low High

1,800

1,600

1,400

:

1,200

.+-

5

3

n

0

a 1,000

0

0

0-

0 800

;

0.

al

z

cc 600

400

4

l\

l\

l\

l\

l\ Canada

/ -+

/

United States

200

t

.~

12345678 9

Low High

Figure 11. Rates per 10,000 popadation for patients under 15

years, excluding newborn infants, discharged from short-stay

hospitals by geographic divisions ranked from low to high on the

beais of rates of physicians: United Statea and Canada, 1978

Figura 12. Rates per 10,000 population for patients under 15

years, excluding newborn infants, discharged from short-stay

hospitals by geographic divisions ranked from low to high on the

basis of rates of padiatriciana: United States and Canade, 1978

do not appear to be as important in Canada, perhaps because diseases of the respiratory system and accidents, poisoning,

. .

of their lower supply, which could result in more children being

cared for by other types of physicians.

Selected diagnoses by division

The discharge rates by geographic division for children

under 15 years of age with a diagnosis in the categories of

Table Z. Rates of hospital discharges for patients under 15 years

with selectad diagnoses, by geographic division: United States,

1978

[Data are for first-listed diagnoses in short-stay non-Federal hospitals. Data

exclude newborn infants and are coded using the Eighth Revision International

Classification of Diseases, Adapted for Use in the United States (ICDA-8)]

Diseases of the Accidents,

respiratory poisonings,

Division system 1 and violencez

New England . . . . . . . . . . . . . . . . . .

Middle Atlentic . . . . . . . . . . . . . . . .

East North Central.,.......,,.. ,

West North Central . . . . . . . . . . . . .

South Atlantic . . . . . . . . . . . . . . . . .

East South Central . . . . . . . . . . . . .

West South Central . . . . . . . . . . . .

Mountain . . . . . . . . . . . . . . . . . . . . .

Pacific . . . . . . . . . . . . . . . . . . . . . . .

Rate per 10,000 population

148

185

254

347

173

296

229

200

149

93

96

99

152

78

96

91

123

89

1ICDA-8 codes 460-519.

21CDA-8 codes 800-999.

and violence are shown in table Z for the United States and in

table AA for Canada. It is tempting to attribute Canadian children’s higher discharge rates for respiratory diseases to Canada’s cold northerly climate. However, within the United

States the more northern divisions did not necessarily have the

highest discharge rates for respiratory diseases. For instance,

Table AA. Rates of hospital discharges for patients under 15 years

with selected diagnoses, by geographic division: Canada, 1978

[Data are for principal or primary diagnoses in short-stay hospitals. Data

axclude newborn infants and are coded using tha Eighth Revision International

Classification of Diseases, Adapted for Use in the United States [I CDA-8]]

Diseases of the Accidents,

respiratory poisonings,

Division system 1 and violence2

Rate per 10,000 population

Newfoundland and Prince Edward

Island . . . . . . . . . . . . . . . . . . . . . . . 445 126

Nova Scotia . . . . . . . . . . . . . . . . . . . 490 123

New Brunswick . . . . . . . . . . . . . . . . 465 113

Quebec . . . . . . . . . . . . . . . . . . . . . . 236 71

Ontario . . . . . . . . . . . . . . . . . . . . . . . 338 110

Manitoba . . . . . . . . . . . . . . . . . . . . . 451 130

Saskatchewan . . . . . . . . . . . . . . . . . 742 212

Alberta . . . . . . . . . . . . . . . . . . . . . . . 478 161

8ritish Columbia !. .,,.... . . . . . . 334 153

1ICDA-8 codes 460-519.

21CDA-8 codes 800–999.

28
the East South Central division had a children’s discharge rate

for respiratory diseases significantly higher than the New England and Middle Atlantic divisions.

The evidence is stronger that children’s discharge rates for

diseases of the respiratory system are related to the supply of

health resources. In the United States the rankings of the divisions by children’s respiratory disease discharge rates were

positively related to rankings by total hospital bed rates

(r, = .833), and negatively related to rankings by physician

rates (r$ ==–.867) and pediatrician rates (r. = –.9 17). The

relationship between respiratory disease discharge rates and

pediatric bed rates was not statistically significant. In Canada

children’s discharge rates for respiratory diseases were positively related to both total hospital bed rates (r, = .883) and

pediatric bed rates (r, = .933), but the associations with physician rates and pediatrician rates were not statistically sign~lcant.

In contrast, the associations between the rankings of the

divisions by children’s discharge rates for accidents, poisonings. and violence and rankings by hospital bed rates, pediatric

bed rates, physician rates, and pediatrician rates all failed to

reach statistical significance in both the United States and Canada, The lack of relationships suggests that less variability exists in the treatment of children for accidents, poisonings, and

violence than in cases of respiratory diseases.

Physician utilization

While it was not possible to compare the utilization of

pediatricians in the United States and Canada, data on the

utilization of all physicians were available from the national

health interview surveys in the two countries. According to the

two surveys, patients were most likely to visit physicians in the

physicians’ offices (table BB). However, the percent of contacts in physicians’ offices was higher in Canada, both for the

under 15 years and the 15 years and over age groups. Hospital

outpatient departments accounted for a higher percent of physician contacts for both age groups in the United States. Hospital emergency departments were more likely to be the place of

a physician contact for patients 15 years of age and over in the

United States, but approximately the same percent of children’s

physician contacts were in hospital emergency departments in

both countries.

The greater proportion of physician contacts in hospital

outpatient departments might indicate less accessible physician services in the United States, which could translate into a

barrier to hospital care. One measure of physician accessibility

is the percent of the population with a physician contact in a

year, which is shown in table CC. For persons of all ages, the

percent with a physician contact was higher in Canada, but the

difference was found in the population 15 years of age and

over. The percents of children under 15 years of age with a

physician contact were almost identical in the two countries, as

were the percents of children under 5 and 5– 14 years of age.

Thus, physicians appear to be equally accessible to children in

the United States and Canada.

If ambulatory care is substituted for inpatient care in t!!e

treatment of U.S. children, they would be expected to have a

higher average number of physician contacts. Statistics on

physician contacts in the two countries are shown in table DD.

For comparability, the average number of physician contacts

per year was based on interview questions about the number of

contacts in the previous 12 months, although in the United

States, a 2-week recall period is generally preferred. Respondents are thought to be less likely to forget contacts in the shorter

time period. In 1978, for example, use of the 2-week recall

period resulted in a 24-percent larger U.S. estimate of physician

contacts per person for all ages and a 40-percent larger estimate for children under 15 years of age. Telephone contacts,

Table CC. Percent of population with a physician contact in a year

by aga: United States, 1978; Canada, 1978-79

[Data are based on household intawiew surveys of the civilian noninstitutional ized

population in tha United Statas and of the noninstitutionalized population

of the Provinces in Canada. Further information about the surveys is provided

in appendix 1]

United

Age group States Canada

Percent

Alleges . . . . . . . . . . . . . . . . . . . . . . . . 75.4 76.8

Under 15 years . . . . . . . . . . . . . . . . . . . . . . . 77.1 77.4

Under 5 years . . . . . . . . . . . . . . . . . . . . . . 90.1 90.4

5-14 years . . . . . . . . . . . . . . . . . . . . . . . . 71.4 71.6

15 years and over . . . . . . . . . . . . . . . . . . . . . 74.8 76.6

Tabla BB. Percent distribution of physician contacts by place of contact, according to age: United States, 1978; Canada, 1978-79

[Data are based on household interview surveys of the civilian noninstitutionalized population in the United States and of the noninstitutionalized population of the

Provinces in Canada. Further information about the surveys is provided in appandix 1]

All ages Under 15 years 15 years and over

United United United

Place of contactl States Canada States Canada States Canada

Percent distribution

All places . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0

Physician’s off ice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76.2 80.7 75.6 80.5 76.3 80.8

Hospital outpatient department . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.2 6.7 8.2 5.7 10.7 6.9

Hospital emergency department . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 5.8 7.9 7.8 4.6 5.2

Other and unknown places . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4 6.9 8.3 6.0 8.4 7.1

lExcludas physician contacts of hospital inpatients and telephone contacts.

29
Table DD. Average number of physician contacts in a yaar by age:

United States, 1978; Canada, 1978-79

[Data are baaed on household interview surveys of the civilian noninstitutionalized

population in the United States and of the noninstitutionalized population

of the Provinces of Canada. Further information about the surveys is provided

in appendix 1]

United

Age group Stetes Canada

Numbar of contacts

per person per year

Alleges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.8 3.3

Under 15 years . . . . . . . . . . . . . . . . . . . . . . . 3.1 2.6

Under 5 years . . . . . . . . . . . . . . . . . . . . . . 4.3 3.4

5-9 years . . . . . . . . . . . . . . . . . . . . . . . . . 2.9 2.5

10-14 years . . . . . . . . . . . . . . . . . . . . . . . 2.2 2.2

15 years and over . . . . . . . . . . . . . . . . . . . . . 4.1 3.5

which might be particularly difllcult to recall over a long time

period, accounted for 18 percent of the contacts of U.S. children under 15 years of age when the 2-week recall period was

used.

Also, to improve comparability, an adjustment was made

in the Canadian data to exclude physician visits to hospital inpatients, which were not included in average number of U.S.

contacts. The total number of contacts in Canada was reduced

by the percent of most recent contacts that were visits to hospital inpatients, which was 3.7 percent for all ages and 4.2 percent for children under 15 years of age. These adjustments did

not make the statistics totally comparable. There are other differences in survey methodology, such as the use of an imputation procedure for nonresponse in the United States but not in

Canada.

As is shown in table DD, the average number of contacts

with a physician in a year was reported to be higher in the

United States than in Canada. Children under 15 years of age

and persons 15 years of age and over had higher average numbers of contacts with physicians in the United States. Within

the groups under 15 years of age, U.S. children under 5 and 5–

9 years of age were reported to average more physician contacts

than Canadian children. These findings are consistent with the

thesis that physician use is substituted for hospital use in the

treatment of U.S. children. There was no difference, though, in

the averages for children 10– 14 years of age.

Health insurance

The costs of hospital care could present a barrier to hospital use for persons without health insurance, and health insurance coverage dhTers in the United States and Canada.

Canada enacted a national hospital insurance program in 1958

and a national medical care insurance program in 1968. Almost

all Canadian residents are eligible for coverage by the pro

grams, exceptions being the armed forces, Royal Canadian

Mounted Police, and inmates of Federal prisons. Insurance

coverage is compulsory for all Canadian residents except in

two Provinces, and even in those Provinces more than 99 percent of the population participates in the programs.44

In the United States most of the population was covered

by some form of health insurance in 1978, but children under

15 years of age were less likely to be insured than persons 15

years of age and over (table EE). Furthermore, within the

group under 15 years of age, the percent with health insurance

was lowest for children under 1 year, and lower for children

1–4 years than for those 5–14 years of age.

Private health insurance covered the largest percent of the

U.S. population in all age groups. As with all forms of insurance,

private plans provided coverage for a higher percent of persons

15 years of age and over than of children under 15 years, and

within the group under 15 years of age, the percent with private

insurance coverage was highest for children 5– 14 years of age,

lowest for children under 1 year.

Medicare, a Government insurance program primarily providing health insurance protection to persons 65 years of age

and over, was the second most common type of insurance for

persons 15 years of age and over. Not surprisingly, Medicare

covered very few children. Medicaid, a government health insurance program that provides benefits to low-income persons,

was the second most common type of insurance for children

under 15 years of age, but it covered a smaller percent of persons 15 years of age and over. Children under 5 years were

more likely to have Medicaid insurance coverage than children

5– 14 years of age. Military insurance programs covered a larger

percent of persons 15 years of age and over than of children

under 15 years of age.

The percent of the U.S. population with some form of

health insurance coverage varied by income (table FF). Persons

with an annual family income of less than $10,000 were less

likely to have health insurance. In addition, children were less

Table EE. Percent distribution of population by health insurance coverage, according to age: United States, 1978

[Data are based on a household interview survey of the civilian noninstitutionalized population. Further information about the survey is provided in appendix 1]

Health insurance coverage Under 1 year 1-4 years 5-14 years Under 15 years 15 years and over

Percent distribution

Total population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0

Insured. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Private insurance . . . . . . . . . .

81.8 86.9 88.6 87.8 89.4

. . . . . . . . . . . . . . . . . . . . . . . . . . 64.9 70.7

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

76.2 74.1 78.7

“0.3 “0.0 *O. 1 0.1

Medicaid . . . .

14.4

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . #.. 13.5 13.7 11.1 11.9

Militaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .

5.4

4,4 4.1 3.6 3.8

Not insured . . . . . .

6.2

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.9 11.7 10.2 10.9

Unknown insurance statue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9.7

2.3 1.4 1.1 1.3 1.0

NOTE: The percent insured is less than the total of the percents with specific types of insurance because persons can have more than one type of insurance coverage.

30
Table FF. Percent of population with health insurance by age and

femily income: United States, 1978

[Data are baaed on a household interview survey of the civilian noninstitutionalized

populatmn, Further information about the survey is provided in appendix 1]

Annual family income Undar 15 years 15 years and over

Percent

All incomes ... .,,.. . . . . . . . 87.8 89.4

Less than $5,000, ., , , ., , . . . 76.2 80.0

$5,000-$ 9,999 . . . . . . . . . . . . 75.1 82.1

$10,000 -$14,999 . . . . . . . . . . 88.0 89.9

$15,000 -$24,999 . . . . . . . . . . 95.3 94.9

$25,000 And over . . . . . . . . . . 96.2 96.0

Income unknown,,,.,...,.. 83.1 84.9

likely to be insured than persons 15 years of age and over in

each of the three income groups below $15,000. These findings

suggest that U.S. children are more likely to have a financial

barrier to hospital care than are the rest of the U.S. population,

or the Canadian population.

To further explore the question of financial barriers, the

rate of hospital episodes was compared by age, income, and

insurance status (table GG). A hospital episode is defined as a

continuous period of stay of 1 night or more in a hospital as an

inpatient, except the period of stay of a well newborn infant.

The statistics were taken from the 1978 National Health Interview Survey, which did not cover the institutionalized population or collect information on persons who died during the reference period. Because of differences in the definition, coverage,

and sampling procedures, the rates of hospital episodes were

lower than the hospital discharge rates obtained from the U.S.

National Hospital Discharge Survey,

For all income groups, the difference in the rates of hospital episodes of children under 15 years of age who were insured

and not insured was not statistically significant. For persons 15

years of age and over, though, the hospital episode rate was 45

percent higher for the insured. In both age groups, the hospital

episode rate was significantly higher for persons with an annual

Table GG. Ratea of hospital epiaodea by annual family income,

health insurance status, and age: United States, 1978

[Dat.1 are based on a household interview survey of the civilian noninstitutionalized

populatmn. Further information about the survey is provided in appendix 1]

Annual family income and

health insurance status Under 15 years 15 years and over

All incomesl,2 . . . . . . . . . . . . .

Insured . . . . . . . . . . . . . . . . .

Not insured.,........,,.

Under $10,0002 . . . . . . . . . . . .

Insured, . . . . . . . . . . . . . . . .

Not ineured . . . . . . . . . . . . .

$10,000 andover2 . . . . . . . . .

Insured . . . . . . . . . . . . . . . . .

Not insured .. !,..,.. .,, .

Rate per 10,000 population

628 1,521

641 1,573

543 1,088

735 1,985

786 2,165

554 1,185

608 1,313

612 1,333

607 1,011

llnclucles hospital episodes of persons whose fsmily income was unknown.

‘Includes hospital episodes of persons whose insurance status wss unknown,

family income of less than $10,000 than for persons with incomes of $10,000 and over. Within the under $10,000 income

group, persons with insurance had higher hospital episode rates

than persons without insurance. Children under 15 years with

insurance had a 42-percent higher rate than those without insurance, and persons 15 years of age and over with insurance

had an 83-percent higher rate than those without insurance.

Within the $10,000 and above income group, children’s rates

of hospital episodes were virtually the same whether or not

they were insured, but persons 15 years of age and over with

insurance had a 32-percent higher rate of hospital episodes

than those without insurance.

Thus, all U.S. persons 15 years of age and over without

insurance, and U.S. children without insurance in families with

incomes of less than $10,000, appear to have a financial barrier to hospital care. In 1978, 6 percent of U. S. children under

15 years of age and almost 9 percent of U.S. children under 1

year of age fell into the not-insured, under $10,000 income

category.

Discussion

Comparison of health services in the United States and

Canada produced some evidence to support both the expkmations that were explored for lower hospital use by U.S. children.

The possibility that ambulatory care was substituted for inpatient care in the treatment of U.S. children was suggested by

the higher rate of pediatricians in the United States than in

Canada and the inverse relationships between the rates of physicians and pediatricians and children’s discharge rates by geographic division. The higher average number of physician contacts per person for U.S. than Canadian children also supported

the substitution explanation.

The possibility that U.S. children may have experienced

barriers to hospital care that did not affect Canadian children

was not indicated by the statistics on supply and distribution of

health resources or physician use. Canada had a higher rate of

pediatric hospital beds and the beds were more widely distributed in all sizes of hospitals than in the United States. However,

the positive relationship between total hospital beds and children’s discharge rates for the geographic divisions of the United

States suggested that U.S. children were readily admitted to

nonpediatric beds. Despite a different distribution of the place

of physician contacts in the United States and Canada, physicians appeared to be equally accessible to children in the two

countries, because the same proportions of U, S. and Canadian

children saw a physician in a year.

The possible barrier to hospital care for some U.S. children

was financial. Canadian children were virtually all covered by

a national hospital insurance program, but a portion of U.S.

children had no health insurance coverage. Younger children

and children in lower income families, who have comparatively

high rates of hospital use, were particularly likely to lack insurance. The lower hospital episode rates of the lower income

U.S. children who had no insurance raises the concern that

these children may not have been able to obtain hospital care

when they needed it because of its cost.

31
Summary

The United States has a hospital discharge rate higher

than many other Western industrialized countries, but the discharge rate of U.S. children is comparatively low. This comparison of hospital use by children in the United States and

Canada was undertaken to explore explanations for the low

U.S. discharge rate.

U.S. children were found to have lower discharge rates

than Canadian children across most age, sex, and diagnostic

groups. These widespread differences suggested that some

general characteristic of children or their health services varied

between Canada and the United States. However, particularly

large differences in discharge rates for some conditions also

seemed to indicate specific variations in the incidence of certain

conditions or medical practices. Most important was the respiratory diseases category in which U.S. children had much

lower discharge rates for conditions such as upper respirato~

infections and hypertrophy of tonsils and adenoids but rates

similar to Canadian children for pneumonia. The lower frequency of tonsillectomy with or without adenoidectomy for

U.S. children also stood out, especially because with the procedure excluded there were no differences in the discharge rates

of U.S. and Canadian children with surgical procedures.

The findings on the general health status of U.S. and Canadian children and on the incidence of specific conditions in the

United States and Canada did not provide a complete explanation for the differences in children’s discharge rates. Infant

mortality was higher in the United States, which helped explain the higher proportion of U.S. newborn infants who were

not healthy, but shed no light on the higher discharge rate of

Canadian children under 1 year, excluding newborn infants.

Children 1–4 years of age had a higher death rate, and children

5– 14 years of age a lower death rate in the United States than

in Canada, which did not explain why the discharge rates for

both age groups were lower in the United States. The hig!her

average numbers of disability days and bed days reported for

U.S. children also were not consistent with their lower discharge rates. Except for pneumonia, respiratory diseases were

not a major cause of death for children in either country, and

differences in death rates for respiratory diseases, including

pneumonia, were slight.

Evidence was found that ambulatory care may be substituted for the inpatient care of children in the United States.

Canada had a higher rate of total hospital beds and pediatric

beds, which could encourage hospital use. The United States

had a higher rate of pediatricians, who are thought to be especially likely to treat children on an ambulatory rather than inpatient basis. A higher average number of physician contacts

per year was also reported for children under 10 years of age in

the United States. An emphasis on treating U.S. children on an

ambulatory basis whenever possible could help account for

both the generally lower children’s discharge rates in the

United States and the dramatically lower rates for less serious

conditions, such as hypertrophy of tonsils and adenoids and

upper respiratory infections.

However, there were also indications that some U.S. children may have confronted financial barriers to hospital care,

unlike Canadian children who were virtually all covered by

health insurance programs. U.S. children under 15 year of age

were significantly more likely than the population as a whole to

be uninsured. U.S. children in families with less than $10,000

annual income were more likely to be uninsured than other

children. Among U.S. children in families with an annual income less than $10,000, those without insurance coverage had a

significantly lower rate of hospital episodes than those with

coverage, suggesting that lack of insurance could have prevented some of the uninsured from being hospitalized when

they needed inpatient care.

Thus, the lower discharge rate for U.S. children should be

considered both a positive finding and a source of concern, The

evidence that ambulatory care substitutes for inpatient care in

the treatment of U.S. children is positive, because hospital care

is not only costly but can result in emotional problems for children. However, the lack of insurance and indications of poorer

health status for young children in the United States should be

of concern to health policymakers. Additional research is

needed to analyze the relative contributions of the positive and

negative factors to children’s hospital use. A better understanding of these factors should be of value to children in the United

States and other countries of the world.

32
References

lNational Center for Health Statistics, B. J. Haupti Utilization of shortstay hospitals, annual summary for the United States, 1980. Vital and

Health Statistics. Series 13, No. 64. DHHS Pub. No. (PHS) 82-

1725. Public Health Service. Washington. U.S. Government Printing

Oflice, Mar. 1982.

2Sundhedsstyre1sen: $vgdomsmonsteret ved somatiske sygehusaf

delinger, 1979. Copenhagen. Sundhedsstyrelsen,1981.

‘Statistics Canada, Health Division Unpublished 1978 data from the

Institutional Care Statistics Section.

4National Health Statistics Centre: Hospital and Selected Morbidi~

Data, 1980, Wellington, New Zealand. National Health Statistics

Centre, 1981.

‘Department of Health and Social Security, Oflice of Population

Censuses and Surveys, and Welsh Oflice Hospital In-patient Enqui~,

Summaty Tables, 1979. London. Her Majesty’s Stationery Otlice,

1982.

6Centraal Bureau vcor de Statistiek and Ministerie van Volksgezondheid en Milieuhygiene: Compendium Ge.zondheidsstatistiek Nederlan~

1979, The Hague, The Netherlands. Staatsuitgeverij, 1980.

7Health Insurance Commission Fourth Annual Report, 1977-78.

Canberra. Australian Government Publishing Service, 1979.

SR, Andersen and J, T. Hulh Hospital utilization and cost trends in

Canada and the United States. Health Services Rev. 4(3): 198–222,

Fall 1969.

‘R Berfenstam: Cross-national comparative studies on hospital use.

W&d Hospitals 9(4):143-149, 1973

lQB Abel-smith: Value for Money in Health Services. London.

Heinemann, 1976.

11National Center for Health Statistics, L. J. Kozak International

utilization of hospital services. Health, United States, 1980. DHHS

Pub, No. (PHS) 81-1232. Public Health Service. Washington. U.S.

Government Printing Office, Dec. 1980, pp. 85-97.

1IS, Afidreopoulos, cd.: National Health Insurance: Can We Learn

From Canada? New York. John WiIey and Sons, 1975.

1~National Center for Health Statistics, L. J. Kozak, R. Andersen,

and 0, A, Anderson: The status of hospital discharge data in

six countries, Vital and Health Statistics. Series 2, No. 80. DHEW

Pub. No. (PHS) 80-1354. Public Health Service. Washington. U.S.

Government Printing Ofllce, Mar. 1980.

1qNational Center for Health Statistics, L. J. Kozak, R. Andersen,

and 0, A. Andersen: The status of hospital discharge data in

Denmark, Scotland, West Germany and the United States. Vital and

Health Statistics. Series 2, No. 88, DHHS Pub. No. (PHS) 81-1362.

Public Health Service. Washington. U.S. Government Printing OffIce,

June 1981.

lsR. S. Duff, C. D. cook, C. Z. Margolis, W. E. Lattanzi, and J.

Landwirth: A review of pediatric inpatient care. Am. J. Dis. Child.

129( 12):1422-1424, Dec. 1975.

16D. s. Mundel: Efficacy and effectiveness of pediatric hospitalization,

in Harvard Child Health Project, Children’s Medical Care <Veedsand

Treatments. Cambridge, Mass. Ballinger Publishing Company, 1977.

17F. A. Cornell, R. W. Day, and J. P. LoGerfo: Hospitalization of

Medicaid childrem Analysis of small area variations in admission rates.

AJPH71(6):606–613, June 1981.

lSW. R. Brewer, and M. A. Freedman: Causes and implications of

variation in hospital utilization. J. Publ. Health Policy 3(4):445-454,

Dec. 1982.

1gK Osgood G. p. Bunch, and W. Shonick: The impact of a pediatric

practice on hospital admissions in a rural area. AJPH 70( 10):1100-

1103, Oct. 1980.

zoL A Aday, R. Andersen, and G. V. Fleming A theoretical frame-

. .

work for the study of access to medical care, Health Care in the U.S.

Equitable for Whom? Beverly Hills. Sage Publications, 1980, pp.

25-45.

21Statistics Canada, Health Divisiom Hospital Morbidity and Surgical Procedures: Preliminary Annual, 1979-80. Ottawa. Statistics

Canada, Mar. 1982.

22Nation~ centerfor Health Statistics, W. R. Simmons: Development

of the design of the NCHS Hospital Dis~harge Survey. Vital and

Health Statistics. Series 2, No. 39. PHS No. 1000. Public Health

Service. Washington. U.S. Government Printing Office, Sept. 1970.

2sStatistics Canada, Health Division: Hospital Morbidi~, 1978.

Ottawa. Statistics Canada, Apr. 1982.

2’@Jational Center for Health Statistics: Vital Statistics of the United

States, 1978, Vol. II, Part A. DHHS Pub. No. (PHS) 83-1101.

Public Health Service. Washington. U;S. Government Printing Oflice,

1982.

25u. s. Bureau of the Census: Preliminary estimates of the population

of the United States by age, sex, and race: 1970 to 1981. Current

Population Reports. Series P-25, No. 917. Washington. U.S. Government Printing Office, 1982.

26Statistics Canada, Health Division: Vital Statistics, 1978, Volume

III: Mortality, Summary List of Causes. Ottawa. Statistics Canada,

June 1980.

27Statistics Canada, Herdth Divisiorx Causes of Death, 1978. Ottawa.

Statistics Canada, Feb. 1980.

28Statistics Canada, Demography Division Final Intercensal Estimates of the Population by Stzx and Age, Canada and Provinces,

June lst, 1977 to 1981. Ottawa. Statistics Canada, 1983.

33
ZgNational Center for Health Statistics: Health survey procedure

concepts, questionnaire development, and definitions in the Health

Interview Survey. Vital and Health Statistics. Series 1, No. 2. PHS

Pub. No. 1000. Public Health Service. Washington. U.S. Government Printing OffIce, May 1964.

30National Center for Health Statistic Health Interview Survey

procedure, 1957-1974. Vital and Health Statistics. Series 1, No. 11.

DHEW Pub. No. (HRA) 75-1311. Health Resources Adminktration.

Washington. U.S. Government Printing Office, Apr. 1975.

31U.S. National Health Survey, W. R. Simmons: The statistical

design of the health household interview survey. Health Statistics.

PHS Pub. No. 584-A2. Public Health Service. Washington. July 1958.

32National Center for Health Statistics, J. A. Bean Estimation and

sampling variance in the Health Interview Survey. Vital and Health

Statistics. Series 2, No. 38. PHS pub. No. 1000. Public Health Service.

Washington. U.S. Government Printing Otlice, June 1970.

33Health and Welfare Canada and Statistics Canada The Health of

Canadians: Report of the Canada Health Survey. Ottawa. Statistics

Canada, June 1981.

34American Hospital Association Hospital Statistics, 1979 Edition.

Data from the American Hospital Association 1978 Annual Survey.

Chicago. American Hospital Association, 1979.

35Statistics Canada, Health Division. Hospital Annual Stati@ks,

1977-78. Ottawa. Statistics Canada, June 1981.

36American Medcsd Association Physician Distribution and Medical

Licensure in the U.S., 1978. Chicago. American Medicrd Association,

1979.

37American Medical Association Medical Education in the United

States, 1977-1978. A4MA 240(26), Dec. 22/29, 1978.

38Department of National Health and Welfare Canada Health

Manpower Invento~, 1979. Ottawa. Department of National Health

and Welfare, 1980.

39National Center for Health Statistics: Eighth Revision International

Class@cation of Diseases, Adapted for Use in the United States.

PHS Pub, No. 1693. Public Health Service, Washington, U.S.

Government Printing Office, 1967.

40J. L. Paratike and C. D. Bluestone Toward rational medications

for tonsil and adenoid surgery. Hosp. Prac. 11(2):79-87, Feb. 1976.

41National Center for Health Statistics: Vital Statistics of the United

States, 1978, Vol. I. DHHS Pub. No. (PHS) 82-1100. Public Health

Service. Washington. U.S. Government Printing Office, 1982.

42S. Y. S. Klmrn. Effectiveness of pediatric hospitalization: The case

of tonsillectomy and adenoidectomy, in Harvard Child Health Project:

Children’s Medical Care Needs and Treatments. Cambridge, Mass.

Ballinger Publishing Company, 1977.

43M. I. Roeme~ Bed supply and hospital utilization: A natural

experiment. Hospitals 35:36-42, Nov. 1961.

44L. Soderstrorn The Canadian Health System. London. Crom Helm,

1978.

q5National Center for Health Statistics, E. McCarthy. Inpatient

utilization of short-stay hospitals by diagnosis: United States, 1978.

Vital and Hea/th Statistics. Series 13, No. 55. DHHS Pub. No. (PHS)

81-1716. Public Health Service. Washington. U.S. Government

Printing Of?ice, Aug. 1981.

46National Center for Health Statistics, R. Pokras, E. J. Graves, and

C. F. Dennison Surgical operations in short-stay hospitals: United

States, 1978. Vital and Health Statistics. Series 13, No. 61. DHHS

Pub. No. (PHS) 82-1722. Public Health Service. Washington. U.S.

Government Printing Otlice, Mar. 1982.

47Commission on professional and Hospital Activities: Hospital

Adaptation of ICDA, 2nd ed. Ann Arbor. Commission on Professional and Hospital Activities, 1973.

48National Center for Health Statistics, M. G. Sirken: Utilization of

short-stay hospitals, summary of nonmedical statistics, United States,

1965. Vital and Health Statistics. Series 13, No. 2. PHS Pub. No.

1000. Public Health Service. Washington. U.S. Government Printing

Ofiice, Aug. 1967.

49National Center for Health Statistics, M. J. Witkhx Utilization of

short-stay hospitals by characteristics of discharged patients, United

States, 1965. Vital and Health Statistics. Series 13, No. 3. PHS Pub.

No. 1000. Public Health Service. Washington. U.S. Government

Printing Office, Dec. 1967.

50World Health Organizatiorx Manual of the International Statistical

Class@cation of Diseases, Injuries, and Causes of Death, Based on

the Recommendations of the Ninth Revision Conference, 1975. Geneva.

World Health Organization, 1977.

34
List of detailed tables

1. Discharge rate and average length of stay for patients under by age and selected diagnostic categories: United States

15 years of age discharged from short-stay hospitals, by and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

age and selected diagnostic categories: United States and 3. Discharge rate and average length of stay for female patients

Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 under 15 years of age discharged from short-stay hospitals,

2. Discharge rate and average length of stay for male patients by age and selected diagnostic categories: United States

under 15 years of age discharged from short-stay hospitals, and Canada, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

35
Table 1. Discharga rate and average length of stay for patients under 15 years of age discharged from short-stay hospitals, by age and selected diagnostic categories: United States and

Canada, 1978

[Forthe United States, data are for first-listed diagnoses in non-Federal hoarxtals. For Canada, data are for principal or primary diagnoais in all short-stay hospnals. Data from both countries exclude newborn Infants

and are coded using the Eighth RevMon International Classification of Diseases. Adapted for Use in the United States (ICDA-8)]

Under 15 years Underl year 1–4 years 5-14 years Under 15 years Underl year 1-4 years 5-14 years

United United United United United United United

Diagnostic categoty and ICDA-8 code

United

States Canada States Canada States Canada States Canada States Canada States Canada States Canada States Canada

All conditions . . . . . . . . . . . . . . . . . . . . . .

Infective and parasitic

diseases . . . . . . . . . . . . . . . . . 001-136

DiarrheaI disease. . . . . . . . . . . ...009

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

Endocrine, nutritional and metabolic

diseases . . . . . . . . . . . . . . . . . 240-279

Diseases of the blood and blood-forming

organa . . . . . . . . . . . . . . . . . . .280-289

Mental disorders . . . . . . . . ...290-319

Diseasea of the nervous system and

sense organs . . . . . . . . . . . . . 320-389

Otitia media without mention of

mastoiditis . . . . . . . . . . . . . . . . ..381

Diseases of the circulatory

system . . . . . . . . . . . . . . . . . . . 390-458

Diseases of the respiratory

system . . . . . . . . . . . . . . . . . ..46O-5l 9

Upper respiratory infections, except

influenza . . . . . . . . . . . . . ..46 O-465

Acute bronchitis and

bronchiolitis . . . . . . . . . . . . . . . . .466

influenza . . . . . . . . . . . . . ...470-474

Pneumonia, all forms . . . ...480-486

Bronchitis, chronic and

unqualified . . . . . . . . . . ...490-491

Asthma . . . . . . . . . . . . . . . . . . . ...493

Hypertrophy of tonsils and

adenoids . . . . . . . . . . . . . . . . ...500

Diseases of the digestive

system . . . . . . . . . . . . . . . . . . .520-577

Diseases of oral cavity, salivaw

glands, and jaws. . . . . . ...520-529

Diseases of esophagus, stomach,

and duodenum . . . . . . . . . . 530-537

Appendicitis . . . . . . . . . . ...540-543

Inguinal hernia . . . . . . . . ...550.552

Other hernia of abdominal

cavity . . . . . . . . . . . . . . . . ..55l. 553

Other diseases of intestine and

peritoneum. . . . . . ...560. 562-569

Gastroenteritis and colitis, except

ulcerative, of noninfectious

origin . . . . . . . . . . . . . . . . . . . . .. 561

Diseases of liver, gall bladder, and

pancreas . . . . . . . . . . . . . ..57O-577

Rate oer . 10,000 . oorwlation . .

666 953 2,051 838 1,342

57

26

13

12

13

9

59

30

8

210

30

20

4

47

13

12

73

68

6

6

15

17

4

7

10

●1

94

57

12

18

13

9

67

33

4

359

78

32

6

49

27

30

122

73

11

7

19

16

4

10

4

1

308

138

37

50

*22

*

119

59

47

619

123

160

*

209

55

*I7

*

260

*

37

*

90

*I8

*26

79

*

3,066

599

421

16

128

26

10

160

99

13

1,124

382

257

21

241

145

28

5

213

8

34

1

79”

15

39

34

2

76

39

11

12

10

*

97

56

*6

326

62

34

*7

90

25

22

74

70

12

*

*

24

*4

9

14

*

146

93

13

13

13

6

104

57

3

617

164

51

8

96

54

58

163

74

16

7

3

24

6

11

7

1

480

28

12

11

8

13

10

40

18

5

133

10

3

3

18

5

8

79

50

5

4

21

8

*2

5

3

*

627

30

12

11

10

12

10

46

19

4

199

20

5

4

16

7

20

118

60

10

5

27

8

2

7

1

1

Averaae Ienath af atav in davs

4.4

3.9

3.6

6.7

7.0

5.0

13.7

3.3

2.1

10.5

3.6

3.7

4.4

3.4

5.5

4.0

3.9

1.9

4.2

2.3

4.5

5.0

‘ 2.2

3.8

6.1

5.9

*8.3

5.3

5.8

5.4

8.5

8.6

5.4

17.5

4.8

3.7

8.7

4.3

4.3

6.0

4.4

7.4

6.2

4.4

1.9

4.6

2.7

4.8

5.7

2.9

4.1

6.3

5.5

10.4

6.0

4.7

4.4

7.9

6.4

“6.7

*

5.6

3.2

11.9

5.0

3.9

4.8

*

5.8

4.8

“5.7

*

5.3

*

5.4

*

2.2

*6.7

*8.2

7.4

*

-,,-

1.3 4.0

6.8

6.4

10.1

8.6

9.3

8.7

7.5

6.0

10.2

7.0

5.4

7.0

6.1

9.1

7.3

7.5

3.2

5.8

5.2

7.1

14.5

3.4

6.9

7.4

6.6

22.1

4.0

3.5

5.9

9.0

4.9

*

3.2

2.0

2.7

3.8

3.5

3.9

*3.2

5.5

3.5

3.7

1.8

3.4

2.3

*

*

2.0

*2.4

5.4

4.8

*

4.8

5.3

4.8

8.7

9.7

6.4

18.8

44

4.0

7.8

4.2

4.0

5.2

4.3

7.1

5.4

4.3

1.8

3.9

3.2

3.8

8.9

2.6

3.0

5.8

4.8

10.4

4.1

3.2

2.8

6.7

6.4

4.8

15,3

2.7

1.7

8.4

2.9

3.9

4.4

3.4

5.3

3.8

3.7

1.9

4.1

2,2

3.7

4.9

2.4

*2.6

5.5

3.9

*

4.6

4.8

3.8

8.2

8.7

4.3

18.1

4.2

2.5

8.6

2.9

3.4

4.4

3.6

6.1

5.6

4.1

1.9

4.5

2.2

4.0

5.5

2.8

3.2

6.0

3.1

8.3
Diseases of the genitourinary

system.......

.......... ..580–629

COlllp!iCations of pregnancy, ~hildbifih,

and the puerperium........ 63&67g

Diseases of the skin and subcutaneous

tissue....

.-............ ..680–709

Diseases of the musculoskeleta[ System

and connective tissue...... 710—73g

Congenital anomalies..... ...740-759

Certain causes of perinatal morbidi~

and mortality... ., ..,......760-779

Symptoms and ill-defined

conditions.............. ..78 f&7g6

Accidents, poisonings, and

violence................ ..800—999

Fracture of skull and face

bones............... ..goo–8o4

Fracture of upper limb..... 810–819

Fracture of lower limb.. ...820-829

Sprains and strains of joints and

adjacent muscles........ 840-84g

Intracranial injury (excluding those

with skull fracture).... ...850-854

Lacerations.............. 870–go7

Other injury............ ..glo-g3g

Burns................. ..g4o–g4g

Adverse effect of medicinal

agents............... ..g6o_g7g

Toxic effect of substances chiefly

nonmedicinal as to

Source................. 98&995

Other complications of surgical and

medical care....,....... 997_ggg

344

13

14

309

20

955

15

112

20956443

372

22

16

444

65

1157

17

112

24

10

116866

55. .

.

37

*18

166

131

57

114****

*19

******

73. .

.

889

216

66

216

110

2425

(’)

253

12

1059

11

40

...

16

10

41

*1

22

9857

*6*

21

11

*8

11

109*

49

...

29

12

51

(’)

83

1317881

24

12

13

13

20

157

2969

15

14*

16

924

18

12

*2

19833

*2

*2

*3

293

14

19

26

45

1105

22

132

24

10

103425

3.6

2.9

4.5

6.3

5.9

9.6

3.5

4.8

4.0

3.2

9.9

4.2

3.3

4.0

3.5

10.2

2.2

3.3

5.5

5.3

4.2

6.6

8.5

8.8

15.1

4.4

5.0

4.6

2.8

13.0

3,7

2.6

4,2

3.3

12.8

2.5

3.0

6.8

5.3 . .

.

6.8

“9.0

7.7

9.6

4.7

6.4****

*3.2

******

5.9 . .

.

8.3

12.2

13.4

15.1

5.7

5.4

3.8

5.3

13.7

9.1

2.9

3.1

3.2

10.7

3.6

4.5

9.3

2.9 . .

.

4.2

5.0

5.0

*8.2

3.1

4.5

2.9

4.9

*13,5

*

2.8

3.5

*2.3

10.3

1.6

3.2*

5.1 . .

.

6.5

7.6

7.7

8.7

4.4

4.9

4.8

3.4

16.5

3.1

2.5

3.7

3.0

12.0

1.7

2.8

6.9

3.6

2.9

3.9

6.2

4.8*

3.2

4.7

4.3

2.9

9.3

*4.1

3.4

4.2

3.3

10.6

*2.6

*3.5

*4.6

5.3

4.2

5.6

8.5

6.0

3.9

5.1

4.6

2.7

12.2

3.5

2.6

4.5

3.4

14.5

3.9

3.2

6.2

I Quantity more thanO but less than 0.5.
C.J Table 2. Discharge rate and average length of stay for male patients under 15 years of age discharged from short-stay hospitals, by age and selected diagnostic categories: United States 03

and Canada, 1978

[For the United States, data are for first-listed diagnoses in non-Federal hospitals. For Canada, data are for principal or prima~ diagnosis in all short-stsy hospitsls. Data from both countries exclude newborn infants

snd are coded using the Eighth Revision International Classification of Diseases, Adapted for Use in the United Stares [ICDA–8)]

Under 75 years Under7 year 1-4 years 5-14 years Under 15 years Under 1 year 1-4 years 5-14 years

United United United United United

Diagnostic categoty and ICDA-8 code

United United

States Canada States Canada States Canada

United

States Canada States Canada States Canada States Canada States Canada

All conditions . . . . . . . . . . . . . . . . . . . . . .

Infective and parasitic

diseases . . . . . . . . . . . . . . . . . 001 –136

Diarrheal diseases. . . . . . . . . . ...009

Neoplasms . . . . . . . . . . . . . . ..l4O–239

Endocrine, nutritional and metabolic

disessas . . . . . . . . . . . . . . . . . 240–279

Diseases of the blood and blood-forming

orgsns . . . . . . . . . . . . . . . . . ..280–289

Mental disorders . . . . . . . . . ..290–319

Disesses of the nervous system and

sense organs . . . . . . . . . . . .. 320-389

Otitis media without mention of

msstoiditis . . . . . . . . . . . . . . . ,, .381

Diseases of the circulatory

system . . . . . . . . . . . . . . . . . ..39 O–458

Diseases of the respiratory

system . . . . . . . . . . . . . . . . ...460-51 9

Upper respiratory infections, except

influenza, ... . . . . ..465 ..46 O-465

Acute bronchitis and

bronchiolitis . . . . . . . . . . . . . . ...466

influenza . . . . . . . . . . . . . ...470-474

Pneumonia, all forms . . . ...480-486

Bronchitis, chronic and

unqualified . . . . . . . . . . . ..490–491

Asthma . . . . . . . . . . . . . . . . . . . ...493

Hypertrophy of tonsils and

adenoids . . . . . . . . . . . . . . . . . ..500

Disesses of the digestive

system . . . . . . . . . . . . . . . . . ..52 O-577

Diseases of the oral cavity, salivary

glsnds, and jaws. . . . . . ...520-529

Diseases of esophagus, stomach, and

duodenum . . . . . . . . . . . . ..530–537

Appendicitis . . . . . . . . . . . ..540-543

Inguinal hernia . . . . . . . . ...550.552

Other hernia of abdominal

csvity . . . . . . . . . . . . . . . . ..55l .553

Other diseases of the intestine and

peritoneum. . . . . . ...560. 562–569

Gastroenteritis and colitis, except

ulcerative, of noninfectious

origin . . . . . . . . . . . . . . . . . . . . .. 561

Diseases of the liver, gallbladder,

and pancreas . . . . . . . . . . . 570-577

Rate per 10,000 population

728 1,061 ‘mnm ‘“-” ‘“- 4 ‘“-

60

28

12

13

14

8

65

34

9

225

32

24

4

54

15

14

70

82

7

7

16

27

*3

9

11

*

100

62

12

19

14

9

74

38

5

397

89

38

6

55

33

36

122

87

11

8

21

27

4

11

5

1

L,d214

327

138

*39

*53

*29

*

133

66

56

722

133

188

*

247

67

*

*

309

*

*42

*

132

*

*32

76

*

.5,40+

636

450

13

129

28

11

175

112

13

1,321

431

313

24

276

180

39

5

281

9

41

1

131

17

45

35

2

76

41

“10

*I5

*I4

*

106

62

*

379

73

40

*8

101

30

25

87

93

*I5

*

*

39

*

“lo

“16

*

I ,343

158

103

13

14

15

6

116

67

4

720

195

60

8

106

66

72

184

93

16

8

3

40

6

13

7

1

509

29

13

11

8

12

9

45

22

5

126

9

*4

*3

20

*5

9

70

57

*4

*5

22

13

*

7

*3

*

675

32

13

11

10

13

10

50

21

4

200

21

5

4

17

8

24

110

67

10

5

29

12

2

7

1

1

Average length of stay in days

4.5 5.3 7.4 4.0 4.7 4.3 4.7

3.9

3.4

6.4

7.0

4.2

15.6

3.3

2.0

12.9

3.7

3.5

4.3

3.5

5.8

3.8

4.0

1.9

3.8

2.4

4.6

5.0

2.3

*3.1

5.7

4.9

*

5.8

5.4

8.5

8.7

5.3

17.9

4.7

3.7

8.5

4.4

4.3

3.7

4.4

7.5

6.1

4.3

1.8

4.4

2.7

4.9

5.7

3.0

4.4

6.2

5.5

10.7

5.7

4.5

4.2

‘6.0

*6.8

*4.4

*

5.6

3.2

4.3

5.0

3.8

4.7

*

5.9

4.4

*

*

4.1

*

*5.9

*

2.4

*

“7.1

5.0

*

6.8

6.4

10.4

8.7

9.0

9.4

7.6

6.1

10.3

7.0

5.4

7.0

6.2

9.2

7.3

7.8

3.1

5.3

5.9

6.8

13.8

3.5

6.9

6.9

6.5

3.9

3.3

*I 3.6

“8.5

*5.5

*

3.4

2.0

*

3.8

3.4

3.9

*3.4

5.9

3.5

3.8

1.7

3.2

*2.4

*

*

2.0

*

*4.2

*5.2

24.6 “

5.2

4.8

8.7

9.7

6.2

9.9

4.4

3.9

7.6

4.2

3.9

5.2

4.4

7.2

5.4

4.2

1.8

3.7

3.2

3.9

9.0

2.6

3.3

5.7

5.0

7.8

3.2

2.9

7.4

6.3

3.7

18.9

2.7

1.8

8.6

3.0

3.2

*4.3

*3.6

5.4

*3.6

3.7

2.0

4.0

*2.4

*3.1

4.9

2.4

*

5.7

“4.0

*

4.9

4.2

8.2

8.3

4.2

20.6

4.0

2.4

8.3

3.0

3,2

4.1

3.6

6.0

6.2

3.9

1.9

4.4

2.2

4.0

5.5

2.9

3.3

6.0

3.1

8.8
Diseases of the genitourinary

system................. ..58 O-629

Complications of pregnancy, childbirth,

and the puerperium

........ 630-678

Diseases of the skin and subcutaneous

tissue................. ...680-709

Diseases of the musculoskeletal system

and connective tissue... ...710-738

Congenital anomalies..... ...740-759

Certain causea of perinatal morbidity

and mortal icy.............. 760-779

Symptoms and ill-defined

conditions.............. .. 780-796

Accidents, poisonings, and

violence................ .. 800-999

Francture of skull and face

bones............... ..8OO-8O4

Fracture of upper limb.. ...810-819

Fracture of lower limb.. ...820-829

Sprains and strains of joints and

adjacent muscles..... ...840-848

Intracranial injury (excluding those

with skull fracture).... ...850-854

Lacerations........... ...870-907

Other injury............ ..91 O-939

Burns................. ..94&94g

Adverse effect of medicinal

agenta............... ..96 O-979

Toxic effect of substances chiefly

nonmedicinal as to

source................. 980-995

Othar complications of surgical and

medical care............ 997-999

32. . .

13

13

369

21

1176

18

14

*2

27

1257454

40. .

.

23

17

534

67

1408

21

152

30

13

148776

●51. .

.

“42*

191

140

*52

117***********

99. .

899

243

76

223

119

2724

(’)

264

13

1358

14

38. .

.

’14

11

44

*1

25

109

****

25

*I5

*8

*lo

*11

*lo

*

58. .

.

30

13

63

(’)

90

151

69

111

27

14

15

15

22

188

28. .

.

10

13

18*

17

120

*5

23

17*

28

11

*4

*5*

*3*

29. .

.

15

19

33

45

1377

27

173

32

14

145235

3.3. .

.

4.8

6.8

5.8

9.6

3.5

4.7

4.6

2.9

9.5

‘4.0

3.2

4.1

3.1

9.3

2.0

3.2

6.0

4.6. .

.

6.4

8.6

8.4

14.7

4.4

5.2

4.8

2.8

13.3

3.5

2.7

4.4

3.4

13.1

2.2

3.0

6.7

*4.2. .

.

*6.8

*

7.7

9.7

*3.9

6.2***********

4.8. .

.

8.2

11.6

13.4

14.7

5.5

5.3

3.7

5.6

14.3

5.3

3.0

3.4

3.6

10.6

3.4

3.5

7.8

2.2. .

.

*4.8

5.3

4.5

“9.0

3.2

4.2****

3.1

*3.4

*2.7

*8.7

*1.8

83.1

*

4.1. .

.

6.3

7.4

7.6

10.5

4.3

5.1

5.1

3.4

16.8

3.1

2.8

3.7

3.2

11.8

1.7

2.7

6.7

3.7. .

.

4.0

7.2

5.1

*

3.5

4.7

4.7

2.7

9.1*

3.2

4.5

*3.6

*10.4

*

*3.4

*

4.9. . .

5.4

8.8

5.7

4.0

5.2

“5.0

2.7

12.5

3.6

2.6

4.6

3.5

15.1

3.7

3.5

6.5

1Quantity more thanO but Ieaa than 0.5.
.P

o

Table 3. Discharge rate and avarage length of stay for female patiants undar 15 years of age discharged from short-stay hospitals, by age and selacted diagnostic categories: United States

and Canada, 1978

[Forthe United Statea, data are for first-listed diagnoses innon-Federal hospitals. For Canada, data are forprincipal orprimaW diagnosis inallshoR-stay hospitala. Data from both countries exclude newborn infanta

and are coded using the Eighth Revision International Classification of Diseases, Adapted for Use in the United States (I CDA-8)]

Under 15 years Underl year 1-4 years 5– 14 years Under 15 years Underl year 1-4 years 5-14 yaars

United United United United United United

Diagnostic categow and ICDA–8 code

United United

States Canada States Canada States Canada States Canada States Canada States Canada States Canada States Canada

All conditions . . . . . . . . . . . . . . . . . . . . . .

Infective and parasitic

diseases . . . . . . . . . . . . . . . ..001 -l36

Diarrhaal disease . . . . . . . . . . . ...009

Neoplaams . . . . . . . . . . . . . ...140-239

Endocrine, nutritional and metabolic

diseases . . . . . . . . . . . . . . . . . 240-279

Diseases of the blood and blood-forming

organs . . . . . . . . . . . . . . . . ...280-289

Mental disorders . . . . . . . . ...290-319

Diseasas of the nervous system and

sense organa . . . . . . . . . . . . .320-389

Otitis media without mention of

mastoiditis . . . . . . . . . . . . . . . ...381

Diseaaes of tha circulatory

system . . . . . . . . . . . . . . . . . . .390-458

Diseases of the respiratory

system . . . . . . . . . . . . . . . . . ..46O-5l 9

Upper respiratory infections, except

influenza . . . . . . . . . . . . . . . 460-465

Acute bronchitis and

bronchiolitis ...,.....,.......466

influenza . . . . . . . . . . . . . . ..47O-474

Pneumonia, all forms . . . ...480-486

Bronchitis, chronic and

unqualified . . . . . . . . . . ...490-491

Asthma . . . . . . . . . . . . . . . . . . . ...493

Hypertrophy of tonsils and

adenoids . . . . . . . . . . . . . . . . . ..500

Diseases of the digestive

system . . . . . . . . . . . . . . . . . . .520-577

Diseases of oral cavity, salivary

glands, and jaws. . . . . . ...520-529

Diseases of esophagua, stomach, and

duodenum . . . . . . . . . . . . ..53 O-537

Appendicitis . . . . . . . . . . ...540-543

Inguinal hernia . . . . . . . . ...550.552

Other harnis of abdominal

cavity . . . . . . . . . . . . . . . . ..55l ,553

Other disesses ofinteatine and

peritoneum. . . . . . ...560. 562-569

Gastroenteritis and colitis, except

ulcerative, of noninfectious

ongm.. . . . . . . . . . . . . . . . . . . ..561

D[seases of liver, gallbladder, and

pancreas . . . . . . . . . . . . . ..57 O-577

601

55

25

13

11

12

9

52

25

7

194

27

16

4

40

10

10

76

54

6

6

15

7

4

5

10

*

839 1,797 2,646 727 ‘--

87

52

11

18

12

8

60

29

4

318

65

25

5

44

22

23

122

57

12

7

17

5

3

8

4

1

288

138

*35

*46

*

*

103

*52

*38

511

112

130

*

169

“43

*

*

208

*

“32

*46

*

*

83

*

560

391

19

126

24

9

145

85

13

916

331

198

18

203

108

17

4

140

8

28

1

24

13

33

32

2

75

38

*13

*9

*

*

89

50

*

270

51

27

*

78

19

18

60

46

*

*

*

*

*

*

*12

*

1,128

132

83

13

12

11

5

91

48

3

508

132

41

8

85

42

43

140

54

16

7

2

7

7

9

6

1

449

27

10

11

8

13

11

35

15

*5

139

12

*2

*3

16

*4

7

89

42

*6

*4

20

*3

*

*3

“3

*

576

28

11

10

10

12

9

42

17

3

198

18

4

4

15

7

17

126

51

11

5

24

3

1

6

1

1

Rates per 10,000 Modulation Averaga length of stay in days

4.4

4.0

3.8

7.0

7.1

6.1

11.9

3.2

2.1

7.4

3.4

4,0

4.5

3.2

5.1

4.3

3.7

1.9

4.8

2.1

4.4

5.0

1.9

4.5

6.8

7.0

*

5.3

5.8

5.3

8.5

9.0

5.5

17.1

4.9

3.8

9.0

4.1

4.4

6.1

4.3

7.3

6.2

4.4

1.9

4.7

2.6

4.8

5.6

2.7

3.8

6.6

5.5

10.1

6.3

4.8

4.7

*1 0.0

“6.0

*

*

5.6

*3.3

*8.3

4.9

3:9

4.9

*

5.5

*5.6

*

*

7.2

*

*4.6

*1.7

*

*

9.7

*

7.7

6.8

6.3

9.9

8.6

9.6

7.9

7.4

5.9

10.0

6.9

5.4

6.9

6.0

9.1

7.3

7.0

3.4

6.7

4.5

7.5

15.8

3.0

6.9

8.2

6.7

19.7

4.0

4.0

3.7

*7.8

*9.9

*

*

2.9

2.1

*

3.7

3.7

3.9

*

4.9

3.5

3.7

1.9

4.0

*

*

*

*

*

*

*4.4

●

5.0

5.4

4.8

8.7

9.8

6.7

30.8

4.4

4.0

8.1

4.3

4.2

5.4

4.2

7.0

5.5

4.4

1.9

4.1

3.3

3.6

8.7

2.4

2.7

6.0

4.5

13.9

3.9

3.3

2.7

5.9

6.5

5.8

12.4

2.7

1.6

*8.2

2.8

4.5

*4.6

*3.3

5.2

*4.2

3.7

1.9

4.1

*2.1

*4.3

4.8

*2.3

*

“5.0

*3.7

*

46

4.6

3.2

8.2

9.0

4.4

15.4

4.5

2.5

8.9

2.9

3.5

4.7

3.5

6.3

4.8

4.3

1.9

4.5

2.1

4.0

5.5

2.6

3.1

6.0

3.2

8.1
Diseases of the genitourinary

system.................. .5g&62g

Complications of pregnancy, childbirth,

andthepuerperium...... .. 630-678

Diseases of the skin and subcutaneous

tissue.................. ..68&7(Jg

Diseases of the musculoskeletal system

and connective tissue...... 71 O-738

Congenital anomalies..... ...740-759

Certain causes of perinatal morbidity

and mortal ity............ ..76r)-779

Symptoms and ill-defined

conditions.............. .. 78&796

Accidents, poisonings, and

violence................ ..80()-ggg

Fracture of skull and face

bones............... ..8 OO-8O4

Fracture of upper limb.. ...810-819

Fracture of lower limb..... 820–829

Sprains and strains of joints and

adjacent muscles...... .. 840-848

Intracranial injury (excluding those

with skull fracture)..... .. 850-854

Laceration........... ...870-907

Other injury............ ..91 O-939

Burns................. ..94O-949

Adverse effect of medicinal

agenta............... ..96 O-979

Toxic effect of aubstancea chiefly

nonmedicinal as to

source................. 980–995

Other complications of surgical and

medical care.......... 997-999

358

13

15

258

18

724

127*

136455

*.

3

*3

334

21

16

344

63

895

1381

18785855

“60. .

.

“31

*

140

122

62

110

***********

46. .

.

869

187

57

209

100

21251

242

118599

42

...

17

*9

37

*I

19

87***

17**

*12

“9**

39. .

.

28

10

38

(’)

75

110575

(’)

21

10

11

10

18

126

31

129

17

10

14

64

*3

147*

11

*6**

*3**

296

13

19

19

46

804

1692

17772524

3.9

2.9

4.2

5.8

6.0

9.5

3.5

4.9

3.1

3.6

10.7*

3.3

3.7

3.9

11.6

2.3

*3.5

“4.7

6.1

4.2

6.8

8.4

9.3

15.7

4.5

4.8

4.3

2.8

12.4

3.9

2.5

3.9

3.0

12.5

2.8

3.2

6.9

*6.3. .

.

*6.9

*

7.6

9.6

5.5

6.7***********

8.3. .

.

8.5

12.8

13.5

15.8

5.9

5.6

3.9

4.9

13.1

12.4

2.7

2.7

2.8

10.9

3.8

5.5

11.8

3.6. .

.

3.7

*4.6

5.6

“7.0

2.9

5.0***

2.3**

“11.6

*1.8

**

6.5. .

.

6.8

7.9

8.0

7.1

4.5

4.5

4.3

3.4

15.9

3.1

2.1

3.7

2.7

12.4

1.7

2.9

7.2

3.5

2.9

3.7

5.5

4.4

2.9

4.5

*3.5

3.2

9.8*

4.1

*3.5

**

*2.6

**

5.6

4.2

5.8

8.3

6.5

3.9

4.9

4.4

2.6

11.7

3.4

2.7

4.1

3.2

13.0

4.1

2.7

6.0

lQuantity more than

O but Iess than 0.5,
Appendixes

Contents

I. Sources of data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

II. Definitions ofselectedterms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

List of appendix tables

I.

II.

III.

IV.

v.

VI.

VII.

VIII.

Hospital discharge datasystems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mortality data systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

National household interview surveys. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hospital facilities datasystems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Physician data systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hospital useterms .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Health status terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Health services terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

43

55

43

46

48

51

53

55

56

57
Appendix I

Sources of Data

Table 1. Hospital discharge data systems

Characteristic United States Canada

Data system National Hospital Discharge Survey, conducted

by the National Center for Health Statistics

(NCHS).

Background In 1962–63, NCHS developed the Master Facility Inventory (MFI), a comprehensive list of hospitals, nursing homes, and other inpatient facilities

in the United States. In 1964 a sample of 95 hospitals was drawn from the MFI for a pilot study

of hospital discharges. A master sample of 690

hospitals was drawn from the MFI in 1965, 350

of which were inducted into the National Hospital

Discharge Survey. An additional 150 hospitals

from the master sample were added to the survey

during the first years of operation. In 1972 and

every 2 or 3 years since, the master sample has

been supplemented by a “birth sample” drawn

from lists of new hospitals added to the MFI since

1965. In 1978 there were 535 hospitals in the

survey sample, 413 of which participated in the

survey.

Methods of data collection A two-stage stratified sampling design is used in

the survey. The first stage is selection of a sample

of hospitals. The primary stratification variables

are bed size and geographic region. Hospitals are

selected in direct proportion to size. Hospitals

with 1,000 beds or more have a sampling probability of certainty, and the sampling probability

decreases to 1 in 40 for hospitals with less than

50 beds. The second stage is a systematic sample

of discharges from the sampled hospitals. The

discharges are selected in inverse proportion to

hospital size. In hospitals with 1,000 or more

beds, the sampling probability is 1 in 100, in hospitals with less than 50 beds, it is 4 in 10.

The sampling frame in nearly all hospitals is

the daily listing of discharges. A random sampling

technique is used, usually based on the terminal

digit of the patient’s medical record number,

An abstract is completed on each sample discharge using the information available on the face

National hospital morbidity statistics, compiled

by Statistics Canada.

One of the requirements of the national hospital

insurance program, which began operation in

1958–6 1, was that each Province collect information on its discharges so that patient eligibility

could be checked and per diem payments to the

hospitals could be determined. The Royal Commission on Health Services, which was serving

while the insurance program was beginning,

recommended that Statistics Canada obtain hospital morbidity records from the Provinces and

compile national morbidity statistics. The Provinces all developed discharge reporting systems,

and national morbidity data were first compiled

in 1960.

The hospital morbidity statistics are not based on

a sample survey but a complete count of inpatient

cases. An admission/discharge form is filled out

for each patient discharged. The staff members of

the individual hospitals complete the forms, but

the coding of diagnoses and surgical procedures

is usually done by Provincial authorities. Hospitals

send the forms to Provincial hospital insurance

commissions, which tabulate data for their own

purposes and prepare a computer tape of data,

which is sent to Statistics Canada. At Statistics

Canada the data tapes are converted to a standard

format, edited for errors and missing data, and

processed.

NOTE: A list of references follows the text.

43
Table 1. Hospital discharge data systems—Con.

Characteristic United States Canada

Coverage

Items collected

Coding

sheet of the patient’s medical record. In about

two-thirds of the hospitals, the abstracting is done

by the medical records department of the hospital.

In the remainder the work is done by the U.S.

Bureau of the Census acting for NCHS. The

NCHS staff code all abstract information, including diagnoses and surgical procedures. The data

are subsequently transferred to computer tapes,

edited, and processed.

The survey covers hospitals in the 50 States and

the District of Columbia for which the average

length of stay is less than 30 days, with the following exceptions: institutional hospitals, such as

prison hospitals and university student health centers; Federal hospitals, such as military and Veterans Administration hospitals; and hospitals with

fewer than 6 beds.

Within covered hospitals, the sample of discharges sometimes excludes patients in long-term

care units, if the units keep records separately

from the rest of the hospital. Discharges of newborn infants are sampled but are excluded from

the published totals.

Items include personal characteristics of patients,

such as date of birth, sex, race, marital status.

and residence (zip cede); administrative information, such as admission and discharge dates, discharge status, medical record number, and expected principal source of payment; and medical

information, up to five diagnoses and three surgical procedures in 1978, and dates of surgical

procedures.

The Eighth Revision International Classl~cation

of Diseases, Adapted for Use in the United

States39 (ICDA–8) was the basic system used

for coding diagnoses and surgical procedures.

However, some modifications have been made in

the ICDA–8 for the survey. A complete list of

the modifications has been published.45.46 Most

important for this study are the exclusion of maternal conditions and conditions of the placenta

and umbilical cord (760-77 1), except for birth

injuries with mention of cause, which are coded

as birth injury (772), and exclusion of some operations inducing or assisting delivery (75.0–75.6,

75.9).

The statistics are collected from all general and

allied special hospitals in the Provinces. Allied

special hospitals include rehabilitation, convalescence, extended care, and chronic hospitals. In

1978, psychiatric hospitals were not covered,

though they may be included in future years. The

Canadian Territories, Yukon and the Northwest

Territories, are not covered.

In some Provinces, data on patients whose

hospitalizations are not paid for by the health insurance program are not reported. Approximate] y

99 percent of the Canadian population is covered

by the hospital insurance program, but some hospitalizations of insured patients may be the responsibility of alternative programs, such as

Workmen’s Compensation. Data on newborn infants are collected but are excludedfromthe published totals.

The items on the admission/discharge forms vary

from Province to Province. A core of information

is collected in all Provinces, but some differences

exist in the definitions and classifications used for

common items. The standard record prepared by

Statistics Canada on each discharge includes age,

sex, principal or primary diagnosis, primary surgical procedure, length of stay, and identification

of the hospital.

The Eighth Revision International Classlycation

of Diseases, Adapted for Use in the United

States39 (ICDA–8) was used for coding diagnoses

and surgical procedures, except in Alberta, which

used the hospital adaptation of the International

Classification of Diseases,47 second edition, which

cannot be perfectly translated into ICDA–8 at all

levels of detail. The conditions and procedures

excluded from the coding list in the United States

were included for Canada, but in this study, the

data on the operations inducing or assisting delivery (75.0-75.6, 75.9) were excluded from the

surgical statistics.

NOTE: A list of references follows the text,

44
Table i. Hospital discharge data systems—Con.

Characteristic United States Canada

Other procedures

Release of data

Missing data procedures Missing data on age or sex are imputed by assigning an age or sex to the patient consistent with

other patients who have the same diagnostic code.

In the rare instance when date of admission or

discharge cannot be obtained, length of stay is

imputed by assigning a length of stay characteristic of other patients of the same age.

A complex estimating procedure is used to obtain

essentially unbiased national estimates from the

sample data. The procedure has three principal

components: inflation by reciprocals of the probabilities of sample selection, adjustment for nonresponse, and ratio adjustment to fixed totals.

Detailed descriptions of the estimating procedure,48’49 and discussions of sampling errors,45,46

have been published.

Annual reports of data from the survey are published in NCHS’S Vital and Health Statistics

Series 13. These reports update summary nonmedical, medical, and surgical data for characteristics of patients and hospitals. Special reports

are also published in the series on selected topics

such as average length of stay, patient charges,

and geographical utilization.

Unpublished data from the survey are available on request from the NCHS Division of

Health Care Statistics, and data for 1970 and

subsequent years are available on public use

tapes.

Missing data on age or sex are imputed according

to a predetermined mathematical model that assigns an age or sex consistent with the patient’s

diagnosis and surgical procedure.

To obtain data for this study on short-stay hospital discharges, the computer files of hospital

morbidity statistics were merged with files that

contained the average length of stay of each

Canadian hospital. The discharge records from

hospitals in which the average length of stay was

less than 30 days were identified using the hospital number on each record, and data from these

records were tabulated separately.

Data are published in annual reports, Hospital

Morbidity, and Surgical Procedures and Treatments, which present number of discharges, discharge rates, and average length of stay by age

and sex and by sex and Province, in the former

report, for each three-digit diagnostic category, in

the latter report for each three-digit surgical code.

Unpublished data are available from the Institutional Care Statistics Section, Health Division, Statistics Canada.

NOTE: A list of references follows the text.

45
Table 11. Mortality data systems

Characteristic United States Canada

Data system National vital statistics system, managed by the

National Center for Health Statistics (NCHS).

Methods of data collection Births, deaths, fetal deaths, induced terminations

of pregnancy, marriages, divorces, and dissolutions of marriages are registered by State and

local authorities. Deaths are generally reported to

a local registrar who sends the records to a State

health department. The State officials transmit

microfilm copies of the records or machine-readable data to NCHS. In 1978 all data from death

registrations were coded at the State level in 7

States. These States provided NCHS with data

on computer tapes. In 29 States demographic data

were coded at the State level and submitted to

NCHS on computer tape, but copies of the death

certificates were also forwarded, and NCHS

coded cause of death. For the remainder of the

States, NCHS received copies of the death certificates and coded all data,

Every State has a law requiring registration of all

deaths, and almost all deaths are registered, but

there is evidence that registration is incomplete in

certain isolated areas.

Completeness

Items collected

●

●

Coding system In

A standard death certificate, developed and periodically revised by NCHS in cooperation with

State and local authorities, is recommended for

use in all States. Because of variations in laws

and practices, not all States use the standard certificate, but most follow it closely. The standard

certificate recommended for use beginning

January 1, 1978, included the following items:

Sociodemographic—sex, date of birth and

death, age, marital status, race, occupation,

citizenship, whether ever in the armed services, and social security number.

Geographic—place of death (county, city or

other location, and hospital), pl,ace of injury,

residence of deceased, place of birth, and

address of parents,

Mortality—underlying cause, immediate

cause, other significant conditions, autopsy,

disposition, and details about injuries.

1978 the Eighth Revision International

ClasslYcation of Diseases, Adapted for Use in

the United States39 was used to code cause of

death.

Release of data Mortality data are published by NCHS in the

Monthly Vital Statistics Report, the annual Vital

NOTE: A list of references follows the text.

46

National vital statistics system, managed by Statistics Canada.

Under Federal-Provincial agreements, the Provinces and Territories are required to register births,

stillbirths, marriages, and deaths, and to collect

uniform items of information about these events.

Microfilm copies of the registrations are sent to

Statistics Canada. Six Provinces also provide

Statistics Canada with machme-readable abstracts

of the registrations. Statistics Canada converts

the registrations from the four Atlantic Provinces

and the Territories to machine-readable form.

The cause of death is coded by trained medical

coders, usually in Provincial offices, but for Newfoundland and the Territories the coding is done

at Statistics Canada.

Almost all deaths are thought to be registered,

though no recent studies have been done on the

coverage of the system. A very small proportion

of deaths are not included in the national statistics

because they are reported after the cutoff date.

Data items collected on all deaths include the

following:

●

●

●

In

Sociodemographic—sex, date of birth and

death, age, marital status, ethnic origin, and

occupation.

Geographic—place of death (Province, area,

and hospital), place of injury, residence of

deceased, place of birth, and birthplace of

parents.

kfortality-underlying cause, designation of

medical attendant, autopsy, and disposition.

1978 the Eighth Revision International

ClasslYcation of Diseases, Adapted for Use in

the United States3g was used to code cause of

death.

Statistics Canada publishes Vital Statistics,

Volume III, Mortality, Summary List of Causes
Table Il. Mortality data systems—Con.

Characteristic United States Canada

Statistics of the United States, and special reporta and Causes ofDeath each year. Special reports,

in Vital and Health Statistics, Series 20. Public such as life tables and analytical studies, are also

use data tapes are made available annually, and published. Unpublished tabulaticms and machinesome unpublished tabulations are available from readable data are available from the Vital Stathe Division of Vital Statistics, NCHS. tistics and Disease R~gi~tries Section, Health

Division, Statistics Canada.

47
Table 1Il. National household interview surveys

Characteristic United States Canada

Survey National Health Interview Survey conducted by

the National Center for Health Statistics (NCHS).

Coverage

Background The survey was begun in 1957 to obtain information on the amount, distribution, and effects of

illness and disability in the United States and on

the health services supplied for or because of

such conditions. It is conducted continuously.

Interviews take place each week throughout the

year in a probability sample of households, and

the data collected over a year form the basis for

annual estimates of health and use of health services. The interview questionnaire is reviewed each

year and supplementary topics are added or deleted periodically.

The survey covers the ,civilian noninstitutionalized

population of the United States. Persons excluded

are patients in long-term care facilities, members

of the Armed Forces, U.S. nationals living in

foreign countries, and persons who died during

the survey reference period.

Methods of data collection Data are collected through personal household

interviews conducted by part-time interviewers

employed and trained by the U.S. Bureau of the

Census. All membersof the household 17 years

of age and over who are home at the time of the

interview are invited to participate and respond

for themselves. The mother is usually the respondent for children, and information is obtained

from an adult family member 19 years of age or

over for persons not at home during the interview.

Between 65 and 70 percent of persons 17 years

of age and over are self-respondents.

Sometimes a random subsarnple of adult

household members is selected to respond to

questions on special topics. Followup questionnaires, for the entire household or for persons with

particular health problems, are also used at times.

As required, these questionnaires are returned by

mail or the interviewer calls again to obtain the

information directly. The interviews average

about 45 minutes but, depending on family size

and the extent of health conditions, can range

from 15 to 90 minutes.

Each year data are collected from approximately 40,000 households on about 110,000

persons. The annual response rate is usually at

least 95 percent of the eligible households.

Canada Health Survey, conducted by the Department of National Health and Welfare and

Statistics Canada.

The survey was proposed in 1974 to obtain better

data on health status, especially self-limited and

self-treated conditions and their consequences.

Pretests were conducted in 1976-77, and in May

1978 the survey began in the eastern Provinces.

The central Provinces were added in June, and

the entire survey population was covered in July

1978. While the survey was planned to operate

continuously, a government-wide policy of expenditure restraint introduced in August 1978

resulted in a halt to data collection in March

1979.

The survey covers the noninstitutionalized population of Canada, except for residents of the

Territories, Indian Reserves, and certain remote

areas defined by the Canadian Labor Force Survey. The excluded groups account for approximately 3 percent of the Canadian population.

The survey had two components, an interview

component and a physical measures component.

Interview data were collected by part-time interviewers employed by Statistics Canada, A member of the household provided information about

characteristics of the dwelling, the persons who

resided there, and the health status and use of

health services of all persons in the household.

Questionnaires on lifestyle and emotional health

were left behind to be completed by each household member 15 years of age and over. The interviewer returned a few days later to pick up these

questionnaires.

In approximately one-third of the households,

physical measures data were collected by parttime nurses employed by the Victorian Order of

Nurses under contract to the Department of National Health and Welfare. The initial interviewer

and nurse worked as a team in these households,

the interviewer scheduling an appointment to return with the nurse to collect the questionnaires

and conduct the physical measures. The nurse

obtained measures of blood pressure, cardiorespiratory fitness, and percent body fat on household members 2 years of age and over and blood

samples from persons 3 years of age and over.

The sample size for the 9 months that the

survey was conducted in all Provinces was 12,218

households, 86 percent of which participated. A

total of 31,668 persons were reported on in the

initial interviews, 23,791 completed the followup

48
Table 1I1, National household interview surveys-Con.

Characteristic United States Canada

Sample design The sampling plan follows a multistage probability

design. The first stage consists of a sample of 376

primary sampling units drawn from approximately

1,900 geographically defined primary sampling

units that cover the 50 States and the District of

Columbia. A primary sampling unit may be a

county, a small group of contiguous counties, or a

standard metropolitan statistical area. Within the

primary sampling units, smaller units called segments are defined in such a manner that each

segment contains an expected four households.

The sampling plan is designed so that national

estimates and estimates for four geographical regions can be obtained.

Items collected Information collected each year includes the following Basic demographic and social characteristics of household members, disability days,

physician and dental visits, acute and chronic

conditions responsible for the disability days and

physician visits, long-term limitation of activity

from chronic disease or impairment and the

chronic conditions associated with the limitation,

short-stay hospital use data, the interval since the

last physician and dental visit, and questions

about 6 lists of chronic conditions, each list involving a specific system of the body (for example,

digestive and circulatory).

Supplements to the questionnaire change

periodically. In 1978, the topics covered in supplements were usual source of care, health insurance coverage, blood donation, immunization,

smoking, and military service.

questionnaire, the physical measures were taken

on 6,131 persons, and blood samples were obtained from 4,829 persons.

The survey followed a stratified multistage clustered sample design. Initial stratification was by

Province, with Quebec and Ontario each divided

into three further strata. The initial strata were

stratified into three additional strata, the first containing major cities, the second other major urban

parts, and the third the remaining, mainly rural,

parts of the region. To minimize data collection

costs, the desired annual sample of 12,000 households was divided into 100 geographic clusters,

and plans called for 10 households from each

cluster to be sampled each month. The 100 clusters were initially allocated to the Provinces proportional to the square root of the Provincial

population and to the urban-rural strata proportional to their respective populations, with the

requirement that the minimum allocation to a

stratum be 2. The sampling plan was designed to

allow both national and Provincial estimates to

be obtained.

When the plan to conduct the survey on an

ongoing basis was changed, adjustments were

made in the number of households selected per

cluster so that a sample size close to 12,000

households could be reached before data collected

was terminated.

The initial interviews obtained information about

the following: household characteristics, social

and economic characteristics, mobility, immigration, disability days, activity limitation, short-term

conditions, accidents and injuries, chronic conditions, impairments, hearing, vision and dental

status, use of professional health services, the

professional providing services, location of services received, reasons services not sought, drug

use, and use of medical devices.

The self-administered questionnaires sought

information about social characteristics, family

disease history, alcohol use, alcohol-related problems, tobacco use, physical activities, seatbelt

use, female preventive behaviors (for example,

breast examinations and pap smear), and psychological well-being.

The physical measures included height,

weight, arm measurement, skinfold, blood pressure, and a cardiovascular fitness exercise. Blood

was tested for immune status, cholesterol, glucose,

uric acid, anemia, liver function, kidney function,

lead. cadmium, copper, and zinc.

49
Table II1. National household interview surveys-Con.

Characteristic United States Canada

Data processing Data on illnesses, diseases, and injuries are centrally coded by NCHS. A modified version of the

Eighth Revision International ClasslYcation of

Diseases, Adapted for Use in the United States39

was used for coding 1978 data.

Data are adjusted for nonresponse by a procedure that imputes to persons in a household

who are not interviewed the characteristics of

persons who are interviewed.

The national estimates are based on a multistage estimation procedure involving inflation by

the reciprocal of the probability of selection, an

adjustment for household nonresponse, ratio adjustment, and poststratification.

Release of data Data from the survey are published in Vital and

Health Statistics, Series 10. Summary statistics

are published in annual reports titled “Current

Estimates,” which are followed by reports containing additional data and analyses. Many unpublished tabulations are routinely generated and

are available from the NCHS Division of Health

Interview Statistics. Public use data tapes of survey data also are available.

Data on health conditions were coded by a central

unit of Statistics Canada according to the ninth

revision of the International Classification of

Diseases.so

All nonresponse and inconsistent data that

could not be resolved during editing was coded

“unknown.” In general, no imputation was performed on the survey data to replace the unknowns.

The national estimates were based on a multistage estimating procedure involving assignment

of weights to households. These weights were the

reciprocal of the probability of selection. Adjustments were made for household, form, and person

unknown values, and for undersampling or oversampling within Province-age-sex groups.

Estimates of annual disability days (including

bed days, major activity-loss days, and reduced

activity days) were adjusted for seasonal variation

based on the seasonal trends shown in the 1978

data from the U.S. National Health Interview

Survey.

Basic tabulations from the survey were published

in The Health of Canadians. 33Further analyses

can be conducted on request to the Research and

Analysis Section, Health Division, Statistics

Canada.

NOTE: A list of referencesfollowsthe.text.

50
Table IV, Hospital facilities data systems

Characteristic United States Canada

Data system Annual Survey of Hospitals, conducted by the American Hospital Association,

Coverage The survey covers all hospitals in the United States

and the associated areas of American Samoa, Guam,

the Marshall Islands, Puerto Rico, and the Virgin

Islands, regardless of whether registered with the

American Hospital Association; however, only data

from registered hospitals in the 50 States, and the

District of Columbia were used in this report. Institutions with less than 6 beds are not defined as hospitals and are not covered by the survey.

Data collection and The American Hospital Association mails questionprocessing naires to hospitals each year. Hospital personnel are

asked to provide information about a year period

ending September 30. In 1978, 55 percent of the

hospitals provided data for the year ending in September. Another 26 percent provided data for the

year period ending June 1978, and the remainder

provided data for year periods ending at a variety of

other times, from December 1977 to December

1978.

In 1978, 90 percent of the 7,015 U.S. hospitals

registered with the American Hospital Association

returned the questionnaires. The percent responding

was lower for hospitals with less than 100 beds and

lowest, 73 percent, for hospitals with less than 25

beds. Among the 215 nonregistered U.S. hospitals,

60 percent returned questionnaires in 1978.

Estimates were made of data from nonreporting

hospitals and missing data. The estimate of the number of beds for a nonresponding hospital was based

on the most recent information available from the

hospital. Estimates of revenues, expenses, admissions,

inpatient days, outpatient visits, and personnel were

based on data reported the previous year by the nonresponding hospital, if available. If not, imputations

were made based on data from hospitals with similar

characteristics. No estimates of facilities and services

data for nonreporting hospitals were made by the

American Hospital Association.

Items collected The survey questionnaires are revised periodically.

In 1978 the items collected included the following

. Hospital ownership and type of service

● Availability of specific types of facilities and

services; for example, postoperative recovery

room, blood bank, respiratory therapy

. Beds, discharges, and inpatient days by specific

types of inpatient. services; for example, pediatric,

burn care, or psychiatric services

Annual Returns of Health Care Facilities, compiled

by Statistics Canada.

All general and allied special hospitals are expected

to complete the Annual Returns. Allied special hospitals include pediatric, maternity, orthopedic, neurological, rehabilitation, convalescence, extended care,

chronic, and outpost hospitals; institutes of psychiatry

and nursing stations. Outpost hospitals and nursing

stations are quite small; most have less than 6 beds.

Mental hospitals complete the Annual Returns, but

their data are tabulated and published separately fi-om

that of other hospitals.

The Provincial health authorities distribute the Annual Returns to hospitals each year, Administrative

personnel in the hospitals complete the Returns according to a standard, detailed set of instructions

developed by Statistics Canada and the Department

of National Health and Welfare. The hospitals send

the completed Returns back to the Provincial authorities, who edit them and forward copies or computer

data tapes to Statistics Canada.

In 1977–78, the reporting period was converted

from a calender year to a fiscal year ending March

31. The hospitals in 3 Provinces reported data for the

fiscal year. All other hospitals reported data for a

15-month period ending in March, and the data were

adjusted by Statistics Canada to reflect a 12-month

period.

A total of 1,252 general and allied special hospitals were operating in Canada in March 1978, 1,207

of which completed the Annual Returns. The reporting hospitals contained 99 percent of the beds in the

operating hospitals. In general, no estimates were

made of data for nonreporting hospitals or of missing

data.

The present forms for the Annual Returns were

adopted in 1976. The principal data items on the

Returns include the following

● Hospital ownership, type of service, and total

number of beds

. Beds and inpatient days by types of inpatient

units

. Movement of patients (patients in hospital at

beginning and end of reporting period, admissions,

51
Table IV. Hospital facilities data systems—Con.

Characteristic United States Canada

● Total beds and utilization, including births, operations, outpatient visits, admissions, discharges,

and inpatient days ●

● Revenue, expenses, and restricted and unrestricted funds

● Personnel on payroll at end of reporting period ●

●

●

●

●

discharges, deaths, and inpatient days) by type

of inpatient unit

Types of diagnostic and therapeutic services,

their staff and expenses, and workloads of

laboratory and radiology

Types and number of visits to ambulatory care

units

Activity of other hospital units, for example

respiratory technology, obstetrical unit, and

laundry

Hospital personnel

Educational programs

Income and expenditures

Release of data A wide array of statistical data from the survey is A wide array of statistical data from the Annual

published annually by the American Hospital As- Returns is published by Statistics Canada in Hospital

sociation in Hospital Statistics. A list of all hospitals Annual Statistics. List of Canadian Hospitals and

by location with summary information on each hos- Special Care Facilities, which reports the name,

pital is also published annually, American Hospital address, ownership, type of service, and number of

Association Guide to the Health Care Field. Addi- beds of each hospital is also published annually by

tional data are available from the Department of Statistics Canada. Additional data are available from

Data Services of the Hospital Data Center, American the Institutional Statistics Section, Health Division,

Hospital Association. Statistics Canada.

52
Table V. Physician data systems

Characteristic United States Canada

Data system Physician Masterflle, maintained by the American

Medical Association.

Coverage Files are maintained on almost all medical doctors

in the United States and U.S. Possessions, both

members and nonmembers of the American

Medical Association. Graduates of U.S. medical

schools temporarily practicing outside of the

country and graduates of foreign medical schools

who are in the United States and meet U.S. education standards for physicians are covered.

Doctors of osteopathy, who account for about

4 percent of active physicians, are not included in

the files, but the American Osteopathic Association collects information on them.

Methods of data collection A file is begun on each individual who enters a

U.S. medical school and each graduate of a foreign medical school who enters the United States.

Additional information is added to the files as the,

physician’s training and career develop. Every

4 years a census is conducted to update the files.

The response rate for the 1977 census was

85 percent. Between the censuses, the files are

updated weekly as information is obtained on

changes in physician activities. The sources of

information include American Medical Association mailings or publications, address company

mailings, physician correspondence, hospitals,

Government agencies, medical societies, medical

boards, and licensing agencies. A questionnaire

may be sent to the physician to veri~ the changes

in activities.

Items collected Each file has two parts. One is historical information that changes infrequently, such as details

about medical school training, internship and residency training, Iicensure, board certification, and

professional affiliations. The second portion,

which is subject to constant change, includes current address, professional activities (average hours

spent in patient care and nonpatient care activities

per week), specialization (average hours spent in

primary, secondary, and tertiary specialties per

week), and present employment (hours spent by

type of employer, such as solo practice, group

practice, and hospital).

Physician Record File, maintained by the Medical Section, Circulation Department, Southam

Business Publications. The Department of National Health and Welfare purchases a copy of

the computer tape 4 times a year from Sales

Management Systems, a division of Southam

Business Publications.

Files are maintained on almost all medical doctors

in Canada, including graduates of foreign medical

schools and Canadian doctors known to be outside

of the country who may or may not return. Doctors of osteopathy, who account for approximately

0.1 percent of all active physicians are not included in the files, but the Canadian Osteopathic

Association collects information on them.

The minimum information kept on file about each

physician is the physician’s name. In some instances the name is obtained from a source that

does not provide an address or other information.

When additional data are obtained, a computer

record of name, address, and coded data is produced on the physician. The files and records are

updated weekly using sources of information such

as Provincial regis@rs, hospitals, medical schools,

specialty associations, Provincial medical associations, the Medical Council of Canada, Departments of Health, pharmaceutical companies,

physician correspondence, telephone directories,

newspapers, and journals. Data are also obtained

from an annual questionnaire distributed to all

physicians by the Canadian Medical Association.

The response rate for the survey is about 35 percent. In addition, Southam Business Publications

sends out questionnaires to doctors about whom

insufficient information has been collected from

other sources.

Data coded for computer records in 1978 included

the following: physician identification numbe~

university or country of graduation and year of

graduation; whether or not registere~ Province,

county and municipality of residence; type of

physician (general practitioner, specialist, intern,

or resident); up to 4 specialties in which certified;

specialty in which, though not certified, the physician spends the majority of time; appointment

(for example, medical school faculty, Government, or hospital); activity status (for example,

active, abroad, or military), and hospital aflliation.

53
Table V. Physician data systems—Con.

Characteristic United States Canada

Release of data Data from the Masterfile are published by the The Physician Record File is one of many such

American Medical Association in the Distribu- files maintained by Southam Business Publication of Physicians, Special Statistical, and Ref- tions and purchased by a variety of customers for

erence Data series. Unpublished data can be mailing list purposes. The National Department

obtained for research and other special purposes of Health and Welfare publishes physician data

from the Department of Data Release Services, from the file annually in Canada Health ManAmerican Medical Association. power Inventory.

54
Appendix II

Definitions of selected terms

Table V1. Hospital use terms

Characteristic United States Canada

Hospital

Discharge

Discharge rate

Average length of stay

Diagnosis

Surgical procedure

Surgical discharge

Newborn infant

Hospital fatality rate

A general or special hospital with an average length

of stay of less than 30 days. Hospitals with fewer

than 6 beds for inpatient use, Federal hospitals, and

hospital units of institutions are not included.

The formal release of a patient by a hospital; that is

the termination of a period of hospitalization by

death or by disposition to place of residence, another

hospital, nursing home, or other place.

The ratio of the number of hospital discharges during

1978 to the number of persons in the population.

The estimate of the civilian population on July 1,

1978, as revised after the 1980 Census, was used

to compute discharge rates.

The total number of patient days accumulated at

the time of discharge by patients discharged during

1978, counting the day of admission but not the

date of discharge, divided by the number of discharges.

The diagnosis identified as principal diagnosis or

listed first on the face sheet of the medical record.

The number of diagnoses is equivalent to the number of discharges.

The surgical procedure listed first on the face sheet

of the medical record.

A patient who underwent at least one surgical procedure during hospitalization. In this report, the

number of surgical discharges is equivalent to the

number of surgical procedures.

An infant admitted by birth to a short-stay nonFederal hospital.

The number of hospital deaths in 1978 divided by

A general or allied special hospital with an average

length of stay of less than 30 days. Mental hospitals

are not included. (See “newborn infant” for an exception to this de finition.)

Same as for the United States. “Discharge” is used

in this report rather than the Canadian term for

deaths and other dispositions, “separation.”

Same as for the United States, except that the estimate of the resident population on June 1, 1978, as

revised aiter the 1981 Census, was used to compute

discharge rates.

Same as for the United States.

In some Provinces, the diagnosis identified as the

condition that required the most medical resources,

and in other Provinces, the diagnosis identified as

the condition that precipitated admission to the

hospital. The number of diagnoses is equivalent to

the number of discharges.

The primary operation, defined as the main or most

important surgical procedure during one period of

hospitalization.

Same as for the United States.

An infant admitted by birth to a hospital or admitted with mother for maternal care. Such infants

in all general and allied special hospitals are included, but almost all infants are born in short-stay

hospitals.

Same as for the United States.

the number of discharges, including deaths, in 1978.

55
Table W!. Health status terms

Characteristic United States Canada

Death rate

Infant mortality rate

Disability days

Bed days

Limitation of activity

Noninstitutionalized population

Cause of death

Neonatal mortality rate

The ratio of the number of deaths during 1978

to the number of persons in the population.

The estimate of resident population on July 1,

1978, as revised after the 1980 census was

used to compute death rates.

The ratio of the number of 1978 deaths of liveborn children who have not reached their first

birthday to the number of live births in 1978.

Days persons had to reduce their usual activities because of illness or injury. Includes days

spent in bed, days in which school or work was

missed or housework could not be undertaken,

and days when persons had to cut down on

usual activities, though not abandon them

completely.

Days persons spent most or all of their time in

bed because of illness or injury, including days

spent in a hospital.

Inability to perform all the usual activities of

the population group throughout the year because of health condition. For children, limitations are in the amount or kind of school or

play activities. For adults, limitations are in

ability to work, do housework, or engage in

social and recreational activities.

Population excluding persons livingin long-term

care institutions. The civilian noninstitutionalized population was used in tables L and

BB-GG. It was estimated based on the sample

of households in the National Health Interview

Survey, with overall totals by age and sex adjusted to independent estimates from the Bureau

of the Census.

The underlying condition to which death is attributed, based on the information reported on

the death certificate and utilizing the international rules for selecting the underlying cause

of death from the reported conditions.

The ratio of the number of 1978 deaths of livebom children who have not reached their 28th

day of life to the number of live births in 1978.

Same as for the United States, except that the

estimate of the resident population on June 1,

1978, as revised after the 1981 census was used

to compute death rates.

Same as for the United States,

Same as for the United States.

Same as for the United States.

Same as for the United States.

Population excluding persons livingin long-term

care institutions. The noninstitutionalized population was used in tables L and BB-DD.

Same as for the United States.

Same as for the United States.

56
Table Vlil. Health services terms

Characteristic United States Canada

Physician

Pediatrician

Hospital bed The average number of beds and cribs, including

pediatric bassinets, isolettes, and neonatal intensive care units, but excluding bassinets for regular

care of newborn infants, set up and staffed for use

by inpatients during the year. Includes all such

beds in non-Federal short-stay hospitals registered

with the American Hospital Association. Any institution that meets the requirements may be registered, if it desires, whether or not it is a member

of the association. The requirements for registration include that the institution have at least 6 inpatient beds, an organized medical staff, registered

nurse supervision, a medical record system, pharmacy, food service, and appropriate diagnostic and

treatment facilities. In 1978, only 1.6 percent of

all U.S. hospital beds were in nonregistered hospitals.

Pediatric bed The average number of beds and cribs in pediatric

units set up and staffed for use by inpatients during

the year. In table T, pediatric beds refers to such

beds in non-Federal short-stay hospitals registered

with the American Hospital Association. Because

not all of these hospitals reported whether they had

pediatric beds, an adjustment was made in the data

for nonreporting For each of the 8 bed-size categories shown in table U, the number of nonreporting

hospitals was multiplied by the percent of reporting hospitals with pediatric units to obtain an estimated number of nonreporting hospitals with pediatric units. The average number of pediatric unit

beds in each bed-size category was then multiplied

by the estimated number of nonreporting hospitals

with pediatric units in the bed-size category. The

result, the estimated number of pediatric beds in

nonreporting hospitals, was added to the reported

totaL The adjustment increased the number of pediatric beds by 4.7 percent.

In table W, pediatric beds refers to the pediatric beds in all reporting hospitals registered with

the American Hospital Association. Federal and

long-term hospitals are included, but they account

for less than 4 percent of all pediatric beds. No

adjustment was made for nonreporting.

An active doctor of medicine practicing in the 50

States or the District of Columbia on December

31, 1978, excluding those who are employed by

the Federal Government and those whose addresses

are unknown. In table T, active doctors of osteopathy are also counted as physicians,

In table T, medical doctors certified as pediatricians by specialty boards by December 31, 1977.

In table W, active non-Federal medical doctors

Beds and cribs, excluding newborn bassinets and

incubators in neonatal units and regular and special

care nurseries. The beds referred to in tables T and

U are beds staffed and available for use at the end

of the reporting period in short-stay hospitals. In

table Y, the beds are beds approved for all general

and allied special hospitals, except the rehabilitation, convalescence, extended care, and chronic

care hospitals. The excluded hospitals are almost

all hospitals with average lengths of stay of 30 days

or more.

Beds and cribs in pediatric units at the end of the

reporting period. In table T, pediatric beds refers

to such beds staffed and available for use in shortstay hospitals. In table Y, pediatric beds refers to

the beds approved for pediatric units in general

and allied special hospitals, excluding the rehabilitation, convalescence, extended care, and chronic

hospitals, which are almost all hospitals with an

average length of stay of 30 days or more.

An active doctor of medicine practicing within the

country on December 31, 1978, excluding those

who are in the military and those whose addresses

are unknown.

In both tables T and Y, an active civilian medical

doctor certified by a specialty board as a pediatrician. Pediatrician in table T refers to those certified

57
Table !/111. Health services terms—Con.

Characteristic United States Canada

who report as of December 31, 1978, that they by December 31, 1977, and in table Y to those

spend most of their time practicing pediatrics, ex- certified by December 31, 1978.

cludlng residents in pediatric training.

Units for the general medical and surgical care of Same as for the United States.

children, usually for patients 14 years of age and

under, but the upper age limit can vary from hospital to hospital.

Geographic division The 50 States and the District of Columbia are For this report each Province was considered a

grouped by the Bureau of the Census into 9 divi- division, except the 2 smallest, Prince Edward

sions as follows: Island and Newfoundland, which were combined

Pediatric unit

●

●

●

●

●

●

●

●

●

New England: Maine, New Hampshire, Verto form 1 division.

mont, Massachusetts, Rhode Island, Connecticut

Middle Atlantic: New York, New Jersey,

Pennsylvania

East North Central: Michigan, Ohio, Illinois,

Indiana, Wisconsin

West North Central: Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska,

Kansas

South Atlantic Delaware, Maryland, District

of Columbia, Virginia, West Virginia, North

Carolina, South Carolina, Georgia, Florida

East South Central: Kentucky, Tennessee,

Alabama, Mississippi

West South Centrak Arkansas, Louisiana,

Oklahoma, Texas

Mountain Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada

Pacific: Washington, Oregon, California,

Population

Hawaii, Alaska

An estimate of the civilian population, as revised In tables T, Y, and AA, an estimate of the resident

after the 1980 census, was used in table T and population, as revised after the 1981 census. The

parts of table W. Revised estimates were not avail- noninstitutionalized population was used in tables

able by division for the population under 15 years BB–DD.

of age. Therefore, it was necessary to use the civilian noninstitutionalized population as estimated

before the 1980 census for table Z and for rates

per 10,000 population under 15 years of age in

table W. The noninstitutionalized population was

used in tables BB–GG.

Physician contact Consultation with a physician about the patient’s Same as for the United States, except that only

health, including consultations with medical doc- consultations with medical doctors are included.

tors, osteopaths, and nurses or other persons acting

under a physician’s supervision. For physician

contact in a year (table CC), a physician visit to a

hospital inpatient could be counted, but such visits

were excluded from the average annual number of

physician contacts (table DD) and place of physician contact (table BB). Place of physician, contact

also excluded telephone contacts with physicians,

which were included in the other tables.

58
Table Vlll. Health services terms—Con.

Characteristic United States Canada

Private health insurance Health insurance provided by non-Government Not applicable.

sources including consumers, insurance companies,

private industry, and philanthropic organizations.

Medicare A nationwide health insurance program providing Not applicable.

health insurance protection to people 65 years of

age and over, people eligible for social security

disability payments for more than 2 years, and

people with end-stage renal disease, regardless of

income,

Medicaid

Milita~

A joint Federal-State welfare program available in Not applicable.

virtually all States that provides medical benefits

for low income persons, including the aged. To

qualify for the program, a person must meet each

State’s definition of “low income.”

Health care programs of the Veterans Administra- Not applicable.

tion (VA) and military services. VA benefits are

potentially available to all honorably discharged

veterans, but priority is given to veterans with a

service-connected disability and to those receiving

a pension from the VA. Military services provide

benefits to eligible dependents of active military

personnel and to military pensioners and their dependents,

Family income A family consists of all people within a household Not applicable.

related to each other by blood, marriage, or adoption. Each member of the family is classified according to the total income of the family of which

he or she is a member. Unrelated individuals are

classified according to their own income. Family

income is the total income received by the members

of a family (or by unrelated individual) in the 12

months prior to being interviewed in the National

Health Interview Survey, including wages, salaries,

rents from property, interest, dividends, profits,

and fees from their own business, pensions, and

help from relatives.

Hospital episode A continuous period of stay of 1 night or more in a Not applicable.

hospital as an inpatient, except the period of stay

of a well newborn infant.

*U. S. GOV13RNN31W FKClilTNG OFFICE : 1984 0-.+21+51/30s 59
NmY Ncms

The U.S. Government Printing Office (GPO) has established a standing order system for NCHS publications. A

standing order is similar to a subscription in that You will receive each new report as it is published. There is no

delay and no need to order each publication separately. Under a standing order, publications can only be paid

for by charges to VISA, MasterCard, or a GPO deposit account. A GPO deposit account can be opened with a

minimum $50.00 deposit.

Check here for those NCHS reports you wish to receive through GPO’s standing order system.

Your service will begin with the next issue released following acceptance of your order.

Vital and Health Statistics series

Code/Series Charge:

❑ ZHS1

❑ ZHS2

❑ ZHS3

❑ ZHS4

•! ZHS5

❑ ZHS1O

❑ ZHS1l

❑ ZHS13

❑ ZHS14

❑ ZHS15

❑ ZHS20

❑ ZHS21

❑ ZHS23

❑ ZHUS

Program and Collection Procedures

Data Evaluation and Methods Research

Analytical Studies [=] m

Documents and Committee Reports

ComparativeInternational Vital

and Health Statistics Reports

Data From the National Health Interview Survey Credit

Data From the National Health Examination Survey and

Card No. 1 II Ill II II II II II IIIIJ

National Health and Nutrition Examination Survey

Data on Health Resources Utilization

Expiration Date

1111

Data on Health Resources

Month/Year

Data From Special Surveys

Data on Mortality GPO Deposit Account:

Data on Natality, Marriage and Divorce

Data From the National Survey of Family Growth De~osit Account No.

Health, United States ~–o

Vital Statistics of the United States New Account ($50.00 minimum)

Code/Series

❑ ZVSN1 Natality

❑ ZVSM2 Mortallty, Parts A&B

❑ ZVSM3 Marriage and Divorce Authorizing signature

(Orders not valid unless signed)

Ship to:

Company or personal name

I I I I I I I I I I I I I 1 I I I I I 1 I I I 1 I I 1 1 I

Additional addresslattentlon Ilne

Llllllll I I I 1 1 I I I I I I I I 1 I 1 I I 1 1 1 I

Street address

I 1 I I 1 I I 1 I I I I I I I I I I I I I I I

City

I I I I I I I I I i I I I I i I I I

(or Country)

II I I I 1 i 1 1 I I I I I I 1 I I mT:::e’lccTEl

PLEASE PRINT OR TYPE (Please onclude Area Code]

Mail ORDER FORM to: Dept. 40A, Superintendent of Documents, U.S. Government Printing Office,

Washington, DC 20402
Vital and Health Statistics

series descriptions

SERIES 1.

SERIES 2.

SERIES 3.

SERIES4,

SERIES 5,

SERIES 10,

SERIES1l.

;ERIES 12.

;ERIES 13.

Programs and Collation ProWdures-Reports describing

the general programs of the National Center for Health

Statistics and its offices and divisions and the data collection methods used, They also include definitions and

other material necessary for understanding the data.

Data Evaluation and Methods Reaaarch-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 Epidemiological Studies-Reports pre.

semting analytical or interpretive studies besed on vital

and health statistics, carrying the analysis further than

the expository types of reports in the other series.

Documants and Committoa Reports-Final reports of

major committees concerned with vital and health statistics and documents such as recommended model vital

registration laws and revi$ed birth and death certificates.

Comparative international Vital and Haalth Statistics

Reports-Analytical and descriptive reports comparing

U.S. vital and health statistics with those of other countries.

Data From tho National Health Interview Survey-Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other

health-dated topics, all based on data collected in the

continuing national household interview suwey.

Data From tfm National Health Examirtetion Survey and

tho National Haalth ●nd Ntstritiorr Ewsnkation SurveyData from direut examination, testing, and measurement

of national samples of the civilian noninstitutional ized

population provide the basis for (1) estimates of the

medically dsfimed ~m of specific diseases in the

United Stetas end the distributions of the population

with respeet to physical, physiological, and psychological characteristi~ and (2) analysis of relationships

among the various measurements without reference to

an explicit finite universe of persons.

Data From the I netitutionalized Population Surveys-Discontinued in 1975. Reports from these surveys are included in Series 13.

Data on Health Resources Utilization-Statistics on the

utilization of health manpower and facilities providing

long-term care, ambulato~ care, hospital care, and family

planning services.

SERIES 14.

SERIES 15.

SERIES 20.

SERIES21

SERIES 22.

SERIES 23.

Data on Health Resources: Manpower and FacilitiesStatistics on the numbers, geographic distribution, and

characteristics of health resources including physicians,

dentists, nurses, other health occupations, hospitals,

nursing homes, and outpatient facilities.

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.

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; ~ographic 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, marria~, and divorce other than es

included in regular annual or monthly reports. Special

analyses by demographic variables; $eographic 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 tha National Mortality and Natality Surveys–

Discontinued in 1975. Reports from these sample surveys

based on vital records are included in Series 20 and 21,

respectively.

Data From tha National Survey 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 ever-married women 1544 years

of age.

For a list of titles of reports published in these series, write to:

Scientific and Technical Information Branch

National Center for Heal th Statistics

Public Health Serv, ce

Hyattsville, Md. 20782

or call 301-436 .NCHS
U.S. DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Public Health Service

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

OFFICIAL BUSINESS

PENALTY FOR PRIVATE USE, $300

THIRD CLASS

BULK RATE

POSTAGEp13~EES PAlO

PERMIT No. G29

DHHS Publication No. (PHS) 84-1477, Serka 5, No. 1