Collecting Practice-level 

Data in a Changing 

Physician Office-based 

Ambulatory Care 

Environment: A Pilot Study 

Examining the Physician 

Induction Interview 

Component of the National 

Ambulatory Medical Care 

Survey 

Vital and Health StatisticsSeries 2, Number 176 November 2017
Copyright information

All material appearing in this report is in the public domain and may be 

reproduced or copied without permission; citation as to source, however, is 

appreciated.

Suggested citation

Halley MC, Rendle KA, Gillespie KA, et al. Collecting practice-level data 

in a changing physician office-based ambulatory care environment: A pilot 

study examining the physician induction interview component of the National 

Ambulatory Medical Care Survey. National Center for Health Statistics. Vital 

Health Stat 2(176). 2017.

Library of Congress Cataloging-in-Publication Data

Names: National Center for Health Statistics (U.S.), issuing body.

Title: Collecting practice-level data in a changing physician office-based 

 ambulatory care environment : a pilot study examining the physician 

 induction interview component of the National Ambulatory Medical Care 

 Survey.

Other titles: Vital and health statistics. Series 2, Data evaluation and 

 methods research ; no. 176 | DHHS publication ; no. 2018-1376. 0276-4733

Description: Hyattsville, Maryland : U.S. Department of Health and Human 

 Services, Centers for Disease Control and Prevention, National Center for 

 Health Statistics, November 2017. | Series: Vital and health statistics. 

 Series 2, Data evaluation and methods research ; number 176 | Series: DHHS 

 pub. ; number 2018-1376 | Includes bibliographical references.

Identifiers: LCCN 2017043093| ISBN 9780840606839 (pbk.) | ISBN 0840606834 

 (pbk.)

Subjects: | MESH: National Ambulatory Medical Care Survey (U.S.) | Ambulatory 

 Care | Health Care Surveys | Data Accuracy | Physicians | Group Practice | 

 United States

Classification: LCC RA974 | NLM W2 A N148vb no.176 2017 | DDC 

 362.12072/7--dc23

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For sale by the U.S. Government Printing Office 

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Washington, DC 20402–9328 

Printed on acid-free paper.
Vital and Health Statistics

Series 2, Number 176

Collecting Practice-level Data 

in a Changing Physician 

Office-based Ambulatory 

Care Environment: A Pilot 

Study Examining the Physician 

induction interview Component 

of the National Ambulatory 

Medical Care Survey

Data Evaluation and Methods Research

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Centers for Disease Control and Prevention 

National Center for Health Statistics

Hyattsville, Maryland 

November 2017 

DHHS Publication No. 2018–1376
National Center for Health Statistics

Charles J. Rothwell, M.S., M.B.A., Director

Jennifer H. Madans, Ph.D., Associate Director for Science

Division of Health Care Statistics

Denys T. Lau, Ph.D., Acting Director

Alexander Strashny, Ph.D., Associate Director for Science
iii

Contents

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Study Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Sampling and Recruitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Theme 1—Inconsistent Understanding of the Definition of “Location” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Theme 2—Lack of Familiarity With Administrative Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Theme 3—Primary Care-oriented Questions Not Relevant to Specialty Care Providers . . . . . . . . . . . . . . . . . . . . . .6

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Text Tables

A Physicians randomly selected to participate in pilot study, by physician and field 

representative identifier and physician department type: 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

B Emergent theme on inconsistent understanding of the definition of “location” from interviews 

with physicians participating in pilot study, by NAMCS survey question and sample 

participant responses: 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

C Emergent theme on lack of familiarity with administrative matters from interviews with physicians

participating in pilot study, by NAMCS survey question and sample participant responses: 2013 . . . . . . . . . . . . . . .7

D Emergent theme on primary care-oriented questions not relevant to specialty care 

providers from interviews with physicians participating in pilot study, by NAMCS 

survey question and sample participant responses: 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
iv

Acknowledgments

The authors would like to 

acknowledge and thank Suepattra May, 

M.P.H., Ph.D., and Dominick Frosch,

Ph.D., for their role in developing

the original design of this study. The

authors would also like to thank Ms.

Katherine Stanley for her assistance

in data management and analysis.

Finally, the authors would like to thank

the participants, and in particular, the

field representatives who allowed the

ethnographers of this study to shadow

them while they did their work.
Page 1 

Background

The landscape of office-based 

ambulatory medical care is changing 

rapidly. Over the past 3 decades, 

a decline has been observed in 

independent, solo, and small group 

practices, and an increase has been 

observed in the proportion of physicians 

in large multispecialty group practices 

(1). For example, only 18% of physicians 

were in solo practices in 2012, down 

from 41% in 1983 (2). Conversely, more 

than 22% of all physicians were working 

in multispecialty group practices in 2012, 

with an even larger proportion of internal 

medicine (36%) and family practice 

(28%) physicians in multispecialty 

groups (2). National Ambulatory Medical 

Care Survey (NAMCS) data during this 

period found that 26% of physicians were 

in multispecialty group practices in 2013, 

up from 20% in 2008 (3,4). Although 

single-specialty practice remains the 

most common model at just over 45% 

of ambulatory care practices (2), care 

is increasingly being delivered in larger 

group settings.

Recognizing this changing 

environment, the National Center for 

Health Statistics (NCHS) has undertaken 

multiple quality improvement initiatives 

and methodological changes to ensure 

that NAMCS remains the leading source 

of data for understanding office-based 

ambulatory health care in the United 

States. These initiatives include: (a) the 

development, rollout, and refinement 

of a computer-assisted, in-person data 

collection instrument; (b) a program 

of reabstraction to assess interrater 

reliability of NAMCS patient record 

forms (PRFs); and (c) pilot studies 

that compare NAMCS in-person data 

abstraction techniques with alternatives, 

such as electronic standardized 

summaries of care obtained from 

electronic health records (EHRs).

Collecting Practice-level 

Data in a Changing Physician 

Office-based Ambulatory Care 

Environment: A Pilot Study 

Examining the Physician 

Induction Interview Component 

of the National Ambulatory 

Medical Care Survey

by Meghan C. Halley, Ph.D., M.P.H., Palo Alto Medical Foundation 

Research Institute; Katharine A. Rendle, Ph.D., M.S.W., Palo Alto 

Medical Foundation Research Institute and University of Pennsylvania; 

Katherine A. Gillespie, M.A., M.P.H., Palo Alto Medical Foundation 

Research Institute; Brian Gugerty, D.N.S., M.S., R.N., and Denys T. 

Lau, Ph.D., National Center for Health Statistics; and Harold S. Luft, 

Ph.D., Palo Alto Medical Foundation Research Institute and University 

of California, San Francisco

Objective

This report examines ways to 

improve National Ambulatory Medical 

Care Survey (NAMCS) data on 

practice and physician characteristics 

in multispecialty group practices.

Methods

From February to April 2013, the 

National Center for Health Statistics 

(NCHS) conducted a pilot study to 

observe the collection of the NAMCS 

physician interview information 

component in a large multispecialty 

group practice. Nine physicians were 

randomly sampled using standard 

NAMCS recruitment procedures; 

eight were eligible and agreed to 

participate. Using standard protocols, 

three field representatives conducted 

NAMCS physician induction 

interviews (PIIs) while trained 

ethnographers observed and audio 

recorded the interviews. Transcripts 

and field notes were analyzed to 

identify recurrent issues in the data 

collection process.

Results

The majority of the NAMCS 

items appeared to have been 

easily answered by the physician 

respondents. Among the items 

that appeared to be difficult to 

answer, three themes emerged: (a) 

physician respondents demonstrated 

an inconsistent understanding 

of “location” in responding to 

questions; (b) lack of familiarity with 

administrative matters made certain 

questions difficult for physicians 

to answer; and (c) certain primary 

care‐oriented questions were not 

relevant to specialty care providers.

Conclusions

Some PII survey questions 

were challenging for physicians 

in a multispecialty practice 

setting. Improving the design 

and administration of NAMCS 

data collection is part of NCHS’ 

continuous quality improvement 

process.

Keywords: physician practice • 

ambulatory medical care • NAMCS

Abstract
Page 2  Series 2, No. 176

NAMCS is intended to provide 

estimates on the characteristics of officebased physicians and their practices, the 

specific health care services ordered or 

provided to patients during office-based 

visits, and changes in health care delivery 

and service utilization over time (5,6). 

NAMCS has collected data periodically 

since 1973 and annually since 1989 to 

better understand ambulatory medical 

care services in the United States (7,8). 

NAMCS consists of two components: 

the physician induction interview 

(PII) and PRF. The PII component 

collects data on physician and practice 

characteristics. Physician characteristics 

include demographics (e.g., age, sex, and 

ethnicity), professional demographics 

(e.g., specialty and board certification), 

professional activities (e.g., patient 

care, teaching, and research), office 

location(s), and patient volume. Practice 

characteristics include ownership, 

size, provider types, ancillary 

services available to the patient (e.g., 

electrocardiogram, lab, and radiology), 

office workforce roles (e.g., medical 

assistant and nurse), tasks performed, and 

EHR information, including capabilities. 

Visit-level data come from manually 

abstracting information about the patient 

and visit from medical and administrative 

charts using PRF. The NAMCS PRF 

component collects patient visit-level 

data, including demographics, vital signs, 

reason for visit, diagnoses, continuity 

of care, diagnostic and therapeutic 

testing or services, and medications and 

immunization. Researchers sometimes 

use data from both sources (e.g., to 

examine whether physicians who have 

lab facilities in their offices are more 

likely to order tests) (9). This report 

focuses on the PII component of NAMCS 

and examines how accurately the data 

collected from a set of physicians in a 

large multispecialty group reflect their 

practice.

To examine potential improvements 

in the PII component of NAMCS, NCHS 

recruited an independent research partner 

to conduct a small, qualitative evaluation 

of the NAMCS PII. The goal was to 

examine how NAMCS data collection 

on practice and physician characteristics 

may be improved given the increasing 

proportion of multispecialty physician 

group practices.

Methods

Study Design

This study used the participant 

observation method for collecting data 

based on the usual NAMCS PII process 

conducted in a large multispecialty group 

ambulatory care setting. Participant 

observation is particularly well suited 

for understanding human behavior in 

context and is also commonly used to 

better understand how everyday practices 

shape the health care system (10) as well 

as to improve survey administration and 

development (11). It can take a variety of 

forms, from “detached observer” to “full 

participation,” and the form is tailored 

to whatever behavior the researcher is 

trying to understand (10). Because the 

goal of this study is to understand issues 

that spontaneously emerge in collecting 

NAMCS PII data in a particular setting, 

the researcher’s role was that of a 

detached observer.

As much as possible, this pilot 

study followed NAMCS’ standard 

protocols in which data are collected 

from a nationally representative sample 

of nonfederal, office-based physicians. 

(Data on community health centers are 

also collected as part of NAMCS, but 

that is outside the scope of this report.) 

Field representatives (FRs), trained 

interviewers representing NCHS, visit 

a stratified sample of physicians to 

collect both a range of information on 

each physician’s practice and patient 

characteristics and visit data for a sample 

of up to 30 randomly selected encounters 

during a designated reporting week.

NCHS employed an ethnographic 

approach to document apparent 

difficulties and inconsistencies arising 

in the NAMCS PII data collection 

process. An ethnographer with advanced 

training in qualitative research (authors 

MH or KR) silently observed FRs 

administering the NAMCS PII to 

physician respondents. To minimize any 

impact of this observation, ethnographers 

provided no verbal or nonverbal 

feedback on the data collection process 

or responses to individual questions from 

FRs or physicians. FRs were instructed to 

conduct the data collection using standard 

NAMCS data collection procedures, 

even though ethnographers were present. 

Data obtained as part of this study were 

excluded from NAMCS datasets. Further, 

as changes are made annually to NAMCS 

data collection protocols, it is important 

to note that the NAMCS 2013 data 

collection protocol and NAMCS 2013 PII 

form were used in this study.

Sampling and Recruitment

This study was conducted in a large 

multispecialty group ambulatory care 

setting (referred to as a “reference clinic” 

in this report). The reference clinic has 

sites located in multiple counties, and this 

study took place at one of these locations. 

The site consists of several buildings on 

adjacent blocks housing a full range of 

primary care and specialty departments 

and administrative support services.

Specifically, for this study, a 

member of the site’s management team 

first provided NCHS with a complete 

list of all ambulatory care physicians 

(approximately 400) practicing 

at the reference site. Using SAS 

SURVEYSELECT (12), NCHS staff 

used this list to randomly identify nine 

physicians. The FRs then approached the 

nine physicians using standard NAMCS 

PII survey procedures, which involved 

an initial telephone contact followed by 

an appointment for the interview (13). 

The FRs explained to the physicians that 

during the PII data collection process, an 

ethnographer would also be present in 

the room to observe the FRs interviewing 

and elicitation style and to identify any 

issues that might arise when fielding 

the NAMCS survey in a multispecialty 

group practice environment. Once the 

physicians consented, the FRs notified 

the ethnographers of the appointment 

times and locations.

Of the nine physicians approached, 

eight were deemed eligible to participate 

in NAMCS; the ninth engaged 

exclusively in administrative duties 

as opposed to clinical work, which is 

among NAMCS’ eligibility criteria. Each 
Series 2, No. 176  Page 3 

of the eight physicians was given an 

information sheet and provided verbal 

consent to be observed and recorded by 

an ethnographer prior to the interview. In 

total, three FRs participated in this study; 

two FRs conducted three interviews each 

and one FR conducted two interviews. 

The institutional review boards of the 

participating institution and NCHS 

approved this protocol.

Data Collection

In addition to audio recording 

the entire NAMCS PII data collection 

process, the ethnographers took field 

notes of their observations, documenting 

any components of NAMCS PII that 

appeared to be particularly challenging 

for physicians to answer as well as the 

strategies the FRs used to attempt to 

address these challenges during the 

interview. Following completion of each 

physician interview, the ethnographer met 

with the FR alone, and the FR provided 

feedback about how they felt the 

interview went. The FRs also described 

any components of the survey they found 

difficult to administer. The ethnographers 

took additional field notes but did not 

provide any feedback to the FRs in 

order to not affect any subsequent data 

collection.

Audio recordings of the interviews 

were transcribed verbatim and then 

destroyed. During transcription, all 

identifying information—including 

physician and FR names, physician 

addresses, and department names—

was deleted to ensure that neither the 

physicians nor the FRs were identifiable.

Data Analysis

Data were analyzed using a 

multiphase, structured thematic approach 

designed to identify difficulties and 

inconsistencies in the NAMCS data 

collection process (14,15). The analytic 

team included two research assistants 

trained in coding qualitative data and 

two ethnographers involved in data 

collection. First, the research assistants 

used Microsoft Excel 2011 to organize 

the eight transcribed interviews by survey 

question and physician response. This 

allowed the team to examine the FRs’ 

questions, the physicians’ responses, 

and any subsequent discussion for each 

item individually and then compare them 

across the eight interviews.

The number of questions the 

physicians answered depended on their 

responses and the skip patterns embedded 

in the survey instrument. For each of the 

potential 187 questions and associated 

responses and conversations, each 

research assistant independently reviewed 

and created a “memo” summarizing 

three domains: (a) whether physicians 

expressed any confusion or hesitation 

regarding how to answer the question 

and the reason physicians appeared to be 

confused (e.g., they were unclear whether 

a question referred to their department 

or the entire multispecialty group); (b) 

guidance given by the FRs in answering 

the questions, noting any differences in 

advice given for the same question; and 

(c) the range of responses physicians

gave, particularly noting inconsistencies

when the answers provided were

expected to have been the same across all

respondents.

Next, the research assistants 

presented recurrent issues within these 

domains to the ethnographers. The 

ethnographers independently reviewed 

all transcripts and memos generated 

by the research assistants, along with 

their own field notes, and developed 

a list of common emergent themes. 

The entire team of research assistants 

and ethnographers then convened and 

reviewed the identified themes together. 

Through consensus, they finalized the list 

of key overarching themes.

Results

Of the eight participating physicians, 

two were primary care providers and six 

were specialty care providers (Table A). 

Relative to the overall organization, the 

reference site had a disproportionate 

number of specialists, which was 

reflected in this sample. There were 

50 key questions on the 2013 NAMCS 

PII administered by the FRs. Some 

questions were skipped based on the 

embedded skipping pattern of the survey, 

and about one-half were multipart 

questions (e.g., 25a, 25b, 25c, etc.). 

The majority of the questions appeared 

to have been easily answered by the 

physician respondents. Because the 

number of questions asked varied by 

physician and many were interdependent, 

quantifying the proportion of questions 

observed to be difficult or confusing to 

answer was not straightforward. The 

results presented in this report focus 

on three central themes emerging from 

reviewing the observations, field notes, 

and transcript analyses. They include: 

(a) an inconsistent understanding of the

definition of “location”; (b) a lack of

familiarity with administrative matters;

and (c) primary care-oriented questions

not relevant to specialty care providers.

These themes are described below, and

examples of physicians’ responses to the

NAMCS survey questions illustrating

these themes are provided in Tables B–D.

Theme 1—Inconsistent 

Understanding of the 

Definition of “Location”

One issue that arose in all eight 

interviews was the lack of clarity in 

the NAMCS questions referencing the 

practice location of the respondents. 

Physicians expressed confusion about 

whether a given question was asking 

about a specific department, a specific 

address within the larger clinic, the main 

multispecialty clinic (which had multiple 

Table A. Physicians randomly selected 

to participate in pilot study, by physician 

study identifier, physician department type, 

and field representative identifier: 2013

Physician study identifier 

(department type)

Field representative 

study identifier

P101 (specialty care) FR01

P102 (primary care) FR02

P103 (specialty care) FR02

P104 (administrator) ---

P105 (specialty care) FR01

P106 (primary care) FR03

P107 (specialty care) FR03

P108 (specialty care) FR03

P109 (specialty care) FR02

--- Data not available, because physician was ineligible for 

study.

NOTES: Among nine randomly selected physicians to 

participate in the pilot study, eight physicians were considered 

eligible and provided data via an in-person interview. An 

ethnographer also recorded the interview (see Data Collection 

for more information). The study participants were sampled in 

the United States.
Page 4  Series 2, No. 176

street addresses), or even the entire 

health care organization, which spanned 

multiple counties. Table B illustrates the 

observed confusion among respondents 

while answering survey questions about 

practice location.

At the beginning of the survey, an 

“in-scope location(s)” question was 

asked to serve as the reference location 

for the remainder of the survey (see 

question 17b in Table B). Physicians 

expressed confusion as to how they 

should respond to this question. While 

seven of the eight physicians ultimately 

selected “group practice” as part of their 

response (selecting multiple categories 

was allowed), six asked for clarification 

or stated that the categories were not an 

obvious fit for the reference site, which 

included multiple groups of physicians 

in various departments organized by 

specialty and spread across multiple 

buildings on the site’s campus. The 

question did not provide details about 

whether the in-scope location refers to the 

entire campus for the group practice, only 

a specific address for the respondent’s 

office, or only a respondent’s department 

(e.g., pediatrics or family medicine).

The uncertainty about the reference 

location made some subsequent survey 

questions difficult to answer. For 

example, question 19b asks, “How 

many physicians are associated with you 

(at this/that in-scope location)?” FRs 

varyingly replaced “at this/that in-scope 

location” with “at this address,” “at the 

clinic,” “in this group practice,” “in this 

[type] department,” “at this location,” 

or simply “here.” In response, five of 

the eight physicians initially answered 

by referencing the entire multispecialty 

clinic and responding with large numbers, 

such as, “I guess about 150, 200, I 

don’t know,” and “probably 800.” Two 

physicians responded by referencing 

their specific department at that site, with 

one reporting that the practice included 

only one other physician. During two 

physician interviews, the FR explicitly 

stated to the respondents that question 

19b generated a lot of confusion in these 

settings. One physician stated that he/she 

did not know. Among six physicians 

who asked for clarification regarding 

the reference location (see examples in 

Table B), three were told by the FRs to 

report the number of physicians in their 

department, one was told to provide 

the number for the whole building, 

and one was told to give the number 

for the entire address. Although these 

physicians worked at the same site, 

physician responses varied from 2 to 800 

“physicians practicing at the reference 

site,” and one answered, “I don’t know.”

Physicians also experienced 

difficulty answering other survey 

questions, such as the capabilities of the 

Table B. Emergent theme on inconsistent understanding of the definition of “location” from interviews with physicians participating in pilot 

study, by NAMCS survey question and sample participant responses: 2013

NAMCS survey question Sample participant response

17b. Choose ALL of the type(s) of settings that describe each location 

where you work. For each location, enter all setting types that apply. 

For each location, also enter the appropriate "scope" status. If any 

even numbered settings are entered, then enter location as out-ofscope.

1. Private solo or group practice

2. Hospital emergency department

3. Freestanding clinic/urgicare center (not part of a hospital 

outpatient department)

4. Hospital outpatient department

5. Community health center (e.g., federally qualified health center)

6. Ambulatory surgicenter

7. Mental health center

8. Institutional setting (e.g., school infirmary, nursing home, 

prison)

9. Nonfederal government clinic (e.g., state, county, city, maternal 

and child health, etc.)

10. Industrial outpatient facility

11. Family planning clinic (including Planned Parenthood)

12. Federal government operated clinic

13. Health maintenance organization or other prepaid practice 

(e.g., Kaiser Permanente)

14. Laser vision surgery

15. Faculty practice plan

● FR01: Okay [typing], this is the current office. Um, let’s see...looking at this list, choose all the 

types of settings that describe your office here at [this address].

P101: ...[reviewing list]...best describes this practice...uh...it’s a free standing clinic.

FR01: Okay, so number three?

P101: What’s the difference between that and number nine, which is a nonfederal government 

clinic?

FR01: Um...is, well first question is, the private, solo, or group practice—does that 

characterize this office or your practice?

P101: I don’t...so, we’re considered a multispecialty group. Not for profit. I'm not quite sure 

what to [inaudible].

FR01: We’ll do specialty group, okay, not for profit. [typing] So I'm just entering this as a note 

because it’s really not um—

P101: It’s not directly—it, it usually characterizes us as a multispecialty group.

FR01: Okay. Um, you can select um up to four.

P101: I can?

FR01: Yeah.

P101: Okay. I would probably go with free standing clinic, number three. Nonfederal 

government clinic, number nine...we have an ambulatory surgery center but... .

FR01: Let’s just, your—

P101: But it’s just my practice?

FR01: Right.

P101: But think those two are probably best characterizing this.

 See footnotes at end of table.
Series 2, No. 176  Page 5 

Table B. Emergent theme on inconsistent understanding of the definition of “location” from interviews with physicians participating in pilot 

study, by NAMCS survey question and sample participant responses: 2013

NAMCS survey question Sample participant response

19b. How many physicians are associated with you (at this/that inscope location)?● FR02: Okay, so not solo. How many physicians are associated with you at this address?

P102: At [this address]?

FR02: At [this address].

P102: Well, it’s actually the group. I'm, I'm a member of is probably 800 physicians.

FR02: Okay...[laughs].

P102: [laughs].

FR02: [inaudible]...invalid number, okay. How many just at this practice, in this building, 

within this [inaudible]?

P102: Well, within this [name of building] practice that I'm practicing with now, there’s four 

others, so a total of five.

● FR01: Okay. And how many physicians are associated with you in this group practice?

P105: So, not just my department but everybody?

FR01: This is one of the questions that keeps, we have a struggle with. So, I would say in 

this department. This is the [department] department.

P105: Okay, and just here, right? So, um, there’s probably like 15 of us. It doesn’t have to be 

exact, right? ‘Cause I mean, you could find out how many exactly.

● FR02: Okay, so that’s nonsolo. How many physicians are associated with you here [at this 

location]?

P109: One. One for this office, but we are a multispecialty group, so I don’t know how to 

answer your question adequately in terms of what the question is asking.

FR02: Sure. Well, it's how many physicians are associated with you at this address, so it’s 

795. So, it would be the total physicians.

P109: Oh, I don’t know the answer to that question. I don’t know.

FR02: Okay, I put “don’t know.”

P109: It’s a large number...

19c. Is this a single- or multispecialty (group) practice (at this/that 

in-scope location)?

● P102: Multi. Well, well if you're just saying the four I practice with, that’s single because 

we’re all practicing [department]. So, I don’t know how you, how you would do that. But, but 

this—since I'm just talking about the people I practice with in [this building] that is strictly a 

primary care [department] practice.

● FR01: No. And is this a single or multispecialty group practice?

P105: Well, it’s multispecialty, that’s like a couple hundred, but what I'm talking about not is 

just single specialty I guess. So...

FR01: Okay, because it’s just [department].

P105: Yeah.

19g. (1–5) Does your practice have the ability to perform any of the 

following on site (at this/that in-scope location)? 1) EKG/ECG, 2) Lab 

testing, 3) Spirometry, 4) Ultrasound, 5) X-ray?

● FR01: Okay. And does your practice have the ability to perform any of the following: EKG/

ECG?

P105: So, now we’re talking about just our department?

FR01: Yeah.

P105: Okay, no.

● FR02: Lab testing?

P102: Well, that’ll be confusing. We draw lab here but we send it to the main lab. So, uh, so 

I work with [name of health care organization], we have our own lab, but we don’t actually 

have a lab on this property, but our nurses draw, they draw the blood. But uh... .

FR02: Okay, so we’ll, I think for lab testing we would put... .

P102: Uh...well I think I have to consider the whole group. We do have lab testing, yeah.

NOTES: NAMCS is National Ambulatory Medical Care Survey. FR is field representative. P is responding physician. EKG and ECG are electrocardiography. Among nine randomly selected physicians 

to participate in the pilot study, eight physicians were considered eligible and provided data via an in-person interview. An ethnographer also recorded the interview. During transcription, all identifying 

information was destroyed (see Data Collection for more information). The study participants were sampled in the United States.

–Con.
Page 6  Series 2, No. 176

in-scope location. For example, question 

19g (1–5) asks whether the physician’s 

practice has the ability to perform 

various types of tests, such as labs, 

x-rays, or ultrasounds “on site at this/

that in-scope location.” At the site, these

tests are not performed within individual

departments but are provided in a central

unit at the site, which may not be in

the same building as a given physician

respondent’s office. When physician

respondents asked for clarification

about the reference location for these

questions, FRs’ responses included:

(a) only their department, (b) the

whole building, or (c) all the buildings

at that address. For example, when

interviewing three physician respondents,

the FRs did not state “on site” when

they asked whether the location had

electrocardiogram capabilities. For two

physician respondents, the FR told them

to respond for just their department,

leading both physicians to answer “no.”

The remaining six respondents did not

request clarification and all answered

“yes.” When asked about laboratory

testing, six of the seven physicians

located in the same building as the lab

(which is separate from the physicians’ 

departments) responded “yes” they

have lab testing and one answered “no.”

The eighth physician, whose practice is

located on the same site, but in a building

with a different address, responded “no.”

Responses were even more divergent

when asked about x-ray and ultrasound,

with four physicians reporting that they

have this capability and four reporting

that they do not, though all had access to

the same facilities at the site.

The ambiguity of the reference 

location also affected question 19c, which 

asks, “Is this a single- or multispecialty 

(group) practice (at this/that in-scope 

location).” For seven of the eight 

physicians, the FRs asked the question 

without any substitutions for “(at this/that 

in-scope location).” Three physicians did 

not request clarification before answering 

“multispecialty clinic.” The other four 

physicians initially stated that it was a 

multispecialty practice, but then noted 

that if the question was referencing their 

department, their answers would be 

“single specialty.” For one physician, the 

FR did not ask the question and instead 

stated, “This is a multispecialty practice,” 

to which the physician respondent did not 

object.

Theme 2—Lack of 

Familiarity With 

Administrative Matters

In this study’s large multispecialty 

group, administrative matters were often 

handled by specialized office staff. For 

certain NAMCS questions related to 

administrative matters, physicians were 

either unable to answer or provided only 

general estimates with low accuracy 

(Table C). For example, question 19i 

asks, “What is your national provider 

identifier?” None of the eight physician 

respondents could provide the number 

from memory. Five provided a number 

after looking it up and three did not answer 

the question. Similarly, for question 

19j—“What is your federal tax ID 

number?”—only one physician provided a 

response after looking it up on their phone. 

Physicians were either unable to answer 

or expressed uncertainty when answering 

administrative questions characterizing 

their practice. For example, question 

42 asks, “Roughly, what percentage 

of the patient care revenue received 

by this practice comes from managed 

care contracts?” Half of the physician 

respondents stated that they did not know. 

The remaining four provided answers only 

after expressing some uncertainty.

To at least one administrative 

question asked during the interviews, 

six physicians stated that someone in the 

organization other than themselves (e.g., 

a staff member, an office manager, or a 

higher-level administrator) would be better 

able to provide an accurate answer. In one 

case, the ethnographer observed the FR 

attempting to follow up with office staff, 

but the FR was unsuccessful in obtaining 

the information.

Certain questions about the practice 

should elicit the same response from all 

physician respondents at the reference 

site. For example, question 32b asks, “In 

which year did you install your EHR/

EMR system?” One physician provided 

the correct year; six provided an incorrect 

year; and one responded, “I don’t know.”

Theme 3—Primary 

Care‐oriented Questions 

Not Relevant to Specialty 

Care Providers

The final emergent theme from these 

interviews was that certain questions 

were perceived by specialty care 

providers as oriented toward primary 

care providers (Table D). For example, 

question 24 includes a series of items 

asking about the type of providers in the 

practice most responsible for performing 

specific clinical tasks. Some specialty 

care providers thought that a number of 

these tasks were not applicable to their 

practices. For example, question 24a 

says, “Records body measurements (such 

as height and weight) and vital signs 

(such as BP, temperature, heart rate);” 

24d says, “Provides immunizations 

(includes both childhood and adult);” 

24g says, “Provides counseling services 

(such as diet/nutrition, weight reduction, 

tobacco cessation, stress management);” 

and 24h says, “Manages the routine care 

of patients with chronic conditions (such 

as hypertension, asthma, and diabetes).” 

In five instances, physicians tried to 

adapt a question to their department 

(e.g., an ophthalmologist described 

taking “eye vitals” or a surgeon adapting 

preoperative counseling for the category 

of counseling). FRs did not encourage 

respondents to do this or provide 

additional examples beyond those listed 

in the questions. For many of these 

questions, specialty care providers stated 

the question was not applicable, including 

one respondent who stated, “This wasn’t 

written for us.”

Discussion

This study provides insights for 

NCHS to further improve NAMCS 

PII data collection and instrument 

development as well as for quantitative 

researchers using NAMCS PII data. 

Key themes include: (a) an inconsistent 

understanding among physician 

respondents of “location” as used within 

the survey, (b) physician respondents’ 

lack of knowledge of administrative 
Series 2, No. 176  Page 7 

Table C. Emergent theme on lack of familiarity with administrative matters from interviews with physicians participating in pilot study, by 

NAMCS survey question and sample participant responses: 2013 

NAMCS survey question Sample participant response

19i. What is your national provider ID at each office location? ● FR02: And what is your national provider identification number?

P109: Uh...I don’t know [laughs]. I'm sorry, I always ask people to fill it in for me, I'm sorry.

19j. What is your federal tax ID at each office location? ● P101: Don’t know that either, my staff—

FR01: Your staff might know that?

P101: My staff would know that.

FR01: Okay. Is it okay if I uh, ask them for that information?

P101: Yes.

● FR02: Okay, let me put that in there. And do you know your federal tax ID number?

P109: No. I don’t know any of these things. [laughs]

29. What is the tax identification number that you use? ● P103: It’s the organization number, and they know it out front but I don’t.

● P108: Um, I'm sure it’s the [Clinic] TIN, which um, I don’t know if I have it in my phone. I can look 

it up.

FR03: Okay, thank you. [looking up number]

P108: No, I don’t have it, sorry.

FR03: Okay, is it okay if I put “don’t know” for this question?

P108: Don’t know, yeah.

● FR03: Okay. A tax identification number, or TIN, is required by payors, such as Medicare to pay 

physicians’ claims. What is your tax identification number that you use? Okay, we can put “don’t 

know,” that’s fine.

P106: It’s why I like being in a big group [inaudible].

32b. In which year did you install your EHR/EMR system? ● FR03: Okay, and so you remember what year uh, the system was installed?

P106: Oh, it was a couple years prior to my arrival, and I’ve been here for 10 years, so probably 

about 12 years ago?

FR03: Okay, so 2001? Does that seem about right?

P106: I guess, probably. Yeah.

FR03: Does it?

P106: Yeah.

● P108: I’ve been here since 2008, and it was installed at that time, so probably a couple years 

prior to that, but I can’t tell you for sure. So as long as I’ve been here, that’s the only answer I ... . I 

think it got installed in 2000 something, but I can’t tell you what year.

FR03: Okay, so I’ll just put that “don’t know” and then in the notes I’ll put 2000—

P108: My experience is ever since I’ve been here.

FR03: Okay, I’ll put at least through 2008.

P108: Yeah.

● FR02: Okay. And in which year did you install the EHR or EMR system?

P109: A long time ago, it was before I started working here.

FR02: And when was that?

P109: I started working here in 2006.

FR02: Okay, um, I can also put, put “don’t know.” Because you're not really sure when it was 

installed?

P109: Yeah.

42. Roughly, what percentage of the patient care revenue 

received by this practice comes from managed care contracts?

● P106: HMO and PPO? Combined?

FR03: Yeah

P106: Yes, it says HMO/PPO but not Medi, Medicaid

FR03: Right. Comes from—yeah, ‘cause I don’t think, well, do you have a managed care contract 

with uh, [our state’s Medicaid program]?

P106: Um...I'm not, I don’t know the answer to that question. Um, but um, we do see [Medicaid] 

patients here, so there must, there’s gotta be some contractual relationship there. Um, so that, 

I would say probably 100%. I mean, all of our, all of our PPO and HMO, there’s contractual 

relationships, yeah.

● P107: Managed care contracts, um...I don’t think any. I, I honestly don’t know.

FR03: Okay, I can put “don’t know”—is that okay?

P107: Yeah, I don’t know.

NOTES: NAMCS is National Ambulatory Medical Care Survey. FR is field representative. P is responding physician. EHR is electronic health record. EMR is electronic medical record. HMO is health 

maintenance organization. PPO is preferred provider organization. Among nine randomly selected physicians to participate in the pilot study, eight physicians were considered eligible and provided 

data via an in-person interview. An ethnographer also recorded the interview. During transcription, all identifying information was destroyed (see Data Collection for more information). The study 

participants were sampled in the United States.
Page 8  Series 2, No. 176

matters, (c) and primary-care-oriented 

questions not relevant to specialty care 

physicians. In addition, there were 

inconsistencies in the ways FRs asked 

survey questions or helped respondents 

answer them. These findings suggest 

that changes to the NAMCS instrument 

and its administration may improve the 

accuracy of data collected from large 

multispecialty groups.

Inconsistent understanding of the 

reference location was a key source 

of confusion in the sampled large 

multispecialty group practice setting. 

Survey items asking for the respondents’ 

practice location did not have a category 

for a multispecialty group practice 

environment. Despite this, seven of 

the eight physician-FR pairs in this 

study provided the “best” response, 

group practice, from the available list. 

Subsequent survey items referred to 

the reference location using different 

terms, such as “clinic,” “department,” 

“location,” and “practice.” In a large 

multispecialty clinic setting, however, 

“clinic” may be interpreted as one 

department, all departments within a 

multispecialty clinic, or all buildings 

located on a given clinic campus.

NAMCS PII instructions and 

data collection protocol regarding 

location could be further improved. For 

example, when the physicians requested 

clarification about the referent location, 

inconsistent guidance was given both 

within a single interview and among 

different FRs. In some cases, physicians 

answered the same question using a 

different referent location. Addressing this 

issue may require NCHS to clarify the 

referent location for each survey question 

as well as provide further training to FRs 

on how best to guide physicians who 

ask for clarification. For some questions, 

the appropriate locational reference 

might be the physicians’ geographic 

site (e.g., a small satellite clinic), which 

may have limited EHR capabilities. 

However, if an option was provided to 

also select partnership with a much larger 

organization, respondents may indicate 

they have greater EHR capabilities (16).

Some researchers, however, may be 

interested in the economic incentives 

the physician may have to order the 

test, which reflect not physical, but 

organizational and ownership structures. 

In small “traditional” physician offices, 

these details are usually irrelevant, but 

they may be critical in interpreting data 

from large, complex practices. Eliciting 

such detail would add further complexity 

to the questionnaire, but it might be 

critical for researchers seeking to explore 

certain hypotheses (9,17).

After this study was conducted in 

2013, ongoing quality improvement 

efforts led to changes made in the 

2015 NAMCS PII survey instrument, 

which states, “The next set of questions 

pertain to characteristics of the sampled 

physicians' practice. How many 

physicians, including you, are associated 

with this practice? Please include 

physicians at [fill in address of sampled 

location], and physicians at any other 

locations in this practice.” This revision 

was intended to help FRs and providers 

better understand what is meant by 

reference location.

Lack of familiarity with administrative 

matters was another theme of confusion. 

Table D. Emergent theme on primary care-oriented questions not relevant to specialty care providers from interviews with physicians 

participating in pilot study, by NAMCS survey question and sample participant responses: 2013

NAMCS survey question Sample participant response

24a. Records body measurements (such as height and weight) 

and vital signs (such as BP, temperature, heart rate)

● P101: We don’t take those sort of vitals, but, but doing core eye vitals would be medical 

assistants.

FR01: Eye vitals?

P101: Uh, vision, eye pressure, um, visual field testing, things like that.

24d. Provides immunizations (includes both childhood and adult) ● P108: Nope, we don’t do that.

FR03: Okay, you don’t do that. They [NCHS] are working on letting us have an N/A category, 

yeah.

P108: Mhm, mhm, that makes sense. I mean, you're testing the feasibility of multispecialty 

clinics for these kinds of questions, it just sounds like most of these don’t apply. You go to [other 

department], they're going to tell you the same thing, also.

24g. Provides counseling services (such as diet/nutrition, weight 

reduction, tobacco cessation, stress management)

● P101: Not applicable [laughs]. This wasn’t written for us.

● P107: Counseling...as in what kind of counseling?

FR03: Well, this one has such as for diet, nutrition, weight reduction?

P107: Well, we have sort of a preoperative counseling.

FR03: That would be the physicians that do that?

P107: No, actually it’s our um, it’s the, [name] the RN and then the nurse practitioner usually do 

kind of these preoperative consultation, you know, what they expect from—surgery kind of thing.

24h. Manages the routine care of patients with chronic conditions 

(such as hypertension, asthma, and diabetes)

● P109: We do not do that, we’re a specialty.

● P107: Uh, we don’t have—so, I'm in a surgical practice, so you know, we don’t typically see 

patients chronically here. They come in either for a pre-op consultation and a post-op visit and 

that’s usually it.

NOTES: NAMCS is National Ambulatory Medical Care Survey. FR is field representative. P is responding physician. BP is blood pressure. N/A is not applicable. RN is registered nurse. Among nine 

randomly selected physicians to participate in the pilot study, eight physicians were considered eligible and provided data via an in-person interview. An ethnographer also recorded the interview. 

During transcription, all identifying information was destroyed (see Data Collection for more information). The study participants were sampled in the United States.
Series 2, No. 176  Page 9 

The NAMCS PII asks about a variety 

of administrative matters, some are 

specific to each individual department 

and others are relevant to the entire clinic 

organization. In large group practices, 

the sampled physicians responsible for 

clinical duties may not be familiar with 

the administrative concerns of their 

practice. Further, for those questions 

that physicians could accurately answer, 

some could have been answered by 

other staff, thus reducing the amount of 

time needed from physician respondents 

(e.g., question 47b, which asks, “Does 

your practice set time aside for same day 

appointments?”).

Identifying the person, such as an 

administrator or department manager, 

who is most knowledgeable and can 

answer the administrative questions can 

be challenging. For example, questions 

about managing department-specific 

schedules may be best answered by a 

clinic manager, but questions about EMR 

implementation may be best answered 

by a central administrator. A different 

NAMCS workflow might determine 

that consistent administrative sources 

provide organization or department-level 

information. This information could 

then be confirmed by the physician 

respondent during the interview. This 

method was used in subsequent NAMCS 

FR training (as described below). 

Reducing the number of questions the 

physician is required to answer may 

increase physician participation rates 

and reduce physicians’ frustration, which 

was evident at certain points during these 

interviews, over the long list of questions 

they are unable to answer.

As the U.S. health care delivery 

system undergoes change, NCHS 

conducts various ongoing assessments 

of its survey questions and methods to 

examine and ensure quality in capturing 

accurate and reliable health care data. 

Ongoing quality improvement activities 

led to changes in 2016, when NAMCS 

FRs were trained to try to collect 

administrative information from a 

knowledgeable person if the sampled 

physician was unable to answer. The 

latest FR training material states, “It is 

unlikely you will actually conduct a full 

Induction Interview with the physician; 

on almost every occasion you will 

interview the office manager or some 

other designee.”

The last emergent theme causing 

confusion was primary care-oriented 

questions not relevant to specialty 

care providers. When physician 

respondents perceived questions as not 

pertaining to them, they responded in 

various ways, with some attempting to 

adapt the question to aspects of their 

specialty, while others simply stated 

that the questions were not applicable to 

them. For example, one question asks, 

“Which type of provider [at your office 

location] most commonly...records body 

measurement (such as height and weight) 

and vital signs (such as BP, temperature, 

heart rate)?” Because some specialty 

providers rarely, if ever, take these kinds 

of body measurements or vital signs, this 

question could be removed for specialty 

providers. Alternatively, this question 

could be tailored to different specialties. 

For example, when interviewing an 

ophthalmologist, the following question 

might be asked, “Which type of 

provider [at your office location] most 

commonly...records body measurement 

(e.g., visual acuity)?” Furthermore, 

ensuring that FRs communicate that 

“not applicable” is a response option 

might help further reduce confusion. The 

2013 form actually allowed a response 

of “Tasks not performed in this office” 

for the workforce items, but it does 

not appear as if that response category 

was encouraged by the FRs. Though 

this theme applied only to a subset of 

questions within the NAMCS instrument, 

given the length of the interviews and 

challenges of recruiting busy physicians, 

addressing this issue could have a 

significant impact on the substantial 

percentage of NAMCS physician 

participants who identify as specialty care 

providers (45%).

Users of NAMCS PII surveys fielded 

prior to 2015 should consider the findings 

from this pilot study. Researchers 

interested in conducting analyses of 

large multispecialty practices should 

be aware that there may be variation 

in responses regarding location as well 

as less familiarity with administrative 

issues among certain physicians. This 

may be noted as a possible limitation 

for analysis. For questions that may 

be most appropriate for primary care 

physicians (e.g., collection of vital signs), 

researchers may consider conducting 

sensitivity analyses of the impact of 

including or excluding responses by 

specialty physicians.

As part of NCHS’ continuing 

quality improvement effort, this small 

qualitative study was conducted to 

describe observations of the NAMCS 

PII data collection process at a single 

large multispecialty, multisite group 

practice, and findings may not apply 

to all similar practices. Based on a 

sample of eight participants, results from 

this pilot study are not generalizable. 

Furthermore, physicians in this pilot 

study were part of a practice setting with 

a very large number of physicians, as 

opposed to most NAMCS physicians who 

typically worked in either solo or group 

practices with an average of three to five 

physicians (18). Additionally, data in this 

study were collected in 2013 and may 

not reflect more recent adaptations of 

the NAMCS PII data collection process. 

Although this study examined data 

collected in 2013, the findings did result 

in specific changes to the collection of 

the 2015 NAMCS data. Further, findings 

in this report raise issues relevant to 

the hundreds of journal articles already 

published using data from the NAMCS 

2013 survey and earlier versions, and 

therefore should be considered by those 

using these data for analyses.

Conclusions

Although based on only one large 

multispecialty practice, this study 

suggests that, as fielded in 2013, aspects 

of the NAMCS PII survey questions may 

be challenging for physicians in these 

practice settings to answer. Since then, 

as part of ongoing quality improvement 

efforts, NCHS has made modifications to 

FR trainings and NAMCS data collection 

procedures, including protocols to collect 

administrative information from an office 

manager or another designee rather than 

the sampled physician. These efforts 

are designed to improve the accuracy of 
Page 10  Series 2, No. 176

the data, reduce respondent burden, and 

increase data collection efficiency.

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included in Series 3 or another appropriate series.

Series 6. Cognition and Survey Measurement

Reports use methods of cognitive science to design, evaluate, 

and test survey instruments. The last Series 6 report was 

published in 1999; these are now included in Series 2.

Series 10. Data From the National Health Interview Survey

Reports present statistics on illness; accidental injuries; 

disability; use of hospital, medical, dental, and other services; 

and other health-related topics. As of 2015, these are included 

in Series 3.

Series 11. Data From the National Health Examination Survey, the 

National Health and Nutrition Examination Surveys, and 

the Hispanic Health and Nutrition Examination Survey

Reports present 1) estimates of the medically defined 

prevalence of specific diseases in the United States and the 

distribution of the population with respect to physical, 

physiological, and psychological characteristics and 2) 

analysis of relationships among the various measurements. 

As of 2015, these are included in Series 3.

Series 12. Data From the Institutionalized Population Surveys

The last Series 12 report was published in 1974; these reports 

were included in Series 13, and as of 2015 are in Series 3.

Series 13. Data From the National Health Care Survey

Reports present statistics on health resources and use of 

health care resources based on data collected from health 

care providers and provider records. As of 2015, these reports 

are included in Series 3.

Series 14. Data on Health Resources: Manpower and Facilities

The last Series 14 report was published in 1989; these reports 

were included in Series 13, and are now included in Series 3.

Series 15. Data From Special Surveys

Reports contain statistics on health and health-related topics 

from surveys that are not a part of the continuing data systems 

of the National Center for Health Statistics. The last Series 15 

report was published in 2002; these reports are now included 

in Series 3.

Series 16. Compilations of Advance Data From Vital and Health 

Statistics

The last Series 16 report was published in 1996. All reports 

are available online; compilations are no longer needed.

Series 20. Data on Mortality

Reports include analyses by cause of death and demographic 

variables, and geographic and trend analyses. The last Series 

20 report was published in 2007; these reports are now 

included in Series 3.

Series 21. Data on Natality, Marriage, and Divorce

Reports include analyses by health and demographic 

variables, and geographic and trend analyses. The last Series 

21 report was published in 2006; these reports are now 

included in Series 3.

Series 22. Data From the National Mortality and Natality Surveys

The last Series 22 report was published in 1973. Reports from 

sample surveys of vital records were included in Series 20 or 

21, and are now included in Series 3.

Series 23. Data From the National Survey of Family Growth

Reports contain statistics on factors that affect birth rates, 

factors affecting the formation and dissolution of families, and 

behavior related to the risk of HIV and other sexually 

transmitted diseases. The last Series 23 report was published 

in 2011; these reports are now included in Series 3.

Series 24. Compilations of Data on Natality, Mortality, Marriage, and 

Divorce

The last Series 24 report was published in 1996. All reports 

are available online; compilations are no longer needed.

For answers to questions about this report or for a list of reports published in 

these series, contact:

Information Dissemination Staff

National Center for Health Statistics

Centers for Disease Control and Prevention

3311 Toledo Road, Room 4551, MS P08

Hyattsville, MD 20782

Tel: 1–800–CDC–INFO (1–800–232–4636)

TTY: 1–888–232–6348

Internet: https://www.cdc.gov/nchs

Online request form: https://www.cdc.gov/info

For e-mail updates on NCHS publication releases, subscribe 

online at: https://www.cdc.gov/nchs/govdelivery.htm.
U.S. DEPARTMENT OF

HEALTH & HUMAN SERVICES

Centers for Disease Control and Prevention 

National Center for Health Statistics 

3311 Toledo Road, Room 4551, MS P08

Hyattsville, MD 20782–2064

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DHHS Publication No. 2018–1376, Series 2, No. 176

CS282973