Vital and

Health Statistics

Advance Data

From Vital and

Health Statistics:

Numbers 71-80

Series 16:

Compilations of Advance Data From Vital

and Health Statistics

No, 8

Data in this report from health and demographic surveys present statistics by

age and other variables on health care coverage, family planning services,

blood carbon monoxide levels, blood lead levels, and ambulatory medical

care, Estimates are based on the civilian noninstitutionalized population of the

United States, These reports were originally published in 1981 and 1982,

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

Notional Center for Health Statistics

Hyaitsville, Maryland

December 1993

DHHS Publication No, [PHS] 94-1867
Trade name disclaimer

The use of trade names is for identification only and does not Imply

endorsement by the Public health Service, U.S. Department of Health and

Human Services.

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

National Center for Health Statistics. Advance data from vital and health

!;tatistics: numbers 71–80. National Center for Health Statistics. Vital Health Stat

16(8). 1993.
National Center for Health Statistics

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

Jack R. Anderson, Deputy Director

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

and Epidemwlogy

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

Extramural Programs

Peter L. Hurley, Associate Director for Vital and Health

Statistics Systems

Robert A. Israel, Associate Director for International

Statistics

Stephen E. Nieberding, Associate Director for

Management

Charles J. Rothwell, Associate Director for Data

Processing and Services

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

and Methodology

David L. Larson, Assistant DirectoL Atlanta
Health Care Coverage Under Private Health Insurance, Medicare, Medicaid, and Military or Veterans

Administration Health Benefits: United States, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Visits to Family Planning Service Sites: United States, 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Patient Profile, NationalReporting System for Family Planning Sefices: United States, l978 . . . . . . . . . . . . . .

Visits to Family Planning Clinics: United States, 1979 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Expected Principal Sources ofPayment for Hospital Discharges: United States, 1979 . . . . . . . . . . . . . . . . . . . . . .

Blood Carbon Monoxide Levelsin Persons 3–74Years ofAge: United States, 1976-80a . . . . . . . . . . . . . . . . . . .

1980 Summary National Ambulatory Medical Care Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Drugs Most Frequently Used in Office-Based Practice: National Ambulatory Medical Care Survey, 1980 . . . . .

Blood Lead Levels for Persons 6 Months–74 Years of Age: United States, 1976-80 . . . . . . . . . . . . . . . . . . . . . . .

Medication Therapy in Office Visits for Hypertension: National Ambulatory Medical Care Survey, 1980 . . . . .

No. 71

No. 72

No. 73

No. 74

No. 75

No. 76

No. 77

No. 78

No. 79

No. 80

...

III
m~~‘&~’ ~‘~~”

n Vital and Health Statistics of the National Center for Health Statistics Number 71 ● June 29, 1981

Health Care Coverage Under Private Health Insurance,

Medicare, Medicaid, and Military or Veterans

Administration Health Benefits: United States, 1978

Division of Health interview Statistics

The National Center for Health Statistics included

a special supplement on health care coverage under

private health insurance and Medicare as a part of the

1978 National Health Interview Survey questionnaire.

While this supplement was not designed to produce

estimates for all types of health care coverage, it did

contain a series of items related to eligibility for

Medicaid and for military and Veterans Administration

health care benefits.1 By making certain assumptions

about how these items relate to the broader concept

of health care coverage, it is possible to obtain estimates of the number of persons eligibile for these

types of benefits.

This preliminary report presents estimates of the

coverage status of persons in the civilian noninstitutionalized population under private health insurance

and the three types of public programs mentioned in

the title. There are many other forms of at Ieast

partial coverage for health care costs, including

neighborhood health clinics and locaJ philanthropic

health-service agencies. “Health care coverage” as

used in this report does not include these forms of

coverage or insurance restricted to dread diseases,

accidents, dental. care, or protection related to income maintenance during periods of Mness. Coverage

restricted to certain groups is also excluded, such as

coverage for Indians whose sole source of care is

through the Indian Health Service.

The focus of this report is on the extent or scope

of health care coverage in the population rather than

on the” question of breadth or depth of that coverage.

Est@ates are shown first by cross-classifying the

coverage status for each person to produce an unduplicated estimate of coverage under the four types

considered together. This is followed by a presentation of estimates for each of the four types of health

care coverage and the procedures foIlowed in

deriving them.

All of the estimates presented in this report are

average annual point prevalence estimates for the

civiIian noninstitutionzdized population. They are

“point prevalence” estimates because they represent

a person’s health care coverage status only at the

time of interview, and for no other period during the

year. They are “average annual” estimates because

the total annuaI National Health Interview Survey

sample consists of summing the results for 52 weekly

representative samples of the civilian noninstitutionalized population.

Technical qualifications related to the estimates

are summarized in the technical notes. For a more

detailed discussion of these qualifications and for a

copy of the questionnaire see the 1978 Current

Estimates (Series 10, No. 130). Additional data on

health care coverage will be available in future publications from the National Center for Health Services

Research based on the 1977 National Medical Care

Expenditure Survey,z and from the National Center

for Health Statistics and the Health Care Financing

Administration based on the 1980 Medical Care

Utilization and Expenditure Survey.

Coverage status of persons

under four types of health

care coverage

The concept of “coverage” is relatively unambiguous for private health insurance and Medicare, and

can be approximated for military and/or Veterans

Administration (VA) health benefits. The closest

corresponding concept for Medicaid is that of “eligibility,” However, because the criteria for Medicaid

eligibility vary among the States, because many

persons only become aware of their eligibility after

seeking medical aid, and finally because of the added

complexity in defining eligibility associated with

“spenddown” provisions there is no generally agreed

on criteria for estimating the number of persons

“covered by” Medicaid.

The Medicaid estimates shown in this report are

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service, Office of Health Research, Statistics, and Technology
2

operationally defined in terms of responses to three

items contained on the 1978 National Health Interview Survey (NHIS) questionnaire. Persons are

defined as having “categorical or reported Medicaid

coverage” if they (1) had a valid Medicaid card at the

time of interview, (2) were receiving Aid to Families

with Dependent Children or Supplementary Security

Income payments, or (3) Medicaid coverage was

given as a reason for not being covered by any health

insurance plan.

Because of the lack of uniformity associated with

the definitions of Medicaid coverage, the estimates

for this type of coverage are shown separately in table

1. The data from the 1978 NHIS indicate that about

179.5 million persons (83.9 percent) in the civilian

noninstitutionalized population were covered by

private health insurance, Medicare, or military and/or

VA health benefits. Among the estimated 31.6 million

persons (14.8 percent) not covered under any of

these three and the 2.7 million persons (1.3 percent)

for whom the coverage status could not be determined, an estimated 10.8 million persons had categorical or reported Medicaid coverage. Combining

these two groups (represented by the boxed cells in

table 1) produces estimates of about 190.3 million

persons (89 percent) in the civilian noninstitutionalized population covered by at least one of the four

types of coverage and about 23.5 million persons

(11 percent) who were not identified as being covered

under private health insurance or any of the three

public prograrns.3

The sum of the estimates in the boxed cells in

table 1 shows that virtually all persons 65 years of age

and over (about 99 percent) were covered under at

least one of the four types of coverage. The corresponding estimate for persons under 65 years of age

is about 88 percent.

Table 2 shows estimates of persons in the civilian

noninstitutionalized population with combined or

unique coverage under private health insurance,

Medicare, and military and/or VA health benefits.

Because the number of persons actually eligible

for Medicaid is not known, Medicaid is excluded from

these estimates of plan combinations. An estimated

67.3 percent of the civilian noninstitutiona.lized

population was covered by private health insurance

only. The combination of private health insurance

and Medicare coverage represents 6.2 percent, and

each of the other plan combinations represents 3.4

percent or less.

Not unexpectedly, the patterns of coverage for

persons under 65 years of age and 65 years of age and

over are quite different. An estimated 75.0 percent of

the younger age groups had coverage under private

health insurance but did not have coverage under

either of the two pub~c programs. For persons

Table 1. Number and percent dktribution of persons by age, covera!y

status under private health insurance, Medicare, and militam’

and/or Veterans Administration health benefits, and by Medicaid

coverage status: United States, 1978

Has valid Medicaid card,

raceivesA FDC or SS1,

and/or reports Medicaid

All

covere~ as reason for no

Age and covera~ status’ health insurance plan

persons —

Reposted as Not reported

meeting at asmeeting

least one any of ~~

criteria2 criteria

All ages, all coverage statuses . .

Covered . . . . . . . . . . . . . .

Notcovered . . . . . . . . . . . .

Unknown if covered . . . . . . .

Under 65 years, all coverage

statuses . . . . . . . . . . . . . .

Covered . . . . . . . . . . . . . .

Not covered . . . . . . . . . . . .

Unknown if covered . . . . . . .

65 years and over, all coverage

statuses . . . . . . . . . . . . . .

Covered . . . . . . . . . . . . . . .

Notcovered . . . . . . . . . . . .

Unknown if covered . . . . . . .

All ages, all coverage statuses . .

Covered . . . . . . . . . . . . . .

Notcovered . . . . . . . . . . . .

Unknown if covered . . . . . . .

Under 65 years, all coverage

statuses . . . . . . . . . . . . . .

Covered . . . . . . . . . . . . . .

Notcovered . . . . . . . . . . . .

Unknown if covered . . . . . . .

65 years and over, all coverage

statuses . . . . . . . . . . . . . .

Covered . . . . . . . . . . . . . .

Notcovered . . . . . . . . . . . .

Unknown if covered . . . . . . .

Number of persons in thousands

213,828 14,846 198~82

EZJZZ&l 4,0zz 175,451

%1

10348 21,295

2:713 47 2,237

191,041 12,762 1782!79

m 2111 Q

155,000

0204 21,1147

2;579 7 2,1133

22,788 2,084 20,703

q If.!.& 20,451

149

133 Ez?l ~~

Percent distribution

100.0 6.9 93.1

Em& 82.1

10.0

1:3 m 1.0

100.0 6.7 93.3

81.1

11.1

1.1

100.0 9.1 90.9

~ 8.4 89.7

H

0.6 0.7

0;6 ‘ 0.5

Ism tie ~ction~ in ~i$ ~epo~ on *,Private Health lnsU,rance C0vera9e,”

“Medicare Coverega,”’ and “Militerv end Veterens Administration

Health Care Covara!# for specifications of how the concept of

‘,covered” is defined for each of the three types of health care covarYSea the section of this report on “Medicaid Coverage” fOr the astimete.s associated with eech of the components of this definition.

34.NOt repor~d,- includes negetive responses, refusals, and unkrlowns

to any one of the components of this concept

65 years of age and over, 54.5 percent had both private health insurance and Medicare, 26.7 percent had

Medicare only,. and 3.3 percent had private health

insurance Only.

The following sections show how the estimates

for each of the four types of health care coverage are

c@?ined. Also shown are estimates of the more detaded aspects of coverage associated with each type.
Table Z. Number of persons by age and Plan combinations of health care coverage under private health insurance, Medicare, and military and/or

Veterans Administration health benefits’; percant distribution according to age: United States, 1978

CoveraW statusand plan combinations

All Under 65 years All Under 65 years

a~s 65 years and over agx 65 years end over

All persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All plan combinations with known coverage status. . . . . . . . : . . .

Private insurance orgy . . . . . . . . . . . . . . . . . .. . . . . . . . . . .

Private insurance and Medicare . . . . . . . . . . . . . . . . . . . . . . .

Medicare on/y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Priority eligibility or reported military-VA covarage oniy . . . . . . . .

Private insurance and priority eligibility or reported military-VA

coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Allthrae types ofcoveraga . . . . . . . . . . . . . . . . . . . . . . . . . .

Medicare and priority eligibility or reportad military-VA coverage . . .

Notcoverad byanyof the three plans . . . . . . . . . . . . . . . . . . .

Unknown coverage or combination status. . . . . . . . . . . . . . . . .

Number of persons in thousands Percent distribution

213,828 191,041 22,788

208,023 185,668 22,365

143,986 143,225 761

13,286 882 12,414

7,210 1,121 6,089

4,924 4,796 128

4,142 3,966 176

1,817 121 1,696

1,005 196 809

31,643 31,351 282

5,805 5,383 423

100.0 100.0 100.0

97.3 97.2 98.1

67.3 75-0 3.3

6.2 0.5 54.5

3.4 0.6 26.7

2.3 2.5 0.6

1.9 2.1 0.8

0.8 0.1 7.4

0.5 0.1 3.6

14.8 16.4 1.3

2.7 2.8 1.9

lE~cludes persons not meeting cri~ria used to define coverage discussed in taxt who ekO did not rePOrt MilitaI’V Or VA coverage SS a IWISOn fOr not

being ccnmred by any health insurance plan.

Private health insurance coverage

Household respondents were asked whether any

family member was covered by a health insurance

plan that paid any part of a hospital bilI, or a doctor’s

or surgeon’s bill for operations. The names of all

plans were listed for which a positive response was

obtained to either or both of these questions. A series

of questions were then asked for each plan that

covered at least one family member. Included were

questions about whether the plan was obtained

through a group, the type of coverage associated with

the plan, each family member’s coverage status in

redation to each of the plans, and whether the plan

had been used during the past year. In tabulating the

data, persons were classified as “covered by private

hezdth insurance” if they were covered by at least

one plan, and as “not covered” if they were classified

as “not covered” under all of the plans listed for

the fami.Iy. They were classified as “unknown” if

their coverage status was not determined for at least

one plan and they were not covered under any of

the other plans (if any) listed for the family.

Table 3 shows that an estimated 166.1 miIlion

persons (77.7 percent) were covered by private health

insurance. An estimated 159.0 million persons (74.3

percent) had both hospital and surgical coverage,

4.2 miIIion persons had only hospitai coverage, and

323,000 persons had only surgical coverage. About

325,000 persons classified as covered had neither

hospital nor surgical coverage, and the type of coverage was not determined for about 2.2 million persons.

& estimated 46.8 million persons (21.9 percent)

did not have private health insurance coverage and

the status of about 1.0 million persons (0.5 percent)

could not be determined.

Table 3. Number of persons by age and type of private health insurance

ccwerage; percent distribution according to age: United States, 1978

Type of private health All Under 65 years

insurance conwaga -s 65 years iwsdover

Number of persons in thousands

All persons . . . . . . . . . . . . . . 213,828 191,041 22,788

Covered . . . . . . . . . . . . . ..l66.O5O 150,928 15,122

Hospital and surgical coverage. . 158,978 145,316 13,662

Hospital, no or unknown

surgical coverage. . . . . . . . . 4,220 3.192 1,028

Surgical, no or unknown

hospital coverage . . . . . . . . 323 243 81

Neither hospital nor surgical

coverage . . . . . . . . . . . . . 325 252 74

Unknown type of covemge . . . 2,203 1$26 278

Notcovered . . . . . . . . . . . . . 48,791 39,310 7,482

Unknown if covered . . . . . . . . 987 803 184

Percent distribution

All persons . . . . . . . . . . . . . . 100.0 1000,. 100.0

Covered . . . . . . . . . . . . . . . 77.7 79.0 66.4

Hospital and surgical coverage. . 74.3 76.1 60.0

Hospital, no or unknown

surgical coverage. . , . . . . . . 2.0 1.7 4.5

Surgical, no or unknown

hospital cwerega . . . . . . . . 0.2 0.1 0.4

Neither hospital nor surgical

coverage . . . . . . . . . . . . . 0.2 0.1 0.3

Unknown type of coverage . . . 1.0 1.0 1.2

Notcwered . . . . . . . . . . . . . 21.9 20.6 32.8

Unknown if cwered . . . . . . . . 0.5 0.4 0.8

knong persons under 65 years of age, the estimated proportion with private health insurance

coverage was 79.0 percent, while about two-out-ofthree persons (66.4 percent) 65 years of age and over

were covered by a private health insurance plan.
4

If the persons for whom either the coverage

status or the type of coverage was unknown are

distributed in the same proportions as for persons

with known coverage status and known type of

coverage, the following adjusted estimates resu1t:4

approximately 166.8 million persons were covered by

private health insurance; of these about 166.4 million

persons had hospital insurance and about 164.6

million persons had surgical insurances

Medicare coverage

Household respondents were asked whether

anyone in the family was covered by Medicare, and

if so, to rndicate which persons were covered. Those

classified as covered were then asked whether they

were covered by the types of benefits that pay for

hospital bills (Part A), physician care (Part B), or

both. Table 4 shows either or both of these forms of

coverage for an estimated 23.6 million persons (11.0

percent). About 21.2 million of these persons were

65 years of age and over and about 2.4 million were

under 65 years of age. This represents a coverage rate

under Medicare of 93.1 percent for the former group

and 1.2 percent for the latter group.

An estimated 22.4 million persons had coverage

under both Part A and B of Medicare. An additional

213,000 persons had coverage under Part A only,

and another 137,000 persons had coverage only

Table 4. Num@r of pereons by age and Medicare coverage; percent

distribution according to age: United States, 1978

Type of Medicare coverage

All Under 65 years

+s 65 years and over

Number of persons in thousands

Allpersons . . . . . . . . . . . ...213.828 191,041 22,788

Covered . . . . . . . . . . . . . . . 23,587 2,359 21.207

Hospital and doctor coverage . . 22,404 2,174 20,230

Hospital, no or unknown

doctor’s coveraga . . . . . . . . 713 109 605

Doctor, no or unknown

hospital coverage . . . . . . . . 137 ●5 132

Unknown type of coverage . . . 312 72 240

Notcovered . . . . . . . . . . . ..l88.733 188,273 1,460

Unknown if covered . . . . . . . . 529 408 120

Percent distribution

All persons . . . . . . . . . . . . . . 100.0 100.0 100.0

Covered . . . . . . . . . . . . . . . 11.0 1.2 93.1

Hospital and dcctor coverage . . 10.5 1.1 88.8

Hospital, no or unknown

doctofscoverage . . . . . . . . 0.3 0.1 2.7

Doctor, no or unknown

hospital coverage . . . . . . . . 0.1 ‘0.0 0.6

Unknown type of coverage . . . 0.1 0.0 1.1

Notcovered . . . . . . . . . . . . . 88.7 98.6 6.4

Unknown if covered . . . . . . . . 0.2 0.2 0.5

under Part B. Distributing the unknown cases in the

same proportions as the known cases produces the

following adjusted estimates for Medicare coverage:

about 23.6 million persons in the civilian noninstitutionalized population were covered by Medicare, with

virtually all of these persons covered by Part A, and

about 23.1 million of them covered by Part B.

The Health Care Financing Administration

(HCFA) produces estimates of persons enrolled in

Medicare. The 1978 estimate is about 26.6 million

enrollees. However, HCFA is not able to distinguish

enrollees on the basis of institutionalization and their

estimate is not, therefore, directly comparable to

those shown in this report (which represent only the

noninstitutionalized population).

Reason for not being covered

by any health insurance plan

An estimated 38.5 million persons were not

covered by private health insurance or Medicare.

Respondents for persons in that category were asked

to select the reasons for this “lack of coverage by any

health insurance plan” from a flashcard containing

the reasons shown in table 5. No reason was given

for an estimated 1.5 million persons. An estimated

41.7 million reasons were obtained for 36.9 million

persons. “Too expensive” was the reason chosen most

often (15.3 million persons), followed by “Care

received through Medicaid or Welfare” (9.1 million

persons), and by “Military dependent (CHAMPUS) or

Veterans benefits” (4.4 million persons).

It should be emphasized that the reasons related

to Medicaid and military and/or VA benefits cannot

Table 5. Number and percent distribution of reasons for not being

covered by any health insurance plan for persons who gave at least

one reason, by type of reason: United States, 1978

Reason for no health

All reasons

insurance plan’ i%s%ZIL ‘~~~~~~~-

All reasons .. . . . . . . . . . . . . . . . . 41,738 100.0

Care received through Medicaid

or welfare . . . . . . . . . . . . . . . . . 9,131 21.9

Unemployed or reasons related to

unemployment . . . . . . . . . . . . . . 3,612 8.7

Cannot obtain due to poor health,

illness, or age . . . . . . . . . . . . . . . 632 1.5

Tooexpensive. . . .“. . . . . . . . . . . . 15,274 36.,5

Dissatisfied with prwious insurance . . . 727 1.7

Don’t believe in insurenca . . . . . . . . . 845 2.3

Healthy, not much sickness in family,

heven’t needed . . . . . . . . . . . . . . 3,274 7.8

Milite~ dependent, (CHAMPUS),

Veterans benefits . . . . . . . . . . . . . 4,408 10.6

Someother reason . . . . . . . . . . . . . 3,735 8:9

lThls que=ion ~= ~kad Of all persons with neither Private health

insuranca nor Medicare.
admmdda5

by themselves serve as a basis for estimating the

number of persons eligible for these two types of

health care benefits: fret, persons eligible for these

types of benefits, who were also covered by Medicare

or private health insurance, were not shown the card

and asked to choose a reason; second, a person may

be aware that he is eligible for either or both of these

types of benefits but not perceive this as the reason

he does not have health insurance. An individual

may, for instance, perceive his unemployment or

limited income as the real underlying reason for not

having health insurance and consider his Medicaid

eligibility as a mere consequence.

Military and Veterans

Administration health

care coverage

Aside from questions related to coverage under

private health insurance and Medicare, the 1978

NHIS questionnaire included items relevant in determining whether persons had priority eligibility to

receive miIitary and/or VA health care benefits.

Veterans were asked (1) whether they had a service

connected disability, and (2) whether they were

receiving a pension from any of the military services

or the VA.

An estimated 3.0 million veterans had a service

connected disability. However, respondents were not

asked whether their disability had been certified by

the VA as service connected. The estimate, therefore,

is based on the respondent-assessed claim of such a

disability.G

An estimated 3.4 m~lon veterans received a

pension from the military, VA, or both. Of these

persons, the VA was the source of the pension for

about 2.0 million,T and one of the military services

for about 1.5 million.

AU veterans with other than dishonorable discharges are potentially eligible to receive health care

benefits from the VA. However, the availability of

these services is limited and a system of criteria has

been established to determine which veterans and

their families qualify for these benefits. The following

criteria are used to determine priority eligibility

status: having a service connected disability, receipt

of a pension from the VA, or being a veteran 65

years of age or over. A somewhat lower priority is

afforded to other veterans if they establish that

they are unable to defray the costs of necessary

hospital charges elsewhere. Dependents and survivors

of certain types of disabled or deceased veterans may

al:o qualify for VA health care benefits. These persons were not, however, directly identified in the

1978 NHIS.

As noted above, an estimated 3.0 million veterans

had a service connected disability. Additionally,

about 2.9 million veterans either received a VA

pension or were 65 years of age or over. These

approximately 5.9 million veterans meet the criteria

discussed above for priority eligibility for VA health

care benefits.~

Aside from the VA, the militmy services themselves offer health care benefits to eligible dependents

of active military personnel and to military pensioners

and their eligible dependents. Civilian dependents

of active military personnel are not directly identified

in the NHIS. However, it is possible to indirectly

estimate the number of eligible dependents. During

1978, there were about 1.8 million wives and dependent children under 21 years of age living at home

with men on active military duty. These persons have

a very high priority for receiving military health care

benefits.

A somewhat lower priority is afforded military

pensioners and their eligible dependents. Even though

questions were not asked to identify these dependents, it is possible to indirectly identify about 2.3

million of them by the family relationship they bear

to the pensioners. These include the wives and

dependent children under 21 years of age living at

home with the military pensioner. Combining the

above estimates for dependents of active military

personnel and of mi.Iitary pensioners, and including

the military pensioners themselves, produces an overall estimate of about 5.6 million persons in the civilian noninstitutionalized population with priority

eligibility to receive health care benefits from the

military.g Certain groups, however, (such as eligible

sumivors of military pensioners who have died)

could not be identified and are, thus, excluded from

this estimate.

Among the 5.9 million veterans identified as

having priority eligibility to receive VA health care

benefits and the 5.6 million persons identified as

having priority eligibility for militmy health care

benefits, 835,000 were identified as having priority

eligibility for both types of benefits. However, the

resulting total of about 10.7 million persons with

priority eligibility for either or both types of health

care benefits does not include other persons with

“military or VA health care coverage” as a reason

for not being covered by any health insurance plan.

Table 6 shows the results of cross-classifying

persons by identified priority eligibility status and

whether or not military and/or VA coverage was

given as a reason for not having a health insurance

plan. An estimated 1.3 million persons with this

reason did not meet the criteria used to identify

persons with priority eligibility for military or VA

health benefits. Under the assumption that these

persons would not claim that their eligibility for these

health care benefits was a reason for not obtaining
6

Table 6. Number of persons by whether military and/or Veterans

Administration coverage was repomd as re~on for no health

insurance plan, and eligibility for military and/or Veterans Administration health benefits and source of eligibility: United States,

1978

Military and/or VA coverage

Eligibility status as reason for no

and source of All health insurance plan

eligibility benefits persons

Yes No No m- Not

sponse asked’1

Number of persons in thousands

All eligibility statuses,all

sources. . . . . . . . . . . 213,828 4,408 32,525 1,544 175,351

Identified priority eli i3 bility, all sources2~ . . . 10,660 3,065 447 69 7,079

Military and VA2~3. . . 835 159

Military only2. . . . . .

●22 4’2 653

4,773 2,614 137 50 1,972

VAonly3 . . . . . . . . 5,052 293 288 “17 4,464

Priority eligibility status

not identified . . . . . . . 203,168 1,343 32,079 1,475 168,272

1N~t ~~ked ,e=on Lmcaumparson not reporsed to lack Private heal*

insurartcaor Madicere coverage.

2E~c}ude~ dap~~den~of daceased or institutionalized militarv Mn-

~oners.

.

Excludes vemrans who qualify for prioriry eligibility solely on the

basisof low income.

health insurance, unless they had a relatively high

priority eligibility status for receiving them, it is

reasonable to include them in the total for persons

with priority eligibility status for the receipt of

military or VA health care benefits. This procedure

produces an overall estimate of about 12.0 million

persons in the civilian noninstitutionalized population

with either coverage or priority eligibility status for

receiving military or VA health care benefits (table 7).

Table 7. Number of persons by military and/or Veterans Administration

health care crweragestatus‘.. United States, 1978

Military amd/or VA health care covera~

Number of persons

in thousands

Allpemons . . . . . . . . . . . . . . . . . . . . . . . . 213,828

Priority eligibility or reported milita~

andlor VAcoveragel . . . . . . . . . . . . . . . . . 12,003

Neither priority eligibility nor reported

military and/or VA covera~ . . . . . . . . . . . . 197,019

Unknown military and/or VA health

banefits coverage . . . . . . . . . . . . . . . . . . . 4,805

1Excludes ~ar~o”~ not meeting criteria used to dafine coverage discussed in taxt who also did not repom military or VA covaraga as a

reason for not being covered by any health insurarscaplan.

Medicaid coverage

As discussed earlier in this report, persons were

defined as having “categorical or reported Medicaid

coverage” if they (1) had a vaIid Medicaid card at the

time of the interview, or (2) were reported as receiving Aid to Families with Dependent Children (AFDC)

or Supplemental Security Income (SS1), or (3)

Medicaid coverage was given as a reason for not being

covered by any health insurance plan.

Based on the number of respondents who presented a valid Medicaid card, it is estimated that 8.2

million persons were enrolled in the Medicaid program in 1978. An additional estimate of 4.9 million

persons eligl%le for Medicaid was obtained based on

the reports of AFDC or SS1 recipients (often called

categorical eligl%ility) who did not show a valid Medicaid card. 10 Together the criteria of a valid Medicaid

card and/or reported receipt of AFDC or SS1 results

in an estimate of 13.1 million persons.

Earlier it was noted that respondents representing

an estimated 9.1 million persons gave Medicaid ccwerage as the reason for not having coverage by any

health insurance plan. As is shown in table 8:, an

estimated 1.7 million (863,000 and 848,000)1 of

these persons did not have a valid Medicaid card and

were not receiving AFDC or SS1. If these 1.7 million

persons are combined with the 13.1 million cited

above, an estimate of 14.8 million persons with categorical or reported Medicaid coverage is obtained.

This figure (14.8 million persons) is an average

annual point prevalence estimate. It is not an estimate

of the total number of persons covered by or eligible

for Medicaid during part or aIl of the 12-month

period. Data from the National Medical Care Expenditure Survey provide an estimate of 20.8 million

persons in the civilian noninstitutionalized population

with Medicaid coverage during part or all of 1977.11

Table 8. Number of persons by whether Medicaid coverage was reported

es a reason for no health insurance plan, and possession of a valid

Medicaid card or receipt of AFDC or SS1: lJni&d States, 1978

Medicaid as raason for no

Possessionof valid All

health insurance plan

Medicaid wre card or

receivesAFD C-SSI

statuses

Yes No ‘nNot

known asked’

Number of persons in thousands

All parsons. . . . . . . . . . 213,828 9,131 27,803 1,544 175,:351

Has Medicaid card and/or

receivesAFDC or SS1 . . 13,135 7,420 1,670 162 3)383

Neither has Medicaid card

nor raceivesAF DC or

SS1 . . . . . . . . . . ...198.444 863 25,750 1,337 170,,$93

Unknown if meetsat least

one of these criteria. . . 2,250 848 383 45 !374

—

1~ Ot ~ked ~a~on ~ca”= pa-n not mporsed to lack Private haal~

insurance or Medicara coveraga.
amcedda7

Discussion

An aspect of the debate on national health insurance has been the growing interest in determining

the extent, breadth, and depth of health care coverage

among the American population. As noted earlier,

whiIe the data presented in this report are relevant to

the issue of the extent of health care coverage, they

are of limited value regarding the breadth and depth

of that coverage. As such, the focus of the discussion

has been on whether or not persons were covered

under any of the four types of coverage or under at

least one of them. As discussed in the following

section, this focus on the question of coverage may

lead to misinterpretations of the results discussed

in this report.

Alternative estimates of

the extent of coverage

The previous discussions of Medicaid coverage

and of reported or priority eligibility under militaxy

or VA health care benefits demonstrate that any

estimate of the number of persons not covered under

any of the four plans derives to a significant degree

from the definition of the concept being measured,

assumptions made about the data, and the type of

statistic being estimated. Within this context, the

following paragraphs briefly indicate some alternative

estimates that might have been derived from the same

data.

Among the approximately 23.5 million persons

shown in table 1 without identified coverage under

any of the four types of coverage, about 2.2 million

were members of families with an annual income of

less than $3,000, about 2.4 million were veterans, and

442,000 were unable to perform the usuaI activity of

their age-sex group due to chronic health conditions

or impairments. Among the same 23.5 million persons, an estimated 738,000 received Medicaid benefits

or VA health benefits during the 12 months preceding the interview. The unduplicated estimate of

those who meet one or more of these criteria is about

5.3 million persons. Thus by assuming that these

persons would have some type of health care coverage, the estimate of those not identified as covered in

table 1 is reduced by 22.4 percent (or to about 18.3

million persons).

On the other hand, certain assumptions made in

classifying persons as “covered” in earlier sections of

this report might be questioned. For example, whether

or not persons with priority eligibility for VA health

care benefits actually are able to receive health care

from the VA depends on a number of factors including their proximity to VA health facilities and

the ability of these facilities to accommodate them.

This type of relationship does not provide the usual

implications for accessibility to health care that

having private health insurance, Medicare, or even

military coverage impIies. In addition, the data in

table 6 suggest that persons with VA eligibility do

not necessarily regard this as an alternative to private

health insurance. Very few of those persons with only

VA coverage gave that as a reason for not being

covered by a health insurance plan. Data are needed

on the extent to which persons with priority eligibility for VA health benefits actually use VA facilities.

Such data will be available in the near future from the

National Center for Health Services Research based

on the 1977 National Medical Care Expenditure Survey, and from the National Center for Health Statistics and the Health Care Financing Administration,

based on the 1980 National Medical Care Utilization

and Expenditure Survey.

Beyond assumptions related to the data itself,

different estimates could be derived by choosing to

use a different and perhaps a more relevant statistic

to estimate. For instance, compared with the average

annual point prevalence estimate of a maximum of

about 23.5 million persons not identified as covered

under any of the four types of coverage, the average

point prevalence estimate for a shorter period of

time (or as of a certain date) might be the more

appropriate statistic; the estimate of persons not

identified as covered under any of the four types

of plans for each of the four quarters of 1978 differ

by as much as 1.1 million persons.

Consideration of further issues (including the

assumptions made in editing the data) and recognition

of the sampling errors associated with the estimates

suggests that the 1978 NHIS data ffle could reasonably serve as a basis to produce an estimate of anywhere from about 7 to 13 percent as the proportion

of the civilian noninstitutionrdized population not

covered under any of the four types of health care

coverage discussed in this report.

Extent of coverage and the

financial burden of illness

There is only a partial association between the

concepts of coverage and of financially unimpeded

access to health care services (except perhaps in the

case of eligibility for full Medicaid benefits or membership in a Health Maintenance Organization).

For instance, many of the persons classified as
“covered” in this report may have experienced relatively large out-of-pocket health expenditures even

though they were covered, while persons classified

as not being covered may have had no health expenditures during the period they were not covered. As

such, the concept of coverage is only partially related

(I) to the issue of the financial burden of illness,

injury, or impairment; and (2) to the issue of the

degree to which people fail to seek needed medical

care because of the potential financial burden associated with obtaining such care.

In summary, the focus given in this report to the

question of the extent of health care coverage, and

the limited consideration given to the question

of the breadth and depth of that coverage, derive

from the strengths and limitations of the types of

data collected on these issues in the 1978 NHIS

and not from the assumption that a mere identification of the so-called “uninsured,” “uncovered,,” or

“unprotected” population is of paramount in~portance to the major issue of the financial burdem of

illness.
dmcedaa9

References

lBecause these items were not included in the 1976 Nationai Health

Interview Survey and because dtiferent assumptions were made in

analyzing the data, comparisons of the results of this study and those

shown in Health Grre Coverage, 1976 (Advana Data No. 44, September 20, 1979) should be made with caution.

‘Reports currently available from the National Center for Health

Services Research include: Data Preview 1: “Who are the Uninsured?”

aud Data Preview 4: “Health Insurance Coverage of Veterans.”

3This estimate of about 11 percent of persons in the _ noninstitutionaiized population not identitled as having coverage differs

from the estimate of 12.6 percent shown as “without insurance coverage” in the recent, “Who are the uninsured?” Data Preview 1 (Nalionsl

Center for Health Services Research) because: (1) the concept “not

identified as covered” differs from the concept “without insurance

coverage,” (2) different criteria were used to define “coverage: and (3)

data from different years snd for different time periods were used to

produce the two estimates.

41n this and in following sections the estimates based on reported data

are shown in the tables. When a signifkant number of unknown cases

are associated with art estimate of major interest, an adjusted population

estimate will be given m the text. The adjusted estimates are derived by

multiplying the percent of persons covered and not covered (i.e., the

unknown cases are excluded) by the number of persons in the entire

civilian noninstitutionalized population.

5As of December 31, 1977 the Health C- F~~~g Adminis*tion

estimates that about 168.2 million persons had hospitai coverage and

about 163.9 million persons had surgical coverage under private health

rnsursmce, (Carro~ M.S., Arnett III, R.H., “Private Health Insurance

Plans in 1977: Coverage, Enrollment and Financial Experience,”

Health FinancingReview, Fm 1979).

b~e VA estimates that about 4 million veterans have a seM@ connected disability and about 1.7 million of these veterans are classWed as having a zero percent seMce connected disability. Presumably,

many of these veterans with a zero percent disabiWy did not report

having a seMce connected disability.

7The VA estimates that about 1 million veterans Were Ie@ivillg a

VA pension and rdrnost 2.3 miilion veterans were receiving VA compensation during 1978. Presumably, about 1 million persons represented in the NI-HSdid not distinguish between receipt of a pension snd

receipt of compensation payments tlom the VA.

s~e VA SIW ~CIU&S in its priority eiigibiity group those veter~s

under 65 years of age with an individual rncome of under $7,000 a

year. It estimates that 11 to 12 miUion veterans have priority eligibility

to receive VA heaIth cam. Combining the under $7,000 srmual income

group of veterans identitiid in the NHIS with the 5.9 miIlion veterans

who meet the priority eligibility criteria ducussed in the text produces

a NHIS estimate of about 11.1 million veterans in the civilian nonrnstitutionaIized population meeting the VA criteria for priority eligibility for VA health care benefits (this estimate is not adjusted for

unknowns).

‘The Pentagon estimates 6 to 7 million civilks were eiigiiIe to receive

milkuy health care benefits during 1978.

1‘Based on the number of respondents who reported receipt of AFDC

or SS1 (regardless of whether or not a valid Medicaid card was presented), it is estimated that a total of 10.7 million persons had categorical eligibility for Medicaid.

1lWflen&Y, G., Walden, D., and Kasper, J.: ‘The Chs@ng Medi=id

Population,” paper presented at the 1980 Annual Meeting of the

American Statistical Asaociatiort, Houston, Texaq Aug. 11,1980.
10 aduancedata

Technical notes

The estimates shown in this’ report are based on

data obtained in household interviews in a continuing

nationwide survey. Each week a probability sample

of households is interviewed by personnel of the U.S.

Bureau of the Census to obtain information about

the health and other characteristics of the civilian

noninistitutionalized population of the United States.

During 1978, interviews were conducted in

approximately 41,000 households containing about

110,000 family members and unrelated individuals.

The total noninterview rate was about 3.8 percent.

The weights of interviewed persons in the segments

containing households in the sample for whom data

were not obtained were inflated to compensate for

household nonresponse.

AU persons 17 years of age and over were asked

to participate in the interview. When this was not

possible, proxy responses were accepted from family

members meeting the NHIS respondent rules. Approximately 63 percent of persons 17 years of age

and over responded for themselves. Proxy responses

were obtained on the remaining 37 percent of adult

family members. All information on persons under

17 years of age is obtained from adult family members

or guardians.

The appendixes of the 1978 Current Estimates

(Series 10, No. 130) should be consulted for a more

detailed discussion of the sample design and weighting

procedures (appendix I) and for a copy of the questionnaire used during 1978. Approximate sampling

errors for estimates contained in this report are

shown in table I (aggregates) and table II (percents).

Table 1. Standard errors of estimates of aggregates

Size of estimate Standard

in tfrousands error in

thousands

35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

300 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

500 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

20,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

30,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

150,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393

Table 11. Standard errors, expressed in percentage points, of estimated

percentages

Estimated percentages

Base of percentages

—

2 5 ro 20

in iisousands

or or or or 50

98 95 90 80

100 . . . . . . . . . . . . . . . . . . 25 3.9 5.4 7.2 9.0

300 . . . . . . . . . . . . . . . . . . 1.5 2.3 3.1 4.2 5.2

500 . . . . . . . . . . . . . . . . . . 1.1 1.8 2.4 3.2 4.0

1,000 . . . . . . . . . . . . . . . . . 0.8 1.2 1.7 2.3 2.9

5,000 . . . . . . . . . . . . . . . . . 0.4 0.6 0.8 1.0 1.3

10,000 . . . . . . . . . . . . . . . . 0.3 0.4 0.5 0.7 0.9

20,000 . . . . . . . . . . . . . . . . 0.2 0.3 0.4 0.5 0.6

30,000 . . . . . . . . . . . . . . . . 0.1 0.2 0.3 0.4 0.5

150,000 . . . . . . . . . . . . . . . 0.1 0.1 0.1 0.2 0.2
mm“@~“ ~‘~

From Vital and Health Statistics of the Nationai Center for Health Statistics Number 72 ● June 29, 1981

Visits to Family Planning Service Sites: United States, 1978

by Bettie L. Hudson, Division of Health Care Statistics

Data highlights

According to data collected for the National

Reporting System for Family Planning Services by

the National Center for Health Statistics, an estimated 7,425,000 medical family planning visits by

females were made to nonmilitary family planning

service sites in the United States. Excluded from

the scope of the National Reporting System for

Family Planning Services are family planning visits

that were made to private physicians. Of these

visits, 38.1 percent were made by females 20-24

years of age.

Of the family plaming visits made by females,

an estimated 77.6 percent resulted in the adoption

or continuation of an oral contraceptive pill, an

intrauterine device (IUD), or sterilization, each of

which is a highly effective contraceptive method

requiring medical services.

About 32.7 million medical services were provided to females at an average rate of 4.4 services

per visit. Four of the 11 medical services specified

in the National Reporting System for Family P1anning Services (the Pap smear, the pelvic examination,

the breast examination, and the blood pRXSUre

check) accounted for 56.2 percent of the total

medical services provided.

Introduction

Since 1972 the Division of Health Care Statistics

of the National Center for Health Statistics (NCHS)

has used the National Reporting System for Family

Planning Services (NRSFPS) to obtain data on the

utikation of family planning services provided by the

Nation’s family planning progrm. I NRSFPS data are

also used by the Department of Health and Human

Services to prepare the annual “Report on FarnilY

Planning Services and Population Research,” made to

Congress, as required under Section 1009 of the

Public HeaIth Service Act (Public Law 94-63).

On July 1, 1977, the NRSFPS was converted

from a fulkount to a sample-based survey. Figure 1

is a facsimile of the primary data collection form

used. Estimates in this report are based on a sample

approach for the entire year.

A brief description of the sample design and an

explanation of the sampling error associated with

the estimates are found in the technical notes in this

report.

According to the NRSFPS definition, family

planning services encompass medical services related

to contraceptive methods (including stefiation)

and treatment for infertili~. These medical services

are’ the Pap smear, pelvic examination, breast examination, blood pressure check, pregnancy testing,

venereal disease testing, urinalysis, blood test, sterilization, infertility treatment, and other medical

services. While family planning services are available

through several components of the Nation’s health

care delivery system, the Nation’s family planning

program distinguishes itself from the other components by its commitment to provide family planning

semices to individuals regardless of economic status.

The Nation’s farniIy planning program, as outlined

in the 1978 report to Congress, is comprised of

public and private agencies that provide family planning services through a network of family planning

service sites. The U.S. Public Health Service provides

a significant financial base for the provision of family

planning services through grants for health services

to many of these agencies.

Data on family planning services are also colIected

in two other surveys-the National Ambulatory

Medical Care Survey (NAMCS),Z and the National

Survey of Family Growth (NSFG).3 NAMCS collects

data on visits to office-based physicians, and NSFG

collects data on family planning visits made by married women ages 1544 years. Because of differences

in the populations sampled, the definitions, and the

data collection procedures, estimates on family planning visits from the three data systems may differ.

US. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service, Office of Health Research, Statistics, and Technology
2 aduancedata

AN? 1~79 O.M.B. 68-R1137

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

PuBLIC HEALTH SERVICE

HEALTH RE.WURCES ADMINISTRATION ASSURANCE OF CONFIDENT IALITV-AI! lnfc.rnutlc.n which WOUM ~rm,t ,~i,.

NATIONAL CENTER FOR HEALTH STATISTICS

fl”tban of ●n Indt.ldual, ● mactlca. or ●n .staalmhmcnt wm be had oa.tid.ntlal,

wm De u-a only by P8rsons .ngagwa m ●a for me Puvswtm of th. SUrv.y ●ne wnt

not 0. awclc.ud cm r.l”wd to otlml c.9.sons or .wa tor ●ny om.r D.. POS.. wo.lilon

Clinic Wit Record for Family Planning Sawices Of *r.lce Is In no way contlng.m on the Pa:t.nt,s Dr.avta”g .ny mfo.~tIo. to.

this Iorm.

1, SERVICE NUMBER

~

11. PREGNANCY HISTORY (Fmtaks only]

A. Hsvc you ever been pm~nt?

‘ ‘AT’ENT NUMBER ~

.IJv” b ❑ NO-- G0rot2

B. How many Ii= bktbt imvc you lmd?

3. OATE OF THIS VISIT

qlnn C. Of thccc, how MSny we now hmng?

D. How many of Your pfe6nsncic$ vm?e snded by Mflblrth,

4. PATI ENT’S SEX

● ~ F.nulc b ~ M~l@

induced aborlion. or miscarmage? (if ..zwo.., p to F /

E. How many of tbcac Pmsnanciet were ●nded by induced

5. ARE YOU OF HISPANIC ORIGIN OR 0ESCENT7 abortion since January 19737

HANO CARO A .0,” ~ ❑ *

F. In whm month 8nd ye.r did your last pmsrmncy ●nd

(r.sudlns of bow it ended)? ( I J

6. PATIENT’S RACE (L3f#ck mm box} Month vu r

● •1 w~t~* c ❑ m18n or FWlflc Istanmr

12. CONTRACEPTIVE HISTORY

b ❑ BIJCk d o Am*rI-n I.dbn or Alash.n m,,..

A. Hsve you ●m umd . mclbod of Mrth control regularly?

.D.et b Df90-Gofof3

7, WHAT IS YOUR BIRTH 0ATE7

● ~t* —-----0 Q Q

HAND CARO D

B, Whst molbod did yOfl tad uw ,.w)UIY? hack ,11 nufhnd rbr ●p@v)

b ❑ If u. Imewn mk-”rnw OM ●,. ~ou..,

# I-J Storlllxatlcn f ❑ condom

(No. of Yaarl) b u Oral (Pull o a Foam/Jolly/Cra#m

R PATlENT STATUS c ❑ IUD h n Natural Oncluetng rhythm]

a ❑ 08anhragm J ❑ Ofhcr

H8ve You .~r hems patient of tbu or my othu clime for fnmity

plannma ml! Z.mvieot? ● ❑ Inmctlorl

.0” - bDNO C. 00 you currently w UMt nxthod (primuy nwlhod ch.ck.d In 12B)?

Ir .,Yes,’. when were you E a patient .t .ny Og a ❑ Ya$--Ga m E b ❑ *

clinic for fmnily plannm’ medical scmces?. _ ~nth

9. EOUCATION

D. In 4s: month snd Yan did You stop usinc that mwthod? I I I

month Ynr

A. Whsf & the hi~h.s: gr.dc (or y“r) of rqufar school you hwe compktcd?

IGrcle onc numSul

S. How Ionc did You ust ttmt method?

012345678910 11121314151617+

— Days 111I- than ● month)

(If -Z*?O,”PO m 10)

— MOnfhs (11IW tMn a Y9W1

— ~--

B. Are YOU PrUUMly ● student in a regular school?

F. Whtrc was the mtthod premibrd or obfsined?

.0””

~lzl~

● n ‘f Msmr.m.slt. . D 0,”9,,0,. ,no”or-,pft.n,

b ❑ clinic Of 0th9r than thh SIta) f fJ O]htr

c ❑ tiseltal (11Oth.r than thl%m.) g ❑ untimm.m

10, FAMILY INCOME ANO FAMILY SIZE a ❑ F71vat, PhySlC18n

k4AND CARO a ●d HANO CARD c

13. MEOICAL SERVICES PROVIOED AT THIS VISIT

A. Wh,ch of the followint groups rcprewnts your tots! combined WC.”

(bcfcue deduclicms) family income for the p~t 12 months? t ❑ PaDsmoar 9 0 urln~lysl~ @.*JJ

●o

0.S1 ,249 d ❑ S6,250.36.749

b D FWVlc .xam

9 n S11,750.

n O Blood tast [n.t.s.)

b ~ S1.25&S3,749 . ❑ sS,750-S13.749 h ❑ unknown

c ❑ Emnst ●xam j O 3f9NU28ti0n

c ❑ s3.750-s6..2e9 f ❑ s13,750-s1-,749

a ❑ E1100dPMWW. k n 1nf9*81tty ‘raatwot

. ❑ *.gnm.y mstlng Ill o ofha, rnadlal “r”ltss

B. How mmy people are in Your fsmUy, that is, the numlwr f I-J V.D. Ialtlng

UIpwrted by this income?

C. ties Ihti mco!ne tnclude ●y pubhc Dssitl.nce?

J ~ ~*S

14. CONTRACEnlVE METHOO AT THE EW OF THIS vISIT

~cl~

D What k YOW ,el,t,omb,p to lb, cbmf earner?

A. Method IChuk ●ll ftNt twly)

● ❑ cntot ●ar-r

8 E Staflllmtlon f O condom

c ❑ OJ.9fncr/50n

b ❑ ‘if*/~uso~no

b g oral (mu) g ~ FoJmlJWYfCrmm

d ❑ other r.1.tiw c D IUD h fJ Mtur.I IInCIUaI.I rwfhml

AGENCY USE ONLY d ❑ Dlsphragm J n Ot-r

A e c o E F

. ❑ l“)utlm M m None

——

1. fL lf “’None, ” give te.son K3fuk mm only)

2. ● n Iw.9narM d ❑ OtMr rncdl-1 f_t0n5

3. b IJ Infwtltlty mtlmt ● O Rclylns on wrfner’s nwlfwd

4.

c ❑ Sutilmg Pr.gnmw f n Dtfwr

5.

6. HRA-192-1

6177

—

Figure 1. Clinic Visit Record for Family Planning Services
Sex, age, race, and ethnicity

In addition to the estimated 7,425,000 medical

family planning visits made by females, an estimated

27,000 medical family planning visits were made by

males to family planning service sites. Because the

size of the NRSFPS sample is not large enough to

allow a detailed analysis by various service and

sociodemographic characteristics, this rePort is

limited to family planning visits made by females.

However, data on family planning visits by males have

been presented in other NCHS publications.4 ~sSs

Figure 2 shows that 88.4 percent of the family

planning visits were made by females under 30 years.

Of these visits made by females in this age range,

32.5 percent were made by those under 20 years,

38.1 percent were made by those 20-24 years, and

17.8 percent were made by those 25-29 years. Females aged 30 years and over accounted for 11.6

percent,

30 years ‘and over

11.6

NOTE: I?ercents are based on 7,425,000 female family planning

visits.

Figure 2. Percent distribution of female family planning visits by age:

United States, 1978

& estimated 66.5 percent of the visits were made

by white females and 31.7 percent by black females.

The remaining 1.8 percent were made by females

of other races. Data for white females (table 1)

show that 67.8 percent of the visits were made by

those under 20 years. In addition, two-thirds of the

visits were made by those aged 20-29 years, and white

females also accounted for a large proportion (61.0

percent) of the visits made by females aged 30 years

and over.

An estimated 9.9 percent of the visits were made

by females of Hispanic origin or descent. The proportion of these visits ranged by age from 5.8 percent

to 19.0 percent.

Table 1. Number and percent distribution of female family planning

visits by race, ethnicity, and education, according to age: Unitad

States, 1978

Age

Race, ethrdcify, All

and education ages Under 2U24 25-29 30 years

20 years years yam and over

Number in thwsands

All visits . . . . . . . . . . . . .7,425 2,410 2~1 1s21 864

Percent distribution

Total . . . . . . . . . . . . . . .. Ioo.o Ioo.o lm.o IW.O 100.0

Race

White . . . . . . . . . . . . ...66.5 67.8 58.3 63.7 61.0

Black . . . . . . . . . . . . . ..3l.7 30.8 30.0 34.0 36.7

Other . . . . . . . . . . . . . . . 1.8 1.4 1.7 2.3 2.3

Ethnicity

Hispanic origin or descent . . . 9.9 5.8 9.0 13.6 19.0

Not of Hispanic origin or

descent . . . . . . . . . . . ..9O.l 94.2 91.0 86.4 81.0

Education

Lassthan12years . . . . . . . 38.7 61.4 25.3 28.6 43.5

12years . . . . . . . . . . . ..39.O 31.3 43.5 43.1 39.5

13yearsor more.. . . . . . . 21.3 7.3 31.2 28.2 17.0

Education

Table 1 shows that 78.7 percent of the visits

were made by females with 12 years of education or

less. For ages 20 years and over, the proportion of

visits made by females with more than 12 years of

education decreased with increasing age.

Pregnancy history

A large proportion (41.8 percent) of the visits

were made by females who had never been pregnant

(table 2). As expected, the proportion of visits

Table 2. Percent distribution of female family planning visits by number of pregnancies, and number of live births, xording to age:

United States, 1978

Am

Pregnancies and All

live births w= Under 20.2425-29 30 years

20 years ywrs years md wer

Total pregnancies. . . . . . . . l(XLO

Naverpragnant . . . . . . . . . 41.6

One pregnancy . . . . . . . . . 26.8

Two pregnancies or more . . . 31.4

Total live births. . . . . . ...100.0

Nolivabirths . . . . . . . . . . 53.2

Onelive birth . . . . . . . . . . 22.6

Two live births or more . . . . 24.1

100.0

64.3

27.6

8.2

100.0

77.6

18.8

3.6

100.01 CO.o 100.0

41.4 21.8 10.4

31.6 25.1 11.6

26.9 53.0 77.8

lal.o 100.0 100,0

56.3 30.4 13.5

26.8 26.0 14.4

17.9 43.6 720
made by females who had never been pregnant

decreased with age, however, the proportion of visits

made by females with two or more pregnan ties

increased with age. Approximately 64.3 percent of

the visits were made by teenagers (under 20 years

of age) who reported they had never been pregnant,

however, 8.2 percent were made by teenagers who

reported two or more pregnancies. Of those visits

made by females 30 years and over, about 10.4

percent reported they had never been pregnant,

compared with 77.9 percent who reported two or

more pregnancies. The proportion of visits made by

females who had had one pregnancy was about the

same for all age gfoups, except those visits made by

femides aged 30 years and over ( 11.6 percent).

About 53.2 percent of the reported visits were

associated with nulliparous females. A large proportion (77.6 percent) of visits by teenagers were made

by those who had never had a live birth, compared

with 3.6 percent who reported two live births or

more (table 2). The proportion of visits made by

females 30 years and over was larger than visits made

by those under 30 years who reported one or more

live births (86.4 percent and 41.6 percent, respectively).

Medical services

According to the NRSFPS classification of family

planning medical services, there were an estimated

32.7 million medical services provided during 7.4

million female family planning visits.

The vast majority of these visits included services

related to contraception, and only 0.1 percent of the

visits included treatment for infertility.

A Pap smear, a breast examination, and a blood

pressure check–basic medical services for female

contraceptors-were provided at 48.2 percent, 50.2

percent, and 86.1 percent of the visits, respectively

(figure 3). Futhennore, a pelvic examination was

provided at 63.2 percent of the visits. It should be

noted that any one family planning visit may involve

several medical services. Thus the percentages in

figures 3 do not add to 100 percent.

The medical service of sterikation was not

commonly provided to females at family pkrming

visits (0.2 percent) and was not generally available at

most service sites.

Venereal disease testing was commonly provided

at family planning visits (44.1 percent), but the

NRSFPS did not collect information on test :results.

Pap smear “.: &.2”@:w:x::z:5m:2:?:5k:~.::::s?:55::*:A:*.x.z

. . , . . . ............................................................................................................

. .........................................................................................................................................................................

Pelvic examination W. 63.2<;:~:~w;~w:w~;;fi:~~:fi:!:~::~;~:~ti~+~w:=::~==:~~

Breast examination :Z$502 :.:.=.:.:.~-:.:.~.:.:.~-:.~.:.~.=.*.~.~~.~.=.=.~~=.~.=.~~ . . . . . . . : . ..:.;:.:.:.x.:.:.x.:.:.x.:.x.:.:.:.x-:.:.:.x.:.:.:.H:.:.:.:.:.N.:.:.:.:.:.:.:.:.:.:.x.x.x.:.:.:-:.:.:

Blood pressure check F.$86+l %G.zz.zz3%:z:<*s$Gszcg$z:%3%:K$:?2:2::~-Fs5%$m

... ....... y~yj .9.?

Pregnancy testing :....... . . . . .....

. ..... ..... . ..............................................................................................................

Venereal disease testing 1.::s::$::::5::::2:2m:5%A:::=.A::sx:wE:2:: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

:.:.>. ........:.....y........y......y............... ............. ..... ... ......... ................. ..................

Urinalysis ://... ~ 3:... -----

. ..... ..............................................................................................................

. . . . ... ....................................................,. . . . - . . - . , . . - - . . . . . - . . . . . . . . . . - . . .

Blood test

Sterilization q ‘0.2

Infertility

Other medical services

I

I I I I I I I I I

o 10 20 30 40 50 60 70 80 90

Percent

NOTE: Percents are based on 7,425,000 female family planning visits.

Figure 3. Percent of female family planning visits, by type of medical services provided: United States, 1978
akmdata5

Pregnancy testing was provided at a smaller proportion of the visits (7.9 percent).

The category “other medical services” comprises

those medical family planning services not otherwise

specified by the NRSFPS. Other medical services

were provided at 51.0 percent of the family planning

visits.

Contraceptive method

adopted or continued

As noted, virtually all of the visits made by

females to family planning service sites were to obtain

medical services related to contraception. The pill

was adopted or continued for about 67.1 percent

of the reported visits (figure 4 and table 3). The

next most popular method was the intrauterine

device. The diaphragm and foam, jelly, or cream

(considered as methods used independently) were

the contraceptive methods adopted or continued at

6.4 and 4.8 percent of the visits, respectively. Sterilization was the contraceptive method adopted or

continued at 1.0 percent of the visits; however, it.

should be noted that females who have elected

sterilization as their method of contraception generally have less need to make routine followup visits

than females on other methods. Overall, 89.8 percent

of the visits resulted in the continuation or adoption

of some contraceptive method.

Table 3 shows that ~though the Pill wss the most

frequently adopted or continued contraceptive

method in each age interval, generally the proportion

of visits involving its use declined with increasing

age, from 77.0 percent of the visits made by females

under 20 years of age to 45.3 percent of the visits

made by females 30 years and over.

While figure 4 shows that 10.2 percent of family

planning visits resulted in neither the adoption nor

the continued use of a contraceptive method, table

3 shows that 3.2 percent of these visits were made by

females who rdied on their partner’s method for

contraceptive protection. In addition, about 2.9

percent of these visits were made by females who

were pregnant, and the remaining 4.1 percent reported other reasons for no contraceptive method.

Other 0.6 ~::::E!I~-

Natural ●0.3=\ A:::Z

Foam, jelly, or cream+

Injection ●0. I \

I&

Y

Diaphragm- 6-~

I

NOTE: Percents are based on 7,425,000 female family planning

visits.

Figure 4: Percent distribution of female family planning visits at which

a contraceptive method was adopted or continued, by method

chosen: United States, 1978.

Table 3. Percent distribution of female family planning visits by contraceptive method adopted or continued, rmcording to age: United

States, 1978

Age

Method Al\

ages Under 2@24 2529 30 years

20 yeara years years and ovar

Total . . . . . . . . . . . . . . .100.0 100.0 100.0100.0 100.0

Pill . . . . . . . . . . . . . . ..67.l 77.0 68.6 60.1 45.3

Intrauterine device . . . . . . . 9.5 4.4 8.9 13.5 20.0

Diaphragm. . . . . . . . . . . . 6.4 3.7 7,3 8.3 7.8

Foam, jelly, or cream. . . . . . 4.8 4.2 4.2 5.1 8.3

Other . . . . . . . . . . . . . . . 2.0 0.8 1.4 2.7 5.8

None-pregnant. . . . . . . . . . 2.9 3.4 2.9 2.3 1.9

None-relying on panner . . . . 3.2 2-6 2.8 3.7 5.7

Non&other. . . . . . . . . . . . 4.1 3.8 3.9 4.2 5.2

References

lNational Center for Health Statistics: Background and development Statktics, No. 45. DHEW Pub. No. (PHS) 79-1250. Public Health

of the NationaJ Reporting System for Family Planning Services, United Service. Hyattaville, Md. Feb. 7,1979.

State% by B. J. Haupt. Vital and Health Statistics. Series 1- No. 13. 4National Center for Health StatistiU. 1974 Annual Report, NationaJ DHEW Pub. No. (PHS) 78-1313. Public Health Service. Washington.

U.S. Government Printing Office, Apr. 1978. Reporting System for Family PhmningSemices, by B. J. Haupt. DHEW

Pub. No. (HRA) 77-1238. Health Resources Administration. Wash2National Center for Health Statistics Office visits for family planning,

National Ambulatory Medical Cam Survey, United States, 1977, by

B. K. Cypress. Advance Data Porn Vital and Health Statistics, No. 49.

DHEW Pub. No. (PHS) 79-1250. Public Health Service. Hyattsville, Md.

Apr. 16, 1979.

3National Center for Health Statistics Use of family planning services

by currently married women 1544 years of age, United States, 1977

and 1976, by G. E. Hendershot.Advance Data from Vital and Health

ington. U.S~Gov6mment Printing Office, May 1977.

5NationaI Center for Health Statistics: 197S AnnuaZ Report, National

Reporting System fw Family PfamringSemices, by B. J. Haupt. DHEW

Pub. No. (I-IRA) 78-1238. Health Resources Administration. Washington. U.S. Government Printing Office, SepL 1977.

6National Center for Health Statistics: 1976 Provisional Data from

the National Reporting System for FamiIy Planning Services, January

1976-Deoember 1976.
6

Technical notes

Sampling design

The 1978 National Reporting System for Family

Planning Services estimates are based on a stratified

two-stage sampling design. The 1978 NRSFPS sample

for the United States encompassed 276,619 female

visit records. A clinic visit record was completed for

each sample family planning visit. A report deline

sting the NRSFPS background, development, and

evolution has been published. I

Estimation

The statistics provided by the NRSFPS for 1978

are derived by a complex estimation procedure. This

procedure, which was used to produce essentially unbiased national estimates for the NRSFPS has two

principal components–inflation by the reciprocal of

the probability of sample selection, and adjustment

for nonresponse.

Sampling error

The statistics presented in this report are based

on a two-stage stratified sample survey and therefore

differ from those that would be obtained based on a

full-count (100 percent) survey using the same data

collection procedures and definitions.

The standard error is primarily a measure of the

variability that occurs by chance because a sample

rather than the population is surveyed. While the

standard error as calculated for this report reflects

some of the random variation inherent in the measurement process, it does not measure any systematic

error that is present in the NRSFPS data. The reader

is directed to refer to “Nonsampling Error” in this

section for additional information on measurement

error. The relative standard error of an estimate is

obtained by dividing the standard error of the estimate by the estimate itself and is sometimes expressed as a percentage of the estimate. The chances

are about 0.68 that the interval specified by the

estimate plus or minus one standard error of the

estimate contains the figure which would be obtained

through a full-count survey of the sampling frame.

The chances are about 0.95 that the interval specified by the estimate plus or minus two standard errors

of the estimate contains the figure which would be

obtained through a full-count survey of the sampling

frame.

In order to derive standard errors that would be

applicable to a wide variety of statistics and that

could be derived at moderate costs, several approxiA list of references follow text.

mations were required. For the categories by age of

female family planning visits presented in this report,

estimates of totals and relative standard errors of

totals are shown in table I. The standard errors for

estimated percentages of visits are shown in table

11.

Table 1. Number of family planning visits by women and relative

standard error, by age: Unitad States, 1978

Age

Relative Number of standad

visitsin

thousands error in

percent

Alleges . . . . . . . . . . . . . . . . . . . . . . . . 7,425 3.4

Under 20 years . . . . . . . . . . . . . . . . . . . 2,410 3.7

20-24 years . . . . . . . . . . . . . . . . . . . . . 2J131 3.5

25-29 years . . . . . . . . . . . . . . . . . . . . . 1321 3.6

30yearsand war . . . . . . . . . . . . . . . . . . 864 3.3

Table 11. Approximate standard error of percent of estimated number

of female family planning visits, by age: United States, 1978

Estimated percent of visits

Am

Ior 5or lOor 200r 300r ~

99 95 N 80 70

Standard error in percentage points

Alleges . . . . . . . . . . . . ..O.2 0.3 0.5 0.6 0.7 0.8

Under 20years . . . . . . . . . 0.2 0.5 0.7 0.9 1.0 1.1

20-24 years . . . . . . . . . . . 0.2 0.5 0.6 0.9 1.0 1.1

26-29 years . . . . . . . , . . . 0.3 0.7 1.0 1.3 1.5 1.6

30years and over. . . . . . . . 0.4 0.8 1.1 1.4 1.6 1.8

Example of use of table: An estimete of 90 percent besed on ell twnage visits has a standard error of 0.7 percent or e relative atendard

error of 0.8 percent (O. 7 percent + 90 Percent).

Nonsampiing error

While nonsampling error is present in most

sample surveys, the NRSFPS was particularly subject to error associated with a gap between the

survey’s universe and sampling frame. This gap

existed because the sampling frame did not include

sites that began providing services after the frame

was finalized in early 1976. Other nonsampling

error includes error due to service site nonresponse,

item nonresponse, information incompletely or

inaccurately recorded, and processing error. Through

a study conducted during 1980 which included site

visits to a probability subsample of the NRSFPS

sample sites, several problems associated with the

collection of data for the NRSFPS were identified.

While the study results are not applicable to the 1978

NRSFPS per se, they are probably indicative of the
difficulties inherent in the 1978 NRSFPS data

collection efforts.

Rounding

Aggregate estimates of family planning visits

in tables are rounded to the nearest thousand. The

percentages were computed based on unrounded

estimates; thus, the figures may not add to the

totals.

Definitions

family planning services are provided on a regular

basis under the supervision of a physician. Private

physician’s offices and group medical practices are

not considered sites unless they receive support

through a Department of Health and Human Services grant for the provision of family planning

services. Military service sites are excluded from

the survey.

Family planning visit .– A family planning visit is

a visit to a family planning service site in which

medical services related to contraception, infertility treatment, or sterilization are provided.

Family planning service site.–A family planning

service site is a location or place where medical

Symbols

--- Data not available

. . . CMegow not applicable

- Quantity zero

0.0 Quantity more than O but lessthan 0.05

● Figure does not meet standards of

reliability or precision
mm‘&yy@’~‘~

From Vital and Health Statistics of the National Center for Health Statistics Number 73 ● June 24, 1981

Patient Profile, National Reporting System for Family

Planning Services: United States, 1978

by Jean E. Foster, formerly with the Division of Health Care Statistics

The National Reporting System for Family

Planning Services (NRSFPS) is a sample survey conducted on a continuous basis by the Division of

Health Care Statistics, National Center for HeaIth

Statistics. The NRSFPS, begun in 1972 to collect

data on clinic-based visits for family planning

services in the United States and some of its terntoties, encompasses medical family planning visits

occ-u.rring in clinics. The clinics include those operated

by public health departments, private organizations

such as affdiates of Planned Parenthood Federation

of Anerica, Inc. or hospitals, and other sites that

provide family planning services. Medical family

planning visits to private physicans’ offices are

excluded from the survey.

The Clinic Visit Record (CVR) is the basic

data collection form used in the NRSFPS. Service

sites that collected NRSFPS data through participation in a computerized record system generally

used a locally developed form containing the CVR

items. The 14 items on the CVR cover basic sociodemographic information about the patient and

include questions about family planning. In this

survey, family planning patients are defined as

individuals who made a visit for medical family

planning services related to contraception, infertility

treatment, or sterilization. Persons seeking only a

pregnancy or venereal disease test are not counted as

family planning patients, nor are persons interested

only in obtaining contraceptive supplies or counseling.

Although the primary sampling unit in the

NRSFPS is the family planning visit, an unduplicated

count of patients can be obtained by identi&ing

1) new patients at the time of their fmt visit, and

2) continuation and readmission patients at the time

of their fmt visit in the survey year. (Readmission

patients are patients who last visited a famiIy planning service site at least one calendar year prior to

1978). Data based on patients, rather than visits, is

inherently limited for NRSFPS data items which

may change from one visit to another. Therefore,

the reader should be cautious when interpreting the

data. Further discussion of the survey methodology

and the sampling variation associated with the statistics, and the definitions of certain terms used in

this report, are included in Technical Notes.

Patient estimates

According to NRSFPS data, about 3,831,000

patients received medical family planning services in

1978 from family planning smvice sites in the United

States. Table 1 shows that 99.6 percent of patients

Table 1. Number, percent distribution, ad enrollment rotasof fanily

planning patients by selected characteristics:United Statas, 1978

SeIarxad

characteristic

NumLw Pamant Enrollin thw- distri- mant rate

sends brition per l,IXW’

All patients . . . . . . . . . . . . . .

sax

Female . . . . . . . . . . . . . . . . .

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

A’11female patients . . . . . . . . . .

Age

Undat15years . . . . . . . . . . . .

15-19 years . . . . . . . . . . . . . .

20-24 years . . . . . . . . . . . . . .

25-28 years . . . . . . . . . . . . . .

3tX34years. . . . . . . . . . . . . .

35-39 years . . . . . . . . . . . . . .

4CM14yeam . . . . . . . . . . . . . .

45years Andover . . . . . . . . . . .

Race

White . . . . . . . . . . . . . . . . . .

black . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . .

Ethnicity

Hispanic . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . .

3,831

3,815

●17

3,815

44

1,225

1,402

569

282

117

49

27

Z616

1.118

81

415

3,400

100.0

98.6

0.4

100.0

1.2

32.1

36.8

17.5

7.4

3.1

1.3

0.7

68.8

28.3

2.1

10.9

89.1

18

77

. . .

77

. . .

119

139

74

35

18

8

. . .

61

181

75

133

73

‘Based on the timeh civilian, noninsritmionalized population aga

154S years.

NOTE: Figuras mey not add to totals dua to rounding.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service, Office of Health Research, Statistics, and Technology
2

in 1978 were women and only 0.4 percent were men.

Since the estimated number of male patients is too

small for reliable estimates based on detailed crosstabulations, this report focuses on female family

planning patients.

Most female medical family planning patients

are 20-24 years old; the enrollment rate peaks at 139

per 1,000 women in that age interval. Teenagers

account for 32.1 percent of all female patients and

women 45 years and over represent only about 0.7

percent. The median female patient age is 22.9

years.

Although there are proportionately more white

than black female patients (68.6 percent and 29.3

percent, respectively), the black enrollment rate is

181 per 1,000 women age 15 to 44 years compared

with the white enrollment rate of 61 per 1,000

women age 15 to 44 years. Women of Hispanic ori@n

comprise 10.9 percent of all female patients, with an

enrollment rate of 133 per 1,000 women age 15 to

44 years. Ethnicity is independent of racial classification and may include persons of all races.

Patient status

Table 2 shows the relatively large proportion

(61.5 percent) of continuation and readmission

patients among women in 1978, which indicates the

extent of previous exposure to the family planning

Table 2. Number and percent distribution of female family planning

patients by patient status, according to selected characteristics:

United States, 1978

Patient status

Selected All Total

characteristic patients New Continu- Reation admit

Percent distribution

All female

patients . . . . . . . . . 3,815 100.0 38.4 51.9 9,6

Age

Under 15 years . . . . . 44 100.0 81.8 18.2 -

15-19 years . . . . . . . 1,225 100.0 53.5 41.7 4.8

20-24 years . . . . . . . 1,402 100.0 32.5 56.6 10.9

25-28 years . . . . . . . 669 100.0 28.8 56.3 12.9

30-34 years . . . . . . . 282 100.0 27.7 58.9 13.5

35-39 years . . . . . . . 117 100.0 26.5 59.0 15.4

4044 years . . . . . . . 49 100.0 22.4 59.2 18.4

45 years and over . . . . 27 100.0 ●22.2 59.3 ‘18.5

Race

White . . . . . . . . . . . 2,616 100.0 42.3 48.7 9.0

Black.. . . . . . . . . . 1,118 100.0 28.6 60.1 11.3

Other . . . . . . . . . . . 81 100.0 50.0 42.5 7.5

Ethnicity

Hispanic . . . . . . . . . 415 100.0 43.1 46.7 10.1

Other . . . . . . . . . . . 3,400 100.0 37.9 52.6 9.6

NOTE: F kwres may not add to totals due to rounding.

program. As expected, continuation and reatimission

female patients tend to be older thzm new Patients.

The proportion of new patients is about 53.5 percent

for the 15-19 age group and drops to about 28.8

percent for the 25-29 age group. The propcmtion of

continuation patients levels off to about 59 percent

beginning with women age 30-34. The median age for

new female patients is 20.4 years, compared with

23.0 years for continuation patients and 24.1 years

for readmission patients.

In 1978, a larger proportion of white female

patients are new patients (42.3 percent) than among

black female patients (28.6 percent). Conversely,

continuation status is higher among black women

(60.1 percent) than among white women (48.7

percent). There are proportionately more new patients

among the Hispanic than among the non-l~ispanic

female patient population.

Female patient demographics

The data in table 3 show that there are at least

2 times as many white as black female patients in

Table 3. Number of female t%mily planning patients by age and peroent

distribution by selected characteristics, according to aw: Unitad

States, 1978

Age

Selecsed All

chiwectaristi-c *S Un&r 20 2@29 30 yaws

years yeans and owr

All female patients . .

Total . . . . . . . . . .

Race

White . . . . . . . . . .

Black . . . . . . . . . .

Other . . . . . . . . . .

Ethnicity

Hispanic . . . . . . . .

Other . . . . . . . . . .

Education

Less than 12 years . .

12 year n........

13 years or more . . .

Student status

Student . . . . . . . . .

Notastudent . . . . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

Public ~istanca income

Receives public

assistance . . . . . . . . . .

Does not receive public

assistance . . . . . . . . . .

Number in thousands

3,815

100.0

68.6

29.3

2.1

10.9

89.1

39.5

38.2

22.3

28.6

70.4

14.7

85.3

1,269 2,071 475

Percent distribution

100.0

70.3

28.0

1.7

6.6

93.3

61.2

30.7

8.0

55.6

44.3

14.1

66.0

100.0 100.0

69.0 62.3

28.8 35.2

2.3 2.7

11.4 20.0

86.6 80.2

25.3 42.9

42.7 38.5

32.0 18.1

18.4 8.8

81.7 80.9

14.7 16.4

85.3 83.8

NOTE: Figures may not add to totals due to rounding.
admce&@3

the two youngest age groups shown (under 20 years

of age and 20-29 years of age). Also, a smaller proportion of teenage women in the youngest age group

was reported as being of Hispanic origin or descent

than were women in the two older age groups.

The proportion of female family planning

patients with less than a high school education (39.5

percent) varied with age, with the lowest proportion

in the 20-29 year age group. About three-quarters

of women in the middle age group reported that they

completed high school or had additional years of

schooling. Public assistance income is one indicator

of family income and relative economic status. Most

patients are not part of families whose income

includes some type of public assistance. The proportion ranged from 14.1 percent among women

under 20 years of age to 16.4 percent among women

30 years of age and over.

Pregnancy history

Tables 4 and 5 present statistics on the pregnancy

history of female patients by age and race, respectively. As expected, the proportion who have never

had a pregnancy decreases sharply with age. A larger

proportion of white women have never been pregnant

than black women. The same pattern is found for live

births: 59.8 percent of the white women and 39.7

Table 4. Number of female family planning patients by age and percent

distrihtion by’ pregnancy histo~, according to age: United States,

1978

Age

Pregnancy All

history ages Under 20 2029 30 years

years years asrdow!r

All female patients . . . . .

Total . . . . . . . . . . . . .

Number of pregnancies

None . . . . . . . . . . . . .

one . . . . . . . . . . . . . .

Two . . . . . . . . . . . . . .

Thrae ormom. . . . . . . .

Number of live births

None . . . . . . . . . . . . .

One . . . . . . . . . . . . . .

Two . . . . . . . . . . . . . .

Three ormom . . . . . . . .

Numkewof fatal deaths

None . . . . . . . . . . . . .

One . . . . . . . . . . . . . .

Twoormom . . . . . . . . .

Number in thousands

3,815 1#269 2,071

Percent distribution

100.0 100.0 100.0

42.4 65.7 35.6

25.9 26.2 28.1

15.2 6.0 19.8

16.4 2.1 15.6

63.9 78.3 48.1

21.8 18.1 25.8

13.4 3.1 17.4

10.9 “0.4 8.7

77.4 84.8 75,0

17.2 13.2 18.9

5.3 2.0 6.0

475

100.0

10.1

11.6

20.2

58.3

13.3

14.3

23.6

48.6

68.2

20.2

11.6

NOTE: Figuras mav not add to totals dua to rounding.

Table 5. Number of female family planning patients by race and percent distribution by pregnancy history, according to race: United

States, 1978

Pregnancy history Total’ Whita Black

Number in thousands

All female patients . . . . . . . . . . . . . 3$15 2,616 1,118

Percent distribution

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

Number of pregnancies

None . . . . . . . . . . . . . . . . . . . . . 42.4 469 31.9

one . . . . . . . . . . . . . . . . . . . . . . 25.9 24.7 28.9

Two . . . . . . . . . . . . . . . . . . . . . . 15.2 14.1 17.9

Thraa ormore . . . . . . . . . . . . . . . . 16.4 14.3 21.2

Number of live births

None . . . . . . . . . . . . . . . . . . . . . 63.9 59.8 39.7

one . . . . . . . . . . . . . . . . . . . . . . 21.8 18.7 29.2

Two . . . . . . . . . . . . . . . . . . . . . . 13.4 12.2 16.4

Thrae ormore . . . . . . . . . . . . . . . . 10.8 9.2 14.7

Number of fetal deaths

None . . . . . . . . . . . . . . . . . . . . . 77.4 77.5 77.3

One . . . . . . . . . . . . . . . . . . . . . . 17.2 17.4 16.8

Two ormom . . . . . . . . . . . . . . . . . 5.3 5.1 5.8

llnc,u~==11 ~ther reses not show =+--w.

NOTE: Figuras may not edd to totals duo to rounding,

percent of the black women reported they had

never borne a live child. However, the proportion of

patients with one or more fetal deaths is the same for

women of both races–approximately 23 percent.

&nong teenage patients, 15.2 percent reported at

least one fetal death, whereas in the over 30 age

group this proportion doubled, primarily due to

longer exposure time associated with increasing age’.

The proportion of women who reported three

or more pregnancies or live births is highest in the

over 30 age group. Approximately 58.3 percent of

these patients reported three or more pregnancies

compared with 15.6 percent of the patients 20-29

years of age. Differences are also apparent by race,

with black patients having the larger proportion of

both three or more pregnancies and three or more

Iive births (21.2 percent and 14.7 percent, respectively).

Contraceptive use

Tables 6 and 7 present statistics on the contraceptive method used prior to the visit and the contraceptive method adopted or continued at the end of

the patient’s visit by age and race, respectively.

These data refer to the f~st visit for new patients and

the fnt visit in 1978 for all other patients. Given this

limitation, table 6 indicates that teenagers are over

three times more likely than either of the two older
4

Table 6. Number of female family planning patients by age and percent distribution by contraceptive use, according to age: United

States, 1978

Age

Contraceptive use

All

wes Under 20 20-29 30 yaws

years yawz and over

All female patients . . . . . . .

Total . . . . . . . . . . . . . . .

Prior contraceptive

method

Pill . . . . . . . . . . . . . . . .

IUD . . . . . . . . . . . . . . . .

Diaphragm . . . . . . . . . . . .

Foam,jelly, orcraam. . . . . .

Natural . . . . . . . . . . . . . .

Sterilization. . . . . . . . . . .

Other . . . . . . . . . . . . . . .

Nomethod used regularly . . .

Current contraceptive

method

Pill . . . . . . . . . . . . . . . .

IUD . . . . . . . . . . . . . . . .

Diaphragm . . . . . . . . . . . .

Foam, jelly, or cream. . . . . .

Natural . . . . . . . . . . . . . .

Sterilization . . . . . . . . . . .

Relyingonpartner . . . . . . .

Other . . . . . . . . . . . . . . .

None . . . . . . . . . . . . . . .

3,815

100.0

57.4

8.7

4.1

3.4

0.5

1.2

3.6

21.0

63.5

9.3

7.4

5.7

0.4

1.2

3.6

0.8

8.2

Numberinthousends

1,269 2,071 475

Percent distribution

Im.o

48.8

2.3

1.3

2.4

“0.6

‘0.3

4.3

39.9

74.6

3.7

4.2

5.0

‘0.2

“0.2

2.8

“0.5

8.7

100.0 100.0

64.8 48.2

9.8 21.5

5.3 6.3

3.4 5.9

“0.5 ‘0.4

1.0 4.0

3.1 4.0

12.2 9.3

62.3 38.9

10.1 20.8

9.0 9.3

5.2 9.5

“0.4 ●1.1

1.0 4.8

3.4 6.3

0.8 *1.5

7.8 8.2

NOTE: Figures maynotadd mtotels duatoro”ndi”*

age groups to have not used a contraceptive method

regularly prior to visiting the clinic. Accordingly, 54.5

percent of the teenage patients reported they had

never made a prior visit to a family planning clinic.

There is no statistical difference between the proportion of white and black patients reporting no prior

contraceptive method.

Overall, 79.0 percent of all female patients reported that some method of contraception was used

prior to their visit. Among contraceptors in all age

and racial groups, the pill is the most prevalent

method used regularly prior to the family planning

visit. However, reported pill use varies considerably

by age. It was the most common prior method used

by women in the 20-29 age range. About 56.5 percent of the white patients and 59.8 percent of the

black patients reported the pill as their prior contraceptive method.

The contraceptive method adopted or continued

after the visit, as mentioned above, represents only a

minimal level of contraceptive services provided at

service sites; method changes which may have occurred at return visits during the year are not represented

in the statistics presented in this report. The proportion of patients reporting no method dropped from

Table 7. Number of female family planning patients by race and per.

cent distribution by contraceptive use, according to rece: United

States, 1978

Contraceptr”veue ToSat’ Wlite Black

Number in thousends

All female petients . . . . . . . . . . . . . 3,815 2,616 1,118

Percent distribution

Total . . . . . . . . . . . . . . . . . . . . . lW.O 100.0

Prior contraceptive

method

Pill . . . . . . . . . . . . . . . . . . . . . . 57.4 56.5

IUD . . . . . . . . . . . . . . . . . . . . . . 8.7 7.8

Diaphragm . . . . . . . . . . . . . . . . . . 4.1 4.7

Foam, jeliy, orc~m. . . . . . . . . . . . 3.4 3.5

Natural . . . . . . . . . . . . . . . . . . . . 0.5 0.6

Sterilization . . . . . . . . . . . . . . . . . 1.2 1.1

Other . . . . . . . . . . . . . . . . . . . . . 3.6 4.3

No method used regularly . . . . . . . . . 21.0 21.5

Current contraceptive

method

Hal l . . . . . . . . . . . . . . . . . . ... 63.5 63.2

IUD . . . . . . . . . . . . . . . . . . . . . . 9.3 8.5

Diaphragm . . . . . . . . . . . . . . . . . . 7.4 8.6

Foam, jelly, or cream. . . . . . . . . . . . 5.7 5.0

Natural . . . . . . . . . . . . . . . . . . . . 0.4 ‘0.4

Sterilization . . . . . . . . . . . . . . . . . 1.2 1.0

Relying on partner . . . . . . . . . . . . . 3.6 3.9

Other . . . . . . . . . . . . . . . . . . . . . 0.8 0.8

None . . . . . . . . . . . . . . . . . . . . . 8.2 8.6

100.0

59.8

10.7

2.9

3.1

“0.2

●1.4

2.1

19.9

64.7

11.1

4.8

7.2

●0.4

1.6

2.8

“0.6

6.7

1Incjudes al] othar races not shown tamer-w.

NOTE: Figures may not add to totals due to rounding.

21.0 percent before the visit to 8.2 percent after the

visit; the comparable figures for teenage patients

are 39.9 percent and 8.7 percent, respectively. The

proportion of noncontraceptors did not differ significantly by race.

Oral contraception is the method most commonly

adopted or continued by all age and race groups; 63.5

percent of all female family planning patients chose

the pill.

More women under 20 years of age (74.6 percent)

than women 30 years of age and over (38.9 percent)

opted to use the pill, whereas the proportions

choosing the IUD, diaphragm, and other methods

generally increases with age. With the exception of

a higher proportion of white patients that adopted or

continued use of the diaphragm, there were no

statistically significant differences between the races

in the choice of birth control methods.

The three most effective methods-the pill, IUD,

and sterilization-account for 74.0 percent of all

female patients. The proportion of patients choosing

or continuing these methods is 78.5 percent for

women under 20 years of age, 73.4 percent for ‘women 20-29 years of age, and 64.5 percent for ‘women 30 years of age and over.
admcedas

Technical Notes

Sampling design

The 1978 National Reporting System for Family

Planning Services estimates are based on a stratified

two-stage sampling design. In the frost stage, a probability sample of 1,195 (about 1 in 4, nationally)

family planning service sites was selected from a

stratified sampling frame developed in 1976.

In the second stage of the sampling plan, family

planning visits occurring at each sample site were

systematically selected. The sampling rate assigned by

NCHS to each sample site depended on the site’s

reported visit volume and the State in which the site

was located. Overall, there were 14 visit sampling rates

used to determine the proportion of each site’s

family planning visits needed for the survey; the visit

sampling rates ranged from 1/1 to 1/30. The 1978

National Reporting System for Family Planning

Services sample for the United States encompassed

138,129 female patient records. A report delineating

the NRSFPS background, development, and evolution has been published. 1

Estimation

The statistics provided by the NRSFPS for 1978

are derived by a complex-estimation procedure. The

estimation procedure used to produce essentially unbiased national estimates for the NRSFPS has two

principal components–inflation by the reciprocal of

the probability of sample selection and imputation

for nonresponse.

Sampling error

The statistics presented in this report are based

on a sample sumey and therefore differ from those

that would be obtained from a full-count (100

percent) survey using the same data collection procedures and deftitions.

The standard error is primarily a measure of the

variability that occurs by chance because a sample

rather than the entire universe is surveyed. While the

standard error, as czdculated for this report, reflects

some of the random variation inherent in the measurement process, it does not measure any systematic error that k present in the NRSFPS data. The

relative standard error of an estimate is obtained by

dividing the standard error of the estimate by the

estimate itself and is sometimes expressed as a perlNation~ Center for Health Statistics: Background and development

of the nationalreporting sYstem forfamily planning services, by B. J.

Haupt. V7tai and Health Statistics, Series l-No. 13. DHEW Pub. No.

(pHS) 78-1313. Public Health Service. Washington. U.S. Government

-tins Office, Apr. 1978.

centage of the estimate. The chances are about 0.68

that the interval specified by the estimate plus or

minus one standard error of the estimate contains

the figure which would be obtained through a fullcount survey of the sampling frame. The chances are

about 0.95 that the interval specified by the estimate

plus or minus two standard errors of the estimate

contains the figure which would be mbtained through

a full-count survey of the sampling frame.

To derive standard errors that would be applicable to a wide variety of statistics and could be

derived at moderate costs, several approximations

were required. For the three basic age categories of

patients presented in this report, estimates of totals

and relative standard errors of totals are shown in

table I. The standard error for estimated percentages

of patients are shown in table II.

Table 1. Number of female family planning patients and relative standard

error, by age: Unitad States, 1978

Age

Number of Relative

patkws in standard

thousends error in

percent

Alleges . . . . . . . . . . . . . . . . . . . . . . 3,815 4.1

Under 20 years . . . . . . . . . . . . . . . . . 1269 4.3

20-29 years . . . . . . . . . . . . . . . . . . . 2,071 4.4

30yaars andover . . . . . . . . . . . . . . . . 475 3.9

Table 11. Approximate standard error of percent of female family

planning patients, by aga: Unitad Stetas, 1978

Estimated percent of patients

Age

lor 5or lOor Wor 300r so

99 95 m &l 70

Standard error in percentage points

Alleges . . . . . . . . . . . . 0.2 0.4 0.6 0.8 0.9 0.9

Under 2U yearn . . . . . . . 0.3 0.7 1.0 1.3 1..5 1.s3

20-28 years . . . . . . . . . 0.3 0.6 0.8 1.0 1.2 1.3

30yaers And over . . . . . . 0.4 0.9 1.2 1.6 1.8 2.0

Example of use of table: An estimate of 90 percent based on all teenage

patients has a standard error of 1.0 percent or a relative standard error

of 1.1 percent (1.0 percent+ 90 percent).

Nonsampling error

While nonsampling error is present in most sample

surveys, the NRSFPS was particularly subject to error

associated with a gap between the survey’s universe

and sampling frame. This gap existed because the

sampling frame did not include sites that began providing services after the frame was finalized in early
6

1976. Other nonsampling error includes that due to

service site nonresponse, item nonresponse, information incompletely or inaccurately recorded, and

processing error. Through an evaluation study conducted during 1980, several problems associated with

the collection of data for the NRSFIPS were identified (i.e., adherence to NRSFPS definitions). While

the study results are not directly applicable to the

1978 NRSFPS results, they are indicative of the

difficulties inherent in the 1978 NRSFPS data

collection effort.

Rounding

Aggregate estimates of family planning visits in

the tables are rounded to the nearest thousand. The

percentages were computed based on rounded estimates; thus, the figures may not add to the totals.

Definitions

Family planning service site.–A family planning

service site is the location where medical family

planning services are provided on a regular basis

under the supervision of a physician. Private physicians’ offices and group medical practices are not

considered sites unless they receive support through

a Department of Health and Human Services grant

for the provision of family planning services. Military

service sites are excluded from the survey.

Family planning visit.– A family planning visit is

a visit to a family planning service site in whiclh medical services related to contraception, infertility treatment, or sterilization are provided.

Family planning patient.-A family planning

patient is an individual who has made one or more

family planning visits.

Medical services. –Medical services include Pap

smears, pelvic exams, breast exams, blood pressure

tests, pregnancy tests, venereal disease tests, sterilizations, infertility treatments, urinalyses and blood

tests (unless included as part of another service), and

other medical services.

Related data

Data for the National Ambulatory Medical Care

Survey come from reports from a sample of officebased physicians; data for the National Reporting

System for Family Planning Services come from a

sample of medical organizations that provide family

planning services. These data systems use information

from the providers of family planning services;

however, the National Survey of Family Growth uses

information from recipients of the services. :Because

of this difference and differences in collection procedures and definitions of terms, statistics on family

planning visits from the three data systems may

differ.

Symbols

. . . Datanot available

. . . Categorynot applicable

Quantityzero

O.(J Quantity more than O but less than 0.05

● Figure does not meet standards of

reliability or precision
From Vital and Heaith Statistics of the National Center for Health Statlstlcs Number 74 .September 4, 1981

Visits to Family Planning Clinics: United States, 1979

by Barbara Bloom, Division of Health Care Statistics

The National Reporting System for Family

Planning Services is conducted by the Division of

Health Care Statistics of the National Center for

Health Statistics. It is an ongoing system that collects data on clinic-based visits for family planning

services in the United States and some of its territories (Guam, Puerto Rico, and the Virgin Islands).

The scope of the National Reporting System for

Family Planning Services includes medical family

planning visits occurring in clinics (operated by

public health departments, private organizations

such as affiliates of the Planned Parenthood Federation of America, Inc., or hospitals) and in other

sites that provide family planning services. Excluded

from the scope of the National Reporting System

for Family Planning Services are all family planning

visits to private physicians’ offices and visits made

only for the detection of pregnancy or venereal

disease or only for obtaining contraceptive supplies

or counseling.

From 1972 through mid-1 977 the National

Reporting System for Family Planning Services

(NRSFPS) was conducted as a full-count survey,

collecting information for every medical family

planning visit at every participating site. Since July 1,

1977, however, the system has been conducted as a

sample survey. The sample design for NRSFPS is

based on a stratified two-stage probability sample.

The fmt stage was the selection of clinics; the second

stage was the selection of family planning visits

occurring at each sampled clinic.

This report examines visits made by women to

family planning clinics in the United States in 1979.

Its focus is on socioeconomic characteristics, pregnancy history, and contraceptive methods. The

reader should note that data from the territories of

Guam, Puerto Rico, and the Virgin Islands are excluded. Male family planning visits are also excluded

because the number of male visits was too smaIl for

reliable estimates. Since the basic unit of analysis is

visits, these data represent the services provided

during the visits of clinic users over the period of a

year. These data should not be interpreted as representing a profde of family planning clinic patients.

Since the estimates in this report are based on a

sampling of family planning clinics rather than on a

complete enumeration, they are subject to sampling

variability. The technical notes at the end of this

report provide a brief description of sampling errors

and guidelines for judging the precision of the estimates presented, as well as definitions of certain

terms. used in NRSFPS. A more detaiIed description

of the sample design and other definitions are being

prepared. 1

1978 data from NRSFPS that focus on visits to

family planning clinicsz and on a patient proffles

have been published. Other data on the utilization of

family planning services are collected by means of

two other surveys-the National Ambulatory Medical

Care Survey4 and the National Survey of Family

Growth. 5 The National Ambulatory ,Medical Care

Survey, ako conducted by the Division of Health

Care Statistics, collects data on visits to office-based

physicians which include a family planning service.

The National Survey of Famiiy Growth, conducted

by the Division of Vital Statistics, provides more

detailed statistics on women who made family

planning visits either to their own physicians or to

organized family planning clinics in the 3 years prior

to the time of the survey. Unlike the other two surveys, however, the data for the National Survey of

FarniIy Growth were collected by means of personal

interviews with a national sampie of women 15-44

years of age who were ever marripd or who had never

married but who had offspring living in the household.

Because of differences in the populations sampled,

the definitions, and the data co~lection procedures,

estimates on famiIy planning visits from these data

systems differ.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service, Off Ice of Health Research, Statlsrics, and Technology
2

Age, race, and ethnicity

Women in the United States made 8,609,000

visits to family planning clinics in 1979, representing

a 16-percent increase over the number of visits

reported in 1978. This increase, however, is largely

attributed to the addition of 169 service sites to the

universe in 1979. The majority, 89 percent, of these

visits were made by women under 30 years of age:

33 percent by teenagers, and 71 percent by women

under 25 years of age (table 1).

Table 1. Number and percent distributions of female family planning

visits by selected socioeconomic characteristics: United States,

1979

Selectad charaetaristic Number in Percent

thousands distribution

All visits . . . . . . . . . . . . . . . . . 8,608 100.0

Age

Under 20 years . . . . . . . . . . . . . 2,865 33.3

20-24 years . . . . . . . . . . . . . . . 3,242 37.7

25-29 years . . . . . . . . . . . . . . . 1,529 17.8

30 years And over . . . . . . . . . . . . 973 11.3

Race

White . . . . . . . . . . . . . . . . . . . 6,057 70.4

Black . . . . . . . . . . . . . . . . . . . 2,387 27.7

C)ther . . . . . . . . . . . . . . . . . . 165 1.9

Ethnicity

Hispanic origin or descent . . . . . . . 1,001 11.6

Not of Hispanic origin or descent. . . 7,607 86.4

Education

Lessthan12 years . . . . . . . . . . . 3,422 39.7

12 years . . . . . . . . . . . . . . . . . 3,435 399

13years or more . . . . . . . . . . . . 1,752 20.4

Public assistance income

Receives public assistance . . . . . . . 1,208 14.0

Does not receive public assistance. . . 7,407 86.0

NOTE: Figures may not add to totals due to rounding.

Seventy percent of all visits were made by white

women. However, looking at visits by age, the proportion of visits made by white women declined for

the two oldest age groups. The proportion of visits

by white women decreased from 72 percent for

women under 25 years of age to 68 percent for

women aged 25-29 years and 66 percent for women

aged 30 years and over (table 2). At 28 percent

overall, the proportion of visits by black women

did not vary significantly with age.

Visits by women of Hispanic origin or descent

accounted for 12 percent of the total number of

visits in 1979. (It should be noted that ethnic classification is independent of racial classification and

may include persons of all races. For example, a

woman of Hispanic origin or descent may be of any

racial category. ) The proportion of visits by Hispanic

women increased signiilcantly with increasing age,

ranging from 7 percent for teenagers to 22 percent

for women aged 30 years and over.

Education

NRSFPS findings reveal that in 197940 percent

of the visits to family planning clinics in the United

States were made by women with less than a high

school education, that is, less than 12 years of education. Both visits by white women (40 percent) and

visits by black women (40 percent) were the same as

this national total (table 3). However, there were

significantly fewer visits by black women who had

some additional years of education beyond high

school (16 percent) than the national average (20

percent).

Educational attainment by ethnicity shows great

disparity from the national average. Women of

Hispanic origin who had less than 12 years of schooling made 57 percent of visits, as compared with 40

percent for the Nation, a difference of 17 percent.

Also, Hispanic women who had additional years of

education beyond high school made significantly

fewer visits to family planning clinics (12 percent)

than all women made (20 percent).

Income

Table 2 shows that 14 percent of visits to family

planning clinics in 1979 were made by women living

in families receiving public assistance income. The

proportion was significantly higher for women aged

30 years and over (16 percent) than for teenagers

(13 percent). In addition, as is shown in table 3, a

greater proportion of visits by black women were

characterized by the family’s receipt of public assistance income (27 percent) than visits by white women

were (9 percent). “However, visits made by women of’

Hispanic origin receiving public assistance income (14

percent) were on a par with visits made by women

who were not of Hispanic origin (14 percent).

Pregnancy history

In 1979, 43 percent of visits to family planning

clinics were made by women who had never been

pregnant. As expected, the proportion decreased

dramatically with age, from 67 percent for teenagers

to 10 percent for women aged 30 years and over

(table 4). In significantly more visits by white

women (47 percent) than by black wome:n (35

percent) and in more visits by women who were

not Hispanic (47 percent) than by Hispanic women

(18 percent), the patient reported she had never been

pregnant (table 5). The same patterns were found for

live births. The proportion of visits made by women

with no live births decreased with age, from 79 percent for teenagers to 13 percent for women aged 30
ackmdaa3

Table 2. Number of female family planning visits by age, and percent distributions by selected characteristics, according to age: United States, 1979

AW

All

*S Under 20-24 25-29 30 years

2U years years years and over

Sehctad charectaristic

Number in thousands

All visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . 8,609 2,865 3,242 1,529 973

Percent distribution

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 ?00.0 100.0 100.0

Race

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70.4

27.7

1.9

71.6 71.7 67.9

27.1 26.5 28.5

1.3 1.8 2.7

66.3

30.8

2.9

Ethnicit y

Hispanicorigin ordescant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Notof Hispanicorigin ordescent. . . . . . . . . . . . . . . . . . . . . . . . . . .

11.6

88.4

6.9 10.7 15.8

93.1 89.3 84.2

22.0

78.0

Education

Lessthan 12years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13yearsormom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38.7

39.9

20.4

62.2 25.1 27.5

31.1 45.1 44.7

6.7 29.8 27.7

47.7

41.0

17.3

Public assistance income

Receivespublicassistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Doesnot raceivepublicassistance. . . . . . . . . . . . . . . . . . . . . . . . . . .

14.0

86.0

13.0 14.1 14.8

87.0 85.9 85.2

15.5

84.5

NOTE: Figur8s maynotadd tototals duo to rounding.

Table3. Numbrof female family planning visiBby meandethnici~, andwment disributions by4wation andpublic =i~ance income,

accordingtorace and ethnicity: Unitad States, 1979

Race Edrnicity

Education and public assistanceincome Hispanic Not of

TotalJ White Black origin Hispanic

or descent on-gin

or descant

Numberinthousands

Allvisits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,608 6,057 2,387 1,001 7,607

Percent distribution

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 1W.o 100.0

Education

Lassthan 12years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13yeersormore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38.7 39.6 40.4 56.8 37.5

399 38.4 43.7 31.6 41.0

20.4 22.0 15.9 11.7 21.5

Public assistance income

Receivaspublicassistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Doesnotreceivepublicassistance. . . . . . . . . . . . . . . . . . . . . . . . .

14.0 9.0 26.9 13.6 74.1

86.0 91.0 73.1 86.4 85.9

11n~lusj~ all o~.r rxS flOt ShoW’I SSp-ratdy.

NOTE: Figuras may not add to totals dua to rounding.
4 adwncedata

Table4. Numkrof female family planning visi@by aW, andpercent distributions bypmgnancies, live Mrths, andcontmceptive methds,

according to age: United States, 1979

Age

Pregnenck, live birdss, and contraceptive method All

ages lJn&r 20-24 25-29 30 years

20 yaars yaars ymrs and over

Allvisks . . . . . . . . . . . . . . . . . . . . . . . . .

Total . . . . . . . . . . . . . . . . . . . . . . . . . . .

Number of pregnancies

None . . . . . . . . . . . . . . . . . . . . . . . . . . .

One . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Twoormore . . . . . . . . . . . . . . . . . . . . . . .

Number of live births

None . . . . . . . . . . . . . . . . . . . . . . . . . . .

One . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Two ormore . . . . . . . . . . . . . . . . . . . . . . .

Contraceptive method

Pill . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Intrauterinedevice . . . . . . . . . . . . . . . . . . .

Diaphragm . . . . . . . . . . . . . . . . . . . . . . . .

Foam,jelly,orcream . . . . . . . . . . . . . . . . . .

Relyingon partner . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . .

None-pregnant . . . . . . . . . . . . . . . . . . . . .

None-other . . . . . . . . . . . . . . . . . . . . . . .

Number in thousands

. . . . . . . . . . . . . . . . 8,608 2,865 3,242 1,528 973

Percent distribution

. . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0

. . . . . . . . . . . . . . . . 43.3 67.1 42.1 22.7 10.0

. . . . . . . . . . . . . . . . 26.2 25.8 31.2 24.8 12.8

. . . . . . . . . . . . . . . . 30.5 7.1 26.7 52.5 77.1

. . . . . . . . . . . . . . . . 53.7 78.8 54.7 30.8 “13.1

. . . . . . . . . . . . . . . . 22.4 17.8 27.2 25.3 15.2

. . . . . . . . . . . . . . . . 23.9 3.5 18.1 43.9 71.7

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

67.5

8.1

6.0

5.2

3.9

2.5

3.2

3.6

76.8

3.3

3.3

4.3

3.4

1.3

4.0

3.6

69.5

7.4

6.9

4.6

3.5

1.7

3.0

3.4

60.5 44.5

12.1 II8.3

8.1 7.6

5.5 9.0

4.1 6.6

3.2 7.4

2.9 2.1

3.6 4.6

NOTE: Figures maynotadd tototals duatoroundlrw.

years and over (table 4). Also, insignificantly more

visits by white women (58 percent) than by black

women (43 percent) and in more visits by women

who were not Hispanic (58 percent) than by Hispanic

women (24 percent) the patient reported having no

live births.

As expected, there were significantly more visits

by women aged 30years and over whohad twoor

more pregnancies (77 percent) and two or more

live births (72 percent) than by women in any other

age category. There were also significant differences

by race and ethnic origin. The data show relatively

more visits were made by black women who had two

or more pregnancies (36 percent) and two or more

live births (28 percent) than by white women (28

percent and 22 percent, respectively); and a larger

proportion of visits were made by Hispanic women

who had two or more pregnancies (55 percent) and

two or more live births (48 percent) than by women

who were not Hispanic (27 percent and 21 percent,

respectively).

Medical sewices

A typical visit to a family planning clinic usually

included at least four different medical services. A

blood pressure test was routinely given in 86 percent

of visits. Other frequently provided services were

pelvic examinations in 59 percent of visits, breast

examinations in 48 percent of visits, urinalyses in

48 percent of visits, and Pap smears in 46 percent

of visits. Pregnancy testing (in conjunction with

other medical services) was performed during only

9 percent of all family planning visits (table 6).

Contraceptive method

During 93 percent of family planning visits some

method of contraception was adopted or the use of

a contraceptive method was continued. Oral contraception was the overwhelming choice of all women

regardless of age, race, or ethnic background. The pill

was adopted or its use was continued in about twothirds of all family planning visits (figure 1). However, pill use did decrease significantly with age from

77 percent of teenage visits to 45 percent of visits

by women aged 30 years and over. Although no

differences were found by race, pill use was significantly lower for visits by Hispanic women (61 percent) than by women who were not Hispanic (68

percent).

The next most popular methods of contraception were the intrauterine device (8 percent) and

the dia@wagm (6 percent). In general, the proportion of visits in which an intrauterine device, diaphragm, or other methods were chosen increased

from the youngest to the oldest age categories.

Higher proportions of visits by black women (9
aduamedata 5

Table 5. Number of female family planning visits by race and ethnicity. and percent distributions by pregnancies, live births, and

contraceptive methods. according to race and ethnicity: United States, 1979

Race Edrnicity

Pregnancies, Jive births, and contraceptive method

Total’ White Black

h ,.,

or

or d(

LJL-*anic Not of

Hispanic igin

?scent

on-gin

or descen t

Number in thousands

Ail visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,608 6,057 2387 1,001 7,607

Percent distribution

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... 100.0 100.0 100.0 300.0 100.0

Number of pregnancies

None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43.3 46.6 35.0

One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17.9 46.7

26.2 25.3 28.8 26.7 26.1

Twoormore. . . . . ,

None . . . . . . . . . .

One . . . . . . . . . . .

Twoormore. . . . . .

Pill . . . . . . . . . . .

Intrauterine devicsr . .

Diaphragm. . . . . . .

Foam,jeliy,or cream.

Relyingon partner . .

Other. .,.......

None-pregnant. . . .

None-other. . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Number of live births

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Contraceptive method

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30.5

53.7

22.4

23.9

67.5

8.1

6.0

5.2

3.9

2.5

3.2

3.6

28.1

57.9

20.1

22.0

67.3

7.5

6.8

4.6

4.3

2.3

3.5

3.7

36.2

43.1

28.5

28.4

68.8

9.1

4.1

6.7

2.8

2.7

2.4

3.4

!55.4

23.8

27.9

48.3

60.6

14.1

3.4

6.6

7.1

2.3

2.8

3.2

27.2

57.7

21.6

20.7

68.4

7.3

6.3

5.0

3.5

2.5

3.3

3.7

l,nc,uda~all otharraws not shown ewarately.

NOTE: Figures may not add tototals due to rounding.

Table 6. Number and percent of female family planning visita, by

medical services provided: United States, 1979

Medical services Number in Pement

thousands

Allvisits . . . . . . . . . . . . . . . . . 8,609 100.0

Papsmear . . . . . . . . . . . . . . . . 3,980 46.2

Pelvic examination . . . . . . . . . . . 5,078 59.0

Breast examination. . . . . . . . . . . 4,137 48.1

Blocd pressure test. . . . . . . . . . . 7,394 85.9

Pregnancy test . . . . . . . . . . . . . . 745 8.7

Venereal disease testing . . . . . . . . 3,592 41.7

Urinalysis . . . . . . . . . . . . . . . . 4,139 48.1

Blocd test . . . . . . . . . . . . . . . . 3,474 40.4

Sterilization . . . . . . . . . . . . . . . ●12 ●0.1

Infertility semicas. . . . . . . . . . . . ●5 ●0.1

Othermedicalsarvices . . . . . . . . . 4,758 55.3

NOTE: Figures do nol add to total since each visit may involve mora

than onemadical service.

percent) and Hispanic women (14 percent) were

associated with intrauterine device usage than visits

by white women (8 percent) and by women who

were not Hispanic (7 percent) were. More visits by

white women (7 percent) and women who were not

Hispanic (6 percent) were associated with diaphragm

usage than visits by black women (4 percent) and by

Hispanic women (3 percent) were.
6

Pill

Intrauterine device

Diaphragm

Foam, jelly, or cream

Relying on partner

None

Other IzEl

1 I I I I I I I

o 10 20 30 40 50 60 -70

Percent

UOTE: Percents are based on 8,609,000 female family planning visits. Figures may not add to total due to rounding.

Figure 1. Percent distribution of female family planning visits at which a contraceptiw method was adopted or continued by method chosen:

United Stetes, 1979

References

~National Center for Health Statistics: Teenagers who use

organized family planning services: United States, 1978, by E.

Eckard. VitaI and Health Statistics. Series 13-No. 57. Public

Health Service, DHHS, Hyattsville, Md. In preparation.

2Natioml Center for Health Statistics: Visits to family planning service sites: United States, 1978, by B. L. Hudson.

Advance Data From Vital and Health Statistics, No. 72. DHHS

Pub. No. (PHS) 81-1250. Public Health Service. Hyattsville,

Md. June 29, 1981.

3National Center for Health Statistics: Patient profile, National Reporting System for Family Planning Services: United

States, 1978, by J. E. Foster. Advance Data From Vital and

Health Statistics, No. 73. DHHS Pub. No. (PHS) 81-1250.

Public Health Service. Hyattsville, Md. June 10, 1981.

4National Center for Health Statistics: Office visits for family

planning, National Ambulatory Medical Care Survey: United

Technical notes

States, 1977, by B. K. Cypress. Advance Data From Vital

and Health Statistics, No. 49. DHEW Pub. No. (PHS) 79-

1250. Public Health Service. Hyattsville, Md. Apr. 16, 1979.

5Natioml Center for Health Statistics: Use of family planning

services by currently married women 1544 years of age:

United States, 1973 and 1976, by G. E. Hendershot. Advance

Data From Vital and Health Statistics, No. 45. DHEW Pub.

No. (PHS) 79-1250. Public Health Service. Hyattsville, Md.

Feb. 7, 1979.

6National Center for Health Statistics: Background and

development of the National Reporting System for Family

Planning Services, by B. J. Haupt. Viral and Health Statistics.

Series l-No. 13. DHEW Pub. No. (PHS) 78-1313. Public

Health Service. Washington. U. S. Government Printing

Office, Apr. 1978.

Sample design

The 1979 National Reporting System for Family

Planning Services (NRSFPS) estimates are based on a

stratified two-stage sample design. In the first stage,

a probability sample of family planning service sites

was selected from a stratified sampling frame that

was developed in 1976 and updated for 1979. In the

second stage of the sampling plan, family planning

visits occurring at each sample site were systematically selected. The sampling rate assigned by the

National Center for Health Statistics to each sample

site depended on the site’s reported visit volume and

the State in which the site was located. Overall, there

were 14 visit sampling rates used to determine the

proportion of each site’s family planning visits needed

for the survey; the visit sampling rates ranged from

1/1 to 1/30. The 1979 NRSFPS sample for the

United States encompassed 376,472 female faunily

planning visits. A report delineating NRSFPS background, development, and evolution has been published.b
Estimation

The statistics provided by NRSFPS for 1979 are

derived by a complex-estimation procedure. The estimation procedure used to produce essentially unbiased national estimates for NRSFPS has two

principal components–inflation by the reciprocal of

the probability of sample selection and imputation

for nonresponse.

Sampling error

The statistics presented in this report are based on

a sample survey and therefore differ from those that

would be obtained from a full-count (100 percent)

su~ey using the same data collection procedures and

definitions.

The standard error is primarily a measure of the

variability that occurs by chance because a sample

rather than the entire universe is surveyed. While the

standard error as calculated for this report reflects

some of the random variation inherent in the measurement process, it does not measure any systematic

error present in NRSFPS data. The relative standard

error of an estimate is obtained by dividing the

standard error of the estimate by the estimate itself

and is sometimes expressed as a percent of the estimate. The chances are about 0.68 that 4he interval

specified by the estimate plus or minus one standard

error of the estimate contains the figure that would

be obtained through a full-count survey of the

sampling frame. The chances are about 0.95 that the

interval specified by the estimate plus or minus two

standard errors of the estimate contains the figure

that would be obtained through a full-count survey

of the sampling frame.

In order to derive standard errors that would be

applicable to a wide variety of statistics and that

could be derived at moderate costs, several approximations were required. For the four basic age categories of patients presented in this report, estimates

of totals and relative standard errors of totals are

shown in table L The standard error for estimated

percents of visits are shown in table H.

Nonaampling error

NonSampling error is present in most sample surveys and includes errors due to service site nonresponse, item nonresponse, information incompletely

or inaccurately recorded, and processing error.

Through an unpublished evaluation study conducted

in 1980, several problems associated with the collection of data for NRSFPS (for example, adherence

to NRSFPS deftitions) were identified. While the

study results are not applicable to the 1979 NRSFPS

per se, they indicate the difficulties inherent in the

data collection effort.

Rounding

Aggregate estimates of family planning visits in

the tables are rounded to the nearest thousand.

Because percents were computed according to unrounded estimates, figures may not add to totals.

Table 1. Number of female family planning visits and relative

standard error, by age: United States, 1979

Age Number in

Relative

thousands

standard

error

Alleges . . . . . . . . . . . . . . . . . . 8,608 4.2

Under 20 years . . . . . . . . . . . . . 2,865 5.1

20-24 years . . . . . . . . . . . . . . . 3,242 4.4

25-29 years . . . . . . . . . . . . . . . 1,528 3.5

30years And over . . . . . . . . . . . . 973 3.9

Table IL Approximate standard errors of percents of estimated number

of female family planning visits, by age: United States, 1979

Estimated percent

Age I or 5 or 10 or 20 or Z;oor 50

99 95 SO 80

Standard error in percentage points

Allages . . . . . . . . . . . . ..O.l 0.3 0.4 0.5 0.6 0.7

Under 20 years . . . . . . . . . 0.2 0.4 0.6 0.8 0.9 1.0

20-24 years . . . . . . . . . . . 0.2 0.5 0.6 0.9 1.0 7.1

25-29 years . . . . . . . . . . . 0.3 0.6 0.8 1.1 1,3 1.4

30years and over. . . . . . . . 0.3 0.7 0.9 1.2 1.4 1.5

Example of us of table: An estimate of 20 percmst of all Wwrage visits

has a standard wror of’ 0.8 percent or a relative standard error of 4.0

percent (0.8 parcsnt + 20 porsent).

Definitions

Family phning service site.–A family planning

service site is a location where medical family planning services are provided on a regular basis under the

supemision of a physician. Private physicians’ offices

and group medical practices are not considered sites

tmless they receive support through a Department of

Health and Human Services grant for the provision

of family planning services. Military service sites are

excluded from the survey.

Family pbzning visit.–A family planning visit

is a visit to a family planning semice site in which

medical family planning services related to contraception, infertility treatment, or sterilization are

provided.

Medical family planning services. –Medical family

planning services include Pap smears, pelvic examinations, breast examinations, blood pressure tests,

pregnancy tests, tests for venereal disease, sterilization, infertility treatment, urinalyses and blood

tests (unless included as part of another service), and

other medical semices.
From Vital and Health Statlst[cs of the National Center for Health Statistics Number 75 ● February 16, 1982

Expected Principal Source of Payment for Hospital Discharges:

United States, 1979

by Edmund Graves and Robert Pokras, Division of Health Care Statistics

Introduction

This report presents statistics on data collected

through the National Hospital Discharge Survey. The

National Center for Health Statistics has continuously

conducted this survey since 1965. In 1979 data were

abstracted from the face sheets of medical records of

approximately 215,000 patients discharged from 416

non-Federal short-stay hospitals. These data were

used to produce estimates of hospital utilization by

an estimated 36.7 million inpatients (excluding

newborn infants) in the United States.

From 1968 through 1970 information on hospital

charges and sources of payment from a subsample of

the hlational Hospital Discharge Survey sample was

collected. 1 No information on charges or sources of

payment was collected from 1971 through 1976.

However. during 1977-79 data on a patient’s expected principal source of payment and other expected sources of payment were collected from the

face sheets of all medical records in the National

Hospital Discharge Survey sample. A report on the

1977 data has been published.2 Statistics in that

report as well as those in this one reflect only the

patient’s principal source of payment. The 1977

report presents estimates of source of payment by

age and sex of patients as well as estimates for leading

diagnostic and surgical categories. This report updates

the basic estimates by age and sex of patients and

provides new analysis by discharge status and surgical

status of patients as well as by hospital location and

ownership. The surrey form used to collect these

data is reproduced in another publication of the

National Center for Health Statistics.s

Within NCHS. there are two other sources of

information on health care costs: the National Medical

Care Expenditures Survey (NMCES’)and the National

Health Interview Survey (lfHIS ). These suneys

provide data on the number of persons in the general

population covered under the different private or

public health plans, A-G and the National Hospital

Discharge Survey (NHDS) provides data on the

hospital population only. Acco~ding to the NHDS,

approximately 6 percent of all patients discharged

from short-stay hospitals had no health insurance.

On the other hand. data from NHIS and NMCES

indicate that 11.0 and 12.6 percent. respectively, of

the noninstitutionaIized population had no health

insurance coverage. This would seem to indicate that

a proportionately smaller number of the uninsured

rather than of the insured are hospitalized. This may

be true. Moreover, many individuals who claim they

have no health insurance coverage may find on being

hospitalized that they are covered under such public

health programs as Medicaid, Welfare, Veterans

Administration health benefits, and the Iike.

According to the National Hospital Discharge

Survey, the percent of hospitalized individuals

covered bjr private insurance was 52.5 percent. This

is much lower than the estimated 77.7 percent of

individuals covered by private insurance found in

the 1978 National Health Intemiew Survey.G This

difference is not unexpected since pubIic health

programs are often billed first for hospital charges,

and individuals citing private insurance coverage may

be using it as a secondary insurance source.

It should be noted that the expected source of

payment recorded on the face sheet of the medical

record may not have been the actual source of payment. For example. a patient admitted to a hospital

following an automobile accident may have cited

Blue Cross as the expected source of payment when.

in fact. an automobile insurance company ultimately

made restitution. Also, because of the manner in

which this variable was collected. there is no way to

determine the charge for the hospital stay or what

proportions of the hospital sta~”and medical services

were covered by the principal source of payment

indicated.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Publlc Health Service, Office of Hea!th Research, Statistics, and Technology
2

Data highlights

Of the 36.7 miIIion patients discharged from

non-Federal short-stay hospitals in the United States

during 1979, 52.5 percent expected to pay for

their hospital stay through private insurance, 27.0

percent expected Medicare to pay for the hospitalization, 8.8 percent expected Medicaid to pay for the

hospitalization, 5.9 percent expected to pay their

own hospital bills, and the remaining 5.9 percent

expected to have their hospital biIls paid through

other sources or not to be charged.

A typical person who was hospitalized in nonFederal short-stay hospitals in the United States

during 1979 was female, white, about 44 years of

age, was hospitalized in the South, was a patient in

a nonprofit hospital, and expected to pay for the

hospitalization through private insurance.

Discussion

Private Insurance

Private health insurance is the major type of

health insurance in the United States. In studies done

in 1976 and 1978 it was estimated that over 70

percent of all persons in the United States were

covered by private insurance.4~G In the National

Hospital Discharge Survey of 1979 it was the expected source of payment for about 50 percent of

all hospital patients. The use of private insurance to

pay hospital costs is a rather unusual method of

payment since a study of 10 of the more developed

countries pointed out that only the United States and

Australia utilized private health insurance plans to a

large extent.7 Another interesting finding of that

study was that the United States and Australia also

had the shortest average lengths of stay of the 10

countries.

Private health insurance consists of Blue Cross

and other private or commercial insurance. It was the

expected source of payment for approximately 19.3

million discharges from non-Federal short-stay

hospitals in 1979. about half of all discharges (table

1). Of these 19.3 million discharges, 19.0 million

(98.7 percent) were under 65 years of age. The

remaining 0.3 million ( 1.3 percent) were 65 years

and over.

The numbers of males and females discharged

were relatively similar for all age groups except

1544 years (table 1). Of the discharges in this age

group. females outnumbered males -by about 5 to 2.

This was due to the large number of females admitted

for delivery and female-specific surgery.2 However,

the percent of males using private insurance and the

percent of females using private insurance was about

the same in each age group.

The average length of stay for patients with private insurance as an expected source of payment was

5.9 days (table 2). This was 1.3 days less than the

average of 7.2 days for all patients discharged from

short-stay hospitals. This difference is partially a

function of age since average length of stay increases

with age, and the average age of patients using private

insurance was 34.4 years compared with an average

age of 43.7 years for all patients (table 3). The shorter

average length of stay means that a proportionately

smaller number of days of care were used by the

patients. Whereas approximately 52 percent of all

discharges were expected to be covered by private

insurance, only about 43 percent of the total! days

of care in non-Federal short-stay hospitals were

used by these patients.

Table 4 provides data on the number and percent

of patients discharged from non-Federal short-stay

hospitals who had one or more surgical or nonsurgical procedures performed during 1979. A total

of 18.9 million or 51.4 percent of alI patients discharged during 1979 had one or more procedures

performed.

Of the 19.3 miIlion patients who expected to

pay for their hospitalization through private insurance, 58.5 percent had one or more procedures

performed (table 5). Women 15-44 years of age had

three times more surgical procedures than men of the

same age had because of the large number of obstetrical procedures.2 Approximately 69.4 percent of

all women 15-44 years expecting to pay for their

hospitalization through private insurance hail one

or more procedures performed, whereas only 53.1

percent of the men 15-44 years with the same characteristic had one or more procedures performed.

Table 5 provides data on the discharge status for

all patients under 65 years and 65 years and over. Of

the 19.3 million patients covered by private insurance

programs, 18.0 million (93.5 percent) were discharged alive and 184,000 (1.0 percent) were discharged dead; the discharge status of 1.1 million

(5.6 percent) were unknown. A total of 17.8 million

(98.8 percent) of the 18.0 million patients discharged

alive were under 65 years. The remaining 223,000

patients ( 1.2 percent) were 65 years and over.

Table 6 shows the number and percent distribution

of patients discharged from non-Federal short-stay

hospitals by source of payment, race. region. and

hospital ownership. Approximately 14.8 million

(76.8 percent) of the 19.3 million patients discharged

from short-stay hospitals who expected to pa:y for

their hospitalization through priv’ate insumn ce were

white. Of the remaining 4.5 million. 1.9 million

(9.8 percent) were of other races and 2.6 million

( 13.3 percent) did not have race stated on the

medical record.

Estimates of the number of discharges by region

showed that the South ?.egion, with 6.4 million
adbancedata 3

Table 1. Number and percent distribution of patients discharged from non-Federal short-stay hospitals by principal expected source of

payment, according to age and sex: United States, 1979

All expected Private Workmen’s Medi- Medi~ Other

Age and sex sources of CompenNo Other

insurance care aid government Self-pay

payment sation payments

charge payments

Both sexes

Alleges . . . . . . . . . .

Under 15 years . . . . . . .

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

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

65 years and over . . . . . .

Male

Alleges . . . . . . . . . .

Under 15 years . . . . . . .

1544years . . . . . . . . .

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

65 years and over . . . . . .

Female

Alleges . . . . . . . . . .

Under 15 years . . . . . . .

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

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

65 years and over . . . . . .

Both sexes

Alleges . . . . . . . . . .

Under 15 years . . . . . . .

1544 years . . . . . . . . .

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

65 years and over . . . . . .

Male

Alleges . . . . . . . . . .

Under 15 years . . . . . . .

1544years . . . . . . . . .

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

65 years and over . . . . . .

Female

All ages . . . . . . . . . .

Under 15 years . . . . . . .

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

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

65 years and over . . . . . .

36,747

3,641

15,488

8,532

9,086

14,705

2,053

4,680

4,017

3,955

22,042

1,588

10,808

4,515

5,131

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

19,289

2,437

10,574

6,017

260

7,399

1,381

3,122

2,765

131

11,889

1,056

7.452

3,252

129

52.5

66.9

68.3

70.5

2.9

50.3

67.3

66.7

68.8

3.3

53.9

66.5

68.9

72.0

2.5

643

. . .

447

182

14

528

. . .

375

143

10

115

“ii

39

4

1.8

. . .

2.9

2.1

0.2

3.6

. . .

8.0

3.6

0.2

0.5

. . .

0.7

0.9

0.1

Number in thousands

9,925 3,227 918

43 675 163

288 1,820 507

1,019 592 228

8.576 139 21

4,437 974 353

19 381 87

148 329 152

554 210 105

3.716 54 10

5,488 2,253 565

23 284 76

140 1,491 355

465 382 123

4,860 85 11

Percent distribution

27.0 8.8 2.5

1.2 18.5 4.5

1.9 11.8 3.3

11.9 6.9 2.7

84.4 1.5 0.2

30.2 6.6 2.4

0.9 18.6 4.2

3.2 7.0 3.2

13.8 5.2 2.6

94.0 1.4 0.2

24.9 10.2 2.6

1.5 18.5 4.8

1.3 13.8 3.3

10.3 8.5 2.7

94.7 1.7 0.2

2,168

235

1,500

372

61

773

136

431

179

27

1,395

99

1,069

193

34

5.9

6.5

9.7

4.4

0.7

5.3

6.6

9.2

4.5

0.7

6.3

6.2

9.9

4.3

0.7

30

5

15

7

4

11

2

3

3

2

20

2

12

3

2

0.1

0.1

0.1

0.1

0.0

0.1

0.1

0.1

0.1

0.0

0.1

0.1

0.1

0.1

0.0

546

83

337

116

11

230

46

120

58

5

316

37

216

58

6

1.5

2.3

2.2

1.4

0.1

1.6

2.3

2.6

1.4

0.1

1.4

2.3

2.0

1.3

0.1

(33.2 percent), and the North Central, with 6.0

million (3 1.3 percent), had the largest numbers of

discharged patients covered by private insurance.

The West, with 2.7 million (14. 1 percent) had the

smallest number of discharges.

Patients discharged from nonprofit hospitals

accounted for 14.2 million (73.6 percent) of the 19.3

million patients covered by private insurance discharged from non-Federal short-stay hospitals. Of

the remaining 5.1 million patients, 3.5 million (18.0

percent) were discharged from State and local government hospitals and 1.6 million (8.4 percent) were

discharged from profitmaking (proprietary) hospitals.

Public health programs

Public health programs include Medicare, Medicaid, Workmen’s Compensation, and other government programs. Together these programs were the

principal expected source of payment for 14.7

million or 40.0 percent of all discharges (table 1).

Of these 14.7 miIlion, 9.9 million (67.5 percent) were

Medicare patients, 3.2 million (21.9 percent) were

Medicaid patients, 0.6 million (4.4 percent) were

covered under Workmen’s Compensation, and the

remaining 0.9 million (6.2 percent) were covered
4 advancedata

Table 2. Number and percent distribution of days of care and average length of stay for patients discharged from non-Federal short-stay hospitals

by principal expected source of payment, according to age: United States, 1979

A II expected Workmen’s Other Private

Age sources of CompenMedi- Medic- No Other

insurance care aid government

payment

Self-pay

sation payments

charge payments

Days of care in thousands

Alleges . . . . . . . . . .

Under 15 years . . , . . . .

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

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

65 vears and over . . . . . .

264,173

15,765

80,913

69,755

97.740

113,329

9,808

54,205

46,738

2,578

4,300 105,319 20,433 5,401 11,595

1,175

6,797

2,951

671

242

55

67

67

63

3,555

426

1,895

1 ;067

166

346 3,230 724

2,719 9,806 2,663

9,904 5,800 1,846

92,350 1,596 167

2,+60

1#391

149

Percent distribution of days of care

Alleges, . . . . . . . . .

Under 15 years . . . . . . .

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

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

65 years and over . . . . . .

100.0

100.0

100.0

100.0

100.0

42.9

62.2

67.0

67.0

2.6

1.6 39.9 7.7 2.0 4.4

7.5

8.4

4.2

0.7

0.1

0.3

0.1

0.1

0.1

1.3

2.7

2.3

1.5

0.2

2.2 20.5 4.6

3.4 12.1 3.3

14.2 8.3 2.6

94.5 1.6 0.2

3:4

2.0

0.2

Average length of stay in days

Allege s . . . . . . . . .

Under 15 years . . . . . . .

1544 years . . . . . . . . .

45-84 years . . . . . . . . .

65 years and over . . . . . .

7’.2

4.3

5.2

8.2

10.8

5.9

4.0

5.1

7.8

9.9

6.7 10.6 6.3 5.9 5.3

5.0

4.5

7.9

11.0

7.9

11.6

4.4

8.7

15.7

6.5

5.1

5.6

9.2

15.7

8.1 4.8 4.5

9.4 5.4 5.3

9.7 9.8 8.1

10.8 11.5 8.0

. . .

6.2

7.6

10.9

Table 3. Number of discharges, days of care, average length of stay, and

average age of patients discharged from non-Federal short-stay

hospitals, by principal axpected source of payment: United States,

1979

In addition, 86.4 percent of the Medicare patients

were 65 years and over, and the average length of

stay for patients of this age group was 10.8 days.

The average age of patients expecting to pay for

their hospitalization through public programs was

58.5 years (table 3). This was 70 percent hjgher than

the average of 34.4 years for patients expecting to

pay hospital bills through private insurance. The

higher average age for patients covered by public

health insurance was because of the high proportion

of Medicare patients.

In the age-by-sex distributions of table 1, the

most prominent sex difference in the number of

discharges was in the age group 15-44 years. For

Medicaid and other government payments there

were more than twice as many female as male discharges in this age group. For Medicare the number

of females and males 1544 years of age were quite

similar ( 140.000 and 148.000. respectively). but for

Workmen. s Compensation the number of males outnumbered the riumber of fe’males discharged by more

than 5 to 1 (375.000 and 72,000. respectively).

Medicare is a government-sponsored program

primarily designed to help older people defray the

costs of hospitalization. Medicare patients accounted

for 9.9 miIlion patients (27.0 percent) discharged

from short-stay hospitals (table 1). Of these 9.9

million. 8.6 million (86.4 percent) were 65 }’ears and

over. Table 4 shows that a total of 3.9 million (38.9

percent) of the Medicare patients had one or more

procedures performed. This was considerably lower

than the 56.1 percent of patients with one or more

procedures performed who were covered under all

Expected sources of payment

All expected

item sources of Self-pay, no

payment Private Public charge, and

other

Total number of

discharges in

millions. . . . . . . 36.7 19.3 14.7 2.7

Total days of care

in millions . . . . . 264.2 113.3 135.5 15.4

Average length of

stay in days . . . . 7.2 5.9 9.2 5.7

Average age of

patients In years . . 43.7 34.$ 58.5 29.9

by other forms of government health payment

programs.

Forty percent of all dischtirges-expected to pay

for their hospitalization through public health programs. and they accounted for 51.3 percent of the

total days of care. As stated earlier, 52.5 percent of

the dischtirges in the NHDS were co~ered b) private

insurance. but they accounted for on]}’ 42.9 percent

of the tottil days of care (table 2). This resulted in

longer average length of stay for patients covered

by public health programs than for those covered by

private insurance-9.2 days compared ~vith 5.9 days.
5

Table 4. Number and percent of patients with procedures discharyd from non-Federal short-stay hospitals by sax. age, and princiPal expected

source of payment: United States. 1979

Sex and age of patients All expected Private Workmen’s Aledi- Medic- 0 ther

sources of CompenNo Other

with procedures insurance care aid government

payment sation

Self-pay charge

payments

payments

Both sexes

Alleges . . . . . . . . . .

Under 15 years . . . . . . .

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

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

65 years and over . . . . . .

Male

Alleges . . . . . . . . . .

Under 15 years . . . . . . .

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

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

65 years and over . . . . . .

Female

Alleges . . . . . . . . . .

Under 15years . . . . . . .

16-44 years . . . . . . . . .

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

65 years and over. . . . . .

Both sexes

Alleges . . . . . . . . . .

Under 15 years . . . . . . .

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

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

65 years and over. . . . . .

Male

Alleges . . . . . . . . . .

Under 15 years . . . . . . .

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

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

65 years and over . . . . . .

Female

Allage.s . . . . . . . . . .

Under 15 years . . . . . . .

1544 years . . . . . . . . .

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

65 years and over . . . . . .

18,896

1,575

9,514

4,207

3,601

6,839

899

2,357

1,894

1,690

12,057

676

7,157

2,313

1s11

51,4

43.2

61.4

49.3

39.6

46.5

43.8

50.4

47.1

42.7

54.7

42.6

66.2

51.2

37.3

11,284

1,142

6,825

3,194

124

3,786

661

1,656

1,404

64

7,498

480

5,168

1.790

60

58.5

46.8

64.5

53.1

47.7

51.2

47.9

53.1

50.8

49.1

63.1

45.5

69.4

55.0

46.3

380

. . .

263

109

9

320

-..

226

87

7

60

. . .

36

22

‘2

59.1

. . .

58.7

59.9

63.1

60.6

. . .

60.3

60.7

70.3

52.4

. . .

50.4

56.8

4!5.5

3,862

14

109

365

3,374

1824

7

50

191

1,575

2,039

5:

174

1,799

38.9

33.8

37.8

35.8

39.3

41.1

36.4

34.0

34.5

42.4

37.1

31.7

41.8

37.4

37.0

Number in thousands

1,491

225

993

219

53

344

123

126

71

25

1,146

102

867

149

28

Percent

46.2

33.3

54.6

37.1

38.0

35.4

32.2

38.5

33.7

45.6

50.9

34.8

58.1

38.9

33.3

460

75

277

98

11

147

38

62

43

4

313

36

216

55

6

50.1

45.8

54.7

43.0

51.3

41.8

44.0

40.6

41.3

45.4

55.4

47.9

60.7

44.5

56.5

1,117

82

849

163

23

307

48

180

68

11

809

33

669

95

12

51.5

34.7

56.6

43.9

37.5

39.8

35.5

41.8

38.0

40.2

58.0

33.5

62.5

49.4

35.3

17

2

10

4

2

5

1

1

1

1

12

1

8

2

1

55.9

39.2

64.0

57.4

42.4

44.3

53.2

41.0

42.5

41.0

62.0

24.9

69.6

72.0

43.6

285

36

188

55

5

105

20

54

28

2

179

16

134

27

3

52.1

43.0

56.0

47.5

51.9

45.7

42.9

45.2

48.8

50.7

56.8

43.0

62.0

46.2

53.0

other sources of payment. One reason for this

difference may be that Medicare patients. who

are primarily elderly people, may be more likely to

be hospitalized for chronic nonoperable conditions.

As shown in table 5 patients covered under the

Medicare program were also more likely to have a

higher mortality rate than patients covered under

other sources of payment. Medicare patients constituted 70.7 percent of all patients discharged dead

even though they constituted only 27.0 percent

of all patients discharged from short-stay hospitaIs.

Again, this is because of the substantially older

average age of Medicare patients.

Approximately 10.6 million (72.3 percent) of

the 14.7 million patients expecting to pay for their

hospitalization through public insurance were white

(table 6). Of the remaining 4.1 million, 2.2 million

(15.0 percent) were of other races, and race was not

stated for 1.9 million (12.6 percent).

An estimated 24.8 percent of other than white

patients discharged from short-stay hospitals had

Medicaid entitlement whereas only 6.2 percent of

white patients discharged from short-stay hospitals

had Medicaid entitlement. An explanation of this

may be that lMedicaid is primarily a program to provide medical benefits to certain low income people

in need of medical care and that people of other

races have proportionately more low income families

than white people. Specifically, in 1979 the actual

poverty level was determined to be S7.412 for a

family of four. In that year 13.3 percent of all

fami~ies were beIow an income level of S7,500. For
6 aduana?data

Table 5. Number and percent distribution of patients discharged from non-Federal short-stay hospitals by age and discharge status, according to

princ!pal expected source of payment: United States, 1979

Age and AIJ expected Private Workmen k Medi- Medic- Other

dischargestatus sourcesof Compen- Self-pay

No 0 ther

insurance care aid government

payment

charge

sarion paymenss

payments

Alleges . . . . . . . . . .

A live . . . . . . . . . . . . .

Dead . . . . . . . . . . . . .

Not stated . . . . . . . . . .

Under 65 years . . . . .

Alive . . . . . . . . . . . . .

Dead . . . . . . . . . . . . .

Not stated . . . . . . . . . .

65 years and over. . . .

Alive . . . . . . . . . . . . .

Dead . . . . . . . . . . . . .

Not stated . . . . . . . . . .

Alleges . . . . . . . . . .

Alive. . . . . . . . . . . . .

Dead . . . . . . . . . . . . .

Not stated . . . . . . . . . .

Under 65 years . . . . .

Alive . . . . . . . . . . . . .

Dead . . . . . . . . . . . . .

Notstated . . . . . . . . . .

65 years and over. . . .

Alive . . . . . . . . . . . . .

Dead . . . . . . . . . . . . .

Not stated . . . . . . . . . .

36,747

33,812

924

2,011

27,661

25,845

287

1,528

9,086

7,967

636

483

100.0

92.0

2.5

5.5

100.0

93.4

1.0

5.5

100.0

87.7

7.0

5.3

19,289

18,034

184

1,071

19,028

17,811

165

1,053

260

223

19

18

100.0

93.5

1.0

5.6

100.0

93.6

0.9

5.5

100.0

85.8

7.3

6.9

643

610

2

31

630

598

2

30

14

12

1

1

100.0

94.9

0.4

4.8

100.0

94.9

0.3

4.8

100.0

90.7

4.8

4.5

Numberinthousands

9,925 3,227 918

8,743 3,024 837

653 40 12

528 162 69

1,349 3,087 897

1,223 2,896 821

51 33 10

75 158 67

8,576 139 21

7,520 128 16

603 7 2

454 4 2

Percent distribution

100.0 100.0 100.0

88.1 93.7 91.2

6.6 1.2 1.3

5.3 5.0 7.5

100.0 100.0 100.0

90.7 93.8 91.5

3.8 1.1 1.1

5.6 5.1 7.5

100.0 100.0 100.0

87.7 92.1 79.1

7.0 4,8 10.0

5.3 3,1 10.9

2,168

2,031

23

114

2,107

1,977

20

111

61

54

4

3

100.0

93.7

1.1

5.3

100.0

93.8

0.9

5.3

100.0

88.5

6.2

5.3

30

29

1

1

26

25

z

1

4

3

1

100.0

94.2

3.8

2.0

100.0

96.3

1.4

2.3

100.0

80.3

19.7

white families this figure was 11.0 percent while for

another sitwas 30.0 percent.8

Estimates of the number of discharges by region

showed that thesoulh Re~ion. with about 5. Omillion

discharges, had the largest number of patients expecting to pay for their hospitalization through

public insurance programs. This was followed by the

h’orth Central Region with 4.1 million. the Northeast

with 3.2 milIion. and the West with 2.5 million

discharges. Even though the number of discharges

varied by region, patients with public insurance

represented approximately 40 percent of all discharges

in each region.

Nonprofit hospitals accounted for 10.2 million

(69.4 percent) of the 14.7 million patients discharged

from non-Federal short-stay hospitals covered under

public programs. Of the remaining 4.5 million

patients. 3.3 million (22. 4 percent) wwe discharged

from government operated hospituls. and 1.2 million

(8.2 percent) wrere discharged from profitrnaking

hospitals. The percent of patients with public health

coverage discharged from nonprofit hospitals (69.4

percent) was lower than the percent of patients

covered by private insurance discharged from the

546

504

8

34

535

495

7

34

11

10

1

z

100.0

92.4

1.4

6.2

100.0

92.4

1.3

6.3

100.0

90.5

5.9

3.6

—— .

same hospitals (73.6 percent). This is not unexpected

since patients covered by public health programs may

be referred to State or local government-owned

hospitals. This is especially true of Medicaid patients

of whom 29.7 percent were discharged from State

or local government-owned hospitals compared with

only 18.0 percent for patients covered by private

insu rdn ce.

Self-pay

Approximately 2.2 million patients (5.9 percent)

expected to pay for their hospitalization principally

b} themselves (table 1). Of these, 1.1 million (49.3

percent) were females 15-44 years of age. This was

].4 times greater then the tots] number of males

expecting to pay for their hospitalization by themselves.

The length of stay) for self-paj’ patients was 5.3

days (table 2). This was almost 4 days less than the

length of stay for patients covered by public health

pro:rams and almost 2 days less than the 7.2 days for

all patients (tabie 3). Lack of financial resources

coupled with the age and reason for hospitalization
achancedata 7

Table 6. Number and percent distribution of patients discharged from non-Federal short-stav hospitals by race and region and type of ownership of

hospital, according to principal expected source of payment: United States, 1979

Race, region, and Ail expected Private Workmen’s Me6i- Medic- Other

sources of Compen. No Other

type of ownership insurance care

government Self-pay

payment sation

aid

payments

charge paymen n

Total . . . . . . . . . . . 36,747

Race

White . . . . . . . . . . . . . 27,451

Another . . . . . . . . . . . 4,572

Not stated . . . . . . . . . . 4,724

Hospital region

Northeast . . . . . . . . . . 7,786

North Central . . . . . . . . 10,647

South . . . . . . . . . . . . . 12.425

West . . . . . . . . . . .

Hospital ownership

Nonprofit . . . . . . . .

Pro fit . . . . . . . . . . .

State or local

government. . . . . .

Total . . . . . . . . .

Race

White . . . . . . . . . . .

Another . . . . . . . . .

Not stated . . . . . . . .

Hospital region

Northeast . . . . . . . .

North Central . . . . . .

South . . . . . . . . . . .

West . . . . . . . . . . .

Hospital ownership

Nonprofit . . . . . . . .

Profit . . . . . . . . . . .

State or local

government. . . . . .

. . 5;889

. . 26,105

. . 2,956

. . 7,686

. . 100.0

. . 74.7

. . 12.4

. . 12.9

. . 21.2

. . 29.0

. . 33.8

. . 16.0

. . 71.0

. . 8.0

. . 20.9

19,289

14,819

1,900

2,570

4,125

6,041

6,402

2,720

14,188

1,621

3,480

100.0

76.8

9.8

13.3

21.4

31.3

33.2

14.1

73.6

8.4

18.0

643

453

79

111

91

163

252

137

444

87

113

I00.0

70.5

12.3

17.3

14.2

25.3

39.2

21.3

69.1

13.5

17.6

Number in thousands

9,925 3,227 918

7,881 1,689 617

800 1,136 198

1,244 401 103

2,154 819 151

2,761 902 229

3,464 989 268

1,546 517 269

7,085 2,065 623

878 202 39

1,962 960 256

Percent distribution

100.0 100.0 100.0

79.4 52.3 67.2

8.1 35.2 21.6

12.5 12.4 11.2

21.7 25.4 16.4

27.8 28.0 24.9

34.9 30.6 29.2

15.6 16.0 29.3

71.4 64.0 67.9

8.8 6.3 4.2

19.8 28.7 27.9

2,168

1,592

331

245

334

441

865

528

1.334

106

728

100,0

73.4

15.3

11.3

15.4

20.3

39.9

24.4

61.5

4.9

33.6

30

24

5

1

1

2

3

24

4

z

26

100.0

80.0

16.7

3.3

3.3

6,7

10.0

80.0

13.3

0.0

86.7

546

375

123

48

110

108

180

147

362

23

161

100.0

68.7

22.5

8.8

20.1

19.8

33.0

26.9

66.3

4.2

28.5

associated with these patients are some of the

principal reasons for the shorter length of stay.

According to the National Health Interview Survey

data, 5L$.2 percent of all reasons given for no health

insurance were that insurance costs were too high.~

In NHDS data, approximately one-half of all

self-insurers are females aged 15-4.4 years, a period

of life when cost of insurance may be a critical factor.

A type of hospital utilization related both to self-pay

status and short average length of stay are obstetrical

conditions,2 conditions which are very common for

the age and sex of half of the self-pay patients.

An estimated 1.1 million (5 1.5 percent) selfinsux-ers had at least one surgical or nonsurgical

procedure performed (table 4). The majority of

these (59.9 percent) were for femaks 15-W years of

age. Females composed about 70 percent of all

self-insurers who had one or more procedures performed.

Approximately 1.6 million (73.4 percent) of the

2.2 million self-insurers discharged from non-Federal

short-stay hospitals were white. Of the remaining

0.6 million. 0.3 million ( 15.3 percent) were of other

races. and 0.2 million ( 11.3 percent) did not have

their race stated in the medical record.

The South Region. with 0.9 million (39.9

percent), had the largest number and percent of selfinsurers discharged from non-Federal short-stay

hospitals. The number and percent of self-insurers

discharged from these hospitals in the other three

regions were 0.5 million (24.4 percent) for the West,

0.4 million (20.3 percent) for the North Central.

and 0.3 million ( 15.4 percent) for the Northeast.

About 1.3 million (6 1.5 percent) of the selfinsurers were hospitalized in nonprofit hospitals. Of

the remaining 0.9 million self-insurers. 0.7 million

(33.6 percent) were hospitalized in a State or 10COI
8

hospital, and 0.1 million (4.9 percent) were hospitali- discharges and days of care in short-stay hospitals.

zed in a proprietary hospital. Females in the 15-44 years of age group composed

40.0 percent of aIl no-charge discharges (table 1) and

No charge 49.7 percent of all no-charge discharges for which one

or more procedures were performed. In addition,

In 1979 an estimated 30,000 patients (table 1) 80.0 percent of the discharges were from the West,

were not charged for approximately 242,000 days of and 86.7 percent were discharged from State c)rlocal

care (table 2). This was only about 0.1 percent of alI govcmment hospitals.

References

1National Center for Health Statistics: Patient charges in

short-stay hospitals, United States, 1968-1970, by M. Moien.

Vital and Health Statistics. Series 13-No. 15. DHEW Pub. No.

(HRA) 74-1766., Public Health Service. Washington. U.S.

Government Printing Office, May 1974.

2National Center for Health Statistics: Expected principal

source of payment for hospital discharges, United States,

1977, by R. Pokras and G. Gardocki. Advance Data From

Vital and Health Statistics, No. 62. DHHS Pub. No. (PHS)

81-1250. Public Health Service. Hyattsville, Md. Oct. 31,

1980.

3National Center for Health Statistics: Utilization of shortstay hospitals. Annual summary for the United States, 1979,

b>’ B. J. Haupt.. Vital and Health Care Statistics. Series. 13-No.

60. DHHS Pub. No. (PHS) 82-1721. Public Health Service.

Wtishington. U.S. Government Printing Office. In press.

4National Center for Health Statistics: Health care coverage:

United States. 1976, by L. S. Corder. Ph.D. Advance Data

From L’ital and Health Statistics, No. 44. DHEW Pub. No.

(PHS) 79-1250. Public Health Service. Hyattsville, Md. Sept.

20, 1979.

5 National Center for Health Services Research: N,ztional

Health Care Expenditures Study, Who are the Uninsured, Data

Preview 1, by J. A. Kasper, D. C. Walden, and G. R. Wilensky.

Office of Health Research, Statistics, and Technology. Public

Health Service. Hyattsvdle, Md. 1980.

6 National Center for Health Statistics: Health care ccwerage

under private health insurance, Medicare, Medicaicl, and

military or veterans administration health benefits, United

States, 1978. Advance Data From VitaI and Health Statistics,

No. 71. DHHS Pub. No. (PHS) 81-1250. Public Health Service.

Hyattsville, Md. June 29, 1981.

7National Center for Health Statistics: Health, United Statesj

1980. DHHS Pub. No. (PHS) 81-1232. Public Health Service.

Washington. U.S. Government Printing Office, Dec. 198CI.

8U. S. Bureau of the Census: Statistical A bstract of the [Jnited

States, 1980. Washington. U.S. Government Printing Office,

1980.
=$Ewz&b9

Technical notes

Source of data

The National Hospital Discharge Survey encompasses patients discharged from short-stay noninstitutionalized hospitals, exclusive of military and

Veterans Administration hospitals, located. in the

50 States and the District of Columbia. Only

hospitals with six beds or more and an average

length of stay less than 30 days for all patients

are included in the survey. Discharges of newborn

infants are excluded from this report.

The universe of the survey consisted of 6,965

short-stay hospitals contained in the 1963 Master

Facility Inventory of Hospitals and Institutions.

New hospitals were sampled for inclusion into the

survey in 1972, 1975, and 1977. In all, 544 hospitals

were sampled in 1979. Of these hospitals, 80 refused

to participate, and 48 were out of scope. The 416

participating hospitals provided approximately

215,000 medical records.

Sample design

All hospitals with 1,000 beds or more in the

universe of short-stay hospitals were selected with

certainty in the sample. All hospitals with fewer than

1,000 beds were stratified, the primary strata being

24 size-by-region classes. Within each of these 24

primary strata, the allocation of the hospitals was

made through a controlled selection technique so

that hospitals in the sample would be properly

distributed with regard to type of ownership and

geographic division. Sample hospitals were drawn

with probabilities ranging from certainty for the

largest hospitals to 1 in 40 for the smallest hospitals.

Sample discharges were selected within the

hospitals using the daily listing sheet of discharges

as the sampling frame. These discharges were selected

by a random technique, usually on the basis of the

terminal digit or digits of the patient’s medical

record number, a number assigned when the patient

was admitted to the hospitaI. The within-hospital

sampling ratio for selecting sample discharges varied

inversely with the probability ‘of selectio-n

hospital.

Sampling errors, nonresponse, and

data edits

of the

Since the estimates for this report are based

on a sample rather than the entire universe, they

are subject to sampling variability. The relative

standard errors presented in table I are obtained by

dividing the standard error of the estimate by the

estimate itself and are expressed as a percent of the

estimate.

About 7.7 percent of the discharges sampled for

the 1977 NHDS did not have information concerning

source of payment on the face sheet of the medical

record. An expected source of payment was imputed

for these discharges based on the sex and age of the

patient.

There were several edits performed on the raw

data. When a principal expected source of payment

was not indicated, but a single expected source of

payment was listed as a secondary source of payment,

the indicated secondruy source of payment was

assumed to be the principal expected source of payment. When Workmen’s Compensation was listed in

conjunction with other insurance sources, Workmen’s

Compensation was taken as the principal expected

source of payment; and when Medicare was listed

in conjunction with other insurance sources (except

Workmen’s Compensation), Medicare was taken as

the principal expected source of payment.

Table 1. Relative standard errors of estimates, by all principal expected

sources of payment

Size of esb”mates IVumter of discha~s Days of cam

10,000 . . . . . . . . . . 27.0 . . .

100,000......... 12.1 15.5

1,000,000. . . . . . . . 9.4 9.4

10,000.000....... 9.1 6.0

100,000,000.. . . . . . . . . 4.2

Definitions

Private insurance. –Health insurance provided by

nongovemment sources including consumers, insurance companies, private industry, and philanthropic

organizations.

Workmen’s Compensation. –A program in all

states under which employees injured on the job

receive financial compensation without regard to

fault.

Medicare (Title XVHI).-A nationwide health

insurance program providing 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. –A joint federal-state welfare program

available in virtually ail states that provide medicaid

benefits for low income persons, including the aged.

In order to qualify for this program. a person must

meet each State’s definition of “low income.”

Other govemnzerit payments. –Government payments in which the expected source of payment
10 ackancedata

cannot be classified in one of the other three government categories. These include payments made under

the Title V Program, Champus (a program designed

to provide medical coverage for dependants of

milita~ personnel), no fault (casualty coverage,

vocational rehabilition. Federal or State research

grant (medical research), or legal hold (prisoner in

medical detention).

Self-pay. –The major share of the total costs for

this hospitalization is expected to be paid by the

patient. spouse, family. or next of kin.

No charge. –There is no charge for hospital costs

for patients admitted with the understanding that

payment would not be expected because the medical

services are provided free of charge lDy the

hospital. This category includes hospital sponsored

welfare, staff services donated, and hospital-sponsored

special research or “teaching” patients.

Other payments. –This includes all other nonprofit sources of payment such as church welfare,

United Way (United Appeal), or Shriner’s Crippled

Children Services.

Definitions of other terms are available in Appendix II of another reports

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
From Vital and Health Statistics of the National Center for Health Statistics Number 76. March 17, 1982

BloodCarbonMonoxide LevelsinPersons3-74YearsofAge:

UnitedStates,1976-80a

by Edward P. Radford, M. D., University of Pittsburgh and Terence A. Drizd, Division of Health Examination Statistics

Air pollution is an often-cited environmental hazard in many cities of the United States. One major

component of air pollution is carbon monoxide, an

odorless colorless gas that is a product of incomplete

combustion. It is one of the pollutants subject to control by the Environmental Protection Agency (EPA)

under the Clean Air Act. National Ambient Air Quality Standards established by EPA allow a carbon

monoxide concentration of 9 parts per million. At

this concentration, 8 hours of exposure would generally result in blood carbon monoxide levels in humans

greater than 1.5 percent.

Industrial plants, electric generating plants, and

automobile exhausts are sources of carbon monoxide

in outdoor air. In homes, gas stoves or furnaces produce this gas. Tobacco smokers are regularly exposed

to higher levels of carbon monoxide than almost all

nonsmokers.

The health effects of exposure to carbon

monoxide are not fully known. However, research

findings in selected population groups indicate that

carbon monoxide acts as an added stress factor to

precipitate cardiac symptomatology or episodes in

persons with hearts already compromised by

coronary disease.1 J2 Additionally, excessive levels of

carbon monoxide in the blood have been found by

some investigators to impair certain perceptual and

motor functions.1 However, further assessment of

the possible deleterious health effects of exposure to

carbon monoxide has been handicapped by the lack

of data for the United States population on the body

burden resulting from exposure. This report presents

aThe laboratory analysis of blood carboxyhemoglobin levels was carried

out under the direction and supervision of Edward P. Radford, hLD.,

Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, under funding from the U.S. Department of

Energy (contract ~DE-AC02-77EV0455 2). Cooperation also was received from Dr. F. Lee Rodkey and Mr. R. Robertson of the National

Naval Medical Research Institute in Bethesda, Maryland, who aided in

the quality control and validation of reported carboxyhemoglobin

levels.

the initial findings from such data–the fmt estimates

of blood carbon monoxide levels ever obtained on a

representative sample of the U.S. population. These

findings should also be pertinent in consideration of

national legislation such as revision of the Clean Air

Act and local ordinances to curb air pollution.

Carbon monoxide is unique among air pollutants

in that the degree of body burden from exposure to

this gas can be directly determined by measuring the

percent of carboxyhemoglobin (the compound

formed from hemoglobin on exposure to carbon

monoxide) in the blood. Blood carboxyhemoglobin

(COHb) levels were measured on a cross-sectional national probability sample of persons representative of

the U.S. civilian noninstitutionalized population 3-74

years of age in the second National Health and Nutrition Examination Survey (NHANES II) conducted

from February 1976 to February 1980. NHANES II

is the fifth in a series of National Health Examination

Surveys conducted since 1960 by the National

Center for Health Statistics. These programs,

described in previous publications,s-s are designed to

collect a broad range of morbidity data on chronic illness and related health information. The primary

emphasis has been placed on obtaining those kinds of

data that can be optimally collected through standardized, direct physical examination, tests, and measurements. Dietary intake and food consumption

information also are collected to be used in the analysis of the interrelationships between nutrition and

health status measures.

Examinations were conducted in specially

equipped Mobile Examination Centers (MEC’S),

which visited 64 locations selected from 1,924 primary sampling units (PSU’S) into which the entire

United States is divided. Each PSU is a standard

metropolitan statistical area (SMSA). a county, or a

group of two or three contiguous counties. The entire

sample consisted of 27,801 persons ages 6 months-74

years. Of these, ?0,322 - persons were examined–a

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. Public Health Service. Office of Health Research. Statistics, and Technology
2

sample response rate of 73.1 percent. The findings below are based on data from a probability half-sample

of 11,368 persons ages 3-74 years selected to receive

the test for levels of carbon monoxide. Of these

11,368 persons, 9,365 came in for examination, and

acceptable COHb blood samples were obtained for

8,411, giving an item nonresponse rate of 10.2

percent for this test.

This report presents national estimates of the distribution of carbon monoxide levels in the blood of

persons ages 3-74 years in the United States by age,

smoking status, race, urbanization status of residence,

annual family income, and season of the year. These

findings will be described and analyzed further in a

report in the Vital and Health statistics swies (in

preparation).

In this report the relative contributions of the

four principal sources of carbon monoxide (smoking,

ambient or outdoor exposures, occupational exposures, and indoor exposures) to COHb levels are examined. Of these, smoking is the most significant and

widespread, although in special circumstances each of

the other contributors assumes some importance.
ackmdaa3

Sources of data

Sample collection and COHb

determination

At the Mobile Examination Center, venipuncture

blood samples were drawn by the nurse. For the carboxyhemoglobin assessments, which were performed

on a subset of examinees ages 3-74 years, at least 1 mI

of whole blood was placed into a 2-ml Vacutainer and

refrigerated until a weekly shipment was made to the

laboratory at the University of Pittsburgh. The specimens were kept cool, but not frozen, in transit.

Carboxyhemoglobin and methemoglobin (metHb)

level measurements were made by the spectrophotometric method of Small et al.g This method utilizes

the difference in light absorption spectra among

oxyhemoglobin, carboxyhemoglobin, and methemoglobin to identify and quantify the proportions of

these compounds in the blood. From blood diluted

about 1 to 70 in dilute ammonia, absorbance measurements are made in the Soret region (390+35 nm)

at four wavelengths with a 1-mm light path; the

equipment employed was a Gilford Model 240

spectrophotometer, with corrections applied to compensate for nonlinearity of the phototube. A series of

simultaneous equations is used to determine the

percents of carboxyhemoglobin and methemogiobin

and, by difference, the percent of oxyhemoglobin.

Measurements have been shown to be accurate and

reliable at all levels of carbon monoxide saturation,

including saturation from O to 5 percent COHb (see

Technical notes), the range found to be least reliable

when monitored with other rapid techniques.

Simultaneous measurement of methemogIobin

level facilitates a determination of the condition of

the blood sample, because an excessively high methemoglobin level indicates that the sample is partially

decomposed. In this report, acceptable samples were

defined as having methemoglobin levels of 5 percent

or less.

Questionnaire and demographic data

Age was defined as age at last birthday at the time

of the household interview. Race was determined by

interviewer observation during the interview. The

interviewer categorized respondents as “white, ”

“black,” or “other.” Data on other races are not presented separately in this report but are included in

the “all races” category. Income was defined as reported total family income during the 12 months preceding the interview.

Based on a preliminary analysis, two season categories were defined. The first categog inciudes data

for all persons in the sample examined during May

through September; the second category includes

data for alI persons in the sarnple examined during

November through March. October and April were

transition months, and inclusion of data for persons

in the sample examined during these months with

those in the season categories they preceded had an

insignificant effect on the overall means. Consequently, these data were excluded from the seasonal

analysis.

Smoking status was derived from questionnaire

data collected on all respondents ages 12-74 years.

Never-smokers were defined as persons who had

smoked fewer than 100 cigarettes in their lifetimes

and were not current smokers. Ex-smokers were persons who had smoked more than 100 cigarettes but

were not current smokers; ex-cigar and ex-pipe smokers were not identified separately but were included

in the never-, ex-, or current smoker category, depending on their cigarette smoking status. Current

smokers were persons reporting that they were current cigarette, cigar, or pipe smokers.
4

Results

In all the following analyses, the primary statistics

of interest are the mean COHb levels for the population subgroup or the proportion of the subgroup with

blood COHb levels greater than 1.5 or 2.0 percent.

The sample sizes for most of the defined subgroups

were large enough to provide national estimates that

are not subject to excessive sampling variability. Unless otherwise noted, statistical significance was

determined at the 5-percent level, as described in the

Technical notes. The tables at the end of the text also

present populanon frequency distributions for COHb

(from which can be determined the proportion of the

population with COHb levels greater than critical

points other than the 1.5 or 2.0 percent used in this

report) and selected p¢iles.

Carboxyhemoglobin concentration by

smoking status and age group

Table 1 and figure 1 show the mean percent of

carboxyhemoglobin concentration in blood among

the U.S. population ages 3-74 years by smoking status

and age. Children in the age group 3-11 years were

assumed to have never smoked, although among the

1.2 percent of the population with COHb levels

greater than 2 percent in this age group, a few smokers may have been present. For healthy nonsmokers,

2 percent is well above the sum of COHb arising from

endogenous metabolism and from minimal exposures

to ambient CO. For this reason, values greater than 2

percent were considered to be the result of unusual

exposures. About 1 percent of the children under 5

years of age had COHb levels greater than 2 percent,

and it is likely that most of these cases represent exposures to sources other than smoking.

Among never-smokers age 12 years and over, 3.6

percent had COHb levels greater than 2 percent (figure 2). The difference between age groups of neversmokers may be due to occupational exposures of the

older group to environments with high ambient CO

levels (such as those experienced by garage mechanics

or taxi drivers).

The ex-smoking population show 5.5 percent

with COHb levels greater than 2 percent, compared

with 3.6 percent for never-smokers age 12 yeas and

over. The higher proportion with COHb levels over 2

percent accounts for the higher mean and standard

deviation for ex-smokers than for never-smokers, because the two medians are nearly identical (0.’77 percent COHb versus 0.74 percent COHb, respectively).

The excess may be accounted for in part or whcdly by

the inclusion in the ex-smoking group of smokers

5

r

4

3

I

2

1

0

~ Confidence intervals

All Never. Ex-smokers Current

stat uses smokers smokers

Smoking status

Figure 1. Mean blood COHb concentration for persons 12-74 years of

age, by smoking status: United States, 1976-80

100 r

~ Confidence intervals

80

60

40

20

n

All Never- Ex-smokers Current

atat uses smokers smc)kers

Smoking status

Figure 2. Percent of sample above 2 percent COHb concentration for

persons 12-74 years of age, by smoking status: United States,

1976-80
akmedda5

who incorrectly reported a history of having stopped

smoking. Incorrect reporting appears to be a particular probIem among older teenagers.

The expected effect of smoking on COHb Ievels

was shown clearly (figure 3), but it is of interest that

9.1 percent of the current smokers had COHb levels

of 1 percent or less—within the usual range for neversmokers. While the prohibition against smoking in the

examination unit may have resulted in lower COHb

levels for some smokers, especially for those examined in the morning, this group with low values

clearly cannot be inhaling much of their own cigarette smoke. Analysis by smoking level, which is not

sho,wn in this report, indicated that Kght smokers (1-5

cigarettes per day) contributed many of these low

values.

The smoking population showed a mean COHb

level of more than 4 percent; for never-smokers, the

mean was less than 1 percent. The standard error for

the smoking group was more than three times as large

as that for the never-smoking group. The large

variability of COHb levels for the smoking group,

along with the relative insensitivity of this group to

an incremental change in the environmental burden

of CO when compared with the never-smoking group,

made it necessary to hit subsequent anaiyses of

Neversmokers

100 -

\

——-

~/’==~-’

[

7

90 -

/

/

Ex-smokers

80 -/

,/

70 -!

60 -/

50

40 :/

30

20 : I

10

0. I I I 1 1 I I 1 I

I

o12345678 9 10

Percent COHb concentration

Figure 3. Cumulative distribution of percent COHb concenlratton for

persons 12-74 years of age, by smoking status: United States,

1976-80

demographic and environmental factors to the neversmoking subjects. For the one-third of the age 12 or

over population that smokes, the subtle effects of

environmental sources of CO are overwhelmed by the

massive impact of smoking.

COHb concentrations for never-smokers

by race and urbanization

The COHb levels for persons in the never-smoked

category are shown in table 2 and figure 4 by urbanization, age, and race. The four urbanization classes

used, based primarily on the population of the standard metropolitan statistical area (SMSA) in which the

individuals resided, were: (1) population over

1,000,000, central city; (2) population over

1,000,000, not in the central city: (3) population

under 1,000,000; and (4) rural. In some subsets, the

numbers of subjects were small (especially among

black persons), but the numbers are generally sufficient to permit reliable comparisons.

SeveraI conclusions are apparent from table 2.

First, among children ages 3-11 years, the mean

COHb level is statistically significantly higher for

those in large cities than for those in smaller cities

and rural areas (mean difference of 0.27, P < 0.01).

Central city children especially show higher values,

with a mean difference of 0.19 percent COHb between those in the central city and those not in the

central city; a further mean difference of Iess than

0.10 percent COHb was found between children

living in the large cities but outside the central city

and those in the smaller SMSA’Sor rural areas. These

differences, however, are not physiologically significant and are in the reported range of variation of

endogenous COHb production. 10 The proportion of

the population with COHb levels greater than 2 percent does not vary systematically with degree of

urbanization. These observations are very simiIar to

those reported by Kahn et al. in their study of St.

Louis, Me., adults.11 There is little indication that

white and black children differ in mean COHb to any

significant extent, although black children are

observed to have slightly higher values in general.

Second, the urban-rural gradient is somewhat

greater for adult never-smokers than for chiidren, although it is still small (a mean difference of about

0.4 percent COHb). Confounding by occupational

exposures to CO among aduIts may contribute to the

larger urban-rural gradient.

Black adults were observed to have consistently

higher COHb Ievels than white adults. This probably

also is explained by greater likelihood of occupational

exposure among black adults. Among white adults in

the central city of SMSA’S with over 1,000,000

population, 5.7 percent had COHB Ievels greater than

2 percent: tht corresponding tigure for black adults

was S.6 percent.
6

1.6

1.5

1.4

1.3

1.2

1.1

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0.0

.

.

T T

m

Iml

El

IE21

1

T

m-1-

Population more than 1,000,000, central city

Population more than 1,000,000, not central city

Population less than 1,000,000

Rural

Confidence intervals

White, 3-11 years Black, 3-11 years White, 12-74 years

Race, age, and level of urbanization

Black, 12-74 years

Figure 4. Mean blood COHb concentration for never-smokers 3-74 years of age by race, age, and level of urbanization: United States, 1976-80
admcec&7

The conclusions drawn above mask, to a large

extent, the variability observed among locations. Although the design for NHANES 11 does not provide

samples representative of the individ,ud s.eiected

SMSA’S, an examination of the proportion of the

population with COHb levels greater than 1.5 percent~ by sample PSU reveals striking differences, even

within a singie urbanization class. For instance, in the

selected locations in SMSA’S over 1 million population, this measure varies from a minimum of 2.4 percent to a maximum of 47.3 percent. This locationby-location variability wilI be examined in more

detail in a subsequent report.

In summary, analysis of carboxyhemoglobin by

degree of urbanization shows an urban-rural gradient

for children and adults. The results for aduits also

may be affected by occupational exposures, apparently to a greater extent among black persons.

COHb concentrations for never-smokers

by season and urbanization

Table 3 and figures 5 and 6 show the results for

adult never-smokers and children by the season during which the blood was drawn. The urban-rural comparisons mentioned above are retained. As described

in the Technical notes, itineraries of MEC’S were designed to sample examinees in the more northern

parts of the United States in the summer and in the

more southern parts of the United States in the

winter, thus mitigating the effects of the severest

winter weather on COHb levels. Thus this sample

does not provide precisely representative U.S. seasonal estimates.

Table 3 shows there is a significant effect of

season on COHb concentration; values found during

the summer months were about 0.3 percent COHb

Iower than those found in the winter for children and

adults. The mean values are reflections ptiarily of

the proportion of persons studied who had a COHb

concentration more than 2 percent, and the seasomd

difference may be ascribed largely to the fraction of

persons with these higher values. The increased proportion of high COHb values obsemed in the winter

months probabiy arises from indoor sources of CO,

which are more important in winter, when homes are

closed. Outdoor sources, especially in the urbanized

areas, also may contribute to high COHb levels because of higher CO emissions in winter.

Indoor sources can include gas stoves, furnaces

and other appliances, as well as possible effects of

passive smoking. Separate analyses of NHANES data

not presented in this report indicate that subjects

living in dweIlings in which the primary heating sysbX.S percent K used here as the upper Iknit for COHb in the absence of

ambientsources of CO (see section titled “Discussion’J.

tern was unvented space heaters (n=208) had significantly higher mean COHb IeveIsthan subjects reporting electric heating (1.06 percent COHb versus 0.74

percent COHb). These results support the hypothesis

that subjects using unvented or portable space heaters

are more likely to have a significant indoor exposure

to CO, a reasonable conclusion given present knowledge regarding the likelihood of CO reIease from

these units into living space.

One indication of the possible contribution of indoor sources is the significantly higher proportion of

never-smokers with COHb concentrations greater

than 2 percent found in the winter months(P<0.01).

For children aged 3-1 I years, 2.9 percent had levels

more than 2 percent COHb in November through

March, compared with none in the summer; for

adults, 5.4 percent had Ievels greater than 2 percent

COHb in the winter, compared with 1.6 percent in

the summer.

The urban-ruraI gradient persists and is similar for

both seasons, at Ieast for children, which confms the

likelihood that this gradient is derived primarily from

exposure to ambient (outdoor) sources of CO. There

may be a sJight additional seasonal effect on adults in

large urban central cities, but this effect does not

appear to be Iarge. The urban-rud difference could

be due to greater occupatiomd exposures in winter

for persons in urban areas.

COHb concentrations for never-smokers

by income and urbanization

Blood carboxyhemoglobin leve~ among the

never-smoking group were analyzed by family income

classification. Table 4 and figure 7 show the results

of this evaluation by urbanization category. In general, the results showed that individuals in the lowest

family income category (Iess than $10,000) had

somewhat higher COHb levels than those in other

income groups. However, the effect of family income

was greatest and most clear for chiidren ages 3-11

years. In terms of the percent of the population of

children with COHb levels greater thah 2 percent,

there were 2.7 percent in the lowest income category,

0.9 percent in the middle income category, and none

in the highest income category, when all urbanization

categories were combined.

This income effect was observed in aJIfour urbanization classes. In every category, the mean COHb

Ievel for children ages 3-11 years was highest for

those in families whose income was less than

$10,000, and the mean COHb IeveI tended to decrease as income category increased. This trend was

attributed primarily to indoor sources of CO because

the other sources of CO either were eliminated (as in

the case of smoking and occupational sources) or held

constant (as in the case of outdoor sources) in this
8 Afamedata

1.4

1.3

1.2

1.1

1.0

0.9

0.8

0.7

0.6

0.5

0,4

0.3

0.2

0.1

0.0

Summer, 3-11 years

. .

TT

Population more than 1,000,000, central city

Population more than 1,000,000, not central city

Population lass than 1,000,000

Rural

Confidence intervals

Winter, 3-11 yeers

A

-r

-r

*

4

-

&

--p

-

ml I

T

T

Summer, 12-74 yaws

Ill -r

T .-

. -

-

-1-

T

-

Winter, 12.74 yaaw

Season, age, and level of urbanization

Figure 5. Mean blood CHOb concentration for never-smokers 3-74 years of age. by season of sample collect Ion, age, end level of urbanization:

United States, 1976-80
ackmeMa9

i3

12

11

10

9

8

.

●

d.

m

Ezl

y

.

Population more than 1,000,000, central city

Population more than 1,000,000, not central city

Population lassthan 1,000,000

Rural

Confidence intervals

bikI-J

Summer, 3-11 years Winter, 3-11 years summer, 12-74 years Winter, 12-74 years

season, age,and level of urbanizm”on

Figure 6. Percent of ample abow 2 percentCOHb for navar+mokere 3-74 years of age, by seasonof smple collection, age, and level of

urbanization: United States, 1976-60
1.4

1.3

1.2

1.1

I

11-sT

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0.0 —

I

Less than $10,000

3-11 years

Ill T

$10,000-19,999

3-11 years

1

T

$20,000 or more

3-11 years

mT T1-

- More than 1,000,000, central city

~ More than 1,000,000, not central city

~ Less than 1,000,000

~ Rural

~ Confidence intervals

.sss than $10,000

12-74 years

$10,000-19,999

12-74 years

Family income, aga, and level of urbanization

F ~

+-9

:.:.:.

::::)

::::::

~.

:yj

:::::.

:yj

.:,:.:

,.....

::y:

:.:.:.

......

. . .

~

....$.

. . ..O.

,:.:.:

:.:.:.

.:.:.:

. . . . . .

:.:.:.

. . . . . .

+x:.:.:.

:::::: .:/.:

:.:.:. .:.:.:

:.:.:.

.,...,

......

...

.....

:.:.:.

......

...

:.:.:O

,./..

,

\

r

\

t

$20,000 or more

12-74 years

Figure 7. Mean blood COHb concentration for never-smokers 3-74 years of age, by family income, age, and Ieval of urbanization: United States, 1976.80
a=cedaa 11

analysis. The obsemed income effect suggests that the mean COHb level for subjects in the lowest

economic status is a major factor in the likelihood of income group was highest in every urbanization catesignificant exposure to CO in the home environment. goxy, none of the differences was statistically signifiFor adults, the differences of COHb level by in- cant. These results are similar to those of Kahn

come category were not striking, despite the fact that et ai.,l 1 who dso were not able to substantiate a re]ain their case occupational exposures may have con- tionship between family income and COHb level

tributed to higher levels that were found. Although among adults.
12 ackancedata

Discussion

Clearly, smoking constitutes the greatest source

of exposure to carbon monoxide; the mean COHb

level for smokers was more than four times the level

for never-smokers, and the smoking effect completely

overwhelmed the much more subtle contributions of

indoor and ambient sources. In addition, adults who

reported a history as ex-smokers may include some

current smokers, and some adult never-smokers may

have COHb levels more than 2 percent as a result of

occupational exposures to CO.

The only population subgroup not subject to the

possible confounding effects of smoking or occupational exposures is children ages 3-11. Their results

were used to assess the contribution of indoor or

ambient CO. The results of children in this age group

(mean COHb of 0.73 percent) indicate that, on the

average, exposures to ambient CO have been well

below the current ambient standard of nine parts per

million, an air concentration at which 8 hours of

exposure generally would result in a COHb level more

than 1.5 percent.1

Although a mean difference of 0.27 percent

COHb was found between central cities and rural

areas, most urban areas showed little evidence of

ambient exposures leading to blood COHb levels

greater than 1.5 percent. Nevertheless, in some large

metropolitan areas, substantial elevations of CO in

blood were observed. Moreover, by chance, no sampling locations were in cities at high altitudes, where

outdoor CO emissions are likely to be more important than at sea level.lz

The analysis of the seasonal changes in COHb

levels in children indicates that in winter, especially in

central city urban areas, a significant fraction is exposed to CO, causing levels of COHb in excess of 2

percent. This CO exposure probably is explained by

indoor sources, such as improperly adjusted or vented

heating or cooking units. Some contribution from

outdoor sources or passive smoking (inhalation of

ambient tobacco smoke products) also may be

present.

The evidence of possible elevated indoor exposures toTO may be significant. If the results for children are extrapolated to the entire U.S. population,

the fact that 2 percent or more may be exposed during the winter to indoor sources of CO in excess of

the outdoor ambient standard (nine parts per million)

emerges as a potential public health problem.

These observations differ from those reported by

Stewart et al.,1s who measured COHb in blood samples obtained from blood donor centers in several

communities in the United States. These investigators

found that for all urban and rural communities, a

significant fraction of samples obtained from nonsmokers showed levels of COHb greater than 1.5 percent. Although NHANES II found similar evidence

of exposure to outdoor CO in a few urban locations,

in general, the values observed in this study were not

indicative of physiologically important exposures

from outdoor sources. The results presented in this

report are consistent with measurements made on

nonsmoking controls by other investigators in various

regions of the country. 1,1IJQS
adamxMa 13

References

1Carbon Monoxide. Report to the Committee on Medical and

Biologic Effects of Environmental Pollutants. Washington.

National Academy of Sciences Press, 1977.

2Coronary Drug Project Research Group: Factors influencing

long-term prognosis after recovery from myocardird infarction-three-year findings of the coronary drug project.

J. Chronic Dis. 27:267-285, 1974. .

3National Center for Health Statistics: Plan and initial program of the Health Examination Survey. Vito] and Health Statistics. PHS Pub. No. 10OO-Series l-No. 4. Public .Health

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

1965.

4 National Center for Health Statistics: Plan, operation, and

response results of a program of chiidren’s examinations. Vital

and Heaith Statistics. PHS Pub. No. 1000-Senes 1-No. 5.

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

Office, Oct. 1967.

5National Center for HeaIth Statistics: Plan and operation of

a health examination survey of U.S. youths, 12-17 years of

age. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-

No. 8. Public Health Service. Washington. U.S. Government

Printing Office, Sept. 1969.

6National Center for Health Statistics: Plan and operation of

the Health and Nutrition Examination Survey, United States,

1971-1973. Vital and Health Statistics. PHS Pub. No. 1000-

Series l-No. 10a and 10b. Public Health Service. Washington.

U.S. Government Printing Office, Jan. 1977.

7National Center for Health Statistics: Plan and operation of

the HANES I Augmentation Survey of Adults 25-74 years,

United States, 1974-75. Vital and Health Statistics. PHS Pub.

No. 1000-Series l-No. 14. Public Health Service. Washington.

U.S. Government Printing Office, June 1978.

8National Center for Health Statistics: Plan and operation of

the second National Health and Nutrition Examination

Survey, 1976-1980. Vital and Health Statistics. PHS Pub. No.

1000-Series l-No. 15. Public Health Service. Washington. U.S.

Government Printing Office, July 1981.

‘Smail, K. A., Radford, E. P., Frazier, J. M., and others: A

rapid method for simultaneous measurement of carboxy-andmethemoglobin in blood. J. App/. Physioi. 31:154-160, 1971.

10Cobum, R. F., Forster. R. E., Kane, P. B.: Considerations

of the physiological variables that determine the blood carboxyhemoglobin concentration in man. J. Clin. Invest.

44:1899-1910, 1965.

11 Kahn, A., Rutledge, R. B., Davis, G. L., and others:

Carboxyhemoglobin sources in the metropolitan St. Louis

population. Arch. Environ. Heaith 29:112-135, 1974.

12Carbon Monoxide in People of Denver. Orleans, LM.and

White, G. F., eds. University of Colorado Environmental

Council. University of Colorado Institute of Behavioral

Sciences. Denver, 1974.

I Sstewafi, R. D-, Baretta, E. D-, platte, L. R., and others:

Carboxyhemoglobin levels in American blood donors. JAMA.

229:1187-1195, 1974.

14 Aronow, w?. S., Hams, C. N., kbe~, M. w., and othem:

Effect of freeway travel on angina pectoris. Ann. Intern. Med.

77:669-676, 1972.

15Ayres, S. “M., Gianelli, Jr., S., and Mueller, H.: Effect of low

concentrations of carbon monoxide. Part IV. Myocardial and

systemic responses to carooxynemoglobin. Ann. IVY A cad. Sci.

174:268-293, 1970.

16woodmff, R. S.: A simple method for approximating the

variance of a complicated estimate. J. Amer. Statis. ASS.

66:411+14, 1971.

17National Center for Heaith Statistics: Psuedo-replication:

Further evaluation and application of the balanced half-sample

technique. Vital and Health Staristicx. PHS Pub. No. 1000-

Series 2-No. 31. Public Health Service. Washington. U.S. Government Printing Office, Jan. 1969.

18Collison, H. A., Rodkey, F. L., and O’Neal, J. D. Determination of carbon monoxide in blood by gas chromatography. Clin. Chem. 14:162-171, 1968.
14 achncdata

Table 1. Percent carboxyhemoglobm by age and smokmg status-sample mzes, wm~ted population estimates, means, standard devm:ions, standard errors, mrlmtad

percentiles, and cumulative frecp.mncy dmtnbuttons: !Jnnad States, 1976-80

Smoking smtus and agel

Standard Standard

Percentiles

nz N3 Mean

devwtion error

5oth 75th 9oth 95th

All smoking statuses

3-74yeara, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9,365

3-llyssar: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,055

12-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,310

Never-smokers

3-74yaarg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,459

3-llyaarc .. c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,055

12-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,404

Ex-amokera

12-74 yaarv . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,,. 1,366

Currantsmokars

12-74y*ara, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,533

Percent COHb

195,877 1.94 2.236

30,066 0.73 0.502

165,812 2.16 2.358

106,042 0.83 0.671

30,086 0.73 0.502

75,976 0.67 0.726

26,655 0.97 0.988

61,016 4.30 2.553

0.037

0.019

0.044

0.021

0.019

0.025

0.031

0.072

0.91

0.67

1.01

0.72

0.67

0.74

0.77

4.15

2.36

0.87

3.17

0.97

0.87

1,01

1.04

5.69

5.49

1.12

5.79

1.33

1.12

1.36

1.58

7.56

6.83

1.42

7.05

1.65

1.42

1.77

2.08

8.68

lSmoking histories arcunavallablo forchlldwnl*$#than 12vasrtof~t.

2n - unwciohmd samplssizc.

3N-popuistlon astlmatc In thousands.
damedaa 15

Table 1. Percent carbo%vhemogiobin by ●W ?nd smoking status-tample sizes, wighted txwdation eatimatae, means, standard deviations, sm.ndarderrors, selected

Parcantilas, ●nd cumulatiw fraquency distributions: United States, 1976-60-Con.

Cumulative percent distribution of populatmn

S0.6 83.1 85.5 67.6 90.0

99.5 99.7 89.7 89.7 88.8

77.2 80.1 82.9 65.4 66.3

16.4 55.3 66.4

28.6 64.7 95.9

14.2 49.9 63.4

72.9

&2

75.6 78.0

!B.9 99.5

7’I .4 74.1

92.4

100.0

91.0

95.6 97.4 98.7

100.0 100.0 100.0

94.8 96.9 98.4

99.4

100.0

99.2

23.7 77.3 93.2

28.6 64.7 95.9

21.8 74.4 92.2

97.0

98.8

66.4

66.0 6S.6

6s.s 88.5

97.7 66.3

98.1 99.3 W.4 89.5 98.6

88.5 88.7 99.7 88.7 69.8

98.9 89.2 88.3 88.4 98.5

98.8

100.0

68.7

66.6 99.9 86.9

100.0 100.0 100.0

89.8 99.8 88.9

100.0

100.0

100.0

19.8 72.1 88.6 64.5 86.2 97.6 98.0 98.1 98.4 86.5 98.8 66.0 88.2 88.4 98.8 89.9

2.1 9.1 15.7 20.8 27.1 33.1 40.4 47.9 55.4 61.9 69.4 76.6 6S.6 92.0 95.9 98.0
Table 2. Percent carboxyhem~fobin for never. smokers by nge, race, and urbanization status–sample sizes, weighted population estimates, means, standard &sviations, standard errors, selected percentiles, and cumulative

frequency distributions: United Statas, 1976-80

Urbanization level, race, WId ap 0 f “fjVIX.S~&eSS 1

Standard Percentiles

“2 f$13 Standard Percent COHb

Mean deviation error

5f7th 75th 90th 95th ~ 1.00 s 1.25 <1.50 ~ 1.75 ~ 2.00 <2.25 <2.50

All urbanization levels

All races4

3-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.11vears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White

3-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-n year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

3-74yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-n years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Population more than 1,CQ0,000. central city

All races

3-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-n years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74yaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White

3-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.11 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

3-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-n years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74v.ws. ..,...... . . . . . . . . . . . . . . . . . . . . . . . . .

Population mom than 1.000,000, not central city

All races

3.74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-n years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White

3-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-n years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

3-74yems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-n years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SatI faotnotas m md of table.

5,459

2.055

3.404

4,512

1,628

2.884

616

373

445

829

231

398

324

104

220

275

117

158

719

262

457

632

228

404

76

30

46

PercantCOHb Cumulative parcent distribution of population

!06,042 0.83

30.%6 0.73

75,976 0.87

89,322 0.60

24,563 0.71

64,759 0.84

13,369 1.02

4,5? 5 0.82

8.875 1.12

12,151 1.11

3,088 0.95

9,052 1.17

7.066 1.05

1.702 0.90

5,386 1.10

4,383 1.22

1,241 1.01

3,142 1.31

16,207 0.91

5,074 0.76

13,133 0.96

16.170 0.90

4,458 0.74

11,732 0.98

1.658 0.93

515 0.83

1,143 0.98

0.671

0.502

0.726

0.645

0.504

0.680

0.890

0.648

1.012

0.691

0.480

0.746

0.606

0.446

0.653

0.872

0.!X6

0.963

0.701

0.430

0.777

0.739

0.449

0.817

0.330

0.297

0.361

0.021

0.019

0.025

0.021

0.021

0.024

0.085

0,048

0.079

0.045

0.047

0.051

0.032

0.045

0.039

0.108

0.063

0.129

0.040

0.051

0.043

0.045

0.055

0.047

0.026

0.052

0.046

0.72 0,97 1.33 1.66

0.67 0.87 1.12 1.42

0.74 1.01 1.38 1.77

0.70 0.94 1.26 1.58

0.65 0.85 1.08 1.40

0.72 0.98 1.32 1.88

0.84 1,17 1.59 1.93

0.76 0.95 1.33 1.57

0.91 1.31 1,77 2.03

1.02 1.31 1.69 2.02

0.87 1.11 1.51 1,76

1.07 1.36 1.76 2.22

0.88 1.25 1.58 1.98

0.82 1.04 1.47 1.73

1.07 1.29 1.60 2.18

1.08 1.44 1.86 2.63

0.92 1.33 1.57 1.95

1.11 1.51 1.84 3.20

0.60 1.09 1.46 1.74

0.74 0.97 1.21 1.45

0.63 1.15 1.55 2.02

0.79 1.08 1.51 1.60

0.69 0.97 1.28 1.46

0.63 1.12 1.58 2.03

0.89 1.15 1.36 1.50

0.84 0.92 1.16 1.17

0.93 1.20 1.36 1.50

77.3

64.7

74.4

79.8

86.2

77.3

64.2

77.1

57.7

49.5

66.2

43,7

53.7

73.8

47.4

44.1

54.2

40.2

69.3

78.1

65.9

70.3

77.9

67.4

59.3

79.7

50,1

88.4

93.0

86.6

89.9

93.6

86.5

78.1

68.2

72.9

71.2

80.6

66,0

75.8

85.3

72.7

63.6

71.7

60.4

83.3

90.9

60.4

82.9

89.7

80.3

83.4

99.1

78.4

93.2

95.9

92.2

94.0

96.0

93.2

87.5

94.7

63.9

83.6

69.5

61.5

86.2

90.2

64.9

77.8

87.3

74,0

90.8

95.9

68.6

69.9

95.3

67.6

97.3

100.0

96. !

95.7

97.7

94.9

98.2

97.8

95.6

92.0

86.4

89.7

91.0

95.0

89.8

93.8

88.8

92.9

85.8

91.9

63.4

95.1

99.0

93.6

94.5

96.9

92.8

100.0

100.0

100.0

97.0

96.8

96.4

97.1

98.8

96.5

95.9

96.2

94.7

94.8

96.3

93.6

95.4

98.5

94.3

93.2

97.7

91.4

88.2

99.9

94.8

95.6

99.9

94.2

100.0

100.0

100.0

97.5

98.9

97.0

97.5

98.9

97.0

96.6

98.3

95.7

96.0

98.3

95.2

86.6

96.5

86.0

84.3

97.7

93.0

97.3

99.9

96.3

97.0

99.9

95.8

100.0

100.0

100.0

98,0

98.9

97.7

98.!

99.0

97.8

98.9

98.3

98.1

97.1

98.3

96.7

98,2

98.5

98.1

94.8

97.7

93.6

96.2

99.9

97.6

98.0

99.9

97.3

I 00.0

100.0

100.0
urbefl[2ati0n ievd, race, andap of nave,.smok~ I

“2 ~wn Standard standard Amen tiles

N3

krcent COHb

deviation error

Wth 75th $Mth 95th < 1.(X7 <1.25 <1.50 < 1.75 ~ 2.00 <2.25 <2.50

f%putatio” le~~ ,h~” 1,~i~

All rarzs

3-74yews . . . . . . . . .. e...... . . . . . . . . . . . . . . . . . .. 2,109

3-n years . . . . . . . . . . . .

12-74 years...........::: ~~~~~~....--.....-..-

811

. . . . . . . . . . . . . . ~ 1,296

White

3.74~ears,,............. . . . . . . . . . . . . . . . . . . . . . 1,654

3-n years . . . . . . . . . . . .

12.74 yews...........:::: :::::...”..”......”- . . . . . . . . . . . . . . - 1.055 5W

Bfack

3.J4wm.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363

3-n years . . . . . . . . . . . .

12-74years . . . . . . . . . . . :::::::::::........ .-.”. ~1

182

. . . . . . . . . . . . .

Rural

All racM

3.74yea,s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.999

3-n years . . . . . . . . . . . ...

12-74years . . . . . . . . . . . ..:::::::::........ . . . . . . . . .. .. .. .. .. 1,249 7W

White

3.74years .. J....,... .............. . . . . . . . . . . . 1.889

3-n years . . . . . . . . . . . .

12-74years . . . . . . . . . . . ~~~;~~~~~~~;~.....- . ..-.

686

. . . . . . . . . . . 1,203

tllack

3.74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

3-llyears . . . ...4.....

12.74years . . . . . . . . . . . ~~~~~~~~~~~....’.”. ‘....

44

. . . . . . . . . . . . . 40

Percent COHb Cumulative percent dwrd.nitlon of population

41,536 0.79

11,816 0.70

29.714 0.83

33,691 0.76

9,071 0.69

24.620 0.79

5,683 0.94

2,214 0.73

3,669 1.06

34,103 0.74

10,071 0.68

24.032 0.77

32,321 0.74

9.325 0.66

22,995 0.76

1.465 0.82

544 0.74

9m 0.86

0.717

o.m2

0.759

0.659

0.618

0.678

1.071

0.623

1.259

0.61M

0.446

0.662

0.610

0.455

0.664

0.646

0.419

0.762

0.036

0.642

0.039

0.034

0.047

0.037

0.067

0.068

0.106

0.034

0.024

0.046

0.635

0.027

0.041

0.106

0.085

0.143

0.69 0.91 1.18 1.43

0.65 0,B2 1.06 1.21

0.71 0.94 1.22 1.56

0.68 0.89 1.11 1.34

0.63 0.8! 1.03 1.21

0.6S 0.92 1.13 1.36

0.76 0.97 1.49 1.92

0,67 0.81 1.10 1.35

0.82 1.10 1.59 1.98

0.65 0.68 1.13 1.47

0.62 0.81 1.02 1.29

0.66 0.88 1.16 1.53

0.65 0.85 1.12 1.44

0.62 0.66 1.02 1.’28

0.66 0.88 1.15 1.49

0.74 0.98 1.48 1.77

0.72 0.94 1.28 1.26

0.74 1.06 1.69 t .77

62.8

88.1

80.6

64.4

89.0

82.5

77.5

87.1

71.8

64.9

89.7

82.9

85.4

89.7

83.6

76.6

66.8

70.5

92.5

95.7

?)1.2

93.6

95.8

93.0

85.5

84.6

60.0

92.2

94.6

91.2

92.5

948

91.5

85.5

68.7

83.1

95.5

97,4

94.7

96.3

97.4

95.9

80.8

96.7

87,2

95.2

86.1

94.8

85.4

86.0

95.1

92.4

98.3

8B.9

66.8

98.2

96.2

97.2

98.2

96.9

93.9

97.6

91.7

96.4

97.2

66.0

86.5

97.2

96.2

93.4

98.3

90.5

97.6

98.4

97.2

97.7

98.5

97.4

96.2

97.6

95.3

97.6

98.7

97.1

97.6

9&6

97.1

97.8

100.0

965

97.8

98.7

97.4

97.8

98.8

97.5

96.8

97.9

96.1

97.6

98.8

97.4

97.7

88.7

97.3

98.7

1000

97,9

98.0

98.7

97.8

98.1

98.8

97.8

97.1

97.9

86.6

98.3

98.9

98.0

98.2

98.8

98.0

98.7

100.0

97.9

lSmOking histories wounwailablo forchildrsnloSsh~ 12v.Msaf ●-.

2n = Unweigh tad semplc sIz..

3N - populalflon estlmatmIn :houmnds.

41ncluda$olhar racial groups i”addntion towhitmandblmk.
Table3. PermntcwbxyhemWlobin fornever-smokers bya@, seSon, andur&nizetion status-Smple sizes, wighted ~pulation estimates, means, stendard &viations, standard errors, seIected ~rmntile$, and cumulative

frequertcy distributions: United States, 1976-80

LJrbanizetion status, season, end a~ of naver~mokers’ Standard Standard Percentiles Parcant COHb

“2 N3 Mean deviation error

50th 75th 90th 95th <1.00 <1.25 <1.50 ~ 1,75 ~ 2.00 <2.25 ~ 2.50

All urbanization levels

November-March

3-74 yearc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.11 YWS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

May-September

3-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-tlyaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Population mora then 1,W6,CHI0, central city

Nowmbar.March

3-74year5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-llyesfs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

May-Septamber

3-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-n years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74yaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Population more than 1,CKX),000, not central city

Novemtw-Mcrch

3-74yems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.11vears . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

~2-74vaars- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.,.

May-Saptemfxw

3-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-llvears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Population lees than 1,000,000

Nowmber-March

3-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-llvaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$2-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

May-September

3-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-n years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12.74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Saa footnotas at and of tab!,.

2,105

795

1,310

2,330

881

1,449

326

105

223

~65

76

89

312

121

191

269

102

187

611

226

3s5

1.075

435

640

Parcent COHb

43,285 0.96

12,421 0.67

30,665 1.00

43,167 0.67

12,372 0.56

30,795 0.71

6,575 1.19

1,628 1.01

4,947 1.25

2,879 0.66

844 0.77

2,034 0.90

8,163 0.98

2,352 0.86

6,611 1.02

7,145 0.78

1,936 0.62

5,207 0.63

13,250 0.96

3,635 0.90

9,615 0.98

20,147 0.67

6,220 0.59

13,927 0.71

0.767

0.655

0.835

0.530

0.327

0.569

0.787

0.565

0.647

0.377

0.369

0.3:3

0.590

0.473

0.642

0.626

0.350

0.936

1.005

0.969

1.033

0.460

0.343

0.488

0.033

0.034

0.037

0.023

0.024

0.024

0.064

0.071

0.073

0.029

0.030

0.034

0.050

0.066

O.ml

0.CX36

0.058

0.070

0.062

0.089

0.064

0.027

0.032

0.026

0.60 1.09 1.55 1.94

0.75 0.97 1.39 1.76

0.83 1.14 1.59 2.07

0.63 0.63 1.05 1.24

0.57 0.77 0.93 1.07

0.64 0.66 1.09 1.28

1.04 1.42 1.86 2.31

0.85 1.28 1.63 i .95

1.11 1.45 1.94 2.31

0.82 1.11 1.26 1.52

0.76 0.92 1.11 1.34

0.65 1.15 1.29 1.52

0.91 1.17 1.54 1.76

0.s4 1.11 1.45 1.66

0.94 1.19 1.58 2.02

0.66 0.89 1.20 1.56

0.65 0.64 0.99 1.07

0.70 0.93 1.42 1.59

0.77 1.00 1.38 1.96

0.69 0.91 1.18 1.83

0.79 1.02 1.49 1.98

0.64 0.84 1.04 1.20

0.59 0.76 0.94 1.11

0.65 0.86 1.07 1.22

Cumulative percent distribution of population

69.4

77.3

66.1

67.9

92.5

S&1

47.1

64.5

41.4

65.4

80.6

59.1

81.1

66.5

58.9

82.9

80.2

80.1

75.6

80.1

73.9

88.6

92.4

67.1

82.4

67.3

60.5

95.2

97.7

84.1

65.4

74.6

62.3

66.4

94.5

83.0

78.7

83.0

76.9

90.7

99.0

67.6

87.5

91.7

85.9

96.1

96.9

95.7

69.0

91.8

87.9

97.5

98.9

86.9

76.6

64.6

76.9

94.4

88.5

93.5

88.7

91.2

87.7

84.6

100.0

92.6

91.4

84.3

90.3

96.1

96.4

97.9

92.8

94.9

91.9

98.6

99.5

96.3

87.8

92.6

66.2

99.0

96.5

100.0

84,8

97.9

93.8

86.6

100.0

96.3

93.0

84.6

92.3

96.9

99.7

96.6

95.3

97.1

94.6

98.9

100.0

86.4

92.6

86.7

91.5

100.0

100.0

100.0

88.3

99.7

95.0

96.6

160.0

95.6

95.1

95.1

95.1

99.1

98.9

96.8

96.1

97.3

95.6

99.1

100.0

98.7

94.6

86.7

93.9

100.0

100.0

100.0

98.0

98.7

97.3

97.5

100.0

86.6

95.4

95.6

95.4

98.3

100.0

99.0

97.0

97.4

98.9

89.2

100.0

98,8

95.6

86.7

95.5

100.0

1OQ.o

100.0

99.1

88.7

98.6

96.0

100.0

97.3

Cn3.o

95.6

96.2

99.4

100.0

99.1
Table 3. Percent carboxyhemoglotin for naver.~kers by aga, aaeson, and urbanization status-sample sizes, wightad population estimates, means, standard obviations, standard errors, selected fmrcentiles, and cumulative

frequency distributions: IJnited States, 1976.80–Con.

Urbanization ttatus, mason. zndz~ of newr-snsokerxl ~mn Standard Stan&rd Percentiles Percent COHb

~2 N3

deviation arror 50th 75th 90th 95th ~ 1.00 <1.25 <1.50 <1.75 <2.00 <2.25 <2.50

Rural

Nowm&r-Merch Parcent COHb Cumulative percent distribution of population

314ywm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 864 15,288 0.86 0.703 0.061 0,73 0.95 1.41 1.64 77.9 87.4 91.6 93.7 86.1 95.4 97.3

%lly ears. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 4,806

12-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0.79 0.528 0.032 0.71

511

0.88 1.23 1.76 64.9 90.3

10,492 0.80 0.772 0.s2 0.74

92.7 64.6

1.01

97.4 97.5 97.8

1.45 1.66 74.7 66.1 91.0 93.3 95.5 95.8 97.1

May-6aptambar

3-74year8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 796 12.944 0.58 0.471 0.026 0.66 0.73 0.91 1.03 94.3 98.1 98.8 99.1 88.3 99.3 88.3

3-n years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74yaars ..,....,,,.. ., ..,.,..,.,,,.,.,,, ,~;~

267 3,363 0.49 0.277 0.026

631

0.49 0.63 0,81 0.90

9,581 0.61 0.520

97,0 99.4

0.026

99.6 69.6 100.0 1Gu,o 100.0

0.5S 0.76 0.93 1.07 93.4 97.7 98.6 96.0 99.1 99.1 99.1

lsmokl”a hlstori.s W. unmvailabla for children leas than 12 Vaars Of ●w.

2n= Untwightod gernpl.slz..

3N _ population ●timato in thou$entts.
Table4. Percent carboxyhem~loMn fornwer-mokers &aw, incom, andurMnizatim status-mmle sizm, wighted wpulation estimates, means, stan&rd &viations, smndard errors, wlectad @rwntilas, andcumulatiw

frequency distributions: United States, 1976-80

Urbanization status, aga, ●nd family incomel

Standard St#ndard

F%centiles

“2 N3 Mean

Percent COHb

devi.c timr error

50th 75th Wth 95th ~1.oo <1.25 <1.50 ~ 1.75 ~ 2.CX7 ~ 2.25 ~ 2.50

All urbanization levels

3-74 years

Less than $l0,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

S10,0W19,999. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$20,W0 or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-11 years

Lass than $10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$10,C410-19,989. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$20,0000rm0ra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74 years

b?ssthan$l0,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$10,0W-19,999. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$20,0000rm0m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Population mora than 1,000,LMO, cantral city

3-74 years

Lcssthan$l0,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$10,000-19,999 . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

S2WOOormor a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-11 years

Less than $l0,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$10,OOO-19,888 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$2f7,Wf00rm0ra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74 years

Lassthan$l0,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$10,0WI-19.899. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$20,0000rm0m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...+

Population mora than 1,MM,WO, not cantral city

3-74 years

L=than$l0,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$1 0J3017-19,998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$20,0Mr0rm0ra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-11 years

Less than $10,6OO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$loKfoo-19,999.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

WtMfOOormore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74 years

Less than $10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$lo,ot7&?9,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$20,0000rm0m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sss footnot” ●t .nd of t.bl..

2,153

1,sss

1,169

795

76s

432

1,358

1,120

757

331

152

108

130

64

38

ml

9s

70

195

239

249

63

107

84

132

132

165

Percent COHb

36,114 0.91

36,9m 0.78

2s.519 0.60

?0,025 0.81

11,369 0.69

7,638 0.66

26,089 0.94

25,551 0.82

20,66t 0.65

6,622 1.16

3.017 1.06

2,634 1.05

1,364 1.01

726 0.95

912 0.82

4.237 1.21

2.291 1.10

1,821 1.16

4,527 1.01

5.780 0.91

6,957 0.81

967 0.93

2,057 0.75

1,622 0.69

3,5s1 1.04

3,732 1.00

5,135 0.243

0.788

0.597

0,609

0.695

0.408

0.345

0.839

0.662

0.682

0.779

0.689

0.644

0.522

0,506

0.408

0.ss7

0.736

0.s70

0.9s8

0.654

0.498

0.469

0.433

0.407

1.100

0.742

0.623

0.031

0.025

0.025

o.04t

0.027

0.023

0.035

0.027

0.033

0.047

0.061

OSW

0.069

0.074

0.042

0.070

0.087

0.063

0.070

0.058

0.046

0.056

0.064

0.061

0.088

0.069

0.049

0.76 1.03 1.41 1.85

0.70 0.92 1.22 1.53

0.70 0.94 1.27 1,57

o.7f 0.92 1.31 1.71

0.66 0.85 1.05 1.28

0.64 0,64 1.08 1.20

0.78 1.07 1.45 1.93

0.72 0,97 1.31 1.64

0.72 0.S6 1.37 1.76

t .05 t.35 1.73 2.38

0.97 1.21 1.60 1.83

0.94 1.32 1.72 2.14

0.90 1.33 1.62 1.76

0.87 1.04 1.33 1.51

0.79 0.95 1.35 !.61

1,07 1.36 1.76 2.45

1.07 1.22 1.52 1.83

1.08 1.45 l.~ 2.16

0.84 l.lf ?.47 2.03

0.82 1.17 1,64 1.72

0.78 1.04 1.36 1.63

0.90 1.10 1.31 1.89

0.75 0.98 1.29 1.44

0,67 0.92 1.f3 t.45

0.80 1.11 1.51 2.24

0.90 1.26 1.69 1.97

0.83 1.05 1.41 1.66

Cunstslative percent distributkm of population

73.6

60.0

79.8

79.3

87.3

68.2

71.2

76.7

76.7

47.1

51.8

55.4

56.8

71.9

77.3

43.9

46,5

45.0

69.1

66.2

72.6

65.7

77.7

82.8

70.1

59.8

69.o

85.3

80.8

69.7

S9.O

94.6

95.6

83.8

89.1

87.5

66.3

79.5

70.3

74.4

83.4

87.7

88.3

78.3

62.0

82.5

79,4

66.1

88.3

88.6

93.7

60.9

74.3

88.1

91.5

94.7

94.0

92.8

97.4

97.7

90.9

93.6

$72.6

81.9

Cm.5

81.7

85.0

84.7

93.0

80.9

89.2

76.3

90.0

89.4

94.0

92.8

95.5

97.5

89.3

86.0

92.7

94.2

97.2

86.0

95.5

88.8

99.0

93.6

86.4

94.8

80.3

94.6

90.4

93,6

96.1

97.3

88.2

94.1

87. i

92.7

95.6

%.8

94.8

100.0

t M.o

92.1

93.2

95.6

95.9

97.9

87.3

97.3

88.1

100.0

95.4

97.4

98.2

93.6

%.6

84.9

98.2

86.1

100.0

92.1

88.7

92.4

93.7

97.0

97.9

88.3

100.0

foo.o

92.1

95.4

97.1

96.7

98.1

97.7

97.6

88.1

tlxl.o

%.3

97.7

96.s

94.5

96.6

9s.0

96.2

Wf.1

100.0

93.3

%.7

97.1

96.4

97.6

96.4

89.3

100.0

ttm.o

95.6

96.2

97.9

97.2

86.5

98.3

97.7

99.1

100.0

97.0

98.2

97.7

8s. 1

96.6

89.6

98.2

9s.1

l(W.O

95.4

%::

98.4

98.2

89.6

99.3

1fM.o

lfm,o

95.6

97.2

89.3
TabIc 4. I%rmnt czrfaoxyi-renrqlohn for newr.w~rs by ~, inccj~, arid urbm-rizati~ SUIUS-SWI@CSiZ.S,w~t~ pqnrlztion zstirrwtss,rrwm-ts,stmdard rbvlmions, standarderrors, sclwted fmrcwttilm, and cumulatiw

frUqWw dwtritwtkw$ IJniw s~t~, 1978-8&~+

Ur&nizmion status,#@, md fa-rrify i~~e 1

~“n starr&rd standard Fercerrti\m Pwxnt COHb

nz N3

Ariatim ●rror 50fh 75fh 90fh 95fh < 1.LM <1.25 ~ 1.50 <1.75 <2.OU <2.25 ~ 2,50

Pqmlation 1ss than l.lMO,MXl

3-74 yews

L.c6athan $10~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$10,OOO49986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$WXMl or mom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3-11 y.zrs

k than $10,LW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$10,000-19,899 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

S20,000 or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12.74 years

k tfun $10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$10,WO-19,889 ~m,mwmm . . . . . . . . . . . . . . ..$. . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rural

3-74 yews

I.u$ thM $10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$10,OCO19,869. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$’20,000or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.11 yews

Las than $lo,m . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$lo,ooo-19#8f16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$20,000 or mow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12-74 wars

f%rrnnt tMHb

872 14,791 0.07

717 14,4(M 0.72

441 10,?36 0.78

331 4,381 0.79

2s9 4,529 0.84

161 2,777 0.63

641 10,500 O.$m

418 9,876 0.76

280 7,952 0.83

755 11,174 0.78

779 13,889 0.73

380 7,994 0.72

271 3,383 0.73

308 4,057 0.67

148 2.322 0.60

I.sssthan $10,IMO

$1OLWO-19S68 . . . . . . ..”. ””.. ’ . . . . . . . . . . . . . . . . . . . . . ::

7,791 0.60

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$20,000 or mor.

9.632 0.75

. . . . . . . . . . . . . . . . . . . . ,, +.,..... . . . . . . . 242 5,673 0.76

0564

0.738

0.916

0.360

0.316

O.MO

0.638

0.837

0564

0.602

0.580

0.s28

0.450

0.327

0.7M

0.657

0,663

0.062

0.033

0.055

0.082

0.027

0.039

0.063

0.039

O.un

O.w

0.032

0.031

0.036

0.038

0.038

O.(M6

0.035

O.(M6

0.7’3 0.86 1.31 1.71

0.88 0.66 1.08 1.36

0.67 0.80 1.14 1.38

0.67 0.64 1.10 1.57

0.54 0.80 0.98 1.15

0.63 0.80 1.05 1.16

0.76 0S8 1.34 1.61

0.69 0.89 1.10 1.31

0.69 0.93 1.16 1.57

0.68 0.92 1.39 1.71

0.65 0.84 1.07 1.38

0.63 0.82 1.06 1.39

0.64 0.s5 1.13 1.71

0.63 0.80 0.96 1.06

0.80 0.74 0,88 0.92

O.w 0.94 1.30 1.71

0.28 O.w 1.14 1.47

0.65 0.67 1.17 1.42

Currxrlatiw pcrwnt distrilnr:iorr of ~1.tion

79.7

85.4

84.3

65.1

91.1

88.4

77.5

82.8

82.5

80,2

88.3

88.6

84.9

80.7

95.3

78.2

64.4

86.1

89.3

94.9

93.8

92.2

97.3

98.3

66.2

93.6

92.2

88.6

93.8

92.7

91.2

96.6

97.1

88.8

92.6

80.8

84.0

98.6

95,7

84.7

98.2

100.0

93.7

95.9

94.2

93.5

95,9

*.1

93.7

87.9

97.1

93.5

95,1

95.6

86.2

98.4

96.6

W.2

88.9

Ilulo

94.6

98.1

86.3

95.3

97.1

88.5

96.7

96.6

97.7

95.1

86.6

96.1

88.1

88.1

87.2

$.;

100.0

88.1

98.9

86.2

97.7

97.4

87.7

97.7

98.8

1W.O

97.6

96.6

86.7

%.6

89,2

97.2

88.8

99,5

too.o

88.6

S8.0

96.2

97.9

97.6

97.7

97.8

98.8

100.0

98,0

97.1

96.7

M.9

99.3

97.6

96.8

88.5

lWJ,O

W.9

88.2

%.7

98.6

88.2

97.9

88.2

98.6

1CULo

88.8

97.9

97.0

tSmok I.-IIIhl$torks ●m unawllsblo for chlhfr.n I*s8than i 2 yams of ●00.

‘n - unvml~tod samplo slza,

3N - popu[atlon cnimatc in thou$and~
Technical notes

Sample design

The information presented in this report is based

on data from the direct standardized physical examinations, tests, measurements, and questionnaires collected in the second National Health and Nutrition

Examination Survey during 1976-80. The target

population of NHANES 11 encompassed the civilian

noninstitutionalized population of the United States,

including Alaska and Hawaii, of persons 6 months

through 74 years of age.

NHANES II utilized a multistage probability design that involved selection of PSU’S, segments

(clusters of households) within PSU’S, households,

eligible persons, and finally sample persons. The sample design provided for oversampling among persons 6

months-5 years, persons 60-74 years of age, and persons living in poverty areas. The U.S. Bureau of the

Census, under contract to the National Center for

Health Statistics, selected, according to rigorous

spectilcations, the NHANES II sample of 27,801 persons. Of this total sample, 20,322 (73.1 percent) were

examined. A half-sample of persons 3-74 years of age

was assigned to receive the test for levels of carbon

monoxide. Of the 11,368 persons originally selected

in the sample to receive the carbon monoxide test,

9,365 came in for examination, and acceptable blood

samples were analyzed for 8,411.

The data in this report are presented as population estimates. Examination findings for each sample

person have been inflated by the reciprocal of the

probability of selecting a person, adjusted for persons

who were not examined, and poststratified so that

final extimates closely approximate the independent

U.S. Bureau of the Census estimates for the civilian

noninstitutionalized population of the United States

by race, sex, and age as of the midpoint of the study,

March 1, 1978.

Adjustment for item nonresponse

Carboxyhemoglobin and methemoglobin values

were imputed for the 954 cases with no or unacceptable samples. The procedure used has been described

as a “hot deck” process; in which the acceptable

values for a case that matches the missing case on a

number of key criteria are imputed to the case with

missing data. For this study, the cfiteria on which the

cases were required to match were smoking status,

age group. race. and location. (Although certain locations were visited twice. each visit was assigned a

unique number, so that matching on examination

location had the effect of adjusting for both season

and degree of urbanization.) Comparison of imputed

and nonirnputed data revealed no substantial changes

in detailed means.

Estimation of standard errors

Because the statistics presented in the text and

detailed tables of this report are national estimates

based on a sample, they differ somewhat from the

figures that would have been obtained if the survey

had been conducted on the complete population. In

other words, the statistics are subject to sampling

variabilityy.

The standard errors presented in tables 14 are

primarily a measure of sampling variability, but they

also include the variation that arises in the measurement process, usually called measurement error.

These standard errors were calculated using a Taylor

Series linearization method. 1b This process approximates the variance of nonlinear (or linear) statistics,

for example, means and proportions, using the fmt

two terms of a Taylor Series expansion. If the higher

order terms of the expansion are negligible and the

sample is of a reasonable size for the domains of

interest, then this approximation provides variance

estimates as reliable as those from the pseudorleplication method adapted for use in the analyses of

NHANES II data.lT Estimates of standard errors are

themselves subject to errors that may be large if the

number of cases or PSU’S on which the estimates are

based is small.

Statistical significance was determined using

z-tests when individual subgroup statistics were compared and using a modified chi-square technique

when testing for effects. Both methods were modified

to incorporate the complex NHANES II sample

design.

Carboxyhemoglobin quality control

Three procedures were employed in the laboratory to ensure validity and reliability of the spectrophotometnc method and to maintain the necessary

quality control on the laboratory determinations:

(1) duplicate determinations on “blind” and arbitrarily selected samples using a completely different

method of measurement, (2) duplicate measurements

on every sample, and (3) regular determinations using

Small’s method and comparisons with previous values

on an independent group of nonsmoking subjects

whose COHb levels would be expected to be very

stable. The first procedure provided a measure of the

validity of the spectrophotometric method and was

essential to detect any baseline drift, a significant

problem when measuring low COHb concentrations

by spectrophcXometry. The s?cond and third procedures provided measures of precision and established the reliability of the final raw data.

The validity of the spectrophotometnc method

was verified by a comparison of results obtained by
dwmedda 23

SmalI’s method with those obtained using the more

accurate and precise (but prohibitively costly and

time-consuming) gas chromatography method. At

regular intervals. seven or eight samples selected to

represent a range of COHb levels were sent to an independent laboratory (that of Dr. F. Lee Rodkey and

Mr. R. Robertson of the Naval Medical Research

Institute, Bethesda. Maryland) for COHb determinations using the reference standard methodology of gas

chromatography. 1~ The values obtained by gas

chromatography were compared to those obtained by

spectrophotometry, and the results were used to

“fine-tune” the baseline adjustment on the spectrophotometric equipment.

At regular intervals, four or five “blind” samples

were sent directly from the MEC’S to both laboratories. About 200 comparisons resulted from this

procedure, with a mean difference of 0.00 percent

COHb and a standard deviation of 0.31 percent

COHb. The correlation coefficient was 0.99.

The precision or reliability of the spectrophotometnc method was confirmed through dual determinations on each sample. Theoretically, the standard

deviation of repeated COHb measurements on a single

sample by this method should be about 0.25

percent.g If measurements on a sample differed by

more than 1 percent COHb (that is, by more than

four standard deviations), the sample was rerun. The

distribution of differences between duplicate determinations followed a Gaussian (normal) probability

curve, with a standard deviation of approximately

0.25 percent.

Finally, sampIes were drawn regularly from a

group of nonsmoking laboratory personnel as a test

of the stabiIity of the spectrophotometnc method.

After analysis, the COHb values were compared with

previous values from the same person. Occasional

high values (greater than 1.2 percent) were verified

by the gas chromatography method and were found

to occur on days when the ambient carbon monoxide

level was high. Thus Small’s method reliably detected

increases in COHb of as low as 0.3 percent.

With the strict quality control on the spe@Tophotometric method. it was possible to reduce the baseline uncertainty of the method to tO. I percent

COHb. This source of error is the only one contributing to the error of mean results obtained from

groups of individuals; all other sources of error would

average to zero. Thus for group comparisons, the

method is considered to be accurate to tO. 1 percent

COHb.

Limitations of data

A1though the quality control and methodological

verification previously described justify a high degree

of confidence in the validity and precision of the results reported here, because of a number of factors

the reader should be cautious not to “over-interpret”

the data, particularly when comparing an individual

subject’s resuIts with population distributions. Chief

among these factors is the relative imprecision of a

single measurement. estimated to be perhaps as much

as 0.25 percent COHb on repeated measurements.

For children, in particular. this variability may represent 25 or more percentile points. For the entire

population, however. this measurement error was

estimated to be no more than 0.10 percent COHb, so

that cross-population comparisons should be only

minimally affected.

Another possible confounding factor is the interaction between the seasonal effect noted in the

results and the itineraries of the Mobile Examination

Centers. To minimize the effects of adverse weather

on response rates, MEC’S traveled through the more

northern parts of the United States in the summer

and the more southern parts in the winter. Thus the

effects of the severest winter weather on carbon

monoxide IeveIs are not represented in these data.

Several logistical factors also must be considered

while interpreting these data. For instance, on rare

occasions, an MEC was situated near major traffic

arteries. These sites may have manifested ambient

carbon monoxide Ievels that were atypically high for

the given locaIe, but it is not possible to quantify this

effect with the available data.

Another logistical factor with possible implications for the interpretation of these data was the

shipping and handling of the samples. After colIection, the samples were refrigerated until a sufficient

number had accumulated for shipment (on ice) to

the lab for analysis. In general, this procedure has not

been identified as a factor that influences the resulting COHb test results. However, several shipments

were lost; others were mishandled and arrived at the

lab in an unanalyzable condition. Finally, some sampies showed such high methemoglobin leveIs (greater

than 5 percent) that the associated values for COHb

were considered unreliable; the high metHb was

evidence of sample deterioration. Of the 9,365

examined subjects who should have had values for

COHb, acceptable samples were not available for 954

(10.2 percent). The distribution of these missing

vaIues did not show any race or sex bias, and the statistical weights for the remaining cases were adjusted

to compensate for this item nonresponse as well as

sample person nonresponse (see the section on Item

nonresponse).

The definition and reporting of smoking status

(see page 6) may have had some impact on the interpretation of resuIts in this report. The remarkably

high COHb vaIues for a few of the ex-smokers leads

to the suspicion that some incorrect reporting may

have occurred in the history. In addition, the surprisingly low values for some current smokers indicate

that their smoking levels (in cigarettes per day or
24

amount inhaled) are so low that they have little or and the COHb Ievel, particularly for current sm~okers.

no effect on COHb levels. This relationship will be examined in the Series 11

Finally, the possibility exists that there is a rela- paper in the Vital and Health Statistics series.

tionship between the time of day of sample collection
From Vital and Health Statistics of the National Center for Health Statistics Number 77. February 22, 1982

1980Summary: National Ambulatory Medical Care Survey

by Thomas McLemore and Hugo Koch, Divisionof HealthCareStatistics

Durirtg 1980 an estimated 575.7 million office

visits were made to nonfederal y employed, officebased physicians in the conterminous United States,

an average of 2.7 office visits per person per year.

These and other estimates presented in this report

are based on data collected in the 1980 NationaJ

Ambulatory Medical Care Survey, a probability

sample survey conducted annually by the Division of

Health Care Statistics of the National Center for

Health Statistics. The physician sample for the

National Ambulatory Medical Care Survey (NAMCS)

is selected, with the cooperation of the American

MedicaI Association and the American Osteopathic

Association, from a list of nonfederally employed

physicians who are principally engaged in officebased practice. Physicians practicing in Alaska and

Hawaii, and physicians in the specialties of anesthesiology, pathology, and radiology are excluded

from the survey.

This report provides an overview of the data

from the 1980 NAMCS. Utilization of office-based

ambulatory medical care services is described in

terms of the number and percent of office visits and

of annuaI visit rates. Utilization statistics are presented

on patient, physician, and visit characteristics as

follows:

Table 1 Patient sex and age

Table 2 Patient race and ethnicity

Table 3 Physician specialty and type

of practice

Tables 4 and 5 Principal reason for visit as expressed by the patient

Table 6 Major reason for visit, prior

visit status, and referral status

Table 7 Diagnostic services ordered or

provided

Tables 8 and 9 Principal diagnosis rendered

by the physician

Tables 10 and 11 Medication therapy ordered or

provided

Table 12 Non-medication therapy

Table 13 Disposition and duration of

visit

Since the estimates presented in this report are

based on a sample rather than cm the entire universe

of office visits, the data are subject to sampling

variability. The technical notes at the end of this

report provide a brief description of the sample

design, an explanation of sampling errors, and guidelines for judging the precision of the estimates. A

more detailed description of the NAMCS sample

design and survey methodology has been pubIiShed.1

Figure 1 is a facsimile of the 1980 NAMCS Patient

Record used by participating physicians to record

information about their office visits. The Patient

Record can be a useful reference as survey findings

are reviewed.

Data highlights

Patient characteristics

Office visit data according to patient demographic

characteristics are presented in tables I and 2. As

shown in table 1, the annual visit rate for 1980 varied

from 2.1 visits per person per year for the 15-24 year

age group to 4.2 visits per person per year for the 65

years and over age group. Females accounted for

about 60 percent of all visits. The annual visit rate for

females (3. 1 visits per person per year) was higher

than the visit rate for males (2. 2 visits per person

per year). White persons accounted for approximately 90 percent of all office visits (table 2). As

also shown in table 2, persons of Hispanic origin

accounted for 5 percent of all visits.

lNational Cknter for Health Statistics: The National Ambulatory

Medical Care Survey, 1977 Summary, United States. Januars-December

1977, by T. Ezzati and T. McLemore. Vital and HeuIth Szaristics. Series

13-No. 44. DHEW Pub No. (PHS) 80-1795.. Public Health Service.

Washington. U.S. Government Printing 0f5ce, Apr. 1980.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service, Office of Health Research, Statistics, and Technology
ASSURA?+CEOF CONFIOENTALIW-AI( t.lorlem,.n w.,.. WwOuu ..,I.W8 ,...,,I,U,,O” O=c.3rlmr.l O*l’lmlrh. Eduuw... ●IW W.lt.r.

of . . ,,,d,.d.w . . . . . . .. . . . . a“! .,,.t.,,,r.mr”, w,,, M *!4 ,..,,O ?.,,!,, m,, I,@ .* m,, Publ. w,th *.* ANo. 003904 b,m90”’ .“LwM8“●nd 10, ,ht .“mmt, .31 ,IM s“,”?, ,“a .“s11 “o, LM amc,owd o, ,. O!l.c, .1 h,,), n-,.., Sw,s,la. ●m T.chmlav

iuxd to .,I,C, mrwn, w ..60., ●“, 0,”,, .Urc,mr mtsmnl *,” l., Nm*h S1., n,cl

1. DATE OF VISIT

+

PATlENT RECORD

NATIONAL AMBULATORY MEDICAL CARE SURVEY

2, ;L#-HOF 3. SEX 4. CDLOR OR RACE 5. ETHNICITY & PATIENT% COMPLAINT(S), SYMPTDM{S), OR OTHER -

REASON(SI FOR ~ VINT [In porkenr’sown wo?dsj

1❑ WHITE

2❑ 51LAcK 1 ❑ HISPANIC ● MOST IMPORTANT

+ :;::” 3 ❑’::;;;:’”

OUIGIN

Z ❑NOT —

HISPANIC

A ❑AMGWCAN INISIAN,

b OTHER

ALASKAN NATIVE

7. MAJOR REASON FOR THIS

VISITI [Check one]

1 ❑ACUTE PROBLEM

2 ❑cHn0N8cPR0BLEM. RouT8NE

3 ❑cwv3NIcPRoBLEM, 6LAREuP

4 ❑,os,suRGERwoaTINJ”w

5 ❑NON4LLNESSCARE (RCI”T(NE

PRENATAL. GENERAL EXAM

WELL 6A6Y, E7C.I

1 ❑NONE ,DEKG

2 ❑ LIMITEO “lSTOFIY,EXAM, 9 ❑ V,SION7CST

3 ❑ GENERAL HISTORY,EXAE.4 IO ❑ EWXSS.COW

4 ❑PAP TEST 11 ❑ MENTAL STATUS

— EXAM.

5 UCLINI CAL~a TEST

6 l-g....,

,, ❑ OTWR,s,,,,,,,

7 ❑tlLOOOPRESSUREC14ECK

& PHYSICIAN% OIAGPX)SES

, PR?NCIPAL OIAGNOSIS/PROBLEM ASSOCIATE WITH lTtM b,

b. 07HIiR SIGNIFICANT CURREN7 01 AGN05~

10.~;:~B::~E, 11- MEDICATION THERAPY THIS VISIT ~ NONE

\ Usinc bm.d or generic names, reco?d al! new and co. tinued meazcarfau entered, inje.wd, adndnfs=md, or oth.rwkx

prowded at this vfwi Include imnwnwn# and demna Euing a2enaj

I

a. FOR PRINCIPAL OIAGIWJSES IN ITEM9D.

q ,Q.o

1.

b. FOII ALL OTHERUEASO?4S.

1.

1

I

—

IF YES, FOR THE

CONDtTION IN 2, 2.

ITEM *? —

I

4 4.

I

12. NON.MEDICATION THERAPY 13. WAS PATIENT

lChcck .11semi-s ordered or provided rhu vmt]

14. ywQ&;p:;Hlfks,T lS. ~TW:ONREFERREO :

FOR THtS VISIT VISIT

BY A~HER 1❑ WI FOLLfW4SP PLANNEO ITSME .CEudy

1 ❑ NONE 6 fJCJIETCOW.4SELING PHYSICIAN? z ❑ RSTURNATSPECIFIED71ME #pcnf **

2 DPHYs,OTHEfIAPY 7 ❑FAMILWSOCIAL 3 ❑FtETURNIF NEEOED,P.R.N.

ph yskckmj

COUNSELING

3 ❑ OPFICE SURGERY

. ❑ FAM,LYPmNN,NG

* ❑ MEOIcAL C0UN5ELlNG , ❑ YES 4 •76LEPwNEFoL--.,p~NME0

9 ❑ 07HER 6FC,W

5 ❑.EFERREOTOOT”ER PHYSICIAN

5 ❑PSVCNOTHERAPY/

THERAPEUTIC LISTENING ,0.0 ~ URETUmNEOTOREFERRING PHYStCt,.U

7 ❑ ADEA,TTO 140S?WAL

* ❑ OTHER /swti/Y/

!&w,”

Phvsician characteristics

Figure 1.1980 National Ambulatory Medical Care Survey PaItent Record

.

Among office-based physicians. genera] and

family practitioners led all other specialties in volume

of office visits. accounting for one-third of all office

visits made during 1980 (table 3). The distribution of

visits by the ph)’sician:s type of practice shows that

55 percent of all visits were made to solo practitioners and 45 percent were made to physicians

engaged in multiple member practice.

office as expressed in the patient’s own words. The

principal reason for visit is the problem. complaint,

or reason listed first in item 6 of the Patient Record.

These data have been classified and coded acccn-ding

to tk Reason .fbr P’isirClussi.fkation for.4lnbdaf(. I-JCare.J -4s shown in table 4. reasons falling into the

Symptom Module accounted for over half of all

visits. with symptoms of the respiration’ and nlusculoskeletal s~;stenls accounting for about 19 percent

Visit characteristics

Reason for risit. -Data in tables 4. and 5 represent the principal reason for visiting the physician’s

2National Center for Health Statistics: A Reason for Visit Classification

for Ambulatory Care. by D. Schneider, L. Appleton, and T. Mc;Lemore.

L’itai awl Healri] S~a[is[ics. Series 2-No. 78. DHEW Pub. No. (PHS)

79-1352. Public Health Service. Wwhington. U.S. Government Printing

Office. Feb. 1979.
duanwMa3

Table 1. Number, percent distribution, and annual rate of office visits

by sex and age of patient: United States, 1980

Number of Number of Percent . .

Sex and age visits in distribution ‘~~~~~

thousands of visits

per yeagl

8oth sexes

Alleges . . . . . . . . . . . . . . 575,745 100.0 2.7

Under 15 years .’. . . . . . . . 109,356 19.0 2.2

15-24 years . . . . . . . . . . . 81,561 14.2 2.1

25-44 years . . . . . . . . . . . 154,695 26.9 2.6

45-64 years . . . . . . . . . . . 129,645 22.5 3.0

65 years and over . . . . . . . . 100,488 17.5 4.2

Female

Alleges . . . . . . . . . . . . . . 346,106 60.1 3.1

Under 15 years . . . . . . . . . 50,503 8.8 2.1

15-24 years . . . . . . . . . . . 54,879 9.5 2.7

25-44 years . . . . . . . . . . . 103,562 18.0 3.3

45-64 years . . . . . . . . . . . 76,385 13.3 3.4

65 years And over . . . . . . . . 60,777 10.6 4.3

Male

All ages . . . . . . . . . . . . . . 229,639 39.9 2.2

Under t5 years . . . . . . . . . 58,852 10.2 2.3

15-24 years . . . . . . . . . . . 26,682 4.6 1.4

25-44 years . . . . . . . . . . . 51,134 8.9 1.8

45-64 years . . . . . . . . . . . 53,260 9.3 2.6

65 years And over . . . . . . . . 39,712 6.9 4.0

1Rates are ~a~ed on ~~timates of The civilian noninstitutionalizeci

population of the United States, excluding Alaska and Hawaii, as of

July 1, 1980.

Table 2. Number and percent distribution of office visits by

race and ethnicity of patient: United States, 1980

Race and ethnicity

Number of Percent

visits in

distribution

thousands

All visits. . . . . . . . . . . . . . . . . . . . . 675,745 100.0

Race

White . . . . . . . . . . . . . . . . . . . . . . . 616,616 89.7

Another . . . . . . . . . . . . . . . . . . . . . 59,129 10.3

Black . . . . . . . . . . . . . . . . . . . . . 52,872 9.2

Asian or Pacific Islander. . . . . . . . . . 4,133 0.7

American Indian or Alaskan native. . . . 2,124 0.4

Ethnicity

Hispani c. . . . . . . . . . . . . . . . . . . 28,720 5.0

Not Hispanic . . . . . . . . . . . . . . . . . . . 547,025 95.0

of all visits. The 20 most common principal reasons

for visit are listed in table 5. The reader is cautioned

that the rankings presented in table 5 may be somewhat artificial because some estimates may not be

statistically different from other near estimates due

to sampling variability. Detailed tabulations of reason

Table 3. Number and percent distribution of office visits by physician

specialty and type of practice: United States, 1980

Number of

Physician specialty and type of piactice -. “

Percan t

“SIB ‘n distribution

thousands

All visits . . . . . . . . . . . . . . . . . . . . . 575,745 100.0

Physician specialty

General and family practice . . . . . . . . . . 191,744 33.3

Medical specialties . . . . . . . . . . . . . . .

Internal medicine . . . . . . . . . . . . . .

Pediatrics . . . . . . . . . . ..-. . . . . .

Other . . . . . . . . . . . . . . . . . . . . .

Surgical specialties . . . . . . . . . . . . . . .

General surgery . . . . . . . . . . . . . . .

Obstetrics and gynecology . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . .

Other specialties. . . . . . . . . . . . . . . . .

Psychiatry . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . .

177,127

69,481

64,223

43,423

172524

28,315

55,123

89,086

34,350

15,856

18,494

30.8

12.1

11.2

7.5

30.0

4.9

9,6

15.5

6.0

2.8

3.2

Type of practice

solo . . . . . . . . . . . . . . . . . . . . . . . . 313,963 54.5

Partnership . . . . . . . . . . . . . . . . . . . . 123,643 21.5

Other, . . . . . . . . . . . . . . . . . . . . . 138,140 24.0

1Includes group practice and other.

for visit data from the 1977-78 NAMCS are in Vital

and Health Statistics, Series 13, Number 56.3

Table 6 shows the number and percent distribution of office visits by major reason for visit,

patient’s prior visit status, and referral status.

Major reason for visit.-In item 7 of the Patient

Record. the physician was instructed to check the

one major reason for the patient’s office visit. Ap

proximately equal proportions of visits were made

for acute problems and chronic problems (36 percent

and 37 percent, respectively).

Prior visit statu.s.-Approximately 85 percent of

the visits to office-based physicians were by patients

who had seen the physician before (“old” patients).

Furthermore, the majority of visits (63 percent) were

made by “old” patients with an “old” problem, i.e.,

problems which had previously been treated by the

physician.

Referral status. -Approximately 4 percent of all

visits were the result of referrals from another physician. However, about 26 percent of all “new”

patient visits were referrals.

Diagnostic services. -Information on various diagnostic services that may be ordered or provided during

an office visit is presented in table 7. A limited

3NationaI Center for Health Statistics: Patients’ Reasons for Physician

Visits, NAMCS, U.S. 1977-78, by B. Cypress. YizaiandHealth Statistics.

Series 13-No. 56. DHEW Pub. No- (PHS) 82-1717. Public Health

Service. Washington. U.S. Government Printing Office, In press.
4

Table 4. Number and percent distribution of office visits by patient’s

principal reason for visit: United States, 1980

Table 5. Number and percent of office visits, by the 20 most common

principal reasons for visit: United States, 1980

Number of

Principal reason for visitand R VC code1

Percent Most common principal reason for Number of

visitsin

~hou=nds distribution

Rank visit and R VC code’1 visitsin Percent

thousands

All visits . . . . . . . . . . . . . . . . . . . . .

Symptom module. . . . . . . . . S001-S999

General symptoms . . . . s001-s099

Symptoms referable to

psychological and mental

disorders . . . . . . . . . . . SIOO-S199

Symptoms referable to nervous

system (excluding sense

organs) . . . . . . . . . . . S200-S259

Symptoms referable to the

cardiovascular and lymphatic

systems. . . . . . . . . . . . S260-S299

Symptoms referable to the

eyes and ears. . . . . . . . . S300-S399

Symptoms referable to the

respiratory system . . . . S400-S499

Symptoms referable to the

digestive system . . . . . . . S500-S639

Symptoms referabla to the

genitourinary system . . . . S640-S829

Symptoms referable to the

Skin, nails, and hair . . . . . S830-S899

Symptoms referable to the

muscuioskeletal system. . . S900-S999

Disease module . . . . . . . . .DOO1-D999

Diagnostic, screening, and

preventive module . . . . . . .X1 OO-X599

Treatment module . . . . . . . . TIOO-T899

Injuries and adverse effects

module . . . . . . . . . . . . .. JOO1-J999

Test results module . . . . . . . .R1OO-R7OO

Administrative module. . . . , .AIOO-A140

0ther2 . . . . . . . . . . . . . .. U990-U999

575,745

313,162

43,730

15,529

17,449

3,336

33,360

54,710

26,011

26,475

38,330

54,233

46,279

112,726

59,110

23,151

2,601

8,830

9,887

100.0

54.4

7.6

2.7

3.0

0.6

5.8

9.5

4.5

4.6

6.7

9.4

8.0

19.6

10.3

4.0

0.5

1.5

1.7

1Based on “A Reason for Visit Classification for Ambulatory Care,”

vital and Health .statistic~ Series 2-No. 78, Feb. 1979

21 ncludes blanks, problems and complaints not elsewhere classified,

entries of “none,” end illegible entries.

history or examination was rendered at 64 percent

of all visits. The procedures ordered or provided

most often were blood pressure checks (34 percent)

and clinical laboratory tests (22 percent). Although a

Pap test was ordered or provided during about 4

percent of all visits, this represents about 7 percent

of the visits by women.

Principal diagnosis. -Tables 8 and 9 present data

on the principal diagnosis rendered by the physician.

The principal diagnosis refers to the first-listed

diagnosis in item 9 on the Patient Record, the one

associated with the patient’s presenting problem. The

I~ltcr]zutiollul Classifkarion of Diseases-9-Cliizical

Modification (ICD-KM)4 was used to classify these

4Comnrission on Professional and Hospital Activities: International

Classification oj Diseases, 9tlj Revision, Clinical Modification. Ann

Arbor. Edwards Brothers, Inc.. 1978.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

General medical examination . . . . X1OO

Prenatal examination. . . . . . . . . X205

Postoperative visit. . . . . . . . . . . T205

Progress visit not otherwise

specified . . . . . . . . . . . . . .. T800

Symptoms referable to the

throat . . . . . . . . . . . . . . . . ..S455

Cough . . . . . . . . . . . . . . . . ..S44O

Back symptoms . . . . . . . . . . . . .S905

WeIL-baby examination. . . . . . . . X105

Skin rash . . . . . . . . . . . . . . . ..S86O

Head cold, upper respiratory

infection . . . . . . . . . . . . . . ..S445

Fever . . . . . . . . . . . . . . . . . ..S010

Earache, or ear infection. . . . . . . .S355

Blood pressure test . . . . . . . . . . X320

Hedache, pain in head. . . . . . . . .S210

Abdominal pain, cramps, spasms . . .s550

Chest pain and related symptoms. . .S050

Acne or pimples. . . . . . . . . . . . .S830

Hypertension . . . . . . . . . . . .. D51O

Vision dysfunctions. . . . . . . . . . .S305

Eye examination . . . . . . . . . . . X230

Ali other reasons . . . . . . . . . . . . . . .

33,853

25,347

16,573

14292

14,337

13233

9,948

9936

9,625

9,535

9,499

9,470

9,354

8,279

8,250

7,910

7,643

6,813

6,659

6,543

338,547

5,9

4.4

2.9

2.5

2.5

2.3

1.7

1.7

1.7

1.7

1.6

1.6

1.6

1.4

1.4

1.4

1.3

1.2

1.2

1.1

58.8

1 ~a~ o“ .4A Reazo” for visit Classification for AmbulatcwY care”

(RVC) Vital and Health Statistics, Series 2-No. 78, Feb. 1979.

Table 6. Number and percent distribution of office visits by patient’s

major reason for visit, prior visit status, and referral status: United

States, 1980

Visit characteristic

Number of Percent visits in distribution thousends

All visits . . . . . . . . . . . . . . . . . . . . .

Major reason for visit

Acute problem . . . . . . . . . . . . . . . . .

Chronic problem, routine . . . . . . . . . . .

Chronic problem, flareup . . . . . . . . . . .

Postsurgery or postinjury . . . . . . . . . . .

Nonilhsess camel . . . . . . . . . . . . . . . . .

Prior visit status

New patient . . . . . . . . . . . . . . . . . . .

Old patient . . . . . . . . . . . . . . . . . . . .

Newprobiem . . . . . . . . . . . . . . . .

Old problem . . . . . . . . . . . . . . . . .

Referral status

Referred by another physician . . . . . . . .

Not referred by another physician . . . . . .

575,745

208,428

162,075

52,703

50,169

102,370

85,519

490 ~26

130,294

359,932

25,370

550,375

36.2

28.2

9.2

8.7

17.8

14.9

85.1

22.6

62.5

4.4

95.6

‘ Includes, for example, routine prenatal cara, ganeral examination, and

well-baby examination.
akmedda5

Table 7. Number and percent of office visits by ti.agnostic wwice

ordered or provided: United States, 1980

Number of

Diagnostic servica visits in Percenr

tfrousands

Table 8. Number and percent distribution of office visits by

principal diagnosis: United States, 1980

Number of

Principal diagnosisand ICD-9-CM code’

Pi?rcent

visitsin distriisurion

thousands

None. . . . . . . . . . . . . . . . . . . . . . . 47,126 8.2

LimitedhistorY/exam. . . . . . . . . . . . . 367,467 63.8

Generalhistory/exam.. . . . . . . . . . . . . 80,790 15.8

Paptest. . . . . . . . . . . . . . . . . . . . . . . 25,419 4.4

cliriicalabtest . . . . . . . . . . . . . . . . .. 125,613 21.8

X-ray. . . . . . . . . . . . . . . . . . . . . . . 41,925 7.3

Bloodpre.ssurecheck. . . . . . . . . . . . . . 195,382 33.9

Electrwardicsgram. . . . . . . . . . . . . . . 16,294 2.8

Visiontest. . . . . . . . . . . . . . . . . . . . 32,726 5.7

Endoscopy. . . . . . . . . . . . . . . . . . . . 4,687 0.8

Mentalstatusexam. . . . . . . . . . . . . . . 8907 1.5

Other. . . . . . . . . . . . . . . . . . . . . . . 29,222 5.1

data. The Supplementary Classification of the ICD-9-

CM, which contains categories for entries other than

diseases and injuries, e.g., general medical andnorrnal

pregnancy examinations, accounted for the largest

proportion of visits (18 percent), with diseases of the

respiratory system accounting for the second largest

proportion (13 percent). The 20 most common

three digit lCD-9-CIU categories are presented in

table 9. The presence of several large categories from

the Supplementary Classification is evident. As in

table 5, these rankings may vary somewhat due to

sampling variability.

Medication t/zerapy.-During 1980, specific information on medication therapy was collected for the

first time in the NAMCS. In item 11 of the Patient

Record, the physician was asked to record, using

brand or generic names, all new or continued medications ordered, injected, administered, or otherwise

provided at this visit, including immunization and

desensitizing agents. The physician was instructed to

list drugs prescribed for the principal diagnosis in

item 11a and all other drugs prescribed at that

visit in item 11b. As used in the NAMCS, the term

drug is interchangeable with the term medication,

and the term prescribing is used in the bro@ sense

to mean the ordering or providing of any medication, either prescription or nonprescription.

The NAMCS drug data have been classified and

coded according to a scheme developed at NCHS

based on the American Society of Hospital Pharmacists’ Drug Product Information File. This new

scheme permits classification by such variables as

specific product name; generic class; entry form

chosen by the physician, i.e., brand name, generic

name, or therapeutic effect desired; prescription

status, i.e., prescription (Rx) or nonprescription

(OTC); Federally controlled substance status (for

addicting or habituating drugs); composition status,

i.e., single or multiple ingredient; and therapeutic

category. Future scheduled reports include one

describing the development of collection and proAll diagnoses . . . . . . . . . . . . . . . . . . .

Infectious and parasitic diseases- . .001 -139

Neoplasms. . . . . . . . . . . . . . .140-239

Endocrine, nutritional, and

metabolic diseases and

immunity disorders. . . . . . . . .240-279

Mental disotiers. . . . . . . . . . . .290-319

Diseases of the newous system and

sense organs . . . . . . . . . . . . .320-389

Diseases of the circulatory

system . . . . . . . . . . . . . . ..390-459

Diseases of the respirato~

system . . . . . . . . . . . . . . ..46 O-5l9

Diseases of the digestive system. . .520-579

Diseases of the ganitourinary

system . . . . . . . . . . . . . . ..580-629

Diseases of the skin and

subcutaneous tissue. . . . . . . . .680-709

Diseases of the musculoskeletal

system and connective tissue . ..710-739

Symptoms, signs, and illdefined

conditions . . . . . . . . . . . . . .780-799

Injury and poisoning . . . . . . . . .800-999

Supplementary classification . . . VO1-V82

Allotherdiagnoses2 . . . . . . . . . . . . . .

Unknown diagnosas3. . . . . . . . . . . . . .

575,745

19,628

16,021

24,166

24,343

52,593

53;69i

72,886

23,421

32,936

36,214

36,839

19,020

46,187

102,237

7,851

7,613

100.0

3.4

2.8

4.2

4.2

9.1

9.3

12.7

4.1

5.7

6.3

6.4

3.3

8.0

17.8

1.4

1.3

l~a=d on tie International classification of Diseas*s. 9th Revision,

Clinical Modification ( ICD-9-CM).

21ncludes diseases of the blood and blood-forming organs (280-289);

complkations of pregnancy, childbirth, and the puerperium (630-676);

congenital anomalies (740-759); and certain conditions originating in

the pwinatal pariod (760-779).

31nc\udes blank diagnosis, noncodable diagnosis, and illegible diawosis.

cessing procedures for the NAMCS drug data and

several reports exploring various aspects of the

NAMCS drug data.

Data on the provision of medication by officebased physicians are highlighted in tables 10 and

11. Data on drug visits, that is, visits at which at

least one medication was prescribed, are presented

in table 10. Forty percent of all drug visits were

made to general and family practitioners. As calculated from tables 3 and 10, some 63 percent of all

office visits resulted in the use of a drug, chiefly for

therapy, but also as a diagnostic or preventive agent.

The percent of drug visits ranged from 35 percent for

general surgeons to 76 percent for internists and

other medical specialists.

Data on the number and percent of drug mentions, that is, the total number of medications listed

in items 1la and 1lb (figure 1), are presented in

tables 10 and 11. As shown in table 10, there were

679.6 million drug mentions in 1980. an average of

1.2 drug mentions for every office visit or 1.9 mentions for every visit at which one or more medications were prescribed. Three physician specialties–

general and family practice, internal medicine, and
6 advamedata

Table 9. Number and percent of office visits, by the 20 most common

principal diagnoses: United States, 1980

Most common principal diagnosis and Number of

Rank ICD-9-CM code 1

visits in Percent

thousands

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Normal pregnancy . . . . . . . . . . . V22

Essential hypertension . . . . . . . . . LIOI

Health supervision of infant or child . V20

General medical examination . . . . . v70

Acute upper respiratory infections

of multiple or unspecified sites . . . 465

Suppurative and unspecified otjtls

media . . . . . . . . . . . . . . . ...382

Neurotic disorders . . . . . . . . . . . 300

Diseases of sebaceous glands. . . . . . 706

Foliowup examinations . . . . . . . . V67

Diabetes mellitus . . . . . . . . . . . . 25o

Special investigations and

examinations . . . . . . . . . . . ..v72

Acute pharyngitis. . . . . . . . . . . . 462

Allergic rhinitis . . . . . . . . . . . . . 477

Obesity and other hyperalimentation. 278

Other forms of chronic ischemic

heart disease . . . . . . . . . . . . ..4I4

Disorders of refraction and

accommr%iation . . . . . . . . . . . . 367

Bronchitis, not specified as acute

or chronic . . . . . . . . . . . . . ..49o

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

Contact dermatitis and other eczema. 692

Other diseases due to viruses and

Chlamydiae . . . . . . . . . . . . . 078

All other diagnoses. . . . . . . . . . . . . .

26,256

25,137

17,496

16,078

15,050

11,748

11,251

10,578

9,682

9.551

9,530

9,361

8,439

8,081

6,958

6,271

6,024

5,921

5,720

5,093

351,522

4.6

4.4

3.0

2.8

2.6

2.0

2.0

1.8

1.7

1.7

1.7

1.6

1.5

1.4

1.2

1.1

1.0

1.0

1.0

0.9

61.1

1 ~a~ed on International classification of Diseases. 9tts Revision. Clinical Modification ( I CD-9-CM).

pediatrics-accounted for 70 percent of all drug

mentions. The distribution of drug menticms by

therapeutic category is shown in table 11. Central

nervous system drugs and anti-infective agent:s were

the leading therapeutic categories, accounting for

32 percent of all drug mentions. Of the drug mentions for anti-infective agents, 86 percent were for

antibiotics.

Non-medication tllerapy.-Table 12 presenik+data

on various types of non-medication therapy that may

be ordered or provided during an office visit. Office

surgery was ordered or performed at about 7 plercent

of all visits.

Disposition of visit. –Data on disposition show

that the majority of office visits involved some type

of scheduled followup. At about 64 percent of the

visits a return visit or telephone followup was planned

(table 13). Approximately 2 percent of the office

visits ended in hospital admission.

Duration of visit. –Duration of visit is that a]mount

of time spent in face-to-face contact between physician and patient. It does not include time spent

waiting to see the physician, time spent receiving

care from someone other than the physician without

the presence of the physician, or time spent reviewing records, test results, etc. In cases where the

patient received care from a member of the physician’s staff, but did not see the physician during the

visit, the duration of visit was recorded as zero

minutes. Some 73 percent of the visits had a duration

of 15 minutes or less (table 13).

More detailed 1980 NAMCS data are forthcoming

in the VituI and Health Statistics series. Questions

regarding this report, future reports, or the N,AMCS

may be directed to the Ambulatory Care Statistics

Branch by calling (301) 436-7132.

Table 10. Number and percent distribution of drug visits and drug mentions by physician specialty: United States, 1980

Number of Number of

Physician specialty drug Percent drug Percent

visits in distribution men tions in distribution

thousands’ thousands

All specialties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General and family practice . . . . . . . . . . . . . . . . . . . . . .

Medical specialties . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internal medicine . . . . . . . . . . . . . . . . . . . . . . . . . .

Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Surgical specialties . . . . . . . . . . . . . . . . . . . . . . . . . . .

General surgery . . . . . . . . . . . . . . . . . . . . . . . . . . .

Obstetrics and gynecology . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other specialties . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

363,489

144,478

131,775

53,091

45,575

33,108

67,912

9,860

23,984

34,068

19,325

5,706

13,619

100.0

39.7

36.3

14.6

12.5

9.1

18.7

2.7

6.6

9.4

5.3

1.6

3.7

679,593

279,186

262,208

118,943

72,825

70,442

100,953

15,881

33,026

52,047

37,245

9,655

27,590

100.0

4’1.1

38.6

1:7.5

1(1.7

10.4

14.9

2.3

4.9

7.7

5.5

“1.4

4.1

lTho~e vi~it~ at which one or more drugs was prescrmed.
aduatmedata 7

Table 11. Number and percent distribution of drug -mentions by

therapeutic categories: United States, 1980

Table 13. Number and percent distribution of office visits by

disposition and duration of visit United States, 1980

Therapeutic categories 1

Number of

drug Percent

men tions in distribution

thousands

All categories . . . . . . . . . . . . . . . . . .

Antihistamine drugs . . . . . . . . . . . . . .

Anti-in fective agents . . . . . . . . . . . . . .

Antibiotics . . . . . . . . . . . . . . . . . .

Antineoplastic agents. . . . . . . . . . . . . .

Autonomic drugs . . . . . . . . . . . . . . . .

Blood forrriation and coagulation . . . . . . .

Cardiovascular drugs , . . . . . . . . . . . . .

Cardiac drugs . . . . . . . . . . . . . ...’

Hypotensive agents . . . . . . . . . . . . .

Vasodilating agents ., . . . . . . . . . . . .

Central nervous system drugs . . . . . . . . .

Analgesics and antipyretics . . . . . . .

Psychotherapeutic agents . . . . . . . . .

Sedatives and hypnotics . . . . . . . . . .

Diagnostic agents . . . . . . . . . . . . . . . .

Electrolytic, caloric, and water balance . . .

Diuretics . . . . . . . . . . . . . . . . . . .

Expectorants and cough preparations . . . .

Eye, ear, nose, and throat preparations. . . .

Gastrointestinal drugs . . . . . . . . . . . . .

Hormones and synthetic substances . . . . .

Adrenals, . . . . . . . . . . . . . . . . . .

Local anesthetics . . . . . . . . . . . . . . . .

Serums, toxiods, and vaccines. . . . . . . . .

Skin and mucous membrane preparations . .

Spasmolytic agents . . . . . . . . . . . . . . .

vitamins . . . . . . . . . . . . . . . . . . . . .

Other therapeutic agents; pharmaceutics

devices and aids . . . . . . . . . . . . . . . .

Therapeutic category undetermined . . . . .

679,593

43,939

104,898

90,081

5,371

25,237

8,312

64,463

26,331

22,633

14,646

110,706

57,800

16,395

25,036

4,673

51,956

42,834

18,899

26,076

24,140

55,843

18,312

968

23,711

55,188

11,541

24,244

9,410

10,017

100.0

6.5

15.4

13.3

0.8

3.7

1.2

9.5

3.9

3.3

2.2

16.3

8.5

2.4

3.7

0.7

7.6

6.3

2.8

3.8

3.6

8.2

2.7

0.1

3.5

8.1

1.7

3.6

1.4

1.5

lBased on the Pharmacologic.therapeutic classification of the Amarican

sOCietY Of Hospital Pharmacists, selected categories reproduced with

the permission of the Society.

Table 12. Number and percent of office visits by nonwmdication

therapy ordered or provided: United States, 1980

Number of

Non-medication therapy visits in Percent

thousands “

None . . . . . . . . . . . . . . . . . . . . . . .

Physiotherapy . . . . . . . . . . . . . . . . . .

Of fice surgery . . . . . . . . . . . . . . . . . .

Family planning . . . . . . . . . . . . . . . . .

Psychotherapy/therapeutic listening . . . . .

Diet counseling . . . . . . . . . . . . . . . . .

Family/social counseling. . . . . . . . . . . .

Medical counsel ing . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . .

303,017

29,281

43,089

12,828

29,024

48,886

13,148

133,425

15,618

52.6

5.1

7.5

2.2

5.0

8.5

2.3

23.2

2.7

Disposition and duration

Number of Percent

visits in

thousands

distribution

Disposition’

No followup planned . . . . . . . . . . . . . .

Return atspecified rime . . . . . . . . . . . .

Return lf needed . . . . . . . . . . . . . . . .

Telephone followup planned . . . . . . . . .

Referred to other physician . . . . . . . . . .

Returned to referring physician . . . . . . . .

Admit to hospital . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . .

Duration

0minutes2 . . . . . . . . . . . . . . . . . . . .

l-5 minutes . . . . . . . . . . . . . . . . . . .

6-10 minutes . . . . . . . . . . . . . . . . . . .

11-15 minutes . . . . . . . . . . . . . . . . . .

16-30 minutes . . . . . . . . . . . . . . . . . .

31minutes ormore . . . . . . . . . . . . . . .

67,442 11.7

34,641 60.2

131,404 22.8

19,955 3.5

15,157 2.6

3,677 0.6

13,088 2.3

1,380 0.2

13,813 2.4

71,894 12.5

175,660 30.5

157,619 27.4

120,900 21.0

35,858 6.2

lMay notad~ to 100. O~incemore than onedisposition was Possible.

2Repre~ents ~ffjce “isi~ jn which there was no face-tO-face cOntact

betwean thapatienr andzhe physician.
8

Technical notes

Source of data and sample design

The information presented in this report is based

on data collected in the National Ambulato~ Medical

Care Survey (NAMCS) during 1980. The target universe of NAMCS includes office visits made within

the conterminous United States by ambulatory

patients to nonfederally employed physicians who

are principally engaged in office practice, but not in

the specialties of anesthesiology, pathology, or

radiology. Telephone contacts and nonoffice visits

are excluded.

NAMCS utilizes a multistage probability sample

design that involves samples of primary sampling

units (PSI-J’S), physicians’ practices within PSU’S,

and patient visits within physician practices. For

1980 a sample of 2.959 non-Federal, office-based

physicians was selected from master files maintained by the American Medical Association and the

Amercian Osteopathic Association. The physician

response rate for 1980 was 77.2 percent. Sampled

physicians were asked to complete Patient Records

(figure 1) for a systematic random sample of office

visits taking place during a randomly assigned weekly

reporting period. During 1980, responding physicians

completed 46,081 Patient Records. Characteristics of

the physician’s practice, such as primary specialty and

type of practice, were obtained during an induction

interview. The National Opinion Research Center,

under contract to the National Center for Health

Statistics, was responsible for the survey’s field

operations.

For a more detailed discussion of the limitations,

qualifications, and definitions of the data collected

in the NAMCS, see VitaI sm.-lHealth Statistics. Series

13. Number 44.1

Estimates presented in this report differ from the

estimates reported in the National Medical Care

Utilization and Expenditure Survey (h’MCUES),

another program of the National Center for Health

Statistics (NCHS). The variation in estimates is due to

differences in survey populations, data collection

methodology, and definitions. The NMCUES, cosponsored by NCHS and the Health Care Financing

Administration (HCFA). is a national panel survey of

households that collected information on visits to

physicians’ offices and hospital outpatient departments. Preliminary survey data as well as a discussion

of the survey methodology are forthcoming from

NCHS and HCFA.

Sampling errors and roundings

of numbers

The standard error is primarily a measure of the

sampling variability that occurs by chance because

only a sample, rather than the entire universe, is

surveyed. The relative standard error of an estimate

is obtained by dividing the standard error by the

estimate itself and is expressed as a percent (of the

estimate. Approximate relative standard errors of

selected aggregate statistics are shown in tables I

and II. Standard errors for percents of visits and

Table 1. Approximate relative standard errors of estimated number of

office visits based on all physician specialties: NAMCS, 1980

Relative

Estimated number of office standard

visits in thousends error in

percent

500 . . . . . . . . . . . . . . . . . . . . . . . . .. C..... 27.3

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.5

2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.1

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.4

10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3

20,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.9

50,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.8

100,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5

550,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1

Example of usa of tabla: An aggregata of 35,000,000 visits has a relative standard error of 5.4 percent or a standard error of 1,[190,000

visits (5.4 percent of 35,000,000).

Table 11. Approximate relative standard errors of estimated number of

office visits based on an individual physician specialty: fiJAMCS,

1980

Relative

Estimated number of office sasnderd

visits in thousends error in

percent

500 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.0

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.3

2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.1

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.8

10,000, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.0

20,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.9

50,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1

100,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.9

Example of use of tabla: An aggregate of 7,500,000 visits has a relative standard error of 9.9 percant or a standard arror of 742,500

visits (9.9 percent of 7,500,000).

standard errors for estimates of drug mentions will

be included in future reports.

Estimates of office visits have been rounded to

the nearest thousand. For this reason detailed figures

within tables do not always add to totals. Rates and

percents were calculated on the basis of original,

unrounded figures and will not necessarily agree

precisely with percents calculated from rounded

data.
Definitions

Ambulatory patient.–An ambulatory patient is

an individual presenting himself for personal health

services who is neither bedridden nor currently admitted to any health care institution on the premises.

Physician.–A physician is a duly licensed doctor

of medicine (M.D.) or doctor of osteopathy (D.O.)

currentIy in office-based practice who spends t~e

in caring for ambulatory patients. Excluded from

NAMCS are physicians who are hospital based;

physicians who specialize in anesthesiology, pathology, or radiology; physicians who are Federally

employed; physicians who treat only institutionalized

patients; physicians employed full time by an institution; and physicians who spend no time seeing

ambulatory patients.

.2ffice.-An office is a place that the physician

identifies as a location for his ambulatory practice.

Responsibility over time for patient care and professional services rendered there generally resides

with the individual physician rather than an institution.

Visit.–A visit is a direct personal exchange

between an ambulatory patient and a physician or

a staff member working under the physician’s supervision, for the purpose of seeking care and rendering

health services.
From Vital and Health Statistics of the National Center for Health Statistics Number 78 ●May 12, 1982

DrugsMost FrequentlyUsed inOffice-BasedPractic=

NationalAmbulatoryMedicalCareSurvey,1980

by Hugo Koch, Division of Health Care Statistics

This report lists and describes the 200 drugs most

frequently utilized in 1980 by physicians engaged in

office-based practice. (Inclusion of trade names is for

identification only and does not imply endorsement

by the Public Health Service or the U.S. Department

of Health and Human Services.) Data are based on

findings from the National Ambulatory Medical Care

Survey.

The National Center for Health Statistics uses the

National Ambulatory Medical Care Survey (NAMCS)

to collect descriptive data about the medical care prcrvided in doctors’ offices. Each year NAMCS data collectors contact a representative sample of the

Nation’s doctom of medicine and osteopathy whose

primary jobs ~e office-b~ed, patient-care practice.

The sampled physicians in turn complete records

(figure 1) for a systematic random sample of their

office visits over a weekly reporting period.

The year 1980 was the first in the 8-year history

of NAMCS that respondents reported the number and

names of the specific drugs they used (see figure 1,

item 11). This resulted in an estimated 679,593,000

mentions of pharmaceutical agents ordered or provided for the purpose of prevention, diagnosis, or

treatment. Mentions included new or continued medications and nonprescription as well as prescription

drugs. The methodology used to collect and process

drug information for the 1980 NAMCS is reported

elsewhere.1

Since the estimates presented in this report are

based on a sample rather than on the entire universe

of office visits, the data are subject to sampling variability. The technical notes at the end of this report

provide a brief explanation of the sampling errors,

and guidelines for judging the precision of estimates.

Table 1 lists, in rank order, the 200 drugs that

1National Center for Health Statistics, H. Koch: The collection and

processing of drug information, National Ambulatory Medical Care

SwveY, United States, 1980. vital and Health Statistics Series 2-No.

90. DHHS Pub. No. (PHS) 82-1364. Public Health Service. Washington. U.S. Government Printing Office. In press.

physicians most frequently ordered or provided at

their office visits. The listing is arbitrarily restricted

to the mentions of drugs that were specifically named

by respondents. This led to the exclusion of four

entry choices that did not identify a specific agent,

indicating only the therapeutic effect desired. These

four therapeutic effects were:

● Allergy relief or shots (unspecified), with

9,986,000 mentions.

● Vitamin(s) (unspecified), with 2,124,000 mentions.

● Vaccination (unspecified), with 1,233,000 mentions.

● Skin preparations (unspecified), with 948,000

mentions.

A superscnptf following a listed drug indicates a

drug family; i.e., a grouping of drugs whose members

have the same core identifier and the same or a

closely similar therapeutic effect. Example: the drug

family ARISTOCORTf includes the following members: ARISTOCORT, ARISTOCORT A, ARISTOCORT FORTE, ARISTOCORT HP, ARISTOCORT

INTRALESIONAL, and ARISTOCORT R.

The reader is cautioned that these rankings, due

to sampling variability, may be somewhat artificial

because some estimates may not enjoy a clear statistical difference from other near estimates.

The 200 drugs comprise only 8 percent of the

total 2,632 drugs named by respondents. However,

they accounted for about 448,707,000 mentions, or

66 percent of the total 679,593,000 drug mentions.

Tables 2, 3, 4, 5, and 6 characterize the 1980

drug mentions according to certain key dimensions,

the knowledge of which is basic to any study of drug

utilization. From these tables the reader may judge

the degree that the ranking 200 drugs are representative of all drug mentions.

Entry status. –The data in table 2 characterize the

drug mentions by their entry status; that is, they reveal whether the doctor recorded the mention by

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service, Office of Health Research, Statistics, and Technology
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Figure 1. Patient Record from the National Ambulatory Medical Care Survay
admce@a3

Table 1. The 200 drugs most frequently used in office-based practice, by name of drug, generic class, and number of mentions:

United States, 1980

Number of

Rank Name of drugq Generic class mentions in

thousands

1

2

3

4

5

6

7

a

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

::

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

All drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

200 drugs most frequently used

LASIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AMPICILLIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PENICILLINf . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .

INDERAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TETRACYCLINEf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ASPIRINf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DYAZIDE . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . . . . .

LANOXIN . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .

POLIO VACCINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

VALIUM

DIPHTHER”lA.+E+ANUi %XO;D.S.PER+USSIS. ::::::::::::::

PREDNISONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MOTRIN

VITAMINi-id;::::::::::: ::::::::::::::::::::::: :::

HYDROCHLOROTHIAZIDEf . . . . . . . . . . . . . . . . . . . . . . . . . . .

AMOXICILLIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DIMETAPP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ERYTHROMYCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

INSULIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ALDOMET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DIOXIN, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TUBERCULIN TINETESTf . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TAGAMET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

HYDRODIURIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

KEFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

E.E.S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ACTIFED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ISORDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TYLENOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

HYGROTON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TYLENOLW/CODEINEf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PHENERGANf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CLINORIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BENADRYL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AMOXIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

KENALOG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DIABINESE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

INDOCIN . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NITROGLYCERIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

THYROID

DARVOCET~N .::::::::::: ::::::;::::::::::::;:;; :::

CORTISPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BACTRIMf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CLEOCINf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NAPROSYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

E.MYCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DIMETANEf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PHENERGANW/CODEINEf... . . . . . . . . . . . . . . . . . . . . . . . . .

SEPTRAf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PREMARINf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

LOPRESSOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DONNATAL, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DECADRONf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NEOSPORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

EIAVIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ALDACTAZIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

INFLUENZA VIRUSVACCINE, . . . . . . . . . . . . . . . . . . . . . . . . .

TRANXENE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DALMANE, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

POTASSIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ALDORIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

COUMADIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SYNTHROID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FUROSEMIDE

AMPICILLIN

PENICILLIN

PROPRANOLOL

TETRACYCLINE

ASPIRIN

COMBINATION DRUG

DIGOXIN

POLIO VACCINE

DIAZEPAM

DIPHTHERIA TETANUS TOXOIDSPERTUSSIS

PREDNISONE

IBUPROFEN

VITAMIN B-12

HYDROCHLOROTHIAZIDE

AMOXICILLIN

COMBINATION DRUG

ERYTHROMYCIN

INSULIN

METHYLDOPA

DIGOXIN

TUBERCULIN

CIMETIDINE

HYDROCHLOROTHIAZIDE

CEPHALEXIN

ERYTHROMYCIN

COMBINATION DRUG

ISOSORBIDE

ACETAMINOPHEN

CHLORTHALIDONE

COM81NATIONDRUG

PROMETHAZINE

SULINDAC

DIPHENHYDRAMINE

AMOXICILLIN

TRIAMCINOLONE

CHLORPROPAMIDE

lNDOMETHACIN

NITROGLYCERIN

THYROID

COMBINATION DRUG

COMBINATION DRUG

COMBINATION DRUG

CLINDAMYCIN

NAPROXEN

ERYTHROMYCIN

BROMPHENIRAMINE

COMBINATION DRUG

COM131NATIONDRUG

ESTROGENS

METOPROLOL

COMBINATION DRUG

DEXAMETHASONE

COMBINATION DRUG

AMITRIPTYLINE

COMBINATION DRUG

INFLUENZA VIRUS VACCINE

CLORAZEPATE

FLURAZEPAM

POTASSIUM REPLACEMENT SOLUTIONS

COMBINATION DRUG

WARFARIN

LEVOTHYROXINE

679,593

9,879

9,795

9,736

9,625

9,478

8,800

7,435

7,105

6,535

6,499

6,067

5,879

5,819

5,813

5,751

5,506

5,377

5,363

5,248

5,237

4,801

4,488

4,482

4,395

4,268

4,176

4,019

3,805

3,815

3,772

3,661

3,541

3,393

3,366

3,284

3,279

3,204

3,181

3,132

3,071

3,043

3,009

2,943

2,808

2,857

2,844

2,824

2,783

2,781

2,683

2,633

2,520

2,449

2,366

2,363

2,257

2,225

2,217

2,202

2,161

2.133

2,106

2,105

Sae footnote at end of table.
4

Table 1. The200drugs most frequently used lnoffim-bawd practice, byname Ofdrug, generic class, andnumber ofmntions:

United States, 1980–Con.

Rank

Number of

Name of drugl Generic class mentions in

t150usands

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

100

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

117

118

119

120

121

122

123

124

125

126

127

128

129

DIURIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ANTIVERT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PRENATAL VITAMINSf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BUTAZOLIDINf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MONISTATf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CELESTONEf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SLOW-K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PEN-VEE-K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

V-CILLINf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

XYLOCAINEf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DILANTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TIMOPTIC . . . . .

V18RAMYCIN . . .

PHENOBAR81TAL

SINEQUAN . . . . .

MINOCIN . . . . . .

DEPO-MEDROL .

ATARAX . . . . . .

HYDROCORTISONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MACRODANTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ORTHO-NOVUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

EMPIRINW/CODEINEf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

L18RAX . . . . . . . . >........ . . . . . . . . . . . . . . . . . . . . . . . . .

DRIXORAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MYCOLOG Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NALFON . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BICILLINf . . . . . . . . . . . . . ...’. . . . . . . . . . . . . . . . . . . . . . . .

ROBITUSSINf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

LOMOTIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FLUOROURACIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PERSANTINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MYLANTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CECLOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TETANUSTOX”OID ..,...... . . . . . . . . . . . . . . . . . . . . . . . . .

CHORIONICGONADOTROPIN . . . . . . . . . . . . . . . . . . . . . . . . . .

CHLOR-TRIMETONf ..,...... . . . . . . . . . . . . . . . . . . . . . . . .

NOVAHISTINEf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CAROTID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ORNATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ARISTOCORTf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ATIVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MATERNA L..........,.. . . . . . . . . . . . . . . . . . . . . . . . . . . .

ACHROMYCINf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SUDAFEDf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

COMBED, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FIORINAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NITRO-BID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MAALOX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ASCRIPTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

LIDEX, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ORINASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

APRESOLINE . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . ...’.. . . .

LIBRIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ACTH

GANTRiSIN” :::::::::::::: :::::::::::::::::::::::: :

ZYLOPRIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SER-AP-ESf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TRIAVIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ESIDRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ILOSONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BRETHINE ..,.........,.. . . . . . . . . . . . . . . . . . . . . . . . . .

ENDURON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

LOIOVRAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MELLARIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

RONDECf, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NORGESIC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHLOROTHIAZIOE

MECLIZINE

MULTIVITAMINS PRENATAL

PHENYLBUTAZONE

MICONAZOLE

BETAMETHASONE

Potassium REPLACEMENT SOLUTIONS

PENICILLIN

PENICILLIN

COMBINATION DRUG

PHENYTOIN

TIMOLOL

DOXYCYCLINE

PHENOBARBITAL

DOXEPIN

MINOCYCLINE

METHYLPREDNISOLONE

HYDROXYZINE

HYDROCORTISONE

NITROFURANTOIN

COM81NATIONDRUG

COMBINATION DRUG

COMBINATION DRUG

COMBINATION DRUG

COMBINATION DRUG

FENOPROFEN

PENICILLIN

GUAIFENESIN

COMBINATION DRUG

FLUOROURACIL

DIPYRIDAMOLE

COMBINATION DRUG

CEFACLOR

TETANUS TOXOID

CHORIONIC GONADOTROPIN

CHLORPHENIRAMINE

COMBINATION DRUG

AMOXICILLIN

COMBINATION DRUG

TRIAMCINOLONE

LORAZEPAM

MULTIVITAMINS PRENATAL

TETRACYCLINE

PSEUDOEPHEDRINE

COMBINATION DRUG

COMBINATION DRUG

NITROGLYCERIN

COMBINATION DRUG

ASPIRIN

FLUOCINONIDE

TOLBUTAMIOE

HYDRALAZINE

CHLORDIAZEPOXIDE

CORTICOTROPIN

SULFISOXAZOLE

ALLOPURINOL

COMBINATION DRUG

COMBINATION DRUG

HYDROCHLOROTHIAZIDE

kRYTHROMYCIN

TERBUTALINE

METHYCLOTHIAZIDE

COMBINATION DRUG

THIORIZAZINE

COMBINATION DRUG

COMBINATION DRUG

2,101

2,093

2,062

2,023

1,976

1,970

1,951

1,932

1,926

1,887

1,877

1,875

1,844

1,790

1,766

1,760

1,742

1,737

1,732

1,724

1,697

1.687

1,670

1,656

1,649

1,642

1,629

1,617

1,610

1,609

1,605

1,598

1,597

1,583

1,568

1,559

1,557

1,539

1,511

1,510

1,503

1,491

1,482

1,482

1,443

1,435

1,433

1,400

1,389

1,388

1,352

1,351

1,343

1,315

1,315

1,314

1,306

1,305

1,299

1,284

1,273

1,253

1,244

1,242

1,241

1,224

See footnote at end of table.
admceda5

Tablel. The200drugs most frequently used inoffice-based practice, by name of drug, generic class, andnumber of mentions:

United States, 1980–Con.

Rank

Number of

Name of drvg 1 Generic class men tions in

thousands

130

131

132

133

134

135

136

137

138

139

140

141

142

143

144

145

146

147

148

149

160

151

152

153

154

155

166

157

158

159

160

161

162

163

164

165

167

168

169

170

171

172

173

174

175

176

177

178

179

180

181

182

183

184

185

186

187

188

189

180

191

192

193

194

195

SOe foot

VA LISONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TERRAMYCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

RETIN-A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PARAFON FORTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

RESERPINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

M-M-R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .

DIPHTHERIA TETANUSTOXOIOS . . . . . . . . . . . . . . . . . . . . . . .

NALDECON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MAXITROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

METAMUCIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

R08AXIN . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MINIPRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8ENTYL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

IONAMIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

QUINIDINEf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PERCOOANf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DARVONf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CORTISONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

THEO-DUR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FLAGYL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DIPROSONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

METHOTREXATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ESTROGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CYTOXAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TOLECTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

LINCOCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TRIAMINICf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NEO-SYNEPHRINEf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PILOCARPINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ALUPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ORAL . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .

FLURESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SOMAf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MEPR08AMATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHLOROPTICf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TITAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MYCOSTATIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ZAROXOLYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TUSS-ORNAOE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DONNAGELf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SALICYLICACIDf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DESQUAM-Xf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NITROGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

LIM81TROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CORDRANf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8ENYLIN SYRUP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

LOTRIMIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BETADINEf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CATAPRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AMINOPHYLLINEf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CORGARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

QUIBRONf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DEMEROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FLEXERIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

IRON PREPARATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SORBITRATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TOLINASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BENZACf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TOFRANIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MEDROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FERROUSSULFATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ERYTHROCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PAVABID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DRAMAMINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SLO-PHYLLINf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

:noto at end of table.

8ETAMETHASONE

OXYTETRACYCLINE

TRETINOIN

COM81NATIONDRUG

RESERPINE

COMBINATION DRUG

DIPHTHERIA TETANUS TOXOIDS

COMBINATION DRUG

COMBINATION DRUG

PSYLLIUM

METHOCARBAMOL

PRAZOSIN

DICYCLOMINE

PHENTERMINE

QUINIDINE

COMBINATION DRUG

PROPOXYPHENE

CORTISONE

THEOPHYLLINE

METRONIOAZOLE

BETAMETHASON E

METHOTREXATE

ESTROGENS

CYCLOPHOSPHAMIDE

PHENTERMINE

TOLMETIN

LINCOMYCIN

COMBINATION DRUG

PHENYLEPHRINE

PILOCARPINE

METAPROTERENOL

COMBINATION DRUG

COMBINATION DRUG

CARISOPRODOL

MEPROBAMATE

CHLORAMPHENICOL

TRIMETHOBENZAMIDE

NYSTATIN

METOLAZONE

COMBINATION DRUG

COM81NATIONDRUG

SALICYLICACID

COM81NATIONDRUG

NITROGEN

COM81NATIONORUG

FLURANDRENOLIDE

DIPHENHYDRAMINE

CLOTRIMAZOLE

IODINE TOPICAL PREPARATIONS

CLONIDINE

AMINOPHYLLINE

NADOLOL

COM81NATIONDRUG

MEPERIDINE

CYCLOBENZAPRINE

IRON PREPARATIONS

ISOSOR81DE

TOLAZAMIDE

COM81NATIONDRUG

IMIPRAMINE

METHYLPREDNISOLONE

IRON PREPARATIONS

ERYTHROMYCIN

PAPAVERINE

DIMENHYDRINATE

THEOPHYLLINE

1,222

1,178

1,178

1,171

1,170

1,170

1,167

1,166

1,162

1,160

1,138

1,128

1,116

1,108

1,107

1,105

1,104

1,100

1,075

1,072

1,057

1,044

1,043

1,030

1,012

1,007

1,003

997

987

979

979

956

952

947

945

942

937

935

932

929

924

922

909

901

9oiJ

896

895

894

891

890

887

885

882

879

879

874

872

870

868

837

834

834

832

828

825

822
6

Tablel. The2~drugs mofifrequently uwdinoffice-&s4 practice, bynamaof drug, generic class, and numberof mentions:

United States, 1980–Con.

Number of

Rank Name of drug ~ Generic ctass mentions in

thousands

196 VASODILAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ISOXUPRINE

197 TOPICORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

818

DESOXIMETASONE

198 COMPAZINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

805

PROCHLORPERAZINE

199 VELOSEF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

782

CEPHRADINE

200 ITALWINf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PENTAZOCINE

781

779

Isuper$crlptf denotes drug familvl

Table2. Numbrand percent distribution ofalldrug mentions, andnum&r, percent diwribution, and~rcent ofalldrug mentions of the200 drugs

moat freauentlv named. bventrv status United States. 1980

All drugs 200 drugs most frequently

named

Entry status Number of Number of

mentions Percent

Percent of

mantions Percent

in distribution in distribution

M drug

thousands thousands

mentions

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679,593 100.0 448,707 100,0 66.0

Generic name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184,464 24.2 128,501

8randname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28.6 76.1

483,567 71.2 320,206

Unknown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

71,4 66.2

31,542 4.6 . . . . . . . . .

Table3, Numbrnr andpercent distribution ofalldrug mentions, andnum&r, ~rcentdistribution, and~rcent ofalldrug mentions of the f2OOdrugs

most frequently named, byprescription status: UnitedStates,1980

All drugs

200 drugs most frequently

named

Prescription status Number of Numberof

mentions Parcent

Pm-cent of

mentions Percent

in distribution in distribution

M drug

thousands thousands

men tions

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679,593 100.0 448,707 100.0 66.0

Prescription drug . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . %1 ,228 82.6 403,807

Nonprescnptiond rug..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

90.0 72.0

85,344 12.6 44,900

Unknown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10.0 52.6

33,021 4.9 . . . . . . . . .
a&mcaaa7

Table4. Number andpercent distribution of alldrug mentions, andnum&r, ~rcentdistri&tion. and@rcentof alldrug mentions of the200 drugs

most frequently named, by Federal control status United States, 1980

All drugs 200 drugs most frequently

named

Federal control starus Number of Number of

men ttons Percent

Percenr of

menrions Percent

in distribution

all drug

in distribution

thousands

mentions

thousands

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Controlled byDEA1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Schedule 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Schedule ill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Schedule IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Schedule V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Uncontrolled, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unknown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

679,593

58,550

5,763

12,037

30,305

10,445

588,022

33,021

100.0

8.6

0.8

1.8

4.5

1.5

86.5

4.9

448.707

40,076

1,984

6,750

22.228

9,114

408,631

100.0 66.0

8.9 68.4

0.4 34.4

1.5 56.1

5.0 73.3

2.0 87.3

91.1 69.5

. . . . . .

lDrug Enforcement Adr’rIir’IkWatiOrr,

Teble5. Number andpercent distribution ofalldrug mentions, andnumhr, percent distribution, andpercent ofaildrug mentions of the200 drug

most frequently named, by composition status: United States, 1980

All drugs 200 drugs mosr frequently

named

Composition status Numberof Number of Percent of

men tions Percent mentions Percent

in distribution in distribution

all drug

rhousands

mentions

thousands

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679,593 100.0 448,707 100.0 66.0

Single-ingredientdmg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468,752 69.0 348,294 77.6 74.3

Combinationdrug . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165,798 24.4 86,840 21.6 58.4

Multivitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13,500 2.0 3,573 0.8 26.5

Unknown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31,542 4.6 . . . ,.. . . .
8

Table6. Number andpercent distribution of alldrug mentions, andnum&r, ~rmntdistribution, and~rcent ofalldrug mentions of the2W drug

mosr frequently named, by therapeutic category: United States, 1980

All drugs 200 drugs most frequently

named

Therapeutic category 1 Number of Number of Percent of

mentions Percent mentions Percent

in distribution in distribution

all drug

thousends thousands

mantions

All categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Antihistamine drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Anti-infective agents (nontopical) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Antineoplasticagents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Autonomicdrugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sloodformationandcoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cardiovascular drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cerdiacdrugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hypotensiveagents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Vasodilatingagents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

central nervoussystemdrugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analgesicsandantipyretics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Psychotherapeutic agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sedativesand hypnotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diagnosticagents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Electrolytic, caloric,andwater balance . . . . . . . . . . . . . . . . . . . . . . . .

Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Expectorantsand coughpreparations . . . . . . . . . . . . . . . . . . . . . . . . . .

Eye,ear, nosa,andthroatpreparations . . . . . . . . . . . . . . . . . . . . . . . . .

Gastrointestinal drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hormonesandsyntheticsubstances . . . . . . . . . . . . . . . . . . . . . . . . . . .

Adrenals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Serums, toxoids,andvaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Skin and mucous membrane preparations . . . . . . . . . . . . . . . . . . . . . . .

Spasmolytic agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

vitarnirss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Otheragants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Undetermined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

679,593

43,939

104,898

90,061

5,371

25,237

8,312

64,463

26,331

22,633

14,646

110,706

57,800

16,395

25,036

4,673

51,956

42,834

18,899

26,076

24,140

55,843

18,312

23,711

55,188

11,541

24,244

10,378

10,017

100.0

6.5

15.4

13.3

0.8

3.7

1.2

9.5

3.9

3.3

2.2

16.3

8.5

2.4

3.7

0.7

7.6

6.3

2.8

3.8

3.6

8.2

2.7

3.5

8.1

1.7

3.6

1.5

1.5

448,707

26,269

64,046

75,526

3,683

13,653

2,840

52,010

24,397

15,848

11,765

80,271

47,408

9,195

19,671

4,466

43,186

39,074

8,681

10,798

15,028

41,781

15,425

18,747

25,783

4,494

9,386

3,262

100.0

5.9

18.7

16.8

0.8

3.0

0.7

11.6

5.4

3.5

2.6

17.9

10.6

2.0

4.4

1.0

9.6

8.7

2.0

2.4

3.3

9.3

3.4

4.2

5.7

1.0

2.1

0.7

66.0

59.8

80.1

63.8

68.6

54.1

35.4

80.7

92.7

70.0

80.3

72.5

82.0

56.1

78.6

96.0

83.1

91.2

47.0

41.4

62.3

74.8

84.2

79.1

46.7

38.9

38.7

31.4

lBawd on thepharmacologic.therapeuticclassificationof the American Sociery of Hospital pharmacists.

brand name orby generic name. (Note: NAMCSrespondents were instructed to use the same entry

status on the NAMCSvisit record (figure I) that they

used on the patient’s medical record and/oron any

prescription written.)

Extensive discussion has occurred during the past

decade about the costs and merits ofprescnbingby

brand name versus the usually less costly generic

name. Since 1970, the generic drug business has

grown faster than the total pharmaceutical market.

To cite one study: “While the market expandedby

10 percent from 1977to 1979,genericsgrew by12.6

percent during that period. By 1979, 14percent ofall

new prescriptions written by physicians were for

generic drugs, up from 7 percent in 1970.”2

It should be emphasized that the extent of

generic utilization revealed by the NAMCS data in

table 2 (24 percent of all drugs mentioned-29 percent of the leading 200) reflects the tofaI utilization

of generic drugs in office-based practice. Thus along

with the generic prescriptions-new ones or refills–

2Mayer, C. E.: Drug industry war heatsup over generics. Washington

Post, Dec. 20, 1981. pp K1-2.

that the doctor intended to be filled by a dispensing

pharmacist, the NAMCS generic fraction includes

such other agents as: nonprescription generics (e.g.,

ASPIRIN or INSULIN); most serums, toxoids and

vaccines (e.g., DIPHTHERIA TETANUS TOXOID

PERTUSSIS); most diagnostic agents (e.g., TUBERCULIN); and a substantial number of other agents–

chiefly antibiotic-injectibles-administered in the doctor’s office.

Prescription status. –The data in table 3 characterize the drug mentions by their Federal legal classification. These data reveal whether the doctor recorded a prescription (Rx) drug or a nonprescription

(over-the-counter or OTC) drug. The choice of a prescription drug by a prescribing physician indicates

relatively more judgmental control by the physician

than does the choice of a nonprescription drug, which

represents a greater reliance on self-care by the

patient. Also, OTC drugs are usually less expensive

than their Rx counterparts. (However, except for

INSULIN, they are not usually covered as an insured

benefit in third-party programs.) Thus it is interesting

to learn from table 3 that at least 13 percent of all

drug mentions were nonprescription drugs.
Federal control status. -A very important issue in

health and social policy is the use of medications

having significant potential for addiction or habituation. Such medications are under the regulato~ CONtrol of the Drug Enforcement Administration (DEA),

an agency of the U.S. Department of Justice. In

table 4 the medications used in office-based practice

am characterized by their DEA control level

(“schedule”). Each successive Schedule, from II

through V, reflects a decreasing potential for abuse,

as follows:

Schedule II (MOI@HINE, DEMEROL, AMPHETAMINES) High potential for abuse. Abuse may

lead to severe psychological or physical dependence.

Schedule III (FIORINAL, PHENDIMETRAZINE,

etc.) Potential for abuse less than for drugs in

Schedule II. Abuse may lead to moderate or low

physical dependence or high psychological dependence.

Schedule IV (VALIUM, PHENOBARBITAL, etc.)

Potential for abuse less than for drugs in Schedule

III. Abuse may lead to limited physical or.psychoIogical dependence.

Schedule V (LOMOTIL. CHERACOL SYRUP.

etc.) Potential for abuse &d dependence less than

for drugs in Schedule IV.

AMCS data in table 4 reveal that a small but critical

proportion (9 percent) of all drug mentions were controlled drugs, of which drugs in Schedule IV enjoyed

the highest frequency of mention.

Composition status. –Table 5 reveals that about

26 percent of all drug mentions were combination

drugs. An issue of long-standing debate in drug

utilization concerns the use of drugs in tixed-ratio

combinations as opposed to single-ingredient drugs.

Combination drugs usually cost more and offer less

flexibility in dosage adjustment; however. they offer

more potential convenience to the patient. The

NAMCS data base permits differentiating singleingredient drugs from combination drugs and can

identify the specific ingredients of the combinations

if this information is required.

Therapeutic category. –Table 6 characterizes the

1980 drug mentions by the chief therapeutic effect

that each was intended to produce. An obvious preeminence is enjoyed by two therapeutic categories,

nontropical anti-infectives and central nervous system

drugs, which together accounted for 32 percent of all

drug mentions. The preeminence was even stronger

(37 percent) among the leading 200.

Inquiries about the NAMCS drug data base or its

1980 findings may be addressed to:

Hugo Koch

Ambulatory Care Statistics Branch

Division of Health Care Statistics

National Center for Health Statistics

Center Bldg. 2, Room 243

Prince George Center

3700 East-West Highway

Hyattsville, Maryland 20782

Phone: (301) 436-7132

Symbols

--- Datanot available

. . . Category not applicable

Quantity zero

0.0 Quantity more than zero but lessthan

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
10

Technical notes

Source of data and sample design

The estimates presented in this report are based

on data collected during 1980 by the National Center

for Health Statistics by means of the Survey

(NAMCS). The target universe of NAMCS comprises

office visits made by ambulatory patients to nonFederal physlc]ans \vho are principally engaged in

office-based, patient care practice. Visits to physicians practicing in Alaska and Hawaii are excluded

from the range of NAMCS, as are visits to physicians

who specialize in anesthesiology, pathology, and

radiology.

NAMCS uses a multistage probability sample design that involves a step-wise sampling of primary

sampling units (PSU’S), physicians’ practices within

PSU’S. and patient visits within physicians’ practices.

For 1980 a sample of 2,959 physicians was selected

from master tiles maintained by the American Medical Association and the American osteopathic Association. The physician response rate was 77.2 percent.

Sampled physicians were asked to complete Patient

Records (figure 1) for a systematic random sample

of office visits made during a randomly assigned

week]y reporting period. Telephone contacts were

excluded. During 1980. responding physicians completed 46,081 Patient Records, on which they recorded 51.372 drug mentions. Characteristics of the

physician’s practice. such as primary specialty and

type of practice, were obtained during an induction

interview. The National Opinion Research Center.

under contract to the National Center for Health

Statistics, was responsible for the survey’s field

operations.

For a more detailed discussion of the limitations,

qualifications, and definitions of the data collected

by NAMCS, see Vital and Health Statistics, Series 13,

Number 44.

Sampling errorsand rounding of numbers

The standard error is a measure of the sampling

variability that occurs by chance because only a sampie. rather than an entire universe, is surveyed. The

relative standard error of the estimate is obtained by

dividing the standard error by the estimate itself and

is expressed as a percent of the estimate. Tables I and

11apply these measurements to drug mentions.

Estimates have been rounded to the nearest thousand. For this reason detailed figures within tables do

not always add to totals. Rates and percents were

calculated from original. unrounded figures and will

not necessarily agree precisely with rates or percents

calculated from rounded data.

Definitions

An ambulatory patient is an individual seeking

personal health services who is neither bedridden nor

currently admitted to any health care institution on

the premises.

A ph~gsiciiitleligible for A:AMCS is a duly licensed

doctor of medicine or osteopathy currently i:n officebased practice whose primary job is caring fctr ambulatory patients. Excluded from NAMCS are: physicians MO are hospital based; physicians who specialize in anesthesiology, pathology, or radiology;

physicians who are Federally employed; ph~ysicians

who treat only institutionalized patients; physicians

employed full time by an institution; and physicians

who spend no time seeing ambulatory patients.

An office is a place that the physician identifies

as a location for his ambulatory practice. Responsibility over time for patient, care and professional services rendered there generally resides with the individual physician rather than an institution.

A l’isit is a direct personal exchange between an

ambulatory patient and a physician or a staff ]member

working under the physician’s supervision, for the

respective purpose of seeking care or rendering health

services.

A drug mention is the physician’s entry of a pharmaceutical agent ordered or provided for prevention,

diagnosis, or, treatment. Generic as well as brandname drugs are included, as are nonprescription as

well as prescription drugs. Along with all new drugs,

the physician also records continued medications, if

the patient was specifically instructed during the visit

to continue the medication.

Table 1. Approximate relative standard errors of estimated number of

drug mentions based on all physician specialties: National Ambulatory Medical Care Survey, 1980

Estimated number of drug mentions

in thousands

Relative

standard

error

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

650.000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27.3

19.7

13.2

10.1

8.2

6.8

6.2

5.8 ,

5.8

Example of use ot table: An aggregate estimate of 175,0001,000 drug

ment!ons has a re19tive standard error of 6.5 percent or a standard error

of 4,875,000 mentions (6.5 parcent of 75,000,000).
ackmdaa 11

Table 11. Approximate standard errors of percent of estimated numbers of drug mentions based on all physician spacialtie~ NAM(28, 1980

Base of percent

(number of drug mentions in thousands)

Estimated percent

1or 99 5 or 95 100r90 20 or 80 30 or 70 50

Standard error in percentage points

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7 5.8 8.0 10.7 12.2

2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13.3

1.9 4.1 5.7 7.6 8.7 9.4

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 2.6 3.6 4.8 5.5

20,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6.0

0.6 1.3 1.8 2.4 2.7

100,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.0

0.3 0.6 0.8 1.1

600,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.2 1.3

0.1 0.2 0.3 0.’4 0.5 0.5

Examplo of use of table: An estimete of 30 percent based on an eggregataof 12,500,000 drug mentions was a standard error of 4.1 percent or a

relative stendard error of 13.7 percent (4.1 percent+ 30perce-nt).
From Vital and Health Statistics of the National Center for Health Statistics NumbeP 79. May 12, 1982

Blood LeadLevelsfor Persons 6 Months-74 Years of Age:

United States, 1976-80

by Joseph L. Annest, Ph.D., Division of Health Examination Statistics; Kathryn R. Mahaffey, Ph’.D., Food and Drug Administration, Cincinnati, Ohio; Dennis H. Cox, Ph.D., Centers for Disease Control, Atlanta; and Jean Roberts, M. S., Division of Health

Examination Statistics

Introduction

One of the more recent growing public health

concerns is the impact of the changing environment

on health.1 As a part of this concern, the Division of

Health Examination Statistics of the National Center

for Health Statistics has measured the degree of exposure of the U.S. civilian noninstitutionalized population to certain toxic substances, including lead. This

has accomplished by determining blood lead concentrations, a common index of lead exposure, on examinees from the second National Health and Nutrition

Examination Survey (NHANES II). The rationale for

measuring exposure to this environmental hazard was

to (1) provide information for the first time about

the distribution of blood lead levels in the general

U.S. population, (2) establish baseline estimates for

future studies to monitor changes in such exposure

over time, <3) provide nonnative information for use

in health policy and regulatory decisions, and (4)

correlate levels of exposure to these toxic substances

with other health and nutritional parameters measured on examinees in NHANES 11.2

Surveillance data, from the Centers for Disease

Control (CDC) on childhood lead poisoning in the

United States gives some indication of the extent to

which lead exposure is a public health problem

among children. A recent Centers for Disease Control

Morbidity and Mortality Weekly Reports states that

for the first 6 months of fiscal year 1981, almost

20,000 children were known to be under pediatric

management for lead toxicity. These CDC surveillance data come from approximately 60 federally

funded screening projects located in about 25 States.

Hazards of industrial exposure to lead are well

documented, but the actual magnitude and significance of general community exposure to lead in the

environment has been a controversial subject for

years.b

This report presents statistics on the distribution

of blood lead levels of persons ages 6 months-74 years

in the United States with respect to age, race, sex,

annual family income, and degree of urbanization (of

place of residence). These are the first national estimates of lead levels in whole blood obtained on a representative sample of the U.S. population. A future

NCHS Series 11 publications is planned to provide

detailed descriptive statistics for blood lead levels for

selected demographic, socioeconomic, health, and

nutritional factors.

NHANES II survey sample design

A brief description of the sample design of

NHANES II is presented in the Technical Notes. A

detailed description of the survey design has been

published.z

From a total of 27,801 NHANES II sample persons, 16,563 persons were asked to provide blood

specimens for use in the assessment of blood lead

levels. These included all children ages 6 months6 years and a half-sample (those assigned odd sample

numbers for the examination) of persons ages 7-74

years. However, some parents refused to have their

young children examined and/or give blood. Some

adults, especially the elderly, were reluctant or unable

to come to the mobile examination units (set up at

centralized locations within the 64 sampling areas)

for exaniination. Also, to a lesser degree, a number of

blood specimens were lost during shipment and processing. As a result, reliable blood lead levels were determined for blood specimens from 10,049 examinees. CapiIlaW blood was obtained from 113 children

ages 6 months-7 years by fingerstick, and venous

blood from the remaining 9,936 exzuninees by venipuncture.

To estimate the potential bias of missing data, the

distribution of sample persons in the lead subsample

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service, Office of Health Research, Statistics, and Technology
2 —-

with missing blood lead data was investigated with

respect to the relevant demographic variables. The

results suggest that sample persons with missing blood

lead data are distributed randomly by race, sex,

income, and degree of urbanization. However, some

caution should be exercised in using these findings because of the high percent of missing data. Approximately 40 percent of the 16,563 sample persons had

no blood lead determinations. Details (tables I and II)

on nonresponse are presented in the Technical Notes.

Further investigation of potential bias due to nonresponse with respect to demographic variables and related medical history components is planned for the

Series 11 report in preparation.5

In this report, statistics are presented for three

age categories to ensure subsamples of sufficient size

for reliable national estimates-preschool children

ages 6 months-5 years, youths ages 6-17 years, and

adults ages 18-74 years.

It should be noted that the mean blood lead levels

and the proportion of children with elevated blood

lead levels presented in this study would be expected

to differ from those obtained from the communitybased lead poisoning prevention programs directed by

the CDC. The CDC program is designed to screen selectively or on request for individual: at potentially

high risk of exposure to lead using initially an erythrocyte protoporphonn (EP) test followed by blood

lead tests on those with EP levels of 50 micrograms

per deciliter (#g/all) of whole blood or morels On the

other hand, the NHANES II utilizes a probability

sample representative of the general U.S. population

selecting individuals for examination and blood lead

determinations independent of their risk of exposure

to lead or their EP test results.
amcdata3

Methods and procedures

The laboratory determinations of blood lead

levels for this national survey were performed by the

Clinical Chemistry Division, Center for Environmental Hwdth, Centers for Disease Control (CDC),

Atlanta. Georgia. and financed by the Division of

Nutrition. Bureau of Foods. FDA, Cincinnati, Ohio.

Descriptions of the materials. methods, and quality

control procedures are presented elsewhere.T~8 Lead

concentrations of NHANES II whole blood specimens

and control specimens were determined by atomic

absorption spectrophotornetry using a modified

Delves CLIpmicromethoci.g Specimens were analyzed

in duplicate with the two assessments done independently in the stime analytic run. The average of the two

measures was used in the analysis presented in this

report.

The foIlowing national estimates are based on

data obtained on 9.933 NHANES II examinees with

blood lead levels ranging from 2.0-66.0 ~g/dl of

whole blood among those who received venipunctures. Although the fingertips were carefuily prepared

to minimize contamination. potential for contanlination during the capiilary blood collection by fingerstick (pricking the tlnger) is recognized.1 O Statistical

analysis of the unweighed data suggested that inclusion of the tingerstick data in this analysis would have

introduced bias to the estimates of mean venous

blood lead levels in children. Overall, for children ages

6 months-5 years. unweighed mean blood lead level

for those receiving fingersticks was observed to be

approximately 6.0 gg/dl higher than for those receiving venipunctures. This observed mean difference was

consistent for black and white people. The three examinees with venipunctures showing blood lead levels

greater than 70.0 pg/dl are extreme cases of lead exposure. These have been considered a separate part of

the distribution of blood lead levels in the general

population. Therefore, the fingerstick data and values

for the three extreme venipuncture cases were excluded from detailed tables 1-7 and further stages of

the analysis. A description (table III) of blood lead

levels for 113 children ages 6 months-7 years receiving fingersticks and of the three extreme cases of Iead

exposure is given in the Technical Notes.
4

Findings

Mean blood lead levels by age,

race, and sex

Mean blood lead level estimates for the U.S.

population differ substantially with respect to age,

race, and sex (figures 1-3 and tables 1-3).

For young children ages 6 months-5 years, mean

blood lead levels are similar among those of the same

age and sex (figure 1). The differences between means

among age and sex groups shown in figure 1 are not

statistically significant at the 0.05 level. However,

mean blood lead levels of black children significantly

exceed those of white children. Overall for this age,

blood lead levels among black children are, on the

average, 6.0 pg/dl higher than among white children.

Overall for children and youths ages 6-17 years,

there is a significant decreasing trend in mean blood

~ White

= ~,,.~

I

95-percent confidence

intervals

Males

24

20 ~

%

=

16

m

a

L

c 12

~

8

0

6 months-2 years 3-5 years

Females

24r -r

6 months-2 years 3-5 years

SOURCE: National Health and Nutrition Examination

Survey, National Center for Health Statistics.

Figure 1. Mean blood lead levels (PbB) of children ages 6 months5 years: Umted States, 1976-80

lead levels with increasing age. Eliminating the effect

of age, significant race and sex differences are

evident. Generally, as age increases the difference in

mean blood lead levels between boys and girls progressively increases. There is a significant inverse relationship of blood lead level with age for black persons; that is, mean blood lead levels decrease as age

(successive age groups) increases through the age of

17 years. The relationship between blood lead level

and age for white children and youths is similar to

that for the respective black groups, except that mean

blood lead levels decline with increasing age until

about age 15 (or the 15-17-year age group) where the

mean blood lead levels are observed to he higher

(figure 2).

For adults ages 18-74 years, the sex difference in

blood lead levels is pronounced and significant. The

mean blood lead levels of men are consistently higher

than those of women in al!, age groups. The differences in these levels between the sexes are similar for

24

20

16

12

8

0;

~ Male

= Female

I

95-percent confidence

intervals

White persons

6-8years 9-11 years 12-14 years 15-’17 years

81ack persons

2

~ 2

‘m

~

m.

1

r2

c 1

E

6-8years 9-11 years 12-14 years 15-17 years

SOURCE: National Health and Nutrition Examination

Survey, National Center for Health Statistics.

Figure 2. Mean blood lead levels (PbB) of youths ages 6-17 years:

United States, 1976-80
akEecMa5

~ Male

= Female

I

95-percent confidence

intervals

White persons

28

24

~

al 20

=

m 16

e

c

~

z

12

8

0

18-24 25-34 35-44 45.54 55-64 65-74

years years years years years years

Black persons

~

3

~

2

0.

c

E

18-24 25-34 3544 45-54 55-64 65-74

years years years years years years

SOURCE: National Health and Nutrition Examination

Survey, National Center for Health Statistics.

Figure 3. Mean blood lead levels (PbB) of adults ages 18-74 years:

United States, 1976-80

white and for black persons (figure 3). In addition,

there is a significant relationship between mean blood

lead Ievei and age. However, the trend in mean blood

lead levels with age differs for white and for black

men. For instance, when the mean blood lead levels

for white and black men are compared, those for

white men increase with age until age group 3544

years and then decrease while those for black men remain high through age group 55-64 years. After accounting for differences in the age distributions for

both races, there are significantly higher mean blood

lead levels among black than among white adults.

Blood lead levels for children by income

and degree of urbanization

The associations of family income and of the degree of urbanization with blood lead levels are generally consistent across all three broad age groups in the

population with lower mean blood lead levels among

the more affluent than among the poor and those in

rural than in urban areas (tables 4 and 5). These associations were most pronounced, however, in children

ages 6 months-5 years. Hence, further consideration

of blood lead levels in this report with respect to

these demographic variables will be limited to the

findings among preschool-aged children.

The most common sources of environmental lead

for young children are air, food, dust, dirt, soiI, water,

and lead-b~sed paint. Lead usually enters the body by

ingestion or inhalation. In very young children, clinical studies have shown that approximately 40 percent

of the lead ingested is absorbed from the gastrointestinal tract, while adults absorb about 5 to 10 percent of ingested lead.

The rate of absorption of airborne lead in relation

to age is not as clearly understood. Although percent

retention of inhaled lead is influenced greatly by

particle size, clinical studiesl 2 suggest that, in general,

20 to 40 percent of the inhaled lead wilI be deposited

in the respiratory tract. However, because of hi:&er

metabolic rates and greater physical activity of children, it is estimateds that under comparable exposure, children inhale two to three times as much

airborne lead per unit of body weight as adults do.

Even at relatively low levels of lead, subclinical

effects of lead exposure in children, including impaired hematopoiesis and neuropsychologic deficits,

have been reported in the Literature.14~15

In each of the three income groups. the mean

blood lead levels of black children are significantly

greater than those of white children (figure 4). The

smallest race difference is in the highest income

group. There is also a significant inverse relationship

between mean blood lead level and income. For this

analysis, three income categories were selected to ensure subsamples of adequate size for computing these

national estimates. In 1978, the income leveI of

$6,000 was near the poverty threshoid for a family

of four as determined by the U.S. Bureau of the

Census.16

Mean blood lead levels are observed to be higher

in the urban areas than in the rural areas for white

and black children with statistically significant differences oniy for the white group (figure 5). Also, mean

blood lead IeveIs for black children are significantly

higher than those for white children within all three

urban-mral groups. This consistent mean difference

between black and white chiIdren indicates that the

observed racial effects are not simpIy explained by

the degree of urbanization. No clearcut explanation

can be given from the results of this study; however,

these resuits are consistent with the findings of other

studies regarding this racial difference-l T-lg

Further investigation of those living in the large

urban areas ( 1 million or more people) (figure 6 and

table 6) revealed that mean blood lead Ievels of black
6

Table 1. Blood lead levels of persons 6 months-74 years, with mean, standard error of the mean, median, and percent distribution, by race and age:

Unned States, 1976-80

—

Estimated Blood lead level (pgldl)

population Number

Race and age in Standard Less exammedz

thousands 1

Mean error of Medt.en than 10-19 20-29 30-39 40-49 50-59 60-69

the mean 10

All races3

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

6months-5 years . . . . .

G17 years . . . . . . . . .

18-74 years . . . . . . . .

White

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

6months-5yesrs . . . . .

6-17 years . . . . . . . . .

18-74 years . . . . . . . .

Black

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

6months-5years. . . . .

6-17 years . . ...’....

18-74 years . . . . . . . . .

Percent distribution

22.1 62.9

12.2 63.3

27’,6 64.8

21.2 62.3

23.3 62.8

14.5 67.5

30.4 63.4

21.9 62.3

13.3 63.7

2.5 45.4

12.8 70.9

14.7 62.9

13.0 1.6 0.2 0.1 0.0

20.5 3.5 0.3 0.1 0.0

7.1 0.5 - - -

14.3 1.8 0.3 0.1 0.0

203,554

16,862

44,964

141,728

9,933

2,372

1,720

5,841

13.9 0.24 13.0

1E.o 0.42 15.0

12.5 0.30 12.0

14.2 0.25 13.0

174,528

13,641

37,530

123,357

8,369

1,876

1,424

5,069

13.7 0.24 13.0

14.9 0.43 14.0

12.1 0.30 11.0

14.1 0.25 13.0

12.2 1.5 0.2 0.1 0.0

16.1 1.8 0.1 0.1 0.0

5.8 0.4 - - -

13.7 1.8 0.3 0.1 0.0

23,853

2,584

6,529

14,740

1,332

419

263

650

15.7 0.48 15.0

20.9 0.61 20.0

14.8 0.53 14.0

15.5 0.54 14.0

20.0 2.3 0.3 0.2 0.1

39.9 10.2 1.4 0.5 0.1

15.6 0.7 - - -

19.6 2.0 0.4 0.3 0.2

lAtthe midpoint of thesuwav, March 1, 1978.

2wi~ lead det~rmin~ti~n~ from bl~~dspacimens draw” by venipuncture.

3 i“~l”de$ data for races not ~h~wn ~eparate}y.

4Numbers maynotadd tototalsduet0 rounding.

Table2. 8100dlead levels of males 6months-74 years, with mean, standard error of themean, median, and~rcent distribution, byram andage:

United States, 1976-80

Estimated Blood lead level (pg/dl)

population Number

Race and age in Standard Less examined2

thousands 1

Mean error of Median than 10-19 20-29 30-39 40-49 50-59 60-69

the mean 10

All rams3 Percent distribution

10.4 65.4 20.8

11.0 63.5 21.2

19.1 70.1 10.2

7.6 64.1 24.2

2.8 0.3 0.1 0.1

4.0 0.3 0.0 0.0

0.7 - - -

3.4 0.4 0.1 0.1

All ages . . . . . . . . . . . 99,062

8,621

22B87

67,555

4,945

1,247

902

2,786

16.1

16.3

13.6

16.8

0.26

0.46

0.32

0.28

15.0

15.0

13.0

16.0

6 months-5 years . . . . .

&17years . . . . . . . . .

18-74 years . . . . . . . .

White

2.6 0.3 0.1 0.0

2.0 0.1 - -

0.7 - - -

3.3 0.4 0.1 0.1

Alleges . . . . . . . . . . . 85,112

6,910

19,060

59,142

4,163

869

753

2,431

15.8

15.2

13.1

16.6

0.27

0.46

0.33

0.29

15.0

14.0

13.0

16.0

11.3 66.0 19.6

13.0 67.6 17.3

21.4 69.5 8.4

8.1 64.8 23.3

6months-5yeers . . . . .

&17 years . . . . . . . . .

lB-74 years . . . . . . . .

Black

4.0 59.6 31.0

2.7 48.8 35.1

8.0 69.9 21.1

2.3 56.4 34.9

4.1 0.7 0.4 0.2

11.1 1.9 0.2 0.3

1.0 - -

4.5 0.8 0.6 0.4

Alleges . . . . . . . . . . . 11,171

1,307

3,272

6,592

664

231

129

304

18.3

20.7

16.0

19.1

0.52

0.74

0.62

0.70

17.0

19.0

15.0

18.0

6months-5 years . . . . .

&17 years . . . . . . . . .

lB-74 years . . . . . . . .

lAt the midpoint of the survey, March 1, 1978.

2with l-ad determinatl~ns from bl~~d$pecimens drawn by vef’tipuncture.

31ncl”desdat~ forrac~n~t~~~n s(r~arately.

4Numb.r$ may noteddto tomlsdue to rounding.
akxedaa7

Table3. Blood lead levels of females 6months-74 years, with mean, ~ndarderror of themean, mdian, aA~rcent diHritition, byram and age:

United States, 1976-80

Estimated Blood lead level (@all)

Race and age

population Number

examined2 Standard Less

thou&dsl

Mean error of Madian than 10-19 20-29 30-39 4G49 50-59 60-69

tie mean 10

All races3

All ages . . . . . . . . . . . 104,492 4,988 11.9 0.23 11.0

6 months-5 years . . . . . 8,241 1,125 15.8 0.42 15.0

&l 7 years . . . . . . . . . 22,077 ,-818 11.4 0.32 11.0

18-74 yearn . . . . . . . . 74,173 3,045 11.8 0.22 11.0

White

All ages . . . . . . . . . . . 88,417 4,216 11.7 0.23 il.o

6 months-5 years . . . . . 6,732 807 14.7 0.44 14.0

6-17years . . . . . . . . . 18,470 671 11.0 0.31 11.0

18-74 years . . . . . . . . 64,215 2,638 11.7 0.23 11.0

81ack

All ages . . . . . . . . . . . 12.682 668 13.4 0.45 13.0

Percent distribution

33.3

13.5

36.6

33.7

34.8

16.1

40.0

34.6

21.5

2.2

17.7

24.7

60.5

63.2

59.3

60.6

59.6

67.3

56.9

59.9

67.3

41.6

71.9

68.1

5.7 0.4 0.1 0.1 -

19.8 3.0 0.3 0.2 -

3.9 0.2 - - -

5.2 0.3 0.1 0.1 -

5.0 0.4 0.1 0.1 -

14.8 1.6 0.1 0.1 -

2.9 0.2 - - -

5.0 0.4 0.1 0.1 -

6 months-5 years . . . . . 1,277 188 21.0 0.69 20.0

&17years . . . . . . . . . 3,256 134 13.6 0.64 13.0

18-74 years . . . . . . . . 8,148 346 12.7 0.44 12.0

lAt fi. midpoint of tho SUrVOY,March 1.1978.

%liti jcad determinations from blood specimens drawn by VOniPUnCtW*.

aln=ludas dam for ra~s~ not ~own mp~rately.

4Numbers may not add to totals dumto rounding.

I

95-percent confidence

intervals

28 r7A ~ -1-

Lassthan s5,000- S15,000

S6,000 14,999 or more

SOURCE: National Health and Nutrition Examination

survey, National Canter for Health Statistics.

10.3 0.7 0.1 0.0 -

45.3 9.2 0.9 0.8 -

10.0 0.4 - - -

7.2 - - - -

~ White

~ ~,.c~

I

95-percent confidence

intervals

24 r

1- 7

Urban Urban Rural

l,oCO,ooo Fewer than

parsons 1,000,000

or more parsons

SOURCE: National Health and Nutrition Examination

Survey, National Canter for Health Statistics.

Figure 4. Mean blood lead levels (PbB) of children ages6 months5 years by annual family income: Unitad States, 1976-80

Figure 5. Mean blood lead levels (PbB) of children ages6 months5 years by degree of urbanization: United States, 1976-80
a

Table 4. Blood lead levels of persons 6 months-74 years, with mean, standard error of the mean, and selectad percentiles, by annual family income,

race, and age: United States, 1976-80

A nnuai family income

Under .S6,000

Race and age

Estimated Standard Percentile

population Number Mean error

in examined2 of the

thousandsl mean 10th 50th 90th

All races3 Blood lead level (#g/all)

Alleges, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6months-5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6-17 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Whtte

All eges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6months-5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6-17 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

All eges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6months-5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6-17years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29,410

2,465

5,046

21 ,89a

21,542

1,408

3,067

17,067

7,355

917

1,927

4,512

1,862

448

230

1,184

1,315

256

140

919

512

176

87

249

14.5 0.40 8.0

20.0 0.56 11.0

14.6 0.61 8.0

14.1 0.38 7.0

14.0 0.44 7.0

lB.1 0.61 11.0

14.0 0.69 8.0

13.7 0.43 7.0

15.8 0.47 9.0

22.9 0.89 14.0

15.7 0.76 10.0

15.0 0.53 8.0

13,0

19.0

13.0

13.0

12.0

17.0

13.0

12.0

15.0

21.0

15.0

14.0

23.0

31.0

22.0

23.0

23.0

26.0

22.0

22.0

24.0

34.0

22.0

23.0

lAtthemidPo, ntof the survey, March 1, 1978.

Zwith leaddeter~inati~n~fr~m bl~odspecimens drawn byvenipuncrure.

sln~l”de~d~taf~r race~nol~hownseparately.
dmcedaa9

Table4. Blood lead levels of persons 6months-74 years, with mean, standard error of themean, andwlected percentiles, byannual family income,

race, andege: United States, 1976-80-Con.

Annual family income

$6,000-14,999 $15,000 or more

Estimated Standard Percentile Estimated

population Number

Standard Percentile

Mean error population

in

Number

exeminedz

error

of the

Mean

examinedz

thousands 1

10th 50rh 90th

of the

mean tfrougnds 1 mean 10th 50th 90th

Blood lead level (pg/dl) Blood lead level (#g/all)

80,416 4,033 14.2 0.25 8.0 13.0 22.0 87,062 3,718 13.5 0.24 8.0 13.0 20.0

7,534 1,083 16.2 0.46 ‘8.0 15.0 24.0 6,428 774 14.1

17,533 672 12.9 0.41 7.0 12.0

0.41

19.0

8.0 13.0 21.0

20,814 761 11.7

55,349 2,278 ‘14.4 0.26 8.0 13.0

0.25

22.0

7.0 11.0 17.0

59,820 2,183 14.1 0.27 8.0 13.0 21.0

68,135 3,413 13.9 0.26 8.0 13.0 21.0 79,707 3,401 13.4 0.26 8.0 13.0 20.0

6,252 887 15.3 0.48 9.0 14.0 22.0 5,707 680 13.7

13,936 531 12.4 0.39 7.0 12.0

0.44

18.0

8.0 13.0 20.0

19,174 705 11.6 0.28

47,946 1,995 14.2 0.26 8.0 13.0

7.0

22.0

11.0 16.0

54,826 2,006 14.0 0.28 8.0 13.0 21.0

10,334 533 16.1 fJ48 9.0 15.0 24.0 4,995 224 14.9 0.58 9.0 14.0 22.0

1,037 163 20.7 0.64 13.0 20.0 30.0

3,159 125

502

14.9

60

0.71 10.0

17.2 0.83 11.0 16.0 24.0

14.0 21.0

6,137 245

1,225

16.2

42

0.60

13.6

9.0 15.0

0.79 7.0

24.0

13.0

3,267

20.0

122 15.1 0.65 9.0 14.0 22.0
10

Table 5. Blood lead levels of persons 6 months-74 years, with mean, standard error of the mean, and selected percentiles, by degree of urbanization

race, and age: United States, 1976-80

Race and age

Degree of urbanization

Urban, 1 million persons or more

Estima red Standard Percentile

population Number Mean error

in exammed2 of the

thousands 1 mean 10th 50th 90th

Al I races Blood lead level (pg/dl)

All ages . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6months-5years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6-17 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White

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

6months-5years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6-17 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

All eges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6months-5years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6-17years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

59,532

4,344

12,893

42.295

46,407

3,112

9,681

33,615

11,687

1,093

3,010

7,585

2,395

544

414

1,437

1,767

358

294

1,115

570

172

111

287

15.0 0.37 9.0

18.0 0.53 10.0

13.8 0.53 9.0

15.2 0.39 9.0

15.0 0.31 9.0

16.6 0.59 10.0

13.3 0.55 9.0

15.3 0.31 9.0

15.5 0.84 9.0

22.2 0.83 14.0

15.3 0.83 10.0

15.0 0.89 8.0

14.0

17.0

13.0

14.0

14.0

16.0

12.0

14.0

14.0

20.0

15.0

14.0

22.0

27.0

20.0

23.0

22.0

24.0

20.0

23.0

23.0

35.0

22.0

22.0 —.

lAtthe midpoint of thesuWeY, March 1, 7978.

Zwlth Iead determinations from blood specimens drawn byvanipunktura.

3 Includes data for raca~ not +own $eparat@ly.
dwlceda 11

Table5. Blmdlead lemlsof ~rsons6mnths.74 yearn, with mean. fiantird error of themean, andsel~ted ~rcentiles, by degree of urbanization,

race, andege: United States, 1976-80-Con.

Degree of urbanization

Urban, fawarthan I million persons Rurai

Estimated Standard PeEentiie Estimated

population Ndmber

Standard Percenriie

Mean error population Number error

in exarninedz of the

Mean

in examined2 of the

thousands mean IOth 50th 90th thousands1 mean 10th 50th 90th

Blood lead level (pg/di) Blood lead level (pg/dl)

79,906 3,869 13.9 0.32 8.0 13.0 21.0 64,116 3,569 13.0 0.40 7.0 12.0 20.0

6,891 944 16.5 0.67 9.0 16.0 24.0 5,627 884 13.9 0.64 8.0 13.0 20.0

16,988 638 12.6 0.35 7.0 12.0 19.0 15,083 668 11.4 0.52 7.0 11.0 16.0

56,027 2,287 14.1 0.33 8.0 13.0 22.0 43,405 2,117 13.4 0.38 7.0 12.0 21.0

67,707 3,144 13.6 0.32 8.0 13.0 21.0 60,414 3.458 12.8 0.39 7.0 12.0 20.0

5,297 699 15,4 0.67 9.0 15.0 23.0

13,871

5,233 819 13.5 0.57 8.0 13.0 19.0

510 12.2 0.36 7.0 11.0 18.0 13,978 620 11.2 0.48 7.0 11.0 16.0

48,540 1,935 13.8 0.32 8.0 13.0 21.0 41,203 2,019 13.3 0.38 7.0 12.0 21.0

9,783 612 15.9 0.54 9.0 15.0 24.0 2,383 150 16.2 0.68 9.0 14.0 25.0

1,246 205 20.3 0.78 12.0 20.0 30.’3 245 42 18.3 2.60 11.0 16.0 32.0

2,717 113 14.5 0.64 8.0 14.0 20.0 802 39 13.9 1.33 8.0 13.0 20.0

5,820 294 15.9 0.70 9.0 15.0 24.0 1,336 68 17.0 0.89 9.0 15.0 26.0
12

I

95-percent confidence

intervals

28 r

24 1- T

Central city Non-central city

SOURCE: National Health and Nutrition Examination

Survey, National Center for Health Statistics.

Figure 6. Mean blood lead levels (PbB) of children ages 6 months5 years in large urban areas: United States, 1976-80

children in the central cities were observed to be

higher than those of black children living in the noncentral cities and rural areas, respectively. These differences were neither statistically significant nor reliable because of the small number of black children in

the sample. However, within the central cities, the

mean blood lead level of black children was significantly higher than that of white children. Other

studies indicate that 13 exposure to lead in central

city children may be associated, to some degree, with

socioeconomic factors. It was observed ii this study

that 43 percent of black compared with 22 percent of

white children living in the central city areas were

from households with annual family incomes of

under $6,000 during the year preceding the time of

interview.

The literature 3 suggests that preschool-aged children from low income households living in the inner

cities (the “urban lead-belt”) are at higher risk of exposure to environmental sources contaminated with

lead than the general child population. Attempts to

include such cross-classifications using the NHANES

II data resulted in group sizes too small to be reliable

estimators for the general population. For example,

while it would have been of interest to determine if

the association between race and blood lead level

differed between various degrees of urbanization by

income groups. the number of examinees within such

groups was too small.

Elevated blood lead levels in children

The consistent difference in blood lead levels between black and white children ages 6 months-5 years

and the presence of higher blood lead levels among

those in the low income group and large urban areas

can also be distinguished by looking at the percent of

children with blood iead levels of 30 gg/dl or more.

According to CDC guidelines published in 1978s 30

pg/dl is the cutoff used in the CDC community-based

lead poisoning prevention programs for referring children for followup.

Based on the CDC guidelines (30.0 Mg/dl or

more), NHANES II data indicate than an estimated

4.0 percent or approximately 675,000 U.S. children

6 months-5 years of age have elevated blood lead

levels (table 7). Among children of this age, 12.2 percent of black children compared to 2.0 percent of

white children had blood lead levels of 30 pg/dl or

more. This difference is significant for boys and for

girls. The percent with elevated blood lead levels are

observed to be slightly higher in boys than girls, but

this difference is not statistically significant at the

0.05 level of probability.

There was a significant decrease in the proportion

of children with elevated blood lead levels with increased family income. This relationship was stronger

for black than for white children. The highest percent

of elevated blood lead levels (18.5 percent) was found

among black children from low income families. For

both white and black children, the percent of Persons

with elevated blood lead levels was lowest in the high

income group.

With respect to degree of urbanization, the percent with elevated blood lead levels living in the central cities was significantly higher for black than

white children. Even in the smaller urban and rural

areas, 10.0 percent of black children were observed to

have elevated blood lead levels compared with less

than 2.0 percent for white children. Caution should

be exercised in interpreting racial differences in rural

areas because of a relatively small number of examined persons (42 cases) in the estimation cell for rural

black children.

Trends in lead levels

Preliminary analyqes suggest that in the 4-year

period of this survey there was a 37-percent decrease

in the mean blood lead levels from 15.8 pg/dl during

the first 6 months of the survey to 10.0 pg/dl during

the last 6 months (figure 7).

Decreases were found for both black and white

races, all age groups, and both sexes (figure 8).

Further analysis indicated that the decline was not

due to seasonal, income, geographic region, or urbanrural differences. Nor was it due to laboratory measurement error or chance.20
Table 6. 9100CIlea ievel~of perSanS 6 rnonths.74 years, with mean, standard error of themeanr and selected percentiles, by large urban areas, race, and age: United States, 1976-80

Large urban areas

Central city Non-central city

Race and age

Estimated Standard Percentile Estimated Stanrr%rd Percentile

population Number Mean error population Number error

in examined2 of the

Mean

examined2

50th 90th thou:nd~~

of the

thousands~ mean 10th mean 10th 50th 90th

All racas3 Blood lead level (#g/all) Blood Iesd level (pg/dl)

Alleges . . . . . . . . . . . . . . . . . . . . . . . . . . 24,580

1,822

5,124

17,614

1,123

266

177

660

14.9 0.67 9.0

20.0 0.71 11.0

14.6 0.87 9.0

14.7 0.70 8.0

14.0

19.0

14.0

14.0

14.0

17.0

14.0

14.0

14.0

21.0

14.0

14.0

22.0

31.0

21.0

22.0

34,908

2,519

7,746

24,643

1,268

257

236

775

15.1 0.30 9.0

16.5 0.60 10.0

13.3 0.59 9.0

15.6 0.29 9.0

14.0 23.0

16.0 24.0

12.0 19.0

14.0 23.0

14.0 23.0

15.0 24.0

12.0 18.0

14.0 23.0

15.0 22.0

19.0 26.0

16.0 22.0

15.0 22.0

6months-5years . . . . . . . . . . . . . . . . . . . .

6-17yaars . . . . . . . . . . . . . . . . . . . . . . . .

18-74years . . . . . . . . . . . . . . . . . . . . . . . .

White

Ailages . . . . . . . . . . . . . . . . . . . . . . . . . . 14,602

885

.2,710

11,007

625

133

86

406

14.8 0.56 9.0

17.4 0.84 10.0

14.3 0.93 9.0

14.8 0.59 9.0

22.0

25.0

21.0

22.0

31,741

2,223

6,949

22,569

1,138

224

207

707

15.1 0.32 9.0

16.2 0.65 10.0

13.0 0.63 8.0

15.6 0.30 9.0

6months-5years .,....... . . . . . . . . . . .

6-17years . . . . . . . . . . . . . . . . . . . . . . . .

18-74years . . . . . . . . . . . . . . . . . . . . . . . .

81ack

All eges . . . . . . . . . . . . . . . . . . . . . . . . . . 8,868

856

2,259

5,742

452

143

84

225

15.4 0,84 8,0

23.1 1.30 14.0

15.0 1.00 9.0

14.8 0.95 8.0

23.0

36.0

21.0

22.0

2,831

238

751

1,842

118

29

27

62

16.0 0.60 9.0

19.2 0.74 14.0

16.0 0.67 10.0

15.7 0.80 9.0

6months-5years . . . . . . . . . . . . . . . . . . . .

6-17years . . . . . . . . . . . . . . . . . . . . . . . .

18-74years . . . . . . . . . . . . . . . . . . . . . . . .

lAt the midpoint of tha survay, March 1, 197S,

2With Iaad detarmlnations from blood SpaCkrIOnOdrawn by Vm?ipuswtur..

Slncludes date for racm nOt shown SOparatdy.
14

Table7. Per@ntof children a~s6months-5 years with blood ledlevels of30.0pg/dl ormore,1 with standard error of thepercant, byselectad

demographic variables: United States, 1976-80

Demographic variable A II White Black All White Black

racesz races2

Percent of ch ildran 113 Standard error

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.0 2.0 12.2 0.5 0.3 1.5

Boys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 2.1 13.4

Girls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0.7 0.5 2.0

3.5 1.B 10.9 0.5 0.4 2.4

Annual family income

Under$6,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.9 5,9 18.5 1.4 1.3 3.6

$6,000-14,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 2.2 12.1 0.7 0.5 1.9

$15,0000rmore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 0.7 2.B 0.4 0.3 1.2

Degree of urbanization of place of residence

Urban, lmillionpersonsormore . . . . . . . . . . . . . . . . . . . . . . . 7.2 4.0 15.2 0.7 0.7 1.5

Central icy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.6 4.5 18.6 1.9 1.9 2.B

Non-cantral city . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.7 3.8 3.3 0.8 O.B 1.4

Urben,fewerthan l millionpersons . . . . . . . . . . . . . . . . . . . . . . . 3.5 1.6 10.2 0.6 0.4 2.4

Rural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 1.2 10.3 0.9 0.5 5.3

Ilhe one chiid (a black mala, family income under $6,000, in a rural area) with an excossivoly high Pb-8 fOVOl (76. Opg/dl) wasaxclud@d. This

exclusion hesa negligible effect on the national estimates shown tsera.

21ncl”(jes dnta for ra~e~ “~~ sh~~” s~~ar~t~ly.

3E~ti~a~edu~jngda~on bl~~dl~adl~vej~d~~r~in~d from ~pe=imens drawn byvanipurrct”re.

‘7r

,~

1976 1977 1978 1979 1980 1981

Year

SOURCE: Adamedfrom reference 20.

Figure7. Mean blood levels of U.S. population 6months-74 years:

United States, February 1976-February 1960
dmmedaa 15

40

35

30

25

20

15

10

5

0

Male Female Black White 0.5-5 6-17 18-74

Overall Sexq Race Age (years)l

SOURCE: Adapted from reference 20.

1Forwhite pmons only.

Figure 8. Percent decrease in mean blood lead levels of U.S. population 6 months-74 years, by sex, race, and age:

United States, February 197B-February 1980
16 arkncedata

Summary

For years excessive exposure to lead has been a

serious public health concern for selected groups of

the population--particularly young children and lead

.smclter ancl other industrial workers. This report provides the first national mtimtites of the blood lead

levels in the U.S. population. based on the findings

from the National Health imd Nutrition Examination

Survey of 1976-80 (NHANES II). Blood lead levels

were determined on a cross-sectional sample representative of the U.S. civiliun noninstitutionalized

population 6 months-74 years of age examined in

NHANES II. These data were obtained for baseline

use in studies of the effect of lead contamination on

health and for identifying areas or groups at high risk

throughout the country.

Based on the CDC guideline for elevated blood

lead levels (30 micrograms or more per deciliter of

whole blood), an estimated 4.0 percent or approximately 675,000 U.S. children ages 6 months-5 years

show evidence of excessive amounts of lead in their

blood. The percent of children with this degree of

elevated blood lead level is significantly higher in

black (12.2 percent) than in white (2.0 percent)

children. Almost one-fifth ( 18.5 percent) of black

children from low income families have elevated

blood lead levels.

Among children 6 months-5 years of age, mean

blood lead levels are significantly higher in black than

in white children across all family income levels and

degrees of urbanization of their place of residence.

Mean blood lead levels are significantly higher among

children from Fdmilies with low income levels and

those in the large urbanized communities ( 1 million

or mo~~ population) than among children from

families with moderate or high income levels and

those living in smaller citiek or rural areas, respectively.

Among children ages 6-17 years, mean blood lead

levels decrease across successive age groups until

about adolescence. For persons 18-74 years ctf age,

mean blood lead levels are positively associated with

age until the middle ages (45-54 year group), ‘with a

moderate decline in the older age groups. Across all

adult age groups. the mean blood lead levels of men

substantially exceed those of women.
acklc4m 17

References

t National Center for Health Statistics: Statistics needed for

determining the effects of the environment on health, report

of the technical consultant panel to the United States National

Committee on Vital and Health Statistics. Vital and Health

Statistics. Series 4-No. 20. DHEW Pub. No. (PHS) 79-1457.

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

Office, July 1977.

2National Center for Health Statistics, A. McDoweIl, A. Engel,

J. T. Massey, and K. Maurer: Plan and operation of the second

National Health and Nutrition Examination Survey, 1976-

1980. Vital and Health Statistics Series l-No. 15. DHHS Pub.

No. (PHS) 81-IS 17. Public Health Service. Washington. U.S.

Government Printing Office, July 1981.

3Centers for Disease Control: Surveillance of chiIdhood lead

poisoning -United States. fiforbidity and Mortality Weekly

Report. Vol. 30, No. 34, DHHS Pub. No. (CDC) 81-8017. Public Health Service. Atlanta. U.S. Government Printing Office,

Sept. 4, 1981. pp. 438439.

4 World Health Organization: Healtit Hazards of the Human

Environment. Geneva. World Health Organization, 1972.

5 National Center for Health Statistics: Blood lead levels of

persons 6 months-74 years, United States, 1976-80. Vital and

HealtiZ Statistics. Series 11. Public Health Service, DHHS,

Hyattsville, Md. To be published.

6Centers for Disease Control: Preventing lead poisoning in

young children. J. Pediatr, 93(4):709-720, Oct. 1978.

7 Centers for Disease Control, E. W. Gunter. W. E. Turner,

W. Neese. et al.: Laboratory procedures used by the Clinical

Chemistry Division, Centers for Disease Control, for the

second National Health and Nutrition Examination Survey

(NHANES II). Atlanta. 1981.

8K. R. Mahaffey, J. L. Annest, H. E. Barbano, et aL: Preliminary analysis of blood lead concentrations for children and

adults: HANES H, 1976-1980. Trace Substances in Environmental Health –XIZI. pp. 37-51, D. D. Hemphill, Ed., Univ. of

Missouri, Columbia, 1979.

‘W. F. Barthel, A. L. Smrek, G. P. Angel. et aL: Modified

Delves cup atomic absorption determination of lead in blood.

J. Assoc. OfJ Anal Chetn. 56:1253-56, 1973.

10J. P. Crisler, N. T. Lao, L. C. Tang, et al.: A micro sampling

method for the determination of blood lead. Microchenz J.

18:77-84, 1973.

11K. R. Mahaffey: Relation between quantities of lead ingested and health effects of lead in humans. Pediatrics 59(3):

448-56, Mar. 1977.

12U.S. Environmental Protection Agency: Air quality criteria

for lead. EPA Pub. No. 600/8 -77-0 17, Office of Research and

Development. Washington. U.S. Government Printing Office,

1977.

13J. s. Lin.Fu: undue lead absorption and lead pOiSOI@ in

children-an overview. In: Proceedingsn Int. ConL on Heavy

Metals in the Environment, pp. 29-52. Torontoj Canada, Oct.

27-31, 1975.

14P. J. Landrigan, E. L. Baker, R. H. Whitworth, et al.: Neuroepidemiologic evahations of children with chronic increased

lead absorption. In H. L. Needleman, cd., Low Lead Exposure:

The Clinical Irnplicgtions of Current Research. Raven Press,

N,Y., 1980. pp. 17-33.

1‘H. L. Need.leman, C. Gunnoe, A. Leviton, et al.: Deficits in

psychologic and classroom performance of children with

elevated dentine lead levels. New Eng. J. Med. 300(13): 689-

732, Mar. 1979.

16 U.S. Bureau of the Census: Consumer income. ch~acteris.

tics of the population below the poverty level: 1978. Current

Population Reports. Series P-60, No. 124. Washington. U.S.

Government Printing Office, July 1980.

17 L H. Billick, A. S. Curran, and D. R. Shier: Analysis of pcdiatnc blood lead levels in New York City for 1970-1976.

Environ. Hlth. Perspect. 31:183-192, Aug. 1979.

18 C. J, Cohen, G. N. Bowers, and M. L. Lepow: Epidemiology

of lead poisoning, a comparison between urban and rural

children. JAJfA 226:1430-1433, 1973.

1‘J. M. Simpson, J. L. Clark, R. S Chaflop, et al.: Elevated

blood lead levels in children, a 27-city neighborhood survey.

Hlth. Serv. Rept. 88:419422, 1972.

20 Centers for Disease Control: BIood-lead levels in U.S. population. Morbidity and fifortality Weekly Report. Vol. 31, No.

10. DHHS Pub. No. (CDC) 82-8017, Public Health Service.

Atlanta. U.S. Government Printing Office, Mar. 19, 1982. PP

132-134.

21 R. S. Woodruff A simple method for approximating the

variance of a complicated estimate. JASA 66:4 11+14, 1971.

22National Center for Health Statistics, P. J. McCarthy: Pseudoreplication, further evaluation. and application of the brdanced half-sampie technique. Vital and Health Statistics. Series

2-No. 31. DHEW Pub. No. (HSM) 73-1270. HeaIth Services

and Mental Health Administration. Washington. U.S. Government Printing Office, Jan. 1969.

23 M. M. Holt: SURREGR, standard errors of regression coefficients from sample survey data. Unpublished. Research Triangle Institute, N.C., 1977.

~4.I. E. Grizzle, C. F. Starmer, and G. G. Koch: AnaIysis of

categorical data by linear models. Biometn.cs 25:489-504,

1969.

25 R. J. Landis, W. M. Stanish, J. L. Freeman, et al.: A computer program for the generalized chi-square analysis of categorical data using weighted least squares (GENCAT). Conzput.

Programs Biomed. 6:196-231, 1976.

26 D. ,Makuc: Interfacing SURREGR and GENCAT to analyze

complex surveys. Proc. Amer. Srat. ASSOC., Statistical Computing Section, pp. 16-19, 1981.

27H. T. Delves: A micro-sampling method for the rapid determination of lead in blood by atomic-absorption spectroscopy. Analyst. 95:431438, 1970.

28 J- M. Hunte~ The summer disease, an integrative model of

the seasonality aspects of childhood lead poisoning. Sot. Sci.

Med. 11:691-703, 1977.
18 ad’imncedata

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
akmadab 19

Technical notes

Sample design

The inforrmtion presented in this report is based

on data from the direct standardized physical examination. tests and measurements, and medical histories

collected in the second National Health and Nutrition

Examination Survey (NHMSES H) during 1976-80.

The target population of NHANES. H encompassed

the civilian noninstitutionalized population (ages 6

months through 74 years) of the United States. including Alaska and Hawaii.

NHANES H utilized a multistage probability design that involved selection of primary sampling units

(PSU’S), segments (clusters of households) within

PSU’S, households, eligibIe persons, and ilnally sample persons. PSU’S are typically composed of a county

or group of contiguous counties. The sample design

provided for oversampling among those p~rsons ages

6 months-5 years, those ages 60-74 yeafi; and those

living in poverty areas (as defined by the United

States Bureau of the Census for the 1970 censuslG ).

The U.S. Bureau of the Census selected the

NHANES II sample of 27,801 persons according to

specifications from the National Center for Health

statistics. Of this sample, 20,322 (73.1 percent) were

examined. A total of 16,563 persons in the NHANES

II sample, incIuding all persons ages 6 months-6 years

and a half-sample of persons ages 7-74 years, were assigned to receive the test for lead levels in the blood.

Of these sample persons, blood specimens were drawn

and analyzed for bIood lead on 10,049 persons giving

an overall response rate of 60.7 percent.

Blood Iead IeveIs and related data in this report

are presented as population estimates; examination

fiidings for each sample person have been inflated by

the reciprocal of selection probabilities, adjusted to

account for persons who were not examined, and

poststratified by race, sex, and age. The final estimates will then closely approximate the independent

U.S. Bureau of Census estimates for the civfiian noninstitutionalized population of the United States as of

March 1, 1978. No further adjustment was made for

examined persons in the lead subsample with missing

blood lead data due to refusal to give a blood specimen or otherwise.

Standard errors and tests of significance

The statistical methods used to analyze the data

take into account the complex survey design of

NHAN’ES 11.2 Complex survey techniques were used

to decrease the cost of sampling a large population.

Although complex survey designs complicate data

NOTE: A list of references follows the texL

analysis, they must be taken into consideration to

avoid the erroneous assumptions that would be made

using a simple random sanlpling method. The latter

usually results in an inferential analysis with too

many significant test results due solely to underestimation of variances.

The standard errors of the weighted means and

proportions of persons with elevated blood lead levels

presented in this report were calcu[ated using the

Taylor Series linearization method.~ I This process

approximates the variance of nonlinear statistics,

e.g., means and proportions, by using a first order

Taylor Series expansion. If the higher order terms of

the expansion are negligible, and if the sample is of a

reasonable size for the domains of interest, then this

approximation provides variance estimates as reliable

as those from the pseudoreplication method adapted

for analyzing NHAIJES II data.zz

For blood Iead analysis in this study, the population was divided into three age groups-children 6

months-5 years, youths 6-17 years. and adults 18-74

years. Regression analysis was performed within each

age group using bIood lead level as the dependent

variable and age as a covariate. The effect on blood

lead level of each of the demographic variables-race,

sex, income, and degree of urbanization-were tested

in this analysis after accounting for age. Tests of significance for comparing the means shown in figure 1

through 6 were performed using a regression program,

called SURREGR,ZS which takes into consideration

the complex survey sample design.

Using the Grizzle-Starrier-Koch (GSK) approach

to categorical data ana.lysis,24 tests of the hypothesis

that there is no difference among population subgroups in proportions of persons with elevated blood

lead levels (table 7) were performed. This analysis involved two stages, (1) estimation of the proportion of

those with elevated blood lead levels for the subgroups of interest and (2) estimation of an appropriate variance-covariance matrix and hypothesis testing

using categorical data analysis. The computation for

this analysis involved interfacing two programs–

SURREGR for the first stage calculations and GENCAT, a program for generalized chi-square analysis

of categorical data, for the second stage.zG~~T

Description of nonrespondents

and exclusions

All NHANES .11 sample persons ages 6 months-6

years and a half-sample of those ages 7-74 years were

to have had blood lead determinations. However, 39.3

percent of these sample persons had missing lead

values due to nonresponse at various stages of partici-
20

pation in the survey. The rate of nonresponse was

greater among preschool-aged children than among

youths or adults (table I). About half (5 1.0 percent)

of the children ages 6 months-5 years compared with

28.6 percent of persons ages 6-17 years and 35.7 percent of adults ages 18-74 years had no blood lead determinations. Among medically examined persons in

the lead subsample (table II), those with missing

blood lead values were randomly distributed by demographic (other than age) and socioeconomic categories. The analysis of the distribution of nonresponse for noninterviewed and nonexamined persons

in these categories is planned for a forthcoming

reports

Blood lead data from blood specimens drawn by

fingerstick (pricking the finger) and from extreme

cases of lead exposure (blood lead values of 70.0

~g/dl or more) were excluded from computation of

national estimates. A description of blood lead levels

for persons receiving fingersticks is given in table III.

Seventy-five percent of the 113 children with blood

lead values who received tingersticks were under 3

years of age. Table IV shows the characteristics of

three persons receiving venipunctures who had blood

lead values greater than 70.0 #g/all. Each of these

three individuals was referred to his personal physician for medical attention.

Quality control methods

Lead concentrations were measured in whole

blood by atomic absorption spectroscopy using a

modification of the Delves method.g~~T All materials

used for collecting and processing specimens were

screened for possible lead contamination. All preparatory work on the specimens, including field and laboratory procedures, were conducted under laminar

flow hoods that provided class 100 air (i.e., air conNOTE: A list of references foUows the text.

taining less than 100 particles/mq of greater than 0.5

micron diameter).

Two quality control systems using bovine whole

blood were set up by CDC. These two systems were

(1) “bench” quality control pools inserted by the

analyst and measured 2-4 times in each analytical run

to make judgments on the day of analysis and (2)

“blind” quality control specimens placed in vials,

labeled, and processed in duplicate to be indistinguishable from regular NHANES II specimens. If the

average of replicate values of either “bench” or

“blind” quality control specimens fell outside of their

respective previously established 95-percent confidence limits, the run was repeated. Also, NHANES II

specimens .-were run in duplicate. When replicate

absorbance values differed by more than 0.025

absorbance or the difference between calculated concentrations for duplicates was greater than 7 #g lPb/dl,

analysis was repeated for the specimen.

The “normal blind” pool with a mean of 13.7

pg/dl had a standard deviation (SD) of 2.2 pg/dl

(0.022 ppm) while the “high blind” pool with a mean

of 25.5 pg/dl had a SD of 3.2 ~g/dl (0.032 ppm:). The

coefficients of variation, that is, the standard deviation expressed as a fraction of the mean blood lead

level for a given pool, for the “bench” quality controls having blood lead levels of 30.0 pg/dl or more

ranged from 7.0 to 15.0 percent.7

Limitations of the data

Rigorous quality control methods were implemented throughout specimen collection and processing and in data processing to ensure validity and

accuracy of the results reported. However, there are

some factors that might affect the data. Foremost is

the relative imprecision of a measurement or measurement error. Based on an analysis of the quality control pools,g the coefficient of variation for the laboratory methods used are approximately 15.0 percent

Table 1. Nonresponse among sample persons ages 6 months.74 years in the iead subsample by age: National Health and Nutrition Examination

Survey, 1976-80

Age

Examined but missing

blood lead values

In lead In rer- /Vet /rrrarsubsamp /e Exam/ned ~xaNmOi~ed Refused

we wed vie wed Blood

Overall to gwe

blood

specimen

drawn 1

specimen

Percent of Perc(en t of

sample

exam inees2

persons2 without

WIrhou r

lead

lead

vajfues

values

Alleges . . . . . . . . . . . 16,563 15,179 1,384 t2,288 2,891 2,239 1,197 1,042 39,3 18.2

6 months.5 years . 5,069 4,876 193 4,118 758 1,634 988 646 51.0 39.7

6-17 years . . . . . . 2,413 2,261 152 1,967 294 245 122 123 28.6 12.5

18-74 years .,......, 9,081 8,042 1,039 6,203 1,839 360 87 273 35.7 5.8

lBY “eniPuncture or flngersxmk.

21n the lead suDsample.
,_

Table 11. Nonresjmnse among examined persons ages 6 months-74 years in the lead subsample by age, race, sex, income, and degree of urbanization:

National Health and Nutrition Examination Survey. 1976-80

Age

6 months-74 years 6 mon ths-5 years 6-17 years 18-74 years

Examined persons Examined persons Examined persons Examined persons

Number of with missing Number of with missing Number of with missing Number of with missing

persons lead values persons lead values persons lead values persons lead values

examined examined examined examined

Number Percent Number Percent Number Percent Number Percent

Demographic variables

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Race

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

sex

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

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Annual family income

Undar$6,000 . . . . . . . . . . . . . . . . . . . . . . .

$6,000-$14,999 . . . . . . . . . . . . . . . . . . . . . .

$15,0000rmore . . . . . . . . . . . . . . . . . . . . .

Unknown . . . . . . . . . . . . . . . . . . . . . . . . . .

Degree of urbanization

Largeurbanl . . . . . . . . . . . . . . . . . . . . . . . .

Smallerurban2 . . . . . . . . . . . . . . . . . . . . . . .

Rural . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12,288

10,263

1,737

298

6,123

6,165

2,291

5,082

4,509

2,239

1,806

18.2 4,118

17.6 3,264

21,1 723

22.1 131

18.3 2,143

18.2 1,975

,634 39.7 1,967 245 12.5

11.9

15.3

13.2

11.6

13.3

13.8

13.7

10.7

14.9

14.3

11.2

12.5

6,203 360 5.8

5.6

7.1

5.4

5.4

6.2

6.8

6.1

4.6

9.7

7.9

6.1

4.0

,311

269

54

40.2 1,616

37.2 313

41.2 38

192

48

5

5,373

701

129

303

50

7

367

66

1,119

1,120

840

794

39.2 1,022

40.2 945

119

126

2,958

3,245

160

200

37.4 268

39.4 780

41.1 852

42.6 67

37

107

91

10

1,271

2,426

2,289

217

86

148

105

21

404

994

758

83

17.6

19.6

16.8

20.4

19.5

18.1

17.5

752

,876

,368

122

949

,647

,522

281

739

562

52

2,993

4,806

4,490

583

669

787

391

639

604

41.2 483

38.8 721

39.7 763

69

81

95

1,561

2,437

2,205

123

149

88
22 acimncedata

and 12.0 percent for control pools with low (less than summer and more southern States during the winter.

30.0 Kg/cil) and high (30.0 IJg/dl or more) mean lead The potential environmental effects on blood lead

levels. respectively. In addition, there are significant levels associated with seasonalityz~ and geographic

within-day and among-day components of variance. location may be confounded, to some undrjter~ned

A possible logistical Factor indirectly influencing degree, with those associated with degree of urbanizathe blood lead data is the itinerary of the Mobile Ex- tion of place of residence.

amination Centers (M EC’’S). To minimize the effects

of adverse weather conditions on response rates, NOTE: A list of references follows the text.

MEC’S were set up in the northern States during the
akmedda 23

Table I Il. Description of raw data on blood lead determinations from specimens collected by fingersticks in children ages 6 months-7 yews:

National Health and Nutrition Examination Survey, 1976-80

Race Number Mean Srandard Mode Median Mtnimum Maximum

examined deviarion

Skewness

(/.sg/dl)

Allracesl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113Z 24.8 15.4 18.0 22.2 7.0 116.0 3.5

white . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 23.2 17.6 18.0 19.0 7.0 116.0 3.7

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...”.. 36 28.3 8.0 27.0 28.0 12.0 47.0 0.1

Ilncludes data forraces not shown Separately.

TabielV. Characteristics of three persons with blood ledvalues greater than 70.0#g/dl whoremived venipuncture: Nat!onal Health and Nutrition

Examination Survey, 1976-80

Demographicfac rors

Blood lead value

(u9/dI) Age in Sex Race Family Degree of

years income urbanization

-—

76.0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Male Black Under$6,000 Rural

80.0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Male White $15,0000rmore Large urbanl

90.0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Male Black Under $6,000 Smaller urban2

Iwith 1 million Or more persons.

Zwith fewer than 1 miilionpersons.
From Vital and Health %atistirs of the National Center for Health Statistics Number 80. July 22, 1982

MedicationTherapyinOfficeVisitsforHypertension:

NationalAmbulatoryMedicalCareSurvey,1980

by Beulah K. Cypress, Ph. D., Division of Health Care Statistics

According to data collected by the National

Center for Health Statistics by means of the National

Ambulatory Medical Care Survey, patients with essential hypertension made an estimated 25.1 million

visits to office-based physicians in 1980. During these

visits there were about 46.5 million mentions of

drugs, either new or continued, for an average of 1.85

drug mentions per visit.

The National Ambulatory Medical Care Survey

(NAMCS) is a probability sample survey conducted

annually by the Division of Health Care Statistics of

the National Center for Health Statistics. The technical notes at the end of this report provide brief information about the source of the data, sampling

errors, and definitions of terms. A complete description of the survey including limitations and definitions was published in Vital and Health Statistics,

Series 13, No. 44.1

Until 1980, an item on the Patient Record form

(figure 1) indicating whether or not medication

therapy was offered by the physician was the only

available information from NAMCS regarding drug

utilization by office-based physicians. In 1980, the

item was expanded to include the reporting of specific drugs, prescription or nonprescription, ordered

or provided by any route of administration during

the visit (see figure 1, item 11). The methodology

used to collect and process this drug information is

described in Viral and Health Statistics, Series 2,

No. 90.Z

Data on drugs utilized during visits with essential

hypertension as the principal (first-listed) diagnosis

1Nationrd Center for Herdth Statistics, T. Ezzati and T. McLemore: The

National Ambulatory hiedieal Care Survey, 1977 Summary, United

States, January-December 1977. J“ital and Health Statistics. Series

13-No. 44. DHEW Pub. No. (PHS) 80-1795. Public Health Service.

Washington. U.S. Government Printing Office, Apr. 1980.

2National Center for Health Statistics. H. Koch: The collection and

processing of drug information, i~ationai Ambulatory hiedicai Care

Survey, United States, 1980. Vital and Health S~atistics. Series 2-No.

90. DHHS Pub. No. (PHS) 82-1364. Public Health Service. Washington.

U.S. Government Printing Office. In press.

are presented in this report. In order to report accurately what the physician prescribed, drug mentions

used in this report are based on the physicians’ entries

on the Patient Record forms. These entries may be

brand or generic names of prescription or over-thecounter drugs. “Drug mentions” includes all drugs

listed in item 11, parts a and b. Part b, it should be

noted, may relate to diagnoses other than hypertension. Therefore, it is assumed that medications

described in this report were ordered for patients

with hypertension but may not necessady be

therapeutic agents for that condition.

Medication therapy status and number

of medications

During 1980, hypertension was the leading illness–related principal diagnosis and accounted for

9 percent of all visits. In about 89 percent of these

visits patients were provided medication therapy

(table 1). This proportion exceeded the average proportion of drug visits for all diagnoses (63 percent).

Table 1 shows that a hypertension visit with one drug

ordered or provided was the most likely event (36

percent), and proportions of visits decreased as the

number of drugs increased. This paralleled the average

prescription pattern shown in figure 2, except that

proportions of visits for hypertension were higher in

every category greater than zero.

Drug mentions

Table 2 shows the number of visits for hypertension by sex. age, and race of the patient, and by problem status and major reason for the visit. The number

and percent of visits in which one or more drugs were

mentioned are shown. These two sets of visit frequencies provide the denominators for the drug mention

rates (DMR) and the drug intensity rates (DIR). The

numerator for both rates is the number of all-listed

U.S. DEF’ARTM ENT OF HEALTH AND HUMAN SE RVICE!j, Public Health !+rrvice, Office of Health Research, Statistics, and Technology
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Figure 1. Patient Record from the National Ambulatory Medical Ccm Suwey
dmcedaa3

Tabla 1. Number and percant distribution of office visits for essential hwa~smsion, by medication therapy status and number of medications:

United States, 1980

Number of

Medication therapy smtus and number of medications

A?rcent

visitsin distribution

thousan&

Total . . . . . . . . . . . . . . . . . . . .

With medioation . . . . . . . . . . . . .

Without medication . . . . . . . . . . .

None . . . . . . . . . . . . . . . . . . . .

1 . . . . . . . . . . . . . . . . . . . . . . .

2 . . . . . . . . . . . . . . . . . . . . . . .

3 . . . . . . . . . . . . . . . . . . . . . . .

4 . . . . . . . . . . . . . . . . . . . . . . .

5orrnore . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medication tharapy status

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Numlxrr of medications

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25,137

22.282

2,855

2,855

8,932

6,894

3,561

2,040

856

100.0

88.6

11.4

11.4

35.5

27.4

14.2

8.1

3.4

21.-

.s>

%

g

Cr

Z

0.

10

0

.

36.9

35.5

27.4

14.2

IN All diagnoses

None 1 2 3 4 5 6 7or8

Number of medications

Figure 2. Percent of office visits for essential hypertension and for all diagrsosasby number of medications: Unitad States, 1960
4

Table 2. Number of office visits for essentialhypertension, number and percent of drug visits, and number of all-listed drug mentions, drug mention

rate, and drug intensity rate, by selected characteristics United States, 1980

Office visits AllIisted Drug Drug

Selected characteristic All Drug Percenr

drug mention intansit~

visits visits’1

of drug mentions rate per mta per

(number in (number in (number in visit2 visip visits

thousands) thousands) thousands)

TomI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sex

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

Age

Under45years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45yearsand over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Race

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Problem status

Newproblem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oldproblem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Major reason for visit

Acute problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chronicproblem, routine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chronicproblem,flareup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Postsurgery orpostinjury . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nonilln=scare . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .

25,137

15,787

9,350

3,019

22,118

22,048

2,940

“148

2,155

22,981

1,985

19,209

2,114

●81

1,748

22,282

14,203

8,079

2,532

19,750

19,507

2,637

“138

1,692

20,590

1,611

17,339

1.946

“63

1,322

88.6

90.0

86.4

83.9

89.3

88.5

88.7

“93.2

78.5

89.6

81.2

90.3

92.1

‘78.6

75.6

46,484

30,365

16,119

5,068

41,416

40,965

5,245

●274

3,380

43,103

3,218

36,471

4,376

’197

2,221

1.85

1.92

1.72

1.68

1.87

1.86

1.78

●1.85

1.57

1.88

1.62

1.90

2.07

*2.43

1.27

2.08

2.14

2.00

2.00

2.10

2.10

1.90

● 1.99

2.00

2.09

2.00

2.10

2.25

●3.13

1.68

lA visit in which oneormore drugs were ordered.

2A11.li~teddrug~+ “umber of vi~i~.

3A11.listeddrugs+ number of drug visits.

drug mentions. Using for the denominator the total

number of visits for hypertension (25.1 million) and

for the numerator thetotal number ofdrugmentions

during hypertension visits (46.5 million) yields a drug

mention rate of 1.85 drugs per hypertension visit.

Using drug visits (22.2 million) for the denominator

yields a drug intensity rate of 2.09 drugs perhypertension visit in which a drug was mentioned. While

the DMR providesan average drug use forhypertension visits, the DIR shows that when patients do receive medication therapy during office visits they are

likely to receive an average of 2.09 drugs. The DIR

is always higher than the DMR because itis basedon

only those visits in which one or more drugs are

utilized, except in the rare case where drug visits

equal all visits. The DMR was higher for hypertension

than for the average of all diagnoses regardless of the

patient’s age group. As figure 3 shows, the DMRincreased as the age group ofthe patient with hypertension increased. The curve for all diagnoses shows a

similar pattern, but the rates for hypertension were

consistently higher. The DMR was higher for females

than for males, but other rates detailed in table 2 did

not vary significantly, probably due to the large sampling error associated with these relatively small

estimates.

Drug status characteristics

Table 3 provides information about the drugs that

were utilized for hypertension patients. The entry

status, or more specifically the physician’s prescribing

mode, in about 80 percent of the 46.5 million drug

mentions was the brand name; 18 percent were

entered by their generic names. An example of the

former is Hydrodiuril; the latter, hydrochlorothiazide.

Both entries represent the same drug. The proportion

designated by brand names during hypertension visits

(80 percent) exceeded the average of71 percent similarly entered during visits for all diagnoses.q

- Most drugs (92 percent) were prescription drugs

(Rx) with nonprescription or over-the-counter (OTC)

drugs accounting for only 6 percent. (Table 4. shows

that of all drugs entered by brand names, 95 jpercent

were prescription drugs and 5 percent were OTC

drugs.) About 73 percent of the drugs mentioned

consisted of a single ingredient, suggesting the poten3National Center for Health Statistics, H. Koch: Drugs most frequently

used in office-based practice: National Ambulatory Medical Care

Survey, 1980. A dvarrceDataFrom Vital and Health Statistics, No. 78.

DHHS I?ub. No. (PHS) 82-1250. Public Health Service. Hyattsville, Md.,

May 13,1982.
2.0 r

1.8

1.7

I

J

0.9

+“

Essential

hypertension

t)~

15-24 25-44 45-64 65 years

years years years and over

Age of patient

Figure 3. Drug mention rate per office visit for essential hypertension

and for all diagnoses, by age of patient: United States;”1 980

tial for ordering by generic name. On the average, 69

percent of drugs mentioned for all visits regardless of

diagnosis were single ingredient drugs.

Only 6 percent of the total drug mentions during

hypertension visits consisted of drugs under the regulatory control of the Drug Enforcement Administration, compared with 9 percent during visits for alI

diagnoses.

Most frequently mentioned drugs

The 30 drugs listed in table 5 accounted for about

60 percent of all drug mentions in office visits for

hypertension. The reader is cautioned that the ranking may be somewhat artificial because some estimates do not differ significantly from other near

estimates due to sampling variability.

As may be expected, 2 therapeutic categories,

hypotensive agents and diuretics, were predominant

among drug mentions when patients visited for hypertension. (In NAMCS, therapeutic categories were

based on the classification system of the American

Hospital Formulary Service.Q) Of the 30 listed drugs,

10 are hypotensive agents, 9 are diuretics, 4 are cardiac drugs, and 2 are replacement solutions

(potassium). Only one is a tranquilizer.

The most frequently utilized generic substances

are shown in table 6. The data in this table represent

the utilization of the generic substance regardless of

whether the substance was prescribed by brand or

generic name. The form of use indicates whether the

substance was used as a single ingredient or in combination with other substances. Hydrochlorothiazide

(10.5 million) was clearly the most frequently used

generic ingredient. About 53 percent of its use was

in combination with other drugs. Some generic drugs

such as diazepam, digoxin, furosemide, ibuprofen,

metoprolol, metalozone, nadoloI, and prazosin were

never prescribed in combination with another substance. Others, such as spironolactone and triamterene, were almost always found in combination

prescriptions.

Additional data on medication therapy in office

visits for hypertension, as well as for other diagnoses,

will appear in a future Vital and Hea[th Statistics publication. Questions regarding this report may be

directed to the Ambulatory Care Statistics Branch by

calling 301-436-7132.

4Amcri~ Society of Hospital Pharmacists, Inc., ?% American Hospital Forrmdary Service. Washington. Jan. 1980.
6

Table 3. Number smd percent distribution of all-listed drug mentions in office visits for essential hypertension, and percent distribution for all

diagnoses, by drug status characteristic% United States, 1980

Drug statuscharacteristic

Hypertension Al!

diagnmas

Number in Percent Percwrt

thousands distribution distribution

ToteI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46,484 100.0 1001.0

Entry status

Genericname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,495 18.3 24.2

Brandname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37,067 79.7

Therapeuticeffect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

71.2

649 1.4 3.2

Undetermined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ’272 ●0.6 1.5

Prescription status

Prescription (Rx)dmg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42,684 91.8 82.6

Nonprescription (OTC)drug . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,899 6.2 12.6

Undetermined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 921 2.0 4.9

Composition status

Single ingredient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ‘ 34,037 73.2 69.0

Combination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11,038 23.8 24.4

Multivitamin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ●487 *1.1 2.0

Undetermined. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 921 2.0 4.6

Federelcontrol status

Controlled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,673

Uncontrolled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42,889 9= :::

Undetermined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 921 2.0 4.9

Table4. Percentdistribution of brand nerna drugmentions in officavisitsfor hypertension by drug statuscharacteristicx United States, 1980

Drug sratuscharacteristic Rsrcent

distribution

Prescription status

Prescription (Rx)drug . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95.4

Nonprescription (OTC)drug. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6

Singla ingredient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Combination

70.!9

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.(0

Multivitamin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1
achmdaa7

Table 5. Number and percent distribution of most frequently mentioned drugs in office visits for essentialhypertension, described by principal

generic ingredient(s) and principal therapeutic category: United States, 1980

Name of drug’1

Number Percent

in distribution Principal generic ingredient

thousands

Principal therapeutic

categoryz

All drug mentions . . . . . . . . . . . . . . . .

Dyazide . . . . . . . . . . . . . . . . . . . . . . .

Hydrochlorothiazide . . . . . . . . . . . . . .

Aldornet . . . . . . . . . . . . . . . . . . . . .

Inderal . . . . . . . . . . . . . . . . . . . . . .2.

Hydrodiuril . . . . . . . . . . . . . . . . . . . .

Hygroton . . . . . . . . . . . . . . . . . . . . .

Lopressor . . . . . . . . . . . . . . . . . . . . .

Lasix . . . . . . . . . . . . . . . . . . . . . . . .

Aldoril . . . . . . . . . . . . . . . . . . . . . . .

Diuril . . . . . . . . . . . . . . . . . . . . . . . .

Ser-ep-as . . . . . . . . . . . . . . . . . . . . . .

Akfectazide . . . . . . . . . . . . . . . . . . . .

Reset-pin e . . . . . . . . . . . . . . . . . . . . .

Apresoline . . . . . . . . . . . . . . . . . . . . .

Potassium . . . . . . . . . . . . . . . . . . . . .

Slow-K . . . . . . . . . . . . . . . . . . . . . . .

Esidrix . . . . . . . . . . . . . . . . . . . . . . .

Valium . . . . . . . . . . . . . . . . . . . . . . .

Motrin . . . . . . . . . . . . . . . . . . . . . . . .

Minipres . . . . . . . . . . . . . . . . . . . . . .

Corgerd . . . . . . . . . . . . . . . . . . . . . . .

Lanolin . . . . . . . . . . . . . . . . . . . . . . .

lnfluertzavirusvaccine typeA,B . . . . . .

Enduron . . . . . . . . . . . . . . . . . . . . . .

Cetapres . . . . . . . . . . . . . . . . . . . . . .

Aspirin . . . . . . . . . . . . . . . . . . . . . . .

Dioxin . . . . . . . . . . . . . . . . . . . . . . .

Enduronyl . . . . . . . . . . . . . . . . . . . . .

Diebinese . . . . . . . . . . . . . . . . . . . . .

Vitamin B-12 . . . . . . . . . . . . . . . . . . .

Residual . . . . . . . . . . . . . . . . . . . . . .

46,484

2,5B3

2.449

2,284

2,090

1,836

1,779

1,569

1,325

910

7B7

786

730

650

644

619

588

578

557

529

479

447

415

402

402

●362

●353

“344

“319

●303

16.496

100.0

5.6

5.3

4.9

4.5

4.0

3.8

3.4

2.9

2.0

1.9

1.7

1.7

1.6

1.4

1.4

1.3

1.3

1.2

1.2

1.1

1.0

1.0

0.9

0.9

0.9

●0.8

“0.8

“0.7

●0.7

“0.7

39.8

. . .

triamterene, hydrochlorothiezide

hydrochlorothiezide

methyldopa

proprenolol

hydrochiorothiazide

chlorthalidone

metoprolol

f urosemide

methyidopa, hydrochlorothiazide

chlorothiazide

reserpine, hydralazine, hydrochlorothiazide

spironokrctone, hydrochlorothiazide

reserpine

hydralazine

potassium replacement solution

potassium replacement solution

hydrochlorothiaz ide

diazepam

ibuprofen

prezosin

nadolol

digoxin

influenza virus vaccine

methyclothiazide

cionidine

aspirin

digoxin

methyclothiazide, deserpidine

chlorpropamide

vitamin B-12

. . .

. . .

diuretics

diuretics

hypotensive agents

cardiac drugs

diuretics

diuretics

hypotensive agents

diuretics

hypotensive agents

diuretics

hypotensive agents

diuretics

hypotensive agents

hypotensive agents

replacement solution

replacement solution

diuretics

sedatives or hypnotics

hypotensive agents

hypotensive agents

cardiac drugs

cardiac drugs

vaccines

diuretics

hypotensive agents

analgesics and antipyretics

cerdiacdrugs

hypotensive agents

anti-diabeticagents

vitamin Bcomplex

. . .

lBm~on~@ physiciansen~ on ~@ patientRmordform. Theentry may baa brwrdor ganaricname. inch.IsionoftrdarrameefOr identification

only anddoesnotirnply endorsementbythe U.S. Public Haalth Sewiceorthe Oepartrnent of Health and HummsSarvicae.

Zlf one ~neric in~adient is listed, the physician~s●rrtry is the generic drug or the physician’s entry isa brand name drug wi’tichconsists cIMefW of ●

Sinde generic ingredient.

3Basedon theclessification system oftheAmericen Hospital Formulary Sewica(A.H.F.S.).
8

Table6. Num&rand percent distribution ofdrugs uwdinoffice visits foressential hypertension by form ofum, according to most frequently

usad generic substances: United States, 1980

Generic substance

Number Form of use

in Total

thousands Single In

ingredient combinations

Percent distribution

Aspirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chlorothiazida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chlorthalidone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Clonidine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Diazepam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Digoxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Furosemida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hydralazine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hydrochlorothiazide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ibuprofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Metoprolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Methyclothiazide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Methyldopa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Metolazone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prazosin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Proprenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rauwolfia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Reserpine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SPironolacton e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Triamtarene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

730

1,304

2,435

737

588

800

?,325

1,763

10,536

557

1,583

784

3,410

405

479

542

2,379

437

2,665

847

2,612

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

65.6

69.2

78.5

62.4

100.0

100.0

100.0

44.5

46.8

100.0

100.0

53.8

68.2

100.0

100.0

100.0

94.1

61.2

30.7

7.1

1.1

33.4

3CL8

21.5

37.6

55.5

53.2

46.2

31.8

5.9

38.8

69I.3

92.9

98.9

Symbols

..” Data not available

. . . Category nonapplicable

Quantity zero

0.0 Quantity more than zero but less than

0.05

z Quantity more than zero but less than

500wherenumbars are roundedto

thousands

●

Figure does not meet standards of

reliability or precision (more than

30 percent relative standard error)

# Figure suppressed to comply with

confidentiality requirements
admcaHa9

Technicalnotes

Source of data and sample design

The information presented in this report is based

on data collected by the National Center for Health

Statistics through its National Ambulato~ Medical

Care Survey (NAMCS) during 1980. The target universe of NAMCS includes office visits”made within

the contenninous United States by. ambulatory patients to nonfederally employed physicians who are

principally engaged in office practice, but not in the

specialties of anesthesiology, pathology, or radiology.

Telephone contacts and nonoffice visits are excluded.

NAMCS utilizes a multistage probability sample

design that involves samples of primary sampling

units (PSU’S), physicians’ practices within PSU’S, and

patient visits within physician practices. For 1980 a

sample of 2,959 non-Federal, office-based physicians

was selected from master files maintained by the

American Medical Association and the American

Osteopathic Association. The physician response rate

for 1980 was 77.2 percent. Sampled physicians were

asked to complete Patient Records (figure 1) for a

systematic random sample of office visits taking place

during a randomly assigned weekiy reporting period.

During 1980, responding physicians completed

46,081 Patient Records, on which they recorded

51,372 drug mentions. Characteristics of the physician’s practice, such as primary specialty and type of

practice, were obtained during an induction interview. The National Opinion Research Center, under

contract to the National Center for Health Statistics,

was responsible for the survey’s field operations.

For a more detailed discussion of the limitations,

qualifications, and definitions of the data collected in

the NAMCS, see Vital and Health Statistics, Series 13,

Number 44.

Estimates presented in this report differ from the

estimates reported in the National Medical Care

Utilization and Expenditure Survey (NMCUES),

another program of the National Center For Health

Statistics (NCHS). The variation in estimates is due to

differences in survey populations, data collection

methodology, and definitions. The NMCUES, cosponsored by NCHS and the Health Care Financing

Administration (HCFA), is a national panel survey of

households which collected information on visits to

physicians’ offices and hospital outpatient departments. preliminary sumey data as well as a discussion

of the sumey methodology are forthcoming from

NCHS and HCFA.

Sampling errors and rounding of numbers

The standard error is primarily a measure of the

sampling variability that occurs by chance because

only a sample, rather than the entire universe, is surveyed. The relative standard error of an estimate is

obtained by dividing the standard error by the estimate itself and is expressed as a percent of the estimate. Relative standard errors of selected aggregate

statistics are shown in tables I and IIL Standard errors

for estimated percents of visits are shown in table II

and IV. Tables I and II should be used to obtain the

standard error of a specific drug mention (e.g.,

Dyazide). Tables III and IV should be used to obtain

the standard error of a group of drug mentions (e.g.,

all drugs prescribed for hypertension).

Estimates of office visits have been rounded to

the nearest thousand. For this reason detailed figures

within tables do not always add to totals. Rates and

percents were calculated on the basis of original, unrounded figures and wilI not necessarily agree precisely with percents calculated from rounded data.

Definitions

An ambulatory patient is an individual presenting

himself for personal health services who is neither

bedridden nor currently admitted to any health care

institution on the premises.

A physician eligible for NAMCS is a duly licensed

doctor of medicine (M.D.) or doctor of osteopathy

(D.O.) currently in office-based practice who spends

time in caring for ambulatory patients. Excluded

from NAMCS are physicians who are hospital based;

physicians who specialize in anesthesiology, pathology, or radiology; physicians who are federally

employed; physicians who treat only instutionalized

patients; physicians employed full time by an institution; and physicians who spend no time seeing ambulato~ patients.

An office is a place that the physician identifies

as a location for his ambulatory practice. ResponsibilTable L Approximate relative standard ●rrors of astwnatednumbers

of office visits based on all physician specialties: NAMCS, 1980

Reletiva

Estimemd number of office visits standard

in thousands error in

percent

500 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.3

I,ooo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.5

2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.1

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.4

10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3

20.000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.9

50,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.9

100,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5

550,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1

Ex8mplo of use of mblo: An aggregato of 75,000,0~ “i~i~ has .

MlatiVO standard Wrrx of 4.7 parcant, or a standard ●rror of 3,525,000

visits (4.7 parcant of 75,000,000).
10

Table 11. Approximate standard errors of percents of estimated numbers of office visi~ besed on all physician specialties: NAMCS, 1980

Base of percen t

Estimated percent

(number of office visits in thousands) 1 or 99 5 or 95 10 or 90 20 or 80 30 or 70 50

Standard error in percent

500 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7 5.9 8.1 10.8 12.4 13.5

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9 4.2 5.7 7.6 8.7 9.5

2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3 2.9 4.0 !5.4 6.2 6.7

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.8 1.9 2.6 3.4 3.9 4.3

10.000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.6 1.3 1.8 2.4 2.8 3.0

20,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.4 0.9 1.3 1.7 2.0 2.1

50,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.3 0.6 0.8 1.1 1.2 1.3

100,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.2 0.4 0.6 0.8 0.9 1.0

500,CQ0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.1 0.2 0.3 0.3 0.4 0.4

Example of use of table: An estimate of 30 percent basad on m! aggregate of 15,000,000 visits has a standard error of 2.4 percent, or a relative

standard error of 8 percrmt (2.4 percent + 30 percent).

ity overtime for patient care and professional services

rendered there generally resides with the individual

physician rather than aninstitution.

A visit is a direct personal exchange between an

ambulatory patient and a physician ora staffmember

working under the physician’s supewision, for the

purpose of seeking care andrendering healthsenrices.

A dmg mention is the physician’s entry of a

pharmaceutical agent ordered or provided–by any

route of administration-for prevention, diagnosis, or

treatment. Generic as well as brand-name drugs are

included, as are nonprescription as well as prescription drugs. Along with all new drugs, the

physician also records continued medications, ifthe

patient wasspecifically instructed during the visit to

continue the medication.

Table II 1. Approximate relative standard errors of estimated number

of drug mentions based on all physician specialties: NAMCS, 1980

Relative

Estimated number of drug mentions standard

in thousands error in

percent

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.3

2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.7

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.2

10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1

Zo,ooo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2

50,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.8

100.000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2

300,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.8

650,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.7

Example of use of table: An aggregata astimate of 75,0013,000 drug

mentions has arelativestenderd error of 6.5 percent ora standard error

of 4,875,000 mentions (6.5 parcent of 75,000,000).
admcecw 11

Table IV. Approximate stan*rd erro=of -rcents ot~imated num~=of drug mentions h*onail physician wialties: NAMCS,19S0

Base of percent

(number of drug mentions in thousands)

Estimatadpement

1 or 99 5 or 95 10 or 90 20 or 80 30 or 70 50

Standard error in percentage points

1,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7 5.8 8.0 10.7 12.2 13.3

2,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9 4.1 5.7 7.6 8.7 9.4

5,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 2.6 3.6 4.8 5.5 6.0

20,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.6

100,000

1.3 1.8 2.4 2.7 3.0

. . , . . . . . . . . . . . . . . . . . . . . . ... . . . . - . . . . 0.3 0.6 0.8 1.2

600,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.3

0.1 0.2 0.3 ;: 0.5 0.5

Examplo of use of table: An astimatw of 30 parcent based on ●n ●ggregate of 12,500.000 drug mentions has ● standard ●rror of 4.1 pmcont or a

ralative standard error of 13.7 percent (4.1 percent +30 percent).

11.S.GovarnmantPtfnlingOfiicw 1993-3D1.01wcQ17
Vital and Health Statistics

series descriptions

SERIES 1.

SERIES 2.

SERIES 3.

SERIES 4.

SERIES 5.

SERIES 6.

SERIES 10.

SERIES 11.

SERIES 12.

SERIES 13.

Programs and Collection Procedures –These reports

describe the data collection programs of the National Center

for Health Statistics. They include descriptions of the

methods used to collect and process the data, definitions,

and other material necessary for understanding the data.

Data Evaluation and Methods Research –These reports

are studies of new statistical methods and include analytical

techniques, objective evaluations of reliability of collected

data, and contributions to statistical theory. These studies

also include experimental tests of new survey methods and

comparisons of U.S. methodology with those of other

countries.

Analytical and Epidemiological Studies –These reports

present analytical or interpretive studies based on vital and

heeith statistics. These reports carry the analyses further than

the expository types of reports in the other series.

Documents and Committee Reports–These are final

reports of major committees concerned with vital and health

statistics and documents such as recommended model vital

registration laws and revised birth and death certificates.

International Vital and Health Statistics Reports –These

reports are analytical or descriptive reports that compare U.S.

vital and health statistics with those of other countries or

present other international data of relevance to the health

statistics system of the United States.

Cognition and Survey Measurement–These reports are

from the National Laboratory for Collaborative Research in

Cognition and Survey Measurement. They use methods of

cognitive science to design, evaluate, and test survey

instruments.

Data From the National Health Interview Survey-These

reports contain statistics on illness; unintentional injuries;

disabili~ use of hospital, medical, and other health services;

and a wide range of special current health topics covering

many aspects of health behaviors, health status, and health

care utilization. They are based on data collected in a

continuing national household interview survey.

Data From the National Health Examination Survey, the

National Health and Nutrition Examination Surveys, and

the Hispanic Health and Nutrition Examination Survey–

Data from direct examination, testing, and measurement on

representative samples of the civilian noninstitutionalized

population provide the basis for (1) medically defined total

prevalence of specific diseases or conditions in the United

States and the distributions of the population with respect to

physical, physiological, and psychological characteristics,

and (2) analyses of trends and relationships among various

measurements and between survey periods.

Data From the Institutionalized Population Surveys –

Discontinued in 1975, Reports from these surveys are

included in Series 13.

Data From the National Health Care Survey–These

reports contain statistics on health resources and the public’s

use of health care resources including ambulatory, hospital,

and Iongterm care services based on data collected directly

from health care providers and provider records.

SERIES 14.

SERIES 15.

SERIES 16.

SERIES 20.

SERIES 21.

SERIES 22.

SERIES 23.

SERIES 24.

Data on Health Resources: Manpower and FacHitiesDiscontinued in 1990. Reports on the numbers, geographic

distribution, and characteristics of health resources are now

included in Series 13.

Data From Special Surveys–These reports contain

statistics on health and health-related topics collected in

special surveys that are not part of the continuing data

systems of the Nationai Center for Health Statistics.

Compilations of Advance Data From Vital and Heaith

Statistics –Advance Data Reports provide early release of

information from the National Center for Heaith Statistics’

heaith and demographic surveys. They are compiled in the

order in which they are pubiished. Some of these reieases

may be foilowed by detailed reporta in Series 10–13.

Data on Mortaiity-These reports contain statistics on

mortality that are not inciuded in reguiar, annual, or monthly

reports. Special analyses by cause of death, age, other

demographic variables, and geographic and trend anaiyses

are included.

Data on Natality, Marriage, and Divorce–These reports

contain statistics on natelity, marriage, and divorce that are

not included in reguiar, annual, or monthiy reports. Special

analyses by health and demographic variables and

geographic end trend analyses are included.

Data From the National Mortality and Natality Surveys –

Discontinued in 1975. Reports from these sampie surveys,

based on vital records, are now published in Series 20 or 21.

Data From the National Survey of Family Growth –These

reports contain statistics on factors that affect birth rates,

including contraception, infertility, cohabitation, marriage,

divorce, and remarriage; adoption; use of medical care for

famiiy planning and infertiii~ and related maternal and infant

health topics. These statistics are based on national surveys

of childbearing age.

Compilations of Data on Nataiity, Mortality, Marriage,

Divorce, and Induced Terminations of Pregnancy–

These include advance reports of births, deaths, marriages,

and divorces based on final data from the National Vital

Statistics System that were published as supplements to the

Monthly Vital Statistics Report (MVSR). These reports provide

highlights and summaries of detailed data subsequently

published in Vital Statistics of the United States. Other

supplements to the MVSR published here provide selected

findings based on final data from ‘lhe National Vital Statistics

System and may be followed by detailed reports in Series 20

or 21.

For answers to questions about this report or for a iist of reports pubiished

in these series, contact:

Data Dissemination Branch

National Center for Health Statistics

Centers for Disease Control and Prevention

Public Heaith Service

6525 Belcrest Road, Room 1064

Hyattsville, MD 20782

(301) 436-6500
DEPARTMENT OF

HEALTH & HUMAN SERVICES

Public Health Service

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National Center for Health Statistics

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