office visits for diseases of the circulatory systemof the circulatory system the national...

Data from theNATIONAL HEALTH SURVEY

Office Visits for Diseasesof the Circulatory SystemThe National Ambulatory

Medical Care SurveyUnited States, 1975-1976

Based on data obtained from a national sampIe of office-basedphysicians, statistics are presented which describe ambulatory medi-caI care during visits for treatment of diseases of the circulatorysystem. Physician utilization patterns are described in terms ofpatient characteristics, patient condition and management, andpractice characteristics. Highlighted diagnoses include essentialbenign hypertension, coronary heart disease, symptomatic heartdisease, cerebrovascular disease, arteriosclerosis, and selected

diseases of veins.

DHEW Publication No. (PHS) 79-1791

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFAREPublic Health Service

Office of the Assistant Secretary for HealthNational Center for Health StatisticsHyattsville, Md. January 1979

Series 13Number 40

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NATIONAL CENTER FOR HEALTH STATISTICS

DOROTHY P. RICE, Director

ROBERT A. ISRAEL, Deputy Director

JACOB J. FELDMAN, Ph.D., Associate Directorfor Amdysis

GAIL F. FISHER, Ph.D., Associate Director for the Cooperative Health Stati.sties System

ELIJAH L. WHITE, Associate Director for Data Systems

JAMES T. BAIRD, JR., Ph. D., Associate Director for International Statistics

ROBERT C. HUBER, Associate Director for Management

MONROE G. SIRKEN, Ph. D., Associate Director for Mathematical Statistics

PETER L. HURLEY, Associate Director for Operations

JAMES M. ROBEY, Ph.D., Associate Director for Program Deve~opment

PAUL E. LEAVERTON, Ph. D., Associate Director for Research

ALICE HAYWOOD, Information Officer

DIVISION OF HEALTH RESOURCES UTILIZATION STATISTICS

SIEGFRIED A. HOERMANN, Director

JAMES E. DELOZIER, Chiej Ambukztory Care Statistics Branch

MANOOCHEHR K. NOZARY, Chiej Technical Services &-anch

STEWART C. RICE, ChieJ Family Phzning Statistics &mch

JOAN F. VAN NOSTRAND, Chiej Long-Term Care Statistics Branch

Vital and Health Statistics-Series 13-No. 40

DHEW Publication No. (PHS) 7!3-1791Library of Congress Catalog Card Number 78-31501

CONTENTS

Introduction ........................... ............................................................... ........................... ......................

Background ................. ................................................... ...................................................................Scope of the Survey ........... ..................... .................. ........................................................................Source and Limitation of the Data .................................... ...................................... ..........................

Major ICDA Group–Dkeases of the Circulatory System ........................................................................Patient Characteristics ............ ............................................................... ...... ......................................Patient Condition and Management ........... ...................................... .................. ................... ............Practice Characteristics .... .................................................................................................................

Selected Dkeases of the Circulatory System ......................................... ............... ...... ...... ...... ...... ..........Patient Characteristics ..................... ............................................................. ....................................Practice Characteristics .................................................................................................... ...... ...... ....Patient Condition and Management ..................................................................................................

Diseases of fie Circtiatory System As Second- or Third-Listed Dia@oses ..................................Diagnostic Concomitance ........................................................................... .................................Patients’ Principal Problem, Complain~ or Symptom ..... .................... ....... .................................Visit Status and Seriousness of the Problem ....................................... ........................................Duration of Visit ........................................................................................................................Disposition of Visit ................................... ........................................................................... .......Referrsd .................................. ............ .............. ...... ............ ...... .................... ..............................Diagnostic-Therapeutic Services ............................. .............. ................. ......................................

References ............................................................................................................. .................................

List of Detailed Tables ..................................................................................... ......................................

AppendixesL Technicaf Notes .................................................. ......................................................................IL Definition of Certain Terms Used in This Repoti ............................... ......................................IIL Survey Instruments ....... ...... ................................ ............................ .............................. ...........

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2.

3.

4.

5.

6.

LIST OF TEXT FIGURES

Percent distribution of office visits for diseases of the circulato~ system, by specialty visited:United States, 1975-76 ........... .............................. ................................. ..................... .................

Average annuaf rate of office visits for selected diseases of the circulatory system by sex ofpatient: United States, 1975-76 ................................................................. ...... ............ ...............

Average annuaf rate of office visits for selected diseases of the circulatory system, by race ofpatient: United States, 1975-76 ...... ................................. ............ ............................................. .

Average annual rate of office visits for essential benign hypertensio~ by race, sex, and age ofpatient: United States, 1975-76 .. ........................... ....................................................................

Average annual rate of office visits for coronary heart disease, by sex and age of patient: UnitedStates, 1975-76 ........... ...... ....................................... ............ ...... ............... ........... ..... ........ ..........

Average annual rate of office visits by females for essential benign hypertension and coronaryheart disease, by age of patient: United States, 1975-76 ............................................................ .

1

:23

3445

56

101112131416181920

20

28

30

394751

5

7

8

9

9

10

,..ill

7. Average annual rate of office visits by males for essentiel benign hypertension and coronary heartdisease, by age of patient: United States, 1975-76 .. .... .. .. .... .. . .... .. ... ... .. . ..... . .. .... . .. ... .. . ... ... .. . .... .. ..

8. Percent of office visits that included blood pressure measurement in the presence and absence ofhypertension, by visit age: United States, 1975-76 .. ... ... .. ... .. .. ... ... ..... .. .. .... .. . .... . ... ... ... .. . .. .. . .... ... ..

A.

B.

c.

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G.

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K.

L

M.

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P.

Q.

R.

LIST OF TEXT TABLES

Number and percent of office visits for all diagnostic classes and number and percent for dkeasesof the circulatory system, by sex, race, and age of patient: United States, 1975-76 ..... .. .. .. .. .. . ....

Number and percent dk.tribution of office visits for diseases of the circulatory system and forselected principal diagnoses: United States, 1975-76 ... . ... ..... ... ... .. .. ... .. . .. .... .. . ... ... .. ... ... . ... ... .. ... ... .

Number, percent distribution, and average annual rate of office visits for essential benign hyper-tension (40 1), by most frequently visited specirdties and sex and age of patient: United States,1975-76 .. . ..... . ... ... . ... ... ... .. ... .. .. .... . .. .... .. . ..... . . .... .. .. .... .. . ..... . ... ... .. . ..... . ... ... ... .. .... . .. ... .. . .. ..................

Number, percent distribution, and average annual rate of office visits for coronary heart dkease(410-4 13), by most frequently visited specialties and sex and age of patient: United States,1975-76 ..... . .. ... .. .. . .... . .. .... . ... ... ... . .... . .. ... .. ... .. .. .. .... .. . ... .. ... .... ... ..... . ... ... .. ... .... ... .... .. . .. ... ... ...............

Number and percent of office visits for selected diseases of the circulatory system listed as secondor third diagnoses: United States, 1975-76 .. .. .... .. . ... ... ...... . .. ... ... . ..... . .. ... .. .... ... .. . .... .. ... ... .. . .... .. .. ...

Number and percent of ot%ce visits for essentird benign hypertension (401) listed as first, second,or third diagnosis, by other most frequent diagnoses: United States, 1975-76 .. .... ... ... ... .. .... ... ... .

Number and percent of office visits for coronary heart disease (41 O-413) listed as first, second, orthird diagnosis, by other most frequent diagnoses: United States, 1975-76 ... .... ... ... .. . .. .... ... . ..... ..

Number and percent distribution of office visits for essential benign hypertension (401) by visitstatus, seriousness of problem, and deposition of visit, according to sex and age of patient:United States, 1975-76 . .. ... . .. . .. .... .. .. .. .. . ... .. .. .... . .. ... .. .. ..... . .. .... .. ... ... . .. . ..... . .. ... . .. . ..... . . .... .... .. .... .. . .. .

Number and percent distribution of office visits for coronary heart disease (410-413) by visitstatus, seriousness of problem, and disposition of visit, according to sex and age of patient:United States, 1975-76 .... . ... .... . . .. ... . ... ... ... . .. ... ... ... .. .. .... .. .. ... .. . .. ... . .. . .... .. ... .. .... ...... .. .... .. .... ... . .. .. ..

Number and percent distribution of office visits for essential benign hypertension (401) byseriousness of problem, according to visit status: United States, 1975-76 . .. .... . .. .. ... .. .. ..... .. .. ... .. .

Number and percent distribution of office visits for coronary heart disease (410-413) by seriou-sness of problem, according to visit status: United States, 1975-76 . .. .... ... .. ... . ... .... . .. .... . .. . .... .. .. ..

Percent of office visits for essential benign hypertension (401) and coronary heart disease (410-41 3), by disposition of visit and seriousness of problem: United States, 1975-76 . . ..... . . ... .. ... . ... ...

Percent distribution of office visits for diseases of the circulatory system by number of types ofdiagnostic and therapeutic services ordered or provided, according to selected principal diag-noses: United States, 1975-76 ... .. .. ... ... .. .... . ... ... . .. ... ... .. ... .. .. ... .. ... ... .. .. ... ... . .. ... .. .. .... . .. .... .. . ... ... .. ....

Number and percent of office visits for selected dkeases of the circulatory system, by diagr.osticand therapeutic services ordered or provided: United States, 1975-76 . .. .... ... ... .. . .. .... .. . ..... . ... ... .. .

Number and percent of office visits for selected diseases of the circulatory syste~ by most fre-quent diagnostic and therapeutic services ordered or provided: United States, 1975-76 ... .... .. ... ..

Number and percent of office visits for essential benign hypertension (401), by visit status,seriousness of problem, and diagnostic and therapeutic services ordered or provided: UnitedStates, 1975-76 .. .. ... ... . ..... . ... ... .. . .... .. .. ... . .. .. .. .. ... .... .. . ... .. . .. ... . .. . ... .. . . .. ... .. . ...... . .. ... .. . ..... . .. ..... . . .... ....

Number and percent of office visits for coronary heart dkease (410-413) by visit status, serious-ness of problem, and diagnostic and therapeutic services ordered or provided: United States,1975-76 .. .. .... . .. .... .. . .... . ... .... .. .. .... . . .... . ... .. .. .. . .... . .. ... .... . .... .. .. .... . .. ..... .. .. .... . .. ... ... .. ... . .. .... ................

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18

20

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s. Number and percent of office visits for essential benign hypertension (401), by sex and age ofpatient and diagnostic snd therapeutic semices ordered or provided: United States, 1975-76 ..... 24

T. Number and percent of off]ce visits for coronary heart disease (410-413), by sex and age ofpatient and diagnostic and therapeutic services ordered or provided: United States, 1975-76 ...-. 25

U. Percent of office visits by selected diagnostic and therapeutic services ordered or provided in thepresence and absence of selected principal di~,oses: United States, 1975-76 ....................... ...... 25

v

SYMBOLS

Data not available ---------------------------------------- ---

Category not applicable ---------------------------- . . .

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

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

Figure does not meet standards ofreliability or precision–— ------------------- *

OFFICE VISITS FOR DISEASES

OF THE CIRCULATORY SYSTEM

Beulah K. Cypress, Ph.D., Division of Health Resources Utilization Statistics

INTRODUCTION

This report presents national estimates of1975 and 1976 visits to office-based physiciansin the conterminous United States, in whichphysicians rendered diagnoses in the category“diseases of the circulatory system.”

HIGHLIGHTS

In 1975-76 patients made 110.6 millionvisits to office-based physicians for treatment ofdiseases of the circulatory system. A principaldiagnosis of essential benign hypertension wasassigned to 42 percent of such visits. Chronicischemic heart disease caused 24 percent; symp-tomatic heart disease, 6 percent; cerebrovasculardisease, 4 percent; diseases of arteries, arterioles,and capillaries, 4 percent; diseases of veins andIymphatics, 8 percent.

Seven of eight visits for essential benignhypertension were made by white persons. In5 of 8 visits the problem was presented by afemale. The median visit age for females was62.0 years; for males, 57.6 years. When chronicischemic heart disease was the diagnosis, themedian visit age for femzdes was 70.5 years; thatof males was 64.1 years. Males aged 35 to 74years visited physicians at a higher rate thanfemales did for care of ischemic heart disease.However, visit rates of females exceeded thoseof males for essential benign hypertension.

Seven in ten visits for cerebrovasculardisease were made by patients 65 years and over.Patients 75 years and older represented the high-

est proportion (39 percent) of visits for thatcondition, but visits by patients 45 years andunder were rare (3 percent). Arteriosclerosis wasalso more common during visits by the elderlywith a median visit age of 75.1 years.

Essential benign hypertension was frequentlyconcomitant with diabetes mellitus and obesity.When hypertension was the principal diagnosis,diabetes mellitus was also listed in about 5 per-cent of those visits. When diabetes mellitus wasthe principzd diagnosis, hypertension was thesecond- or third-listed diagnosis during 14 per-cent of such visits. Obesity was an additionaldiagnosis in 10 percent of hypertension visits;hypertension was second- or third-listed in 5percent of all visits for a principal diagnosis ofobesity. Diabetes mellitus and obesity were rdsocommonly coincident with ischemic heart dis-ease. However, ischemic heart disease and hy-pertension were not frequently diagnosed duringthe same visits.

Physicians used electrocardiograms (EKG’s),X-rays, and laboratory tests more often duringinitial patient visits than when the patient pre-sented an “old” problem. Blood pressure wasmeasured about 80 percent of the time whenhypertension was present, but ordy about 30percent of visits included blood pressure meas-urement when hypertension was absent. Nonhy -pertensive females were more Iikely to havetheir blood pressure taken than were nonhyper-tensive males. When hypertension was notpresent, the rate of blood pressure measurementincreased with age.

1

BACKGRO(JND

The data were collected in the NationalAmbulatory Medical Care Survey (NAMCS), acontinuous sample survey conducted by theDivision of Health Resources Utilization Statis-tics of the National Center for Health Statistics.Detailed information regarding the backgroundand methodology of the survey were publishedin Vital and Health Statistics, Series 2, No. 61.1Separate data for 1975 and 1976 were reportedin Series 13, No. 33 and in Advance Data Re-port No. 30.z~s

This is the first series report based onNAMCS data for combined calendar years 1975and 1976, and the first series report from thatsurvey with a focus on diagnoses. Statisticsrepresenting 1975-76 visits for essential benignhypertension, a member of the diagnostic groupof circulatory system diseases, were summarizedin an advance report.A Other brief reports basedon data from 1975, 1976, or combined yearsfeatured physician specialty profiles and visitsby persons aged 65 years and over. s-l A

Information about a maximum of threediagnoses for each sampled visit was collectedduring the survey. Each participating physicianwas requested to list on the data collection formthe principal diagnosis, the physician ‘S evalua-

tion of the patient’s condition related to thechief complaint or other reason for visit. Up totwo additional significant diagnoses known toexist for the patient at that time could also belisted, but these were not necessarily related tothe current visit. Diagnoses were classified andcoded according to the Eighth Revision Interna-tional Classification of Diseases, Adapted forUse in the United States (ICl)A). 15 The princi-pal or first-listed diagnosis is the primary empha-sis of this report. However, patterns of coexist-ing diagnoses are often revealing, and additionaldata regarding second- and third-listed diagnosesare given where they are relevant and meaningful.

The data used in this report encompass themajor ICDA category, diseases of the circulatorysystem, code 390-458. In addition to a generaldescription of the utilization pattern of ambula-tory care for the class of circulatory diseases,this report provides detailed information about

patient, clinical, and practice characteristics ofvisits for selected most frequent, well-defineddiseases within the class, for example,, essentialbeni~ hypertension, ICDA code 401.

For clarity, categories of diseases, such as“diseases of the circulatory system” or “diseasesof the respiratory system, ” are referred to in thisreport as “major ICDA group. ” Specific diseaseswithin the groups are identified by their three-digit codes and designated as “principal,”“second,” or “third” diagnosis depending on thepriority given by the physician.

Prior to data presentation, the scope of thesurvey and limitations of the data are describedbriefly to assist the reader in interpreting theestimates. A detailed description of the 1975-76survey, including technical details, definitions,and survey instruments, appears in the appen-dixes to this report. The 1975 and 1976 surveyswere conducted in identical fashion using thesame instruments, definitions, and procedures.The 2 years of data were combined to providegreater reliability of estimates. Therefore, thereader shouId note that estimates of numbers ofvisits contained in this report are for a 2-yearperiod, but ratios and rates represent averageannual estimates.

SCOPE OF THE SURVEY

The basic sampling unit for NAMCS is thephysician-patient encounter or visit. “Encoun-ter” and “visit” are used interchangeably in thisreport.’ Only visits in the conterminous UnitedStates in the offices of nonfederally employedphysicians classified by the American MedicalAssociation (AMA) or the American OsteopathicAssociation as “office-based, patient care” wereincluded in the 1975-76 NAMCS. In addition,physicians in the specialties of anesthesiology,pathology, and radiology were excluded fromthe physician universe. Major types of ambula-tory encounters not included in the 1975-76NAMCS were those made by telephone, those

‘The term “contact” is reserved to apply only to thatpart of the visit or encounter that involved a face-to-faceinterchange between physician and patient.

made outside of the physician’s office, and thosemade in hospital or institutional settings. It isplanned to extend the survey to include theseencounters in the future as resources permit.

The definitions of “office,” “physician,”“patient,” and “visit” as they determine eligi-bility for NAMCS are presented in appendix H.

SOURCE AND LIMITATIONOF THE DATA

The data presented in this report were de-rived from information provided by a nationalprobability sample of office-based physicians.A sample of 6,529 physicians was contacted dur-ing 1975-76. Of the 5,604 physicians who wereeli@ble for the study, 4,476 (79.9 percent)participanted in the study, providing data concern-ing a random sample of some 114,000 patientvisits.

SpeciaIly trained interviewers visited thephysicians prior to a designated reporting week,provided survey materials, and informed eachphysician and staff member about the methodsand definitions to be used. During a randomlyassigned 7-day reporting period, the samplephysician maintained a listing of all office visits.For a systematic random sample of those visits,data were recorded on an encounter form pro-vided for that purpose (see appendix III).

Readers are urged to review the three appen-dixes to this report. These appendixes provideinformation necessary for proper understandingand interpretation of the statistics presented.Appendix I contains a general description of thesurvey methods, the sample design, and the datacollection and processing procedures. Imputa-tion methods, estimation techniques, and esti-mates of sampling variation are also presented.Because the statistics in this report are based ona sampIe of ambulatory visits rather than on all

visits, they are subject to sampling errors. There-fore, particular attention should be paid to thesection in appendix I entitIed “Reliability ofEstimates.” Examples of relative standard errorsand instructions for their use are given in appen-dix L

Definitions of the terms used in this reportand in the survey operations are presented inappendix II. Facsimiles of survey materials,including Ietters, Patient Record forms, and In-duction Interview forms are reproduced in ap-pendix III.

By means of another program of NCHS, theHeaIth Interview Survey (HIS), data are col-lected on the utilization of physician servicesbut from a different universe. Estimates providedby HIS may differ from those in NAMCS be-cause of differences in collection procedures,populations sampled, and definitions. Data fromHIS are published in Series 10 of Vital andHealth Statistics.

The distinction between prevalence of adisease and physician visits for a disease shouldbe kept in mind when interpreting the data. Forobvious reasons, physician visits do not neces-sarily reflect the degree to which a condition ispresent in the population, even though visits tothe physician’s office may be motivated by apathological condition or the visit may result inthe detection of the condition. The N.4NICSwas designed to provide information about theprovision and use of certain ambulatory medicalcare services and is, therefore, a rich source ofdata concerning utilization of physicians’ serv-ices when visits are characterized by specificdiseases. Prevalence data may be obtained fromother surveys conducted by NCHS.b

bFor example, see publications of HIS (Series 10)and the Health and Nutrition Examination Survey(HANEs) (Series I 1).

MAJOR ICDA GROUP– DISEASES OF THE CIRCULATORY SYSTEM

Patients’ problems, compkints, or symptoms visits to office-based physicians in 1975-76.were diagnosed as caused by diseases of the cir- These visits accounted for about 10 percent ofculatory system in an estimated 110.6 million visits for dl dia~oses, and comprised the second

3

leading morbidity-related diagnostic group (dis-eases of the respiratory system was first with14 percent).

PATl ENT CHARACTERISTICS

Visits for diseases of the circulatory systemranked first among major ICDA groups whenpatients visiting were 45 years of age or older.The number of office visits for all diagnosesaccording to age groups and the proportions ofvisits for each age group visiting for diseases ofthe circulatory system are listed in table A. Pro-portions of visits increased with advancing age.For visits by patients under 45 years of age, only2 percent included a circulatory problem; 16

Table A. Number and percent of office visits for all diagnosticclasses, and number and percent for diseases of the circula-tory system, by sex, race, and age of patient: United States,1975-76

All diagnosticclasses

Sex, race, and age

All visits..

Sex and race

Female . .. . .... .

White .. .. .. .... .. .... . . .. ..Black and other . .. ..

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

White . .. ... ... .. .. .... .. . ..Black and other . .. ..

Age

Under 35 years .... .. . .35444 years ... ... .. .. .. .45-54 years ... .. .... .. .55-64 years .. .. . ... .. .. .65-74 years .. . .. ... ... . .75 years and over .. . .

Numberof visitsin thou-

sands

1,155,900

697,727

625,20172,525

458,174

413,32044,853

555,806122,805147,082

143,060120,317

66,831

Per-cent

ofvisits

100.0

100.0

100.0100.0

100.0

100.0100.0

100.0100.0100.0100.0100.0100.0

Diseases of thecirculatory system


sands

110,617—

62,656

55,7896,866

47,961

44,0443,916

7,4997,796

19,217

27,60529,67418,B24

Per-cent

ofvisits

9.6

9.0

8.99.5

10.5

10.78.7

1.36,3

13.119.324.728.2

lAbout 84 nercent were visits bv members Of the black race.2About 72 ~ercent were wsits b; members of the black ra~e-

percent of visits by patients between 45 and 64were similarly diagnosed; and 26 percent of alloffice visits by patients 65 years or older werefor this major ICDA group. Additional distribu-tions and rates of visits by sex and age are pro-vided in table 1.

For those persons who visited physicians,proportions of visits for diseases of the circula-tory system did not significantly differ by race(table A). Although the visit rate shown in table1 was higher for white persons than for mem-bers of black and other races, the same wastrue of all NAMCS visits regardless of thediagnosis. That white persons tended to visitoffice-based physicians at a higher rate than didmembers of all other races was shown in HIS .16

Although there were, on the average, morevisits per person in the population by femalesthan by males for circulatory problems, a higherproportion of visits by males than visits by fe-males included a circulatory problem,. Of the458.1 million visits by males estimated inNAMCS, 11 percent were for circulatory systemdiseases; of the 697.7 million visits by females,9 percent included this disease group (table A),

PATIENT CC)NDiTION ANDMANAGEMENT

Most visits for circulatory disorders were forregular care of a preexisting condition or for asudden exacerbation of a preexisting chroniccondition (74 percent total). Acute conditions,defined as those having a relatively sudclen or re-cent onset, initiated about 14 percent of thesevisits, and an additional 12 percent representedfollowup care of a previously treated acute con-dition. (Here as elsewhere in this report dataare used which are taken from source data andare not shown in tables or charts. )

The high degree of chronically ill patientsamong those visiting for diseases of the circula-tory system and the tendency of these patientsto seek continuous medical care were reflectedby the ratio of 5.4 visits by returning patientswith continuing problems to each new-problemencounter. New-problem encounters includednew patients and patients the physician had seen

before but not for the current problem. Contin-uous rather than episodic care was more likelywhen visits were diagnosed as diseases of the cir-culatory system than when other systems wereinvolved since there were proportionally fewernew-problem encounters in this disease groupthan in any other major ICDA group.

Ongoing patient management was demon-strated by physicians’ instructions to return at aspecified time or to return if needed, given dur-ing 93 percent of visits. In only 3 percent ofvisits was no followup planned. When a diseaseof the circulatory system was diagnosed, physi-cians relied on telephone followup for only 2percent of visits, less often than when othermorbidity-reIated major ICDA groups were in-voIved. About 3 percent of these visits resultedin admittance to a hospital.

PRACTICE CHARACTERISTICS

Figure 1 illustrates the division of visits fordiseases of the circulatory system by physicianspeciahy. Most visits made were to offices ofgeneral and family practitioners and internists,specialists whose combined practices comprisedabout 35 percent of office-based physicians inthe United States in 1975 according to theAMA.lT

All otSpec

Figure 1. Percent distribution of office visits for diseases of thecircu Iatory system, by specialty visited: United States, 1975-76

Table 2 shows the minimum amount of vari-ation in proportions of visits by geographic loca-tion. Differences between proportions of visitsto physicians’ offices in metropolitan and non-metropolitan areas, and between SO1Oand otherpractice arrangements tend to reflect the distri-bution of physicians in the United States.

SELECTED DISEASES OF THE CIRCULATORY SYSTEM

In the ICDA, related diagnoses within the visits in 1975 -76.= Chronic ischemic heart dis-

category of diseases of the circulatory system ease, the third leading morbidity-related condi-are grouped by sequences of three-digit rubrics tion, accounted for 2 percent of the total.(e.g., ischemic heart disease includes codes 410 The balance of this report presents patterns

through 414). The number and percent of visits of office-based medical care for these and other

for each sequence are listed in table B. Percents selected diseases of the circulatory system.

of visits for the most frequent specific principaldiagnoses within each sequence are also shown.Essential benign hypertension accounted for thelargest number of visits among the diseases of

CThe data classified as “morbidity related” apply to

the circulatory system (42 percent) followed byvisits where the principal diagnosis fell in any of the 17major ICDA groups (codes 000-999). The two highest

chronic ischemic heart disease (24 percent). proportions of NAMCS visits in 1975-76 were in the

Essential benign hypertension also ranked first ICDA supplementary classifications, “Medical or special

among a.11visits for morbidity-related pnncipaIexaminations” (code YOO), and “Medical and surgical

diagnoses (at the 3-digit ICDA level), compris-aft ercare” (code Y1O). “Prenatal care” (code Y06) wasthe fourth leading diagnosis. See Advance Data Report

ing 4 percent of the over 1.1 billion estimated No. 30 for additional information on ranks of diagnoses.

5

Table B. Number and percent distribution of office vis!ts for diseases of the circulatory system and for selected principal diagnoses:United States, 1975-76

Diagnosis and ICDA codel

Active rheumatic fever and chronic rheumatic heart disease .. ... .. .. .... .. . .... .. . .... .. .. ... .. .. .... . .. ... .. .. .... .. . .... .. .. ...39 O.398

Hypertensive disease ... . ... .. .... . ... .. .. ... .. . .... .. .. ... ... ..... . . ... ... .. ... ... . ... . .. .... .. .. .. .. . .. .... ... .... . ... ... .. . .... . .. .... ... ...........4OO4O4Essential benign hypertension .... .. . ..... .. . .... .. . .... .. . ... .. ... ... .. .. .. ... .. ... .. .. ... . .. .... . ... ... ... . .... . ... ... . ... .... . . .... ... . ... . .. ...4Ol

Ischemic heart disease . .. ... ... .. .. .... ... ... ... . ... .. .. ... .. . .. .. .. .. ... .. .. .... .. . ... .. .. ... .. . . .... . .... ... . .. .... . .. ... .. .. ... . ... .... . . ..........4lO.4l3Acute myocardlal infarction and othar acute and subacute forms of ischemic heart disease .. .... . .. .. .. . ...410-41 1Chronic ischemlc heart disease .. .. ... . .... .. . .... . .. .... . .. .... .. . .... .. .. ... .. .. .... . .. .... . ... ... .. . ... ... . .... . ... .... .. .... .. .. ... .. .. ... . ....4l2Angina pectoris .. .... .. .. .... .. . ... .. .. ... .. . .... ... . .... .. . .... . .. .... .. .. .... . .. ... .. .. .... .. . ... .. ... .. ... .. .... . . ... .. .. ... .. ... ......................4I3

Other forms of heart d!sease .. .. .... .. . .... . .. .... .. .. ... . .. .... .. .. ... . .. .... . ... .. ... . ..... . . .... . ... ... .. .. .... . ..... .. .. .. .. ... .. ... .... .. . ...42O429Symptomatic heart disease ..... . .. ... .. .. .... . .. ... .. .. ... ... . ..... .. .... .. . .... .. . .. .. .. .. .... .. .. .. .. .. .... .. .... .. .. ... .. .. .... . .. ... .. ... . .. . ...427

Cerebrovascular disease . .. .. .... . . ..... . .. ... ... .. ... . . ... .. .. . .... .. .. .... .. .. .. .. .. ... .. ... .... . .. .. .. .. . .... .. .... .. .. ... ... . ... ... . ... .. .........43O.438

Diseases of arteries, arterioles, and capillaries .... .. . .... . .. .... .. . .... .. .. ... .. .. .... . . .... .. . .. ... .. . .... . ... .. ... .. .... . . .... ... .. ... ..44O.448Arteriosclerosis .. . .. .... . .. .... . .. .... .. .. .. .. .. .... .. .. .... . . ..... .. . .... . ... .. ... .. ... .. .. .... . .. ... ... . ..... . . .... . ... .. ... .. ... .. . .....................44O

Diseases of veins and Iymphatics and other diseases of the circulatory system . ..... .... ... . .. .. ... . .... .. .. ... ... .. .. ...45 O.458Phlebitis and thrombophlebitis .. .... .. .. .... .. .. ... .. . .... .. . .... . ... ... .. .. .... .. . .... . .. .... .. . .... . .. .... . ... .... .. . .... .. .... .. .. . ... .. .. .....45l

Varicose veins of lower extremities .. . .... . .. .... .. .. .... .. .... .. .. .... . .. .... . ... ... . .. .... .. .. .... . .. ... . ... ... .. .. ... .. . .. .. . .. .. .... . . ......454Hemorrhoids ..... . ... .... ... ... .. .. ... .. .. ... .. .. .... . ... ... . ... ... .. .. ... .. .. ... .. .. .... . .. .... .. .. .. ... . .... ... . ... .... . .. ... . .... .......................455


sands

110,617

1,867

47,12046,128

31,3142,319

26,0202,975

9,1617,052

4,505

4,4412,019

12,2102,930

2,4283,686

Parcentdistri-bution

ofvisits

100.0

1.7

42.641.7

28.32.1

23.52.7

8.36.4

4.1

4.01.8

11.02.6

2.23.3

1 Diagnostic groupings and code inclusions are based cm the Eighth Revision Interns tional Classs”ficationOfDiseases. Adarwd fof’ usein the United States, 1965.

PATl ENT CHARACTERISTICS

Essential benign hypertension (401).–Visitrates for essential benign ~y~ertension, coronary

heart disease,d and other selected diseases of thecirculatory system are plotted in figure 2 by sexand in figure 3 by race. Demographic data arealso detailed in tables 3 and 4.

Seven of eight office visits for care of essen-tial benign hypertension were made by whitepersons. In 5 of 8 visits the probIem was pre-sented by a female. The highest proportion ofvisits was in the age group 55-64 years. Visit

dThe term “coronary heart disease” is used inter-changeably with the ICDA terminology “ischemic heartdisease” in this report. Both terms refer to the groupof heart ailments, acute and subacute ischemic heartdisease (410-41 1), chronic ischemic heart disease (412),and angina pectoris (41 3).

rates increased with advancing age up to agegroup 65-74 years. Females visiting were, on theaverage, older than males, since the median visitage for females was 62.0 years and for males itwas 57.6 years.e

There was a marked difference in visit ratesby sex beginning at about age 44, with the fe-male rate peaking at age group 65-74 years,about 10 years later than the male rate peaked(figure 4). The advanced female age at visitsfor hypertension as opposed to the youngermale age at such visits may be related to greatersusceptibility of males to other cardiovasculardiseases that preempt essential benign h yperten-sion as primary diagnosis. The Framingham

‘Median visit age should not be confused with medianpatient age. The median visit age is based on initial andreturn visits some of which may be by the same patient.

6

““”” mMale &ggj

Essential benign Coronw Symptomatic CerebrwawJlar Arterio. Phlebitis Varicose

h) pertension heart heart diseaseHemorrhoids

sclerosis and(407) dmease

veins ofdisease (430438) (4401

(4s5)thrombo. Ioww

{410.413) (427) phlebitis extremities[451) (4W

PRINCIPAL DIAGNOSIS AND ICDA CODE

Figure 2. Average annual rate of office visits for selected diseases of the circulatory system, by sex of patient: Unitad States, 1975-76

Study demonstrated that for persons with defin-ite hypertension the incidence rates of diseasessuch as coronary heart disease and congestiveheart failure were substantially higher for malesthan for females of the same age. 18 Therefore,while the diagnosis may remain essential benignhypertension as females age, a principal diagno-sis of this disorder for visits made by males mayhave been supplanted earlier by other diagnoses.

Coronary heart disease (410-413). –Visitrates for patients with coronary heart diseasediffered from those for patients with essentialbenign hypertension. Beginning with age group35-44 years and up to age 74 years, visit ratesfor males who had coronary heart disease ex-ceeded rates for females (figure 5). This is notsurprising in view of the foregoing discussionsuggesting thathypertension is

a dia~osis of ‘essential benignoften supplanted by its cardio-

vascular sequelae at an earlier age among malesthan among females. Unlike essential benignhypertension, there was no drop in visit rate forthe oldest age groups.

In figure 6, visit rates for essential benignhypertension and coronary heart disease are con-trasted for visits by females only. Figure 7 illus-trates visit rates among males for the same twodiseases.

The changing relationship of visit rates forthese two diseases, depending on the sex of thevisiting patient, can be observed in figures 6and 7. For office visits by females, rates werehigher for essential benign hypertension than forcoronary heart disease from age 35 years to agegroup 65-74 years (figure 6). The hypertensionrate dropped at age 75 years and over and thecoronary heart disease rate continued to rise. Visitrates for these two conditions were different

7

120

r

I100

80 -

60 –

40 -

20 –

o-

Wwerlyion

Coronawheart

dis?a$e(410.413)

Sym::pt,c Cerebrovascular Arterio. PhlebKis Varicose Hemorrhoidsdisease sclerosis and veinsof (455)

disease (430438) (440) thrombo. lower(427) phlebitis extremities

(451) (454)

PRINCIPAL DIAGNOSIS AND ICOA COOE

Figure 3. Average annual rate of office visits for selected diseases of the circulatory system, by race of patient: United States, 1975-76

when male patients visited. For males, hyper-tension rates exceeded those of coronary heartdisease up to age ‘group 55-64 years, after whichthe hypertension rate dropped and the otherrate continued to rise (figure 7). For males aged65-74 years the coronary heart disease rate washalf again as large as the rate for essential benignhypertension; for visits by mzdes 75 years andolder the rate for the first disease more thandoubled that of the second.

Males visiting for chronic ischemic heartdisease were younger than females with the samediagnosis. The median visit age for males was64.1 years in contrast to a median visit age of70.5 years for females (table 4). One explana-tion for the older median visit age for femalesmay be found in the mortality statistics of theUnited States.lg In 1975, male deaths fromcoronary heart disease exceeded female deaths‘from the same cause in every age group up to 80years.

Differences in median visit age betweenthe two sexes for acute ischemic heart disease

(which included acute myocardiaI infarction)and angina pectoris were not statistically signifi-cant.

Symptomatic heart disease (42 7). –Patientspresenting symptomatic heart disease wereyounger than those presenting so’me otherforms of heart disease. About 16 percent ofthese visits were made by patients under 45years old, compared with about 5 percent in thesame age group for chronic ischemic heartdisease.

Cerebrovascular disease (430-438). –Cerebro-vascular disease visits more often included elderlypatients than did hypertension or heart disease.Seven in ten visits for this disease were made bypatients 65 years and over. Patients 75 yearsand older contributed to the highest proportionof visits made for cerebrovascular disorders(39 percent); such visits by patients under 45years were rare (3 percent). Of all circulatoryproblem visits , cerebrovascuk.r disease had thelowest proportion of visits by patients under45 years. As a result, the median visit age of

8

550 r

500 -

450 -

400 -

Femalezg 350 -

~

80.z 303 -

j.

5: 250 -

?$

; \> 200 - Male

150 -

lcil -

50 -

0, I I I I I 1Under 35-44 4554 55.64 6574 75 and

35 overAGE IN YEARS

Figure 4. Average annual rate of office visits for essential benign

hypertension, by sex and age of patient: United States,

1975-76

71.2 years for this disease was relatively highcompared to other circulatory diseases.

The relationship of hypertension to heartdkease and to cerebrovascular disease, particu-larly as a precursor of stroke, has been estab-lished. Research findings also suggest thatcerebrovascular disease resulting from hyperten-sion prowesses at a slower rate than does heartdisease resulting from hypertension.zo If thisis true, then the later age of the onset of cere-brovascular disease may welI be reflected in theolder median visit age estimated in NAMCS.

Visits for cerebrovascular disease were aboutequally divided between men and women.

Arten-osclerosis (440]. –The median visitage for patients afflicted with arteriosclerosis

‘% I

150 !-

100

50

I_. .

n

/

/

/“,/’

Ii

ii

/’Male I

i:

i’ IFemale

i/’

/“/’

/’/=

/“i

ii

/’/’

/’i

i./’

Under 3544 45-54 55.64 65-74 75 and35 Over

AGE IN YEARS

Figure 5. Average annual rate of office visits for coronary heartdisease, by sex and age of patient: United States, 1975-76

was the highest of all circulatory problems,75.1 years. According to vital statistics reports,death rates due to arteriosclerosis did not attainany significant proportions until the age of atleast 65 years. For example, the 1975 deathrate due to arteriosclerosis for persons 65-74years old was 26.6 per 100,000 populationcompared with 303.1 for cerebrovascular dk-ease and 132.37 for heart disease. At ages75-84 years, the rate of death due to arterio-sclerosis was 159.4.21 Thus, either arteriosclero-sis was not diagnosed untiI later years or patientswith arteriosclerosis who had greater longevitycontinued to visit physicians (thus raising themedian visit age).

There was no significant difference in” visitrate nor in median visit age between femaIe andmale patients.

9

550 ~

500 –

450 –

400 -

zG 350 —

~3;z 300 –

zs.

a& 250 -

K< Hwene.slon,x~

: 200-

,’ Coroniw heart disease150-

100-

50-

0 IUnder 35.44 45.54 55.64 65.74 75 and

35 over

AGE IN YEARS

Figure & Average annual rate of office visits by females for

essential benign hypertension and coronary heart dieease,

by age of patient: United States, 1975-76

Phlebitis and thrombophlebitis (451), vari-cose veins of the lower extremities (454),hemorrhoids (455). –In contrast to visits forarterial disease, visits for diseases of veins weremade by younger patients. About half of thevisits for phIebitis and thrombophlebitis as weIlas for varicose veins of the lower extremitiesincluded patients under 55 years, as reflectedby the median visit ages of 53.9 years and 55.1years, respectively. Of all circulatory diseases,the lowest median visit age was reported forhemorrhoids, 45.6 years. Visits for hemorrhoidswere rarer for persons 65 years and older thanwere any other visits made for diseases of thecirculatory system. OnIy 14 percent of the

500

450

400

350

zgk<

$ 300

%.z

~; “260 -

E.

: \200a

1-~>

150 I Coronary hearsdiseasf’ ,

100 ,,

50

0 JUnder 35-44 45.54 55.64 65.74 75 and

35 overAGE IN YEARS

Figure 7. Average annual rate of office visits by males for essen-

tial benign hypertension and coronary heart disease, by age

of patient: United States, 1975-76

visits made because of hemorrhoids were madeby persons in that age group, and only 3 percentwere made by persons 75 years and older.

Visits for phlebitis and thrombophlebitisas well as for varicose veins of the lower extremi-ties were more likely to include a female thanwere visits for heart disease or cerebrovasculardisease; the reverse was true for males. However,proportions of visits made because of hemor-rhoids did not differ significantly by patient sex.

PRACTICE CHARACTERISTICS

With minor exceptions, estimates of charac-teristics of physicians’ practices related to visitsfordid

most specific circulatory disease diagnosesnot vary appreciably from the findings in the

10

Table C. Number, percent distribution, and average annual rate of office visits for essential benign hypertension (401), by mostfrequently visited specialties and sex and age of patient: United States, 1975-76

Specialty

General and family practice . .. .. .... ... ... . .. ... .. .. .... ... .. .. . ... .. .. ... . .. ... .. . .... . . .... . ..Internal medicine . .. .. ... .. ... .. .. .. .... . .. ... .. .. .. .. .. ... .. . .... .. . ... .. .. .. ... . ... . .. ... .. . ... . .. .Ganeral surgery ..... . . .... .. . .... .. . ..... . .. .. ... .. .. .. .. .. .. .. .... .. .... . .. ... .. . ... . ... ... . . .. .. . .. .Obstetrics and gynecology .. .. .. ... . .. .... . . ... .. .. ... .. . ... .. . . .... . . .... . .. ... . .. .... . . ... .. .. .Cardiovascular diseases ... ... ... . .. .. . . .... .. . .... . .. .. ... . .... .. . ... . .. ... .. . .... . .. .... . .. .. . .. ..

General”and family practice . ... . ... .. .. . ... .. .. ... . .. .... ... ... .. .... ... . ... .. . ... .. .. .. .. . ... ..Internal medicine .. ... .. . .... .. ..... . . .... .. . ... ... .... .. . ... .. .. ... . .. .... ... .. . .. .... .. . ... . ... .. ..General surgery . .. . .... .. .. ..... .. ... .. . .... .. .... .. . ... . . ..... . .. ... . .. .... . . ... . .. ... .. . ... .. . .... ..Obstetrics and gynecology .... .. . .... .. . ... .. .. ... . .. .... . ... .. . ... .. .. . .... . .. ... .. . .. ... . ... .. .Cardiovascular diseases .. . .. .... .. . ... .. . .... .. . ... .. .. ... . . ..... . .. ... . .. ... . .. .... . . ... .. .. ... .. .


sands

27,17912,779

2,190727

1,461

. . .

. . .

. . .

. . .

. . .

Percent distribution

100.0 64.4 35.6 62.0 38.1100.0 60.5 39.5 68.8 31.2100.0 63.1 36.9 63.4 36.6100.0 86.2 * 71.2 28.8100.0 54.1 45.9 64.2 35.8

Visit rate per 1,000 in population

65.1 81.0 48.1 45,0 240.730.6 35.8 25.1 23.5 92.9

5.2 6.4 4.0 3.7 18.71.7 2.9 * *1.4 ●4 .93.5 3.7 3.3 2.5 * 12.2

Table D. Number. Dercent distribution .andaveraae annual rate of office visits forcoronarv heart disease (41 0-413), bymostfreauently.visited specialtie; andsexand age of patient: United States, 1975-76

Number Sex Age

Specialtyof visits

Totalin thou-

Female MaleUnder 65 years

sands 65 years and over


General and family practice ... . ... ... . .. .. ... .. ... .. .... .. . .... .. .... .. .. .. .. .. .. .. . .... ... .. .. . 14,920 100.0 50.7

I

49.3 42.9 57.1Internal medicine .... .. .. .... .. . ... . .. . ... ... ... .. . ... .. .. .... .. . ... .. . .. .. . . .... .. . ... .. .... .. . .... . 11,722 100.0 45.6 54.4 46.7 53.3Cardiovascular diseases . . ... ... ... . .... . .. .... .. . ... . .. .... . .. ... . ... ... .. .. .. .. .. .. .. .... .. .. ... .. 3,089 100.0 39.9 60.2 48.2 51.8

I I Visit rate per 1,000 inpopulatlon

General and family practice .. . .... .. . ... .. .. ... .. . .. .... . ... . ... ... .. .. .. .. . .... . . .... .. ..... . . . . . .Internal medicine .. . .... . ... ... .. . .... .. . ... . .. . .... .. ... .. .. ... .. . .... . . .. .. .. . .... . ... .. .. .. ... . . .. . . .Cardiovascular diseases .. .... . .. .... . . .... . .. ... .. . ... .. ... .. .. .. ... .. . .... .. . .... . .. .. ... . .. ... .. . . . .

35,8 35.0 36.5 17.1 198.428.1 24.7 31.7 14.6 145.4

7.4 5.7 9.2 4.0 37.2

major group (diseases of the circulatory system) ease. TabIes 6 and 7 relate type and area loca-detailed in an earlier section. Distributions of tion of practice to specialties visited because ofvisits for the specific diseases according to geo- hypertension and coronary heart disease.graphic region, metropolitan and nonmetro-politan areas, and type of practice are shown intable 5. PATl ENT CONDITION

Table C shows the extent to which hyper- AND MANAGEMENTtension visits varied bv age and sex of Patientwhen the mostwere considered.table D for visits

freq;en;ly visited specialties Most statistics presented in this report re-Similar details are given in Iate to principal or first-listed diagnoses. Themade for coronary heart dis- cIinical picture of patients who utilize physician

11

resources would be incomplete, however, with-out information regarding the frequency of caregiven patients troubled by circulatory problemsnot necessarily related to the patient’s principalcomplaint.f Visits in which circulatory systemdiseases were second- or third-listed diagnosesprovide additional data about the number oftimes a disease was a recognized and diagnosedcondition, although it may not have been theprimary diagnosis at the visit.

Furthermore, it was shown earlier that mostvisits in which the principal diagnosis was listedin the diseases of the circulatory system groupincluded visits by middle-aged and elderlypatients who are generally acknowledged to suf-fer from multiple maladies, many of which areclassified in other major ICDA groups. Theseailments are also listed on the Patient Recordas “other significant diagnoses. ” All conditionsthe physician finds germane to the visitingpatient, therefore, reflect patterns of diseaseconcomitance.

Diseases of the Circulatory SystemAs Second- or Third-Listed Diagnoses

Table E shows the number of visits in whichdiseases of the circulatory system were identi-fied as additional diagnoses. The volume ofestimated visits which included each specificdisease increased considerably when a maximumof three known patient conditions were con-sidered. As an example of the use of this table,there were 46.1 million visits with a principaldiagnosis of essential benign hypertension (tableB). Adding this number to the 28.6 million visitsshown in table E for essential benign hyperten-sion vields a total of 74.7 million visits in which/essential benignknown to existUsing the data

hypertension was a conditionfor the patient at that time.in tables- B and E similarly,

‘Although most diseases are characterized by syn-dromes or configurations of complaints, an attempt ismade in NAMCS to relate the principal diagnosis to themost important complaint presented by the patient.A discussion of patients’ principal complaints or symp-toms follows in a later section of this report.

Table E. Number and percent of office visits for selecteddiseases of the clrculatorv svstem listed as second or third

diagnoses: United States, 1975-76

Diagnosis and ICDA codel

All visits ... . ... .. .. ... .. .. .... .. .. .... . .. ... ..

Essential benign hypertension ... . .. ....401

Coronary heart disease .... ... .. .. ...410-413Symptomatic heart disease .. .. .. .... . ....427Cerebrovascular disease . .. . .... .. ...430-438Arteriosclerosis .. .. .... . ... ... . .. ..... . .. .... ...44OPhlebitis and thrombophlebitis . . .. .....45lVaricose veins of lower extremities...454

Hemorrhoids .. .. ... ... . ... . ... ... .. .. ... .. .. ....455

-1-Number Per-of visits centIn thou- Of

sands visits

1,156,900 100.0

28,590

L

2.520,887 1.8

7,830 0.72,771 0.24,119 0.4

904 0.11,559 0.11,297 0.1

lDiag~ostic groupings and code inclusions are based on theEighth Revision In ternati”onal Classification of Diseases, Adaptedfor Use in the United States, 1965.

coronary heart disease was a listed diagnosisduring 52.2 million visits.g

Recent hypertension prevalence data areavailable from HANES.ZZ These data in con-junction with NAMCS visit data wherein essen-tial benign hypertension was a principal, second-,or third-listed diagnosis provide some insightinto the utilization of office-based ambulatorymedical care resources by those in need of treat-ment. According to the findings of HANES,an estimated 23.2 million adults aged 18-74years had definite hypertension, 23.4 millionhad borderline hypertension, and 81.4 millionwere normotensive. However, HANES alsoshowed that of the borderline and normoten-sive groups, 8.9 percent and 2.0 percent, respec-tively, took re~lar medication for high bloodpressure, leading to an assumption in HANESthat an additional 3.7 miIIion adults had con-trolled hypertension, or a total essential benignhypertension prevalence of 26.9 million. If 37.3million, the average yearIy visits (one-half ofthe 74.7 million visits in which essential benignhypertension was a listed diagnosis), is divided

gwhen first., second., ~d third-listed diagnoses are

considered, total visits for two or more diseases are notadditive since it is possible that the two or more diseaseswere diagnosed during the same visit.

12

Table F. Number and percent of office visits for essential benign hypertension (401) listed as first, second, or third diagnosis, by other

most frequent diagnoses: United States, 1975-76

Hypertension I HypertensionI isted as first listed as second

diagnosis or third diagnosis

Diagnosis and lCDAcodelNumber Per- Number Per-of visits cent of visits centin thou- Of in thou- Of

sands visits sands visits

All visits . ..... .. . ... .. .. ... .. . .... .. .. .. . ... ... .. . .... . .. ... .. .... .. . ... . ... .. .. . . ... .. . ..... . .. ... . . .... . .. .... . ..r . .. .. ... 46,128 100.0 28,590 100.0

Diabetes mellitus .... . .... ... . . .... .. ... .. .. . .... .. .... .. ..... . . ..... . .. .. .. .. .. .. . . ... .. .. ... . . .... . ... .. .. .. .... .. .... . .. ... . ...25OObesity

2,054 4.5 4,038 14.1. .. .... . .. ... .. . .... ... . .... .. ..... . .. ... ... .... .. . .... ... ... . .. ... ... . ... .. . ... .. . ... .. . .... . .. ... .. .. .. .. . . ... .. .. ... .........277 4,674 10.1

Neuroses .. ... .1,425 5.0

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..3oo 1,380 3.0Arteriosclerosis..

1,125 3.9. ... . .... .. .. .. ... . ... ... . ... .. .. ... .. . ... ... . .. .. . .. ... . . .... . .. .... .. ... ... . ... .. . .... .. . .... . .. .. ... . ... ... ... .440 649 1.4 * 340 1.2

Bronchitis, emphysema, asthma.. . ... .. .. .. .. .. ... .. . .... .. . .... .. ..... . .. .. .. ... .. . .. .... . . .... . .. ... ... . .. . .. ...490-493 ’575 1.3 948Arthritis and rheumatism, except rheumatic fever

3.3. . .. .. .. .. ... . .. .... . .. .. .. .. .... . .. ... . .. ... ... . ... .. ..71 O.7l8 2,038 4.4 2,957 10.3

lDi~gnosti~ groupings and code inclusions are basedon the Eighth l?evision International Clastificati-on of Diseases, Adapted foi- usein the United States, 1965.

by the HANES essentiaI benign hypertensionprevalence of 26.9 million, there was an esti-mated average minimum visit rate of 1.4 visitsto office-based physicians per year for each per-son aged 18-74 years in the population whohad hypertension. This utilization rat e providesa benchmark for future estimation and evaluat-ion of the utilization of physician resources bythe segment of the population needing treat-ment for essential benign hypertension. Onereason for the low rate of utilization may wellbe due to the fact, shown in HANES, that 55percent of the population estimated to havedefinite hypertension were never diagnosed ashypertensive.h As consumer education reducesthis number, the rate of utilization may increase.

Diagnostic Concomitance

The pattern of coexistence of hypertensionwith other diaamoses not necessarily in thegroup “diseases of the circulatory system” isdescribed in table F. The same type of analysisfor coronary heart dkease is shown in table G.The first item of note (which is evident by its

‘Data in HANES were collected from 1971 to 1974.There is reason to believe that the percent of never-dia~osed hypertensives was slightly less in 1975-76.

absence) is that hypertension and coronary heartdisease were not assigned to first, second, orthird diagnoses interchangeably, to any greatdegree. That is, when hypertension was the prin-cipal diagnosis, coronary heart disease rarelywas included as a second or third condition.When essential benign hypertension was asecond- or third-listed diagnosis, coronary heartdisease was not the principal diagnosis. The samesituation prevailed for coronary heart diseaseas shown in table G. These data lend support tothe idea offered earlier that its cardiovascularconsequences eventually supplanted essentialbenign hypertension as a diagnosis during visitsto physicians.

The diagnoses Iisted in tabIe F were mostfrequently observed during visits when hyper-tension was present. For exampIe, when hyper-tension was the principal diagnosis, diabetesmellitus was the second or third diagnosis inabout 5 percent of the 46.1 million visits. Whenessential benign hypertension was the second-or third-listed diagnosis, a striking 14 percent ofthose 28.6 million visits were diagnosed primar-ily as diabetes mellitus. Simiku-ly, obesity wasan additional diagnosis ii 10 percent of visitsmade for essential benign hypertension, and wasprincipal dia~osis for 5 percent of visits whenessential benign hypertension was listed as

13

Table G. Number and percent of office visits for coronary haart disease (410-413) listed as first, second, or third diaonosis, bv other

most frequent diagnoses: United Statas, 1975-76

Diagnosis and ICDA code]

All visits .... .. ... ... .. .. ... .. . .... .. .. ... ... .... .. . .... .. .. ... ... . ... ... .. .. .. .. .... . ... ... . ... ... .. .. ... . .. . .... ... ... .. ...

Diabetis mellitus...,.. .. .. .... . . ..... . ... .... . . .... .. .. ... . ... ... .. .. .... .. .... .. .. .... . .. ... .. .. . .. ... .. .. .. . . .... . .. .... . .. . ....25OObesity . ... ... .. .... . ... ... .. . ..... . . .... . ... ... .. .. .... . . .... ... .. .. .. .. .... . . .. ... . ... .. .. .. .... .. . .... . .. .... .. .. .. .. .. . .... . .. .....277Cerebrovascular disease ... . .... . .. .... ... . ... .. .. .... . . ...... .. .... . .. .... .. . .... .. . .... .. .. ... .. . ... ... .. ... .. .. .... ..43 O.438Bronchitis, emphysema, asthma ... ... ... .. . ... ... ..... .. . ... .. .. ..... . . .... ... . .. ... . ..... . . ..... . .. ... ... . .... ...49O.493Arthritis and rheumatism, except rheumattc fever .. .. . .... .. . .... .. . .. .. .. .. ... ... .... . ... ... .. .. ..... ...71 O.7l8

Coronary heartdisease listed asfirst diagnosis

+

Number Per-of visits centin thou- Of

sands visits

31,314 100.0

2,029 6.51,079 3.5

623 2.0838 2.7

1,469 4.7

-..

2oronary heart dis-,asa listed as secondor third diagnosis


sands

20,887—.

1,574*

618847

1,344

Per-cent

ofvisits

100.0

7.5*

3.04.16.4

lDia~no~tic ~rouPin~s and code inc]u~ions are based on the Eighth Revision International Cbsification OfDiseases,Adaptedfor usein the United States, 1965.

second or third diagnosis. Neuroses; arterio-sclerosis; bronchitis, emphysema, and asthma;as well as arthritis and rheumatism (exceptrheumatic fever) also appeared in conjunctionwith essential benign hypertension in a substan-tial number of visits.

Four types of diagnoses most commonlycoincident with hypertension also co-occurredwith coronary heart disease (although essentialbenign hypertension itself did not, as pointedout earlier). Diabetes mellitus; obesity; bronchi-tis, emphysema, and asthma; and arthritis andrheumatism (except rheumatic fever) togetheraccounted for about 17 percent of the visits inwhich coronary heart disease was a principaldiagnosis. Excluding obesity, these diseaseswere primarily responsible for 18 percent ofvisits when coronary heart disease was listedsecond or third by the physician. It may seemunlikely for coronary heart disease to be“second” to bronchitis or arthritis, but thereader is reminded that the assignment prece-dence of one diagnosis over another on theNAMCS Patient Record was not dictated by itsseverity but by its relationship to the mostimportant reason for that visit expressed by thepatient. Cerebrovascular disease, which did notoccur frequently in conjunction with hyperten-sion, emerged as a concomitant diagnosis withcoronary heart disease during visits. Since cere-brovascular disease is often a consequence of hy-

pertension, it is not surprising that cerebrovascu-Iar disease and hypertension were not frequentlyconcurrent much as coronary heart disease, whichis also a potential consequence of hypertension,was not frequently concurrent with essentialbenign hypertension.

The number of visits for diseases belongingto other major ICDA groups that co-occurredwith arteriosclerosis, cerebrovascular disease,and diseases of veins were insufficient to use asa basis on which to determine two-way relation-ships within the limits of good reliabilityy. How-ever, arteriosclerosis and cerebrovascular diseasewere concurrent with other members of theirown ICDA group. Arteriosclerosis numberedamong diseases that were extant with essentialbenign hypertension, while cerebrovascular dis-ease figured among those associated withcoronary heart disease, as pointed out pre-viously.

Patient’s Principal Problem,Complaint, or Symptom

It is instructive to examine data on visitsthat culminated in diseases of the ckculatorysystem diagnoses in terms of the problemsthat motivated patients to visit physicians.These problems help to explain why patientsseek ambulatory medical care and are there-fore useful indicators of health resources utiliza-tion.

14

The problem, complaint, symptom, or otherreason for visit expressed by the patient, whichin the physician’s judgment was most respon-sillle for the patient making the visit, was enteredon the Patient Record. It was coded accordingto a symptom classification developed especiallyfor NAMCS.Z3 (The principal diagnosis is thephysician’s ewduation of the patient’s condi-tion associated with this chief complaint.) Theterms “problem,” “complaint,” and “symptom”are used interchangeably in this report.

Essential benip hypertension. –The prob-lems presented most frequently when the visit-ing patient was diagnosed as hypertensive arelisted in table 8. It is known that essentiaIbenign hypertension is generally asymptomaticfor- a long period of time. However, the closelyrelated symptoms of headache, vertigo, fatigue,and nervousness appeared in about 16 percentof visits and represented the most frequentpatient symptoms (after deletion of nonsympto-matic reasons of “high blood pressure” andmedical examinations).

A1though abnormally high blood pressuremay be a si~ of essentizd benign hypertension,studies have shown that patients have littlesensory awareness of blood pressure. Usuallyelevated blood pressure is determined objectivelythrough measurement by a medical provider.

.Therefore, it is probable that in the 27 percentof visits in which “abnormally high blood pres-sure” was coded, patients were visiting for acheckup and were repeating a prior profes-sional evaluation rather than articulating theirown physicial discomfort. In this sense, highblood pressure would not necessarily be con-sidered a symptom arising from internzd stimulussuch as headache would be. Under this assump-tion, high blood pressure (27 percent) togetherwith visits for which no patient symptom wasindicated by the physician (40 percent) andgeneraI medical examination (2 percent)–a totalof 69 percent of visits with a diagnosis of essen-tial benign hypertension–when compared to the16 percent of visits made because of headache,vertigo, fatigue, and nervousness, provides arough measure of asympt omatic versus sympto-matic reasons for visit expressed by patients.

The most frequently reported symptomswere not more likely to be presented by one sex

than by the other. Neither did the number ofvisits for each symptom differ significantly whenpresented by patients under 65 years of age orby patients 65 years and older.

Coronary heart disease. –The most frequentproblems presented by patients during visitsfor this disease are shown in table 9. Unlikevisits made for essentiaI benign hypertension,visits made because of coronary heart diseasewere more often subjectively symptomatic thanthey were asymptomatic. About one-third of allsuch visits occurred because of chest pain,shortness of breath, and other symptoms refer-able to the cardiovascular system. Fatigue,vertigo, and headache were general symptoms .which together accounted for another 10 per-cent. Pain, swelIing, and injury of the lowerextremities was given as a reason in about 2percent of the visits made because of coronaryheart disease.

Patients visiting for checkups such as thosedesignated by “abnormally high blood pres-sure” (4 percent) and “progress visit” (30 per-cent) may have also experienced symptoms ofheart disease and general symptoms, but thesesymptoms may not have been expressed by thepatient at that visit.

Coronary heart disease patients under 65years of age were more likely to present theproblem of chest pain than were older patients,but other symptoms were not significantly re-lated to one age group or the other.

Differences by sex among patients present-ing varous symptoms were also not statisticzdlysignificant.

Other diseases of the circulatory system. –Patients visiting for treatment of symptomaticheart disease were also likely to complain ofphysicial difficulties. Predictably, the two ,mostcommon reasons were irregular pulsations andpalpitations (22 percent) and shortness of breath(16 percent). An additional 10 percent involvedvarious other symptoms referable to the cardio-vascular system. Pain, swelling, and injury of thelower extremities was reported during 5 percentof visits.

Patients complained mainly of vertigo (23percent) during visits for cerebrovascular disease.Vertigo and fatigue together motivated 28 per-cent of arteriosclerosis visits.

15

Complaints associated with diseases of theveins were clearly physiczd manifestations of theconditions. “Problems of the lower extremi-ties” and “varicose veins” were mainly respon-sible for visits diagnosed “varicose veins of thelower extremities. ” Phlebitis patients ako com-plained mainly of lower extremity problems.Equally obvious problems caused visits forhemorrhoids.

Visit Status and Seriousnessof the Problem

Although complaints and diagnoses identifythe nature of patient visits, problem status andthe degee of seriousness of the problem de-scribe the intensity of patients’ problems. Datafor these two variables are presented in table 10.

It was mentioned earlier that new-problemencounters (those visits in which a problem ispresented for the first time, whether by a new

patient or by a patient the physician had seenbefore) were not the rule for the major ICDAgroup of cirmdatory diseases. There was somevariation on that score among specific principaldiagnoses, however, which was worthwhileexamining. It can be seen from table 10 thatvisits for diseases of veins (phlebitis and throm-bophlebitis, varicose veins of lower extremities,and hemorrhoids) were proportionally morefrequently new-problem encounters than wereother circulatory diseases. Equally apparent isthe fact that visits for hypertension and chronicischemic heart disease were more likely to becontinuing problems than were visits for otherdiagnoses shown in the table.

Visit status in terms of patient sex and ageis provided in table H for hypertension visits,and in table J for coronary heart disease visits.

“Seriousness” refers to the physician’s clini-cal judgment as to the extent of the patient’simpairment that might result if no care were

Table H. Number and percent distribution of office visits for essential benign hypertension (401 ) by visit status, seriousness of problem,and disposition of visit, according to sex and age of patient: Unitad States, 1975-76

Visit status, seriousness, and disposition

All visits .. . .. ..... . . ..... . .. ..... . . .... .. . ..... .. .. .... . . .... .. . .... .. . .... .. ... ... . ... ... .. .. ... .. ... ... .. .. .... . .. .. .

Visit status

New patient . ..... . .. ... .. .. .... . ... .. . .. .. ... .. .. .... . . .... .. .. ... .. .. ..... ... ... .. . .... .. . .... .. .. .. .. ... .... . .. .... . .. ... ... .. ....Returning patient, new problem .. .. . .... . .. . ... .... ... .. . ..... . .. ... .. .. ... ... . ... .. .. .... .. . ..... . . .... .. .. .. .. .. .. .. .. .Returning patient, continuing problem .. .... .. .. ... . ... ... .. ..... .. . .... .. .. .. ... . .... .. . .. .. . ... .... .. .. .. .. . ... .. .. .

Seriousness

Serious or very serious ..... .. .. .. ... .. .... . .. .. .. .. .. .. .. .. .... .. .... .. .. .... .. .. .. .. .. .... . .. ... .. .. .... .. .. ... .. . .... .. .. ... .Slightly serious . ... .. ... .. .. .... . . .... .. .. .... . .. ... .. .. ... ... .. ... . .. .. . .. ... .... ... ... . .. .. .. .. .... .. .. ... .. .. .... .. .. ... ... . .. ...Not serious .. . ..... .. .... .. .. .... .. .... .. . .... .. .. ... .. .. ... ... . .... . .. .... .. . .... . ... ... .. .. ... . .. ... .. . .... ... . .. ... . .. ... .. ........

Disposition

Return at specified time .... .. .. ... .. . .... ... .... . .. ... .. . . ...... ... .. . ... .... . .. ... .. .. .... .. .. ... . .. ... ... . .... ... .. .. .. . ....Return if needed .. . .... .. .. ... . .. .... ... . ... .. .. ... .. .. ... .. .. ... ... . .... .. .. .. ... . ... ... .... .. .. .... . .. ... .. .. .... . ... .. .. .. ... ..Referred to other physician or returned to referring physician . .. .... . .. .... .. .. .. .. .. .... . ... .. .. .. . ... ..Otherz ... ... . .. .... . ... ... ... .... .. .. .... . .. ... .. .. .... .. . ... .. .. ... . ... ..... . . .... . ... ... . ... ... .. . ..... . . ... .. .. .... .. .. .... .........

Sex I Age

Female I Male I Under I65 years65 years and over

Number of visits in thousands

29,287 I 16,840 I 29,596 I 16,532

Percant distribution

100.0

5.05.8

89.3

20.847.032.2

86.810.0*2.O

4.2

100.0

4.86.0

89.2

24.745.230.1

84.910.7*2.3

5.8

100.0

5.95.7

88.4

22.747.230.1

87.29.02.55.1

100.0

3.06.3

90.7

21.344.833.9

84.112.5*1.5

4.3

lperCent~willnOtaddtO100,0b~~~”sesome patient visits had morethan1diwositiors.21nc]udeSadmitto hos.~it~],*Ofollo~p planned, telephone followuP, or other disposition.

16

Table J. Number and percent distribution of office visits for coronary heart disease (410413) by visit status, seriousness of problem,and disposition of visit, according to sex and age of patient: United States, 1975-76

Visit status, seriousness, and disposition

All visits .. .. .. ... .. . .... .. . .... . ... .. .. .. ... . .. ... .. . ... .. .. .. .. .. ... . .. .... . .. ... .. . ... .. . .... ... ... . .. ... .. . .... . . ...

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

Visit status

New patient .. .. .. .... . ... .. ... . ... ... . .... . . .... .. . ... .. .. .. ... . .... . . .... . . .... .. . ... . ... .. .. .. .. .. .. .... .. .... . .. ... .. . ... .. . ... ..Returning patient, new problem .. ... .. .. .. .. .. .... .. .... .. . ... .. . ... .. . ... .. .. .. .. . . ... ... ... ... . ... .. .. .. ... . ... . .. .. .. .Returning patient, continuing problem ... .. .. ... . ... . .. .... . . .... . .. ... .. .. ... .. . .... ... .. ... . ... . .. ... .. .. .. .. . ... .. .

Seriousness

Serious or very serious .. ... . ... ... .. .. .. .. .. ... . .. .... .. .... . .. ... .. .. .. .. .. ... . .. .... . ..... .. . .. .. ... ... . . .... . ... ... ... .. .. ..Slightly serious ... .. .. ... . .. .... .. . .... . .. ... .. .. ... . .. ... . .. ... ... . ... .. . .... . .. .. .. .. ... . .. ... .. .. .. .. .. ... .. . ... .. .. ... . ... .. .. . .Not serious ... . .. .. .. .. ... ... . .... .. . ... ... . ... .. .. .. ... . ... . ... .. .. .. ... .. . .. .. . .... ... .... . . .... .. . ... .. .. ... .. . ... .. .. ... . .. ... . .. .

Disposition 1

Return at specified time .. .. . .... . . ..... . .. ... .. .... . .. ... .. .. ... .. . .. .. .. ... .. . .... . .. ... . .. ... . .. ... .. . .... .. .. ... . . .... . .. ..

Return if neaded .. ... ... ..... .. .... . .. ... .. . .... . .. ... .. . .... .. . ... . ... .. . ... ... . . .... .. . ... . .. .... . .. ... .. . .... . . .. .. .. . ... .. . ...Refer[ed to other physician or returned to referring physician . .. ... . .. .... . . .... .. . ... ... . .. .. .. ... .. . ...Otherz .... ... . .. .. . .. ... . ... ... .. . .... .. . ... .. .. ... . .. ... .. .. ... .. .. .. .. .. ... .. .. ... . .. ... .. .. ... . .. ... . .. ... .. .. ... . .. ... .. .. ... . .....

Sex Age

Female I MaleUnder

65 years

65 yearsand over


14,828 I 16,485 [ 14,093 I 17,221


100.0

available. Using this criterion, physicians wererequested to rate the patient’s condition on a4-point scale ranging from “not serious” to“very serious.” Although the same definition of“seriousness” was provided to all participantsin the survey, it is difficuIt to determine thedegree of adherence to it. Medical specialistsvary in training emphasis and degree of prog-nostic Iatitude. The data shouId be viewed inthis context.

Degree of seriousness appeared to vary fromone type of diagnosis to another. Essentialbenign hypertension was more often judged inthe two less serious categories, and coronaryheart disease was more frequently judged in themore serious categories. Except for phlebitisvisits which were about equally divided on eachhalf of the seriousness range, diseases of theveins were assigned to the less serious categoriesmore frequently than to the more serious cate-

5.07.1

88.0

51.533.415.1

86.68.7

*3.85.4

I percents will not add to 100.o because some patient visits had ImXe than 1 disposition.21ncludes admit to hos~ital, no fo]lomp planned, telephone followup, or other disposition.

100.0

4.97.1

88.0

52.932.314.8

86.17.7

++3.18.1

100.0

8.06.3

85.7

55.929.514.6

85.77.2

++4.18.0

100.0

2.47.8

89.9

49.235.615.2

86.99.1

*2.95.9

gories. Arteriosclerosis visits were also among;he group evaluated as less serious.

The relationship of seriousness to patient orprobIem status was examined and results are pre-sented in tabIe K for hypertension visits andtable L for coronary heart disease visits. Forboth of these diagnoses, the judgment of sever-ity was apparently not reIated to the status ofthe visit (new or returning patient) or to thestatus of the problem (new or recurring prob-lem), because variations among estimates werenot statistically significant. That is, new patientswere not more often categorized as “serious”or “very serious” than were returning patients,nor were new-problem visits more often judged“serious” or “very serious” than were old-problem visits.

Because the estimates yieIded by the serious-ness scale that was used to judge these chronicproblems were not conclusive, some comment

17

Table K. Number and percent dlstrlbutlon of office wsits for essential benign hypertension (401 ) by seriousness of problem, according

to visit status: United States, 1975-76

Visit status

New patient ... .. .... .. . .... . .. . ... .. .. ... .. .. .... .... ... . .. ..... ... ... .. .. .. .. . .. ... .. .. ... .. .. .... . .. ... .. .. .... .. .. ...Patient seen before, new problem ... .. .. ... .. . ... .. .. ... .. .. .... . . .... .. . .. . .. . .... . .. ... .. .. .... .. .. ...Patient seen before, continuing problem .... . .... .. . .... . .. .... .. .. ... .. . .... .. .. .... . .. .... . .. .... .. .. ...


sands

2,2542,709

41,165

II I I

*kPercent distribution

!Ell%EE

Table L. Number and percent distribution of office visits for coronary heart disease (410-413) by seriousness of problem, according to

Visit status: United States, 1975-76

Numberof visits

SeriousVisit status Total

Slightly Notin thou-

or veryserious serious

sandsserious


New patient .... . .. ..... . .. .... .. .. .... .... .. ... . .... .. .. ... ... .. .. .. .. .... .. .. ... . ... ... .. .. ... ... . ... .. ... ... .. .. .... . . 1,538 100.0 57.1 26.2 16.7Patient seen before, new problem ... . .... .. . ... .. .. .... .. .. .... .. . ... .. .. .... .. . .... .. . .... .. .. .... . .. .... . .. 2,220 100.0 52.1 23.8 24.1Patient seen before, continuing problem ..... .... ... . .. .... .. . .... .. .. ... .. .. ..... . . .... . ... ... .. .. .... .. . 27,556 100.0 52.0 33.9 14.1

on the complexity of this scale is indicated. Acursory examination seems to indicate that theseriousness of patients’ problems may have beenjudged on the basis of the patient’s ability tofunction while receiving medical care. Forexample, if left untreated, essential benignhypertension has potentially very serious conse-quences. But patients who visit physicians andadhere to a treatment regimen ordinarily func-tion very well (and it has been shown that mostvisits were made by returning patients with con-tinuing problems). The frequent assignment ofessential benign hypertension visits to a “notserious” or “slightly serious” category suggeststhat the basis for assignment might have beenability to function rather than amount of im-pairment that would result if the condition werenot treated, since it is acknowledged that agreat deal of impairment would result if essentialbenign hypertension were not treated or no carewere available for it. A similar assumption couldbe made about other life-threatening diseases

which were not frequently classified as “serious”or “very serious. ” While the proportion ofcoronary heart disease visits classified at the

serious end of the scale was statistically greaterthan its opposite category, the difference be-tween proportions of not serious and very seriousvisits was not as great as might be expected for adisease that is so often fatal without propermedical care. The slightly higher proportiondesignated “serious” or “very serious” could bedue to the fact that patients complaining ofshortness of breath and chest pain clearly donot function very well, which also suggestsability to function as a criterion for judgingseriousness.

However, ability to function may be onlyone dimension of the multidimensional natureof the seriousness attribute. If a factor analyticapproach to measurement of seriousness weretaken, the results could differ considerably.

Duration of Visit

Visit duration is the amount of time spentby the physician in direct encounter with thepatient as estimated by the physician. The meancent act duration is the average number ofminutes per visit when the visit included a con-

18

tact with the physician. Thus, contact durationwhen only other staff was contacted is includedin the survey but excluded from the calculationof the mean.

Time spent by the physician is an importantfactor in patient management and is a usefulindex of medical care utilization by the pubIic.Although some visits require and consume muchof the physician’s time, others do not. This isnot to imply that care is not rendered. In theframework of the NAMCS definition, visits mayuse none of the physician’s time, but treatmentmay have been appropriately delegated to thephysician’s staff. Physicians also devote time topatient care that is not necessarily performed inthe presence of the patient, such as evaluatingtest results, reading X-rays, reviewing histories,and consulting with other physicians. Durationestimates for principal diagnoses are presentedfor comparative purposes and not as the totaltime spent in patient care.

Table 11 lists the mean contact durationsfor selected circulatory problems. For properinterpretation of these estimates, the standarderrors also shown in tabIe 11 should be takeninto consideration using appropriate methodol-Ogy.i For each disease, table 11 provides meancontact duration separately for patient age, sex,and visit status.

The mean contact duration of all NAMCSvisits was 15.3 minutes (+0.2 minutes). The aver-age duration of visits for heart disease was sig-nificantly longer than the overall average, butvisits for hypertension, cerebrovascular disease,and other diseases of the circulatory systemtook about the average time.

The average time spent in treating patientsfor some disorders was affected by patient status(new or returning) in some cases, and by prob-lem status (new or recurring) in others. Whenhypertension was presented as a new problem tothe physician, either during an initial encounteror on a return visit, the visit lasted longer (24.0minutes and 18.7 minutes, respectively) thandid visits involving returning patients with hy-pertension as a continuing probIem (13.5

‘See appendix I for “Estimates of differences be-tween two statistics. ”

minutes). The duration of the new-patientencounter was significantly Ionger than that ofthe returning patient with a new problem.Initial visits for ischemic heart disease (acute orchronic) and symptomatic heart disease were,on the average, longer than visits in which thepatient had previously consulted the physician.New patients seeking treatment for angina pec-toris and cerebrovascuhr disease also requiredmore time than patients returning for continu-ing care of these problems required. Differencesamong types of visits for other dia~oses werenot statistically significant.

The longer duration of initial encountersfor some circulatory diseases may be due to theneed for more intensive workup in new-patientvisits. For example, 57 percent of all initialvisits for hypertension included a general exami-nation as opposed to 23 percent of return visitsfor a new problem and only 10 percent of visitsfor an oId problem.

Disposition of Visit

Continuity of care is an important aspect ofpatient management especiaUy for the aging andchronically ill. The intent of physicians regard-ing ongoing care is reflected by the dispositionof the visit. Office-based physicians treatingpatients for the most frequently reported dis-eases of the circulatory system concluded themajority of visits with instructions to returnat a specified time. Patient compliance withthese instructions was shown in the high pro-portions of visits that included patients return-ing for further treatment (table 10). For eachdiagnosis listed, visits that culminated in instruc-tions to return at a specified time were propor-tionately comparable with return visits for treat-ment of continuing problems.

Instructions were not disproportionatelygiven to males and females making visits forhypertension and coronary heart disease. Neitherdid age make a significant difference insofar asthe proportions of visits with these instructionswas concerned (tables H and J).

Attesting to the asymptomatic nature ofmost visits made for essential benign hyperten-sion, the disposition of very few visits was ad-mittance to a hospital. As might be expected,a higher proportion of acute ischemic heartdisease patients (14 percent) were recommended

19

for hospitalization than were those with otherforms of heart disease.

The seriousness of the patient’s problems ap-peared to be related to the physician’s followupdecision in hypertension and coronary heartdisease visits. Proportions of visits in which nofollowup was planned became pro~essivelysmaller as the probIem became more serious(table M). For example, no followup was plan-ned in 4 percent of all visits for hypertensionjudged not serious as opposed to 2 percent ofvisits for hypertension judged serious or veryserious. For coronary heart disease, the contrastwas even broader. For those visits evaluated asnot serious no followup was scheduled in sevenof ten visits compared with less than one in tenof those considered serious or very serious.Conversely, proportions of hypertension visitsthat included instructions to return at a speci-fied time grew progressively larger as the prob-lem increased in seriousness. For coronary heartdisease, any increase in seriousness also warrantedinstructions to return at a specified time. Themore casual instruction, “return if needed,”was used more frequently following visits judgednot serious than after those of a more seriousnature.

Table M. Percent of office visits for essential benign hyperten-sion (401 ) and coronary heart disease (410-41 3), by dispo-sition of visit and seriousness of problem: United States,

1975-76

Diagnosis, ICDA code,land seriousness

of problem

Essential benignhypertension (401 )

Serious or very serious ... . ... ..

Slightl vserious...................Not serious .. ... ... . .... .. . ... .. .. ...

Coronary heartdisease (410-413)

Serious or very serious ... . ... ..Slightly serious .. . .... . .. ... .. .. ...Not serious .. .... . .. ... . ... ... .. .. ...

Nofoliowupplanned

1.72.23.8

0.61.46.6

Returnat

specifiedtime

Percent

90.088.080.5

87.288.179.2

Returnif

needed

6.89.2

14.2

6.87.8

14.2

lDiagno~ti~ groupings and code inclusions are based on the

Ei.ghth Revision Interns tional Classification of Diseases, Adaptedfo; Use in the United States, 1965.

20

Referral

About 3 percent of patient visits folr diseasesof the circulatory sys tern were referred to otherphysicians; this was close to the avera,ge for allICDA !#OUpS. Only about 2 percent of allessential benign hypertension visits and 3 per-cent of alI coronary heart disease visits werereferred. GeneraI and family practitioners re-ferred 4 percent of their total visits for essentialbenign hypertension and coronary heart diseaseto other physicians or agencies. For intern-ists, the referral rate for these two diagnoseswas 2 percent.

Diagnostic-Therapeutic Services

The NAMCS was designed to produce dataon the diagnostic and therapeutic services orderedor provided by the physician during the currentvisit. The Patient Record did not have the flexi-bility to probe whether procedures were singleor multiple. Therefore, estimates provide infor-mation about the general nature rather than theextent of the physician’s workup. For example,if “clinical lab test” was checked on the form itwas not known whether a blood test alone wasperformed or whether blood, urine, and sputumtests were ordered. Similarly, an indication of“X-ray” provided no clue as to the number orsit e(s) of X-rays taken during a single visit. As aresult, total estimates of clinical lab tests or X-rays indicate the number of each type of service

rather than the total number of all such services.Estimates of services that are usually renderedonce during a visit such as a history or examina-tion, EKG, or blood pressure check, are closerto the actual number of times each was done.This caveat also applies to therapeutic servicessuch as drug prescription and injection whichcould be single or multipIe.

Number of services. –The number of differ-ent types of services is a useful indicator of am-bulatory medical care utilization by patientspresenting different conditions. In general,physicians tended to order or provide a higherthan average number of types of services duringmost visits made for diseases of the circulatorysystem, while such visits in which no serviceswere provided were less than the average numb erfor aH NAMCS visits. Except for diagnoses of

Table N. Percent distribution of office visits for diseases of the circulatory system by number of types of diagnostic and therapeuticservices ordered or provided, according to selected principal diagnoses: United States, 1975-76

Principal diagnosis and ICDA codel

All principal diagnoses .. . .... . . .... .. .... .. . .... . .. ... .. . .... . . .... .. . ... .. .. ... . .. ... . .. ... .. . .

Essential benign hypertension . .... . .. ... . .. .. .... .... . . .. .. .. . .... . ... .. . .. ... . .. .... .. .... .. .. .. .. ...4Ol

Acute ischemic heart disease . . ... .. .. .... . .. ... .. . ... .. .. ... . .. .... .. ... .. .. ... .. . ... ...! ... . . ..4lo4llChronic ischemic heart disease ... . .. ... .. .. ... .. . .... . .. ... .. . ... .. .. .. .. .. .. ... . ... .. . .... . .. ... . .. ..4l2Angina pectoris . ... .. .. .... .. . .... .. .. .. .. . ..... . .. ... .. .... .. .. .. .. .. .... ... ... ... ... .. . .... . . .... . .. .... .. ..4l3Symptomatic heart disease ... . ... .. . ... .. .. ... . .. ... ... . . ... . .. ... . .. ... . .. ... .. .. .. ... ..... . . ... .. ....427Cerebrovascular disease . .. .. .... . .. .. .. ... .. .. ... .. . ... ... . ... .. . .... ... ... . .. .. ... . ... .. .. ... . .. ..43O~38Arteriosclerosis .... .. . .... . ... ... .. . ... .. . . .... . .. ... . .. ... .. . ... .. .. ... . .. ... . .. .... . . ... ... . .... . .. .... . . ...440

Phlebitis and thrombophlebitis .. . .... . . .... . .. .... .. . .. ... . .... . . .... .. .. .. .. .. .. .. . ... ... . ... . .. ....45lVaricose veins of lower extremities . . ..... . . .... . .. ... .. .. ... . .. .... . . .... . .. ... . .. ... .. . ... .. .. ....454

Hemorrhoids .. .... .. . .... .. . ..... ... ... . .. ... .. . ..... .. .... . .. ... . .. .... . .. ... .. . ... . ... .. .. .. ... .. .. .. .. .. ....455

ITotalNo

services

100.0_

100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

Onetype

ofservice

Twotypes

ofservices


2.5

0.80.30.70.30.90.91.00.81.3

2.6

26.0

16.19.7

10.89.6

12.314.217.914.638.831.9

30.6—

28.317.923.616.524.126.724.232.426.533.8

Threetypes of

services ormore

40.9

54.872.164.973.762.858.357.052.233.431.7

1Diagnostic grouPing5 and code inclusions are based on the Eighth Revision International Classification of Diseases, Adapted for usein the United States,’194s.

varicose veins of lower extremities and hemor-rhoids, visits for the diagnoses listed in table Nincluded higher than average proportions ofvisits characterized by three types of servicesor more. These proportions clearly exceededthose of the same diseases in which two servicesor less were included.

Selected diapostic services. –Tables O and Prelate specific diagnostic and therapeutic servicesto visits for the most frequently diagnosed cir-culatory diseases. For visits diagnosed “hyper-tension” and ‘~coronary heart disease,” tables

Q and R link patient management, exemplifiedby diagnostic and therapeutic services, to patientcondition, as evidenced by visit status and prob-lem seriousness. Provision of services accordingto sex and age of patients visiting for essentialbenign hypertension and coronary heart diseaseis described in tables S and T.

The limited history and examination wasclearly the preferred method of gathering basicdata by physicians since about half or morevisits for the various circulatory disorders in-cluded this type of procedure. The comprehen-sive general history and examination was usedmore often when the diagmosis was heart diseaseor cerebrovascular disease than when othercirculato~y disorders were dia~osed. The less

liberzd use of the generaI history and examina-tion than the limited type during all visits fordiseases of the circulatory system is reasonablein view of the high rate of return visits. Themore comprehensive examination was used in57 percent of visits when new patients werediagnosed as having essential benign hyperten-sion in contrast to ordy 10 percent when suchhypertension was a recurring problem. It wasalso more frequently chosen for initial visits dueto coronary heart disease (68 percent) than forsuch “old’’-probIem visits (13 percent). On theother hand, the limited history and examinationwas more often selected as the appropriate typewhen the physician had seen essential benignhypertension and coronary heart disease patientsbefore, whether for new or recurring problems.It appears that less exhaustive examinationswere necessary when physicians had prior knowl-edge of or medical records for returning patients.

Predictably, EKG’s were used more oftenduring heart disease visits than when othercirculatory diseases were principaJ diagnoses.Heart activity was tested more often duringcoronary heart disease new-problem visits thanduring visits in which that disorder was a recur-ring problem. However, EKG’s were used spar-ingly in the absence of hypertension, coronary

21

Table O. Number and percent of office visits for selected diseases of the circulatory system, by diagnostic and therapeutic servicesordered or provided: United States, 1975-76

Diagnostic or therapeutic service

All visits .. . .. ... .. .. .... .. . .... .. . .... .. .. .... . . .. .. .. .. .... . .. .... .. . .... . .. .... . . .. ... . .. .... .. .. .... .... .. .. ..

Diagnostic services:Limited history and examination ... ... . .. .... .. . ..... .. .. .. ... . ..... . .. ... ... . .... . .. .... .... .... .. .... .. . ...General history and examination . .. ... ... . .... .. . .... .. . .... ... .... .. . ..... . ... ... .. .. ... .. . .... . ... ... .. .. ...Laboratory procedure or test ... .. .. .... . ... ... .. .. ... ... ..... . ... ... .. . .... .. .. ... ... . .. ... .. ..... .. .... .. .. ...X.ray ... .. .. ... ... .. ... ... . ... .. .. .... .. .. .... . .. ... .. .. ... ... ..... . .. .... .. .. .. .. .. ... ... .. .... ... ... .. .. .... .. .. .. .. .. .....Blood prassure check... .. .... .. . ... .. .. .... . . .. .. .. .. .... .. .. ... .. ... .. .. .. .... . .. .... . .. .... .. . .... .. . ..... . ... ... .Electrocardiogram ..... . .. .... . ... ... .. . .... .. . .... . .. . ... .... .... . ... .... . . .... .. .. ... . .. .... .. .. .... .. .. ... . .. .... ..

Therapeutic services:Drug administered or prescribed2 .. . .. ... ... . ... .. .. .... .. . ... ... . ... .. ... .. ... . .... . .. .... .. .. .... . .. .... .. ..injection or immunization ... ... .. ... .. .. .... . . .... . .. .... ... . ... .. .. .... .. .. .... .. ..... . .. .... .. .. ... .. . .... .. .. .Medical counseling and psychotherapy or therapeutic listening . ... .. ... ... . ... .... . . ... .... . ..

Other services3 .. . .. .... .. . .... .. ... .. .. .. .... . .. .... . .. ... .. . .. .... . . .... ... .. .. .. .. .... .. .. ... . .. . ... .. . . .... ... . ... .. .. ..-

Essential

benignhyper-

tension(401 )

Coronaryheart

disease

(410-413) T

Sympto- Carebro-matic vascularheart disease

disease (430-(427) 438)


46,128

54.912.820.6

4.779.9

7.7)

61.09.8

16.6

5.0

31,314 I 7,052

Percentl

62.9

16.225.4

7.076.625.8

55.612.121.2

5.9

61.620.823.910.467.232.7

55.913.216.4

7.3

4,505

62.218.425.2*5.971.7*6.7

52.112.821.0

7.7

lpercents will not add to 100.0 because most patient visits required the prOVkiOII of more than 1 treatment or ‘ervice.*Includes prescription and nonprescription drugs.3Jnc]udes no sewice5 rendered, hearing test, vision test, endoscopy, office surgerY, physiotherapy, and other ‘ewices.

Table P. Number and percent of office visits for selected diseases of the circulatory systam, by most frequent diagnostic and thera-peutic services ordered or provided: United States, 1975-76


All visits .. .... .. .. ... ... . ... .. .. ... ... . ... .. .. ... .. .. .... . ... ... .. . ... .. . ..... . ... ... .. . .... .. .. ... .. . ..... .. . ... .. ..

Limited history and examination .. ... . .... . .. ... .. .. ... ... ..... .. ..... . .. .... .. . .... .. .. ... .. .. .. ... .. ... .. .. .. .. .. . ...

Blood pressure check .. .... .. .. ... . .. .... .. .. ... .. . .... . ... ... .. . ..... . . .... . ... ... .. . ..... . .. ... .. ... .. .. .. .... . .. .... . .... ..Laboratory procadure or test .. .. ... . .. .... .. . .... . ... ... .. .. .... .. . ... .. .. ... ... . .... . .. .... . . ..... . .. .... .. .. . ... .. .... .Encloscopy .. .... . ... ... .. .. .... .. . .. .. . .... ... .. .. .. ... .. . .... .. ... .. ... . ... .. .. ... .. .. .... . .. .... . .. .... .. .. ... . .. .... .. . .... ..

Drug administered or prescribed2 .. .... . ... ... .. . .... . .. ... ... . ... ... . .... . .. .... .. . .... . .. .... .. ... ... .. . ... .. .. .... . .Medical counseling and psychotherapy or therapeutic listening .. .. ... .. .. .. ... .. .. ... ... . ... .. .. ..... ..

Phlebitis Varicose

Arterio-and veins of

throm- IowerHemor-

sclerosisbophle- extremi-

rhoids

(440) bitis ties (455)

(451 ) (454)


2,019 I 2,930 I 2,428 I 3,686

62.358.6

*16.9

6i :527.5

Pert

68.350.328.3

56:620.6

,tl

53.827.1*8.5

36:923.6

48.628,5*8.122.342.8

*11.2

lpercents will not add to loo-obe~au~e most patient visits required theprovisim of more than I treatment or service*In~l~des prescription and nrmprescripticm drugs.

22

TableQ. Numberand percentof office visits for essential benign hypertension (401), by visit status, seriousness of problem, anddiagnostic andtherapeutic services ordered or provided: United States, 1975-76


All visits .. .... .. .. ... .. .. ... .. . ... .. . ... .. .. ... .. . ... .. .. .... . . ... .. . ... .. .. ... .. . ....

Limited history and examination .... .. . .... . .. ... .. .. .. ... . ... .. . .... . .. .. .. .. ... .. .. .. .General history and examination .... . ... .... ... .. .. . .... . . .... .. .... .. .. .. .. .. ... . .. ....Laboratory procedure or test . ... .. . ... . .. .... . . .. .. . . .. ... . .... .. . ... .. . ... .. . ... .. .. . .. .X-ray ... ... . .... . .. .... .. .. .... . ... ... .. .. .... . . .... .. .... . . .... ... ... ... .... .. . ... .. . ... .. . .... .. .. ...Blood pressure check .. .. .. ... .. . .... . . .... . .. ... .. .. .. ... .. .. .. .. ... .. .... . ... .. .. .. .. .. .. ... .Electrocardiogram .. .... .. .. .... .. . .... . . .... . .. ... . ... ... .. . ... . .. .... . . ... .. .. ... . .. ... .. . ... .Drug administered or prescribed ... . .. .... .. . ... .. . ... ... . .... . . ... .. . ... .. .. ... .. .. .. .Injection or immunization . .. ... .. .. .... . .. ... . ... ... . .. ... . .. ... ... . ... . .. ... .. .. ... ... ....Medical counseling . . .... . ... ... .. . .... .. .... . .. .... . ... . .. .. ... .. . ... .. . . ... .. . ... . ... ... .. .. ...0ther3 ... . .... .. .. .. .... .. . .... ... .... . .. ... .. . .... . ... .. . ... .. ... ... . .. .... .. . ... .. . ... .. . .. .. .. .. ...

Visit status I Seriousness of problem

Numberof visitsin thousands

2,254 I 2,709

28.3 56.956.7 22.843.1 34.621.7 *8.O78.6 73.322.7 *19.857.0 62.5*3.1 *5.O

●11.6 *1 5.3*16.6 ‘$7.7

41,165 I 10,244

Percentl

56.29.8

18.43.6

80.46.1

61.110.514.8

5.0

55.016.523.4

6.379.210.563.311.217.4

7.7

21,373

56.411.119.8

3.782.2

7.063.8

9.415.3

5.4

14,510

52.512.819.65.1

77.16.7

55.39.5

11.76.7

lPercentsWill~otaddto Ioo.obecausernostpatientvisitsrequiredtheprovisionofrncmtlsmI tr~~trnentor SeWice.2~nc]U&Sprescription and nonprescription drum31n~ludes hearing test, vision test, endoscopy, office surgery,physiotherapy,Psychotherapyor tkerweuticlisteni% findother

services.

heart disease, and symptomatic heart disease(table U).

Electrocardiograms were also more likely tobe used during coronary heart disease visitsevaluated as “serious” or “very serious” than,when the problem was less serious.

X-rays appear to have been used with re-straint during visits for circulatory diseases,occurring more frequently during hypertensionand coronary heart disease new-probIem visitsthan in visits for recurring problems.

Clinical laboratory tests were ordered inabout 1 in 4 visits for coronary heart disease,symptomatic heart disease, cerebrovascular dis-ease, and phlebitis and thromb ophlebitis;

and about 1 in 5 hypertension visits. Use oflaboratory tests did not differ significantlyamong types of visits when coronary heartdisease was the dia~osis. However, laboratorytests were less likely to be ordered for patientspresenting hypertension as a recurring problem.

In general, the data pointed to a tendencyof physicians to use EKG’s, X-rays, and labora-

tory tests conservatively. For the two leadingdia~oses (essential benign hypertension andcoronary heart disease), emphasis was placed onproviding most services during first visits.

Patient sex and age were not deciding fact orsin the use of examinations, X-rays, or lab tests.Patients under 65 years of age were more likelythan older patients were to have heart activitymeasured by EKG during visits made for coro-nary heart disease, but differences by sex werenot statisticzdly significant.

Blood pressure measurement. –Blood pres-sure measurement is an efficient and economicaldiagnostic tooL It was used more often duringvisits made for diseases of the circulatory sys-tem than for any other ICDA group. About 8of 10 visits for essential beni=m hypertension andcoronary heart disease included blood pressurechecks, and about 7 of 10 for cerebrovasculardisease (table O). Blood pressure was measuredless often for diseases of the arteries and veinsthan for other types of circulatory system dis-eases.

23

Table R. Number and percent of office vmts for coronary heart disease (410-413), by visit status, seriousness of problem, anddiagnostic and therapeutic services ordered or provided: United States, 1975-76


All visits .. . .. ... .. .. .... .. ... .. ... . .... . . ..... . ... .... ... .... . ... ... .. . .... .. .. .... . ..

Limited history and examination .. .. ... .. .. .... . .. .... . .. .... .. .. ... .. .. ... .... ..... . .. .

General history and examination ... .... . .. ... ... . ... ... .. .... .. . .... .. .. ... ... . .... .. .. .Laboratory procedure or test .. .... .. .. ... .. . .... . .. .... .. .. ... ... . .... . .. .... .. ... ... .. .. .X-ray .... . .. .... .. .. .... .. . .... .. .. .... . ... ... .. .. .. .. .. . ... .. .. ... .. .. .... .. .. .... . .. .... ... .. .. .. .. ..Blood pressure check .. . ... ... .. .. .... .. . ..... . .. .... .. . .... .. .. ... ... . ... .. .. ... ... .. .. ... .. ..Electrocardiogram .. .... .. .. ... ... . .... . .. .... .. . .... .. . .... .. ... ... .. . ..... .. . ... .. .. .... .. . ...Drug administered or prescribed2 ..... . .. ... ... . .... .. . .... ... . .... .. . .... . ... ... ... . ...Injection or immunization ... .. .... . . ..... .. . .... .. . .... . ... .... . .. .... .. .. ... .. .. ... .. ... ..Medical counsel ing .. .... ... .... .. . ... .. .. .... .. .. ... ... . ... .. .. .... .. .. .... . ... ... . .... .. .. .. ...0ther3 . .. .... .. ... ... .. .. .... . .. .... .. .. ... ... . .... . ... .... . .. ... .. .. .... .. .. .... .. . .... . ... ... .. .. ...

Visit status Seriousness of prc}blem

Patient seen beforeSerious

NewContin- or Slightly Not

patient Newuing

very serious seriousproblem

problem serious


1,538 I 2,220

22.967.541.431.679.156.740.6

2.021.513.3

58.925.126.814.870.442.452.811.015.6

4.6

27,556 I 16,357

Percentl

65.412.624.4

5.076.922.756.712.718.2

8.3

65.516.826.2

7.375.931.358.111.621.5

7.9

10,284

61.315.025.8

7.377.321.053.813.516.4

8.6

4,673

57.216.622.0

5.177.117.050.710.410.4

9.0

lpercent~ ~ill not add to I 00.0 be~a~~e most patient visits required the provision of more than I treatment or se~ice.

or therapeutic listening, and other

.21nclude5 prescription and nonprescription drugs.31ncludes hearing test, vision test, endoscopy, office surgery, physiotherapy, psychotherapy

services.

Table S. Number and percent of office visits for essential benign hypertension (401), by sex and age of patient and diagnostic and

therapeutic services ordered or provided: United States, 1975-76


All visits .. .... . .. ... ... .. .... . .. .... .. . ... ... . .... .. . ..... .. . ..... . .. ... .. ... .. ... . .... .. . .... . .. .. .. .. .. .... . ... ... .. .

Limited history and examination ..... .. . ... . .. . .... .. .. ... . ... ... ... . .... .. .. .. .. . .. ... ... . .... . .. ..... . ... .. .. .. ... .. .. .General history and examination .... . .. ... .. .. ... ... .. ... .. ... ... . ... ... .. . .... .. .. ... .. .. .... .. .. ... .. ... .. .. .. .... . .. ..Laboratory procedure or test .. .. .. .... .. . ... .. ... ... .. .. .... . .. .... . ... ... .. . ..... ... .... . .. .... .. .. .... .. . ... .. .. .... .. .. .X.ray .. .. . ..... . .. ..... . .. ... .. .. .... . ... ... . .. .. ... . . ..... .. . ... ... .. ... .. .. ... .. .. .... . ... ... .. .. .... .. . .... .. .. ... .. . ... ..............Blood pressure check .. .... .. .. ... ... .. .... . . .... .. .. .. .... .. ... .. .. ... . .. . .... . .. .... . ... ... .. .. .... . .. .... .. . ... .... . ..... .. ..Electrocardiogram ... ... .. ... .. . .... . ... .... .. .. ... . .. .. .. ... .. .. ... . .... ... . .... .. .. ... ... . ... .. .. .... .. . .... . .. .... ... . .... ... . .Drug administered or prescribed ... .. .... .. .. .. .... .. .. .. ... ... .. .. ... .. .. .... .. .. ... ... . .... . .. .... .. . ..... . . .... .. .. ..

Injection or immunization .. ... . ... ... .. .. .... .. . .... . .. .... .. .. .... .. .. .... . .. ... .. ... ... .. . ... .. .. .... .. .. ... .. ... .... .. ...Madical counsel ing .. .. . ..... . .. ... .. .. .... .. .. ... . .. .... .. .. .... .. .. ... .. ... .. ... . .... .. . .... .. .. .... .. . .... .. .. ... . .. .... ... . ...Psychotherapy or therapeutic listening .. . .. .. . ... .... . .. .... .. .. .... . .. .... .. .. .... .. .... .. .. .... . ... ... . ... .. .. . . ....

0ther3 .. .. .. ... .... . .. .... ... . .... .. .. .. .. ... ... . .. ... .. .. .... .. .. ... . .. ..... . .. .... .. .. ... .. . .... ... . ... .. .. .... .. .. ... .. .. .. .........

Sex I Age

Female H-l&?&65 yearsand over

Number of visits In thousands

29,287 I 16,840 I 29,596 I 16,532

55.112.5

20.94.2

79.76.7

63.111.614.5

2.23.7

Percent 1

54.5 53.713.4 14.4

19.9 20.35.5 5.2

80.2 79.49.4 8.9

57.4 60.76.7 9.4

14.9 16.4‘1.6 2.1

5.0 4.2

lpercent~ ~il[ not add to 100,0 because most ~atient visits reauired the cmovision Of mOre than 1 treatment or service.

57.010.1

21.03.8

80.85.5

61.510.611.4++1.7

4.2

21ncjudes prescription and nonprescription dr~gs.SlncJudes hearing test, vision test, endoscopy, office surgery, physiotherapy, and other services.

24

Table T, Number and percent of office visits for coronary heart disease (410-413), by sex and age of patient and diagnostic andtherapeutic services ordered or provided: United States, 1975-76


All visits .. .... .. .. .. .. .. .... . .. .... . .. .. .. .. .. .. . . ... .. . ..... .. .... .. . ... . ... .. .. .. ... . .. .... . . .... . . .... .. . ... . .. ... . .

Limited history and examination .... . .. ... . .. ... .. . .. .. .. . ... .. .. .. .. ... . ... .. ... .. . ... .. . ... .. .. .... . .. .. . .. .. .. .. .. .. ..G=neral history and examination .... .. .. .. .. .. ... .. . ... . .. .... . . .... . ... .. . ... .. .. .. .... . . .... . .. ... . .. ... .. .. ... . .. .. ...Laboratory procedure or test .. .. .. .... . .. .. ... .... .. .. .. .. .. .... . . .... .. .. .. .. . ... .. . ..... . . .... .. .... .. .. .. .. .. .. ... . .... .X.ray ... ... . .... .. .. ... .. . .... .. .. ... .. .. ... . .. .... .. . ... .. .. ... . .. ... .. .. .... . . ... .. . ... .. .. ... . .. . ... .. . ... .. .. ... . .. ... . ..............Blood pressure check .. . .... . .. ..... .. . ... . .. ... . .. ... .. .. ... . ... ... . .. ... .. .. ... . .. ... .. .. .. .. .. ... .. . .... . .. ... . .. .... . . ... ...Electrocardiogram .. .. .. . . .... . ... ... .. . ..... .. ... . .. .... . .. ... ... ... .. .. ... . .. ... .. .. ... .. .. ... . .. .... . . .... . .. ... .. . ... . .. . ... ..

Drug administered or prescribed ... .. ... . .. .... .. . .... . .. ... .. .. ... . . .... . .. ... ... . ... . .. ... . .. .... . ... . .. .. .. .. .. ... .. .injection or immunization ... ... .. . .... . .. ... . .. ... .. .. ... .. .. .. .. .. ... .. . .. .. ... ... .. .. .. .. .. .... .. .... .. .. .. .. .. .. .. .. .. .. .Medical counseling .... .. .. .. ... . .... .. . .... . . .... . .. .... . .. ... . .. . ... .. . ... .. . ... .. . .... . .. .... . .. .... . ...... .. .. .. .. ... . ... .. .. .Psychotherapy or therapeutic listening .. . .... ... .. ... .. ... .. . .... . . .... .. . ... . .. .... . .. ... . .. .... . .. .. ... .... . ... .. . ..0ther3 .. .. .... . ... .. .. .. .... .. .. ... . .. . ... .. .. .. .. .. ... . .. .... .... .. . .. ... .. . .... .. . ... . .. .... . .. ... .. .. ... . . .... .. .. ... . .. ... .. . ... ...

Sex I Age

Female I Male I Under I 65 years65 years and over


14,828 I 16,485 I 14,093

Percent]

64.115.624.2

6.976.622.558.415.416.8*3.1

4.7

61.816.726.5

7.076.628.853.1

9.019.4*3.O

5.7

60.818.525.1

8.278.430.952.1

8.519.5*3.7

5.4

17,221

64.614.325.7

5.975.121.658.515.017.1*2.5

5.1

lpe,cents ~,ill not add to 100.cI ijec~”se most patient visits required the prOViSiOn Of more than 1 treatment or ‘ewice-

21n~1udeS prescription m-id nonprescription dr@.

31ncludes hearing test, vision test, endoscopy, office surgery, physiotherapy. and other se~ices.

Table U. Percent of office visits by selected diagnostic and therapeutic services ordered or provided in the presence and absence ofselected principal diagnoses: United States, 1975-76

—


Essential benign hypertension (401 ):Present .. ... ... .. .... .. .. ... . ... ... .. .. .. .. .. ... .. . ... ... .... . .. ... .. ... .. .. .. .. .. . .... . . .... . ... .. .. . .. .. . .. ... .. .. ..Absent ... .... . .. .... . ... ... . .. .... . .. ... .. . .... .. . ... .. . ... .. .. ... . .. .... . .. ... .. . ... .. .. ... . .. .... .. .. .. .. .. ... . . ...

Coronary heart disease (410413):Present .. .... . .. .... .. .. .. .. .. ... ... . ... .. .. ... .. . ... . ... ... .. .. ... .. .. ... . .. .. .. .. .... .. .... . ... .. . ... .. .. .. .... .. . ..Absent .. .... .. .. ... .. .. ... . .. .... .. . ... .. .. .. ... . .... ... .... . . ... ... . .... ... .. .. .. ... .. .. ... . .. .... .. .... .. ..... .. ...

Symptomatic heart disease (427):Present .. . .... . .. ... ... . ... .. . .... ... .... .. .. .. .. .. ... . .. .... . . .... .. .. .. .. .. ... . .. ... ... .... .. . ... .. .. .. .. .. . .. ... ...

Absent ... ... . .. .... .. . ... ... . .... . .. ... .. .... .. . .... ... . ... .. . .... .. . ... .. .. .. .. .. .... ... ... . . .... . .. ... .. ... .. .. . ...

Carebrovascular disease (430-438):Present .. ... .. . ..... .. .... . .. ..... .. .... . . .... . ... .. .. .. .. ... .. .. .. .. ... . .... .. . .. ... .. .. .... . . .... . .. ... . ... ... . . ....Absent .. ... .. . .... .. . ... .. .. .... .. . ... .. . .... . .. .. .. .. .... .. . .... .. . ... . . ..... . .. ... .. .. ... . .. .... . ... .. .. .. .. . ... .. .

Lebora-Drugs,

BloodElectro- tory

pre-pres-

cardio- X-rayscription

sure pro-and

checkgram cedure

nonpre-or test

scription

79.931.2

76.632.0

67.233.0

71.733.0

7.73.2

25.82.7

32.73.2

6.73.3

Percent

4.77.7

7.07.6

10.47.5

5.97.6

20.622.9

25.422.7

23.922.8

25.222.8

61.042.8

55.643.2

55.943.5

52.143.5

1DiagnoStj~ ~rouP jn~s and code jnclusjons are based on the Eighth Revision Irrterna tional Classification Of Diseases, Adapted for usein the United States, 1965.

25

The recognition of the importance of con-tinuous blood pressure monitoring for patientssuffering essential benign hypertension and coro-nary heart disease is evident in the almost equalproportions of blood pressure measurementsincluded in new- and return-patient visits (tablesQ and R).

It was observed that only about one-thirdof the visits for diagnoses other than diseases ofthe circulatory system included blood pressuremeasurement. The data also showed that althoughsuch measurement was included very frequentlyin the presence of hypertension, it was not asoften included in its absence. Fi~re 8 illustratesthe dramatic differences in blood pressure meas-urement between visits in which essential benign

hypertension was present (as principal, second.or third diagnosis) and those in which it was notIisted as a diagnosis. The procedure was includedin visits from males and females alike whenessential benign hypertension was present, butwithout such dia~osis, the blood pressure offemales was more often measured than was theblood pressure of males. This was probably dueto more frequent measurement of blood pres-sure for female patients during the childbearingyears. Blood pressure measurement during non-hypertension visits increased with age, butwas not dependent on age if essential benignhypertension was present.

Although essential benign hypertension visitswere the prime targets for blood pressure meas-

‘“”r

HYPERTENSION DIAGNOSIS LISTED80

Female = 79%Male = 78%

60

HYPERTENSION DIAGNOSIS NOT LISTED40

Female = 34%Male = 24%

20

0- 1 I I 1 I I IUrider 15.24 25-34 3544 45-54 55.64 65.74 75 and

15 over

VISIT AGE tN YEARS

IFigure 8. Percent of office visits that included blood pressure measurement in the presence and absence of hypertension, by vkit age:

United States, 1975-76

26

urement, such monitoring was also done withgreat frequency for heart disease and cerebro-vascular disease visits as shown in table U.However, the significantly decreased use of suchmeasurement in the absence of these diseasesdeserves comment.

Periodic blood pressure measurement isimport ant both in treating essential benignhypertension and as a screening device to detectthe disease. The Joint Nationa.I Committee onDetection, Evaluation, and Treatment of HighBlood Pressure has recommended that all healthcare professionals routinely take a patient’sblood pressure regardless of the patient’s reasonfor visit.24 Physician visits would appear to bethe [email protected] environment for implementation ofthis recommendation, but according to NAMCSdata the suggestion has not yet been widelyadopted.25

It should be noted that some underreportingof blood pressure measurement in NAMCSmay have produced estimates somewhat lowerthan the actual number of measurements made.Visits often include a general examination inwhich blood pressure is routinely checked. Areview of data for essential benign hypertensionvisits which included general examinations re-‘veaIed that bIood pressure was separately re-

corded (as it was supposed to be) in 85 percentof such visits. This may be an indication ofunderreporting, or such measurement may havereally been omit ted in some examinations (al-though it is not likely). In any case, underreport-ing probably accounted for only a small part ofthe fewer number of blood pressure checks dur-ing some visits than in others. Furthermore,there does not appear to be any systematicbias connected with such underreporting.

Selected therapeutic services. –Drugs were ahighly frequent form of therapy during mostvisits made for diseases of the circulatory sys-tem. Except for varicose veins of the lower ex-tremities and hemorrhoids, drugs were prescribedor administered in over half of visits for themost frequently diagnosed circulatory diseases.

Drugs were prescribed more often whenhypertension, coronary heart disease, and symp-tomatic heart disease were present than whenthey were absent, but seriousness of the problem,or patient sex or age did not affect the decision.

Medical counseling frequency did not differsignificantly by sex for the disease groupsessentia.I benign hypertension and coronaryheart disease. Hypertensive patients less than 65years of age were counseled more often thanwere older patients with that disorder.

000

27

REFERENCES

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2National Center for Health statistics: The Nation~

Ambulatory Medical Care Survey: 1975 Summary,United States, January-December 1975, by H. Kochand T. McLemore. Vital and Health Statistics. Series 13-No. 33. DHEW Pub. No. (PHS) 78-1784. Public HealthService. Washington. U.S. Government Printing Office,Jan. 1978.

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4National Center for Health Statistics: Office visitsfor hypertension, National Ambulatory Medical CareSurvey: United States, January 1975-December 1976,by B. K. Cypress. Advance Data From Vital and HealthStatistics, No. 28. DHEW Pub. No. (PHS) 78-1250.Public Health Service. Hyattsville, Md., Apr. 28, 1978.

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dermatologists, National Ambulatory Medical Care Sur-vey: United States, January 1975-December 1976, byH. Koch and T. McLemore. Advance Data From Vitaland Health Statistics, No. 37. DHEW Pub. No. (PHS)78-1250. Public Health Service. Hyattsville, Md., Aug.29, 1978.

6Nationa1 Center for Health Statistics: Office visits to

orthopedic surgeons, National Ambulatory MedicalCare Survey: United States, January 1975-December1976, by H. Koch. Advance Data From Vital and HealthStatistics, No. 33. DHEW Pub. No. (PHS) 78-1250.Public Health Service. Hyattsville, Md., July 18, 1978.

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ophthalmologists: National Ambulatory Medical CareSurvey, United States, 1976, by H. Koch and T. Ezzati.Advance Data From Vital and Health Statistics, No. 31.DHEW Pub. No. (PHS) 78-1250. Public Health Service.Hyattsville, Md., July 14, 1978.

8 National Center for Health Statistics: Office visits to

doctors of osteopathy: National Ambulatory MedicalCare Survey, United States, 1975, by H. Koch. AdvanceData From Vital and Health Statistics, No. 25. DI-IEW

Pub. No. (PHS) 78-1250. Public Health Service. Hyatts-ville, Md., Mar, 22, 1978.

9 Nation~ Center for Health Statistics: Office visits to

general surgeons: National Ambulatory Meclical CareSurvey, United States, 1975, by R. O. Gagnon. AdvanceData From Vital and Health Statistics, No. 23. DHEWPub. No. (PHS) 78-1250. Public Health Service. Hyatts-ville, Md., Mar. 24, 1978.

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11Nation~ Center for Health Statistics: Office visits toobstetrician-gynecologists: National Ambulatory Medi-cal Care Survey, United States, 1975, by T. Ezzati. Ad-vance Data From Vital and Health Statistics,, No. 20.DHEW Pub. No. (PHS) 78-1250. Public HealtJ~ Service.Hyattsville, Md., Ma-. 13, 1978.

12National Center for He~th Statistics: Office visits to

internists: National Ambulatory Medical Care Survey,United States, 1975, by B. K. Cypress. Advance DataFrom Vital and Health Statistics, No. 16. DHEW Pub.No. (PHS) 78-1250. Public Health Service. Hyattsville,Md., Feb. 7, 1978.

13Nation~ Center for He~th Statistics: Nation~ Am-

bulatory Medical Care Survey of visits to general andfamily practitioners, January-December 1975, by B. K.Cypress. Advance Data From Vital and Health Statistics,No. 15. DHEW Pub. No. (PHS) 78-1250. Public HealthService, Hyattsville, Md.. Dec. 14, 1977.

14National Center for Health Statistics: Ambulatorymedical care rendered in pediatricians’ ofilces during1975, by T. Ezzati. Advance Data From Vital andHealth Statistics, No. 13. DHEW Pub. No. (HRA) 77-1250. Health Resources Administration. Hyattsville,Md., Oct. 13, 1977.

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Government Printing Office, Mar. 1975.

28

17Goodm~, L. J., and Mason, Il. R.: Physician Distri-

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21Nation~ Center for Health Statistics: Annual sum-mary for the United States, 1976: Births, deaths, mar-riages, and divorces. Monthly Vital Statistics Report.Vol. 25, No. 13. DHEW Pub. No. (PHS) 78-1120. PublicHealth Service. Hyattsville, IUd., Dec. 12, 1977.

22National Center for Health Statistics: Blood pressurelevels of persons 6-74 years, United States, 1971-1974,by J. Roberts and K. Maurer. Vital and Health Statistics.Series 1l-No. 203. DHEW Pub. No. (HRA) 78-1648.

Health Resources Administration. Washington. U.S.Government Printing Office, Sept. 1977.

23Nation~ Center for He~th Statistics: The NationalAmbulatory Medical Care Survey: Symptom classifica-tion, by S. Meads and T. McLemore. Vital and HealthStatistics. Series 2-No. 63. DHEW Pub. No. (HRA) 74-1337. HeaIth Resources Administration. Washington.U.S. Government Printing Office, hfay 1974.

24NationaI Heart, Lung, and Blood Institute: Reportof the Joint National Committee on Detection, Evalua-tion, and Treatment of High Blood Pressure. DHEWPub. No. (NIH) 77-1088. National Institutes of Health,Bethesda, Md.

25Cypress, B. K.: The role of ambulatory medicalcare in hypertension screening. Am. Pub. Health Assoc.]. (In press).

26National Center for Health Statistics: Replication:An approach to the analysis of data from complex sur-veys, by P. J. hlcCarthy. Vital and Hea{th Statistics.Series 2-No. 14. DHEW Pub. No. (HSM) 73-1269. HealthServices and Mental Health Administration. Washington.U.S. Government Printing Office, Apr. 1966.

27National Center for Health Statistics: Pseudorepli-cation: Further evaluation and application of the bal-anced half-sample technique, by P. J. McCarthy. Vitaland Health Statistics. Series 2-No. 31. DHEW Pub. No.(HSM) 73-1270. Health Services and hlental HealthAdministration. Washington. U.S. Government PrintingOffice, Jan. 1969.

29

LIST OF DETAILED TABLES

1. Number, percent distribution, and average annual rate cf office visits for diseases of the circulatory system, by age, sex, andrace of patient: United States, 1975-76 .. . .. .. ... .. .... .. .. . ... .... . .... .. .... .. .. .. . .... . ... ... .. .. .... . .... . ... ... .. .... . ... ...... . . .... . .. .... ... .. .... . .. . .............

2. Number and percent distribution of office visits for diseasas of the circulatory system by type of practice, according to $leo-graphic region and metropolitan and nonmetropolitan areas, with average annual visit rates: United States, 1975-76 .. . ..... .. ... .

3. Number and percent distribution of office visits for diseases of the circulatory systam by age, sex, and race of patient,according to selected principal diagnoses: United States., 1975-76 .. . .. .... . ... .... .. .. .... .. . ..... .. .. .. .. .. .. ... . ... ... .. .. .. ... .. .. ... .. . .... .. .. ...... . ...

4. Median visit age and standard error of the median for diseases of the circulatory system, by sex and race of patient andselected principal diagnoses: United States, 1975-76 . .... . .... . .... .. .. .. .... ... .... . .. .. .... .. .... .. .. . .... . .. .... .. ... ... ... .. .. .. .. .. .. ... ..... . ... ... ... .. .... ..

5. Number, percent distribution, and average annual rata of office visits for diseases of the circulatory system by geographicregion, metropolitan and nonmatropol itan areas, and type of practice, according to selected principal diagnoses: UnitedStates, 1975-76 .. ... . ... .. ...... ... ... .. . .. ..... .... .... .. ..... .. .. ... .. ... .. ... .. .. .. .. .... . ... .... . . ...... .... .. .. .. . ..... .. ...... . . ..................................................

6. Number, parcent distribution, and average annual rate of office visits for assential banign hypertension (401), by most fre-quently visited specialty, geographic region, metropolitan and nonmetropolitan areas, and type of practice: United States,1975-76 . .... .. . .... .. . .. . .... . . .. .... .. . .. ... .. .. .. ... . .. .... .. . .... . ... .... . .... .. .. .. ... .. . .... .. .. .... .. .. ... ... ... ... .. ... .............................................................

,7. Number, percent distribution, and averaga annual rate of office visits for coronary heart disease (410-413), by most fre-quently visited specialty, geographic region, metropolitan and nonmetropolitan areas, and type of practice: United States,1975-76 ... . ..... .. . .... .. ... ... ... .. .... ... ... .... .. ... .. ... .... . ... .... . ... . .. . .. .... . . .. .. .. .. .... ... . .... .... ..... . .. .... .. .............................................................

8. Number and percent of office visits for essential benign hypertension (401), by sex, age, and most frequent principal prob-lem of patient: United Statesr 1975-76 .. .. .... .... . .. ..... .. .... .. . . .... .. . .... .. ... ... . .. .. .... .. .... .. . . .... .. ... ... .. .. .... .. . .... .. .. .... .. ... . .. .. .. ... ...............

9. Number and percent of office visits for coronary heart disease (410-413), by sex, age, and most frequent principal problemof patient: United States, 1975-76 .. .... . . ...... . . ..... .. ... .. .... .. ... . ... ... . .... ... . ...... .. . ... ... ..... . .... .. . .... ... .. ... . .. .... ... .. .. .... . .. ..... . ...................

10. Number and percent distribution of office visits for diseases of the circulatory system by problem status, seriousness ofproblem, and disposition of visit, according to selected principal diagnoses: United Statesr 1975-76 .. .... ... .... . .. ...... .. .. .... .. .. . ... .

11. Mean contact duration and standard error of mean contact duration of office visits for diseases of the circulatory system,by age and sex of patient, visit status, and selected principal diagnoses: United States, 1976-76 .. . .. .. .. .. . . .. .. .. .... . ... .. .. .. .. ... ... .. .. .

12. Mean contact duration and standard error of mean contact duration of office visits for diseases of the circulatory system,

by age of patient, visit status, and selected principal diagnoses: United States, 1975-76 ... . .... .. .. .. .. ... ... ... ... .. .. .. ... .. .. .. .... . . .... .. .. . .

31

32

32

33

33

34

34

35

35

36

36

37

30

Table 1. Number, percent distribution, and average annual rate of office visits for diseases of the circulatory system, by age, sex, andrace of patient: United States, 1975-76

Sex and race

All visits . .... . . .... . .. .... . .. .... . .. ... .. . .... . .. ... . ... .

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

Black and otherl .. .. . .... . . .... .. .. ... .. . .... . .. ... . .. ...

Female . .. .... .. .... ... .. .. ... . ..... .. .... . ... .. .. . .... . .. .... . .. ... . ... ..Male .. ... . .... . .. .... .. . .... . ... .... . . .... . .. ... .. .. ... .. .. .... .. .... ... .. .

All visits ... .. . .... .. . .... . .. ... ... .... . . ..... . . ... .. .. ...

Female .. .. .... . ... ... .. .. ... .. . .... .. .. .. .. .. .. .. . . .... . . .... . ... .. ... . ..Male .... .. . .... .. ... ... .. . .... . .. .... . ... .. .. .. ... .. . .... . .. ... . .. .... .. .. .

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

Female .. . . .... .. .. .... . .. .... . . .... ... .. ... . .. .... . . .... . . .... ... . .. ... . .Male .. .... . .. ... .. ... .. ... . .... . ... .. .. ... .. ... . ... . ... .. .. . .. .. .. .. ... . .. .

Black and other ... ... .. .. .. .... .... . .. ... .. . ... .. ... .. ... .

Female ... . .. ... ... . ... ... . .... . .. ... .. .. .... . .. ... .. . ... . .... .. .. . .. .. .. .Male .. .. ... .. .. .... . .. .... . .. ... .. . .... ... . .... . .. ... . .. ... .. . ... ... . ... .. .

Number I II I I

110,617 100.0

62,656 100.047,961 100.0

99,634 100.0

55,789 100.044,044 100.0

10,783 100.0

6,866 100.03,916 100.0

$...265.1

. . . 290.2

. . . 238.3

. . . 275.4

. . . 298.5

. . . 250.8

. . . 197.3

. . . 236.6

. . . 152.8

55-64 65-74years years

75 yearsand over


6.8 7.0 17.4 25.0 26.8 17.0

6.3 6.5 15.8 23.3 28.2 20.07.4 7.8 19.4 27.1 25.0 13.2

6.3 6.7 16.9 24.9 27.4 17.8

5.7 6.0 14.8 23.6 28.8 21.17.1 7.6 19.5 26.6 25.5 13. ?

11.2 10.4 21.8 25.2 22.0 9.4

11.4 10.6 23.4 20.7 23.3 10.5*1 0.8 *10. I 19.1 33.0 19.7 *7.4


30.8 I 174.4

32.2 174.7

29.4 174.0

30.5 165.530.2 175.7

I

=t%i

411.5

408.6414.7

386.1426.1

583.4316.8

703.9

703.8704.1

704.2699.7

700.4746.7

1,088.2

1,143.81,015.5

1,147.91,052.6

1,104.4671.2

1,199.9

1,272.41,078.3

1,307.01,137.3

688.2*5 I 7.9

lAbO”t 87 percent were visits by members of the black ‘ace.

31

Table 2. Number and percent distribution of office visits for diseases of the circulatory system by type of practice, according togeographic region and metropolitan and non metropolitan areas, with average annual visit rates: United Statesr 1975-76

Geographic region and area


sands

Alltypes

ofpractice

solo Otherl

Averageannual

visitrate per1,000 inpopula-

tion


All visits .. . .. .... .. .. .... . ..

Northeast ... . .... .. . .... .. .. .... .. .. ... . .. ..

110,617

29,59430,33431,62719,061

80,63229,984

100.0

100.0100.0100.0100.0

100.0100.0

65.2

75.568.659.752.9

62.771.9

34.8

24.531.440.347.7

37.328.1

265.1

302.9270.5235.3261.2

281.8228.8

lInc]ude5 group and partnership a~angernents.

Table 3. Number and percent distribution of office v!sbts for diseases of the circulatory system by age, sex, and race of pat!ent, according to selected principaldiagnoses: United States, 1975.76

Age I Sex Race

I

BlackWhite and

other

Numberof wsitsIn thou-

sands

Total Under75

3535-44 45-54 55-64 65-74 years

Femaleyears years years years and

Male

yearsover

Prlnclpal diagnosis and ICDA codel


30.2

26.423.225.01B.618.1

‘12.1

20.125.714.2

25.229.931.328.231.229.329.8

21.6‘15.2‘1O.6

10.6‘1 3.5

26.4‘1 2,6

23.638.950,6

“8.0+’9.3“3,1

Essential benign hypertension ,...,.., . . .. .. . . . .. . ....401

Acute ischemic heart d!sease .,.., . . .. . . . .. .. ...410.41 1Chronic ]schemic heart disease .. . . .. . . . ..412.. .. . .. ..4l2Angina pectoris . . .. .. . .. . . . .. . . . .. . . . .. ., .. . . .. . . . . .. . . .. ...413Symptom.stlc heart disease .. . . . .. .. . ....427............427Cerebrovascular disease .. . . .. . . . .. .. . .. . ..430438Arteriosclerosis .,.........,....,....,....,....,.,..,.........44•

Phlebltls and thrombophlebltls .. . .. .. .. . . . .. . .. . ...451

Varicose veins of lower extremities ., . . .. . . . . . ...454Hemorrhoids . .. .. . .. . . . .. . . . .. . . .. . . . . .. . . ,..,, . . . . .. . .. .. ...455

46,128

2,31926,020

2,9757,0524,5052,019

2,9302,4283,686

100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

5.9●2.1“1.2“2.1

9.0‘2.0●o .5

“14.8“14.2

29.5

8.2“6.9

3.6“3.2“6.7“1.0●4.5

“12,2‘1 3.6

19.1

19.921.214.328.911.0

●1O.6‘2.523.321.923.5

63.542.947.847.051.149.6

63.468.781.544.4

36.557.152,253.048.950.436.631.318.555.6

87.694.092.292.591.594.094.7

93.593.291.2

12.46.07.87.58.56.05.3

6.56.88.8

1Diagnostic groupings and code inclusions are based on the Eighth Revision International Classification of Diseases, Adapted for Use in the United States, 1965.

32

Table 4. Median visit age and standard error of the median for d!seases of the circulatory system, by sex and race of patient and selected principal diagnoses:United States. 1975-76

RaceSexBoth sexes

Stand-ard

errorof the

Female Male Wh !te I Black andother

Stand-ard

errorof the

medianin

years

0.84.71.05.13.03.43.43.94.34.5

!

Stand-

LStand-

ardMedian error

wsit of theage median

inyears

57.6 0.960.1 4.764.1 1.459.6 3.966.5 1.968.7 2.275.1 4.6

57.8 5.4●58.6 7.9

45.4 4.4

Stand-ard

errorof the

medianin

years

Principal diagnosis and lCDA code]Median

wsit

aw

arderror

of themedian

on

Medianvisitage

Med!anwsitage

63.862.567.561.366.571.275.153.955.145.6

Medianvisitage

62.064.970.563.666.775.075.153.454.045.9

medtansn

years

0,73.40.83.01.42.01,82.73.53,1

years

Essentml benign hypertension .. .. .. . .. .. . .. .. . .. .. . . . . .. .. . ....401

Acute ischemic heart disease ... . .. . .. .. .. . . . .. . . . .. . . . . ..4l 0411Chron,c ischemic heart disease ... . .. . . .. . . . .. . . . .. . . . . .. .. . ....412Angina pectoris . . .. .. . .. .. .. . .. .. . . . . .. .. .. . .. .. . .. . .. .. .. . . . . .. .. . .. ..4l3Symptomatic heart disease .. . . . .. .. . .. . . . .. .. . .. .. . .. .. . .. .. . . ...427

Cerebrovascular disease .. . . .. . . . . .. .. . .. .. . .. .. . . . .. . .. .. . ..43O43.Arteriosclerosis .. .. .. . .. . . . .. . . . .. .. . .. .. . . .. . . .. . . . . . .. . . . .. . . . .. . . . ..44CPhlebitis and thrombophlebit!s .. . .. .. .. . .. . .. .. .. . . . . .. .. . . ...451Varicose veins of lower extremities . . .. .. .. . .. . .. .. . . . .. . . ...454Hemorrhoids . .. .. . .. .. . .. .. . .. . . . . . .. . .. .. . .. .. . .. .. . .. .. . .. .. . .. . . . ....455

60.863.267.8

0.73.50.8

56.8●51.3

62.3

1.95.31.57.97.86.27.0

16.418.6

9.9

61.9 3.3 “56.567.1 1.6 60.571.5 2.2 “67.875.1 2.9 “75.155.7 3.355.0 0.545.9 3.3

‘49.0●58.4●41.7

‘Diagnostic groupings and code inclusions are based onthe Eigi?tlz Rct,ision Intemarional Classification of Disemes, Adaptetifor UscintJ?e United States, 1965.

Table5. Number, percent distribution, and average annual rate of office visits fordiseases of thecirculatory system bygeographic region, metropolitan

andnonmetropol itanareas, andtype ofpractice, according toselemed principal diagnoses: United States, 1975-76

Principal diagnosis and lCDAcodel

Number

of visitsin thou-

sandk

AreaType of

practice

I

solo Other2

*

Metro-

politan

Non-

metro-

politan

Essential benign hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...401

Acute ischemic heart disease . . . . . . . . . .. . . . . . . . . .. . . . ..41 O-4l 1

Chronic ischemic heart disease .. . . . . . . . . . . . . . . . . . . . . . . . . . ...412

Angina pectoris . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .413

Symptomatic heart disease .. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . ....427

Cerebrovascular disease .. . . . . . . . . . . . . . . . . . . . . .. . . .. . . . ...430438

Arteriosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..44o

Phlebitis and thrombophlebitis .. . . . . . . . . . . . . . . . . . . . . . . . ....461

Varicose veins of lower extremities . . . . . . . . . .. . . . . . . . . . ...454

Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...455

46,128

2,319

26,020

2,975

7,052

4,605

2,019

2,930

2,428

3,686

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

100.0 27.0100.0 ●24.7

100.0 27.6

100.0 23.0

100.0 24.9

100.0 26.9

100.0 26.0

100.0 27.0

100.0 ‘23.4

100.0 23.0

29.0

30.7

26.0

23.6

24.1

29.3

42.7

24.0

*18.B

28.0

28.1

28.2

31.8

33.2

30.1

●19.3

29.3

43.4

35.5

16.1

●16.5

18.2

21.5

17.9

13.8

●1 2.0

“19.6

‘14.3

19.2

71.7

70.2

73.6

75.4

73.5

73.5

68.8

74.6

73.4

77,0

28.3

29.8

26.4

24.6

26.6

26.5

31.2

25.4

26.6

23.0

69.7

64.9

64.9

55.2

53.9

66.6

74.0

63.6

52.3

58.0

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

30.3

35.2

35.1

44.9

46.1

33.4

26.0

36.4

47.7

42.0

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

. . .

22.4


95.9

4.8

54.6

7.0

17.4

10.1

●2.9

6.4

7.8

9.7

101.4

‘5.2

64.9

8.8

17.3

8.5

‘3.3

●7.9

‘4.8

9.7

115.5

5.7

66.9

7.8

18.1

11.6

4.9

7.6

6.2

9.9

99.6

5.3

52.4

5.6

14.3

9.1

4.8

5.7

4.9

6.5

Essential benign hypertension . . . . . . . . . . . . . .. . . . . . . . . . . . . . . ..4Ol

Acute ischemic heart disease . . . . . . . . . . . . . . . . . . . . . . . . ..41 O4l 1

Chronic ischemic heart disease .. . . . . . . . . . . . . . . . . . . . . . . . . . ...412Angina pectoris . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .413

Symptomatic heart disease .. . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . ...427

Cerebrovascular disease .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . ..43O438

Arteriosclerosis . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . .. . . . . . . . . ...44O

Phlebitis and thrombophlebitis . . . . . . . . . . . . . . . . . . . . . . . . . . . ..45l

Varicose veins of lower extremities..., . . . . . . . . . . . . . . . . ...464

Hemorrhoids . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...456

I 10.5 127.5

5.6 ●5.962.3 73.6

7.1 7.0

16.9 17.9

10.8 12.4

4.8 *5.4

19.36.4

60:2

6.3

15.1

11.8

7.7

6.3

●4.1

7.4

7.0 8.1

5.8 ●5.8

8.8 8.7

lDiagno~tjc grouPing~ and code jnclusion~ are b~~ed On the Eighth Revision International Cla.WIicaD”On of Diseases Adawdfw use in the united

States, 196S.‘Includes group and partnership arrangements.

33

Table 6. Number, percent distr!butlon, and average annual rate of of flea visits for essential benign hypertension (401), by most frequently visited

specialty, geographic region, metropolitan andnonmetropolitan areasrand type of practice: United States, 1975-76

Most frequently visited specialty

General and family practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internal medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . ..

General surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cardiovascular diseases .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General and family practice . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .

Internal medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . .


Number

of visitsin thou-

sands

27,179

12,779

2,190

1,461

.

. .

,..

. . .

II Geographic region I Area

Tots I

North- North Metro-Non-

CentralSouth West

eastmetro-

politanpolltan

100.0 22.9

100,0 35.2

100.0 ‘16.8

100.0 45.2

65.1 63.6

30.6 46.0

5.2 ‘4,2

3.5 6.8


32.8 29.9 14.4 62.9 37,1

23.5 21.3 20,1 87.6 12.4

36.8 29.3 ‘15.0 66.8 33.2

‘8.2 ‘27.3 ‘19.3 98.5 *1.6

Vmit rate per 1,000 in population

79.5

26.8

7.2

‘1.1 w

Type of

practice

solo

IOtherl

75.9

55.9

76.4

65.7

24.1

44.1

23.6

34.3

--1-.......... ...

lIncludes group and partnership arrangements.

Table 7. Number, percent distribution, and average annual rate ofoffice visits forcoronary heart disease (41 0-413), bymostfrequently visited specialty,

geographic region, metropolitan andnonmetropolitan areas, andtype of practice: United States, 1975-76

Geographic regionType of

NumberAraa

practice

Most frequently wsited specialtyof visits

Totalin thou-

North- NorthNon-

Metro-sands

CentralSo,uth West

eastmetro-

politansolo Otherl

politan

General and family practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Internal medicine . . . . . . . . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cardiovascular diseases .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General and family practice . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .. . . . .. . . .

Internal medicine . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


14,920

11,722

3,089

100.0

II21.3

100.0 32.0

100.0 36.1


27.8 I 31.9 19.0 I 61.3 38.7 72.1

26.3 24.7 17.1 83.6 16.4 58.5

*9.9 30.8 23.3 97.2 “2.9 38.5

I I Visit rata per 1,000 in population

,.. 35.7

II32.5

I37.0

I

35.4 38.9

I31.9 44.1

. 28.1 38.4 27.4 21.5 27.5 34.2 14.67.4 11.4 ‘2.7 7.1 9.8 10.5 ‘0.7

27.9

41.6

61.5

. . .

I...... ..... .,.

l~nclude~ group a“d partnership arrangements

34

Table8. Number and percent of office visits foressential benign hypertension (401), bysex, age, andmost frequent principal problemof patient: United States, 1975-76

Principal problem and NAMCScodel

All principal problems ................ .........................................

Progress visit ..........................................................................98O. 985Abnormally high blood pressure ....................................................2O5Headache ........ ........................................................................ .......O56Vertigo ............................................. .............. ...............................O69Fatigue ................... ........ ............ ............ .......................................oo4General medical examination ...................................... ........... ........9ooNervousness ...................................................................................81 O


sands

46,128

18,33612,582

2,7592,4711,216

973696

Per-cent

ofvisits

100.0

39.827.3

6.05.42.62.11.5

Sex Age1 i 1

Female I Male I UnderI

65 years65 years and over

Number in thousands

29,287 [ 16,840 i 29,596 ] 16,532

37.227.0

6.65.63.2

●2.O*1.7

Percent

44.2 40.827.7 27.5

4.9 6.44.9 4.6

*1.7 2.3●2.2 2.2*1.2 *1.6

37.926.9

5.16.7

*3.2“2.0*1.3

lSYmPtomatic ~rouPin~s and code number inclusions are based on a symptom classification developed for use in NAMCS.

Table 9. Number and percent of office visits for coronary heart disease (410-41 3), by sex, age, and most frequent principal problem ofpatient: United States, 1975-76

Principal problem and NAMCS codel

All principal problems .. ... . .... . . .... .. . .... .. .. .. .. .... .. .. .... ... ... .. .. .. ..

Progress visit ..........................................................................98O. 985Chest pain ... ............................ ................................................ .......322Other symptoms referable to cardiovascular system ......................220Shortness of breath ...................................... ........ ...... ....................3O6Fatigue ...................... ........ .................... ........................................oo4Abnormally high blood pressure .. .. .. . .... . .. .... .. . ... .. . ... .. . ... .. . .... . .. .... ..2O5Vertigo .. .. .... . .. ... ... .. ... . .. ... .. .. ... . .. ... .. . .... . .. .... . ... .. .. . ... .. . ... .. .. .... .. .... . ..O69Pain, swelling, injury of lower extremities .. . .. .... . .. .. ... . .. ... . ... .. . .... ...400Headache .... .. .. . .... . .. .... .. .. .. .. .. ... . .. .... . .. ... .. . ... .. .. .. ... . ... . .. .. ... .. ... . . .... ...O56

of visitsin thou-

sands

31,314

9,5276,4292,0731,9781,6321,218

830678608

Per-cent

ofvisits

100.0

30.420.5

6.66.35.23.92.72.21.9

Sex I Age

Female IIMaleUnder 65 years

65 years and over

Number in thousands

14,828 I 16,485 I 14,093 I 17,221

Percent

26.419.4

7.47.46.74.83.0

●2.8*2.8

34.021.5

5.95.43.83.02.3

*1.6●1.1

31.4

26.55.84.0

‘3.8●3.2●1.5*I .1*2.1

symptomatic groupings and code number inclusions are based on a symptom classification developed for use in NAMCS.

29.615.6

7.38.26.34.53.6

●3.1*1.9

35

Table 10. Number and percent d(str(butson of office wslts for diseases of the c!rculamry system by problem status, seriousness of problem, and disposition of visit,

accmd!ng to selected prlnclpal dlagnmes. United States, 1975.76

Pr#nclpal diagnos!s and ICDA codelN umber

of VlsltsIn thou.

sands

Total

Seriousness ofproblem

D!spositmn2Problem status

I

NewCOn-tlnu-

IIlgproblem

I

22.266.550.556.348.149.338.953.319.313.7

Essent!al benign hypertension .. . . . .. .. . . .. . . .. .. . . . . ..,..401Acute !schemm heart dmease.,. ..,.., . . . .. . . .. .. . . ...410411Chronic lschemsc heart disease .. . . .. .. . .. . , . . .. . . . .. . .. ....412Angina pectorls ..,....,.,..,.,..,.,,...,....,....,.,.,,. .,.413Symptomatic heart disease . .. . .. . . . .. . . .. . .. .. .. . . . ....427Cerebrovascular d!sease .. . .. .. . .. .. . .. .. . .. .. . .. . . . .. .. ..43O438Artermsclerosns .. . .. . . . .. . . . .. .. . .. .. .. . .. .. .. . . . . .. . . . .. .. . .. .. . ...44OPhlebmis and thrombophlebms .. . . . . .. . . .. . .. .. . ...451Varicose veins of lower extremities .. . . . . . .. . . . . .. .. . ...454Hemorrhoids . . .. . . . . . .. .. .. . . . ...455

46,1282,319

26,0202,9757,0524,505

2,0192,9302,4283,686

100.0100,0100,0100,0100,0100,01000100.0100.0100.0

10.818.110.322.418.315.219.229.031.852.8

89.281.989.777.687.784.880.871.068.247.2

77.833.549.543.751.950.861.146.7

80.786.3

86.176.3.S7,881,178.678.770,072.968.651.1

11.311.7

8.713.812.714.422.7?6.016.530.0

0.613.8

2.12.65.35,42.08.78.86.1

——

5.34.45.3

13.39.27.7

13.58.39.6

18.8

1Diagnostic grou PI ngs find code mclusmns me based on the Eighth Revision Internn tional Classification of Diseases, Adapted for Use in the United Stc7teS, 196S.2Perce”ts will “ot add to 100,0 became some oatmnt vmits had more than 1 dxsvosition.3[ncludes no followup planned, referred to other physicitm. returned to referring physician. and other disposition.

Table 11, Mean contact duration and standard error of mean contact duration of office visits for diseases of the circulatory system, by aga and sex of

patient, visit status, and selected principal diagnoses: United States, 1975-76

All

ages

Patient sexPatient age Visit status

65 years

and over

Patient seen before

Principal dlagnosls and ICDA codelUnder

55 yaars

Newpatient New

problem

COn-

tinu-

ing

problem

Female Male

Mean contact duration in minutes

Essential ben!gn hypertension .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .. . . . . . . ..4Ol

Acute !schemic heart disease .. . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .. . . .. . . . . ...41 O4l 1

Chronic ischemic heart d!sease .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . ..4l2

Angina pectoris . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .. . . . . . . . . .. . ..4l3

Symptomatic heart disease .. . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...427

Cerebrovascular disease .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . ..43 O.438

Arteriosclerosis . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .. . . . . . . ..44OPhlebitls and thrombophlebitis . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . .. . . . . . ...451

Varicose veins of lower extremities . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . ...454

Hemorrhoids . . . . . .. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . ...455

14.3

17.7

16.9

18.7

18.2

15.8

16.1

14.6

13.7

16.1

14.7

17.2

17.3

18.3

17.8

16.6

20.714.9

12.9

16.6

13.6

18.3

16.6

19.3

18.5

15.5

15.0

14.0

16.2

19.1

14.1

18.6

18.9

18.8

18.0

15.4

17.0

14.5

13.6

16.6

14.7

17.0

16.9

18.6

18.3

16.3

14.6

14.8

14,4

15.7

24.0

36.6

29.8

29.6

30.0

28.4

26.1

22.5

16.3

19.0

18.7

16.2

20.2

23.4

20.0

20.4

18.5

15.916.7

15.1

13.5

16.9

16.0

16.6

17.1

14.7

14.513.3

12.6

15.3

Standard error of mean contact duration in minutes

Essential ben!gn hypertension . . . . . . .. . . . . . . . . . . . . . . . . . . . . 401

Acute ischem,c heart disease, . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . ...410411

Chronic lschemic heart disease .. .. . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . . . . ...412

Angina pectorcs. . . . . . . . . . . . . .. . . . . . . . . . .. . . . . . . . . . . . . . . . 413

Symptomatic heart disease...,.. . . . . . . . . . . . . . . . . . . . . . .. . . . . . .. . . . . . ...427

Cerebrovascular disease .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . ..430-438

Arterloscleros!s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,..., . . ...440

Phlebitls and thrombophlebltls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . ..45l

Varicose ve!ns of lower extremities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...454

Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . ...455

029

0,91

0,42

0.72

0.63

0.87

0.88

0.651.27

0.67

0.35

1.18

0.61

0.86

0.82

0.85

2.67

0.781.43

0.71

0.33

1.30

0.481.28

0.77

1.24

0.85

1.05

1.39

1.26

0,32

1.64

0.57

1.33

0.66

1.48

1.47

0.811.57

0.82

0.40

0.93

0.49

0.95

0.99

0.69

1.20

0.740.74

0.80

1.62

7.26

2.02

3.64

3.57

3.96

6.96

3.77

3.49

1.77

1.12

2.67

1.72

3.11

1.55

2.28

4.02

1.43

2.20

1.31

0.29

0.88

0.44

0.82

0.61

0.84

0.67

0.571.16

0.79.

lDlagnostlc groupings and code mclus]ons are based on the Eighth Revision Znternan”onal Classification of Diseases, Adapted for Use in the UnitedStates, 1965.

36

Table 12. Mean contact duration and standard error of mean contact duration of office visits for diseases of the circulatory system, byage of patient, visit status, and selected principal diagnoses: United States, 1975-76


Essential benign hypertension .. . ... .. .. ... .. . ... . .. .... . ... .. .. .... ... . .... .. ....4OlAcute ischemic haart disease ... .. . .... .. .... . ... ... . .. .. .. .. .. ... . .... . . ...41 O4l 1Chronic ischemic heart disease ... ..... ... .. .. .. .. .. .. ... . .. .... .. ..... . .... .. .. ..4l2Ang[na pectoris .. . .. . ... .. . .. ... .. .... . .. . .... . . .... . .. ... .. . ... .. .. ... .. . .... . . .... .. ...4l3Symptomatic heart disease . . ... ... .. .. ... . .. .... . . ... . .. .... .. .... . . .... . .. ... .. ...427Cerebrovascular disease .. . ... .. .. ... .. .. ... . .. ... ... . ... .. . ... .. .. ... . . ... .. ..43O438Arteriosclerosis ..... .. .... ... . .... . ... .. .. . ..... . .. ... .. . ... .. .. ... . .. ... . ... .. . . ..... . ..44OPhlebitis and thrombophlebitis .. . . .. ... . .. .. .. .. ... .. . .... . .. .... . .. ... . . ..... ..45lVaricose veins of lower extremities ... ... . ... .. . .... .... .. .. . ... . .. ... .. .. .....454Hemorrhoids .... .. ..... . ... ... . .. ... .. .. ... .. ... .. .. . .... . . .... .. .. .. . ... .. .. .. ... .. .. ....455

Essential benign hypertension ... .. ... . .. ... .. .. ... . .. .... .. . ... . .. ... . ... .. .. .. ..4Ol

Acute ischemic heart disease ... .. .. ... .. . .... . .. ... . .. .... .. .... . .. ... .. ...41 O.4l 1Chronic ischemic heart disease . .. .. ... .. . ... . .. ... .. . ..... . .. ... ... .... .. .... ....4l2Angina pectoris ..... . . .... .. .. ... . ... ... .. . ... .. .. ... .. . ... . .. .... .. .. .. . ... .. .. .. .. .. ...4l3Symptomatic heart disease . ... . .... ... .... .. . .. .. .. .. .. .. .. .. .. .... . . .. .. .. . .... ...427Cerebrovascular disease . .. . .. ... .. ... ... .... . .. .... . .. .. .. . ... .. .. ... . ... .. ...43O438Arteriosclerosis .. . .... . ... .... . . .... . ... . .... . .. .. . ... .. . .... . .. ... .. . .... . .. . ... .. .... ..44OPhlebitis and thrombophlebitis .. . ... .. ... ... ... . ..... .. . .... ... ... ... ... .. . .....45lVaricose veins of lower extremities .. ... .. .. ... . .. ... . .. ... .. . ... .. . .... . .. ... .454Hemorrhoids . .... . ... ..... .. ... .. .. ... . ... ... .. .. .. .. . .... . . ..... ... ... .. . .. ... . .... . . ....455

Under 65 years

Newpatient

23.634.929.628.327.124.830.722.715.619.0

Patient seen before

I

Con-New tinu -

problem ingproblem

65 years and over

~ Patient seen before

wMean contact duration in minutes

20.718.222.018.618.022.213.615.616.214.5

13.716.116.016.4

16.515.017.713.411.014.6

25.139.030.433.539.732.722.120.922.418.6

15.514.119.126.923.419.320.016.511.019.8

Standard error of mean contact duration in minutes

1.7212.34

2.534.203.614.565.274.06

3.791.91

1.614.103.942.821.913.485.531.772.461.47

0.340.97

0.601.130.980.581.630.681.09

0.85

3.395.56

2.567.15”7.246.689.598.54

10.29

3.25

0.965.411.585.652.153.194.982.614.49

2.14

13.118.116.116.517.514.513.913.016.019.0

0.321.17

0.480.980.751.160.691.081.421.86

lf)ia~nostic ~rouPin~s and code inclusions are based on the Eighth Revision In tematiomd chSSifiCUtiO?I Of Diseases; A dap~~d .fo~ usein the United States, 1965.

37

I.

II.

111.

I.

II.

I.

II.

APPENDIXES

CONTENTS

Technical Notes ................... ..........................................................................................................Statistical Design .... .............. ........ ........ .. ...................................................................................Data Collection and Processing ................................................................ .................................Estimation Procedures .............................................. ................................................................Reliability of Estimates ........................................................................................... ...... .......... ..Tests of Si~ificance ......................................... ...... ..................................................... .... .. .... ..Population Fi~resand Wte Computation ..... ..........................................................................Systematic Bias .........................................................................................................................

Definition of Certain Terms Used in This Re~ort ....................... ............ ........................ ................Terms Relating to the Survey .................~....................................................................... ...........Terms Relating totbe Patient Record Fom ..................... ...................... .. ........ ........................

Survey Instmments ......... ...................................................... .............................. ...........................Introductory Letter From Director, National Center for HeAth Statistics .......................... ......Patient Record and Patient Log ................................................................................................Induction Interview Form ........................................................................................................

LIST OF APPENDIX FIGURES

Approximate relative standard errors for estimated numbers of office visits, 1975-76 NationalAmbulatory Medical Care Survey ................................................................................................

Approximate relative standard errors for percentages of estimated numbers of office visits, 1975-76 National Ambulatory Medical Care Survey ............................. ............................... ................

LIST OF APPENDIX TABLES

Distribution of physicians in the 1975-76 National Ambulatory Medical Care Survey sample andresponse rates, by physician’s specialty ............................................................................ ............

Estimates of the civilian noninstitutionalized population of the United States used in computingaverage annual rates in this publication, by age, race, sex, geographic region, and metropolitanand nonmetropolitan areas: United States, 1975-76 ............................. ..................... ..................

3939404242454546

474748

51515253

43

44

40

45

APPENDIX 1

TECHNICAL NOTESj

This report is based on data cdIected in theNational Ambulatory Medical Care Survey(NAMCS). The NAMCS is an annual samplesurvey of office-based physicians conducted bythe Division of Health Resources UtilizationStatistics of the National Center for HealthStatistics. The present report is based on infor-mation coIlected during 1975 and 1976.

Statistical Design

Scope of the swuey. –The target populationof NAMCS encompasses office visits within theconterminous United States made by ambula-tory patients to nonfederally employed physi-cians who are principally engaged in office prac-tice, but not in the specialties of anesthesiology,pathology, or radiology. Telephone contactsand nonoffice visits are excluded.

Sample [email protected] N~lCS utilizes a mul-tistage probability design that involves probabil-ity samples of primary sampling units (PSU’s),physician practices within PSU’S, and patientvisits within practices. The first-stage sample of87 PSU’S was selected by the National OpinionResearch Center (NORC), the organization re-sponsible for NAMCS fieId and data processingoperations and under contract to the NationalCenter for Health Statistics (NCHS). A PSU isa county, a group of adjacent counties, or astandard metropolitan statistical area (SMSA).A modified probabiIity-proportional-to-size pro-cedure using separate sampling frames forSMSA’S and for nonmetropolitan counties wasemployed. After sorting and stratifying by size,region, and demographic characteristics, each

jPrepared by Thomas McLemore, M. S.P.H., Divi-

sion of Health Resources Utilization Statistics.

frame was divided into sequential zones of 1milIion residents, and a random number wasdrawn to determine which PSU came into thesample from each zone.

The second stage consisted of a probabilitysample of practicing physicians selected fromthe master files maintained by the AmericanMedical Association (AMA) and American Osteo-pathic Association (AOA) who met the follow-ing criteria:

Office-based, as defined by AMA and AOA.

Principally engaged in patient care activities.

Nonfederally employed.

Not in the specialties of anesthesiology,pathology, clinical pathology, forensic pa-thoIogy, radiology, dia~ostic radioIogy,pediatric radiology, or therapeutic radiol-ogy.

Within each PSU, all eligibIe physicians werearranged by nine specialty groups; general andfamily medicine , intemaI medicine, pediatrics,other medical specialties, general surgery, ob-stetrics and gynecology, other surgical special-ties, psychiatry, and all other specialities. Then,within each PSU, a systematic random sample ofphysicians was selected in such a way that theoveralI probability of seIecting any physicianin the United States was approximately con-stant.

During 1975-76 the total NAIk4CS sampleincluded 6,529 physicians. Sample physicianswere screened at the time of the survey to assurethat they met the aforementioned criteria; 925physicians did not meet all of the criteria andwere, therefore, ruled out of scope (ineligible)

39

for the study. The most frequent reasons forbeing out of scope were that the physician wasretired, deceased, or employed in teaching,research, or administration. Of the 5,604 in-scope (eli@ble) physicians, 4,476 (79.9 percent)participated in the study. Of the participatingphysicians, 679 physicians saw no patients dur-ing their assigned reporting period because ofvacations, illness, or other reasons for beingtemporarily not in practice. The physician sam-ple size and response rates by physician specialtyare shown in table I.

The final stage was the selection of pa-tient visits within the annual practices of thesample physicians. This involved two steps.First, the total physician sample was dividedinto 52 random subsamples of approximatelyequal size, and each subsample was randomlyassigned to 1 of the 52 weeks in the survey year.Second, a systematic random sample of visitswas selected by the physician during the as-signed week. The sampling rate varied for thisfinal step from a 100-percent sample for verysmall practices to a 20-percent sample for verylarge practices, as determined in a presurvey

interview. The method by which the samplingrate was determined is described later in theTechnical Notes and in the Induction Interviewform displayed in appendix III. During 1975-76information was collect ed on 113,921 patientvisits by means of NAMCS.

Data Collection and Processing

Field procedures. –Both mail and teIephonecontacts were used to enlist sample physiciansinto NAMCS. Physicians received introductoryletters from NCHS (see appendix III) and AMAor AOA. When appropriate, a letter from thephysician’s specialty organization, endorsing thesurvey and urging his participation, was enclosedwith the NCHS letter. A few days later, a fieldrepresentative from NORC telephoned the sam-ple physician to explain the study briefly andto arrange an appointment for a personal inter-view. An initially nonresponding physicizin wasgenerally recontacted via a telephone call orspecial explanatory letter and requested to re-consider participation in the study.

During the personal interview, the field

Table 1. Distribution of physicians in the 1975-76 National Ambulatory Medical Care Survey sample and response rates, by physicianspecialty

Physician’s specialty

Number of physicians

6,529

1,687

1,765

938435392

2,316

679558

1,079

761

468293

925 5,604

260 1,427

245 1,520

124 81474 36147 345

189 2,127

54 62548 51087 992

231 530

79 389152 141

1,128 4,476

333 1,094

337 1,183

202 61253 30882 263

381 1,746

113 51294 416

174 818

77 453

45 34432 109

Responserate

79.9

76.7

77.8

75.285.376.2

82.1

81.981.682.5

85.5

88.477.3

40

representative determined the sample physician’seligibilityy. ascertained his cooperation, deliveredsurvey mat erials with verbal and printed instruc-tions, and assi~ed a predetermined Monday-through-Sunday reporting period. A short inter-view concerning basic practice characteristics,such as type of practice and expected number ofoffice visits, was administered. Office staff whowere to assist with data collection were invitedto attend the instruction session or were offeredseparate instruction sessions.

Before the beginning of and again during theweek assigned for data collection, the NORCinterviewer telephoned the sample physician toanswer possible questions and to insure thatprocedures were going smoothly. At the end ofthe survey week, the participating physicianmailed finished ,survey materials to the inter-viewer who edited the forms for completenessbefore transmitting them for central data proc-essing. Problems or missing data at this stagewere resolved by interviewer telephone followupto the sample physician; if there were no prob-lems, field procedures were complete with re-spect to the sample physician’s participation inNAMCS. After the end of the survey year eachsample physician was sent a thank-you letterfrom NCHS along with one of the survey’sstatistical reports.

Data collection.–The actual data collectionfor the NAMCS was carried out by the physicianaided by his office staff when possible. Two datacollection forms were employed by the physi-cian: the Patient Log and the Patient Record(appendix 111). The Patient Log is a sequentiallisting of patients seen in the physician’s officeduring his assigned reporting week. This Iistserved as the sampling frame to indicate thevisits for which data were to be recorded. Aperforation between the patient names andpatient visit characteristics permitted the physi-cian to remove patient names thus protectingthe confidentiality of the patient.

Based on the physician’s estimate of the ex-pected number of office visits and expectednumber of days in practice, each physician wasassi~ed a patient sampling ratio. These ratioswere desi=~ed so that about 30 Patient Recordswere completed during the assigned reportingweek. Physicians expecting 10 or fewer visits

each day recorded data for all of them; thoseexpecting more than 10 visits per day recordeddata for every second, third, or fifth visit, basedon the predetermined sampIing interval. Theseprocedures minimized the data collection work-load and maintained approximate equal report-ing levels among sample physicians regardless ofpractice size. For physicians assigned a patientsampling ratio, a random start was provided onthe first page of the log, so that predesignatedsample visits on each succeeding page of thelog provided a systematic random sample of pa-tient visits during the reporting period.

Data processing. –In addition to complete-ness checks made by the NORC field staff, cleri-cal edits were performed upon receipt of thedata for central processing. These proceduresproved quite efficient, reducing item nonre-sponse rates to a negligible amount-2 percentor less for each data item.

Information contained in items 5 and 9 ofthe Patient Record were coded in a separatemedical coding operation. This coding was per-formed by the American Medical Records As-sociation, under subcontract to NORC. The datain item 5, the patient’s reason for visit, werecoded according to a special classification sys-tem deveIoped for that purpose.zs The diag-nostic information, item 9 of the Patient Record,was coded according to the Eighth Revision In-ternational Classification of Diseases, .4daptedfor Use in the United States (ICDA).IS A maxi-mum of three entries was coded from each ofthese items. A two-way independent verificationprocedure with 100-percent verification wasused to control the medical coding operation.Differences between coders were adjudicated atNCHS.

Information from the Induction Interviewand Patient Record was keypunched, with 100-percent verification, and converted to computertape. At this time, extensive computer consist-ency and edit checks were performed. Dataitems still unanswered at this point were imputedby assigning a value from a Patient Record withsimilar characteristics; imputations were basedon physician specialty, major reason for visit,and broad diagnostic categories.

NOTE: A list of references follows the text.

41

Estimation Procedures

Statistics produced from NA.MCS were de-rived by a multistage estimating procedure.The procedure produces essentially unbiasednational estimates and has basically three com-ponents: (1) inflation by reciprocals of the prob-abilities of selection, (2) adjustment for nonre-sponse, and (3) a ratio adjustment to fixedtotals. Each of these components is describedbriefly in the material that follows.

Inflation by reciprocals of sampling pro ba-bilities. –Because the survey utilized a three-stage sample design, there were three probabili-ties: (1) the probability of selecting the PSU,(2) the probability of selecting a physicianwithin the PSU, and (3) the probability y of select-ing a patient visit within the physician’s practice.The last probability was defined to be the exactnumbqr of office visits during the physician’sspecified reporting week divided by the numberof Patient Records completed. All weekly esti-mates were inflated by a factor of 52 to deriveannual estimates.

Adjustment for nonresponse. –Estimatesfrom NAMCS data were adjusted to account forsample physicians who refused to participate inthe study. This was done in such a manner as tominimize the impact of nonresponse on finalestimates by imputing to nonresponding physi-cians the practice characteristics of similar re-sponding physicians. For this purpose, similarphysicians were judged to be physicians havingthe same specialty designation and practicing inthe same PSU.

Ratio adjustment. –A poststratification ad-justment was made within each of nine physi-cian specialty groups. The ratio adjustment wasa multiplication factor that had as its numeratorthe number of physicians in the universe in eachphysician specialty group, and as its denomina-tor, the estimated number of physicians in thatparticular specialty group. The numerator wasbased on figures obtained from the AMA-AOAmaster files, and the denominator was based ondata from the NAMCS sample.

Reliability of Estimates

Since the statistics presented in this reportare based on a sample, they will differ somewhat

from the figures that would be obtained if acomplete census had been taken using the sameforms, instructions, and procedures. However,the probability design of NAMCS permits thecalculation of sampling errors. The standarderror is primarily a measure of sampling variabil-ity that occurs by chance because only a samplerather than the entire population is surveyed. Ascalculated in this report, the standard error alsoreflects part of the variation which arises in themeasurement process. It does not incIude esti-mates of any systematic biases that may be inthe data. The chances are about 68 out of 100that an estimate from the sample would differfrom a complete census by less than the stand-ard error. The chances are about 95 out of 100that the difference would be less than twice thestandard error and about 99 out of 100 that itwould be less than 2Y2 times as large.

The relative standard error of an estimateis obtained by dividing the standard error by theestimate itself and is expressed as a percentage ofthe estimate. For this report, asterisks (*) arepresented along with the estimate for any esti-mate with more than a 30-percent relative stand-ard error.

Estimates of sampling variability were cal-culated using the method of half-sample replica- ‘tion. This method yields overall variabilitythrough observation of variability among ran-dom subsamples of the total sample. A descrip-tion of the development and evaluation of thereplication technique for error estimation hasbeen previously published.zG~z 7

Approximate relative standard errors foraggregates and percentages are presented in fig-ures I and II. In order to derive error estimatesthat would be applicable to a wide variety ofstatistics and could be prepared at moderatecost, several approximations were required. As aresult, the relative standard errors shown in fig-ures X and H should be interpreted as approxi-mate rather than exact for any specific e:stimate.Directions for determining approximate relativestandard errors from the figures foHow.

1. Estimates of aggregates: Approximaterelative standard errors (in percent) foraggregate statistics, such as the numberof office visits with a given characteristic,

42

are obtained from the curve in figure I,or calculated by the following formula:

RSE (x) = d 0.0009113499 + 54”1;306 -100

where x is the aggegate of interest inthousands.

2. Estimates of percentages: Approximaterelative standard errors (in percent) forestimates of this type can be calculatedfrom the curve in figure I as follows. Ob-tain the relative standard error of thenumerator and denominator. Squareeach of the relative standard errors, sub-tract the resulting value for the denomi-

This calculation has been made for sev-eral percentages and bases and is pre-sented in figure H. Alternatively, theformula

54.14306 (1 -~) .100RSE(@=~ ~.%.

can be used to calculate RSE for anypercentage (p) and base (x, in thousands).

3. Estimates of rates where the numeratoris not a subclass of the denominator: Ap-proximate relative standard errors forrates where the denominator is the totalU.S. population or one or more of theage-sex-race groups of the total popula-tion are equivalent to the relative stand-

nator from the ~esulting value for the.

ard error of the numeratornumerator, and extract the square root. obtained from fi,gure I.

Figure 1. Approximate relative standard errors for estimated numbers of office visits, 1975-76 National Ambulatory

that can be

Medical Survey

ii54

5.$

3 3

2 ~

.1 .1

100 1,000 10,000 100;000 1,006,000

SIZE OF ESTIMATE (IN THOUSANDS)

Example of use of this graph: An estimate of 10 million office visits (read from scale at bottom ofgraph) has a relative standard error of 8.0 percent (read from scale at left of graph) or a standard errorof 800,000 office visits (8.0 percent of 10 million visits).

43

Figure 11. Approximate relative stendard errors for percentages of estimated numbers of c,ffice visits, 1975-76 National AmbulatoryMedicel Care Survey

1009080

:

50

40

30

20

1098

:

5

4

3

2

1

:765

,4

,3

2

.1

12 346

‘789102 345

6 7 B 9100

ESTIMATED PERCENTAGE

Example of use of this graph: An estimate of 20 percent (read from scale at bottom of graph)based on an estimate of 10 million visits has a relative standard error of 14.7 percent (read from scaleat left of graph) or a standard error of 2.9 percentage points (14.7 percent of 20 percent).

4. Estimates of differences between twostatistics: The relative standard errorsshown in this appendix are not directlyapplicable to differences between twosample estimates. The standard error of adifference is approximately the squareroot of the sum of the squares of eachstandard error considered separately.This formula will represent the standarderror quite accurately for the differencebetween separate and uncorrelated char-acteristics, although it is only a roughapproximation in most other cases.

The half-sample replication procedure wasalso used to calculate standard errors for the

specific estimates of mean contact duration ofvisit presented in this report; these standarderrors are presented in tables 11 and 12 alongwith the estimates.

In addition to sampling error, survey resultsare subject to reporting and processing errorsand biases due to nonresponse or incompleteresponse. There is no way to compute the mag-nitude of these errors. However, these types oferrors were kept to a minimum by methodsbuilt into the survey procedures. Extensivepretesting and careful attention was given tophasing of the questions and the terms em-pIoyed and their definitions in order to eliminateambiguities and encourage uniformity,, Stepstaken to reduce nonresponse bias were discussed

44

in the sections on field procedures and datacollection. Errors in coding and processing werereduced by verification and consistency checks.

Tests of Significance

In this report, the determination of statisti-cal inference for single comparisons is based onthe t-test with a critical value of 1.96 (0.05level of significance). The Bonferroni techniqueis used for simultaneous testing of multiplecomparisons. Terms relating to differences, suchas “higher,” “Iess,” and so forth, indicate thatthe differences are statistically significant.Terms such as “similar,” “no difference,” andso forth, mean that the difference between thestatistics being compared is not statisticallysignificant. Lack of comment regarding thedifference between any two statistics does not

mean the difference was tested and found to benot sibgpificant.

Population Figures andRate Computation

The population figures used in computingaverage annual visit rates are presented in tableII. These figures are based on an average of theJuly 1, 1975 and July 1, 1976, provisional esti-mates of the civilian noninstitutionalized popu-lation of the United States obtained from theU.S. Bureau of the Census. Because NAMCSincludes data for only the conterminous UnitedStates, the original Census estimates were modi-fied to account for the excIusion of Alaska andHawaii from the study. For this reason the pop-ulati~n estimates should not be considered asofficml poptdation estimates and are presented

Table II. Estimates of the civilian non institutionalized population of the United Statesl used in computing average annual rates in thispublication, by age, race, sex, geographic region, and metropolitan and non metropolitan areas: United States, 1975-76

Allages

75yearsandover

Race, sex, geographic region, and area

Race and sex

All races ..... . .. ... ... .... . .. .... .. . ... .. . ... .. .. .... . .. ... . ... ... . .. ... .

Male ... ... ..... .. .. ... .. . .... .. .. .... .. .. .. .. .. .. .. . . .... .. .. ... .. . .. .... ..... . .. ... . .. ....Female .. .. . .... ... ... .. ... ... .. . .... . ... ... .. . .... . . .... .. . ... .. . .... .. .. .. ... . ... . .. ....

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

Male .. .... .. . ... .. ... .. . ... .... . .. .. .. .. . ... .. .. .... . ... ... ... .. .. . .... . .. .... . . .... .. . ... .Female .. .. .... . ... ... . .. .... .. . .... . .. .... . ... .... .. . ... . . .... . ... .. .. .. .. .. .. .... . ... .. .

All other ... .. .. .. .. .... .. .. .. .. .. .... .. .. .. .. .. .... . .. .. ... . ... .. . .... . .. .. ..

Male . .. ... .. .. .. ... .. .. .... . .... . .. .. .... . . .... .. .. ... . .. ... .. . ... .. . .... .. . .... .. ... .. .. ..Female . .... ... ... .. .. .... .. . ... ... . ... ... . ... . .. ... .. .. .. .. .. .... . . .... .. .. ... . . ... .. .. ..

Geographic region

Northeast .. .. .. ... . .. .... .. .. .. ... . ... .. .. ... . ... .. .. .. .. .. .. .... . ..... . . .... . .. ... .. . ..North Central .. . .. ... . .... . .. . .. .... . . .... . . .. .. .. .. .. .. . . .. .. .. .... .. .... ... ... .. . ..

Number in thousands

208,610 13,634

5,9147,721

12,337

7,844

2,9314,913

7,159

121,822 22,353 23,349 19,608

100,639107,971

181,285

60,57561,247

103,702

10,73711,616

19,571

11,24212,107

20,790

9,24010,368

17,727

87,82393,462

27,324

12,81614,509

48,84956,06367,21236,486

143,08665,524

51,88151,821

18,120

9,51310,058

2,782

10,06310,727

2,558

8,3769,352

1,881

5,3396,998

1,298

2,6524,507

685

8,6949,426

. . .

.-.---. . .

. . .

. . .

1,2241,558

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

---. . .

1,1791,379

..-

. . .------

---..-

8641,016

..-

. . .-..---

-..-..

575723

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

. . .---

279406

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

-.. ,. . .

West ... . . ... . .. .. ... . ... ... .. .. .... ... ... . ... ... . .. ... ... . ... .. .. ... . . ... .. . .. .. . ... .. ... . .

Area

Metropolitan . . .... . .. ... .. .. ... . .. .... . .. ... .. .. ... .. . .... .. . ... . . .... .. .. .. .. .. .... . .Nonmetropolitan .. .... . . ... ... . ..... . .. ... .. .... .. .. ... . .. ... . .. ... . ... .. .. .. ... . ..

lE~~ludes Alaska and Hawaii.

45

here solely for the purpose of providing de-nominators for rate computations.

Average annual visit rates in this report werecalculated as follows. The numerator was ob-tained by dividing the estimated number of of-fice visits for 1975-76 by 2, to obtain an averageannual number of office visits. This number wasthen divided by the appropriate populationfigure to obtain an average annual visit rate.As previously discussed, reliability estimates foraverage annual visit rates can be calculated fromfigure I.

Systematic Bias

There have been no attempts to determinesystematic bias in the data reported here or tomeasure the impact of any biases. There are sev-eraldatathat

factors, h~wever, that the user of theseshould understand, all of which indicate

these data underrepresent the total number

o

of office visits to office-based physicians. Some-.of those factors are:

1.

2.

The sampling frame for the 1975 and1976 NAMCS included all nonfederallyempIoyed, “office-based, patient care”physicians on the AMA-AOA masterfiles. There are certainly physicians notso classified who, at the time of the sur-vey, would have met the criteria for thatclassification. Visits to these physiciansare not represented in these data.

Physicians who participated in NAMCSdid a thorough and conscientious job inkeeping the Patient Log; however, theprobability that a patient was accident-ally omitted from the survey is muchgreater than the probability that apatient was incIuded who did not makea visit. This factor could also, introducea bias into the data.

00

46

DEFINITIONS

Terms Relating to the Survey

APPENDIX II

OF CERTAIN TERMS USED IN THIS REPORT

Patients. –Can be classified as either:

O~-_ice(s). -Premises that the physician iden-tifies as locations for his ambulatory practice.Responsibility over time for patient care andprofessional services rendered there generallyresides with the individual physician rather thanwith any institution.

Ambulatory patient. –An individual present-ing for personal health services, neither bedrid-den nor currently admitted to any health careinstitution on the premises.

Physician. –Can be classified as either:

In-scope: AH duly licensed doctors of medi-cine and doctors of osteopathy currentIy inpractice who spend some time in caring forambulatory patients at an office Iocation.

Out-ofscope: Those physicians who treatpatients only indirectly, including specialistsin anesthesiology, pathology, forensic pa-thoIogy, radiology, therapeutic radiology,and diagnostic radiology, and the followingphysicians:

●

●

●

●

physicians in miIitary service

physicians who treat patients only in aninstitutional setting (e.g., patients innursing homes and hospitak)

physicians employed full time by anindustry or institution and having noprivate practice (e.g., physicia,~s whowork for the Veterans Administration,the Ford Motor Company, etc.)

physicians who spend no time seeing am-bulatory patients (e.g., physicians whoonIy teach, are engaged in research, orare retired).

In-scope: All patients seen by the physicianor member of his staff in his office(s).

Out-of-scope: Patients seen by the physicianin a hospital, nursing home, or other ex-tended care institution, or the patient’shome. [Note: If the doctor has a p7ivateoffice (which fits definition of “office”)located in a hospital, the ambulatory pa-tients seen there would be considered “in-scope.”] The foIIowing types of patients areaIso considered out of scope:

. patients seen by the physician in anyinstitution (including outpatient clinicsof hospitals) for which the institutionhas the primary responsibility for thecare of the patient over time

● patients who telephone and receive ad-vice from the physician

. patients who come to the office only toleave a specimen, pick up insuranceforms, or pay their bills

. patients who come to the office only topick up medications previously pre-scribed by the physician.

Visit. –A direct, personal exchange betweenambulatory patient and the physician (or mem-bers of his staff) for the purpose of seeking careand rendering health services.

Physician specialty. –Principal specialty (in-cluding general practice) as designated by thephysician at the time of the survey. Thosephysicians for whom a specialty was not ob-tained were assigned the principal specialty

47

recorded in the Master Physician fdes main-tained by AMA or AOA.

Rega”on of practice location. –The four geo-graphic regions, excluding Alaska and Hawaii,which correspond to those used by the U.S.Bureau of the Census, are as follows:

Region

Northeast . . . . . .

North Central . . .

South . . . . . . . . .

West . . . . . . . . . .

States included

Connecticut, Maine, Nlassa-chusetts, New Hampshire,New Jersey, New York,Pennsylvania, Rhode Island,Vermont

Illinois, Indiana, Iowa, Kan-sas, Michigan, Minnesota,Missouri, Nebraska, NorthDakota, Ohio, South Da-kota, Wisconsin

Alabama, Arkansas, Dela-ware, District of Columbia,Florida, Georgia, Kentucky,Louisiana, Maryland, Missis-sippi, North CaroIina, Okla-homa, South Carolina, Ten-nessee, Texas, Virginia, WestVirginia

Arizona, California. Colo-rado, Idaho, Montana, Ne-vada, New Mexico, Oregon,Utah, Washington, WyO-ming

Metropolitan status of practice location. –Physician’s practice is classified by its location inmetropolitan or nonmetropolitan areas. Metro-politan areas are standard metropolitan statis-tical areas (SMSA’S) as defined by the U.S.Office of Management and Budget.

The definition of an individual SMSA in-volves two considerations: first, a city or citiesof specified population that constitute thecentral city and identify the county in which itis located as the central county; second, eco-nomic and social relationships with “con-tiguous” counties that are metropolitan incharacter, so that the periphery of the specificmetropolitan area may be determined. SMSA’Smay cross State lines. In New England, SMSA’Sconsist of cities and towns, rather than counties.

Terms Relating to thePatient Record Form

Age. –The age calculated from date of birthwas the age at last birthday on the date of visit.

Color or race. –On the Patient Record, coloror race includes four categories: white, Negro/black, other, and unknown. The physician wasinstructed to mark the category which in thephysician’s judgment was most appropriate forthe patient based upon observation and/or priorknowledge of the patient. “Other” was restrictedto Orientals, American Indians, and other racesneither Negro nor white.

Patient’s principal problem(s), complaint(s),or symptom(s) (in patient’s own words) .—Thepatient’s principal problem, complaint, symp-tom, or reason for the visit as expressed by thepatient. Physicians were instructed to record keywords or phrases verbatim to the extent pos-sible, listing that problem first which in thephysician’s judgment was most responsible forthe patient’s visit.

Seriousness of problem in item 5a. –Thisitem includes four categories: very serious,serious, sIightly serious, and not serious. Thephysician was instructed to check one of thefour categories according to his or her own eval-uation of the seriousness of the patient’s prob-lem causing this visit. Seriousness refers to physi-cian’s clinical judgment as to the extent ofthe patient’s impairment that might result if nocare were given.

Major reason(s) for this visit. –The patient’smajor reason(s) for the visit were classified bythe physician into one or more of the followingcategories:

Acute problem: A condition or illness havinga relatively sudden or recent onset (i.e.,within 3 months of the visit).

Acute problem, follow up: A return visitprimarily for continued medical care of apreviously treated acute problem.

Chronic problem, routine: A visit primarilyto receive reguIar care or examination for apreexisting chronic condition or illness (on-set of condition was 3 months or morebefore this visit).

48

Chronic problem, jlareup: A visit primarilydue to a sudden exacerbation of a preexist-ing chronic condition.

Prenatal care: Routine obstetrical care pro-vided prior to delivery.

Postnatal care: Routine obstetrical care orexamination provided following delivery ortermination of pregnancy.

Postoperative care: A visit primariIy for carerequired following surgical treatment. In-cludes changing dressing, removing suturesor cast, advising on restriction of activities orroutine aftersurgery checkup.

Well adult/child exam: General health main-tenance examinations and routine main-tenance examinations and routine periodicexaminations of presumably healthy per-sons, both children and adults. Includesannual physical examinations, well-childcheckups, schooI, camp, and insurance ex-aminations.

Family planning: Services or advice thatenable patients to determine the number andspacing of their children. IncIudes bothcontraception and infertility services.

Counseling/advice: Information of a healthnature that would enable the patient tomaintain or improve his physical or mentalweI1-being. Included would be advice regard-ing diet, changing habits or behavior, andgeneral information regarding a specificproblem.

Immunization: Administration of any inocu-lation of specific substances to produce adesired immunity; this includes oral vac-cines. (Allergy shots are not included in thiscategory, but are entered under “other.”)

Referred by another physician/agency: Medi-cal attention prompted by advice or referralfor consultation or treatment from anotherphysician, hospital, clinic, health center,school nurse, minister, pharmacist, and soforth. Does not include self-referral or re-ferral by family or friends.

Administrative purpose: Reasons such ascompleting insurance forms, school forms,work permits, or discussion of patient’s bill.

Other: The reason for this visit is not coveredin the preceding list.

Principal diagnosis. –The physician’s diagno-sis of the patient’s principal probIem or com-pIaint. In the event of multiple diagnoses, thephysician was instructed to list them in order ofdecreasing importance; “principal” refers to thefirst-listed diagnosis. The diagnosis representsthe physician’s best jud~ent at the time of thevisit and may be tentative, provisional, ordefinitive.

Other significant current dia~osis. –The di-a~osis of any other condition known to existfor the patient at the time of the visit. Otherdiagnoses may or may not be related to thereason for that visit.

Treatments and semices ordered or pro-vided. —These include the folIowing:

Limited history/exam: History and/or physi-cal examination that is limited to a specificbody site or system, or that is concernedprimarily with the patient’s chief complaint,for example, pelvic exam or eye exam.

General histoy/exam: History and/or physi-cal examination of a comprehensive nature,including all or most body systems.

Clinical lab test: One or more laboratoryprocedures or tests including examination ofblood, urine, sputum, smears, exudates,transudates, feces, and gastric content, andincluding chemistry, serology, bacteriology,and pregnancy test.

Blood pressure check: Self-expkmatory.

EKG: Electrocardiogram.

Hearing test: Auditory acuity test.

Vision test: Visual acuity test.

Endoscopy: Examination of the interior ofany body cavity, except ear, nose, andthroat, by means of an endoscope.

Office surgery: Any surgicaI procedure per-formed in the office this visit, includingsuture of wounds, reduction of fractures,application/removal of casts, incision anddraining of abscesses, application of support-ive materials for fractures and sprains, and

49

all irrigations, aspirations, dilatations, andexcisions.

Drug prescribed: Drugs, vitamins, hormones,ointments, suppositories, or other medica-tions ordered or provided, except injectionsand immunizations.

X-ray: Any single or multiple X-ray examina-tion for diagnostic or screening purposes.Radiation therapy is not included in thiscat egory.

Injection: Administration of any substanceby syringe and needle subcutaneously, intra-venously, or intramuscularly. This categorydoes not include immunizations, enemas, ordouches.

Immunization/desensitization: Administra-tion of any immunizing, vaccinating, or de-sensitizing agent or substance by any route,for example, syringe, needle, orally, gun, orscarification.

Physiotherapy: Any form of physical ther-apy ordered or provided, including anytreatment using heat, light, sound, or physi-cal pressure or movement, for example,ultrasonic, ultraviolet, infrared, whirIpool,diathermy, cold therapy, and manipulativetherapy.

Medical counseling: Instructions and recom-mendations regarding any health problem,including advice or counsel about diet,change of habit, or behavior. Physicians areinstructed to check this category only if themedical counseling is a significant part of thetreatment.

Psych o therap y/therapeu tic listening: Alltreatments designed to produce a mental oremotional response through suggestion, per-suasion, reeducation, reassurance, or support,including psychological counseling, hypnosis,psychoanalysis, and transactional therapy.

Other: Treatments or services renderedwhich are not listed in the preceding cate-gories.

Disposition. –Eight categories to (describe thephysician’s disposition of the case are pro-vided as folIows:

No followup planned: No return visit ortelephone contact was scheduled for thepatient’s problem on this visit.

Return at specified time: The patient wastold to schedule dn appointment or wasinstructed to return at a particular time.

Return if needed, P.R.N.: No future ap-pointment was made, but the patient wasinstructed to make an appointment with thephysician if the patient considers it neces-sary.

Telephone followup planned: The patientwas instructed to telephone the physician ona particular day to report on his progress, orif the need arises.

Referred to other physician/agency: The pa-tient was instructed to consuIt or seek carefrom another physician or agency. The pa-tient may or may not return to this physi-cian at a later date.

Returned to referring physician: Patient wasreferred to this physician and was now in-structed to consult again with the physicianor agency which referred him.

Admit to hospital: Patient was instructedthat further care or treatment wj.11be pro-vided in a hospital. No further office visitswere expected prior to that admission.

Other: Any other disposition of the case notincluded in the above categories.

Duration of visit. –Time the physician spentwith the patient, but does not include the timepatient spent waiting to see the physician, timepatient spent receiving care from someone otherthan the doctor without the presence of thephysician, and time spent reviewing records,tests results, and so forth. In the event a patientwas provided care by a member of physician’sstaff but did not see the physician during thevisit, “duration of visit” was recorded as zerominutes.

50

APPENDIX Ill

SURVEY INSTRUMENTS

INTRODUCTORY LETTER FROM DIRECTOR,

NATIONAL CENTER FOR HEALTH STATISTICS

@

**,...-%,,‘%:

DEPARTMENTOF HEALTH. EDUCATION. AND WELFARE:. ~.% “Sk .+’s PUBLIC HEALTH SERVICE

HEALTH RESOURCES ADM lNISTRATION

RDCKVILLE, MARVLANO X4X

NATIOFIALCENTER FOR

HEALTH STATISTICS

Endoriitw Orwnimtions

Am,rk,. M,dlcal A“OClal10.Jam.% H. SammOns, M.D.Exuutlb’* WC*Prwla.ntNatle”U M.dlc81 AmOGlallOnAlff*d F. Flm.rExu.utlv. Olroctor

Annrlean AUd.mYOt O-mitolossJohn M. Sliaw, M.D.s8.r.t.w.T,Us.r.r

Am.rkan AUeamY O* Family?hy$lelmls

Rawr Tu%k9nExCCUtlW Dlrcctor

Am.rlcm A8ademY of N..r.WsYSmlaY A. N.l%onEx.c.tl..Olrut.r

A~y:;;,AudB my of OrthOmndlC

Charlsiv. Hwk. M.0.Exm.ttb’c Olroctor

Am.rle.tI A..a9mY of P4.tciasRolnrt G. Fraz!ar, M.D.Exocutlw Dir.ctor

Amdc.n Cell.so of Omtatrktam,.* Cy”...si%tsts

grrr:tnor+. Purm, M.D.

Am.rlc8. Cd19W d FbY!4.h.1Edward C. Roo.now. Jr., M.D.Executw. vtic9Pwl*nt

AnlwYc,” COIIW9 .t P?OV9.IIWMed1cln9

ward IMntl.yExocutlv. Dlr.ctor

Ammrlc,” CO11W8 Of SU~#*Onlc. Ro!l!ns H..1O.. M.D.EXUUUV9 00rutoI

Am.rlc.n Ost*on*thk AIm.1.flomEdward P. Crow*lLO. 0.E.u.tlv. Du.ctor

Am.rlca” PmCtOlOW S0C19tYAlblmdroF. Cutro,M.D.sur*tarY

Am,,lc.” PsyChlatrlC A1lOCl&ttO.M4vln sabmln, M.O.M9dlc.1 Olr.ctor

mi.rk.. sect.ty d Int.rnalA4mdlcln*

Wlllhm R. RamwEx.cutlv. Dlroctor

Am.rk,n sOcl*tY of Plasm ●ndR..o”,lwcl Iv. s.rs-ns. Inc.

Dallas F. WM1*YEx9cutlv. Vlc. Pr.Sld.M

Dear Dr.

The NatiDnal Center for Health Statistics, aa part of itscontinuing program to provide information on the healthstatus of the American people, is conducting a NationalAmbulatory Medical Care Survey (NA.YCS).

The purpose of this survey is to collect informationabout ambulatory patients, their problems, and theresources used for their care. The resulting publishedstatistics will help your profession plan for moreeffective health services, determine health manpowerrequirements, and improve medical education.

Since practicing physicians are the only reliable sourceof this information, we need your assistance in the NAMCS.As one of the physicians selected in our national sample,your participation is essential to the success of thesurvey. Of course, all information that you provide isheld in strict confidence.

Many organizations and leaders in the medical professionhave expreaaed their support for this survey, includingthose shown to the left. They join me in urging yourcooperation in this important research.

Within a few days, a survey representative will telephoneyou for an appointment to diacusa the detaila of yourparticipation. We greatly appreciate your cooperation.

Sincerely yours,

Oorothy P. RiceOirector

Am.,lcan u,oIo.Ic A19=W1O.Hal a. J.n”l.9&Jr., M.0.Exuuth- 01r9ctor

A,,.a,l,tlo”.f AmOrlc.. M.dl-lCOII.,*S

John A, 0, COOP.1, M. D., UI.O.Prnf$d.nt

51

PATl ENT RECORD AND PATl ENT LOG

C532204

PATIENT LOG

~~each oat,,”! am.,,, record name andt,meof .,s, $ c,” the log below F., the @!ent en.

lewd . . I,ne *3. ako corwkle !he pawntrecord 10 !he r,ght

1---am

1pm

1

3

Record Items 1

L----all

for thw pattentPm

tCONTINUE LISTING PATIENTS

ON NEXT PAGE

ASS URANCEOF CO NFIDENTIALITY– AII “fwma!,on >,h#ct.,vo.tdvc rm\ldcnt,f,catnonO fa”, nd,v,duala pmct, c?, m an e,tablmhmwt wII be held Conf,den! aal, wJI b. used ..!, b. wrson$ ewwgcd m and fcr C532204thepurpow of the.. r.evndwll not l,ed,.ck.cd oc .4wwJ,0.ww, rww..r .sed for any.lherp.wxe

1. DATE OF VISIT PATIENT RECORD

.=7$T7+NATIONAL AMBULATORY MEDICAL CARE SURVEY

2. DATE OF BIRTH 4. COLOR OR 5. PATIENTS PRINCIPAL PROBLEM(S) PROBLEM ,, ,,EM ,, ] 7. ;G;:E::Z:E,6. SERIOUSNESS OFRACE COMPLAINT(S). LIR SYMPTOM(S) ~ VISIT

=7%7’+ —

(In paftenr’x own words] (Check OITe)

, D WHITE YES ‘. NO: VERY SE RICUS

3. SEXz O NEGRO/ a MOST

t

8LACK IMPORTANT : SERIOUS // YES, 10! the problem

, D FEMALE I @ OTHER : SLIGHTLY SERIOUS ,mdicaled m ITEM 5a ‘

6. MAJOR REASON(S) FOR THIS VISIT IChect a//maw rea.wml

u, ❑ ACUTE PROBLEM s L WELL AD(JLTICHILD EX4M

L: a ACUTE PROBLEM. FOLLOW-UP . Z FAMILY PLANNING

o. ❑ CHRONIC PROBLEM, ROUTINE :: COUNSELING, ADVICE

. . @ CHRONIC PROBLEM. FLARE-LIP ~ IMMUNIZATION

., ~ PRENATAL CARE G REFERRED BY OTHER PHYS, AGENCY

., ❑ POSTNATAL CARE , C ADMINISTRATIVE PURPOSE

,- ❑ POSTOPERATIVE CARE1

. E OTHER (SWcdy)

fOmradve mocedure)

10. DIAGtiOSTIC/THERAPEUTIC SERVICES flFIOEREO/PROVIOEO THIS VISIT fChecka//thafapp/y)

01 n NONE

02 ❑ LIMITED HISTORY/EXAM

03 n GENERAL HISTORYIEXAM

04 ❑ CLINICAL LAB. TEST

05 0 BLOOO PRESSURE CHECK

D6 •l EKG

07 0 HEARING TEST

08 ❑ VISION TEST

09 0 ENWSCOPY

10 II OFFlcEsURGERY

II Cl DRUG PRESCRIBED

12 D X-RAY

13 ❑ INJECTION

M o iMMUNIZATION/DESENSITIZATION

15 Q PHYSIOTHERAPY

16 ❑ MEDICAL COUNSELING

17 n P8YCHOTHERAPYITHERAPEUTIC

LISTENING

18 ❑ OTHER (S+wcifyl

?A-34-4 DEPARTMENT OF HEALTH, EDUCATIO:V. S.75 PUBLIC HEALTH SERVI

HEALTH RESOURCES ADMINISNATIONAL cENTER FoR HEALTH

9. PHYSICIAN’S PRINCIPAL OIAGNOSIS ~S VISIT

a DIAGNCSS ASSOCIATED WITH ITEM 5, ENTRY

—— ——

b OTHER SIGNIFICANT CURRENT OIAGNOSES

(In order of ,mportance)

II. OfSPOSITION ~VISIT

(Check 8// lhaf apply)

❑ NO FOLLOW-UP PLANNED

❑ RETURN AT SPECIFIEO TIME

0 RETURN IF NEEDED, P R N

❑ TELEPHONE FOLLOW-UP PLANNEO

❑ REFERREO TO OTHER

PHYSICIANIAGENCY

❑ RETURNED TO REFERRING

PHYSICIAN

D AOMIT TO HOSPITAL

I U OTHER (Specify)

LND WELFARE O.M.B

ATIoNATISTICS

12. DURATION OF~ VISIT [Treeactuallyspenf wifhphyx;clzn)

MINUTES

fS8.S72106

INDUCTION INTERVIEW FORM

CONFIDENTIAL*NORC-4233

TIME AMBEGAN : PM

Form Approved.OMB No. 68R1498 1

NATIONAL AMBULATORY MSDICAL CAKE SURVEY

INDUCTION INTERVIEW 11111(Phys. ID Number)

I BEFORE STARTING INTERVIEW

1. ENTER PHYSICIAN I.D. NUM8ER IN BOX TO RIGHT, AEOVE

2. ENTER DATES OF ASSIGNED R31PORTINGWEEK IN Q. 2, P.2

Doctor, before I begin, let me take a minute to give you a little background aboutthis survey.

Although ambulatory medical care accounta for nearly 90 per cent,of all medical carereceived in the United States, there is no systematic Information about the charac-teristics and problems of people who consult physicians in their offices. ‘lhiskindof information has been badly needed by medical educators end others concerned withthe medical manpower situation.

In response to increasing demands for this kind of information, the National Centerfor Health Statistics, in close consultation with representatives of the medicalprofession, has developed the National Ambulatory Medical Care Survey,

Your own task in the survey is simple, carefully designed, and should not take muchof your time. Essentially, it consists of your participation during a specified7-day period. During this period, you simply check off a minimal amount of infornia-tion concerning some of the patients you see.

Now, before we get into the actual procedures, I have a few questions to ask aboutyour practice. The answers you give me will be used only for classification and *analysis, and of course all information you provide is held in strict confidence.—

1. First, you are a(ENTER SPECIALTY FROM CODE ON FACE SHEET LABEL,)”

Yes . . . . . . . . .No. . . . (ASKA) , .

A. IF NO: What is your specialty (including general practice)?

Is that right?

. . 1

. . 2

(Name of Specialty)

*All information which would permit identification of an individual, a

practice, or an establishment will be held confidential, will be used only by personsengaged in and for the purpose of the survey, and will not be disclosed or released

,to other persons or used for any other purpose.

a

53

2. XOW,doctor, this study will be concerned with the ambulatory patients you willsee in your office during the week of (READ REPORTING DATES ENTERED BELOW).

(that’s a (that’s a

—f Monday) through I Sunday)month date month date

Are you likely to see ~ ambulatory patients in your office during that week?

Yes, . . . . .(GOTOQ. 3). . 1

No . . . . . . (ASKA) . ...2

A. IF NO: why is that? RECORD VERBATIM, THEN READ PARAGIQPH BELOW

Since it’s very important, doctor, that we include any ambulatory patientsthat you & happen to see in your office during that week, I’d like toleave these forms with you anyway--just in case your plans change. 1’11plan to check back with your office just before (STARTING DATE) to makesure, and I can explain them in detail then, if necessary.

GIVE DOCTOR ~E ~ PATIENT RECO~ FORMS AND GO TO Q. 9, P. 6.

54

3. A. At ~hat office location will you be sseing ambulatory patients during that7-day period? RECORD UNDER A BELOW AND ASK B WHEN INDICATED.

B. IF HOSPITAL EllERGENCYROOM’OR HOSPITAL OUTPATIENT DEPARTMENT, OR OTHERINSTITUTIONAL LOCATION IN A: Thinking about the ambulatory patients you seein (PLACE IN A), do you, yourself, have principal responsibility for theircare over time, or does (INSTITUTION IN A) have primary responsibility fortheir care over time? CODE LJNDERB BELOW.

c. Is that all of the office locations at which you expect to see ambulatorypatients~ring that week?

Yes. . . . . . . . . . 1No . . . . . . . . . .2

IF NO: OBTAIN ADDITIONAL OFFICE LOCATION(S), ENTER IN “A” BELLW, AND REPEAT.

A. I B.Principal

Office Location Responsibility?

Insti-Physician tution

(1) 1 2

(2) 1 2

(3) 1 2

(4) 1 2

JD.

In Scope?

Yes No

1 2

1 2

1 2

1 2

D. FOR EACH OFFICE LOCATION ENTERED IN A, CODE YES OR NO TO “IN SCOPE” ABOVE.

IN SCOPE (Yes)

Private officesFree-standing clinics

(non-hospital based)Groups, partnershipsKaiser, HIP, Mayo ClinicNeighborhood Health CentersPrivately operated clinics

(except family planning)

IN CASE OF DOUBT, ASK: Is that

I OUT OF SCOPE (No) [

Hospital emergency roomsHospital outpatient departmentsCollege or university infirmariesIndustrial outpatient facilitiesFamily planning clinicsGovernment-operated clinics

(VD, maternal & child health, etc.)

(clinic/facility/institution) hospital based?

IS that (clinic/facility/institution) governmentoperated?

IF ALL LOCATIONS ARE OLIT OF SCOPE, THANK THE DOCTOR AND LEAVE.

PATIENT RECORDS MUST BE COLLECTED FROM ALL IN-SCOPE LOCATIONS) REGARDLESS OF ANSWER TO B -- PRINCIPAL FWSPONSIi31i.iTY.

55

4, A. During that week (REPEAT DATES), how many ambulatory patients do you expect

to see in your office practice? (DO NOT COUNT PATIENTS SEEN AT [OUT-OF-SCOPELOCATIONS] CODED IN 3-B.)

ENTER TOTAL UNDER “A” BELOW AND CIRCLE ON APPROPRIATE LINE.

B. And during those seven days (REPEAT DATES IF NECESSARY), on how many ~S doyou expect to see any ambulatory patients? COUNT EACH DAY IN WHICH DOCT~REXPECTS TO SEE ANY PATIENTS AT AN IN-SCOPE OFFICE LOCATIOPT.

ENTER TOTAL UNDER “B” BELOW AND CIRCLE NUMBER IN APPROPRIATE COLUMN.

DETERMINE PROPER PATIENT LOG FORM FROM CHART BELOW. READ ACROSS

ON “TOTAL PATIENTS” LINE UNDER “A” AND CIRCLE LETTER IN APPROPRIATE“DAYS” COLUMN UNDER “B.”

THIS LETTER TELLS YOU WHICH OF THE FOUR PATIENT LOG FORMS (A, B, C, D)SHOULD BE USED BY THIS DOCTOR.

LOG FORM DESCRIPTION

A--Patient Record is to becompleted for ALLpatients Iiste=n Log.

B--Patient Record is to becompleted for everySECOND patient listedon Log,

C--Patient Record is to becompleted for everyTHIPD patient listedon Log.

>kD--patient Record is to be

completed for everyFIF~ patient listedon Log,

A. B.Expected total Total ~ in practicepatients during during week.survey week,

ENTER TOTALENTER TOTAL FROM FROMQ. 4-B, DAYSQ. 4-A.

1 2 3 4 5 6 7

1- 12 PATIENTS AAAAAAA13- 25 “ B AAAAAA

26- 39 “ I CBAAAAA

40- 52 “ CBBAAAA

53- 65 “ ID C B B AA A

66- 79 “ DCBBBAA

80- 92 “ DDCBBBB

93-105 “ DDCBBBB

106-118 “ DDCCBBB

119-131 “ DDCCBBB

132-145 “ DDDCCBB

146-158 “ DDDCCBB

159-171 “ DDDCCCC

172-184 “ DDDCCCC

185-197 “ DDDDDDD

198-210 “ DDDDDDD

I 211+ “ DDDDDDD

*In the rare instance the phyeician will see more than 500 patients during his

assfgned reporting week, give him two D Patient Log F=s and instruct him to com-plete a patient record form for only every tenth patient. Then you are to draw an Xor line on line 5 on every other page of the two folio pads, starting with page 1 ofthe pad.

56

5. FIND PATIENTLOG FOLIO WITH APPROPRIATELETTERAND ENTER LETTERAl!llNUMBEROF THIS FORM HERE.

(FolioNumber)

6. HAND DOCTOR HIS FOLIO AND EXPLALNHOW FORMS ARE TO BE FILLED OUT. SHOW DOCTORTHE INSTRUCTIONSON POCKET OF FOLIO Am ITEM 10 DEFINITIONSON CARD IN FOLIO,TO WHICH HE CAN REFER AFTER YOU LEAVE.

RECORD VERBATIMBELOW ANY CONCERN,PROBLEMSOR QUESTIONSTHE DOCTOR RAISES.

7. IF DOCTOR EXPECTS TO SEE AMBULATORYPATIENTSAT MORE THAN ONE IN-SCOPELOCATIONDURING ASSIGNEDWEEK, TELL HIM YOU WILL DELIVER THE FORMS TO THE OTHER LOCATION(S).ENTER THE FORM LETTERAND NUMBER(S)FOR THOSE LOCATIONSBEIOW, BEFORE DELIVERINGFORM(S). .

Location PatientRecord Form Letter & Number

8. During the surveyweek (REPEATEXACT DATES),will anyone be availableto helpyou in fillingout these records (at each IN-SCOPElocation)?

Yes . . . . (ASKA) . . . 1

No . . . . . . . . . . .2

A. IF YES” Who would that be?—.

RECORD NAME, POSITIONAND LOCATION.

NAME I POSITION I LOCATION

B.

‘INTERVIEWER:WAS PERSONBRIEFBY YOU?Yes I No

1 2

1 2

1 2

1 2

;?INTERVIEWERSHOULD BRIEF SUCH PERSON IF POSSIBLE,

57

g. Do you have a solo practice, or are you associated with other physicians in apartnership, in a group practice, or in some other way?

solo, . . . . . . . . . . . . .1partnership . . (ASK A-C) . . . 2Group . . . ..(AC)A-C) ..,3

+-- Other (SPCIFY AND ASK A-C). . . 4

IF PARTNERSHIP, GROUP, OR OTHER:

A. Is this a prepaid group practice? Yes . . (ASK[l]) . . . 1No . . . . . . . . . .2

[11 IF YES TO A: What per centof patients areprepaid? per cent

B, How many other physicians areassociated with you? NUMBER OF PHYSICIANS:

c. What are the specialties of the other physicians associated with YOU?

Specialty Number of Physician

(1)

(2)

(3)

(4)

(5)

10. Now I have just one more question about your practice. (NOTE: IF DOCTOR PRAC’rICES

IN LARGE GROUP, THE FOLLOWING INFORMATION CAN BE OBTAINED FROM SOMEONE ELSE.) ,

A. What is the total n,mnberof full-time (35 hou’rsor more per week) employees of your (partnership/group) practice? Include persons regularly employed who are now on vacation, temporarily ill,etc. Do ~ include other physicians. RECORD ON TOP LINE OF COLUNN A BEWW.

(1) How many of these full-time employees are a . . . (READ CATEGORIES BEWW AS NECESSARY ANDRECORD N[C;13CROF EACH lN COLUNN A.)

B. And what is the Lotal number O{ part-time (less than 35 hours per week) employees of y&r(partnership/group)practice? Again, include persons regularly employed who are now on vacation,ill, etc. Do not include other physicians. RKCORD ON TOP LINE OF COLUMN B BELOW.

(1) How many of these part-t,me employees are a . . . (READ CATEGORIES BELOW AS NECESSARYAND RECORD NUNhER OF IAcH IN COLUNN B.)

1A. B.

Employees Full-time Part-time

(35 or more hours fweeh) (Less than 35 hours lweek)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

ToTAL:

Registered Nurse . . . . . . . . . . . . . . .

Licensed Practical Nurse , . . . . . . . . . .

NursingAide. . . . . . . . . . . . . , . . ,

Physician Assistant* . . . . . . . . . . . , .

Technician. . . , . . . . . . . , . . , . . .

Secretary or Receptio”~st . . . , . , . . . .

other (SPECIFY)

TOTAL:

—

,’,Physician AS SISLJTIL must he a gr.oduateof an accredited training program for Physician Assistants

(ptljSICi,~:]Xt118dLrS, ;hdc , etc.) or certified by the I!ailonal Board of Nedical Examiners through the

Ler Llll C:l!l On Lxam fur ilsslstant to the Prlrnary Care Pnysician,

..

58

11. During the past seven (7) days, shout hnw many house calls did you make?

NUMBER OF HOUSE CALLS:

12. During the past seven (7) days, how many times did you provide to patients

advice or consultation by telephone?

None. . . . . . . .1

1-9 . . . . . . . .2

10-24 . . . . . . .3

25-49 . . . . . . .4

500rmore . . ...5

BEFORE YOU LEAVE, STRESS THAT ~ AMBULATORY PATIENT SEEN BY THE DOCTOR DURINGTHE 7-DAY PERIOD AT ALL IN-SCOPE OFFICE LOCATIONS (REPEAT THEM) IS TO BE IN-CLUDED IN THE SURVEY~HAT EACH PATIENT IS TO BE RECORDED ON THE LOG, AND ONLYTHE APPROPRIATE NUMEER OF PATIENT RECORDS COMPLETED.

Thank you for your time, Dr. . If you have any (more) questions,

please feel free to call me. My phone number is written in the folio. 1’11

call ~ on Monday morning of your survey week just to remind you.

13. TIME INTERVIEW ENDED . . . . . . . . AMPM

14. DATE OF INTERVIEW . . . . . . . . . . . . . . .

I i I II II(Month) (Day) (Year)

COMPLETE ITEMS I AND 11 ON THE LAST PAGE

IMMEDIATELY AFTER THE INTERVIEW.

59

i. How much interest do you think thedoctor has in the survey?

Great interest . . . 1

Some interest . . . . 2

Little interest . . , 3

No interest . . . . . 4

Can’t tell , . . , . 5

-8-

11. How confident are you that thedoctor will complete the forms?

Definitely will . . 1

Probably will . . . 2

Doubtful . . . . . 3

INTERVIEWER NUM6ER INTERVIEWER’S SIGNATURE

60 ●U.S. GOvEmJMsNT PKtNT2NG OFFICE : 1979 O-2 B1+259/5

VITAL AND HEALTH STATISTICS Series

Series 1. ProL~ams and Collection Procedures. –Reports which describe the general programs of the NationalCenter for Health Statistics and its offices and divisions and data collection methods used and includedefinitions and other material necessa~ for undmstandinq the data.

Series 2. Data Ezsaluation and Mctlzods Research. –Studies of new statistical methodolo~ including e::peri-mentaf tests of new survey methods, ztudies of vital statistics collection methods, new analyticaltechniques, objective evaluations of reliability of collected data, and contributions to statistical theory.

Series 3. Analytical Studies. –Reports presenting anaivticd or interpretive studies based on vital and health

statistics, carrying the analysis further than the expositor types of reports in the other series.

Series 4 Documents and Committee Reports.– Final reports of major committees conc~rned v;ith ~ital andhealth statistic~ and documents such as recommended model vital registration Im.A.xand revised birthand death certificates.

Series 10. Data From the Health Interz’ieul Suroey. –Statistics on illness, accidental injuries, disability, use ofhospital, medical, dental, and other services, and other health-related topics, all based on data collectedin a continuing national household interview survey.

Serifs 11. Datu From the Health Examination Survey and the Health and Nutriticm Examination Survey. –Datafrom direct examination, testing, and measurement of national samples of ihc civilian noninztitu-tionalized population provide the basis for two types Of reports: (1) estimates Of the medically definedprewdence of specific diseases in the L’nited States and the distributions of the population v:ith respectto physicaf, physiological, and psychological characteristics and (2) analysis of relationships among thevarious measurements without reference to an explicit finite uni~~erse of perscms.

.Wies 12. Data From the Institutionalized Population Surzwys, –Discontinued effective 1975. Future reports ftwmthese surveys will be in Series 13.

Series 13. Data on Health Resources L’tilization. –Statistics on the utilization of health manpower and facilitiesproviding long-term care, ambulatory care, hospital care, and family planning Gervices.

Series 14. Data on Health Resources: Manpo uw and Facilities. –Statistics on the numbers. geographic di~tri-bution, and characteristics of health resources including physicians, dentists, nurses, other healthoccupations, hospitafs, nursing homes, and outpatient facilities.

Series 20. Data on Mortality. –Various statistics on mortality other than as included in regular annual or monthlyreports. Special analyses by cause of death, age, and other demo~~aphic variables; georyaphic and timeseries analyses; and statistics on characteristics of deaths not ava~lable from the vital records based onsample surveys of tho~e records.

Series 21. Data on Natality, Marriage, and Diz,orcc. –\ ’arious statistics on natdity, marriage, and divorce otherthan as included in regular annual or monthly reports. Special analyses by demokwaphic variables:geographic and time series analyses; studies of fertility: and statistics on characteristics of births notavailable from the vital records based on sample surveys of those records.

Series 22. Data From the National Mortality and Nutality Surveys. –Discontinued effective 1975. Future report~from these sample surveys based on vital records will be included in Series 20 and 21, respectively.

Series 23. Data From the National Survey oj” Family Gro zoth. –Statistics on fertility. family formation and dis-solution) family phsnning, and related maternal and infant health topics drrived from a biennial sz.m.wyof a nationwide probability sample of ever-man-id v.wnsen 15-44 ;:ears of ase.

For a list of titles of reports published in these series, t,:rite to: Scientific and Teehnical Information Branch

National Center for IHedth StatisticsPublic Health SemiccEI\a,ttsvilir. Md. 207S2