Advance Data from Vital and Health Statistics: Numbers 261–270

Vital and Health Statistics

Advance Data From Vital and Health Statistics: Numbers 261–270

Series 16: Compilations of Advance Data From Vital and Health Statistics Noi 27 Data in this report from health and demographic surveys present statistics by age and other variables on injury reiated visits to hospital emergency departments; ofice visits for giaucoma and office visits to neurologists; the relationship between cigarette smoking and other unheaithy behaviors among our Nation’s youth; 1993 summaries of the National Hospitai Discharge Survey, Nationai Hospitai Ambulatory Medicai Care Survey, and the Nationai Ambulatory Medical Care Survey; urban and rural classification of nationai heaith providers; and characteristics of prepaid pian visits of office-based physicians, ,Estimatesare based on the civiiian noninstitutionaiized population of the United States, These reports were originally pubiished in 19?5,

U,.% DEPARTMENT OF HEALTH AND HUMAN SERVICES Publlc Health Service Centers for Disease Control and Prevention National Center for Health Statistics Hyattsvllle, Maryland April 1996 DHHS Publlcatlon No. (PHS) 96-1886 -.

‘ All material appearing in this report is in the pubiii domain and may be repnxkad or copied without parrnission citatiin as to source, however, is appreoiatad.

Suggested clfation

statistics; numbers 261-270. National Canter for Health Statistics. Vii Health Stat 16(27). 19S6. National Center for Health Statistics Jack R. Anderson, Acting Director Jennifer H. Madans, Ph.D., Acting Deputy Director Jacob J. Feldman, Ph.D., Associate Director for Analysis, Epidemiology, and Health Promotion Gail F. Fisher, Ph.D., Associate Director for Planning and Extramural Programs Jack R. Anderson, Acting Associate Director for International Statistics Stephen E. Nieberding, Associate Director for Management Charles J. Rothwell, Associate Director for Data Processing and Services Monroe G. Sirken, Ph.D., Associate Director for Research and Methodology Injury-Related Vkits to Hospital Emergency Departments: United States, 1992 ...... No. 261 Office Visits for Glaucoma: United States, 1991–92 ...... No. 262 Relationship Between Cigarette Smoking and Other Unhealthy Behaviors Among Our Nation’s Youtk United States, 1992 ...... No. 263 1993 Summary: National Hospital Discharge Survey ...... No.264 Underreporting of Race in the National Hospital Discharge Survey ...... No. 265 Urban and Rural Chissiikation of National Health Provider Inventory Providers: United States, 1991 ...... No. 266 Office Visits to Neurologist United States, 1991-92 ...... “..”””””” ...... No. 267 National Hospital Ambulatory Medical Care Survey: 1993 Outpatient Department Summary ...... No. 268 Characteristks of Prepaid Plan Visits to Office-Based Physicians: United States, 1991 ...... No. 269 National Ambulatory Medicdtie Swey:1993S~arY ...... No. 270 Number 261 ● Februaty 1, 1995 Advance Data w From Vital and Health Statistics of the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

Injury-Related Visits to Hospital Emergency Departments: United States, 1992 by Catharine W. Burt, Ed. D., Division of Health Care Statistics

During the 12-month period from (ED) in non-Federal, short-stay and Data highlights January 1992 through December 1992, general hospitals. an estimated 89.8 million visits were Because the estimates presented in ● m 1992, 34 million ED visits made to hospital emergency this report me based on a sample rather (37.8 percent) were injury related. departments. Of these, 34.0 million than on the entire universe of hospital ● There were 13.5 injury visits to visits (37.8 percent) were iujnry related. ED visits, they are subject to sampling hospital emergency departments for T& report summarizes injury data variability. The technical notes found at every 100 persons in the population. horn the 1992 National Hospital the end of this report include a brief ● Males had a signilicsntly higher rate of Ambulatory Medkal Care Survey overview of the sample design used in injmy-mlated vMts than females had. ● (NHAMCS), a national probabtity the 1992 NHAMCS and an explanation Accidental falls and motor vehicle sample survey conducted by the of sampling errors. A detailed accidents were the leading causes of Division of Health Care Statistics, description of the 1992 NHAMCS injuries resulting in visits to an Centers for Dkease Control and sample &sign and survey methodology emergency department. Together, they Prevention. Statistics are presented on has been published (2). accounted for 41 percent of s@ed patient and v~lt chmactrxistics of injury The ED Patient Record is used by causes of injury. They represent visits to hospital emergency departments hospitals participating in the NHAMCS 13 percent of all visits to an in the United States. An earlier report to record information about patient emergency department. presents a general overview of tidings visits. This form is reproduced in figure ● Persons in the age groups under from the iirst year of the NHAMCS 1 and is intended to serve as a reference 15 y- and 65 y- and OWX had emmgency data (l). for readers as they review the survey higher mtes of visit for accidental falk The National Center for Health findings presented in this document. For Compaled with those 15=24 y- Statistics inaugurated the NHAMCS in this repo~ a v~lt was considered to be 2544 y- and 45-64 years of age. December 1991 to gather and injury related if “injury, first visit” or ● “open wound of head” was the most disseminate information about the health “injury, follow-up” was recorded in frequent principal diagnosis for care provided by hospital emergency item 9 or if a cause of injury was injury-related ED visits. and outpatient departments to the provided in item 10. Data for item 9 ● Wound care was performed at population of the United States. The were missing on less than 1.5 percent of one-third of the injury-mkued visits. survey, which is endorsed by the the xwxmky missing responses to this ● Medkation was administered or American Hospital Association, the item were not imputed. Visits not prescribed at the majority of injury- Emergency Nurses Association, and the specified as injury related in item 9 but rekted visits, with general analgesics American College of Emergency had a cause of injury provided in item most commonly mentioned. Physicians, collected data on more than 10 accounted for 6.3 percent of the Over 9.2 billion dollars were spent on 36,000 visits to emergency departments visits in this analysis. injury-related ED visits in 1992.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention National Center for Health Statistics cm CENTERS FOR DIS=E CONTROL AND PWVENllON 9 Arhranmt ~atn Nn- 261 ● F@bruarv 1.1995 HW.s..”- ---- ..-. -- . . -- . --..,---- #

8.DATE OF VISIT 6. SEX 6. RACE .7. ETHNICITY 8. EXPECTEDSOURCE(S)OF PAYMENT 9, MAJORREASON (Check QI1that apply) FOR THIS VISIT ❑ I (_J White (Check one) ~ , ~m,,e 20 Slack 1 D Hupmic I ❑ Madie#e s D Fl~l~{$ther 1 ❑a Injury, first visit 3 a AtiwWacific 2 D Medicaid ❑ 2 injury, follow-rap L DATE OF BIRTH Islander 6 Patient paid 2 ❑ Male z ❑ Not 3 D Illnaee, first visit 4 ❑ $d$arr Hispanic 30 &%m3nt 7 ❑ No charge 1 I ❑ 4 a Illnass, follow-up Eskimo/ 4 a ~~:&i*l 8 Other Wmth Dav Year 5 a 0t5wr reaaon Aleut

10.CAUSEOF INJURY 11.PATIENT’SCOMPLAINTS), SYMPTOM(S).OR OTHER 12.PHYSICIAN’SDIAGNOSES (Complete ~injury is marked REASON(S)FOR THIS VISIT (In patient’s own words) m 9. De.rcnhe cause mad ploce of injury.) . a. Principal dlagnosl$/ problem associated a. Moat important: with item 1la.

b. Othec b. Other:

c. Other: c. Other: I 13.URGENCYOF THIS VISIT 15.DIAGNOSTIC/SCREENINGSERVICES 16.PROCEDURES(Check .11provided on this uivit) (Check only one) (Check .[1 ordered or provfded.) I ~ None 6 0 Wound core 1 ❑ Urgarrt/Emcrgmt I D None 7 D Chad x.ray z ❑ Endomchcal 7 ❑ Eye/ENTcar. 2 D Nonwmant 2 D Blood pressurw ahaek 9 l_J Extremity x.rav iratubatlon ❑ 8 D Orthopadlc care 3 a Urirrdysis IO CTseardMRl 30 CPR ❑ 14.IS PROBLEMALCOHOL- 9 Bladdar mtfratw 4 a HIV serolow Ii o otw~~gnostk 4 a IV fluids OR DRUG-RELATED? !0 O Lunrb.rp.rrcturu 6 0 Dthar blood taat s O NG tube/ 12 fJ Other (SPecIYY) gastric Iwaee I D Ntitlmr a O EKG II ❑ Other(s) (SPCWY) 2 ~ Alcohol-relamd 7 (J Marital ataw..xarn 3 0 Omg.ra12ted

4nBoth

17.MEDICATION 18.DISPOSITIONTHIS VISIT 19.PROVIDERSSEEN (Reeord all new or continued medieatton ordered, administered. orprtxrided (Check all thatappiy) THIS VISIT at thie visit. Use the earne brand name or generic nome entered on any Rx (Check all that apply) or medical record. Include irnmunieotbna and deaenaitiehg agents.) I a Return to ED PRN 1 ❑ ReskJetat/lntarrt ❑ Nwra 2 n Return to ED - appakrtnmrt 2 ~ Staff physician 3 0 R~rn to referring physicim

1. 3 ❑ Othar physician 4 U Rfir tO .tkr wsician/c\inic ❑ 5 Mmit to hos9ital 4 ❑ Physicim ateistant 2. 6 ❑ Tranafar to other facillty 5 ~ Nursa practitioner 7 ~ ODA/diad in ED 3. 6 D Ragiatared numc 8 0 Left AMA

7 l--J ULaad Pr4cttml 9 ❑ No followup falanned $. IO O Othar (Specify) 8 ❑ Nurse’s aide

Figure 1. National Hospital Ambulatory Medical Care Survey Emergency Department Patient Record

Patient characteristics visits by patient’s age, sex, and race are for males and females. Fhwre 2 shows shown in table 1. Persons 15–24 years the visit rates by age and

Table 1. Number, percent distribution, percent that are injury related, and annual rate of injury-related emergency department visits, by selected patient and vieit characteristics: United States, 1992

Number of Number of Percent vklts per vklts In Percent injury 100 persona Patient and VISIYchamterktlc thousands dktributlon related’ per yeaP

Patient characteristic

Ailin]ury-related vlslts ...... 33,950 100.0 37.8 13.5

Age Undsr15yaars ...... 8,714 25.7 36.7 15.4 15-24 YsMs...... 6,937 20.4 46.7 20.2 25-44 years ...... 11,277 33.2 41.4 13.9 45-84 yeats ...... 3,959 11.7 31.6 8.2 85-74years ...... 1,458 4.3 25.1 7.9 75yearsandover ...... 1,605 4.7 23.4 13.0

Sexerrdags: Female ...... 14,812 43.6 31.8 11.5 Under15years ...... 3,567 10.5 35.0 12.9 15-24year3 ...... 2,670 7.9 33.2 15.4 25-44ysers ...... 4,714 13.9 33.6 11.4 4W54year3 ...... 1,796 5.3 27.1 7.1 6E-74years ...... 940 2.8 26.1 9.2 75yearserrdover ...... 1,124 3.3 25.9 14.6

Male ...... 19,138 56.4 44.3 15.7 Urrder15year3 ...... 5,147 15.2 41.8 17.8 15-24year3 ...... 4,267 12.6 62.8 25.0 ,25-44years ...... 6,584 19.3 49.7 16.4 45+4yeara ...... 2,163 6.4 38.8 9.3 86-74years ...... 518 1.5 21.1 6.3 75yearsandover ...... 480 1.4 19.0 10.4

Raceandaga: White ...... 28,154 82.3 39.9 13.4 Undar15yaare ...... 7,227 21.3 42.8 16.1 15-24ysara ...... 5,823 17.2 50.2 21.2 25-44yeals ...... 8,970 26.4 43.6 13.2 45-64ysars ...... 3,331 9.8 32.9 8.0 85-74years ...... 1,283 3.8 25.6 7.8 75yeareandover ...... 1,520 4.5 24.2 13.6

Black ...... 4,987 14.7 29.1 15.9 Under15yeare ...... 1,311 3.9 25.5 14.6 15-24ysars ...... 972 2.9 33.8 19.1 25-44yeara ...... 1,974 5.8 33.8 20.2 45-84yeara ...... 524 1.5 24.8 10.5 85-74yeare ...... 138 0.4 20.7 8.4 75yeersarrdover ...... 67 0.2 13.3 6.8

Allotherraces ...... 808 2.4 37.3 7.7 AalarrlPaciticlstarrder. .<...... 529 1.5 37.8 . . . Americanlndian&ktmo/Aleut...... 279 0.8 35.3 . . .

Emer~ncydepartment chatacterktic

Geographicreglom Northeast ...... 6,346 20.1 37.4 13.6 Midwest...... 9,268 2e.4 36.9 16.1 south ...... 9,892 S0.7 32.8 12.4 west ...... 6,261 19.8 35.7 12.3

‘Permntofallen’wgency departnwntviaitain aachcatego~that areinjurymlebd, %aadonU.S.Buraauof theCerwsaatirnatesof thedvilian,noninatitutkmalisad populatimoftheUnSad 3tatasasofJulyl, l~2. 4 Advance Data No. 261 ● February 1, 1995

persons) than the South and West 30 r (12 visits per 100 persons) did (table 1). _ Male ~ Female I 25 Prior-visit status The majority of injury-related visits 18 (87.9 percent) were first-time visits. While just 5 percent of illness-related visits to ED’s were classitiedas follow-up visits, 9.7 percent of the injury-related visits were follow-up visits from a previous injury visit. The majority of ED visits (62.2 percent) were made for illness and 37.8 percent were made for injury (table 2).

Under 15-24 25-44 45-64 65-74 75 ears 15 years years years years years anJ over Urgency of this visit Almost half of the first-visit injury Figure 2. Annual rate of injury-related visits to emergency departments by patient’s age cases were classified as urgent by and sex: United States, 1993 hospital staif. In comparison, only 15.8 percent of follow-up injury visits

Table 2. Number, percent distribution, and annual rate of vlait to hospital emergency were classified as urgent. Urgency of departments by major reason for visk United States, 1992 visit was defined as those visits in which the patient requires immediate Number of Nurrrbar vfsltsper attention for an acute illness or injury of Vlsns Percent 100 persons that threatens life or function and where Wit chatacteristlc In thousands dfsfrfbuflon per year’ delay would be harmful to the patient. AIIEDvMs2...... 89,796 100.0 35.7 Hospitals made slightly ditferent interpretations about how they Allinjury-relafedvk.lts...... 33,950 37.8 13.5 lnJury-flretvlalt ...... 28,388 31.6 11.3 determined urgency for the survey. In Injury-follow-upvlsif...... 3,178 3.5 1.3 some cases, the determination of Stated cauaaof lnjury3...... 2,383 2.7 0.9 urgency was based upon the severity of Illness-flrat visit ...... 1,467 1.6 0.6 the patient’s symptom(s); in other cases, Illness-follow-upvisit...... 129 0.1 0.1 Other reason’ ...... 787 0.9 0.3 it was based upon the patient’s diagnosis or the nature of the lreatment Allothervlsits ...... 55,846 62.2 22.2 provided.

‘Based on U.S. Bureau of the Census estimates of the civilian noninstitutionalksd population of the United Statea as of July 1, 1932. %D is emergency department. Cause of injury %d.das vbifs not re.cfdd as injury related but had a cause of injury recorded in tiem 10. ‘lndudas vidls with blank or other majar reasons recc+ded in tiem 9, yet had a cause of injury in item 10. Up to three external causes of injury wem coded and classified according to the Mernational overall ED visit rate for black persons visits were for injuries, almost two- Ckmi$cation of Diseases, 9th Revision, was significantly higher than for white thirds of the ED visits for males aged Clinical Modification (ICD-9-CM) (3). persons, there was no significant 15–24 years were for injuries. White Table 3 shows the number of annual dflerence between the ED injury visit persons in all age groups tended to have injury-related ED visits for the lirst- rates for white and black persons, a higher proportion of ED visits for listed cause of injury, using the major whether using crude or age-adjusted injuries compared with black persons. cause of injury categories spec&xl by rates. However, black persons between the ICD–9-CM @codes) along with the ages of 25 and 44 did have a any subclassification codes that had significantly higher injury-related visit Visit characteristics reliable estimates. E-code data were reported for 84 percent of the injury- rate than did white persons in that age Geographic region category. related visits. In visits where the place Examining the percent of ED visits There were slight regional of occurrenm was listed as the tirst that were injury related for each differences in the utilization of ED cause, the second cause was used for population subgroup in table 1 shows services for injuries. The Midwest had a purposes of this analysis. Almost that while overall one-third of the ED higher injury visit rate (16 visits per 100 one-thiid of the injury-related visits Advance Data No. 261 ● February1, 1995 5

Table 3. Number and percent distribution of Injury-refated emergency department visits by cause of injury United States, 1992

Nuntw of vW& Percent CaUaa of injury and E code’ in thousands dtatrfbufion

Alllnjwy-related visits ...... 33,950 100.0

Olheracoktants ...... E916-E928 10,388 30.5 Sfmckbyfaillng object ...... E916 639 1.9 strfldng agahrsf orafruckby objects orperaons...... E917 3,018 8.9 Caughthrorbefween obJec@...... E318 670 2.0 Machinery ...... ES19 486 1.4 Cuffhrgorpiercinginstruments...... E92cI 3,077 9.1 Flreamrmkaile...... E922 87 0.3 Hotsubsfance,caustioorcorroslve maferiaf...... E924 473 1.4 Overexertio n ...... E927 1,567 4.7 Otherandunspecffladmusas...... E928 195 0.6 Accidentalfals ...... E880-E888 7,706 22.7 Fatifromstebs ...... E880 639 1.9 Fatlfromladdem ...... ,.< E881 201 0.8 Fatlfrombullding ...... E882 162 0.5 Fatl into hole ...... E883 171 0.5 Otherfalifromoneleveltoanother ...... E834 9s7 2.3 Fetlonsarneievel ...... E8a5 1,289 0.4 Otherandunepactfiedfalls ...... E83r3 4,223 12.4 Motorvehicieacckfenfs,trafficand non-traffic ...... E81o-E825 4,130 12.2 Othermotorvehlcle acddentlnvoMng coilieion wlthanother motorvehide...... E812 403 1.2 Motorvehtcta aoddenti nvolvlngcoiltsionwifh othervehkle ...... E813 62 0.2 Moforvehktecollkdonwifhpadastrian ...... E814 178 0.5 Oihermotorvehlcle accidant lnvolvhrgcollision on highway ...... E815 101 0.3 Motorvahtcia acddarrtduetolossofcontrolwithout coilfdononhighway ...... E816 114 0.3 Noncoliialon motorvehicieacckfantwhile boarding oralighfing ...... E817 73 0.2 Othernoncollision motorvehlcleacddent ...... E818 323 1.0 Unspecffledmotorvehkfeacddant ...... E819 2,684 7.9 Othermotorvehidenontrafticaccldant ...... E824 66 0.3

HomldWmdlnju~pupow&inflid@ byotherparaons ...... E960-E963 1,5= 4.6 Fight,brawi, rape ...... E960 5a6 1.7 Aesauitbyoutthr@iardnginstrument...... Egr36 173 0.5 Unapectfiadassautf ...... E966 731 2.2 Acckfentsdueto naturalandenvkonmentalfactors...... E900-E30s 1,374 4.0 Venomousanlmalsandptants ...... E905 442 1.3 Otherln]urycauaadbysrrlmata.... .’, ...... E906 664 2.5

Acckfentscaiaedbysubnrsraion,suffocation, andforelgn bodies ...... E910-E915 1,040 3.1 Foreignbodylrreye ...... E914 646 1.9 Foreign bodyhrotherortflce ...... E915 324 1.0

Ofherroadvehideacddenta ...... E826-EE23 636 1.9 Otherroadacddent,...... E826 547 1.6 Acckfenthrvohfinganimelbelngrldden ...... E828 73 0.2 Surglcalandmedkal proceduresaethe causaofabnormal raacfionofpafient oriafercomplkaflon withoutmentlon ofmlsadventuraatthetlme ofprocedure...... E87s-E879 404 1.2 DuetosurgfcaVmedtoalprocedure...... E878 226 0.7 Duetoothermadkslprooadure...... E87g 178 0.5

Din@, medicind and biological substmces causing aWe~effeda intheqetiicu~ ...... E930-E349 370 1.1 Duetounspeciffeddrugs ...... E947 118 0.3 Accldantatpoisoningby druga,madicinal substances, andblologkata...... E850-ES56 333 1.0 PofaonlngbyanaQasks,a ntipyretka, andantkheumalke ...... E85Q so 0.3 Polsonlngbyotherdrugs ...... E856 171 0.5

Accidental polaonlng byothersdldand Ikfukfsubstances, gases,andvapora ...... E860-E8&g 192 0.8

Sukkfeandself-hrftktedinjury...... E950-E959 180 0.5 Affemptadsulchiabyaolldorlkfuldaubafancas...... E950 90 0.3

Accldentscausedbyfireandftames...... 7.... E890-E899 127 0.4 Unspeclfledflres ...... E833 74 0.2

Ofhe~ ...... 202 0.8 Unknown...... 5,351 15.8 lBasadon the /nWrr#fl.xra/ chssikafbn d D/seases, Sth Revision, clinical Modification (lCD-S-CM) (3). %cludaa all other msjor E-cede categories where the eatirmte was too low to be raliable. 3includea unoxlable, illegible, and blank E-code$, 6 Advance Data No. 261 ● February 1, 1995

“intentional injury” (either by self or others) is perhaps abetter label when using the classification for morbidity purposes. All Accidental others falls Table 4 shows the annual visit rates 29% 27% and percent distribution of these top five injury causes by selected patient characteristics. The data show that persons in the age categories under 15 years and 65 years and over had higher rates of visits for accidental falls than the other age categories. Not Motor vehicle Violence accidents surprisingly, persons between 15 and 24 related 14% 6Y. years had the highest rate of visits for motor vehicle accidents. The rates of visits related to intentional injuries were highest among persons between 15 and 44 years. The data also show that black , Note IncludesontythoseInjury-relatedvisitswith codable cause otInjwy. persons were more likely than white Figure 3. Percent distribution of leading causes of Injury treated at emergency department persons to make an ED visit because of visk United States, 1992 violence (3:1) and motor vehicle accidents (5:3). On the other lhand, white persons wem more likely to make were under the general category of occurrence than do some of the major a visit due to accidental falls than were “Other accidents” (E916-E928) categories. Figure 3 presents the top five black persons (3:2). Figure 4 displays (30.5 percent). “Accidental fritls” causes of injury if E-codes are ED injury-related visit rates by race for (E880-E888) (22.7 percent) and “motor categorized in a slightly different the top five causes of injury. vehicle accidents” (E81O-E825) manner. Sdll, “accidental falls” and Using the E-code data at the fourth (12.2 percent) wem the second and third “motor vehicle accidents,” as delined digit level, the estimates may be largest categories. Table 3 also presents above, accounted for 41 percent of the combined to provide reliable estimates the estimates for individual 3-digit codes injury-related visits with E-codes. of certain categories of injuries. For within the larger categories. The codes However, combining “accidentally example, table 5 shows the number of listed were those for which the numbs struck by persons or objects” (E916) visits to ED’s related to tirearms, pedal of visits were large enough to provide a with “struck by falling objects” (E917) cyclists, pedestrians, and motorcyclists. reliable estimate. The most frequently places this category, labeled “struck Place of occurrence information was occurring 3-digit E-code was accidentally” in figure 3, among the provided for less than 15 percent of the “unspecified fall” (E888) (12.4 percent leading causes. “Accidents caused by injury-related visits with appropfite of total). The category “other road cutting or piercing instruments or causes of injury (e.g., E850-E869 or vehicle accidents” (E826), which objects” (E920) alone accounted for E880-E928) and is therefore not includes bicycle accidents, accounted for 11 percent of the causes of injury-related discussed in further detail. A separate over half a million ED injury visits. visits. Combining “homicide and injury itim for place of occurrence was added “Unspecified assault” (E968), “figh~ purposely inflicted” (E960-E969) with to the 1993–94 Patient Record form to brawl, rape” (E960), and “assault by “suicide and self-inflicted injury” improve reporting of this information. ~cutting or piercing instruments” (E966) (E950-E959), as a measure of injury have reliable estimates within the caused by violence, places it among the Alcohol- or drug-related broader category of “homicide and top five causes of injury in visits to problem injury purposely inllicted by other emergency departments. These five persons.” Together these 3 codes causes accounted for over 70 percent of The proportion of visits that were accounted for 96 percent of the speehic injury-related visits in 1992 where a alcohol related was higher for injury- causes within the larger category. cause was specified. It should be noted related ED visits (3.6 percent) compared Combining various E-code that although the E-co& classification of with noninjury related visits categories at and above the 3-digit level injury causes includes the terms (2.3 percent). Nelson and Stussman (4) yields interesting results for “homicide” and “suicide,” very few examined E-code data for different summarization purposes. The major visits with these causes ended in death responses to item 14, “Is problem groupings in table 3 might be combined in the emergency department. In facti alcohol or drug related?”, on the ED in a better way because some of the there were so few cases observed in the Patient Record and found that an injury individual E-codes within “other sample that reliable population estimates was three times as likely to L’@classified accidents” have a greater frequency of could not be made. The term as “homicide and injury purposely Advance Data No. 261 ● February1, 1995. 7

Table 4. Number, annual rate, and percent distribution of injury-ratatad emergency department visits by selected pattent characteristics, according to the top five causes of injury: United States, 1992

Cause of injury’

Motor Cut by Arxidentaf vehicle struck Selecled characteristic Total fails acokfsnts aocfdarrfal(y Obysxts violence OfheF

Number of visifs in thousands

Alllnjury-relafed vkdts...... 33,950 7,706 4,130 3,657 3,077 1,714 13,666

Rate per 1,000 personss

AlllnJuty-related visits ...... 135.0 30.6 16.4 14.5 12.2 6.8 54.3

Age

Undsr15ye8rs ...... 154.4 44.8 9.4 20.0 12.7 2.9 64.7 15-24 years ...... 201.7 27.4 36.1 26.0 19.3 15.9 77.0 X+4yeara...... 138.7 21.5 19.1 13.4 14.3 10.4 59.9 45-64 yearn ...... 81.6 20.5 10.2 7.6 8.1 2.9 32.4 65yeareendover ...... 99.5 46.6 10.1 5.8 4.6 “0.6 29.7

Sex

Female ...... 114.6 30.8 15.3 102 8.1 5.3 44.7 Male ...... 156.6 30.5 17.8 19.1 16.6 8.4 64.5

Race

White ...... 134.4 32.2 15.2 14.8 12.1 5.3 54.7 Black ...... 158.5 24.7 25.5 15.5 13.5 17.7 61.6 Other ...... 78.8 17.5 13.1 5.9 10.8 “4.1 25.6

Percent distrbuflon

Allinjury-relatedvleits ...... 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Age

Under15years ...... 25.7 32.8 12.8 30.8 23.2 9.5 26.7 15-24yeara ...... 20.4 12.2 30.1 24.4 21.6 32.0 19.4 25-44years ...... X32 22.7 37.6 23.9 37.6 49.3 35.7 45-84yeara ...... 11.7 12.9 11.9 10.1 12.8 8.1 11.5 65yearsarrdover ...... 9.0 79.4 7.5 4.9 4.6 “1.1 6.7

Sex

Ferrrafe ...... 43.8 51.7 48.0 36.1 WI 40.3 42.3 Male ...... 56.4 48.3 52.0 83.8 85.9 59.7 57.7

Race

White ...... 82.9 87.5 77.2 85.0 82.6 65.0 63.8 Black ...... 14.7 10.1 19.4 13.3 13.8 32.5 14.2 Other ...... 2.4 2.4 3.3 1.7 3.6 “2.5 2.0

‘Basedonthe/ntemat&a/ ChssiriafiwofDkeases, SthRevision,ClinicalMcdif?esfiin(3),Accidanralfalls(EW3-ESS8); Mdorvehdeawdents (E810-ES25~Sfrwk sccidentelly(E318-E9 17); Sharp obpcts (E320~ Vibnce (E950-E3S9). %ther includes visits for causq other than Iho$e Iiited in table plus unmdabls causes and blank causss of injuty. 3Bassd on U.S. Bureau of Cerws sethnstes of the civilian noninsfiiufiinalized popufsfion of the Unfisd States as of July 1, 1332.

inflicted” in an alcohol- and drug-related related to alcohol and/or drugs had a coded aecordmgto AReasonfor Wsit visit in comparison with all other visits. greaterlikelihood (61)ofbeingeaused ClassijcationforAmbulatory Care Alcohol and drug use wasdetemnined by violence than were visits not so 0WC)(5).Thepficipal reasonisthe by thehospitalstalf ifthepatient classhied. problem, compkdng or reason listedin indkatedorstdl suspectedthataleohol item llaoftheEDPatientRecord. or drugs played apart intheinj ury, The RVC is divided into the eight Reason forvisit whetherby the patientoranother modules or groups of reasons displayed person. Patient’s use ofalcohol ordrugs Initemllofthe EDPatient in table 6. Half of all injury-related wa8notnecessarily veritiedbyblood or Recor&thepatient’s (orpatient visits were made for reasons ckssitied urinetests.1’hese data undoubtedly surrogate’s) ’’compltint(s), symptom(s), in the injuries and adverse effects underestimate the roleofakoholand orotherreason(s) forthisvisitin the module. About 43.2 percent were in the drugs inEDinjury visits. patient’s own words” isrecorded. Upto symptoms module with the largest Notwithstanding,visits classifiedas three reasons forvisit are classiiedand being symptoms referable to the 8 Advance Data No. 261 ● February 1, 1995

(14.0 percent), and “fractures” (800- 829) (11.2 perce-nt). There wemno sex _ White m Black differences for the principal diagnoses except that males tended to havea higher percent of their dmgnoses as “open wounds” compared to females (28.2 and 18.7 percent respectively). There were few mce differences in 18 diagnoses although white persons tended

14 to have higher rates of “fractures” and 12 “crushing injuries” (925–929) than black persons had. There wem 1.8 million visits that had an injury d~osis (N-code) that were not indicated by hospital stall to be injury related or to have a cause of injury recorded in item 10 of the Patient Aooidental Motor vehicle Struck Shsrp Violenca falls acoidents accidentally objects Record. These visits are not included in this report 83 injury visits. Figure 4. Annual rate of injury-related visits to emergency department by patient’s race The we of N-co& most frequently and leading sausea of injury United States, 1992 found for the principal diagnosis dtiered, as expected by age of patient and cause of injury. Vkita for lpatients Table 5. Number, peroen~ and rate of visits to emergency departments by selsoted causes 65 years and over were twice as likely of Injury United Statea, 1992 to have a principal diagnosis of “fracture” compared to younger Number of Peru3nt of Rate per visits /n injury 1,000 patients. Patienta between the ages of 15 Selected cause’ thousands V/sits personsz and 44 years were twice as likely to

Firearm s ...... 112 0.3 0.4 have a principal diagnosis of “sprains Pedal cyclists...... 321 0.9 1.3 and strains” compared to other age Pedaatftans...... 74 0.2 0.3 groups. Chddren under 15 years were Motorcyclists...... 62 0.2 0.2 one and a half times mo~ likely to have lB*edon the/ntematima/ C/-iFkatbn of Di*=ea WhRewsion. Cllnbal Modifi*ion (3): Firearms [ES’22, E955.O-.4, an open wound dimnosis than were E9S5.O-.4, E970, and E9B5&4] Psdal cyclkts (ESkI-E807(.3), E810-ES25(.6), E82=&9(.1)~ Pedesfris& in rrwtor”vehicle accidents (E810-E825(.7)); Motorcyclists (E810-E825(.2)). olde; patienta. SM-arly, of the top five %ased on U.S. Bureau of the Census esthmtes of the civilian noninsfiiuflonahzed popuk,fion of the Untied states as CJJuly 1, ---- causes of injury visits to emergency departments, visits resulting from accidental falls were mom likely to musculoskeletrd system, accounting for recorded in item 12. Up to three result in a “fracture” diagnosis than 27.4 percent of the visits. dmgnoses are coded and classified were other causes (21). Visits due to The 20 most frequently mentioned aecordmg to the ICW9-CM (3). As motor vehicle accidents more lklcely principal reasons for visi6 representing expected, injury and poisoning resulted in a principal diagnosis of 52.6 percent of all visits, are shown in (ICD-9-CM codes 800-999) accounted “sprains and strains” compared to other table 7. It is important to note that the for 81 percent of all visits, and diseases causes (2:1). “Open wounds” was found rank ordering presented in this and other of the musculoskeletal system (710-739) most often for visits caused by cuts tables may not always be Aiable accounted for 5 percent. Supplementary from sharp objects (86.7 percent). because near estimates may not differ classification dmgnoses (those unrelated “Open wounds” was also the leading from each other due to sampling to injury or illness such as general principal diagnosis for patients struck variability. “Upper extremity examimtion) were made for 4 percent of accidentally or who were victims of lacerations” was the most frequently the injury-related visits. The mnainhg intentional injuries (about 28 percent mentioned specific reason for visit 10 percent were distributed over all the each). (6.8 percent). other major categories. The 20 most frequently reported Within the main ICD-9-CM injmy principal diagnoses are shown in table 8. These are categorized at the three-digit Principal diagnosis category (N-codes), most of the principal diagnoses were “open codtng level of the ICD–9-CM and The principal diagnosis or problem wounds” (870-897) (24.1 percent), account for 55.5 percent of all injury- associated with the patient’s most “sprains and strains of joints and related ED visits. The most commonly important reason for visit and any other adjacent muscles” (840-848) recorded diagnosis was “open wound of significant current diagnoses are (14.4 percent), “contusions” (920-924) head other than eye or ear” (873), Advance Data No. 261 ● February1,1995 9

Table 6. Numbar and parcsnt distribution of injury-related emergency department vlsita by patient’s principal raaaon for vtaiti Unitad Stataa, 1992

Number of P61cent Prlnc@l mason for vkt and RVC wds’ ftE2x?a dlsfrtwfkm

Allvlslta ...... 33,950 100.0

Syrrpto mmodule...... S001+933 14,663 43.2 General symptoms ...... scrol-sow 1,s48 5.7 symptomsreferableto psychobgicaVrnentaldlsordera ...... Sloo-Slee 197 0.6 symptomsreferableto the nervoussystem (excludingsense organs)...... S200-S259 1,016 3.0 symptomsreferableto the cardlovascular~~hatic system...... S260-S293 42 0.1 Syrrptomareferabl etotheeyaaan daars ...... s300—3sgg 704 2.1 syqtomareferable totheraqdratoryaystem ...... S400-S499 403 1.2 Syr@ornerefersble tothed@etlvesyatem...... S500-SS39 606 1.8 Syn_ptomerafwatrletothe@torrrinaryeystem...... SS4rF382S 120 0.4 Syrr@omsreferable totheetdn, hair,arrdnalls...... S630-SS99 327 1.0 Syr’rptornsreferableto the muscutoskalstalsystem ...... s90&3$ree 9,268 27.4 Dbeaeamoduia ...... 0001-0999 84 0.2 Dlsgrrostic/aweeningarrdpreventivemodula...... X1C+X599 151 0.4 Traafrnerrtmodula ...... TIoo-T6e9 1,276 3.6 Injurlasand advereeeffecte module...... J60%@sre 17,061 50.3 lnjurybytypa and/or bcatbn ...... Joo1-J79s 14,6al 43.3 injury,NOS ...... J800-J633 1,s65 5.8 Polaoningandadversaetfecte...... J900-J999 405 1.2 Taslrasuits module ...... RIoo-fww “24 *0.I Admlnlslratlvemodule...... ,.. .AIOA1404O “24 %1 Other ...... UWO—U339 2.0

‘BaaadonARaaaon rbrWsfiClaaafioatkmforAnkwlakvy&ra (RVC)(5). %cludes problemsand mmpbinta net akwhera classii, entriesof “’None:bhks, and illegibbdries.

Table 7. Number, percent distribution, and cumulative percent of Injury-rehted emergency department viaita by the 20 prlnoipal raaaona for visit most fraqusntiy mentioned by patient= United States, 1992

Nunbr of klens h *nf CumulaWe Prhc@al mason for vIM and RVC cede’ thousands dsrrbufkw

Alllrrjuryvlstta ...... 33,950 100.0 . . .

UpperextramHylacerstbns ...... J225 2,321 6.8 8.6 Facalacaratbns ...... J21o 1,463 4.4 11.2 Handandflrrgarsymptome ...... sgw 1,225 3.6 74.8 Head,nack,andfacainjury ...... J505 1,066 3.1 18.0 Harrdarrdfingarinjury...... J570 993 2.9 20.9 Nacksymptorne ...... s900 933 2.7 23.6 Backsymptoma...... sg05 913 2.7 26.3 ffiWSyfl@OMS ...... S325 860 2.6 2s.9 Anklesymptoms ...... sew 633 2.5 31.4 Footandtoesymptome ...... sew 784t 2.3 33.7 Headsndnacklaceratbns ...... J205 728 2.1 36.8 Sutura-ln8ertbn/ramoval...... T565 693 2.0 37.9 AcckbnlNOS ...... J81o 687 2.0 33.8 Shouldersymptoms...... sg40 642 1.9 4*.8 Armsymptome ...... S945 635 1.9 43.6 Pakr,epacifledsftenotraferabfs...... S055 621 1.6 45.5 Haadache,palnlnhead ...... s210 621 1.6 47.3 Lagsymptome ...... sg~ 801 1.8 48.1 Lowbacksymptome...... sgIo 601 1.8 60.8 Wrisfeyrrptom s ...... w~ 591 1.7 52.6 Allotherreasons ...... 15,634 46.0 86.6 Blank ...... 466 1.4 100.0

‘BamdonARaason forViitC/aaa,?iitjon forAtiu/atoryCam (WC)(5). 10 Advance Data No. 261 ● February 1, 1995

Table 8. Number, percent distribution, and cumulative percent of injury-related emergency department visits by the 20 principal diagnoses most frequently rendered by hospital staff United States, 1992

Number of Wits In Percent Cumulative Princ@al dlagnosb and \CD-SLCM code’ thousands dlstrfbuflon percent

Allvisits ...... X3,950 100.0 . . .

Openwoundof head(otherthan eyeorear) ...... 873 2,561 7.5 7.5 Contusion oflowerlhnbandotherun?pacified sites ...... 924 1,755 5.2 12.7 Openwoundofflngar ...... 863 1,604 4.7 17.4 Spralnsandafrairrsofunepecitiadparfsof back...... 647 1,597 4.7 22.1 Sprakrsandstralnsofanklaandfoot ...... 845 1,311 3.9 26.0 Openwoundof olherand un?+x3ctfiadsif%, excaptllmbs...... 879 1,257 3.7 29.7 Contusion ofupperliti ...... 923 1,255 3.7 33.4 Contusion offace,acaip,sndnacksxcapt eyes ...... 920 883 2.5 35.0 Contus40noftmnk, ...... 922 744 2.2 36.1 Injury, olherandunspecified ...... 959 720 2.1 40.3 Openwoundof hand,excspttinger...... 882 675 2.0 42.2 Intracranial injuryof otherarrd un?pecltied nattrra...... 854 564 1.7 43.9 Openwoundof knee,lag(exceptthlgh), andsnkla ...... 691 548 1.6 45.5 Encounterforotherand unapeclfisd proceduraeandattercare...... V58 540 1.6 47.1 Fracfureofradiusanduhta ...... 813 518 1.5 46.6 Sprskrsandetrslnsofwrlstandhand...... W2 518 1.5 50.2 8pfatnsandatrainsofkrreeandleg...... 84.4 509 1.5 51.7 Ffactureofoneormorephaktngas offhan d ...... 818 482 1.4 53.1 Superflctal injwyofeyeandadnexa ...... 918 442 1.3 54.4 Unspeclfieddlsordaraofthebacic ...... 724 392 1.2 55.5 Allotherdlagnoses ...... 15,095 44.5 100.0

lBased on the /rrfernafiorra/ c/8s”fh+orI of Dkeaseq Sth Flevisiin, Clinical Mcdificatiwr (lCD-S-CM) (3).

Table 9. Number and percent distribution of emergency department visits and percent of total visits that are Injury related, by selected diagnostic andlor screening services: United States, 1992

Number of Percent viaifs In Percent InJury Dlagnosfic and/or screening servlca ordered orprvvfded by phyefcfarr’ thousands diafrfbution ralatec?

Allin]ury-related visits ...... 33,950 100.0 07.8

Blood presaure ...... 25,202 74.2 08.1 Extremltyx ray ...... 12,091 35.6 819.3 Othardiagnosllclmaging ...... 4,147 12.2 44.3 Otherbloodtesf ...... 3,397 10.0 13.2 Cheatxray ...... 2,657 7.8 $7.6 Mentalstatusexam ...... 2,044 6.0 38.7 Urinalysis ...... 2,063 6.1 15.1 Etectrocardlogram (EKG) ...... 1,495 4.4 12.6 CTscan/MR13...... 860 2.5 09.8 HlVserology4 ...... 92 0.3 34.2 Other ...... 4,584 13.5 25.9 None ...... 3,819 11.2 35.2

‘Total may exceed total number of visits becsuse more than one service may be reported per visii. %ercant of all enwgency department visits in each cetegory that are injury related. 3CT is computerized tomography. MRI is megnetic reeonanca imaging, $-W IS human irnrnmxteticiency virus. occurring at 7.5 percent of all injury Approximately 88.8 percent of all related. Half of allinjury-related visits visits. injury-related ED visits included one or for accidental falls involvedan moredhgnostic orscreeningservice. extremity xray. Vkitsduetomotor Diagnostic and screening Themostfrequently mentioned vehicle accidents orviolence were more dmgnosticservice wasbloodpressure likely to have blood tests andtninalysis services check, recorded at74.2 percent of visits, performed compared toinjuryvisitsfor Statistics onvtious diagnostic and Extremityxray(35 .6percent)wasthe othercanses. screening services orderedorprovided second most frequent diagnostic Readersshotddnote thatforitems by hospital staffduring an injury-related procedure. About 9 of every 10 ED 8,15,16, 18, and19, hospital statYwere ED visit are displayed in table 9. vi8it8 with extremity xrayswereinj ury asked to check all ofthe applicable Advance Data No. 261 ● February 1,1995 11

Table 10. Number ●nd percent distribution of InJury-related emergency department vlelte and percent that we injury related, by selected procedurw United States, 1992

NunLw of Pemsrrt vMs In Percent Irrjuiy Prooedureprwk#ad by hoqltal star7’ fhouserrds dMfbuffon ralatec#

AIIVMS...... 33,950 100.0 37.8

Woundcare ...... 10,757 31.7 93.1 Otihopsdlccara ...... 6,706 19.8 34.8 Intrevenousflukts...... 2,075 6.1 18.0 Eyeand/orear,nose,andthroatcare ...... 1,241 3.7 49.9 Bladdercatheter ...... 415 1.2 17.9 Naeogsetrktubeend/orgaetrklavags ...... 372 1.1 42.4 Endotracheatln!ubafkm ...... 110 0.3 27.0 CPR3 ...... 63 0.2 21.6 Other ...... 2,470 7.3 36.9 None ...... 13,226 33.2 25.7

‘Ttilrnayexceed totslnumberdvisits becsusemcrethan onepmceduremsy bereportad pervisit ?%wmtotallemwgsmcy departmentviaitsineach categorylhstareirrjwy relatad. 3cp~ is ~a~~pulmnaw rasuscitat”kxt

Table 11. Number and percent distribution of injury-related emergency department visits and percent that are injury related, by number of medications provided or prescribed: United States, 1932

Number of Percent vieltsin Percart InJury Nurnbarofmedications r?rouserrck dktribufion related’

AllirtJu~ralatedvk4fs...... =,950 100.0 37.8

None ...... , 12,812 37.7 46.2 One ...... 12,244 36.1 41.8 Two ...... 5,691 16.8 30.2 Three ...... 2,004 5.2 24.8 Four ...... 723 2.1 22.4 Fiveormcm ...... 476 1.4 17.9

lpemnt ~ all ~mwency depati~nt visits in each cate90rythat are iniuryMlaad.

Table12.Number, parcentdistrlbution, cumulathrepercen~ andtherapeuttcclaesiflcation ofthe15drugsmost frequaritly provided or prescribed In injury-related emergency department vleita by entry name of drug: United Statee, 1992

Number of mentionsIn Percent Cumulative 77wapaufio Enbyrranreofdmg’ thousenck disfnbufion paroarrf oiaaehYoatkvr2

Alldrugmentions ...... 34,910 100.0 ......

Tetanus-relafedbiologioals...... 3,311 9.5 9.5 V8cclneaandantleerums Tylenol ...... 2,692 7.4 16.9 Gsneralanatgeaks Motrtn...... 2,216 6.3 23.3 Ganerelanelgesks Tylenolwithoodelne ...... 1,790 5.1 26.4 Gensralanafgeska Toradol ...... 1,079 3.1 31.5 Generalana)geeks Oernerol ...... 1,017 2.3 34.4 General anaigeaks Anvil ...... 873 2.5 36.9 Genera!anaigaaks Vkodin ...... 794 2.3 33.2 Genemlanrdgesks Keflsx ...... 701 2.0 41.2 Cephaksperins Darvocet-N ...... 668 i .9 43.1 General analgealca Lkkoaine...... 635 1.8 44.9 Locafaneathetke Ibuprofen, ...... 627 1.8 46.7 General arselgssks Neosporln ...... 607 1.7 48.4 Antlb8cferial agan18 Flsxerll, , .,.,...... ,,...... 546 1.6 50,0 Muadereiaxants Benadryl ...... 507 1.5 51.6 Antlhkfeminee Allothermentlorm ...... 16,946 48.6 100.0 . . .

‘Theentrymade bythehos@talaratl cnthapreaoription orothermed!cd racord$.Thbrnay katredananm, genertorwrm,or d+airadtheqsutie sffacl. z~arapeut~ damnmtlon b bsaad on the IVsfkmd /Jr&gCodeDkwObrM1985 Edition(8), 12 Advance Data No. 261 ● February 1, 1995

Table 13. Number, percent distribution, and cumulative percent of drug mentions for the 15 most frequently usad generic sutmtancss in inJury-rsiatsd emergency department visits: United Stctes, 1992

Number of mentions In Percent Cumulative Generic substance thousands’ dlafdbuflon percent

Alldrug rnenllons ...... 45,207 100.0 . . .

Acetemlnophen ...... 6,759 15.0 15.0 Ibuprofen ...... 3,869 8.6 23.5 Tetanustoxoid ...... 2,793 6.2 29.7 Codeine ...... 2,006 4.4 34.1 Diphtherletoxold ...... 1,673 4.1 36.3 Lidocslne ...... 1,230 2.7 41.0 Bacitrechr ...... 1,195 2.6 43.6 Mepeitdine ...... 1,086 2.4 46.0 KetorolacTromethamhre ...... 1,079 2.4 4s.4 Dlhydrocodelne ...... 924 2.0 50.5 Polymyxin B ...... 846 1.9 52.3 Cephsfexlrr...... 792 1.6 54.1 Neproxen ...... 741 1.6 55.7 Neomycin ...... 734 1.6 57.4 Propoxyphene . ~ ...... 715 1.6 58.9 Allothermentions ...... 18,561 41.1 100.0

‘Frequency of mention combines single-ingredient agents with mentioms of theagent esaningredient inacomMnationdrug.

Tabie 14. ‘Number and percent distribution of emergency department visits and percent of total visits that are injury reiatad, by patisnt’a expected source ofpaymenh Unitsd States, 1992

Number of Percent vlalta In Percent Injury fxpectedsourceof payment’ morrsarrda dlatrtbuUon ralatd

Allvkits ...... 33,950 100.0 37.8

Prlvateantiorcommerclel ...... 13,869 40.9 42.9 Medlosid ...... 5,072 14.9 24.9 Patient-paid ...... 5,006 14.7 40.4 Medicare ...... 3,129 9.2 23.0 HMO ancVorotherprepald ...... 2,701 8.0 41.1 Othergovemmerrl ...... 1,759 5.2 43.6 Nocharge ...... 213 0.6 27.4 Other ...... 3,877 10.8 80.1 Unknown ...... 464 1.4 32.2

‘Total may excead total number c1 visits because more than one pay sourcamay be mded for each vM. 2Parcant of all wnargency depadment visits In each category that are Injuty ralafad.

Table 15. Number and percentdistributfon of emergency department visits and percant oftotsi visits that are injury reiated, bytypeof provider scat: United States, 1992

Number of Percent visits in Percent Injury Typeofprovfder’ thousands dlstrlbutfon relater+

AllvIsits ...... 33,950 100.0 37.6

3faffphyslclan ...... 28,466 83.8 36.4 Fmglsterednurse...... 28,350 83.5 36.0 Otherphysician ...... 3,799 11.2 36.1 Rsaldentantiorlntem ...... 3,750 11.0 30.5 Nuraa’sakle ...... 3,210 9.5 37.8 Llcanssdpractlcslnurae ...... 2,039 6.0 34.9 Physiclen eseiatant ...... 664 2.5 49.2 Nuraapreofifloner ...... 564 1.6 31.7

‘Total may exceed total number of visits because more than one provider maybe reported per vi$it. 2Percant of all errwgency department visi!g In each category that are Injury related. Advance Data No. 261 ● Februarv1.1995 13

Table 16, Number, percent dlstrlbutton of injury-related emergency department visits and percent that are injury related, by disposition of vlslk Unltad States, 1992

Nurrrbar of Percent vM% in Percent Irr]wy Dkpos/tkwr’ thousands dlatribuflon rslateti

Allvisits ...... 33,950 100.0 37.8

Refer toolherphysickm/clinic ...... 13,54s 39.9 40.8 Retumto emerganoy department aeneeded...... 8,928 26.3 38.8 Retumto referring physician ...... 6,957 20.5 36.6 Retumto emergency dspatment appolnhnent...... 2,881 8.5 86.9 No followup planned ...... 2,325 6.8 43.6 Admittohoaplfaf ...... 2,072 6.1 17.1 Translertootherfacility ...... 340 1.0 31.1 Leftagalnstrnedicaladvloe...... 316 0.9 30.2 Deadonarrkwfordiedinemargancy department ...... “51 90.2 “18.2 Other ...... 1,650 4.9 36.0

‘Total may exmd total number or visit. because mere than one disposition may be repwted par visii +ercant of all amargency department visits i. each cetegow that are inj.!y related. categoriesforthat item, with theresult thatmultipleresponses couldbecoded for each visit. A145,655 Dsaths Procedures I?rocedureswereperformedat 60.8percent of injury-relatedED visits (table10), which was twice the percent for illne8s-relatedvisit8.The most frequentlymentionedprocedurew38 wound carc,recordcd at 31.7percentof thevisit800rthopedic carewasthe pmcedurewith the secondhighest fiequency,ocmrring at one-lifth of the visits. Roughly94 Percentofall visits withwoundcare ororthopediccare wmidentiliedas related to aninjury. Injury visits were less likely to require the use of intravenousfluids compamd Figure 5. The injury~yramid: United Statas, 1992 with illness-relatedvisits (6.1 and 19.5percentrespectively). of 1.1 drug mentions per injury-related immuni2iig agents most ti-equently ED visitor 1.8 mentions per injury- provided or prescribedduring injury- Medication therapy relakd drug visit. Only one drug related ED visit8.They 8ccountedfor Medicationwas used at 62.3percent mention was recordedat 36.1percent of about onequruter of all drug mentions. of the injury-relatedvisits. Hospital staff the injury-relatedvisits. Medications Of the top drug name8mentionexlmost were instructedto record all new or were administeredor prescribedless are classifiedas general analgesics.This continuedmedicationsorderedor f@uently for injury-relatedvisits is W on tie therapeuticcategories provided at the visi~ including comparedwith illness-relatedvisits used in the Nm”onal Drug Code prescriptionand nonprescription (62.3 and 73.3percent respectively). Directory, 1985 edition (NIX!)(0. preparations,and immunizingand The 15 most frequentlymentioned The 15 most tlequentiy used desensitizingagents.As many as five medicationsin injury-relatedED visits generic substancesfor 1992 injury- medicationsor drug mentions could be are presentedin table 12 accordingto related ED visits are shown in table 13. coded per visit. Visit8with one or more the name written on the ED Patient Drug products contrdniig more than one drug mentions are termed “drug visits” Record by the health care provider ingredient(combmationproduct8)are for thii report. Table11 shows the regardlessof whetherit is a brand name, includedin the data for each ingredent. frequencyand percent of numbers of generic name, or therapeuticeffect. For example,acetaminophenwith medicationsadministeredor prescribed Tetanus-relatedbiological, Tjdenol,and codeine is included in both the count for during the visit. There was amaverage Motrin were the three drugs or acetaminophenand the count for 14 Advance Data No. 261 ● February 1, 1995

codeine. Acetaminophen was the generic of injury-related ED visits resulted in resulting in ED visits are highest among ingredient most frequently used in drugs hospital admission (table 16). This is males 15-24 years of age. Close to or&red or provided by hospital staif, lower than the 18 percent of illness- two-thirds of all ED visits for this occurring in 15 percent of drug related visits that ended in population were for injuries. Continued mentions. The top 15 generic substances hospitalization. Roughly one-quarter of reliance on injury prevention programs, accounted for almost 60 percent of all the injury-related visits had a disposition especially targeted to thii population, drug mentions. As expected, the top of “Return to ED as needed.” This should help to reduce resources spent in generic substances in injury-related means no followup is planne~ but if the health care, loss of productivity, loss of visits are different from those for condition worsens, the patient should life, and loss of quality of life as a illness-related ED visits. Only return. Patients in injury-related visits result of personal injuries. These data acetaminophen, ibuprofen, and codeine were more likely to be scheduled for support the injury prevention programs appear on both lists of top 15 generic another ED appointment compared with that emphasize nonviolent solutions to substances. illness-related visits (8.5 and 2.6 perceng conflicts, elimination of alcohol and respectively). Vkits resulting from drug abuse, and incn?ased education in accidental falls and motor vehicle Expected source of payment home, school, recreational, workplace, accidents were more likely to result in a and transportation safety procedures and Expected source of payment for hospital admission for the patient (9.2 practices. The 1992 NHAMCS data injury-related visits (table 14) was most and 11.2 percent respectively) than were often private/commercial insurance injury visits for other causes provide the first national data on (40.9 percent). “Medicaid” and (5.2 percent). nonfatal causes of injury resulting in “patient-paid” each accounted for about emergency medka.1 care. Analysis of data by E-codes supports the prevention 15 percent of the injury-related visits. Impact of data “HMO/other prepaid” and “Medicare” efforts that promote individual practices were each mentioned at about 8 percent The NHAMCS data present a better and behaviom that reduce a person’s of injury-~lated ED visits. The picture of the impact of injuries on risk of injury, such as proper storage of patient-paid category includes the health care utilization. Figure 5 presents firearms in the home, avoiding drinking patient’s contribution toward “co- the injury pyramid indicating the and driving, using safety restraints while payments” and “deductibles.” Whiie national estimates from which relative riding in an automobile, and wearing a tijuries made up 37.5 percent of the ED rates of various health care events and helmet when riding a bicycle or workload, they accounted for 60 percent death may be determined. The following motorcycle. of the visits whose payment source was rates are based on 59.6 million reported Additional reports that utilize the categorized as “other” on the form. It is injuries that were obtained from the 1992 NHAMCS data will be possible that visits paid by worker 1992 National Health Interview Survey published. In addition, a computer compensation were recorded under (7). For every 100 injuries requiring tape containing both the emergency “other.” A separate category for worker medical attention or resulting in the loss and outpatient department data is compensation was placed on the of at least one-half day tkom usual available at a nominal cost from the 1995–96 Patient Record to provide activities, there were 110 physician National Technical Information office visits (8); 57 emergency better information for future analyses. Service. These data will also be About 40 percent of the “Other department visits; 4.5 hospitalizations available on CD-ROM and diskettes. Government,” “HMO/Other prepaid,” (9); and 0.24 deaths (10). Another way Questions regarding this report may “Private commercial,” and “Patient- of comparing the relative impact of be directed to the Ambulatory Care paid” visits are injury related. Only injuries is using the number of deaths as Statistics Branch by calling about 24 percent of the Medicare and the base. For each death in 1992 Medkaid visits are injury related. resulting from an injury, there were 19 (301) 436-7132. hospitalizations, 233 ED visits, and 450 physician office visits. References Providers seen this visit The impact of injuries comprises a A registered nurse or staff physiciau significant portion of health care 1. McCaigLF. National Hospital was seen at 84 percent of injury-related expenditures in the United States. The Ambulatory Medical Care Survey ED visits (table 15). These percents are average cost of an ED visit in 1987 was 1992 emergency department summary. Advance data from vital not significantly different from those $166 (11). After adjusting for changes in and health statistics; no 245. the consumer price index between 1987 corresponding to all ED visits. Hyattsville, Maryland: National and 1992, the cost in 1992 dollars Center for Health Statistics. 1994. would be $271. Based on this cost, the Disposition of this visit 2. McCaig LF, McLemore T. Plan and annual national cost of visits to ED’s operation of the National Hospital The most frequent disposition was alone for injury-related purposes is over Ambulatory Medical Care Survey. to refer the patient to another physician 9.2 billion dollars. The 1992 NHAMCS National Center for Health Statistics. or clinic (39.9 percent). Only 6.1 percent data revealed that the rates of injuries Vital Health Stat 1(34), 1994. Advance Data No. 261 ● February1,1995 15

3. Public Health Service and Health 6. Food and Drug Administration. National Center for Health Statistics. Care Financing Administration. National Drug Code dwectory, 1985 1994. International classification of ed. Washington Public Health 10. Kochanek KD, Hndson BL. Advance d~eases, 9th revision, clinical Service. 1985. report of final mortality statistics, modification. Washington, D.C.: 7. Benson V, Marano MA. Current 1992. Monthly vital statistics repoti, Public Health Service. 1991. estimates from the National Health vol. 43, no. 6. suppl. Hyattsville, 4. Nelson CR, Stussman BJ. Alcohol- Interview Survey. National Center for Maryland National Center for Health and drug-related visits to hospital Health Statistics. Vital Health Stat statistics. 1994. emergency departments: 1992 10(189). 1994. 11.1987 National Medical Expenditure 8. Schappert SM. National Ambulatory National Hospital Ambulatory Snrvey Public Use Tape 14.5; Medical Care Survey. Advance data Medical Care Survey 1992 Household Survefi Ambulatory from vital and health statistic% no summary. Advance data tiom vital MedicaI Visit Dataj Calendar Year 251. Hyattsvili~ Maryland National and health statistics no 253. 1987. Center for Health Statistics. 1994. Hyattsville, Maryland National 5. Schneider D, Appleton L, Center for Health Statistics. 1994. 12. Shah BV, Barnwell BG, Hnnt PN, McLemore, T. A reason for visit 9. Graves EJ. 1992 Summary National LaVange LM. SUDAAN user’s classification for ambulatory care. Hospital Dkcharge Survey. Advance manual release 5.50. Research National Center for Health Statistics. data from vital and health statistic$ Triangle Park, North Camlinrc Vital Health Stat 2(78). 1979. no 249. Hyattsvill% Maryland Research Triangle Institute. 1991- 16 Advance Data No. 261 c Februarv 1, 1995

occurs by chance when only a sample, Table L Approximate relative standard Technical notes errors for estimated numbers of emergency rather than an entire universe, is department visk National Hoepltal Ambulatory Medioal Care Survey, 1992 Source of data and surveyed. The standard error also reflect3 part of the measurement error, sample design Relative but does not measure any systematic Estimated number of standard emergency department efror in The information presented in this biases in the data. The chances are 95 visits in thousands percent report is based on data collected in the out of 100 that an estimate horn the 1992 National Hospital Ambulatory sample differs from the value that would lo ...... 71.1 50.4 Medical Care Survey (NHAMCS) from 20 ...... be obtained from a complete census by 50 ...... 32.0 December 2, 1991 through December less than twice the standard error. 58 ...... 29.7 27, 1992. The data were adjusted to The standard errors that were used 100 ...... 22.8 produce annual estimates. The target 200 ...... 16.4 in tests of significance for thi3 report 500 ...... 10.8 universe of NHAMCS includes visits were calculated using generalized linear 1,000 ...... 8.1 made in the United States by patients to models for predicting the relative 2,000 ...... 6.4 5,000 ...... 5.1 emergency departments (ED’s) and standard error for estimates based on the outpatient departments (OPD’S) of 10,000 ...... 4.6 linear relationship between the actual 20,000 ...... 4.3 non-Federal, shofi-stay, and general standard error, as approximated using 50,000 ...... 4.1 hospitals. Telephone contacts are 100,000 ...... 4.0 SUDAAN software, and the size of the excluded. estimate. SUDAAN computes standard NOTE The smallest reliible estimate for visits to hospital A fore-stage probability sample emergency depertmenfs is 58,0C0. Estimates below thB figure design is used in NHAMCS. It involves errors by using a fimt-order Taylor have a relefive sfendard error greater than 30 peroent and are approximation of the deviation of deemed unreliable by by NCHS stendards. samples of primary sampling unit8 Exemple of use of table An aggregate estimata of 20 million estimates horn their expected values. A visk has a relafiwe afendard error of 4.3 pert.ant or a (PSU’S), hospitals with ED’s and/or standard error of 880,000 visits (4.3 percent of 20 Mien). OPD’S within PSU’S, EDs within description of the software and the hospitals and/or clinics within OPD’S, approach it uses has been published Table Il. Approximate relative standard and patient visits within EDs andh (12). The relative standard error (RSE) errors for estimated numbers of drug of an estimate is obtained by dividing mentions at emergency department visik clinics. For 1992, a sample of 524 National Hospital Ambulatory Medical Care non-Federal, short-stay, and general the standard error by the estimate itself. Survey, 1992 hospitals was selected from the SMG The result is then expressed as a percent Relative Hospital Market Database. Of this of the estimate. Estimated number standsrd group, 474 hospitals we~ in scope, or Relative standard errors for of drug mentions error in in thousends percent eligible to participate in the survey. The emergency department estimates are hospital response rate for the NHAMCS shown in tables I and II. Standard errors lo ...... 71.9 during this period was 93 percent. for estimates in percents of visits and 20 ...... 50.9 50 ...... 32.4 Hospital staff were asked to complete a drug mentions are shown in tables III 59 ...... 29.9 Patient Record (figure 1) for a and IV. Multiplying the estimate by the 100 ...... 23.1 systematic random sample of patient RSE will provide an estimate of the 200 ...... 16.6 visits occurring during a randomly 500 ...... 11.1 standard error for the estimate. 1,000 ...... 6.5 assigned 4-week reporting period. The Alternatively, relative standard 2,000 ...... 6.8 number of Patient Record forms errors for aggregate estimates may be 5,000 ...... 5.5 completed for ED’s was 36,271. 10,000 ...... 5.0 calculated using the following general Characteristics of the hospital, such 20,000 ...... 4.8 formulz where x is the aggregate of 50,000 ...... 4.6 as ownership and expected number of interest in thousands, and A and B are 100,000 ...... 4.5 ED visits, were obtained from the 200,000 ...... 4.5 appropriate coefficients flom table V. hospital administrator during an the NOTE The smallest ml!able estimate of drug mentions at induction interview. The U.S. Bureau of visits to hoepifal amergency departments is 59 millimn. the Census, Housing Surveys Branch, RSE (x) = A+:v1OO Estimates below this figure have a re!afive standard error d greater than 30 parcent and are deenmd unreliable by NCHS was responsible for the survey’s data standards. Similarly, relative standard errors Exemple of uee of table: An aggregate estimate of 10 million collection. Data processing operations drug mentions hes a relafiie standard error of .55 peraant or for an estimate of a percent maybe a sfendard error G4S50,000 drug mentions (.5.5 percent of 10 snd medlcd coding were performed by million). the National Center for Health Statistics, calculated using the following general Health Care Surveys Section, Research formulz using the appropriate coefficients from Triangle Parkr North Carolina. table V. ‘s’(’)= Ev’oo Adjustments for hospital Sampling errors nonresponse where p is the percent of interest The standard error is primarily a expressed as a proportion, and x is the Estimates horn NHAMCS data measure of the sampling variability that denominator of the percent in thousands, were adjusted to account for sample Advance Data No. 261 ● February 1, 1995 17

Table Ill.Approximate standard errors of percents of estimated numbers of emergency department visik National Hospital Ambulatory Medical Care Survey, 1992

Eetknatedparcant Base ofpercent @7itS h thousands) 1 or 99 5 or 95 10 or90 20 or 80 30 or 70 40 or 60 50

Standard ermrinperoentaga points lo ...... 7.1 15.5 21.3 2&4 32.5 &l.8 35.5 20 ...... 5.0 10.9 15.1 20.1 23.0 24.6 25.1 50 ...... 3.2 6.9 9.5 12.7 14.6 15.6 15.9 100 ...... 2.2 4.9 6.7 9.0 10.3 11.0 11.2 200 ...... 1.6 3.5 4.8 6.4 7.3 7.8 7.8 500 ...... 1.0 22 3.0 4.0 4.6 5.9 5.0 1,000 ...... 0.7 1.5 2.1 2.8 3.3 3.5 3.6 2,000 ...... 0.5 1.1 1.5 2.0 2.3 2.5 2.5 5,000 ...... 0.3 0.7 1.0 1.3 1.5 1.6 1.6 10,000 ...... 0.2 0.5 0.7 0.9 1.0 1.1 1.1 20,000 ...... 0.2 0.3 0.5 0.6 0.7 0.8 0.8 60,000 ...... 0.1 0.2 0.3 0.4 0.5 0.5 0.5 100,000 ...... 0.1 0.2 0.2 0.3 0.3 0.3 0.4

Examp!aofuseofiabkAnestirnateof40 Pwc%ntbasedonanaggregateestimate oflOmNionvisitshasasfandarderrord 1.1 percantorarelafive sfandarderrorof2.8percant(l.l percent dwided by 40 percent),

Table IV.Approximate standard errors of percents of estimated numbers of drug mentions at emergency department visi&KNational Hospital Ambulatory Medical Care Survey, 1992

EWnatedpercent Base ofpercwrt (dregmentionsin thousands) 1 or 99 5 or 95 10 or90 20 or 80 30 or 70 40 or 60 50

.%mfardermrinpercentaga points lo ...... 7.1 15.6 21.5 28.7 32.9 35.1 35.9 20 ...... 5.0 11.1 15.2 20.3 23.2 24.8 25.4 50 ...... 3.2 7.0 9.6 12.8 14.7 15.7 16.0 100 ...... 2.3 4.9 6.8 9.1 fo.4 11.1 11.3 200 ...... 1.6 3.5 4.8 6.4 7.4 7.9 8.0 500 ...... 1.0 2.2 3.0 4.1 4.6 5.0 5.1 1,000 ...... 0.7 1.6 2.2 2.9 3.3 3.5 3.6 2,000 ...... 0,5 1.1 1.5 2.0 2.3 2.5 2.5 5,000 ...... 0.3 0.7 1.0 1.3 1.5 1.6 1.6 10,000 ...... 0.2 0.5 0.7 0.9 7.0 1.1 1.1 20,000 ...... 0.2 0.3 0.5 0.6 0.7 0.8 0.8 50,000 ...... 0.1 0.2 0.3 0.4 0.5 0.5 0.5 Ioo,ooo ...... 0.1 0.2 0.2 0.3 0.3 0.3 0.4 200,000 ...... 0.1 0.1 0.2 02 0.2 0.2 0.3

Exampleofuseof tabbAnestirrmte ofEOpsrcentbased onanaggregateestimate oflOmillionvi$if$has astandmderrord 1.1 Percentorarelative sfand8rdwrorof2,2 percent(l.lpercunt dwided by 50 percent).

hospitals that were in scope butdld not sample clinics that were in scope but statistically significant dhlerences participate in the study. This adjustment did not participate in the study. TM (0.05 level of significance over all wascaIculated to minimize the impact adjustment was calculated to minii analyses performed on estimates in a of response on final estimates by the impact of response on final estimates table). Txms relating to dtierences such imputing to nonresponding hospitals by imputing to nonrespondmg ED’s or as “higher than” indicate that the data from visita to similar hospitals. For clinics’ data from visits to similar EDs difference is statistically significant. A this purpose, hospitals were judged or clinics. For this purpose, ED’s or lack of comment regarding the similar if they were in the same region, clinics were judged similar if they were d~erence between any two estimates ownership control group, and in the same ED or clinic group. does not mean that the diKereme was metropolitan statistical area control tested and found to be not significant. group. Test of significance and In the tables, estimates of ED visits rounding have been rounded to the nearest Adjustments for ED and/or thousand. Consequently, estimates will clinic nonresponse The determimtion of statistical infenmce is based on the t-test. The not always add to totals. Rates and Estimates ftom NHAMCS data Bonfemoni inequality was used to percents were calculated from original were adjusted to account for ED’s and establish the critical value for unrounded figures and do not 18 Advance Data No. 261 ● February 1, 1995 necessarily agree with percents Table V. Coeffiolants appropriate for determining relative standard error by type of estimate for hospital emergency departments: National Hospital Ambulatory Medical Care calculated from rounded data. Survey, 1992

Coefficient with use for Definition of terms esthetes In thousands

F’atienl-h individual seeking Type of estimate A B personal health services who is not currently admitted to any health care Vlslts...... 0.00158 5.04053 Drug mentions ...... 0.00235 5.14293 institution on the premises. Hospital-All hospitals with an average length of stay for all patients of less than 30 days (shofi-stay) or hospital whose specialty is general (medical or departments open less than 24 hours are Non-urgent—A visit wherein the surgical) or children’s general Federal included if staffed by the hospital’s patient does not require attention hospitals, hospital units of institutions, emergency department. immediately or within a few hours. and hospitals with fewer than six beds Wsit—A direct personal exchange Injury-related visit—A visit during stalTedfor patient use are excluded. between a patient and a physician or which hospital st.atl indicated that the Emergency department-Hospital other health cam provider working visit was a result of any kind of facility for the provision of unscheduled under the physician’s supewision, for accident or injury includlng but not outpatient services to patients whose the purpose of seeking care and limited to falk, lacerations burns; conditions require immdlate care and receiving personal health services. intentional injurky unintentional which is st.atfed 24 hours a day. If an Urgendemergent-A visit wherein poisonings by drugs, medicinal ED provided emergency services in the patient requires immediate attention substances, blologicals, gases, or vapors; different areas of the hospital, then all for an acute illness or injury that adverse reaction to drugs; complications these areas were selected with certainty threatens life or function and where of surgical and medical procedures; and into the sample. Off-site emergency delay would k harmful to the patient. insect and animal bites. Advance Data No. 261 ● February 1, 1995 19

Symbols --- Data not available . . . Category not applicable Quantity zero 0.0 Quantity more than zero but less than 0.05 z Quant”~ more than zero but less than 500 where numbers are rounded to thousands * Figure does not meet standard of reliabilityor precision 20 Advance Data No. 261 ● February 1, 1995

Trade name dlaclaimer

The use of trade names is for identification only and does not imply endorsement by the Public Health Service, U.S. Department of Health and Human Services. Suggested citation Natfonal Center for Health Statistioa Copyright Information Burt CW. Injury-related visits to hospital Director emergency departments: United States, 1992. All material appearing in this report is in the Manning Feinleib, M. D., Dr. P.H. Advance data from vital and health statistics; public domain and may be reproduced or Deputy Director no 261. Hyattsville, Maryland: National Center copied without permission; citation as to Jack R. Anderson for Health Statistics. 1995. source, however, is appreciated.

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DHHS Publication No. (PHS) 95-1250 5-0411 (2/95) Number 262 . March 30, 1995 Advance Data

FromVital and Health Statisticsof the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

Office Visits for Glaucoma: United States, 1991-92 by Susan M. Schappert, M.A., Division of Health Care Statistics

Introduction and 1992 data. Figures representing summarizing general findings from the 2-year totals rather than averages are 1991 and 1992 NAMCS have been During the 2-year period 1991–92 noted as such in the text. published (24). there were an estimated 17.5 million A copy of the Patient Reeord form, visits made to nonfederally employe~ the survey instrument used by office-based physicians in the United Patient characteristics States at which the principal, or participating physicians to rword first-listed dmgnosis was glaucoma-an information about their patients’ office visits with a principal diagnosis of average of 8.7 million visits per year. visits, is shown in figure 1. In item 11 glaucoma are deseribed in terms of the An additional 3.2 million visits over this of the form, physicms are requested to patient’s age, sex, and race, and same period included glaucoma as the record a principal diagnosis (the geographic region of the visit in table L seeond- or third-listed diagnosis. dmgnosis most closely associated with The overwhelming majority of glaucoma This report presents national the patient’s most important reason for visits were made by persons 45 years of estimates pertaining to glaucoma-related visit) as well as any other current age and over (92.8 percent), and more office visits. These estimates are based diagnoses. Up to three diagnoses are than half (61.3 percent) were made by upon data collected in the National coded and classified aeeording to the females. About nine-tenths Ambulatory Medical Care Survey International Classijicatwn of Diseases, (88.3 percent) of the visits were made (NAMCS), a national probability sample 9th Revisioq Clinical A40dijicatwn by white persons. survey conducted by the Division of (ICD-9-CM) (1) for each visit. This ‘fhe ovemll rate of office visits with Health Care Statistics of the National report focuses primmily on office visits a principal dmgnosis of glaucoma was Center for Health Statistics, Centers for at which the patient’s principal 3.5 viMs per 100 persons per year. Visit Disease Control and Prevention. diagnosis was reeorded as glaucoma rates rose with age, and significant Statistics are presented on patient (K!D--9-CM COdOS 365.0-365.9). Such increases were noted in eaeh age group characteristics, physician praetiee visits are termed “glaucoma visits” characteristics, and visit characteristics throughout this report. after the age of 44, that is, among for visits with a diagnosis of glaucoma, It is necessary to keep in mind that persons 45-54 years, 55-64 years, The 1991 and 1992 National the estimates presented in this report are 65–74 years, and 75 years and over. Ambulatory Medical Care Surveys based on a sample, rather than on the (Wsit estimatesfor persons under the shared identical survey instruments, entire universe of office visits, and as age of 25 years were not statistically definitions, and procethues. The such, they are subject to sampling reliable and have been omitted tlom the resulting 2 years of data have been variability. The technical notes at the age analysis.) ‘IEe visit rate was highest combined to provide more reliable end of this report include a brief for persons 75 years of age and estimates. Inmost cases, the estimates, discussion of the sample design, over-an average of 26.8 visits per 100 percent distributions, and rates presented sampling errors, and guidelines for use persons per year (figure 2). in this report reflect average annual in evaluating the precision of NAMCS The glaucoma visit rate was higher estimates based on the combined 1991 estimates. Additional reports for females than for males overall, with

swlc&. ~@ % U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Heaith Service f Centers for Disease Control and Prevention National Center for Health Statistics CIX *%% CENTERS FOR DIsEAsE CONTROL 4ma AND PREVENTON 9 AAmnee Ilata Nn 9R9 a March Ml 1QQR -“.”,.”” W“. W ,.”. -“- - . ..”. “.. ““, . ““”

Anmntua 01 Oontld..llalify-All [.1.m.tlon wh(eh would JI.nnlt Id.ntlfloall.n .1.. O.partm.m of H.shh ●nd Hunan Barvlm. Indlvldu.1, . P,aclio., o, .“ .stabll,hmmf will b. h,ld Co”fld.”tld, UIIII b. we My by Cmtars for D133**e Cmlrol W130nb Ongsg.d in .nd for th. PUIPOSM of th3 SUN*Y and W no: b. dl.clo.od or Publk H8alth 33wk. m!+amd to c.thw fmr..ns w UIti f.r .ny othu p.rpo.., Nti!+n.1 C+m.r (or H9dlh St.tlsuaa ID 1. DAT2 OF VISIT PATlENT RECORD OMB No. 0920-0234 ~ Expires 4-30-93 NATiONAL AMBUIJXTORY MEDICAL CARE SURVEY CDC S4.21D

2. DATEOF WITH 4. COLOR OR RACE 5. ~NICITY S. EXPECTEDSOURCE(B)OF 7. WAS PATIENT 8. 18TNISVISIT PAYMENT[Check all that or)p;y] REFERRED FOR INJURYRELATED? ~ 1 ~ white THIS VIBJTBY Hhpanlc I ❑ HMO/othw prepaid 6 ❑ ~~’lclal 1❑ Y*S 20N0 i •l c+lgln ANOTNER 2 ❑ ❑lack z❑ Medicare 6 n PatIen2 paid PNYBICIAN? Not 9. DOES PATlENT 3. SEX Asian / Pacific 8MOKE CIGARET’TEB? s❑ Istandw 2 D Hispanic 3 ❑ Modlc2id 7 ❑ No ch6r06 1 m Yes 11JY63 1❑ Female z ❑ Malo Amcrhn Indlnn I *QM ❑ ❑ 4 ❑ OWr govwnmml 8 ❑ Othw s Unknown 4 Eskimo/ Aleut 2UN0

10.PATIENT’SCOMPLAINTS),SYMPTOM S), 11. PHYSICIAN’S OIAGNOSES 12. HAVEYOU OR 13, ~fiS&Av~&M OR OTHERREASON(S)4{OR THISVISI ANYONE INYOUR . [Inpatitnres own wor&] PRACTICESEEN {Check all fhat apply . P&y= PATlENTBEFORE? regardless of any enby in itcm 1 IJ & Mm knptiti Wllhwe-n1Oa 1UY2$ 2i-JNo 1 ❑ None of below

.2 ~ Odpressbm b. Olhac b. Cihm tt p% for the condition In itam 118? 3.2 NypdfWtu2an 4 ❑ Hypcrcho16stordtenria 1 ❑ Yes 2DN0 c.Omw cm 5 ❑ obesity

14.AMBULATORY8URQICAL 1S. DIAGNOSTIC/ BCREENINQSERVICE8 16. THERAPEUTICSERVICES PROCEDURE(S) (Check all ordered or prm,ldedl [Check all ordered mprovided. ficludc mcdicorion] lRecord any oufpallcvdd!u~,wwic or I ❑ None 11 ❑ Pap test fhera utlc procedure. For rhrfirst, ❑ ❑ chccr appropriaw bores.] 2 Blood pmsure !2 strep 2hm7!ttezt I ❑ None 6 ❑ Drug abu66 OTHER THERAPY: 3 ❑ Urinalysis 13❑ HIV serology 7 Q Alcohot nbusa 4 ❑ EKG - resting 14 ❑ ch01e3tu01 rn.sslxa &XJOU;;;G 1 m ~ Psychotherapy ❑ 15 ❑ Other lab test BD Srrwklng cessation ❑ a 6 EKG - MWCiS8 14 CW?OGthJOhll~~ I ❑ Schwuw s ❑ Local m68thesld ❑ ❑ 2 l_JOlet Isn t16dring aid 6 Mammogram 16 H@zring test 9 ❑ Fzmlly/ COC131 2 ❑ Performed 4 C Rribnzl an-theda ‘rI_J Chest x-ray 17 ❑ VilU22 a2uitY 9 ❑ Exmise 16 ❑ ph@0thW2W 10 ~ Growth / Avdopfn.nt e ❑ Other radblogy 18 ❑ Montzt tiatus exam ❑ 5 ~ Ganerd nnzmthesia 4 I-J Cfwktwol rwductien ❑ 17 otiW7 til,mpy [.fP2c{fij 100 Othu {Specfil ❑ II F.zmltyplannlng o ❑ AUargy ta8tlng 6 Walght reckmtlon tz ❑ Othzr oounssling b. 20 I_J Sp4mm0by

17. MEDICATION Ifnone, chsck hsm a Z. NW m~j~ti~? 18. DISPOSITIONTHISVISIT 19. ~~RATION [ChrckalI fha2nppiyi {Rrcord all new Yel No THIS VISIT or cunfimed [rime &flwIty tmdiraltom I ❑ No follow-up planned i. SPCIUwith ordered or In 20 physiciun] provided ar 2 ❑ Return at speciflad tlmc fhw vim, U$< ❑ the SOM< brand 2. ~u 20 3 Return if need6d, P.R.N. nameor generic 4 U Telephone fdllow-up plrmrwd nameMer#d o)t 9. any I/x or oflce In 2U 6 ❑ Rstomed to other @ly8i0i61fl medicol record, Include iinmuni22n* e ❑ Roturrmd to relting plrysloian and dcsensihzing 4. ID 20 agents] 7❑ Admit to tmspltil 8 rJ other [Spec(f)j MInfne6 s. ~D 20

Figure 1. Patient Record form females making an avemge of 4.2 visits respectively. Further analysis of noteworthy because it has been found per 100 for each year compared with 2.8 age-specific visit rates by race was that black persons tend to have higher visits per 100 males. While increasing hampered by the fact that visit estimates intraocular pressure, the main rates by age were observed for both for black persons in several of the age determinant and risk factor for females and males, age-specific rates groups were too low to ensure statistical glaucomrt than white persons (5), that were not found to k significantly reliib~Ity. Aggregation of the estimates glaucoma is the most common cause of dfierent by sex in any age category. into broader categories (for example, 65 irreversible b~mdness among black The rate of visits with a principal years and over and 75 years and over) Americans(6), and that black Americans diagnosis of glaucoma waa not showed rates for black persons that are at a higher risk of primary open- significantly difkrent for white persons appeared to be substantially larger than angle glaucoma than are their white than for black persons. White Wrsons for white persons in these age groups, counterparts (7). Javitt et al. have noted made an average of 3.7 visits per 100 but none of the apparent dilYemux that glaucoma is six to eight times more persons per year compared with 3.0 were statistically significant because of prevalent among black persons in this visits per 100 black persons. For persons the high standard errors assm+it.ed with country, but that black persons are not ages 45 years and over, the rates for the low estimates. receiving care for open-angle glaucoma white persons and black persons were The lack of difference in race- at the same rate as older white 10.6 and 10.9 visits per 100, specilic visit rates for glaucoma is Americans (8). Advance Data No. 262 ● March 30,1995 3

Table 1. Number, percent dlstrlbution, and annual rate of office vislta with a principal both in the AMA mastefie and in the dlagnoals of glaucoma by patient’s age, sex, race, and geographic region of the visit averaged over a 2-year period: United States, 1991-92 NAMCS.) Glaucoma was the second most Wit Number fate ikquently reported principal dmgnosis Selectedpafknt and of vkits in Percent per 100 at office visits to ophthahnologists after visitcharacterkika thousands distribution persons’ eatarac~ accounting for 15.3 percent of Allvisits ...... 8,742 100.0 3.5 the visits to this specialiy (table 2). It

Age should be noted that the ranked order presented in this and other tables in this Under 25yeare ...... “56 “0.7 “0.1 25-44 years ...... 564 6.5 0.7 report may not always be reliable 45-54 years ...... 720 8.2 2.7 because some estimates may not be 55-64 yeafs ...... 1,315 15.0 6.2 statistically dtierent from other near 65-74 yearn ...... 2,s31 32.4 15.4 75yeers andover ...... 3,254 37.2 26.8 estimates due to sampling variabtihy.

Sex Visit characteristics Female ...... 5,359 61.3 4.2 Under 25yeafa ...... “45 *0.5 “0.1 Referral status and prior-visit 25-44 years ...... ’265 93.0 “0.6 45-54 yeara ...... 414 4.7 3.0 status 55-64years ...... 897 6.0 6.3 Data pertaining to patient’s referral 65-74years ...... 1,809 20.7 17.8 75yearsarrdover ...... 2,126 24.3 27.9 status and prior-visit status are shown in

Mefe ...... 3,382 38.7 2.8 table 3. Only 6.8 percent of all glaucoma Undar25yeers ...... *I2 *0.I “0.0 visits during 1991–92 were the result of 25-44years ...... “299 “3.4 “0.7 a referml by another physician. 45-54yeats ...... Ym8 “3.5 “1.6 55-84years ...... 618 7.1 6.2 However, of all visits made by new 65-74years ...... 1,021 11.7 12.4 patients (that is, patients who had not 75yeersarrdover ...... 1,126 12.9 24.6 seen the physician previously), about

Race two-thiids (68.1 percent) were recorded

White ...... 7,721 88.3 3.7 as referrals fi’om another physician. In Black ...... 934 10.7 3.0 contras4 about one-third (31.6 pereent) Other ...... *87 *1.0 “0.9 of all nonglaucmua v~lts made by new

Geographic region patients (that is, visits with a principal

Northeast ...... 1,662 19.0 3.3 diagnosis other than glaucoma) were the Midwest...... 1,724 19.7 2.8 result of referraIs from other physicians. south...... 3,844 41.7 4.3 The majority (89.1 percent) of west ...... 1,711 19.6 2.1 glaucoma visits were made by patients ‘BasedonU.S, BureauoftheCensus astimatasoftha oivifiannoninafWtiinalizad populationforJuiy 1, lWl,ardJu~l, 1ss2, who were making return visits to the averagedoverthe 2-yearpsricd, physician for care of their condition. Compamtivedatatim theNational Physician practice Ten percent of the viMs were made by HospitalAmbulatory MedicalCamSurvey characteristics new patients. However, by age group, showthatbktck-ns accountedfm 17.3 percent of the visits by persons About three-quarters (76.8 percent) about one-thkl (36.6 pement) of the 45-64 years were made for new ofallglaucoma visits during 1991–92 glaucomavisitsmade tohospitaloutpatient problems, compared with 9.0 percent of weremade toophthalmologist.s. The those 65 years of age and over. “New -~t8(@D’s)rn lwcompaKXl remainder (23.2 percent) were made to WithWhite- (61.3percent). problem” visits include those made as a other specialists, including physicians new patient or as a continuing patient. However, theestimated numberofOPD who deseribed themselves as glaucoma The chronic natme of glaucoma is visitswiththispincipal diagnosiswasonly specialists. (Because the Amexican highlighted by the fact that among all 278,0MoveraU, muUing inestimatesthat Medical Association’s (AMA) master return visits for the care of previously wemtoolowtopennit meaningfnlanalysis file, upon which the determination of byraceandage. heated problems, ghtueoma was the fifth physicianspecialtyfor NAMCS most frequently recorded principal Office visit rates did not &tier purposes is basr@ did not have a dmgnosis related to illness or injury. statistically by geographic region of separate specialty code for physicians Among visits with this prineiprd thecoun~, exeeptthat the rate was reporting themselves to the AMA as dmgnosis, there were 4.1 return visits higher in the South (4.3 visits per 100 glaucoma specialists, such physicians recorded during the 2-year period for persons) than inthe West (2.1 visits were classified as “other” specialists per 100 persons). 4 Advance Data No. 262. March 30,1995

Reason for Wit Classi$catiori for 30 Ambulatory Care (WC) (9). This r classification is divided into eight modules, or groups of reasons. These 25 are shown in table 6. The disease module accounted for the highest percent of visits with a first-listed 20 dngnosis of glaucoma (46.9 percent), indkating that the majofity of visits were made by persons whose condition 15 had been diagnosed previously and was known to them. Thk finding corresponds with the high return visit 10 ratio found among glaucoma visits that 6.2 was discussed earlier. The disease 5 module was followed by the diagnostic, screening, and preventive module (27.2 percent), the treatment module n m (9.7 percent), and the symptom module 25-44 45-54 55-64 65-74 75 years (9.4 percent). years years years years and over

Age of patient Diagnostic and screening services NOTE: Estimates for persons under 25 years of age were statistically unreliable. The majority (82.3 percent) of glaucoma visits included a visual acuity Figure 2. Annual rate of office visits with a principal diagnosis of glaucoma by age of examination ordered or provided by the p;tien~ averaged over a 2-year period: United States, 1991-92 physics compared with 4.8 pereent of all other Om~ visits (that is, visits that Table 2. Annual numbar and percent distribution of office visits to offfce-based did not liit glaucoma as a principal ophthalmologists by the 10 most frequently mentioned principal dlagnoeaa, averaged over a 2-yasr period: United States, 1991-92 diagnosis). Overall, 82.5 million office visits included a visual acuity exam Number of during 1991–92, and glaucoma was the vklts In Percent Cumulative Prlncpal dkgnosk and ICB9GM coda’ thousands distribution percent most frequently recorded principal dmgnosis at these visits, accounting for Allvlslts ...... 43,884 100.0 ... 17.4 percent of the total. Cataract ...... 366 7,196 16.4 16.4 About one-third (32.7 percent) of (?JhJcOInS...... 365 6,715 15.3 31.7 glaucoma visits included one diagnostic Disorders of refraction and accommodation ..367 5,871 13.4 45.1 service ordered or provided by the Organ or tissue replaced by other means . . .V43 2,731 6.2 51.3 Other retinal dlsordere...... 362 2,214 5.0 56.3 physic- about half (52.4 percent) Other disorders of eye...... 379 1,961 4.5 60.8 included two diagnostic services. With Spedal investigations and examinations. . . .V72 1,S38 4.2 65.0 the exception of visual acuig~,none of Disorders of conjunctival...... 372 1,805 3.7 68.7 the specified categories was reported at Dlabates mellitus ...... 25o 1,335 3.0 71.7 Inflammation of eyelids...... 373 1,296 3.0 74.7 frequencies high enough to yield relible Allotherdlagnoses ...... 11,121 25.3 100.0 estimates, and 54.2 percent of the visits reported “other” diagnostic services that ‘Based on the /ntemationa/C/assifbatimof Diseases,5’thRevision,C/inice/ Modifkatbn (lCD-e-CM) (f). were unspecified as to type. Data on diagnostic services are shown in table 7. every visit that was recorded as a new (36.6 percent), payment made by the problem encounter (table 4). patient (18.8 percent), Medicaid (8.0 Principal diagnosis percent), and HMO/preprrid plan Expected source of payment (7.1 percent) (table 5). Glaucoma is classified into more specific dmgnoses according to the In item 6 of the Patient Record Reason for visit International Ckmsi$cation of Diseases, form the physician is asked tcrlist the 9th Revision, Clinical Modi$cation expected source of payment for the In item 10a of the Patient Record (ICD-9-CM) (l). Of the total number of visiu more than one source may be form, the physician is asked to record glaucoma visits made during 1991–92, listed by the physician for eaeh visit. the patient’s most important complain4 the majority (63.2 percent) were coded Medieare was the expected source of symptom, or other reason for the visit as unspecified glaucoma (ICID-9-CM payment at 61.9 percent of visits with a using the patient’s (or patient code 365.9); 20.7 percent were open- principal diagnosis of glaucou surrogate’s) own words. These responses angle glaucoma (ICD-9-CM code followed by private insurance have been classified and coded using the 365.1); and 14.0 percent were coded as Advance Data No. 262. March30,1995 5

Table 3. Number and percent distribution of offfca visits with a principal diagnosis of those 65-74 years and 4.4 percent of the glaucoma by rafarral rttatusand prior-visit status, averaged over a 2-yaar period: United States, 1991-92 diagnoses among those 75 years and over. For visits by all age groups, Number of visitsIn Perc3nt glaucoma was the 10th most frequently Witcharacteristic thousands dktribuffon reported morbidity-related principal diagnosis and the 13th most frequent Allvlsls ...... 8,742 100.0 principal diagnosis during 1991-92. Referralstatus (MorbWy-related diagnoses am defined Patlantwasrsferrad byartotherphyskian . . . . 597 6.8 here as those classifiable to disease or Patfantwae notreferred byanotherphyskian. . 8,144 93.2 injury, in contrast to nonillness- or

Prior-vtsffstatus noninjury-mlated visits. Examples of visits with diagnoses that are not Newpatienf ...... 877 10.0 Ofdpatlent...... 7,864 90.0 morbidlly related would include visits Newproblem ...... “74 -0.9 for routine pregnaney examination or Oldproblam ...... 7,790 89.1 general rnedcal examination.)

Table 4. Number and percent of oftlce visits and return visit ratio for the 10 most Concomitant diagnoses frequent principal diagnoses among return visits for the care of previously treated prob- Iama,averaged over a2-yearperIod: UnitadStataa,1991 -92 About one-quzu-ter(26.4 percent) of glaucoma visits had a seeond diagnosis Number of visitsin Return listed on the Patient Record form, and Ptfnc#?a\d/agnosisandlCD-5=CMcoda’ thousands Percent visitLatiot 9.1 percent included a rhiid diagnosis.

Allretumvlslts ...... 443,996 100.0 . . . Cataract was the most frequently reported second- or third-listed Essentialhypertension...... 401 23,552 5.3 4.0 Norrnafpregnancy ...... v22 20,655 4.7 2.4 diagnosis, showing up at about Heafthsupervfsfonoflnfantorchffd...... V20 12,643 2.8 2.1 12.5 percent of all visits with a principal Suppuratfveandunspecifladotltlsmadia. . ..382 12,067 2.7 0.9 dmgnosis of glaucoma. Dfabatesrnaliftus...... 25o 11,810 2.7 3.4 Generalmedkaf examination...... ,v70 9,246 2.1 0.5 Physician’s checklist of selected Acuteupperrespiratory infections...... 465 8,774 2.0 0.4 GfsUCOMS ...... 365 7,730 1.8 4.1 conditions Asthma ...... 493 7,678 1.7 2.4 Affar@crhlrsitis ...... 477 8,737 1.5 1.9 In item 13, which was added to the Patient Record form for 1991, lBassd on the /ntomatiwra/ C/assifiition of Diseases, 9th Revision, C/inics/ Modifn8tbn (lCC-9-CM) (1). %tum vKi ratii is therstiiof visils nwda by pfevioustj seem pstients for the care of lxevioustj treatad problems to visk mede physicians were requested to report if for the treatment of new problems. “New probbm” visii maybe msde by elher new or OH patients. the patient had any of four medkal condition%hypertension, Table 5. Number and percent distribution of office visits with a principal diagnosis of hypercholesterolem@ obesity, and glaucoma by expected source(s) of payman~ averaged over a 2-yaar period: United States, 1991-92 depression-regardless of what was coded as the tirs~ seeon~ or third Nurn!mrof dmgnosis in item 11 of the Patient Vklfsh Percent Expectedsource(s)ofpayment’ thousavro% dlsfrlbufion Record form. At 11.2 pereent of glaucoma visits, physicians cheeked Aflvfaffs ...... 8,742 100.0 hypertension as an accompanying Madfcara...... 5,409 81.9 condition. However, virtually none of Prfvatekommerdafirrsuranca...... 3,196 36.6 the glaucoma visits during 1991–92 Patfant-pafd...... 1,641 18.8 Madkald ...... 700 6.0 included a second or third diagnosis of HMO/otherprepafdpfan2...... 624 7.1 hypertension in item 11 of the Patient Othsrgovemment ...... 412 4.7 Record form. This suggests that Other ...... *249 “2.9 Nocharge ...... “105 “1.2 physicians tend to underreport existing Unknown...... 966 “0.8 chronic conditions as a diagnosis in item 11. ‘Numbsrsrrraynot addtototalsbecawre morethsnoneexpected sourceofpayrr-wmt maytmrepotied pervisit. %fMOkhealth rnsintenanm organizafkm. Therapeutic services borderlineglaucoma (ICD-9-CMeode by older adults isundersco~d bythe 365.0). Wits for glaucoma me tiding that for persons in the age Therapeutic services ordered or deseribed by speciiic diagnosis in groups 65-74 and 75 years and over, it provided at glaucoma visits are shown table 8. was the third most fiquently reported in tables 9–11. Medication therapy was The prominence of glaucoma 28 a principal diagnosis, accounting for the most frequently mentioned principaldiagnosis among office visit8 3.2 pereent of the diagnosa among therapeutic serviee at glaucoma visits, 6 Advance Data No. 262. March30,1995

Table 6. Number and percent distribution of oftloe visits with a principal diagnosis of recorded at 79.6 pereent of visits glaucoma by patient’a principal reason for vlsl~ averaged over a 2-year period: United States, 1991-92 (table9). Thisissignificantiy higher than the63.3percent ofallother visita Number of vlslts Percent at which mdlcation therapy was Prfnc@a\ reason for vkff and RVC code’ In thousands diatrfbutton mentioned. Nonmedieation therapy was AllviaHs ...... 8,742 100.0 mentionedat 12.4pereent ofglaucoma

Synptom module ...... SOOIA999 825 9.4 visits, with counseling (4.9percent), Vlaiondysfunctions ...... S305 536 6.1 eorrectivelenses (4.4percent), and other Another...... “289 *3.3 therapy (5.4percent) recordedbythe Disesee moduie ...... DOOI-D999 4,096 46.9 physician as either ordered or provided Glaucoma ...... 0415 4,041 46.2 at the visit. Another ...... “55 “0.7 As used in the NAMCS, the term Diagnostic, acreenlng, andpreventlve frrodule. . . . .XIOO-X599 2,380 27.2 “drug” is interchangeable with the term Other andunspecffIed diagnostic teafs ...... X370 1,972 22.6 “mediation” and includes rr.tl newer Eyeexamination ...... X23Q “315 “3.6 continued medieations ordered or Another ...... “93 “1.0 provided at the visit, including both Treatment module ...... TIOO-T699 846 9.7 prescription and nonprescription Progreasviait, not otherwiaespecitied...... T800 W2 6.2 Atlolher ...... -304 “3.5 preparations, immunizing agents, and desensitizing agents. The term “drug Tesfresulfsmodule ...... RIQO-R7QQ “84 91.0 Other ?, ...... U99Q-U999 511 5.s mention” refers to each mention of medication on the Patient Rexmrdform. lBaaadon “AReasomforvisit ClsssiffcationforAmbulatoryCare”(RVC) (9). Because doctors ean record lmore than %cludes problem and complaintsnotelsewhereclsasifmd,entriesof “none,”bbmks,and illegib!eentries.Noneofthe visits had reasonscoded in the mjurissand adverseeffsctamoduk (JOOI-J999)or the adrdnistrattiemodule(AIOO-A140). onedrugpervisi4 thetotalmunberof drug mentions will generally be higher Table 7. Number and percent distribution of office visits with a principal diagnosis of than the number of visits. The term glaucoma by diagnostic and screening services, averaged over a 2-year period: “drug visit” refers to any visit in which Unltad States, 1991-92 atleast one drug isordered or provided Nunrber of by the physician. An earlier report is Diagnostic and screening sefvlme vlslts In Percent ordered orperfornred at the vlal~ thousands distribution available that describes the method and instruments used in collecting and Allvlsite ...... 8,742 100.0 processing NAMCS drug data (10). None ...... 1,208 13.8 There were about 27.7 million drug VIsualacuity ...... 7,196 82.3 mentions at glaucoma visits during Ofhe+ ...... 5,110 58.5 1991–92, an average of 13.8 million

Number of diagnostic and screening services mentions per year. This yields an ordered or performed at the Welt average of 2.0 drug mentions per drug None ...... 1,208 13.8 visit or 1.6 drugs ordered or provided One ...... 2,862 32.7 per vKlt overall. Two ...... 4,579 52.4 About one-third of glaucoma visits Threeormora ...... “93 “1.1 included a single mediation lNumbersrnaynotadd tototals beosusemorstkm onecatemwyrrraybereportedpervicii. (33.6 percent), while approximately 2W.2pr@nt ofglauwm viati$includedunspetifmddiagnostnsewi=$ noneof thespecificdiagnosticserv!ocsliited onthe one-ilfth (21.6 percent) listed two PatientRscordform(withthe exceptionofthe visualacuityexamination)were recordedat frequencieslargeenoughto provide estimatesthatwsrestatiitical~ reliable. medications and one-quarter (24.4 percent) listed three or mom Table 8. Number and percent distribution of offfoe visits with a principal diagnosis of medications. glauooma bydetailed diagnosis, averaged over a2-yearperiod: UnitedStatas, l 991-32 As expected, most of the drugs Nurribar of prescribed were classified aa ophthalmic vklts In Percanf drugs, specifically agents used to treat Pt7nc@al dkumosta and CD-.9-CM COde’ thousands distribution glaucoma (59.6 pereent) and ocular Allvians ...... 8,742 100.0 anti-infective and anti-inflammatory Borderflneglaucorna...... 365.0 1,222 14.0 agents (9.6 percent). Drug mentions at Preglaucoma, unapecifkd ...... 365.00 792 9.1 glaucoma visits am listed in table 10 by Other borderline glaucoma . . .365.01,365.02 “39 “0.5 therapeutic classifkation, based on the Oculerhypertendon...... 365.04 391 4.5 National Drug Code Directory, 1985 Open-angleglaucorna...... 385.1 1,809 20.7 Open-angleglaucmna, unapecifed . ...365.10 808 9.2 edition (11). Prhnaryopen-angfeglaucoma...... 365.11 932 10.7 The m~ority of drugs mentioned at Otheropen-angle glaucoma . . .365.12.365.13 “69 “0.8 glaucoma visits were single-ingre&ent Prtrnatyangle-dosura glaucoma...... 365.2 *186 “2.1 preparations (91.3 percent), were Unspecified glaumma...... 365.9 5,525 63.2 prescribed as trade names rather than generies (71.4 percent), and were 'Based onthe/nfemafitia/ C/sifcatbn of Di%ases,9th Re@bn, C/iniu/Mtiifkatbn (lCBKM) (l). Advance Data No. 262 ● March 30,1995 7

Table 9. Numbar and percent dlstrlbutfon of office visits with a principal dlagnosls of the current visit. Physicians were asked glaucoma by therapeutic servlcee, averaged over a 2-year pericd: United States, 1991-92 to record up to two ambulatory surgical Number of procedures per visit. These were coded Therapeuticsarvlces vlsltsIn Percent orderedorprovkiad at the Vlsttt thousands dktrlbuflon according to the International Classificationof Diseases, 9th Revision, AIIvIsHs...... 8,742 100.0 ClinicalModijkatiotq Volume3

Medlcatlon therapy (ED-9-CM) (l). Ambulatory surgery was recorded at New or continuing medication ...... 6,962 79.6 Visits without mention of medication ...... 1,779 20.4 an estimated 1.2 million glaucoma visits over the 2-year period (an average of Number of new or continued medications 616,000 visits per year), and a total of None ...... 1,779 20.4 1.3 million procedures wem scheduled One ...... 2,938 33.8 or performed. The proportion of Two ...... 1,869 21.6 glaucoma visits wifh mention of Three ...... 1,589 18.2 Fourormom ...... 545 6.2 ambulatory surgery (7.1 percent) is not significantly difTerent than the Nonmedication therapy 6.0 pereent of visits with principal None ...... 7,659 87.6 dmgnoses other than glaucoma that Othercounsallngz ...... 425 4.9 included ambulatory surgery in Corracflvelensas ...... 3s6 4.4 Otherlherapy ...... 470 5.4 1991–92. While no specific ambulatory Ambulatory surgary procedures were recorded at fiequeneies None ...... 6,125 92.9 large enough to obtain reliable Oneormoraprocedures ...... 616 7.1 estimates, all of the surgical procedures

‘Numbsrsmay notadd to totals because mera ihen ona category may ba reported pa vM. mentioned were related to the eye and %ounseling other than the spediad categories of diet, exercke, webht raductiin, alcohol .busa, smoking -sat??., and femiiykoekd. included operations on the iris, diary body, sclera and anterior chambe~ iridotomy and simple iridectomy,

Table10.Number and percent distribution ofdrugmentions bytharapeutic claesificaticn operations on the lens operations on the for office visits with a principal diagnosis cf glaucoma, averaged over a 2-year paricd: retina choroi~ vitreous, and posterior United States, 1991-92 chambeq and operations on the orbit Nurriwr of and eyeball (ICD-9-CM, Volume 3, drugmerrfforrs Percent codes 12-14, 16). Therapeuticciasslfkation’ in thousands dtsfrfbution

Alldrugmantions ...... 13,835 100.0 Disposition of visit Ophthatmlcdrugs ...... 10,930 79.0 Nine of ten glaucoma visits Agents uesdtotreef glaucoma. , ...... 6,241 59.6 Ocular antf-hsfecffve and arstI-lntlsmmstoty (93.3 pereent) resulted in a scheduled agents ...... 1,330 9.6 return visit. In confras$ 62.0 pereent of Mlscellaneousophthalmic preparations . . . . . 1,199 8.7 all other visits included a scheduled “160 “1.2 Mydrietksandcyclopiegics...... retmn visit. The predominance of this Cardiovascular-renaldrugs...... 1,136 8.2 type of d~position among gIaueoma Diuretics ...... S07 5.6 Other ...... “330 *2.4 visks is mirrored in the correspondingly high return tilt ratio that was discussed Other ...... 1,767 12.8 Unc18eeiffecVmlscellaneous...... 9511 *3.7 previously. Data on disposition of visit are shown in table 12. ‘l%erspautimciass isbawrfontlmetandard drugdassificatiorsuaed intheNatioms/Drvg Cod8LXmot~,f9S.5 Eddbrr(ll). %dudasthefolbwing dssaiitbrwanasthatb drugs,antimicmbialqrents, Psychophsrrnacobgiidrugs, gastrointtimal agents,matabolk andnufriant qersts, hcmnonesandaganfsafkting honmonal mechanisms, immuriologbagemts, $IWmumus Duration of visit mambrsne, onco~cs, drugs used for pain relisf, and raspirabxy tract drugs. The mean duration of physicirtn- available only by prescription was also prominen~ occurring in patient eontaet for glaucoma vishs was (92.8 percent). 16.6 percent of drug mentions at 21.7 minutes, compared with 17.3 Drug mentions at glaucoma visits glaucoma visits. minutes for office visits in general. are displayed in table 11 according to Mean duration dcxx not include visits in their most frequently occurring generic Ambulatory surgical procsdurss which no face-to-face contact with the ingredients. Tmolol was the generic physician oczuned. Physician-patient ingredient that appeared most frequently, The 1991 NAMCS added a new eontaet only includes the time s~nt in showing up in 21.4 pment of all item perminiig to whether ambulatory actual face-to-face contact between glaucoma drug mentions. Pilocarpine surgery was scheduled or performed at physieirrn and patient. Data on duration 8 Advance Data No. 262. March 30,1995

Table 11. Number, percent distribution, and therapeutic classification for the five most of glaucoma visits are shown in frequently occurring generic ingredients In drug mentions at office visits with a prlncipsl diagnosis of glaucoma, averaged over a 2-year period: United States, 1991-92 table 12.

Number of dmg mentions Percent Therapeutic Visits with a second or third Generfc /ngrad/ent’ In thousands distribution Ckreeifkatior? diagnosis of glaucoma

Atl mentions ...... 13,835 100.0 . . . In addhion to the estimated total of Timolol ...... 2,957 21.4 Agents used to treat glaucoma 17.5 million office visits with a Pkwarplne...... 2,295 16.6 Agents used to treat glaumma Betexotol hydrochloride. . . . 1,2s4 9.3 Agents used to treat glaumma first-listed diagnosis of glaucoma during Dlpivefrhr ...... 1,055 7.6 Agents used to treat glaucoma 1991–92, there were 3.2 million office Levobunolsl hydrochloride . . 911 6.6 Miscellaneous ophthalmic preparations visits at which a second or third diagnosis was listed as glaucoma. Visits ‘Fruquency of mention combines single-ingredient agents tih rnsmtions of the agent as an ingredient in a corrbination drug. 27herapeufii classiticstion is based on the f’ffffionel DrugCodsDirectoy,f9&5 .Edikm (11). In cases where a generic ingredient in wlich the second or third d~agnosis had more than one theraptitc clessitication, it was listed in the cstegory which ocourred with the greatest frequency. was glaucoma were not found to differ significantly horn visits in which the principal diagnosis was glaucoma in Table 12. Number and percent distribution of office visits with a principal diagnosis of glaucoma by disposition and dumtion of visig averaged over a 2-year period: terms of the age, sex, or race of United States, 1991-32 patients.

Number of At office visits in wK1chglaucoma vis/ts in Percent was the second- or third-listed diagnosis, VW charsctertetlc thousands dletttbutlon the principal diagnosis was listed within

Allvlstts, ...... ?3,742 100.0 the major ICD-9-CM coding (classof disorders of the eye and adnexa Dlspodtlon of visit’ (ICD-9-CM COdeS 360-379) Return at epedfied time...... 8,164 93.3 62.9 percent of the time. No specific Other ? ...... 814 9.3 dmgnosis was recorded at ilequenckx Duration of vkdt high enough to provide reliable 0mirrutes3 ...... “39 “0.4 estimates, although the frequency of l-5mlnutes ...... 764 6.6 visits with a principal diagnosis of 6-10mkrutes ...... 1,657 19.0 cataract approached statistical reliabWy. 11-15 minutes ...... 1,936 22.1 16-30 mltrutss ...... 1,809 20.7 More than 30 minutes...... 2,547 2e.1 Glaucoma visits between 1975

‘Numbers rnsy not add to totals because more then one disposition may be reported per visit and 1992 $hfleof the other sped. diiposifion categories had frequencies large enough to provide estimstes thst were atstistic?diy

%isita ;t which there was no face-to-fase sontacl between the phywcian and the patient. In 1975, glaucoma was the ninth most frequently mentioned morbldity- related principal diagnosis among persons 65 years of age and oldw, by 1992, it was the fifth. Overall, glaucoma 8.7 visits were estimated at 4.5 million during 1975–76, an average of 2.3 8 million per year. However, the average for 1991 and 1992 was 8.7 million-an increase of 284.6 percent (figure 3). 6 Visits for glaucoma by age and sex of patients between 1975 and 1992 are 4.3 4 shown in table 13. Race data have been 3.1 omitted from the table because 2.3 glaucoma visit estimates for the black 2 population prior to 1989 were statistically unreliable when using NAMCS data. 0 1 Annual rates of glaucoma visits 1975-78 1980-81 1985 1989-90 199f-92 between 1975 and 1992 for the U.S. Year population in general are shown in NOTE. Based on 2-year averages, except 1985. figure 4, using both crude and age- adjusted rates. Both the crude and the Figure 3. Office visits with a principal diagnosis of glaucoma United States, 1975-92 age-adjusted rates for 1991–92 were Advance Data No. 262. March30,1995 9

Table 13. Number, percent distribution, and annual rate of offtce visits with a principal 65-74 was not found to dtier diagnosis of glaucoma by patient’s age and sex United States, 1975-S2 significantlybetween 1975 and 1992, Year Reasons for the substantialincrease

Patierrf ctraracferistic 1975-76 1960-S1 1965 1983-90 1991-92 in rates ofglaucoma-related officevisits during 1975–92are unckar. Data ffom Number of vlstts In thousands’ the National Health Interview Survey Attvisns ...... 2,273 3,080 4,304 6,083 8,742 (NHIS) show an increasein the overall rate of persons reporting a glaucoroatous Age condition,fkom5.7 conditionsper 1,000 Undar25years ...... “75 “45 ●62 *27 *5S X-44yesla...... *138 2s3 ’214 *ZW 564 persons in 1977 to 10.4 conditionsper 45-84 yeara ...... 827 934 1,218 1337 2,035 1,000persons in 1991 (12,13).Age- 6S-74years ...... 706 897 1,356 1,s81 2,831 specificrates for glaucomawere not 75yemend over ...... 527 910 1,464 2,405 3354 available horn the NHIS during the Sex 1970’s,but an increase in glaucomatous

Fenzafe ...... 1,398 1,884 2,610 3,847 5,3s3 conditionswas noted among persons 65 Male ...... 875 1,215 1,895 2,246 3,382 years of age and over between 1982 and 1991,from 41.8 conditionsper 1,000 Percentdistrbution persons to 57.0 conditionsper 1,000 AIIvLsII s ...... 100.0 100.0 100.0 100.0 100.0 persons (14). Age In 1991, the NationalEye Institute

Undar26yeara, ...... *3.3 *1.5 ●1.4 “0.4 “0.7 of the National Institutes of Health 2G’44yeals ...... “6.1 7.6 “5.0 “3.8 6.5 issued new governmentguidelinesfor 45-64years ...... 36.4 ?23 26.3 25.2 23.3 glaucomatesting that advise all 65-74years ...... 31.0 28.1 31.5 31.0 32.4 Americansages 60 and older and black 75yeereendover ...... 23.2 29.8 33.8 39.5 37.2 Americansages 40-59 to nxeive Sex glaucomascreeningtests at least once Fernefe ...... 61.5 60.5 60.6 63.1 61.3 every 2 years. This heightened Male ...... 38.5 39.5 33.4 36.9 38.7 awarenessof the need for early Visit rate per 100 persorrsz detection of glaucomajin combination

Allvistts ...... 1.1 1.4 1.8 2.5 3.5 with new diagnosticproceduressuch as laser tomogmphicscannersaud Fourier Age ellipsometrythat yield more precise Undar25ye8rs ...... “0.1 “0.0 *0.1 “0.0 90.1 measurementsthan am possible with 25-44years ...... “0.3 0.4 “0.3 ‘0.3 0.7 photographyand ophthalmoscopes(15), 46-64ye81s ...... 1.9 2.3 2.7 3.3 4.3 6%74years ...... 5.2 5.8 8.2 10.5 15.4 may result in even higher visit rates for 75yeafaandover ...... 6.7 10.2 14.1 20.8 28.8 glaucoma than are seen in the 1991-92 NAMCS survey data. Sex Female...... 1.3 1.6 2.2 3.1 4.2 References Male ...... 0.9 1.1 1.5 1.3 2.8 1. Public Health Service and Health %&edonBurawofthe Cerrsus~-imks~the dvifiannoninstitutbnalizedpopulationforJulylof eachsurveyyear. Rateafor Care Finsncing Administration, mMMyeam am basdonan average ofthepopulatmnestimtesfor Julyl ofeaAy~r oftie2-year ~rid. Suwey~m fmm 197S-SSdidnothwiudeAbrslraor Hawaii, Intem8tional Classification of Diseases, 9th Revision, Clinical Modification. Wsahingtou Public signiticantlyhigher thanthosereported comparedwithfemales ineachofthe Health Service. 1980. in 1975-76. years analyze~except for1975-76. 2. Schappert SM. National Ambrdstory VWratesincreased fortheage About one-quarter(23.2percent)of Medicsl k Survey: 1991 summary. Advance dsta from vital groups4544 years, 65-74 years, and glaucomavisitswem made bypersons and health statistics; no. 230. 75yearsandoverbetween 1975and 75 years ofageaud overin 1975-76, Hyattsvitl% Msryland: National 1992 (figure5).Among persons 65years but 37.2percent of the total were made Center for Health Statistics. 1993. ofage and over, the rate ofglaucoma by this age group in 1991-92. Them 3. Schappert SM. Nationrd Ambulatory visit3went from 5.7vi&tsper 100 was acmrespondingdecreasein the MwEcal Cme Survey: 1991 per80nsin1975to 19.9 vi.Msper100 percent of visits made by persons45-64 smmnsry. Nationsl Center for Health persons in 1992.Vksitrates increasedfor years, from 36.4percent of visits in Statistics. Vital aud Health Stat 13(116). both sexesbehveen 1975 and 1992. 1975-76, to 23.3percent in 1991-92. 4. Schappert SM. National Ambulatory Significantdtierences werenotedinthe The percent of visits made by persons Medical Care Survey 1992 overallgkmcoma visitrates formales summary. Advsnce data horn vital 10 Advance Data No. 262. March 30,1995

7. Tlelsch JM, Sommer A, Katz J, 4.0 — Crude rata —— Age-adjusted rate Royall RM et al. Racial Variations in [ the Prevalence of Primary Open- angle Glaucoma. Journal of the American MedicaJ Association. 1991. 226:369-74. 8. Javitt JC, McBean AM, Nicholson GA, Babish JD et al. Undertreatment of Glaucoma among Black Americans. New England Journal of Medicine. 1991.325:1418-22. 9. Schneider D, Appleton L, McLemore T. A reason for visit classification for ambulatory care. National Center for Health Statistics. Vlkd and Health Stat 2(78). 1979. 10. Koch H, Campbell W. The collection 0.5 and processing of drug information. National Ambulatory Me&al Care t Survey, 1980. National Center for

1975-76 1980-81 1985 198+90 199i-92 Health Statistics. Vital and Health Year Stat 2(90). 1982. NOTES Based on 2-year averages, except 1985. 11. Food and Drug Administration. Age-adjusted estimates are based on the 1975-76 U.S. population. National Drug Code Directory, 1985 Edition. Washington Public ‘Health Figure 4. Annual rate of office visits with a principal diagnosis of glaucoma United States, 1975-92 Service. 1985. 12. Feller, Bmbrua A. Prevalence of selected impairments, United States, 1977. National Center for Health Statistics. Vital and Health Stat Patient’s age 10(134). 1981. _ 65-74 years ~ 75 years and over 13. Adams PF, Benson V. Current 26.8 estimates from the National Health Interview Survey, 1991. National Center for Health Statistics. Vital and R Health Stat 10(184). 1992. 14. National Center for Health Statistics. Current estimates from the National Health Interview Survey United States, 1982. Vital and Health Stat 10(150). 1985. 15. Cotton P. Glaucoma Detection before Damage, Fewer Side Effects May Be Possible. Journal of’the &nerican Medical Association. 1990. 2641793.

1975-76 196Q-81 1985 1989-90 199+92 Year

NOTE Based on 2-year averages, except 1985.

Figure 5. Annual rate of offloe visits with a principal diagnosis of glaucoma by patients 65-74 years and 75 years and OVSKUnited States, 1975-92

and health statistic no. 253. Therapy of the Glaucomas, 6th ed. Hyattsville, Maryland: National St. Louis C.V. Mosby. 1989. Center for Health Statistics. 1994. 6. Danyluk AW, Paton D. Diagnosis and 5. Hosklns HD, Kass MA (eds). Management of Glaucoma. Clinical Becker-ShatTer’s Diagnosis and Symposia. 1991. Vol. 43. No. 4. 2–2. Advance Data No. 262. March 30,1995 11 Technical notes for a systematic random sample of office recommended that caution be exercised visits occurring during a randomly when interpreting differences in race Source of data and sample assigned l-week reporting period. data and individual physician specialties. design Responding physicians completed Despite the difference in sample 33,795 Patient Record forms in 1991 sizes, the 1991 and 1992 surveys were The information presented in this and 34,606 Patient Record forms in identical in terms of survey instruments, report is based on data collected in the 1992. definitions, and procedures. The National Ambulatory Medical Care Characteristics of the physician’s resulting 2 years of data have been Survey (NAMCS) over the 2-year practice, such as primary specialty and combined to provide more reliable period from January 1991 through type of practice, were obtained horn the estimates. All estimates, percent dfitributions, and mtes presented here, December 1992. The target universe of physicians during an induction unless otherwise notedj reflect 1991 and NAMCS includes office vtilts made in interview. The U.S. Bureau of the 1992 data that were averaged over the the United States by ambulatory patients Census, Housing Surveys Branch, was 2-year period. to nonfederally employed physicians responsible for the survey’s data who are principally engaged in office collection. Processing operations and Sampling errors practice, but not in the specialties of medical coding were performed by the anesthesiology, pathology, or radiology. National Center for Health Statistics, The standard error is primarily a Telephone contacts and nonoffice visits Health Care Survey Section, Research measure of the sampling Variti-tilty that are excluded. Tliangle Park North Carolina. occurs by chance when only ak%mple, A multistage probability sample For 1992, several changes were rather than an entire universe, is design is used in NAMCS, involving made in the sample design of the surveyed. The relative standard error of an estimate is obtained by dividing the samples of primary sampling units NAMCS that should be considered in standard error by the estimate itselC the (PSU’S), physician practices witim the interpretation of the survey results. re,sult is then expressed as a percent of PSTJ’S,and patient visits within In an effort to even the precision of the estimate. physician practices. The PSU’S are estimates across each of the physician Relative standard errors (RSE’s) for counties, groups of counties, county specialty strata in the sample design, the estimated numbers of office visits, equivalents (such as parishes or decision was made to increase the expressed as 2-year averages for the independent cities), or towns and proportion in the sample of specialists in period 1991–92, are shown in table I. townships (for some PSU’S in New general surgery, psychiatry, otolar- Relative standard errors for estimated England). For 1991, a sample of 2,540 yngology, and neurology. Although this numbers of drug mentions, also nonfederal, office-based physicians was would result in a conesponding decrease expressed as 2-year averages, are selected from master files maintained by in the sample of the larger physician the American Medical Association and specialties, most notably general and American Osteopathic Association. family practice, internal medicine, and Table L Approximate relative standard errors for eatfmated numbara of office Physicians were screened at the time of ptilatrics, the precision of the3e visits: Nationat Ambulatory Medical Care the survey to ensure that they were estimates tended to be much higher Survey, 1991-92 eligible for survey participation. Of relative to the smaller speciah.ies, and it E#matad nurrkr those screenti 1,887 physicians were was expected that the end result would of officetidfs eligible (in-scope) to participate in the bean acceptable balance of precision (~raseed as annual avafagas) Relatiw standatd survey. l%e remaining 653 physicians levels across all strata. in Uwuswxls errorh percent were ineligible (out-of-scope) due to However, the reduced number of reasons of being retir@ employed general practitioners, internists, and 50 ...... 78.4 100 ...... 55.5 primarily in teaching, research, or pediatricians sampled in 1992, coupled 2?50 ...... 35.2 administration, or other reasons. The with the high percents of sampled S46 ...... 20.0 physician response rate for the 1991 physicians in these specialties who were 500 ...... 25.0 NAMCS was 72 percent. determined to be ineligible (out-of- 1,000 ...... 17.8 2300 ...... 11.6 For 1992, a sample of 3,000 scope) for survey participation, resulted 5,000 ...... 8.5 nonfe&ral, offi-based physicians was in low numbers of survey respondents in 10,000 ...... 6.5 seIected ilom master files maintained by these categories and a lowering of the 25,000 ...... 4.9 50,000 ...... 4.2 the American Medical Association and precision of these estimates Mative to W13,000 ...... 3.8 herican Osteopathic Association. Of other survey years, especially when 250,000 ...... 3.6 those screene 858 physicians were d~aggregated by other variables such as 500,000 ...... 3.5 race. Because vkits made by black ruled ineligible (out-of-scope); 2,142 NOT= The srtdesf refiible estimate for visits to aggrqated were in-scope for the survey. The patients were often found to be cIustered 8PM= k *,Coo Visits pa ysar [or a 2-yssr total of ~i,~ Visii). Estimates below ths @urs hsve a rslafive physician response rate for the 1992 among the sampled physicians and were standard error greater than S0 psroant and are desmsd NAMCS was 71 percent. more likely to be made to general and unrefiabb by NCHS standards. Exampls of use 01 &b. An aggragrsta esthmte of 10 nilbn Sample physicians were asked to family practitioners, which were visitsPef Yom has a rslatii standard error of 6.5 percent or a complete Patient Record forms (figure 1) undersampled in 1992 it is standard error of 650,000 visits (6.5 percent of 10 million). 12 Advance Data No. 262. March 30,1995

Table Il. Approximate relative standard Table lV.Approximate standard errorsof percentefor estimated numbers ofdrug errors for estimated numbers of drug mentions: National Ambulatory Msulical Care Survey, 1991-92 mentions: National Ambulatory Medical Cara Survey, 1991-92 Base of percswf Esthrratadpercwrt (Vkifs,expreaaedas Eshated number annual aversges, 7 or 5 or 10 or 20 or 30 or 40 or of dmg mentions In thousands) 99 95 90 80 70 60 50 (expressed as annual averages) Relative standard Standard error in percentage points In thousands error In percent 50 ...... 10.8 23.7 32.7 43.6 49.9 53.4 54.5 50 ...... 109.0 100 ...... 7.7 16.8 23.1 30.8 35.3 37.7 38.5 100 ...... 77.2 250 ...... 4.9 10.8 14.6 19.5 22.3 23.9 24.4 250 ...... 48.9 500 ...... 3.4 7.5 10.3 13.8 16.8 18.9 17.2 500 ...... w? 1,000 ...... 2.4 5.3 7.3 9.7 11.2 11.9 12.2 674 ...... 30.0 2,500 ...... 1.5 3.4 4.6 6.2 7.1 7.6 7.7 1,000 ...... 24.7 5,000 ...... 1.1 2.4 3.3 4.4 5.0 5.3 5.5 2,500 ...... 16.0 10,000 ...... 0.8 1.7 2.3 3.1 3.5 3.8 3.9 5,000 ...... 11.7 25,000 ...... 0.5 1.1 1.5 2.0 2.2 2.4 2.4 10,000 ...... 8.8 50,000 ...... 0.3 0.8 1.0 1.4 1.6 1.7 1.7 25,000 ...... 6.5 100,000 ...... 0.2 0.5 0.7 1.0 1.0 1.2 1.2 50,000 ...... 5.5 250,000 ...... 0.2 0.3 0.5 0.6 0.7 0.8 0.8 100,000 ...... 4.9 500,000 ...... 0.1 0.2 0.3 0.4 0.5 0.5 0.6 250,000 ...... 4.6 Examp!e of use of table An estimate of 20 parcant based on an estimate of 10 m![liin drug mentions per year has a standard 500,000 ...... 4.4 error of 3.1 parcent orarelatie stsndard efrorof 15.5 percent (S.l percant divided by20psrcent).

NOTE The smallaat reliable estmnate ot drug mentions to aggregated speciaftiea is 874,000 drug mentions per year (or a2-yeartotalof 1,347,000 mentions). Estimates below this figure have a relatiie standard error greeter tkm 30 percent andamdeamed unreliable by NCHS standards, theappropriate coefficients fromtableV. coefficient fiomtable V. (The 3year

Example of use of table An aggregate estimate of 25 nWon Therelativestandard errorobtainedin aggregate is obtained by multiplying the drug mentkmsperyaar hasara!etiveatstiard errorofS.5 average estimate by 2.) parcent or a standard error of 1,625,000 dmg mantiins (6.5 this way applies to both the 2-year total parcent cd 25 Mien). and the 2-yem average.

Rm(p) = Ip; (;-P). 100 presented in table IL Standard emors for RSE(X)= A++ o1OO estimated percents of visits and drug 4 mentions aredisplayed intables III and Similarly, relative standard errors Adjustments for nonresponse Iv. forpercentsmaybe calculated using the Estimates from NAMCS data were Alternatively, relative standard following general formul% where p is adjusted to account for sample errors for 2-year averages maybe thepercent ofinterest andxisthe physicians who were in-scope but did calculatedusing the following general denominator of the percent in thousands not participate in the study. This formuh where x is the average of (andthe denominator isthe2-year adjustment was calculated to miniiz.e interest inthousrmds multipliedby2 to aggregate estimate rather than the the impact of reqxmse on final estimates obtainrhe2-year total,andAand Bare average), using the appropriate by imputing to nonrespondiqg physicians data from visits w similar physicians. For thk purpose, physicians Table Ill. Approximate standard errors of percents of estimated numbers of offfce visits: National Ambulatory Medical Care Survey, 1991-82 were judged similar if they had the same specialty designation and practiced Base of percent Estimated percent in the same PSU. (idsffs, expressed as annual averages, 1 or 5 or 10 or 20 or 30 or 40 or h thousands) 99 95 90 80 70 60 50 Test of significance and

Standard error in percentage points rounding 50 ...... 7.8 17.1 23.5 31.3 35.9 36.4 33.2 In this repom the detemnination of 100 ...... 5.5 12.1 16.6 22.2 25.4 27.1 27.7 250 ...... 3.5 7.8 10.5 14.0 18.1 17.2 17.5 statistical inferenee is based on the 500 ...... 2.5 5.4 7.4 9.9 11.4 12.1 12.4 two-tailed t-test. The Bonferroni 1,000 ...... 1.7 3.8 5.3 7.0 S.o 8.6 8.8 inequality was used to establish the 2,500 ...... 1.1 2.4 3.3 4.4 5.1 5.4 5.5 critical value for statistically significant 5,000 ...... 0.8 1.7 2.4 3.1 3.8 3.8 3.9 10,000 ...... 0.6 1.2 1.7 2.2 2.5 2.7 2.8 dtierences (0.05 leve~ of significance) 25,000 ...... 0.4 0.8 1.1 1.4 1.8 1.7 1.8 based on the number of possible 50,000 ...... 0.3 0.5 0.7 1.0 1.1 1.2 1.2 comparisons within a particular variable Ioo,ooo ...... 0.2 0.4 0.5 0.7 0.8 0.9 0.9 or (combination of variables) of interest. 250,000 ...... 0.1 0.2 0.3 0.4 0.5 0.6 0.8 500,000 ...... 0.1 0.2 0.2 0.3 0.4 0.4 0.4 Terms relating to differences such as “greater than” or “less than” indicate Exsmpbofuseof tabkAnastimataof 20percentbasadon anest@kof25miliion visbperyearhss astandarderrcfof 1.4 that the dtierenm is statistically percent or a relafiie a4andard arror of 7.0 percent (1.4 percent divided by 20 percent). Advance Data No. 262. March30,1995 13

Table V. Coefflcienta appropriate for determining relative standard errors by type of patierm associate with the particular estimate and physician group= National Ambulatory Medical Care Survey, 1991-92 physician. Coe~clent for use with esfimetes in thousands Physicizzn-A physician is a duly

TW of esfimate andphyskian speciaffy A B Iieensed doctor of medieine (M.D.) or doctor of osteopathy (DO.) who is visits currently in office-based practice and Overetltotals ...... 0.001157131 61.31199989 who spends some time caring for Generatand famllypraofice ...... 0.007330504 54.54704362 ambulatory patients. Excluded tlom the Osteopathy ...... 0.01402452 18.13642054 NAMCS are physicians who am hospital Internalmedidne...... 0.008718567 55.2166744 Pediahfcs...... o.oo79e43e6 35.23091766 based who speeiake in anesthesiology, Generatsurgery ...... 0.006665247 10.65103125 pathology, or radiolog~ who are Obetetrtceandgynecology...... 0.00919564 25.59962011 federally employe~ who treat only Orthopedicsurgery...... 0.00s1337 24.20372144 Cardlovesculardieeeees ...... 0.01363253 12.56469271 institutionalized patien~ or who are Derrnatotogy...... 0.01276351 10.26901649 employed fidl time by an institution and Urologicalswgery...... 0.008000282 11.92853664 spend no time seeing ambulatory Psychiatry...... 0.009414736 12.66630675 Neurology...... o.01314n4 5.38720816 patients. Ophthalmology...... 0.007936146 23.64617495 Wsit—A visit is a direct personal Ototaryngology...... 0.007549396 8.0936265 exchange bt%veen an ambulatory patient Allotherepecialties ...... 0.0153701 a 35.00317779 and a physician or a staff member Drug mentions working under the physieiau’s Overalltotais ...... 0.001853163 118,69462 supervision, for the purpose of seeking Generalendfamllypradlce ...... 0.009065669 100.36778 care and rendering personaI health Osteopathy ...... 0.01656477 23.472S982 services. Excluded horn the NAMCS tntematmedidne...... 0.01146498 103.21367 Pedtatrlcs ...... 0.01245118 26.7351n86 are visits where medkal care was not Generalsurgery ...... 0.03935224 8.06W6786 provide@ such m visits made to drop off Obefefrfcsendgynecokcgy...... 0.01454044 31.24056408 speeimens, pay bills, make Orthopadicsurgery...... 0.01566053 23.3833057 appointments, and walk-outs. Cerdlovsec.ulerdieeases...... 0.01575914 24.23751806 Oarnlefology...... 0.01239377 15.34507357 Urotogicaisurgery...... 0.0188n19 10.66S6669 Psychiatry...... 0.01430555 15.e93744s Neurology...... 0.01532433 6.67244393 Ophthalmolqy ...... 0.0251486 25.1361195 Otolaryngology...... 0.008374063 12.25916054 Atlotherspeciattiee ...... 0.0226223 57.79950436

significant.Alaek ofcommentregarding Drug mention—A drug mention is theditFerencebetween any two the physician’s entry on the Patient estimatesdoesnot meanthatthe Record form of a pharmaeeutieid agent dilfereneewaatested andfoundtobe —by any route of administration- for nonsignificant. prevention, diagnosis, or lreatment. Inthetables, estimates ofoffice Generic as well as brand-name drugs are visitshavebeen roundedtothe nearest includedj as are nonprescription and thousand. Consequently, estimates will prescription drugs. Along with all new nota.lwaysaddto totals.llatesand drugs, the physician also records percents werecalculated fromoriginal continued medications if the patient was unrounded figures and donot specifically instructed during the visit to nece.wtrilyagree withpercenta continue the medkation. Physicians may calculatedfromrounded data report up to five mediations per visit. Drug visit-A drug visit is a visit at Definitionofterms which mediation was prescribed or provided by the physician. Ambulatorypatient-An ambulatory O@ce—An office is the space patient is anindividual seeking personal identified by a physician as a location health serviccs who isnotcurrently for his or her ambulatory praetiee. admitted toanyhealth eareinstitution Offices customarily include consultation, on the premises. examination, or treatment spaces that 14 Advance Data No. 262 ● March 30,1995

Symbols . . . Data not available

,.. Category not applicable

Quantity zero 0.0 Quant”~ more than zero but less than 0.05

z Quantity more than zero but less than 500 where numbers are rounded to thousands

* Figure does not meet standard of reliability or precision Number 263 ● April 24, 1995 I Advance Data m FromVkal and Health Statisticsof the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

Relationship Between Cigarette Smoking and Other Unhealthy Behaviors Among our Nation’s Youth: United States, 1992 by Jean C. Willard and Charlotte A. Schoenborn, M. P.H., Division of Health Interview Statistics

Introduction numerous specific, measurable health than youth who did not participate to be objectives. Many of the objectives regular or heavy smokers (6). Much of The transitional period between specifically target health-threatening this earlier research was based on childhood and adulthood is a time in behaviors among adolescents and young samples of youth who were in school, which youth experience many physical adults. with data collected in a classroom changes, as well as a developing sense Progress toward achieving the setting. This report expands upon earlier of self and increasing emotional National Health Objectives for the Year research by delineating the relationship independence (l). During this time, 2000 is monitored closely at the Federal between cigarette smoking and other adolescents often develop behaviors that level. Much research was devoted to high risk behaviom among adolescents extend into adulthood (2). Young people establishing baseline prevalence in the general household population of may experiment with risky health estimates of high risk behaviors and the United States, including youth who behaviors, some of which have long developing objectives based on both the have Ieft school either prematurely or by term health consequences (3). Some baseline estimates and a realistic graduating. Examining the relationships adolescents use these behaviors to bond appraisal of what cah be accomplished between smoking and other high risk with peers, improve their social image, by the end of the decade. While the behavio~ may provi& CIUWon how to and appear independent and mature (l). objectives set targets for individual reduee smoking and other unhealthy Recently, health risk behaviors of behaviom, a large body of research behaviors among adolescents, thereby adolescents have been the foeus of suggests that many high risk behaviors furthering progress toward achieving the considerable study (4-13). are interrelated. The recent Surgeon National Health Objectives for the Year Cigarette smoking almost always General’s Repot Preventing Tobacco 2000. begins in the adolescent years (5,14) and Use Among Young People (l), This report uses data horn the 1992 smoking at early ages increases the risk summarized studies that have shown National Health Interview Survey of of beaming ill or dying horn causes attributable to smoking (l). Reduction in relationships between smoking and other Youth Risk Behavior (NHIS-YRBS) and smoking prevrdenee among adolescents health-threatening behaviors such as presents prevalence estimates for is one of the objectives established in drinking alcohol, using illicit drugs, selected unhealthy behaviors among the National Health Objectives for the using smokeless tobacco products, adolescents in the United States Year 2000 (2). These objectives -g mqms, engaging in physical according to smoking status. These 311COIIlpSSS 22 pliOlity WfXiS, including fights, ever having had sexual unhealthy behaviors, consistent with tobacco, alcohol and other drugs, intercourse, and failure to wear seat earlier studies, include drinking alcohol; >hysical activity and fitness, nutrition, belts. Research has also shown that consuming more than five aIcoholic violent and abusive behavior, and family adolescents who participated in beverages in a row using marijuq Naming. Each priority area contains interscholastic sports were less likely eoeaine, and smokeless tobacco;

S**VJQ. ~6+’$ % U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Heatth Service Centers for Disease Control and Prevention National Center for Health Statistics CENTERSCDCFOR DIsEAsE CONTROL ‘4L AND PREVENTION 2 Advance Data No, 263 ● April 24, 1995

carrying weapon~ physical fighting; representing an overall response rate of relationships between smoking and a sexual intercourse; failure to use a seat 73.9 percent. variety of other behaviors during the belt lack of exercise; and consumption Rather than using the traditional adolescent and young adult years. of fewer than five servings of fruits and face-to-face interview or self- Age-specific analyses (not shown) vegetables daily. These behaviors are of administered questionnaires, the revealed that the relationships between significant public healti concern as NHIS-YRBS used a unique smoking and other unhealthy behaviors were stronger at the younger ages, but evidenced by thek inclusion in the audiocassette technology, developed in remained consisten~ if somewhat National Health Objectives for the Year collaboration with researchers at 2000. attenuated, among youth 18–21 years of University of Michigan’s Survey age. The data presented in this report Research Center. This technology provide an overview of unhealthy zitlowed the youth to listen to the Definition of smoking terms behaviom that are recognized as questions, using a personal headset and important for the current future health of Definitions for smoking status in the to record answers on an answer sheet our Nation’s youth. However, these data national health objectives are aimed at that contained only answer categories. do not provide specific tracking adults. For adults, current smoker is a The answer sheet did not contain any information for the objectives because person who has ever smoked 100 information that would altow pruents or of the age specificity of most objectives. cigarettes in his or her lifetime and others in the household to know what smokes “now”- “now” being defined questions the youth was answering. The Data and methods by the respondent. Recent measures of voice on the interview tape matched the smoking status assess regularity of The N131S-YRBSwas developed to sex of the respondent males heard a smoking in adults by distinguishing provide estimates of health risk male voice and females heard a female between “everyday” and “some day” behaviom for the noninstitutionalized, voice. This data collection method smokers. These definitions may not be household population of youth aged ensured greater privaq and increased appropriate for adolescents. 12-21 years. The NHIS is a continuous, data quality for youth with poor reading Consistent with other studies of nationwide, household interview survey skills. adolescents, current smokers are defined of the civihan noninstitutionalized Using data tlom the 1992 NHIS- as youth who have smoked at least one population of the United States, YRBS, this report presents prevalence cigarette in the past 30 days. Former conducted by the National Center for estimates for selected unhealthy smokers are youth who had smoked at Health Statistics (NCHS)(15). Interviews behaviors among male and female least one cigarette every day for 30 days are conducted for NCHS by the adolescents 12-21 years old and at some time in their lives, but had not interviewing strollof the U.S. Bureau of examines the relationship between smoked cigarettes in the past month. the Census. Information is obtained cigarette smoking and each of the other Experimenters are youth who had about the health and sociodemographic behaviors, using age-adjusted statistics. smoked at least one or two puffs of a cigarett~ but had never smoked characteristics of each member of the Table 1 contains percents and standard cigarettes every day for 30 daysand had household. Each year, special topic errors for each of the selected unhealthy not used cigarettes in the past 30 days. surveys are included in conjunction with behaviom by smoking status. These “Never smokem” ate youth who had the basic NHIS. These topics change unadjusted statistics (table 1) are used never had even one or two puffs of a annually. In 1992, theNHIS-YRBS was for discussions of overall prevalence. cigarette. Definitions for other terms one of the special topics. Table 2 contains percents, age-adjusted used in thk report are in the technical Within each NHIS sample family, to the full NHIS-YRBS sample, and the notes. one youth who was attending school and associated standard errors. For data on up to two youth who were not in school sexual intercourse, age adjustment was Findings or whose in-school status was unknown Iiited to the NHIS-YRBS sample aged were selected for the NHIS-YRBS 14=21 years because only youth 14 Figure 1 shows prevalence of interview. Youth in all NHfS sample years and older were asked the smoking among youth aged 12-21 families, including emancipated youth questions related to sexual experiences. years. About 29 percent of male youth (married youth and/or those not living Age-adjusted statistics are used in all and 26 percent of female youth were with a parent or guardian), were eligible dkcussions of findings concerning current smokers in 1992 and about for selection. The youth were followed relationships between smoking and other 3 percent of both sexes were former back approximately two months after unhealthy behaviors. Age-adjusted smokers. About 28 percent of male the initial household interview. NHIS- statistics control for variations in the age youth and about 30 percent of female YRBS interviews were conducted in dktributions of the various smoking youth had experimented with cigarettes, person from April 1992 through March status groups. Statistics for all youth but had never smoked regularly. About 1993. NHIS-YRBS interviews were ages 12–21 years are shown in order to 40 percent of youth had never taken a completed for 10,645 youth, provide an overall view of the puff of a cigarette. Advance Data No. 263 ● April 24, 1995 3

and females, respectively), and engaging - Current smoker EZ9 Former smoker = Experimenter W Never smoker in sexual intercourse (62.7 percent and 58.7 percent of males and females, 50 f- respectively). Prevalence of cocaine use was only about 1 percent for both 40.3 40.3 40.4 groups. 40 ~ Although the patterns among the behaviors appear similar for .ma.Iesand females, prevalence estimates for some 30 behaviors dtiered markedly between the sexes. Among the more noteworthy dii%erencesare: male youth were more 20 likely than female youth to have engaged in a physical fight in the past year (47.9 percent versus 29.2 percent); 10 to have carried a weapon in the past month (23.5 percent versus 5.6 percent); to have used smokeless tobacco 0- (13.4 percent versus 1.5 percent); and to All Maie Female have used marijuana (12.2 percent

Figure 1. Percent of youth 12-21 years of age by smoking status and sex United Statea, versus 9.2 percent). Female youth 1992 (52.7 percent) were more likely than male youth (39.9 percent) to get Table 1 shows the prevalence of general, the patterns appear similar for selected unhealthy behaviors among adolescent males and females. For @adequate exercise (deiined as exercising less than three times per male and female adolescents by example, among both male and female smoking status. Figures 2 and 3 display youtkii failure to eat at least five semings week). Prevalence of consumption of any alcohol was about the same for overall prevalence of these behaviors for of tilts and vegetablm daily had the male (45.3 percent) and female youth males and females, respectively. The highest prevalence of the unhealthy data in figures 2 and 3 correspond to behaviom examined (86.1 percent and (44.0 percent), although males column 1 of table 1. Together these data 87.9 percen~ respectively), followed by (29.1 percent) wem somewhat more show the overall pattern of unhealthy failure to always use seat belts likely than females (22.0 percent) to behaviors among U.S. adolescents. In (70.2 percent and 61.4 percent of males have had five or more drinks in a row. Figures 1-3 and table 1 show prevalence estimates of unhealthy behaviom among U.S. adolescents. Using these estimates and the population Drank alcohol 4s.3 table in the technical notes of this Had five of mor;~p~ repor$ the reader can estimate the numbers of youth who are both smoking Used marijuana and engaging in other high risk Usad cocaine behaviors. Analysis of interrelationships between smoking and other unhealthy Used smokelsss tobacoo behaviors should be restricted to the Carried a weapon data in table 2. Physical fiiht Table 2 presents data on the relationship between smoking and Sexual intercourse1 selected other unhealthy behaviors Did not use seat belt among adolescents, adjusted for Exercisedfewer than three ditTerences in the age composition of the times a week various smoking status groups. Ate fewer than five 86.1 servings of fruits Generally, youth who had never smoked and vegetables daily were significantly less likely to have 0 20 40 60 80 100 engaged in each unhealthy behavior Percent studied than were current smokers. With IAge8 14.21 years andneverm~rrad. a few exceptions, “never smokers” were also less likely than former smokers or Figure 2. Prevalence of seiactad unheaithy behaviors among adoieecent maies: experimenters to participate in unhealthy United States, 1992 behaviors. 4 Advance Data No. 263 ● April 24, 1995

in the past 30 days, compared with 23.0 percent of “never smokers.”

Drank alcohol 44.0 Figure 4 shows the percent of youth who drank alcohol in the past month by five or more drinks in a row smoking status and sex. Among cnrmnt smokers, prevalence of alcohol Used marijuana consumption in the past month was Used cocaine about the same for males and females. Among those who have never smokez Used smokeless tobacoo males were slightly more like~y than females to have consumed alcohol in the Canied a weapon past month. Table 2 also shows that Physical fight current smokers (50.3 percent) wem considerably more likely than former Sexual intermurse’ smokem (25.5 percent), experimenters

Did not use seat belt (21.3 percent), and “never smokers” (9.5 percent) to have had five or more Exercised less than three times a week drinks in a row in the past month. Rates Ate less than five 87.9 of episodic heavy drinking were servings of fruits and vegetables daily somewhat lower for females than for ! , * 1 t 1 males across all categories of smoking 0 20 40 60 60 100 status, but the pattern remained the Percent same.

1Ages 14.21 years and never married. Marijuana and cocaine use Figure 3. Prevalence of selected unhealthy behavfors among adolescent femafes: As with alcohol, drug use among United Staes, 1992 our Nation’s young people is a major problem and the focus of extensive Drinking avoid episodic heavy drinking prevention efforts. Table 2 shows past (sometimes called binge drinking) if month use of each of two drugs— Alcohol consumption among youth they do drink. Table 2 shows that after marijuana and cocaine-by smoking has serious short term and long term controlling for differences in age status. Among youth 12-21 years of healtl consequences. Prevention efforts composition, about three-quarters age, controlling for differences in age are d~ected at encouraging young (74.4 percent) of current smokers aged composition, 26.5 percent of tadoleseent people to abstain from alcohol and to 12–21 years old had consumed alcohol current smokers reported marijuana use in the previous 30 days compared with 10.3 percent of former smokers, - Current smoker W Former smoker ~ Experimenter m Never smoker 6.2 percent of experimenters, and only

100 1.5 percent of youth who had never smoked. Among both males and females, current marijurma use was considerably more prevalent among 80 73.7 75.1 current smokers than among youth who were not currently smoking. Table 2 also shows that 3.5 percent of current 60 smokers 1>21 years old had used E cocaine in the previous month. Although g data for former smokers, expmimenters, ~ 40 and “never smokers” do not meet reliibdity stanckuds, patterns indicate that prevalence may be lower in these 20 groups.

Smokeless tobacco 0 Smokeless tobacco use among our Male Female Nation’s youth is a serious public health

Figure 4. Percent of youth who drank alcohol In the past month, by smoking statua and concern. Like so many other behaviors, sex United States, 1992 use of smokeless tobacco (chewing Advance Data No. 263 ● April 24, 1995 5 tobacco and snuff) is frequently taken previous 30 days, compared with about more than twice as likely as “never up during the adolescent years. Table 2 one-tenth of youth who had never smokers” (19.8 percent) to have engaged shows that after controlling for smoked. Figure 5 shows that adolescent in physical fighting in the past year. differences in age composition, male male smokers were more &m twice as adolescents who were current smokers likely (39.4 percent) as males who had Sexual intercourse (28.1 percent) and former smokers never smoked (16.5 percent) to have The NHIS-YRBS includes data on (27.5 percent) wem almost seven times carried a weapon. Rates of carrying sexual intercourse for adolescents 14-21 more likely to have used smokeless weapons among male former smokem years of age. For this repor4 analysis tobacco in the past month than were (30.8 percent) and experimenters was restricted to youth who had never male youth who had never smoked (22.1 percent) ranked between the other been married. (4.1 percent). Although the small two groups. Adolescent female current Prevalence of sexual intercourse number of female adolescents reporting smokers were more thau four times as among never married adolescents was use of smokeless tobacco makes likely (11.0 percent) as female youth high across all smoking status groups. estimates of this behavior unreliable for who had never smoked (2.6 percent) to Table 1 indicates fhat 6 of 10 never most subgroups, the data suggest that have carried a weapon during the married adolescents 14 years old and currently smoking females may be more previous month. As with males, female older (60.8 percent) had engaged in likely to be users of smokeless tobacco experimenters (5.8 percent) mnked sexual intercourse at some time in their than other adolescent females. between those of current and “never lives. There appears to be a relationship smokers” on the mte of those who between cigarette smoking and sexual Carrying weapons and physical carried weapons. Due to the small intercourse. Current smokers fights number of female former smokers who (80.0 percent) and former smokers Table 2 also movides imtmtant carried weapons, data for thii group (80.4 percent) were most likely to have insights into the ;xtent to wh;ch youth were unreliable. engaged in sexual intercourse compared engage in two types of violent Table 2 shows that male cummt with 60.6 percent of youth who had only behavior+amying weapons and smokers (64.1 percent) were more likely experimented with cigarettes and engaging in physical fights-according than males who had experimented with 41.4 percent of youth who had riever to smoking status. After controlling for cigarettes (47.1 percent) and those who smoked at all (table 2). differences in age composition, about had never smoked (38.4 percent) to have onequarter of youth who were current been involved in a physical fight in the seatbelts smokers reported carrying a weapon past year. Among female adolescents, current smokers (443 percent) were Injuries are one of the l-mg such as a gun, knife, or club during the causes of death among adolescents and young adults. Injury deaths among those 15–24 years of age are largely attributable to motor vehicle accidents - Cunent smoker - Former smoker IZZl Experimenter UMIIUiMNever smoker (2). Overall, 65.8 percent of adolescents did not rdways use seat belts when they rode in a car (table 1). Table 2 shows that over three-quarters (76.6 pmmt) of L 39.4 40 current smokers did not aIways wear a seat belt compmd with about one-half (55.7 percent) of adolescents who had 30 never smoka with the other two groups falling in between.

Vigorous exeroise Regular participation in vigorous exercise is recognized as having 10 important health benefits for people of all ages, including youth. In the NHIS-YRBS, youth were asked how 0 often in the past week fhey engaged in Male Female any activities that made them sweat or breathe hard. The percent of youth who 1~ta fm female f~w smokersare statisticallynreli~le. reported participating in such vigorous —. — activities 3 or more days in the week Figure 5. Percent of youth who carried weapons in the past month, by smoking status and sex: United States, 1992 preceding the interview is shown in table 2, according to smoking status. 6 AdvanceData No. 263 ● April 24, 1995

Overall, prevalence of regular, vigorous differences between smoking and seniors, 1976-%9. Am J Public exercise among adolescents was low nonsmoking teenagers were also Health 81(3):372–77. 1991. (46.2 percent), regardless of smoking noteworthy for carrying weapons, 7. Centers for Disease Control. status (table 1). Table 2 shows that physical fighting, sexual intercourse, and Tobacco, alcohol, and other drag use 49.6 percent of adolescent current failure to use seat belts. For two risk among high school stndents-United States, 1991. MMWR 41(37):698-03. smokers exercised less than 3 times behaviors+xercising less than three 1992. during the week preceding the survey; times per week and eating fewer than 8. Webster DW, Gainer PS, Champion 44.8 percent of “never smokers” five servings of hits and HR. Weapon carrying among exercised thk infrequently. vegetables-smokerx simiiarly had inner-city junior high school higher prevalence rates than those who students: defensive behavior vs Eating habits had never smoke~ but the differences aggressive delinquency. Am J Public Guidelines for healthy eating were less striking. Her&h 83:1604-8.1993. generally recommend eating five or The interrelationships behveen 9. Vanderschmidt HF, Lang JM, more servings of fruits and vegetables smoking and other unheatthy behaviors Knight-WiUiams V, Vanderschmidt GF. Risks among inner-city young daily. The National Health Objectives are undoubtedly complex. Multivariate teens: the prevalence of sexual for the Year 2000 address this issue for analyses are needed to delieate the nature of these interrelationships. The activity, violence, drugs, and adults, but not for children or youth, smoking. Journal of Adolescent data presented here suggest that high Nevertheless, the NHIS-YRBS asked Health 14:282-88.1993. youth about tilt and vegetable risk behaviors may cluster. That is, 10. Centers for Disease Control. Physical consumption during the day preceding youth who engage in some high risk fighting among high school the interview. Overall, 87.0 percent of behaviors are liely to be engaging in students-United States, 1990. all adolescents consumed less than five others. Interventions that target multiple MMWR 41(6):91-94. 1992. servings of fruits and vegetables high risk behaviors may be more 11. Centers for Disease Control. Sexual (table 1). Table 2 shows that effective in getting youth to adopt behavior among high school students-United States, 1990. consumption of fewer than the healthy behaviors than programs that MMWR 40(51). 1992. recommended miniium quantities of target a single behavior. 12. Centers for Disease Control. fruits and vegetabks was somewhat References Vigorous physical activity among more common among adolescents who high school students-United States, currently smoked (89.6 percent) than 1. Centers for Disease Control. 1990. MMWR 41(3). 1992. among those who had never smoked Preventing tobacco use among young 13. Centers for Disease Control. Selected (83.6 percent). people: a report of the Surgeon tobacco-use behaviors and dietary General. Atlrmkx National Center for patterns among high school Discussion and conclusions Chronic Disease Prevention and students-United States, 1991. Health Promotion, Office on MMWR 41(24). 1992. This report provides a broad Smoking and Health, 1994. 14. Centers for Disease Control. overview of the links between smoking 2. Public Health Service. Healthy Reducing the health consequences of and other high risk behaviors. Although people 2000: national health smoking: 25 yeas of progress, a it does not establish causal links, it does promotion and disease prevention report of the Surgeon General. show a consistent association between objectives. Washington: U.S. Washington: Public Health Service. smoking and other unhealthy behaviors Department of Health and Human DHHS Publication No (CDC) 89-8411.1989. among adolescents, further strengthening Services, 1991. Designing health promotion 15. Benson V, Marano MA. Current the evidence that unhealthy behaviors 3. approaches to high-risk adolescents estimates from the National Health among adolescents are interrelated. In through formative research with Interview Survey, 1992. National almost all cases, current smokers had youth and parents. Public Health Rep Center for Health Statistics. Vital the highest and “never smokers” the 108(supp. 1): 68-7.1993. Health Stat 10(189). 1994. lowest rates of other risk behaviors. The 4. Marcus SE, Giovino GA, Pierce JP, 16. Kolbe LJ, Kann L, Collins JL. dtierences were particularly striking for Harel Y. Measuring tobacco use Overview of the Youth Risk use of other addictive substances such among adolescents. Public Health Behavior Surveillance System. Public as alcohol, marijuan% and smokeless Rep 108(l) :2&24. 1993. Health Rep 108(supp. 1): 2-10.1993 tobacco current smokers were 3–17 5. Escabedo LG, Marcus SD, Holtzman 17. Centers for Disease Control. Heatth risk behaviors among adolescents times more likely than adolescents who D, Giovino GA. Sports participation, who do and do not attend school— had never smoked to have used these age at smokmg initiation, and the risk of smoking among US high United States, 1992. MMWR 43(8). other substances in the past 30 days. school students. JAMA 269(11): 1994. (Data for cocaine were suggestive of a 1391-95.1993. similar relationship, but were not 6. Bachman JG, Wallace JM, O’MaUey statistically reliable due to small PM, et al. Racial/ethnic dtierences in numbers of youth reporting cocaine smoking, drinking, and illicit drug use.) Although not quite as dramatic, use among American high school Advance Data No. 263 ● April 24, 1995 7

Table 1. Percent of youth ages 12-21 yeare who engaged in seleoted unhealthy behaviors by type of behavior, sex, and smoking statu= United States, 1992

All snroldng Current Former Never statuses smoker smoker Expwimerrfer smoker

Standard Sferrdad SkmCfard Standard .5?andSrd UnheaUiYrybehevio+ and sex Persenf error Percent error Percent error Percent error Percent error

Drank alcohol

Bolheexee ...... 44.6 0.69 77.9 o.e3 55.5 3.40 46.7 1.12 17.6 0.79 Mefe ...... 45.3 0.88 78.2 1.31 56.4 5.69 48.0 1.64 18.8 1.00 Female ...... 44.0 o.e4 77.7 1.29 54.9 4.01 4e.4 1.57 16.5 i .07

Had five or more dtfnks in a row

Both eexss ...... 25.6 0.58 54.5 1.07 28.8 2.80 23.4 1.00 6.8 0.51 Male ...... 22.1 o.7e 5e.5 1.42 34.6 4.92 26.7 1.43 8.2 0.76 Femefe ...... 22.0 0.75 48.8 1.57 24.0 3.10 202 1.23 5.4 0.61

Usedrrrerijusna

Bofheexes ...... 10.7 0.39 2e.1 1.04 11.7 2.13 6.8 0.56 1.1 0.18 Male ...... 12.2 0.59 31.1 1.49 16.4 3.97 7.8 0.64 1.6 0.30 Fenrafe ...... 9.2 0.46 26.8 1.35 7.8 I.%r 5.8 0.70 0.6 0.18

Used cocaine

Bothsexes ...... 1.2 0.11 3.9 0.37 “1.5 0.75 “0.3 0.03 ‘0.1 0.06 Msle ...... 1.4 0.16 4.2 0.57 “1.6 1.15 “0.4 0.75 “0.2 0.08 Fernefe ...... 1.0 0.15 3.5 0.55 “1.5 1.00 “0.2 0.11 90.1 0.07

Used smokeless tobacco

Bothsexes ...... 7.5 0.37 16.1 0.90 14.2 3.07 6.2 0.51 2.1 0.25 Male ...... 13.4 0.65 27.9 1.53 22.4 5.72 11.2 0.95 3.6 0.44 Femafe ...... 1.5 0.20 2.9 “1.4 0.84 1.4 0.38 “0.6 0.19

Csnledaweepon

Bolheexes ...... 14.5 0.42 23.2 0.91 18.9 3.13 13.3 0.76 9.2 0.64 Mafe ...... 23.5 0.72 35.0 1.43 29.9 5.88 21.5 i .35 16.2 0.92 Ferrrale ...... 5.6 0.39 10.1 0.93 9.s 2.79 5.7 0.66 2.4 0.39

Engaged In physkal fight in past year

EkNhsexes ...... 38.6 0.62 46.7 1.09 42.3 2.99 38.2 1.06 33.2 0.89 Mefe ...... 47.9 0.86 57.7 1.52 49.5 5.21 44.9 1.51 42.9 1.23 Fenrefe ...... 23.2 0.78 38.7 1.54 36.4 3.98 28.1 1.37 23.4 1.11

Ever had sexual Intercourse*

Bothaexes ...... 60.8 0.77 81.7 0.98 82.4 2.70 61.8 1.28 37.9 1.28 Mate ...... 62.7 1.02 81.8 1.34 *80.8 4.12 61.8 1.86 42.5 1.65 Fernefe ...... 58.7 1.07 81.6 1.41 *84.1 3.20 61.9 1.76 %3.2 1.77

Did not always use seat half

Bothaexes ...... 65.8 0.69 75.5 1.05 67.2 3.13 66.9 1.13 58.4 1.00 Male ...... 70.2 0.88 79.7 1.27 77.7 4.21 70.4 1.47 62.9 1.33 Female ...... 61.4 0.94 70.8 1.63 53.4 4.13 63.7 1.80 53.8 1.38

Exercisadvborously fewer than3tImesinpast weel?

Bothaaxee ...... 46.2 0.52 54.4 1.06 55.3 3.17 46.1 1.03 40.1 0.94 Mate ...... 389 0.80 50.2 1.49 55.0 5.17 37.2 1.46 33.3 1.19 Femefe ...... 52.7 0.85 59.2 1.49 55.5 4.01 54.4 1.40 46.9 1.32

Ate fewer than five servings of fndta arrdvegetsblesyesterday

Bothsexes ...... 67.0 0.42 89.8 0.71 91.3 1.66 882 0.64 83.1 0.73 Mace ...... 86.1 0.56 69.4 0.95 93.3 2.42 87.6 1.03 82.2 1.01 Female...... 87.9 0.57 90.3 0.93 69.7 2.25 30.8 0.77 64.0 0.95

‘Fleferenca period Is past30 days un!a.ss othenvise spacified. 2Ages 14-21 yaars and never maniac!, %igcfous is dafined as axercise that made the youth sweat and breathe hard. 8 Advance Data No. 263 ● Am’il 24, 1995

Table 2. Age-adjusted percent of youth ages 12-21 years who engaged in selected unhealthy behaviora by type of behavior, sex, and smoking status: United States, 1992

All smoking Current Former Never statuses smoker smoker Experimenter smoker

.Standsrd .Sfsndard .%indard Standard Standard Unhealthy behavio~ and sax Perc3rrt error Percent error Percent error Percent error Percent error

Drank alcohol

Both aexes ...... 44.3 0.61 74.4 1.11 47.0 3.92 45.4 1.01 23.0 1.02 Male ...... 45.3 0.80 73.7 1.60 50.4 6.23 45.4 1.49 25.2 1.s4 Femafe ...... 43.4 0.85 75.1 1.56 41.6 3.25 45.4 1.42 20.8 1.29

Had five or more drfnks In a row

Both aaxea ...... 25.4 0.53 50.3 1.22 25.5 2.93 21.3 0.88 9.5 0.69 Male ...... 29.2 0.72 53.7 1.61 31.5 4.57 24.7 1.27 12.0 1.07 Female ...... 21.7 0.71 46.4 1.80 18.8 2.89 18.2 1.11 7.2 0.81

Usedmarl]uana

Both saxes ...... 10.7 0.38 26.5 1.02 10.3 2.19 6.2 0.52 1.5 0.25 Mafe ...... 12.3 0.58 28.0 1.48 15.2 3.98 7.4 0.79 2.3 0.43 Female ...... 9.1 0.45 24.7 1.34 5.4 1.30 5.2 0.62 ‘0.8 0.25

Usedcmaine

Bothaexes ...... 1.2 0.11 3.5 0.48 -f .1 0.55 ‘0.3 0.09 “0.2 0.10 Male ...... 1.5 0.18 3.5 0.47 ‘1.4 0.99 “0.4 0.14 “0.3 0.13 Female ...... 1.0 0.15 3.6 0.79 “1.0 0.82 “0.2 0.10 “0,2 0.12

Used smokeless tobacco

Bothaexes ...... 7.5 0.37 16.1 1.02 13.7 3.50 6.1 0.49 2.4 0.28 Mace ...... 13.5 0.65 28.1 1.76 27.5 6.48 11.1 0.92 4.1 0.52 Female ...... 1.5 0.21 3.0 0.60 ‘1.5 0.92 1.5 0.36 “0.6 0.20

Carriedaweapon

Bothsexes ...... 14.5 0.41 25.6 1.12 20.2 3.42 13.8 0.78 9.5 0.59 Male ...... 23.4 0.71 39.4 1.74 30.8 6.40 22.1 1.37 16.5 1.02 Female ...... 5.6 0.38 11.0 1.10 “11.3 4.29 5.8 0.70 2.6 0.43

Engaged in physical fight In paat year Both saxas ...... 38.6 0.59 54.7 1.09 48.6 3.50 38.3 1.05 29.0 0.86 Male ...... 47.7 0.81 84.1 1.40 53.9 5.42 47.1 1.39 38.4 1.32 Female ...... 29.3 0.77 44.3 1.70 41.8 5,20 29.6 1.45 19.8 0.95

Ever had sexual intercoursa2 Bothaexes ...... 60.8 0.72 80.0 0.99 80.4 3.27 60.6 1.13 41.4 1.40 Mete ...... 62.4 0.96 79.9 1.38 77.7 5.58 60.0 1.61 45.9 1.85 Female ...... 59.1 1.05 80.0 1.42 82.9 3.43 61.0 1.64 36.6 1.89

Did not ahvays use seat beff

Bothsaxas ...... 65.8 0.68 76.6 1.03 71.6 3.05 67.7 1.11 55.7 1.11 Mace ...... 70.2 0.87 80.6 1.38 79.0 4.34 70.9 1.44 60.3 1.56 Female ...... 61.4 0.93 72.2 1.61 66.3 3.81 64.9 1.56 51.2 1.47

Exercised vigorously fewer than 3timesinpastweef?

Bofhsexes ...... 46.2 0.56 49.6 1.17 48.9 3.78 44.1 1.00 44.8 1.00 Male ...... 40.1 0.79 45.6 1.62 51.5 6.27 36.1 1.42 37,7 1.39 Female ...... 52.4 0.83 54.0 1.64 45.6 4.44 51.6 1.40 51.7 1.43

Ate tewer than five servings of fruits and vegetables yesterday

Both saxes ...... 87.0 0.42 89.6 0.80 91.2 1.94 89.0 0.65 83.6 0.74 Male ...... 86.1 0.58 66.4 1.18 92.8 2.61 87.5 1.04 82.7 1.05 Female ...... 87,9 0.57 90.7 1.00 90.1 2.91 90.5 0.82 84.5 1.01

‘t?eferenca period IS psst 30 days unless otherwise speehed. 2Agas14-2f years and never married. %gorousisdefinedas axercisethat !mdethe youfhsweatand breathe hard. NOTE Tdalage-adjustd ~r@ntsmy dtiershgMly fromtotal percents shown lntablel duetominor variations lnfiemnonre$ponse among youth inthevarious smoMngtiatus groups. Advance Data No. 263 ● Ai)t’il 24, 1995 9

Technical notes tobacco use including cigarettes, are referred to as 1992 results although chewing tobacco, and snufi alcohol the &ta were collected from April 1992 Target population consumption; illegal drug use and through Mamh 1993. perceptions of risks associated with their In. collaboration with researchers at The estimatespresented in this ustz nutrition, including weight control; report me based on data from the 1992 University of Michigan’s Survey National Health Interview Survey of physical activi~, injury control, Research Center, extensive Youth Risk Behavior (NHIS-YRBS). including hehnet use when riding methodological testing was conducted The National Health Interview Survey bicycles and motorcycles; violence, during the development of the NHIS- (NHN) is a continuous, nationwide, including frequency of physical fighting YRBS to determine the optimal mode of household interview survey of the and carrying weapons; overnight stays data collection from adolescents. Results civilian noninstitutionalized population away from home and without indicated that due to the sensitive of the United States, conducted by the permission sexual history and practices nature of the questions on the NHTS- National Center for Health Statistics and AIDS education at home and in YRBS, privacy and confidentiality (NCHS), Centers for Disease Control school. This survey is part of the Youth would be of paramount concern to teens and Prevention (CDC). Risk Behavior Surveillance System during the interview. Youth indicated The NHIS-YRBS was a followback (YR13SS). The YRBSS was developed that they would be mom likely to survey of a subsample of youth ages by the Division of Adolescent and answer questions honestly if the 12–21 years who were identified at the School Health of the National Center for questions could not be heard by others time of the 1992 NHTS household Chronic Disease Prevention and Health in the household. Further, younger teens interviews. Within each NHIS sample Promotion, Centers for Disease Control and those with less developed reading family, one youth attending school and and Prevention (cDC), to monitor the skills found a written questionnaire to up to two youth not in school or whose major health risk behaviors of American be dficult to complete. For these in-school status was unknown were youth. The surveillance system is reasons, questions were asked of teens randomly selected for the NHLS-YRBS described elsewhere (16). The majority using a portable audio headset. They interview. Youth in all NHIS sample of the YRBSS is school-based and has recorded their answers on an answer families, including emancipated youth been tracking behaviors of in-school sheet that included only answer (mamied youth and/or those not living youth since 1990. The 1992 NHIS- categorh, not questions. In addition to with a parent or guardian), were eligible YRBS added a new dimension to the providing @vacy and beiig easier for for selection. The youth were study of health risk behaviors among less advanced readers, this mode of data interviewed approximately 2 months American youth by providing estimates collection had the added benefit of after the irdtial NHM interview. of risk behaviors for out-of-school youth providing standardation in asking lVHIS-YRBS interviews were conducted (17). Out-of-school youth were questions that eliminated the normal in person from April 1992 though oversampled in the IWHS-YRBS to variations that occur when an March 1993. The ages shown in thk achieve reliable estimates for this interviewer asks the questions. report represent the youths’ ages at the hard-to-reach group; a special question time of the initial NHIS intemiew, was added to the basic NHIS Response rates which may not be the same as their ages questionnaire in 1992 to determine Of the 13,789persons 12–21 years at the time of the IWIIS-YRBS school status for the YRBS sample. of age idendlied as eligible in the basic interview because of the 2-month lag NHIS interview, NHIS-YRBS interviews between the two data collection points. Data collection methods were completed for 10,645 youths, The questions on sexual intercourse Interviews are conducted for NCHS representing a response rate of were asked of all youth who were 14 by statl of the U.S. Bureau of the 77.2 percent of eligible respondents and years old or older by the time of the Census. The basic health and an overall response rate of 73.9 percent NHIS-YRBS interview. However, for demographic questionnaire of the NHIS (the product of the YRBS response rate consistency with other data presented in is administered in a personal interview, (77.2 percent) and the response rate for this repo@ the data on sexual with telephone follow-up permitted for the basic NHIS household interview intercourse shown in tables 1 and 2 am hard-to-reach people. Basic health (95.7 percent)). limited to youth who were 14 years old information is collected for every School status was ascertained in at the time of the initial NHIS member of the family residing in the two ways. At the time of the initial household interview. household. Based on the roster of family NHIS questionnak, 8,062 youth were description of the survey members listed at the time of interview, currently in school or on vacation tlom a subsample of youth was selected for school, 1,886 youth were not in school, The NHN-YRBS provides estimates the NHIS-YRBS. and the school status of the remaining of health risk behaviors for the Because the samphng frame was the 697 adolescents was unknown. At the noninstitntionalized household 1992 NHIS and three-quartm of the time of the NHIS-YRBS interview, population of youth ages 12-21 years. data were collected in 1992, for ease of 8,203 were currently in school or on I’epics covered in the YRBS include: reading, findings from the NHIS-YRBS vacation from school, 2,384 were not in 10 Advance Data No. 263 ● April 24, 1995

school, and the school status of the of complex sample surveys. The Former smokers—Youth who had at remaining 58 youth was not ascertained. unadjusted percents were calculated one time smoked at least one cigarette Due to some field difficulties in using PROC CROSSTABS. The per day for 30 days, but had not smoked rostering eligible youth, the number of age-adjusted percents were calculated cigarettes in the past month. teenagers selected for the NHIS-YRBS using PROC DESCRIPT. The entire Experimenters-Youth who had was somewhat smaller than the number NHIS-YRBS sample (age groups: 12-13 smoked at least one or two puffs of a of youth ultimately identified as having years, 14-17 years, and 18–21 years) cigarette, but had never smoked been eligible for interview. Hence, the was used as the standard population. For cigarettes every day for 30 days and had response rate for the NHIS-YRBS was the data on sexurd intercourse, age not used cigarette3 in the last 30 days. somewhat lower than it might have been adjustment was limited to the two older Never smokers—Youth who had had all eligible youth been given the groups because the question was asked never had even one or two puffs of a opportunity to respond. Another factor only of youth 14 years and older. Data cigarette. that may have contributed to the YRBS for tables 1 and 2 were tabulated using Drank alcohol21 years old. Table I shows the Consumed at least 5 drinks within a NHIS-YRBS. Comparison of numbers of youth in the total U.S. couple of hours in the past month. respondents and nonrespondents population and in each of the four Smokeless tobacco-snuff such as indicated that the two groups were not smoking status subgroups. This table Skord, Skoal Bandhs, or Copenhagen, or substantially dtierent in terms of their can be used to estimate numbers of chewing tobacco such as Redman, Levi sociodemographlc profiles. Item youth engaging in combinations of Garre% or Beechnut. nonresponse ranged from 0.15 to smoking and other health risk behaviom. Marijuana-Marijuana, grass, or 7.86 percent for the questions discussed Population estimates derived by using pot. in this report. table I maybe slightly different from Cocaine—Any form of cocaine, those that would be obtained had the including pow&r, craclG or freebase. Sample design and statistical exact denominators for each individual Carried a weapon-Gun, kniie, or testing variable been provided. However, the club, carried at least once in the past 30 The NHIS sample is selected so that dtierences will be small and of no days. a national probabiMy sample of statistical consequence. Physical ji@t-Had bn involved households is interviewed each week All dtierences cited in this report in at least one physical fight in the past throughout the year. A detailed are statistically significant at the .05 year. discussion of the sample design is level. The t-tes~ with a critical value of Wgorous exercise—Exercise that available in Current Estimutes from the 1.96, was used to test all comparisons caused sweating and heavy breatMmg. National Health Interview Survey, 1992 that are discussed. Lack of comment Fewer than jive servings offiwits (15). Because the estimates shown in regardhg the dtierence between any and vegetables—Adolescents were this report are based on a sample, they two estimates does not mean that the asked about their consumption of are subject to sampling error. The dtierence was tested and found not to selected foods the day before the standard error is a measure of sampling be statistically significant. interview and could respond that they error. The standard errors shown in had consumed the food once, twice or Definition of terms tables 1 and 2 of this report were more, or not at all. The foods were fruit calculated using SUDAAN (SUrvey Current wnokers—Youth who had juice, fn@ green sala~ and cooked DAta ANalysis), developed by the smoked at least one cigarette in the past vegetables. The sum of the youth’s tilt Research Triangle Institute for analysis 30 days. and vegetable intake was obtained by

Table L Number of youth by cigarette smoking status and age, United Statee, 1992

Ages 12-21 years Ages 14-21 years’

Smoking status Total Males Females Total Males Females

Number In thousanda

Allyoulhz ...... 33,518 16,816 16,702 23,412 12,152 11,260 Current smokers ...... 9,132 4,818 4,314 7,336 4,042 3,295 Former smokem ...... 1,033 468 565 739 372 367 Exparimentera ...... 9,835 4,759 5,076 7,478 3,7S4 3,744 Never smokers ...... 13,516 6,771 6,747 7,859 4,005 3,654

lNever married and 14-21 years d age at time of NHIS initial household interview. ‘Excludes youth for whom srwiring status is unknown. Advance Data No. 263 ● April 24, 1995 11 adding 1 for each time the youth said Symbols “once” and 2 for each time the youth . . . said “2 or more.” Thus, the prevalence Data not available of fndt and vegetableintake is a . . . Category not applicable conservativeestimatebecause youth who had more than 2 servingsof a food Quant”w zero * were countedas having had only 2 Figure does not meet standard of servings. reliability or precision (more than 30-percent relative standard error Availability of data and ralated in numerator of percent or rate) data sources ●✍ Figure does not meet standard of The NHIS-YRBSis availableon reliability and quantity zero data tape from the Division of Health InterviewStatistics.The NHIS-YRBS public use data tape includes data for all questionsincludedin the youth risk behaviorquestionnaireas well as all other health and demographic ‘ informationgath=d during the initial householdinterview.For some youth ages 18-21 years, data tkomthe NHIS-YRBScan be linked to other specialtopics that were part of the 1992 IWIIS,includingAIDS Knowledgeand Attitudes,CancerControl, Cancer Epidemiology,and Family Resources. The NHIS-YRBSis also availableon CD-ROMfrom the U.S. Government Printing Officeand tim the National TechnicalInformationService.Contact the NationalCimterfor Health Statistics’ Data DisseminationBranch for ordefig information. 12 Advance Data No. 263 ● April 24, 1995

Suggested citation Copyright information National Center for Health Statistics

Willard JC, Schoenborn CA. Relationship All material appearing in this report is in the Acting Director between cigarette smoking and other public domain and may be reproduced or Jack R. Anderson unhealthy behaviors among our Nation’s copied without permission; citation as to youth: United States, 1992. Advance data source, however, is appreciated. Acting Deputy Director from vital and health statistics; no 263. Jennifer H. Madans, Ph.D. Hyattsville, Maryland: National Center for Health Statistics. 1995.

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DHHS Publication No. (PHS) 95-1250 5-0740 (4/85) Number 264 ● May 24, 1995 Advance Data w From Vital and Health Statistics of the CENTERS FOR DISWSE CONTROL AND PREVENTION/National Center for Health Statistics

1993 Summary: National Hospital Discharge Survey by Edmund J. Graves, Division of Health Care Statistics

Introduction section entitled “Technical notes.” A submitting machine-readable data tapes. description of the development and In 1993, approximately 32 percent of the During 1993, there were an design of the original NHDS, which was hospitals used this method to submit estimated 30.8 million d~charges of in operation from 1965–1987, has been data. More detailed analyses of NHDS inpatients, excluding newborn infants, published (l). DitRrences may exist data iue published in Series 13 of the between data for 1988–93 and earlier from short-stay non-Federal hospitals in NCHS Etal and Health Statistics years because of the redesign of the the United States. These discharges reports. survey. accounted for 184.6 million days of Medical data were coded according Data highlights inpatient hospital care. The dkcharge to the International Classijicatwn of rate was 120.2 per 1,000 population and Diseases, 9th Revision, Clinical Utilization by patient and hospital the average length of stay was 6.0 days. Modijkatr-on (ICD-9-CM) (2). Up to characteristics These and other statistics presented seven diagnoses and four procedures in this report are based on data collected were coded for each discharge. Although The number, rate, and average by means of the National Hospital diagnoses included in the ICD-9-CM length of shy of discharges tlom Discharge Survey (NHDS), a continuous section entitled “Supplementary short-stay non-Federal hospitals are survey that has been conducted by the classification of external causes of injury shown by age, geographic region, and National Center for Health Statistics and poisoning” (codes EIKWE999) sex in tables 1–3. Of the 30.8 million (NCHS) since 1965. In 1993, data wem were used in the NHDS, these diagnoses d~charges from short-stay hospitals abstracted from the medical records of are excluded from this report. during 1993, an estimated 12.3 million approximately 235,000 discharges from Beginning in 1991, all ICD-9-CM were for males and 18.6 million were 466 short-stay non-Federal hospitals. procedure codes were used in the for females. The discharge rate per Beginning in 1988, a new three-stage NHDS. In previous years, selected codes 1,000 population for females was 141, stratilied sample design was put in were excluded. These were primarily which was 44 percent higher than the operation. A brief description of the new codes for certain miscellaneous rate of 98 for males. The number and design, data collection procedures, diagnostic and therapeutic procedures. rate of discharges were higher for estimation process, and definitions of Starting in 1985, some hospitals females than for males lmgely because terms used in thii report are in the participating in the IWDS have been women 154.4 years of age were

I Acknowledgments This report was prepared in the Division of Health Care Statistics.Jean Kozak of the Hospital Care Statistics Branch provided technioal assistancein developingthe styleand contentof thisreport.Elaine Wood of the HospitalCare StatisticsBranchverifiedthe data. Maria Owings, also of the HospitalCare StatisticsBranch,and George Wolfe of the TechnicalServices Branch, producedestimated parameters for relative standarderror equations.CharlesAdams and Malcolm Graham of the TeohnicalServices Branchdid tie computerprogrammingfor the report. This reportwas edited by KlaudiaCox and typeset by Annette F. Facemire of the PublicationsBranch, Divisionof Data Services.

SWlcu.o R+ U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES pn m <4 Public Heaith Service d Centers for Disease Control and Prevention c National Center for Health Statistics U& ‘k.= c-S FOR DIsEAsE CONlllOL 4 AND PREVENTION 2 Advance Data No. 264 ● May 24, 1995

Table 1. Number of discharges from short-stay hospitals by selected characteristics: fkquentlyh ospitalized for deliveries and United States, 1993 pregnancy-related conditions. [Discharges of inpatients from non-Federal hospitals. Excludes newborn Infants] lheaverage length ofstaywas 6.5 Both days for males and 5.6 days for females Selected characteristic sexes Male Female during 1993. Theaverage length ofstay Number In thousands ofthe4.Omillion womenwhowere Total...... 30,825 12,262 18,563 hospitalized for deliveries was2.4 days. The average length of stay waE5.2 days Age for chddren under 15 years ofage,4.2 Under 15years, ...... 2,141 1,193 846 15-44 years...... 11,200 3,179 8,021 days for the 15-44 years age group, 6.2 45-64 years ...... 6,283 3,143 3,141 days for those 45-64 years of age, and 65yeare andover ...... 11,201 4,748 6,453 7.8 days for the group 65 years of age Region and over.

Northeast ...... 6,965 2,931 4,033 Thenumberofdkcharges from Midwest ...... 7,097 2,900 4,197 shom-stayhospitals bygeogrryphic South ...... 11,580 4,448 7,132 region during 1993 ranged frolm 11.6 West ...... 5,183 1,963 3,200 millionintheSouth to5.2millionin the West. Regional differences in the numberofdischarges wereaocounted for in partby variations inthe Table2. Rateof discharges from short-stay hospitals by selected characteristics: population sizes. l%e dkchargemtesper United States, 1993 1,000 population ranged from 136in the [Dischargesof inpatients from non-Federal hospifals. Excludes newborn Infants] Northeastregionto 93inthe’West. Bofh Average lengthsof stay bygeographic Selected charecterlstlc sexes Ma/a Female region wem 5.1 days inthe Wes45.7 Number per 1,000 population days inthe South, 6.1 days in the Total...... 120.2 98.4 140.8 MidwesC and 7.0 days in the Northeast.

Age Utilization by diagnosis Under15yeare ...... 37.7 41.1 34.2 15-44years ...... 95.4 54.5 136.0 Thenumber and rates of discharges 45-64years ...... 126.6 131.5 1Z2.5 and average length of stay for each 65yearsandover ...... 341.6 357.2 330.9 ICD–9-CM diagnostic chapter and Region selected categories within chapters are Northeast ...... 135.6 116.6 151.6 shown by sex and age in tables 4-6. In Midwest...... 116.4 97.9 13%9 1993, 5.6 million dkcharges had a South ...... 130.6 104.0 155.5 West ...... 93.3 72.0 114.2 principal or fist-listed diagnosis in the ICD-9-CM diagnostic chapter of diseases of the circulatory system. Other

Table 3. Average length of stay for discharges from short-stay hospitals by selected leading ICD–9-CM dmgnostic chapters characteristics: Unltad States, l 993 were supplementary clmsifications

[Dlszharges of inpatients from non-Federal hospitals. Excludes newborn Infants] (including females with &liveries) (4.4 million discharges), diseases of the Both Selected characteristic saxes Male Female respiratory system (3.1 million dkcharges), and diseases of the Nutierotdays digestive system (3.1 million Total...... 6.0 6.5 5.6 dkcharges). Approximately

Age 53 percent of the discharges from Under15yeacs ...... 5.2 5.0 5.4 non-Federal short-stay hospitals were 15-44yeaB ...... 4.2 5.8 3.5 included in these four ICD-9-CM 45-64yeam ...... 6.2 6.3 6.1 diagnostic chapters. 65yearsandover ...... 7.8 7.5 8.1 Within the chapters, the common Region diagnostic categories were deliveries, Northeast ...... 7.0 7.4 6.7 heart dkease, malignant neoplasms, Midwest ...... 6.1 6.5 5.8 pneumom psychoses, and fmctures. South, ...... 5.7 6.3 5.4 West ...... 5.1 5.8 4.6 Excluding deliveries, these last five dmgnostic categories were leadhg Advance Data No. 264 ● May 24,1995 3

first-listeddiagnosesfor both males and catheterization,and dmgnostic females. ultrasound and for the group 65 years Common diagnosesfor children of age and over, arteriographyand under 15 years of age were acute angiocardiography,diagnostic respiratoryinfections,pneumonb and ultrasound and computerizedaxial asthma.For the age group 15-44 years tomography. of age, frequentdiagnoseswere deliveries,psychoses,and fractures.For those 45-64 years of age and References 65 years of age and over, heart disease and malignantneoplasms were major 1. Simmons WR. Development of the causesof hospitalization.Average design of the NCHS Hospital Discharge lengths of stay ranged from 1.3 days for Survey. National Center for Health chronic diseaseof tonsils and adenoids Statistics. Vital Health Stat 2(39). 1970. to 12.0 for psychosis. 2. Public Health Service and Health Care Financing Administration. International Utilization by procedure Classidcation of Diseases, 9th Revision, One or more surgicalor nonsurgical Clinical Modification. Washington Public prcxxdureswere performedduring an Health Service. 3rd ed. 1980. estimated20.0 million of the 30.8 3. SMG Marketing Group, Inc. Hospital million hospitalizationsin 1993.A total Market Database. Chicago: Healthcare of 41.6 million procedures,or an Information Specialists. 1987. averageof 2.1 per dkcharge where at 4. SMG Marketing Group, Inc. Hospital least one procedurewas performecL Market Database. Chicago: HealthCare were recordedin 1993. Information Specialists. April 1991. The number and rate of all-listed 5“ Shah BV. SESUDN Standard errors program for computing of standardized proceduresin 1993 for each ICD-9-CM rates from sample survey data. Research procedurechapterand selected Triangle Park, North Carolina Research categoriesare shown by sex and age in Triangle Jnstitute. 1981. tables 7 and 8. More than three-fourths of all the surgicaland nonsurgical proceduresperformedduring 1993were in 5 of the 16 ICD-9-CM procedure chapters.These chaptemwere miscellaneousdiagnosticand therapeutic procedures(13.6 million), obstetrical procedures(6.8 million), operationson the digestive system (5.1 million), operationson the cardiovascularsystem (4.4 million), and operationson the musculoskeletalsystem (3.2 milIion). Withii the chapters,frequent proceduresfor males were arteriography and angiocardiography,cardiac catheterization,dmgnosticultrasoun~ and compukxizedaxial tomography. Procedurescommonlyperformedon females were episiotomy,fetal EKG and fetal monitoring,cesareansection, and repair of obstetriclaceration. Commonlyperformedprocedures for childrenunder 15 years of age were respiratorytherapyand spinal tam for the age group 15-44 years, episiotomy, fetal EKG and fetal monitoring,and cesamansection; for those 45-64 years of age, arteriographyand angiocardiography,cardiac 4 Advance Data No. 264 ● May 24, 1995

Table 4. Number of discharges from short-stay hospitals, by first-llstsd diagnosis, sex, and agcx United Ststea, 1993

[Dlech&ges of inpatients from non-Federal hos itats. Excludes newborn infants. Diagnostic groupings and cods nun’here are beeed on the /nternet/onel Cbeeffkatkm of Dfseasas, 5ih Revision, Clinical Modifkatlons (1’CC-0-CM)]

sex Age

Under 15 1544 4s-64 65 years Category of first-lkted diagnosis and ICD-3-CM code Total Male Female years years years and over

Allconditione ...... 30,825 12,282 18,563 2,141 11,200 6,283 11,201 Infectiousandpsrssitl cdiseeees...... 001-139 797 390 407 169 231 120 276 Sepflcemla ...... 038 270 118 152 18 28 44 180 Neoptaame ...... 140-289 1,855 759 1,098 39 346 564 865 Malignant neoplesms...... 140-208.230-234 I ,492 690 792 31 180 459 811 . Malignant neoplssm oflargelntestlne and rectum . . . .153-154,197.5 157 73 64 “7 46 103 . Matignsrd neoplesm oftrachea, bronchus, sndlung . . .162,197.0,197.3 104 114 80 “7 75 111 * . Malignant neoplaemofbreast ...... 174-175.198.81 168 167 36 62 71 Benign neoplasrns and neoplasms of uncertain behavior andunspecifled nature ...... 210-223,235-239 373 69 304 “8 186 125 74 Endocrine, nutritional and metabolic dkeasas, andimmunltydisordera ...... 240-279 1,210 480 730 90 256 300 564 D!abeteemelllfus ...... 250 484 212 252 15 120 147 182 Volumedepletion ...... 276.5 347 128 216 57 50 50 168 Diseaaesoflheblood andblood-forming organe ...... 280-263 327 149 178 50 100 83 113 Mentatdlsordere ...... 290-319 1,827 959 688 75 1,063 375 268 Psychoses ...... 290-299 1,054 500 564 30 564 237 222 . Alwhoidependencssyndrome ...... 303 252 183 59 175 62 13 Diseaeesofthenervoussyetemand eenaeorgans ...... 320-389 691 312 369 95 179 154 252 Dlsassesofthecentral nervous system ...... 320-236.340-349 276 119 159 29 98 61 90 Diseeeesoftheearandmastoldprocess...... 360-369 118 59 59 52 17 20 29 Dtseasesofthedrculatorysyatem...... 390459 5,633 2,865 2,747 25 421 1,599 3,587 Hearfdfsease ...... 391 -392.0,393-398,402,404,41 0418,420-429 3,951 2,078 1,873 13 242 1,167 2,529 * Acutemyocardiet infarction ...... 410 745 435 310 47 250 446 . Coronaryatherosclerosls ...... 414.0 4s2 322 170 25 208 256 “ Otherischemlcheertdiseasa ...... 411413,414.1-414.9 842 447 395 45 2s9 489 . Cardiacdyerhythmkae...... 427 549 267 262 42 123 380 . Congestive hesrffailura ...... 428.0 875 334 481 21 169 681 * Cerebrovaeculerdlsease ...... 430-486 641 365 456 38 172 629 Diseaeesoftherespiratorysyetem ...... 460-519 3,142 1,528 1,614 667 468 576 1,430 Acuterespiratoryhrfecflons...... 460-466 400 204 196 222 62 41 75 . Chronicdisease oftonsllsend adenokfs...... 474 37 17 20 26 9 Pneumonia ...... 430466 1,164 598 586 209 142 191 642 Asthma ...... 493 466 191 278 159 128 94 87 Dieeeeesofthedlgestlve system ...... 520-579 3,079 1,358 1,721 206 878 610 1,165 * Lflcersofthe stomach andsmelllntestlne...... 531-534 216 114 102 34 81 120 Appendicitis ...... 540-543 223 131 92 47 131 23 16 Ingulnet hernia ...... 550 83 76 “6 ‘6 17 19 40 Noninfectlousentetftis andcoltils...... 555-558 350 139 211 87 107 61 95 . Cholelithisels ...... 574 476 134 242 168 146 161 Dlseasesofthegenitourlnarysystem...... 560-629 1,915 663 1,252 62 746 446 662 . Calculusofkidneyendureter...... 592 225 143 62 104 64 36 * * Hyperpfeslaofprostate ...... 600 185 185 . . . 44 140 . . Compiicationsofpregnency,chiktbirth, endthepuerperium’. . . .630-676 594 . . . 594 592 . . . * * Abotfions andectopic and molarpregnancies ...... 630-638 133 . . . 133 132 . . . Diseasesoftheskin andsubcutaneoustlesue ...... 860-709 451 214 237 37 129 105 180 Mellulftisendabacasa...... 681-682 304 146 155 23 34 76 111 Dieeases of themusculoskeletsf system andconnecflve tlSSue...... 710-739 1,561 697 874 37 461 433 611 Arthropathieeend relateddleordere...... 710-719 541 215 325 11 111 114 305 . Intervertebraidlscdlsordere...... 722 391 219 172 206 131 55 Congenttalanomslles ...... 740-759 150 82 89 105 28 10 “8 * . . Cetiain condfiione originating intheperinatal period...... 760–779 139 81 58 134 .Symptoms, signs, sndiil-definedcondifIons...... 760-799 327 153 174 53 134 87 53 Injuryendpolsonlng ...... 800-999 2,718 1,395 1,323 236 i ,007 515 959 Fractures, allsifes ...... 800=329 1,017 440 577 77 303 144 434 Fractureof neckoffemur ...... 820 307 72 235 ● *8 20 276 Intracreniai injuries (exdudingthose whh skull fracture) ...... 950-654 160 102 58 30 72 23 35 Lacetationeandopenwounde...... 970-9@t 171 129 42 20 107 25 20 .Supplementary claseKtcatlons...... vol-V82 4,419 166 4,251 57 4,110 105 147 . Femaleswithdellvertee ...... V27 4,015 . . . 4,015 11 4,001 ,..

‘The first-listed diagnoses for ferneles wth deliveries is coded V27, shown under “Supplenmntary c!assmcatioM” Advance Data No. 264 ● May 24,1995 5

Table 5. Rate of discharges from short-stay hospitals, by first-listed diagnosis, sex, and age: United States, 1993 her s of inpatients from non-Fedarel ho Itele. Exdrrdee newborn infants. Diagnostic grouphrge end coda numbers era basad on the krtemat/ona/ Ck’aaificatfon of %&~3th Reviakwr, CllrrkalModh7catlona &J4-CM)J

sax AGIS

Under 15 1544 45-64 65 years Category of first-lkted diagnosis end ICO-9-CM cods Total Male Female years years yeara and over

Atlcondifkxrs ...... 1,202.1 964.2 1,407.9 377.3 845.5 t ,268.1 3,415.7 Infeotlous andparaeitic diaeasae ...... 00I-IW 31.1 31.3 30.9 28.6 19.7 24.3 64.7 Septicemia ...... 036 10.5 9.5 11.5 3.2 2.4 8.9 64.9 Neeplaems ...... 140-239 72.3 60.9 83.2 7.0 29.5 117.8 270.0 Metignent naopfaams ...... 140-208.230-234 57.8 55,3 60.1 5.5 15.4 92.6 247.4 . Metlgnsnt neoplasm of large Intestine and reotum ...... 163-154.197.5 6.1 5.9 6.4 ●0.6 9.3 31.5 . Mstignsnt neoplasm of traohea, bronchus, end lung . . ...162.197.0.197.3 7.6 9.2 6.1 “0.6 15.1 33.9 . * Mslignsrrf neoplasm of breast ...... 174-175.198.81 6.6 12.7 3.0 12.4 21.5 Benign neopiaams end neoplaarns of uncwrtsfn behavior end unspedflsd nature ...... 210-221r,235-233 14.5 5.5 23.1 -t .4 14.2 25.2 22,7 Endoorfne, nutritional end metsbollc dia8esas, endimmuntly dfeorders ...... 240-279 47.2 38.5 55.4 15.9 21.8 60.6 17f.9 Dlabates rnsllttus ...... 250 18.1 17.0 19.1 2.6 10.2 28.8 55.4 Volumadapletion ...... 276.5 13.5 10.4 16.5 10.0 4.3 10.1 57.7 Disasaes of the blood and bkrod-forming organs...... 280-289 12.7 11.9 13.5 8.9 8.5 12.8 34.4 Mentetdleordsra ...... 230-319 71.3 77.0 65.9 13.2 92.8 75.8 87.7 Psydrosas ...... 280-299 41.1 40.1 42.0 5.3 46.1 47.9 67,8 * Aloohol dependence syndrome ...... 303 9.8 15.5 4.5 14.9 12.5 4.1 Diesaaee of the nervous system and sense organs ...... 320-363 26.5 25.0 28.0 16.6 15.3 31.1 76.9 Dlseeees of the centrat nervous system ...... 320-336.340-343 10.8 9.8 12.1 5.2 8.3 12.3 27.6 Disaeeeeof lheeersnd meatokfprooass...... 380-3S9 4.6 4.7 4.5 9.1 1.5 4.0 9.0 Dkmeeasoftheckculetoryey item...... 390-K3 219.6 231.6 208.4 4.4 35.9 322.7 1,093.9 Heertdlseeaa ...... 391 -382.0,3834S8,402,404,41 0-416,42048 1!%1 166.8 142.1 2.4 20.6 235.4 771.3 * Acute rnyocardiaf infercfion ...... 410 29.0 34.9 23.5 4.0 50.5 136.0 * Coroneryatheroscfameis ...... 414.0 192 25.8 12.9 2.2 42.1 78.7 . Otheriachemic heart diea@3 ...... 411-413,414.1-414.9 32.8 35.9 29.9 3.8 60.3 152.0 . Canliacdyarhythmlee ...... 427 21.4 21.5 21.4 3.5 24.9 115.8 . Congaatlve traertfalhrm ...... 428.0 34.1 31.6 36.5 1.8 34.1 207.6 . Cersbrovsecular cWsass...... 430—436 32.8 30.9 34.6 3.2 34.7 192.0 DWesasofth ere~ir8forysy etem...... 460-519 122.5 122.8 122.4 117.6 33.3 116.3 436.2 Acute reaplretory hrfaoflons...... 460+66 15.6 16.4 14.9 38.2 5.3 82 2%2.7 . Chronlcdissaas oftonsllssrrd adenokfe...... 474 1.4 1.3 1.5 4.5 0.8 Pneumonia ...... 4S0-466 46.2 46.0 44.5 36.9 12.1 38.5 195.9 Asthma ...... A83 18.3 15.3 21.1 28,0 fo.9 19.0 26.6 Diawweaofthe dlgaetlvesydem...... 620-579 120.1 109.0 130.5 36.3 74.9 163.6 361.2 Utceraofthe stomech arrdsrnsl lintesfhre...... 531-5W 8.4 9.1 7.7 * 2.9 12.4 36.6 Appendldtis ...... 540+13 8.7 10.5 7.0 8.3 11.2 5.8 4.8 Ingulnal hernia ...... 550 3.3 8.1 *0.6 ●I.4 1.4 3.8 12.2 Nonhrfecflous enterll!s sndcolitle ...... S55-55S 13.7 11.1 16.0 15.3 9.1 12.3 29.0 Clrolellfhleefs...... 574 18.6 10.8 25.9 ● 14.3 23.5 49.0 Diseaaasofthegenltorrrhtsrysyetem...... 560-623 74.7 53.2 95.0 10.9 63.6 89.9 201.8 * Csfcrrlueofktdneysndureter...... 582 8.8 11.5 6.2 8.8 16.9 11.1 * ● Wfmrpkraieofprostate ...... 600 7.2 14.8 . . . 8.9 42.7 * . Co~il*lonsofpmgnmq, M#&inh, andthepuerpsrttrmt. ., . . ...630-676 23.2 . . . 45.1 50.4 . . . * . Abortionssndeotoplc errdmolerpmgnenctea ., ...... 630-639 5.2 . . . 10.1 11.3 . . . Dtaeaassofthestdn endsuboutsmaoustiesue ...... 680-706 17.6 17.2 18.0 6.5 11.0 21.3 54.8 Cellulltlsandabeoass ...... 661-662 11.8 11.9 11.8 4.1 8.0 15.3 33.7 DLsaasasofthemtrsouloakeletal systemendoonnecfive tissue...... 7lO-733 80.9 55.1 66.3 6.5 41.0 87.4 166.3 Arfhropathlesandrelataddiaordara...... 710-719 21.1 17.3 24.7 1.9 9.5 22.9 63.0 . hrtervertabratdlecdteordera...... 722 15.3 17.6 13.0 17.5 26.3 16.7 Congenlfalarromstles ...... 740-759 5.9 6.5 5.2 18.5 2.3 2.0 “2.4 . . Certehr condttlons originating lntheperinatat period...... 760-779 5.4 6.5 4.4 23.6 . Syn@ome, signs, sndlffdatlrrad conditions ...... 780-798 12.7 12.3 13.2 9.3 11.4 17.5 16.3 Injury sndpoisonkrg ...... 800-898 106.0 112.0 100.4 41.9 65.8 103.9 232.3 Fredures,elislfes ...... 800-629 39.7 35.3 43.8 13.5 25.8 29.1 150.7 * Fradureofneokoffemur ...... 620 12.0 5.8 17.8 -0.7 4.1 64.1 Intmcmnlel injutfas (sxdudingthoeswllh skuilfrscture) ...... 650+51 6.2 8.2 4.4 5.3 6.1 4.6 10.7 Laoamtlonserrdopsnwounds ...... 870-804 6.7 10.4 3.2 3.5 9.1 5.1 5,9 Suppkmtentaryclsssifications...... VO1-V82 172.3 13.5 322.4 10.1 350.3 21.1 44.8 * Fernslaswith dallverlas ...... V27 156.8 . . . 304.5 2.0 S41.o . . .

I/The first-listeddi~noses forfsmake withdeliveriesis mdsd V27, shovrnunder %upplamntary daa$ifiostions.” 6 Advance Data No. 264 ● May 24,1995

Table 6. Average length of stay for discharges from shoti-stay hospitals, by first-listed diagnosis, sex, and agw United States, 1993

her es of Inpeflents from non-Fedaral ho Itala. Excludes newborn Infants. Diagnostic groupln~ end coda numbacs are based on the /rrternat/ofra/ C/ass/fket/ofr of !&ass!, gfhi+.wkkm, Cllnti\ModMmt[om$L=M)]

Sex Age

Under 15 15-44 45-64 65 yeais Category of flfat-listed diagnosis and lCIM&CM mde Total Male Female yeara years years and over

Numberofdays Allcondltlons ...... 6.0 6.5 5.6 5.2 4.2 8.2 7.8 infectious and parasitic diseases...... 001–139 7.9 6.4 7.5 4.4 7.7 9.5 9.6 Septicemia ...... 038 10.6 10.9 10.3 7.7 11.7 12.1 10.3 Neoplaeme ...... 140-238 7.4 8.3 6.7 7.2 4.8 7.3 8.4 Malignant neoptaams ...... 140-208.230-234 8.1 8.5 7.7 7.0 6.1 8.0 8.6 . Metlgnant neopiaem ofisrge intestine end rectum ...... 153-154.197.5 11.0 10.5 11.4 “9.3 9.8 11.7 . Malignant neoplaam oftrachea, bronchus, and lung . . . .162,197.0,197.3 8.7 8.4 9.0 “6.5 8.6 8.9 . . Malignant neopleemofbraaef...... 174–175,198.81 3.7 3.7 3.2 3.9 3.6 Benign neoplasme and neoplasma of uncertain behavlorand unapeclflednature ...... 210-229,235-’239 4.5 5.9 4.1 “8.0 3.5 4.5 6.1 Endocrfne, nutritional and metabolic diseases, andlmmunify dlaorders ...... 240-279 6.6 6.4 6.7 4.1 5.2 6.1 7.8 Diabetes rnallitus ...... 250 7.5 7.2 7.7 4.5 5.0 7.3 9.6 Volume depletion ...... 276.5 5.9 5.5 6.2 2.7 6.2 5.2 7.0 Diseaees of the blood and blood-formlng organs...... 260-289 5.8 5.7 5.9 4.5 5.3 5.8 6.8 Menfeidlsordare ...... 290-319 10.3 9.6 10.6 14.5 9.3 10.5 12.5 Psychoses ...... 290-289 12.0 11.6 12.3 16.1 10.9 12.4 13.7 . Alcoholdependencesyndrome...... 303 8.5 6.2 9.3 6.4 8.5 9.2 Diaeaeesoflhe nefvouseystemand aeneeorgsns ...... 320-389 5.4 5.7 5.3 4.2 5.1 5.2 6.3 Dlseaeesofthecenfral nervous system ...... 320+38.340-349 8.5 9.1 8.1 6.2 6.7 8.1 11.5 Dleeaaasoftheearandmaafoldproceae...... 380-389 3.1 2.5 3.7 3.4 2.0 2.9 3.5 Diseaeesoftheclrculatoryayetem...... 380-452 6.7 6.3 7.0 5.2 5.3 5.9 7.2 Heartdiseaae ...... 391 -392.0,393-338,402,404,410-41 6,420422 8.3 6.0 6.6 5.8 4.7 5.5 6.8 Acute myocardlal inferctton ...... 410 7.4 7.0 7.8 . 5.5 6.6 8.0 . Coronary atherosclerosis ...... 414.0 6.0 5.6 6.7 4.1 5.2 6.9 . Other iechemtc heart dleeaaa ...... 411-t13,414.l-114.9 4.5 4.5 4.6 3.2 4.1 4.9 . Cardiac dyerhythmlas ...... 427 4.6 5.0 4.7 2.7 4.4 5.2 . Congaaflveheartfallure ...... 428.0 7.5 7.0 7.3 6.2 6.5 7.6 * Cerabrovaaculerdlsaasa ...... 430-436 8.4 6.1 8.7 9.0 8.3 8.4 Dlseaaasoftheraephatoryeyatem ...... 460-519 6.7 6.5 7.0 3.8 4.9 6.9 8.6 Acute respiraforyinfections ...... 480-4W 4.0 3.6 4.4 3.2 3.6 4.4 6.4 Chronlcdlsmaaoftonsilssndadenokfa...... 474 1.3 1.2 1.3 1.3 1.2 * neumonia . . . .’ ...... 43- 7.6 7.6 8.0 4.6 6.6 7.4 9.2 Asthma ...... 493 4.4 3.6 4.9 3.4 3.5 5.4 6.7 Diaeaaesofthe digestlvesystem ...... 520–579 5.7 5.6 5.7 4,0 4.4 5.4 7.1 . Ulceraofthe stomach andsmallinteatlne...... 531-534 6.7 6.5 6.8 4.9 6.1 7.5 Appendlcltls ...... 540-543 4.5 4.6 4.3 5.0 3.6 5.1 8.7 Anguinathernia ...... 550 2.7 2.6 “4.8 “2.5 1.6 1.9 3.7 Noninfectious enteritis sndcoiltls...... 555-558 4.8 4.6 5.0 2.5 4.0 5.5 7.8 . Cholellthiaeis ...... 574 4.2 4.8 4.1 3.3 3.2 6.1 Dieeaaesofthegenttourhrrysystem...... 580-829 4.5 4.7 4.4 4.1 3.4 4.0 6.1 . Ceiculusofktdneymd ureter...... 532 2.9 2.8 3.2 2.8 2.6 4.0 . . Hyperplaeieofprostate ...... 600 3.8 3.8 . . . 3.3 3,9 . . Complicationsofpregnancy,chiidbirth, andthepuerperium’...... 630-676 2.6 . . . 2.6 2.6 . . . . . Abortions andectopicand molarpmgnancles ...... 830-638 2.0 . . . 2.0 2.0 . . . Dieeaaesoftheskhr andsubcufaneoustlasue ...... 880-703 7.6 7.9 7.3 3.9 6.5 7.5 9.2 Cellulitiearrdabscaes ...... 881-882 6.6 6.7 6.4 3.8 5.8 6.8 7.7 Dteaaeeeofthemueouloekeletel syetemand connective tissue...... 710-733 5.8 5.1 6.4 4.7 3.7 4.8 8.2 Arthropathtesend relsteddlaordere...... 710-719 6.8 6.0 7.4 4.2 3,3 6.1 8.5 * Interverfebretdiacdlaordara...... 722 4.0 3.6 4.5 3.5 3.9 5.9 Congenitaienomeiiee ...... 740-759 6.7 6.1 7.3 7.2 4.6 4.8 “6.0 . “ . Certahr condttlons originating lntheperlnatai petiod...... 760-779 11.3 11.3 11.3 11.5 symptome, signs, endill-deflnedcondiflons ...... 780-799 2.6 2.7 2.8 3.1 2.4 2.3 4.1 Injuryandpoiaonlng ...... 800--339 6.4 5.8 6.9 4.6 4.8 6.3 8.5 Frectfrres, aiisites ...... 8~29 7.5 6.7 8.0 4.3 5.6 6.4 9.4 . Fracfureof neckoffemur ...... 820 10.3 10.5 10.2 “10.1 to.4 10.3 Intrecrsnlal lnjurlas (excludlngthosewtih skuiifreoture) ...... 850-854 7.3 7.1 7.5 2.9 7.5 7.5 10.5 Lacerafionsandopenwounds ...... 670-904 3.7 3.5 4.2 3.3 3.0 4.5 6.3 Supptamantaryctassificattons...... VOI-V82 2.9 8.3 2.7 6.1 2.5 6.0 11.9 . Femeteswlth daliverfes ...... v27 2.4 2.4 2.6 2.4 . . .

'The fir%t-li8teddiagnoses for fem?Jestithdefiverba baled V27, shown under’’Supplmmtatycf a88Frarfiom” Advance Data No. 264 ● May 24,1995 7

Table7. Number of all-fistedprocedures for discharges from short-stay hospftafa,by procedure category,se% and age: United States, 1993

~%~f iPti..kfm.mn-FeAA hWti*.=d.&snehlnfm!s. PmmdmgmWIn@mdm nu*aeba~ontie/tiem~n~ ~/~ht/onot FfeWon, C//rr/ca/IWIW/cefforrs ([CD-3-CM)]

sax ALE

Undsr 15 1544 45-64 65 years Pmedure category arrd CD-3-CM code Total Male Female y&ars years years errd over

Nu*frrthousende

All Procedures ...... 41,606 16,142 25,466 1,863 16,021 9,178 14j546 Operelkmsonfhenervouss ysfem...... 01-05 309 448 460 166 327 163 211 Splneftep ...... CB.31 334 166 166 140 66 47 58 . Operaffons on fheendoufne system...... 0647 90 25 64 30 35 22 Oparetiorrs on fheeye ...... C8-16 331 166 203 19 63 81 206 Operations ontheear ...... 18-MI 83 4s 35 40 22 13 “8 operaffons onthen~, mwfh,sndpherynx...... 21-23 390 213 177 77 163 64 66 . Torrsflfecfomywlthorwlfhwt adenokfecfomy ...... 28.2-28.3 50 24 26 31 16 . Operefforrson fhere@reforysystam...... 30-34 986 554 432 46 167 277 475 Bronohoscopywfthorwfthouf bbpsy...... 33.21-33.24.33.27 301 173 126 13 56 68 142 Operetfonson thecardbvaswiar system ...... 35-s9 4,410 2,619 1,791 131 486 150 2&4 . Removslofcoronery artery obstruofon...... 36.0 ~8 266 130 30 165 163 Coroneryarfery bypess@t l/...... ,...... 36.1 465 353 1s3 21 205 260 CerKfiecoefheterfzafbn ...... 37.21-37.23 1,010 613 397 14 90 420 465 hrserffon,nspfacement, removat, end revfdon . * ofpaoemaker feadeordevice ...... 37.7-37.8 281 147 141 42 232 . Shunt orvescular b~ ...... 33.0-39.2 773 99 74 19 56 94 * f-femodlelysfs...... , ...... < ...... 39.95 328 168 161 73 117 137 Opsratfons onthehemio andlyr@mkey sfem...... 4O+ 377 197 161 22 63 117 176 Opemfionson fhedigesfive system ...... &-= 5,Q96 2,106 2$90 169 1,376 1,342 2$210 Endoscopyof small lntsstinewlth orwifhoufbbpsy ...... 45.1145.14$.16 632 367 465 11 143 207 471 . En&+d~lnfeSl~wMorwHhd~~...... 45.21 -45.26 517 211 306 74 133 307 . Parffafexdsbn of fargeinteeffne ...... 45.7 207 93 113 24 60 120 Appendectomy, exdudirrgirrddentel ...... 47.0 250 135 115 49 146 35 17 . Chotecyalesfomy...... 51.2 502 146 354 162 Im 166 Rapefroflngulnelhemfa ...... 53.0-53.1 109 96 13 10 19 27 54 * Lysbofpsrffoneela~esbns ...... 54.5 347 58 269 171 84 90 Operatforrsonfheurfnerysystem...... 56-59 653 610 35 317 all 570 . CySoacopywffhorwfltroutbk$wy...... 57.31-57.s3 326 211 118 60 63 161 Operallonsonfhemsbgerrkrtorgsrrs...... W-64 466 466 . . . 30 Xl 96 312 . Prosfatecfomy...... 60.2-60.6 317 3f7 ...... 66 250 Operaffonsonfheferrrsbgenffeforgarrs. , ...... 65-71 2,197 . . . 2,197 ●6 1,464 492 245 . Oophoractomyands@rgo-oophorectomy ...... 65.3-65.6 443 . . . 443 225 164 52 . Bkderatdestrudbrr orocdusbn offsfbpiarr tubas ...... 66.2W56.3 364 . . . 364 363 . . Hysterectomy...... 66.3-68.7.66.9 562 . . . 562 326 172 63 . DfiatbnandcurWa~ofufwus...... W.O 127 . . . 127 99 19 “9 Ra@frcfoystocebandreckwafs...... 70.5 159 . . . 153 41 60 56 . Obsfetrbafprccechrres ...... 72-75 6,763 . . . 6,763 19 6,740 . . . Epfsfofomywifhor wifhoutforcepsor . vacuumextradfon...... 72.1,72.21,72.31,72.71,73.6 1,!s62 . . . 1562 1,555 * . . . * AdKfdafn@ureofmwnbrenes...... 73.0 744 . . . 744 742 . . . . Ceearesnesctbrr ...... 74.0-74.2.74.4.74.39 917 . . . 917 . 915 . . . . . FetatEKG (ecf@)andfetelmorrifodng, nototherwbeapecKled . . . .75.32.75.34 1,142 . . . 1,142 1,136 . . . . . Rspelrofcummtobstetrfole.cerdon ...... 75.5-75.6 860 . . . 860 857 . . . . OpemfkmsonthemuacoloskebtafeySem ...... 76-S4 3= 1,6+10 1,623 151 1,2W 796 1,a43 . Parffafexdsbnofbone ...... 76.2-76.3.77.6-77.6 227 123 104 86 76 50 Openredudbnoffracfurewffhintemeffixstbn ...... 79.3 423 175 247 13 142 79 183 . ExofdonordeetrucffonofinfervertebmtcW ...... 80.5 S33 163 150 175 115 44 * Totafhfpre@aoernenf...... ,...... 81.51 125 51 74 9 31 63 . . Tofsffmesmpkwernsnt ...... 81.54 179 62 117 42 131 @etibwontielnteguwti~sy9m...... 65-86 1,364 565 799 74 475 364 450 * . Mastectomy ...... 85.4 124 123 24 43 57 DeMdementofwound,fnfedlon,orbum ...... 26.22.66.28 334 764 150 20 106 66 118 Sfdn@f...... 86.6-66.7 120 69 51 11 46 28 34 Mbcakmewsdlegrrcetfcandtherspeufloprocedures...... 87-39 13s99 6,455 7,143 654 3,036 3,S91 6,3f5 Compuferfzedsxleltomography ...... 87.03.87.41 ,67.71,66.01,66.36 1,156 565 534 59 272 251 576 * Pyetogram ...... 87.73-87.75 197 106 89 73 59 6f Ati~~~wdm@ti~q~u~ng~tut~eW...... 68.4-66.5 1,731 1,024 706 19 163 663 6?XJ Dfagrrcdouffraeound ...... 86.7 1,420 572 646 60 354 318 666 CkWM~~nkOfing ...... 68.6 505 239 266 23 69 12? 271 Redbkrfopsscan ...... S2.&92.l 412 173 239 12 68 103 222 Raspkatorytherapy...... s3.9 676 427 449 165 117 165 409

‘Thenumberofdischargeawithacorontiryartery bypassgraftwas3fW,C00. 8 Advance Data No. 264 ● May 24,1995

Table 8. Rate of all-listed procedures for discharges from short-stay hospitals, by procedure category, sex, and age: United States, 1993

her es of inpatients from non-Federsl hos We. Excludes newborn infants. Procedure groupings and coda numbets are baaed on the Interrratlonal C/assif/cat/on of E%aa!,Wrf7evlekm, C/lnlm/Mod#/@t/ons (kDWM)]

Sex Age

Under 15 15-44 45-64 65 years Procedure category and K-XI-9-CM code Total Male Female years years vears and over

Allprocedures ...... 16,225.6 12,955.9 f9,315.6 3,283.4 13,653.6 18,521.8 44,360.0 Operatlonsonthe nervoussysfem ...... o1-05 354.5 360.7 348.6 330.9 278.5 369.4 644.6 Spinattap ...... 03.31 130.1 134.6 125.8 247.0 75.3 93.8 178.4 . Operafionsontheendoctfne syefem ...... 06-07 35.0 20.2 48.9 25.2 70.9 65.8 Operefionsontheeye ...... 06-16 152.4 151.1 153.7 34.1 70.4 163.2 634.5 Operationsontheear ...... 16-20 32.5 38.4 26.8 89.9 19.1 25.9 “25.8 Operations onthenosa, mouth,and pharynx ...... 21-29 152.2 171.3 134.1 135.7 136.7 170.3 201.6 . Tonefllecfomywith orwithout adenoldecfomy...... 28.2-28.3 19.6 19.1 20.0 54.3 13.6 . Operationsonthe respiratory system ...... 30-34 384.4 444.7 327.4 80.7 159.7 559.3 1,449.9 Bronchoscopywllh orwlthoutbiopsy...... 33.21-33.24.33.27 117.3 138.6 97.2 23.7 49.5 176.8 432.2 Operstionsonthecardlovaecularayafem ...... 3~~ 1,719.8 2,102.0 1,358.7 230.0 414.2 3,148.5 6,811.7 . RernovalofcoronaryarfeIyobslructon ...... 36.0 155.3 215.2 98.7 25.6 372.9 556.4 Coronaryarterybypaaegraffl/...... 36.1 189.3 283.2 100.5 17.9 413.2 791.8 Cerdiaccatheterlzdlon ...... 37.21-37.23 393.8 491.6 301.3 24.9 76.7 648.2 1,479.8 InsertIon, replacement, removal, and revision * . ofpacemakertaadsordevice...... 37.7-37.8 109.6 112.8 106.6 85.0 708.2 . Shuntorvaecuhvbypaee...... 39.~9.2 67.5 79.4 56.2 16.4 116.0 285.5 . Hernodiaiyele ...... 39.95 128.1 134.5 122.1 62.3 235.9 419.1 Opsratkmsonthe hemicend lymphatlcsystem ...... 40-41 147.1 157.7 137.0 38.4 53.5 235.6 536.2 Operstkmsonthedlgeetiveeyafem ...... 42-U 1,987.4 1,690.7 2,267.7 298.6 1,172.3 2,707.5 6,738.7 Endoscopy ofarnall intestine wlthorwllhout biopsy. . .45.11 -45.14,45.16 324.5 234.3 353.0 18.9 121.8 418.1 1,437.1 * Endoscmpy oflarge intestine wlfhorwlthout biopsy ...... 45.21 -45.25 201.7 169.6 232.0 62.7 268.0 936.0 . Parflet exdelon oflarga intestine ...... 45.7 80.6 74.8 86.0 20.8 120.6 367.3 Appendectomy, exdudingincldental ...... 47.0 97.5 106.5 87.1 87.2 126.4 71.2 52.0 . Cholecyetecfomy ...... 51.2 195.6 118.6 268.4 155.4 302.2 512.8 Repalrofinguinal herni a...... 53.~53.l 42.6 77.3 9.9 18.0 16.0 53.7 163.7 . Lysisofperitonealadheslons...... 54.5 135.5 46.7 219.3 145.3 169.7 273.6 Operafionsontheurlnarysyatem...... 55-59 492.4 524.0 462.5 61.1 270.4 668.1 1,737.3 . Cyatoecopywlth orwithoufblopsy...... 57.31-57.33 128.2 169.2 69.4 51.3 166.8 552.8 Operatkmsonthe rnalegenlfalorgans...... 6~64 182.6 375.8 . . . 53.3 25.4 193.4 952.2 . prostatectomy ...... 60.2+o.6 123.7 254.6 ...... 133.5 761.3 Operafionsonthefemale genifalorgans ...... 65-71 856.6 . . . 1,666.0 “10.0 1,238.9 993.0 747.6 . Oophorectomy endaalpingo-oophorecfomy...... 65.=5.6 172.6 . . . 335.6 191.7 331.3 159.7 “ * Bilateral deetrudlon orocclusbnof falloplantubes ...... 66.2-66.3 149.6 . . . 2el .0 326.4 . . . . Hysterectomy...... -. - ...... 68-~8.7.68.9 219.0 . . . 426.0 278.2 347.1 191.5 Dilationandcureftageofuterus...... 69.0 49.6 . . . 96.4 ● 84.6 38.7 “26.1 Repalrofcystocelaandrecfoceb ...... 70.5 62.1 . . . 120.8 35.1 121.5 176.5 * Obsletrtcalprocedurse ...... 72–75 2,637.3 . . . 5,129.6 33.9 5,743.7 . . . Eplelotomywifhor withoutforcapeor . . vacuumexfrsctton ...... 72.1,72.21,72.31,72.71,73.6 606.9 . . . 1,164.4 1,325.6 . . . . * Artlffciaf ruptureofmembranes...... 73.o 290.3 . . . 564.6 631.9 . . . . * Ceesrean.wdlon ...... 74.0-74.2,74.4,74.99 357.7 . . . 695.8 780.0 . . . . Fetaf EKG (sca~)endfetaJ monltorlng, nototherwlse epecffled . .75.32,75.34 445.5 . . . 866.4 * 970.4 . . . . . Fmpalrofcurmntobetetrklacemtlon ...... 75.5-75.6 X35.3 . . . 652.2 730.0 . . . Operefionsonthe musculoskeletsl system...... 76-34 1,256.9 1,264.5 1,230.9 265.6 1,049.2 1,610.2 3,182.2 . Parflal excieion ofbone ...... 76.2-76.3,77.6-77.8 88.6 98.8 78.9 82.1 152.8 153.1 Open reducflon offracturewlfh interneJ Wdbn...... 79.3 164.8 140.8 187.4 23.0 120.8 159.7 575.0 . Exc!slon ordestmcfion oflntewerfebrd disc ...... 80.5 130.0 147.2 113.7 148.8 231.5 133.7 . Totathipraplacement ...... 81.51 48.8 41.1 56.1 7.8 ‘63.4 252.5 . * Totalkneereplacement ...... 81.54 69.7 49.8 6s.5 85.5 400.0 Operaflonson theintegumentary system ...... 85-86 531.7 453.5 605.7 129.8 405.2 735.2 1,372.7 . . Mastectomy ...... 85.4 48.3 93.1 20.2 86.8 173.1 Dsbridamantofwound, infedion, orbum ...... 86.22.86.28 130.2 147.9 113.5 35.1 91.9 176.8 361.3 .Wfngraft ...... - ...... 86.~67 46.7 55.4 38.4 18.9 39.6 57.2 104.0 Miecallaneousdiagnostlcandtherepeutic procedures ...... 87-99 5,302.9 5,181.3 5,417.9 1,505.4 2,589.2 6,843.1 19,259.2 Corrqmterizedexls!tomography ...... 87.03,87.41,87.71,66.01,66.= 451.8 453.3 450.3 104.4 231.9 505.9 1,757.9 . Pyelogmm ...... - . . . ..87.7~7.7~ 76.8 86.4 67.8 62.1 118.4 187.2 Arteriography andangiocardlography udngcontrasfm aterld. . . . .88.4-68.5 674.9 822.2 535.7 33.2 156.0 1,410.4 2,531.1 Diagnostlcultraaound ...... 86.7 553.9 459.3 643.2 105.9 302.0 641.7 2,097.6 Circulatoymonltoring ...... 896 196.9 192.0 201.5 40.3 75.6 246.7 626.7 Radlolaobpescan...... 92.0-92.1 160.6 139.1 181.0 21.3 59.0 219.8 676.1 Res@afoiytherepy...... 93.9 341.7 342.6 340.8 326.2 99.4 333.1 1,246.2

%te rate per IOO,COO popubtion of dmcharges wfih a mmnary aflery bypass grafl was 120.8. Advance Data No, 264 ● May 24,1995 9

Technical notes on a stratified three-stage design. The confidential information and are not first stage consists of a selection of 112 available to the public.) Survey methodology primary sampling units (PSU’S) that comprise a probability subsample of Presentation of estimates Souroe of data PSU’S to be used in the 1985-94 The relative standard error of the National Health Interview Survey. The TheNational Hospital Discharge estimate and the number of sample second stage consists of a selection of Survey covers discharges from records on which the estimate is based noncertainty hospitals from the sample noninstitutional hospitals, exclusive of (referred to as the sample size) are used PSU’S. At the third stage, a sample of Federal, military, and Department of to identify estimates with relatively low discharges was selected by a systematic Veterans Affairs hospitals, located in the reliabfity. random sampling tectilque. 50 States and the DMrict of Columbia Because of the complex sample Only short-stay hospitals (hospitals with Two data collection procedures design of the NHDS, estimates of less an average length of stay for all patients were ‘used for the survey. The first was a than 5,000 are not presented; only an of fewer than 30 days) or those whose manual system of sample selection and asterisk (*) appears in the tables. These specialty is general (medical or surgical) data abstraction. The second was an estimates generally have a relative or chikhn’s general are included in the automated method used for standard error of more than 30 percent survey. These hospitals must also have approximately 32 percent of the or are based on a sample of fewer than six beds or more statTed for patient use. respondent hospitals in 1993, that 30 cases. Estimates of 5,000 to 9,000 From 1988 through 1990, the involved the purchase of data tapes from are preceded by an asterisk (*) to NHDS sampling frame consisted of abstracting service organizations, State indicate that they should not be assumed hospitals that were listed in the April data systems, or hospitals. to be reliable. These estimates rue 1987 SMG Hospital Market Database In the manual system, the sample generally based on fewer tlan 60 cases. (3), met the above critefi~ and began selection and the transcription of accepting patients by August 1987. In information ffom the hospitrd records to 1991 the sampling fmme was updated to Sampling errors and rounding abstract forms were performed at the include hospitals from the 1991 SMG of numbers hospitals. The completed forms, along Hospital Database (4). For 1993, the with sample selection control sheets, The standarderroris primarilya sample consisted of 528 hospitals. Of were forwarded to NCHS for coding, measure of sampling variability that the 528 hospitals, 15 were found m be e&ting, and weighting. Of the hospitals out of scope (ineligible) because they occurs by chance because only a sample went out of business or otherwise failed using the manual system in 1993, tibout rather than the entire universe is to meet the criteria for the NHDS 55 percent had the work performed by surveyed. The relative standard error of universe. Of the 513 in-scope (eligible) their own medhl records staff. In the the estimate is obtained by dividing the hospitals, 466 responded to the survey. remaining hospitals using the manual standard error by the estimate itself and system, personnel of the U.S. Bureau of is expressed as a percent of the estimate. Sample design and data collection the Census did the work on behalf of The resulting value is multiplied by 100, NCHS. so the relative standard error is TheNCHShas conducted the For the automated system, NCHS expressed as a percent of the estimate. NHDS continuously since 1965. The purchased tapes containing machine- Estimates of sampling varialMity original sample was selected in 1964 from a frame of short-stay hospitals readable medka.1 record data that were were calculated with SESUDAAN listed in the National Master Facilby systematically sampled by NCHS. software, which wmputes standard Inventory. That sample was updated The medical abstract form and the errors by using a first-order Taylor periodically with samples of newly automated data tapes contain items approximation of the deviation of opened hospitals. Sample hospitals were relating to the personal characteristics of estimates from their expected values. A selected with probabilities ranging horn the patien~ including birth date, sex, description of the software and the certainty for the largest hospitals to 1 in race, and marital status, but not name approach it uses has been published (5). 40 for the smrdlest hospitals. WMin and address; administrative information, The constants for relative standard each sample hospital, a systematic including admission and discharge dates, error curves for the 1993 National random sample of discharges was discharge status, and medical record Hospital Discharge Survey m presented selected. A report on the design and numbm and medical information, in table I. The relative standard error development of the original NHDS has including diagnoses and surgical and RSE(X) of an estimate X maybe been published (l). nonsurgical operations or procedures. estimated horn the formukc Beginning in 1988, the NHDS Since 1977; patient ZIP Code, expected RSE(X) = 100 -X sample includes with certainty all source of paymen~ and dates of surgery hospitals with 1,000 beds or more or have also been collected. (The medical where X, @ and bare as detied in 40,000 discharges or more annnalIy. The record number and patient ZIP Code are table I. remaining sample of hospitals is based 10 Advance Data No. 264 ● May 24, 1995

Table L Estimated parameters for relative standard error equations for National Hospital rtdmission to (but not including) the date Discharge Survey statistics by selected characteristfca: United States, 1993 of discharge. Number of Average length of stay-The number discharges or Number of first-listed diagnoses procedures of days of care accumulated by patients discharged during the year divided by Charaderietlc a b a b the number of these patients.

Total...... 0.00129 1,082.615 0.00178 483.926 Terms relating to diagnoses Sex Male ...... 0.00425 332.S43 0.00661 273.720 Diizgnosis-A disease or injury (or Fernate ...... 0.00304 417.946 0.003s6 636.779 factor that influences health status and

Age contact with health services that is not Undar15years ...... 0.06552 110.056 0.03770 110.109 it8elf a current illness or injury) on the 15-44 year9 ...... 0.00818 245.201 0.00s63 304.399 medical reeord of a patienL 45-64years ...... 0.00826 182.876 0.00509 127.555 Principal diagnosis—The condition 65yeareandover ...... 0.00410 314.867 0.00176 551.656 established after study to be chiefly Region responsible for occasioning the Northeast ...... 0.00282 307.085 0.00561 321.543 admiision of the patient to the hospital Midwest ...... 0.00686 660.696 0.00648 212.188 for care. South ...... 0.002s9 543.012 0.00373 418.823 First-listed diagnosis-The coded west ...... -0.00193 1,689.447 0.0065S 1,0s7.077 diagnosis identified as the principal diagnosis or listed tlrst on the face sheet or discharge summary of the lmedical E&imateshavebeen rounded tothe hospitals, hospitril units of institutions, record if the principal diagnosis cannot nearest thousandth. Forthis reason, and hospitals with fewer than six beds be identified. The number of first-listed figureswithintables donotalwaysadd st.aEed for patients’ use. dwoses is equivalent to the number of tothetotals.Rates andaveragelengths Patient—A person who is formally discharges. ofstay werecalculated from original, admitted to the inpatient service of a unrounded figures andwillnot short-stay hospital for observation, care, Terms relating to procedures necessarily agree precisely with rates or dmgnosis, or treatment. The terms average lengths of stay crtlculated from “patient” and “inpatient” are used Procedure—A surgical or rounded data. synonymously. nonsurgical operation, diagnostic patient admitted precedure, or special treatment reported Testsof significance Newborn infant—A by birth to a hospital. on the medical reeord of a patient. In this repro% statistical inferenee is Discharge—The formal release of a Beginning with the 1991 data, all based on the two-tailed t-test with a patient by a hospital that is, the ICD-9-CM procedure codes are used in critical value of 1.96 (0.05 level of termination of a period of the NHDS. Previously selected codes, primarily codes for miscellaneous significance). Terms such as “higher” hospitrrliiation by death or by diagnostic and therapeutic procedures, and “less” indicate that dflerences are deposition to place of residence, nursing were not used. statistically significant.. Terms such as home, or another hospital. The terms All-1istedprocedures—The number “simiiar” or “no difference” mean that “discharges” and “patients discharged” of procedures on the face sheet of the no statistically significant difference are used synonymously. exists between the estimates being medical reeord. In the NHDS a Discharge rate—he ratio of the maximum of four procedures are coded. compared. A lack of comment on the number of hospital discharges during a difference between any two estimates Rate of procedures—The ratio of year to the number of persons in the does not mean that the difference was the number of procedures during a year civilian population on July 1 of that tested and found not to be significant. to the number of persons in the civilii year. population on July 1 of that year Terms relating to Days of care—The number of determines the rate of procedures. hospitalization patient days accumulated by a patient at time of discharge. A stay of less than 1 Hospitals-AU hospitals with an day (patient admission and dkchrtrge on Demographic terms average length of stay for all patients of the same day) is counted as 1 day in the Population—The U.S. resident fewer than 30 days or hospitals whose summation of total days of care. For population excluding members of the specialty is general (medical or surgical) patients atiltted and discharged on Armed Forces. or children’s general are eligible for different days, the number of days of inclusion in the National Hospital care is computed by counting all days Age—Patient’s age at birthday prior Discharge Survey, except Federal from (and including) the date of to admiision to the hospital. Advance Data No. 264 ● May 24,1995 11

Geographicregion-Hospitals arc Symbols classifiedby location in one of the four --- Data not available geographicregions of the United States that correspondto those used by the . . . Category not applicable U.S. Bureau of the Census. Quant”Ryzero Regwn States included 0.0 Quantity more than zero but less than 0.05 Northeast. . . . Maine, New Hampshire z Quantity more than zero but less Vermont4Massachusetts, than 500 where numbers are Rhode Island rounded to thousands Connecticut New York New Jersey,and ● Figure does not meet standard of Pennsylvania reliability or precision (more than 30-percent relative standard error Midwest.. . . . Michigq Ohio, Illinois, in numerator of percent or rate) India Wisconsin, # Figure suppreaeed to comply with Minneso@ Iowa confidentiality requirements Missouri, North Dako@ South Dako@ Nebraslq and Kansas south ...... Delawm Marylau& District of Columbia Virginia WestViigin@ North Caro~& south Carolin% Georg@ I?lori@ Kentucky, Tennmq AlabQ Mississippi,Arkansas, Louisian&Oklahomajand Texas west...... Mona Idaho, Wyoming,Colorado,New Mexico,Arizom Utah, Nev~ Washington, Oregon,Califomi& HSWtil, and Alaska 12 Advance Data No. 264 ● May 24, 1995

Suggested citation Copyright Information National Center for Healthl Statistics

Graves EJ. 1993 Summary : National Hospital All material appearing in this report is in the Acting Director Discharge Survey. Advance data from vital public domain and may be reproduced or Jack R. Anderson and health statistics; no 264. Hyattsville, copied without permission; citation as to Acting Deputy Director Maryland: National Center for Health source, however, is appreciated. statistics. 1995. Jennifer H. Madans, Ph.D.

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DHHS Publication No. (PHS) 95-1250 5-1237 (5/95) Number 265 ● July 6, 1995 Advance I Data From Vital and Health Statistics of the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

Underreporting of Race in the National Hospital Discharge Survey by Lola Jean Kozak, Ph.D., Division of Health Care Statistics

Introduction non-Federsl general and short-stay discharge at the hospital, either by specialty hospitals located in the United hospital SW or personnel of the U.S. Race data horn the National States. In 1990, data were abstracted Bureau of the Census, on behalf of Hospital Discharge Survey (NHDS) has horn mcdica.1records of 266,000 NCHS. The other, an automated metho~ become increasingly incomplete in discharges from 474 hospitals. In 1991, involves the purchase of data tapes from recent years. This report examines 484 hospitals provi&d data from abstracting service organizations, State factors related to the underreporting of 274,000 medical records, and 494 data systems or hospitals. race and explores the effects of the hospitals provided data from 274,000 Further information about the un&rreporting on NHDS estimates of medical records in 1992. survey design, data collection hospital use by race. A major concern is Beginning in 1988, a 3-stage procedure, sampling errors, and whether discharges for each racial group definition of terms used in this report stratified sample design was put into are equally likely to be underestimated. can be found in the section entitled operation for the NHDS. For the tit If underreporting of race is a general “Technical notes.” phenomenon, then the NHDS estimates stage! primary sampling units (Psu’s) D- from the NHDS have been were sample@ in the secon~ hospitals of hospital use for each racial group are used to examine racial d&erences in too low. However, if dficharges for were sampled from the PSU’S, and the patterns of hospital use that may reflect some mcial groups are more likely to be third stage consisted of sampling differences in access to care or in the underestimated than others in the discharges within the selected hospitrds. distribution of health problems. Recent NHDS, using the data to make In addition, hospitals with 1,000 beds or studies that have used race data from comparisons across racial groups could more or 40,000 discharges or more per the NHDS have investigated a variety of be misleading. year were selected with certainfy. topics, including hysterectomy (l), HIV The NHDS has been conducted Since 1985, two data collection (2), stroke (3), children’s asthma (4), continuously by the National Center for procedures have been used for the preechnpsia and eclampsia (5), Health Statistics (NCHS) since 1965. NHDS. One is a manual system in appendicitis and appendectomy (6), The dam for the survey come Ilom a which data are abstracted from the face coronary arteriography and conmary sample of inpatient records that are sheet or d~charge summary of the bypass surgery (7), hip flWtURX (8), and obtained from a national sample of medical record for each sampled idiopathic cardiomyopathy (9).

Acknowledgments This reportwas prepared in the Divisionof Health Care Statistics.Linda Lawrenceand Chuck Dennisonof the HospitalCare StatisticsBranch provided operationaldata and assistad with the descriptionof the survey. Michael J. Monsour, formerly of the TeohnioalServices Branch, producedthe parametersfor relativestandarderrorequations.The reportwas edited by KlaudiaM. Cox and lypeset by Annetts F. Facemire of the PublicationsBranch,Divisionof Data Services.

SUWCJ$.O ## % U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service !( Centers for Disease Control and Prevention National Center for Health Statistics CENTERScmFOR DISEASE CONTROL k= 4 AND PREVENTKJN 2 Advance Data No. 265 ● July 6, 1995

Hospital reporting patterns The majority of hospitals that participate in the National Hospital Discharge Survey (NHDS) report race for all or ahnost all discharges. In 1992, for example, 296 hospitals (59.9 percent) reported race on 97–100 percent of their sample records (table 1). The discharges not identified by race come primarily from a small group of hospitals that do not report race for any or almost any of 0 “ 1 1 1 1 1 I 1 I 1 their discharges. In 1992, 63 hospitals 1982 1983 1984 1985 1986 1987 1988 1989 1980 1991 1992 (12.8 percent) reported race cm less than Year 3 percent of sampled records. These 63 hospitals accounted for 83.4 percent of Figure 1. Percent of discharges with race not stated: United States, 1982-92 the sampled records with race not stated in the 1992 NHDS, and 70.7 percent of the estimated number of dischmges with The NHDS race data have never the Health Care Fwcing race not stated. been 100 percent complete. From 1982 Administration, and natahty data from Nonreporting hospitals, which are through 1989, discharges with race not the Division of Vital Statistics. Finally, defined in this report as those providing stated ranged from 8.9 to 11.5 percent of adjustment of NHDS race data for race data for less than 3 percent of total discharges. Then, in 1990, the underreporting will be discussed. proportion of discharges with race not discharges, have increased in number in recent years (figure 2). In 1989 there stated incma.sed to 15.7 percent. In Highlights 1991, 17.8 percent of discharges were were only 17 nonreporting hospitals, but the number jumped to 45 in 1990, not identified by race, and in 1992, The number of hospitals in the 19.8 pereent of discharges were in the NHDS that reported race for less than increased to 50 in 1991, and to 63 in 1992. Nonreporting hospitals accounted racenot-stated category (figure 1). 3 percent of discharges increased TWOmain factors were found to be from 17 in 1989 to 63 in 1992. for 50 percent of the sampled records related to the increasing underreporting Most of the hospitals that did not with race not stated in 1989, but for 81-84 percent in 1990-92. of race in the NHDS. FirsL a growing report race in the 1990-92 period Most of the hospitals that did not number of the hospitals that participated used the automated data collection in the NHDS in 199G92 did not report method. report race in the 1990-92 period used the automated data collection method. race for any of their patients. In 1989, Based on data from previous years As described earlier, the automated 17 hospitals did not report race, but in and county populations, hospitals that method refers to the purchase of 1992 the number had increased to 63. did not report race in 1990-92 were medical record data in electronic form Nonreporting hospitals made up only likely to have a higher proportion of fkom abstracting service organizations, 12.8 percent of the hospitals white discharges than hospitals that State data systems, or hospitals. In participating in the survey in 1992, but reported race. contrast data collected via the manual accounted for 70.7 percent of the A specific race was reported for only method were transcribed fmm the discharges with race not stated. SeCon& 25–35 percent of Hispanic patients in medical reeord to abstract forms race was not reported for the majority of the 1990-92 perio@ most Hispanic specifically for the NHDS. patients that were identified as Hispanic. patients were probably white. As shown in figure 2, only 5 In 1992, 16.0 percent of the discharges In comparison with the number of hospitals that did not report race used with race not stated were identified as discharges estimated from the the automated data collection method in Hispanic. 1990-92 National Health Interview 1989, but in 1990, 31 nonreporting These two main problems will be Survey, NHDS estimates of hospitals used the automated method. In discussed further in the following discharges were signhicantly lower 1991, 35 nonreporting hospitals used the sections of this report. Approaches to for white patients, but not automated data collection method, as did estimating the racial distribution of significantly different for black 48 nonreporting hospitals in 1992. The patients not reported by race will also patients. number of nonreporting hospitals using be examined. To further evaluate the Proportional adjustment of NHDS the manual method only increased from effects of the underreporting of race, the race data may produce more accurate 12 in 1989 to 15 in 1992. NHDS race data will be compared with estimates of white discharges, but it A concerted effort was made to data from other sources, including does not improve comparisons improve the NHDS response rate in the hospital use data from National Health between racial groups. 1990’s, which resulted in a substantial Intmview Survey, Medicare data from Advance Data No. 265 ● July 6,1995 3

Table 1. Number and percent distribution of hospitals by proportion of sample records Race for nonreporting with race reported: United States, 1992 hospitals ~:~~fi~{$On-Federal hOw~~sthat~~~batd fntheNatbnalHospRd Diecharge~un/eY. Exciudesrww An importantquestion to investigate Hospitals is whether nonreporting hospitals have Proportion of records with race reporfed Number Percenf the same racial distribution of dmcharges as reporting hospitals. TWo Allremrds ...... 494 100.0 approaches were taken to answer this 0.C-2.9parcant ...... 63 12.8 3.0-49.9 percent ...... 15 3.0 question. FirsL &ta tim previous years 50.0-74.9 persant ...... 21 4.3 were reviewed. The NHDS was 75.0-S8.9percent ...... 41 8.3 redesigned in 1988, and with some 90.0-96.9 parcent ...... 58 11.7 97.0-100.0 percent , ...... 296 59.9 exceptions (some hospitals went out of business, a few new hospitals were added to the sample in 1991), the same hospitals were in the sample from 1988 through 1992. Among the 63 hospitals @ Automated - Manual that did not report race in 1992 were 26 that had reported race in at least 1 year from 1988-91. For each of these 26 hospitals, the percent d~tibution of the weighted number of discharges by race was obtained for the most recent year in which race WBSreported. This percent distribution was multiplied by the weighted number of discharges from the 10 hospital in 1992. rl The resulting distribution of 1990 1991 1989 1992 discharges by race for the 26 hospitals Year of survey combmed is shown in table 2. The Figure 2. Number of hospkais not raportfng race that used the automated and manual estimated proportion of patients who methods of data ooikretfom 1989-92 were white W8Ssignificantly larger in the 26 nonreporting hospitals (87.3 percent) than in hospitals that Tabie 2. Percent dhtrfbutton of discharges by raea, for 26 nonraportfng hospitals based reported race in 1992 (75.2 pmxmt). on previous data and for reporting hospitals: United States, 1882 The reporting hospitals had higher [Discharges of inpatients fmm non-Fedaral short-stay ho?pitals. Excludes newborn infants] proportions of patients who were black all other races, and race not stated. 26 non- reporfkrg Because the 26 hospitals that Rata IrospnaIs* E&2$ previously reported race may or may not

Percent distrbufion be representative of all the hospitals that did not report race, a second approach Aflraces ...... 100.0 100.0 White ...... 87.3 75.2 to estimate the racial dktibution of Black ...... 8.3 13.9 d~charges from nonreporting hospitals Another races ...... 2.1 4.2 was used. This involved an examination Racanotsfated ...... 2.3 6.7 of the populations they served. The lNOnmP~ng ho$p~akr~oned ram for ISSS than 3 percant of dscharges. Radal ddributionWes~~ onthe * r~nt 1990 Census provided data on the racial de$a mporfed W esch hospital. %ospifals thsf &ported mce for 2-100 pemant of disohargsa. d~tributions of counties (10) that can be used to approximate service areas of hospitals despite the fact that some increase in the number of hospitals systems that used the National Uniform hospitals may serve only part of a participating in the survey, horn 408 in Billj or UB-82 (and its successor, county or multiple counties. 1989 to 474 in 1990,484 in 1991, and UB-92) for data collection. The National A prehninary test was conducted to 494 in 1992. Many hospitals that had Uniform Bill was established for investigate whether it would be not participated in previous ye8rs agreed processing hospital bills and does not reasonable to use county population to participate in the NHDS through the include race as a required item. ‘IEus, distributions by race as proxy measures automated systems. Much of the data the race of discharges w83 often not for the distribution of dficharges by obtained using rhe automated method included in the data horn such systems race. A 20-percent stratified random were from State data systems or other purchased for the NHDS. sample was taken of the hospitals that 4 Advance Data No. 265 ● July 6, 1995

reported race for 97–100 percent of their black calculated for nonreporting hospitals not reporting race. Hospitals discharges in 1992. The county in which hospitals were significantly lower than that do not report race almost never each sampled hospital was located was the proportions in reporting hospitals. report ethnicity. However, certain other identified and the percent dMribution of The “all other races” category hospitals report all or ahnost all patients the population of the county by race accounted for larger proportions of identified as Hispanic in the race not was obtained. This percent distribution dischwges for the nonreporting than for stated category. In 1992, for example, was multiplied by the weighted number the reporting hospitals, but these 112 hospitals reported race for less than of discharges from the hospital in the proportions may have been somewhat 3 percent of their Hispanic discharges, county. overestimated, as in the preliminary test. and these hospitals accounted for The resulting distribution of These findings afe not definitive, two-thirds of the Hispanic discharges dkcharges by race for the sample but along with the data on racial not identified by race. hospitals was 76.8 percent white distributions in previous years, they These 112 hospitals were more patients, 17.5 percent black patients, and suggest that nonreporting hospitals may liely to provide data through the 5.6 percent patients of other races. In have a higher proportion of white manual data collection system than the comparison, the distribution reported for discharges and a lower proportion of automated system. In the manual these sample hospitals was 80.0 percent black discharges than reporting system, NCHS strM are instructed to white dk.charges, 15.2 percent black hospitals. code records as “race not stated” when discharges, and 4.1 percent discharges of Hispanic is written in as a race. other races. Hispanic patients Automated system data are not coded by Although not exac~ the population NCHS staff and do not necessarily Race and ethnicity are separate data follow this practice. In 1992, a total of d~tribution of a county appeared useful items for the NHDS. On the ethnicity as a general indkator of the racial variable, patients are identified as being 32 NHDS hospitals were found in which all Hispanic discharges were assigned to distribution of discharges from a of Hispanic origim non-Hispanic origin, the “other” race category. These were hospital in the county. Thereforq the or not stated. Ethnicity, in general, is not predominantly hospitats using the procedure used in the test was applied well reported. For example, in 1992, automated data collection system. to the nonreporting hospitals. The only 24.6 percent of all NHDS Some of the hospitals that have rdl county in which each nonreporting dkcharges were identified as Hispanic their Hispanic discharges assigned to the hospital was located was identified and or non-Hispanic. Because ethnicity data “mce not stated” or “other” race the percent d~tribution of the population are not reliable, these Ma are not categories are known to be using data of the county by race was obtained. This released horn the NHDS. collection forms that do not separate percent distribution was multiplied by Data on Hispanic origin are race and ethnicity. Other hospitzds the weighted number of discharges from discussed here &cause patients probably also use combined Megories. the nonreporting hospital in the county. identified as Hispanic usually have The Federal standards for reporting race The resulting d~tributions of missing race data. As shown in table 4, and ethnic statistics (11) allow race and discharges by race for nonreporting more than half of Hispanic patients were ethnicity to be collected in a combhwl hospitals are shown in table 3. For each in the racenot-stated category in format in which Hispanics are not year 1990 through 1992, the proportion 1990-92. Another 13-17 percent were identified by race. of discharges that were white calculated reported in the “other” race category, so If identified by race, the evidence for nonreporting hospitals was only 25-35 percent were identified as a indkates that most Hispanics “inthe significantly higher than the proportion specific race during thii 3-year period. “race not stated” and “other” categories in reporting hospitals. Conversely, the The lack of race data for Hispanic would be classified as white. Among proportions of discharges that were patients is sepamte fkom the problem of

Table 3. Percent distribution of discharges by race for nonreportinft.- hotdtals. based on countY. population. . and for rePorting.— hospitals,. according to year: United States, 199=2 - [Dlaohargas of Inpatlenta from non-Fedaral short-stay hospitals. Excludes newborn infants]

1990 1991 1992

Nonreporfirg Report/n Nonrapotiing Repofllnq Nonreportiyg Repott/n ~ 4 Race hoqifals i hospifels hospifels ‘ hospitals hospifals hosplteis

Percent distribution

All races ...... 100.0 100.0 100.0 100.0 100.0 100.0 W/Me...... 83.0 77.7 83.8 76.4 83.2 75.2 Black ...... 11.4 13.1 10.5 13.6 10.6 13.9 All other races ...... 5.6 3.5 5.7 3.8 6.2 4.2 Race notefated ...... 5.7 6.2 6.7

‘ NonrepoRing hospifeh rsported race for kes than 3 percent of dkcharges. Rem distribution was based on the papuleticm of the caunly where the hcepifal was located. %ospitats that repotied race for S-10+ percent of dmcharg.s. Advance Data No, 265 ● July 6, 1995 5

Table 4. Percent distribution of discharges by race for patients identified as Hispanic, for 1990 through 1992. In each of the 3 according to yswm United States, 1990-92 years, the NHIS estimate of total [Discharges of Inpatients fmm non-Federal short-stay hosplfefs. Excludes newborn Infants] dficharges was not significantly ditTerent Race 1990 1991 1992 ffom the adjusted NHDS estimate.

Percent dkdrbution However, the estimated number of Allracas ...... 100.0 100.0 100.0 discharges for white patients tlom the White ...... 33.3 28.0 23.1 NHIS was significantly higher than the Black ...... 0.8 “0.8 0.8 adjusted NHDS estimate each year. The AmerloanlndkinrEsldmo/AleuforAshrrrPaclflc Islander. . 0.9 3.5 1.7 Other ...... 13.3 14.4 17,2 NHIS estimate was 22 percent higher in Racenotstated ...... 51.8 53.4 57.3 1990,26 percent higher in 1991, and 30 percent higher in 1992. The estimated number of discharges for black patients from the NHIS was not Hispanic discharges reportedasa Before comparing NHIS estimates significantly dilTerent from the adjusted specilicracein 1992, 90.4percentwere with NHDS estimates of hospital use, NHDS estimate of black discharges in identitiedas white, 3.1percent as black, the NHDS estimates were adjusted. any of the years. NHIS estimates of and 6.5 percent as American Indd Patients hospitalized for less than 1 day d~charges for other racial groups were Eskimo/Aleut or A&m/Pacific Islander. were excluded kecause the NHIS data not available. In addition, the U.S. Bureau of the were only for overnight stays. Persons Census estimated that in 1990 the discharged dead and those transferred to Medicare Iong-term care institutions were Hispanic population was 91.3 percent Another source of information on exclud@ although the NHDS data white, 5.4 percent black, and 3.3 ~rcxmt the race of hospital discharges is the would probably still include some American Indian/E&imo/Aleut or Health Care Financing Administration persons who died or were A&n/Pacific Islander (12). Thus, the (HCFA), which obtains data on the institutionalized during a 6-month lack of information on the race of the hospitalizations of Medicare period. All newborn infants were majority of discharges identified as beneficiaries. In 1990, HCFA reported exclude4 as is usual for NHDS Hispanic is likely to affect NHDS 10,522,000 discharges from short-stay estimates, although some sick newborn hospitals for Medicare beneficiaries (16). estimates of white discharges infants may be included in tie NHR disproportionately. estimates. The adjustments do not make Of these, 9,037,000 (85.9 percent) were identified as white, 1,185,000 the NHDS and NHIS data completely Comparisons (11.3 percent) were other than white, alike, but they should be more and 300,000 (2.9 percent) wem not comparable. National Health Interview Survey identified by race. The adjusted NHDS estimates and The NHDS estimate of discharges If dischargesof white patients are the NHIS estimates of discharges from with Medicare as the pMcipal expected underestimated to a greater extent than short-stay hospitals are shown in table 5 discharges of patients of other races in the NHDS, this should be evident in Table 5. Number of discharges estimated from the National Hospital Discharge Survey and the National Health Interview Survey, by year and race: United State+ 1990-92 comparisons of estimate3 nom the [Discharges of hrpaflents from short-stay hospitals] NHDS to data from other sources. A comparison was made of NHDS data Nafbnal Hoq?Ral Natkmd Health Year and race DischargeSurvey’ InfervfewSurvey with data from the National Health Interview Survey (NHIS), which also 1990 Number in thousands produces estimates of hospital use by Aflraces2 ...... 27,250 27,058 race (13-15). White ...... 1s,713 22,821 Black ...... 3,300 3,692 The NHIS is based on a different universe and uses different definitions 1331 and data collection procedures than the Aflracas* ...... 27,275 26,873 white ...... 18,084 22,778 NHDS. The estimates of hospitalizations Black ...... 3,s95 3,420 are obtained from interview questions about overnight stays in short-stay 1992 hospitals during the previous 6 months. Aflracas2 ...... 27,283 27,033 White ...... 17,423 22,607 Hospitalizations of persons who died or Black ...... 3,363 3,654 were institutionalized during the ‘Oischargasfrom non-Fedswal hoapitds. Exdudaa nawbm infants, dschargas to Icog-term cars inattutiins, patienfa diaohargsd reference period are excludd as are dsa~ amf discharges with inpatient stays 04 lass than 1 day. hospitalizations of healthy newborn 21ndudes pstiints of all races and patients Wmsa race was no! atatad. infants. 6 Advance Data No. 265 ● July 6, 1995

Table 6. Number of discharges for women with deliveries and number of Ilve births, by also support the thesis that white year and race United States, 1990-92 patients are markedly underestimated in Discharges for the NHDS. women with Live Year end race deliveries’ births 2 Adjustments for underreporting 1990 Number in thousands Allracss ...... 4,025 4,158 Table 7 shows the number and rate White ...... 2,431 3,290 of discharges by race as estimated from Black ...... 584 664 Allolherraces ...... 262 164 the NHDS in 1990-92. These estimates Race notefated ...... 748 are compared with estimates produced by two types of adjustments. The fist is 1991 proportional adjustmen~ a strategy used All races ...... 3,973 4,111 White ...... 2,244 3,241 by researchers to compensate for the Black ...... 557 683 underreporting of race in the NHDS (1, Allotherracas ...... 289 187 4, 8). In this approach, the discharges in Racenotsfated ...... 883 the race-not-stated category are assigned

1992 to spechic race categories based on the

Allraces ...... 3,910 4,065 distribution of the discharges whose race White ...... 2,148 3,202 is known. Black ...... 511 674 For example, in the 1992 NHDS, Allotherraces ...... 334 190 24,838,000 of the estimated 30,951,000 Racenotstated ...... 916 discharges were identified by race. !Dbchargasof inpatienfa from non-Federal short-stay hospitals eafimated from the National Hospital IMcharge Surwy, Among the discharges identified by race, %rats from blrlh oartficetes, Rata of mother assigned to child. 80.6 percent were white, 14.9 percent were black, and 4.5 percent were other 6ource ofpayment w6s1O,625,OOO place in non-Federat short-stay hospitats, races. Distributing the 6,113@O0 discharges in1990. 0fthese,8,135,000 and because one delivery can result in discharges in the race-not-stated (76.6 percent) we~ identified as white, multiple births. However, the dtierences categofy in the same proportions, and 1,037,000 (9.8percent) were black in total number of deliveries and births 4,927,000 wem added m the white andorherraces. Theremaining were not significantly different in the category, 909,000 to the black category, 1,452,000 (13.7 percent) were in the 1990-92 period. and 278,000 to the other races category. race-not-stated category. The racial distribution of live births Proportional adjustment would be Theestimatesof totalMedlcare reported from birth certificates (17) is appropriate if the evidence suggested dkcharges horn these two sources were compared to the racial distribution of that patients of atl races were equally notsignificady different. Likewise, the women with deliveries from the NHDS underreported. Because white patients estimate ofdkcharges for Medhmre in table 6. The number of live births appear to be underreported to a greater patients ofblack and other races from identified as white was 35 percent higher extent than patients of other races in the HCFA was not significantly different than the number of white women with NHDS, proportional adjustment would from the NHDS estimate for this group. deliveries in 1990,44 percent higher in not be expected to correct accurately for However, theHCFA estirnateofwhlte 1991, and 49 percent higher in 1992. In nonresponse. Using this adjustmen4 Me&aredischarges was significantly 1990, the number of black live btis white dk.charges woutd still be higherthantheNHDS estimate. Thus, was 17 percent higher than the NHDS underestimated, and discharges of these findings also suggest that white estimate of black women with patients in the other race categories patients are more likely to be deliveries; it was 22 percent higher in would be overestimated. The relative underesd.matedin the NHDS than 1991, and 32 percent higher in 1992. differences in dischtuge rates between patients of other races. The number of live btis that were racial groups am not allected by other races was not sigticantty proportional adjustment. Thus, Birth certificates dtierent from the estimate of women comparisons of proportionally adjusted Information about race from bti with deliveries of other races in 1990. rates across racial categories are no certificates was atso compared to NHDS However, in 1991 and 1992, there were different than comparisons of unadjusted data on the race of women hospitalized more women with deliveries in the rates. for deliveries. Beginning with 1989, the “other races” category than live btis. Numbers and rates of discharges data from bti certificates have been This was due to a large number of resulting from a population-based tabulated by the race of the mother. The women with deliveries in the NHDS adjustment are also shown in table 7. number of btis would be expected to who were reported as an unspecific The population-based adjustment used be somewhat higher than the mudwr of other race. These data suggest problems the populations of the counties in which women with deliveries estimated from with NHDS estimates for all the racial nonreporting hospitals were located to the NHDS because not all births take categories of women with deliverk, but estimate the racial dMribution of Advance Data No. 265 ● July 6, 1995 7

Table 7. Number and rate of discharges, by year, race, and type of estimate: United States, 1990-92

[Discharges of inpatients from non-Federal short-stay hospitals. Exciudas newborn infants]

Dkcharga rate Discharges In thousands per 1,000 population

NHDS Proportional Population-based NHDS Pr~offkvrsi Population-baaed Year and race estimate’ acfiustrnenf2 a@sfment3 estimate’ adjuafmarrt2 adjustment=

1990 White ...... 21,376 25,366 24,995 102.8 122.0 120.2 Black ...... 3,611 4,285 4,038 119.2 141.4 133.3 Aliotherraces ...... 958 1,137 974 89.8 118.5 101.5 Raoa notstated ...... 4,s43 781 ......

1991 White ...... 20,818 25,317 25,078 99.3 120.8 119.8 Black ...... 3,717 4,521 4,1s4 120.5 148.5 135.6 Allothernxas ...... 1,036 1,260 1,046 103.0 125.2 104.0 Racenotetated ...... 5,528 790 ......

1992 White ...... 20,018 24,945 24,778 94.6 117.8 117.1 Back...... 3,692 4,601 4,219 117.8 146.9 134.7 Atiotherraces ...... 1,128 1,405 1,142 107.5 1S4.0 108.9 Racenotefated ...... 8,113 811 ......

‘Unadjustedrace datafromNationalHospitalDiichargeSurvey(NHDS). %iHDS race data wth diacharg= in race notstatedcategorydistributedto race categoriesin proportionsof dischargeswtihknownmea, %HDS race data withdischargesfromnonmpding hospitalsdktributedto race categoriesbasedon county. pomdationaand Hisoaniodsohamasnotidenfifkdas spadfiorace dntributedto raw ca+tegorlasin the proportionsofthe Hiapank populatkm

discharges in those hospitals. Thk based adjustment were similar. It should the automated data collection system ha3 procedureisdescribed inthesection, be notes however, that both of these kecome an integral part of the NHDS “Race for nonreporting hospitals.” In adjustment are expected to survey design. Approximately one W addltion,Hispanic dischargesinthe underestimate white discharges to some of the hospitals that participate in the race-not-stated categoxyandthe “other extent. The adjusted estimates of black survey now provide data through the race’’category wereassigneda race discharges and discharges of all other automated meth@ and msny are usingthemial dktributionofthe races were not significantly different unwilling to participate in a manual Hispanic population asestimakyibythe from the unadjusted rates. system. U.S. Bureau of the Census. Another solution would be to add Thepopulation-based adjustment race to the UB-92 form. This could Discussion greatly increase the amount of race data assumes that patients arehospitalized in reported through the automated method. the same proportions that they me in the Racedatafrom the NHDS became However, the NHDS is onIy a secondary population, which is probably not the increasingly incomplete in recent years user of UB-92 data. The principal users, case (13–15). In addition, the primarily Imause a growing number of insurance companies and the Health population-based adjustment does not hospitals that participated in the survey Care Financing Administration, do not result in an assignment of race to all did not provide racial data on any of view a bfig form as the best place to discharges, only to those horn the their patients, Most of these hospitals collect race data. They have enrollment nonreporting hospitals and Hispanic used the automated data collection forms that provide information on the patients. In 1990-92,781,000 to method. They submitted tapes of data race of beneficiaries (18). 811,000 discharges remained in the that were usurdly collected for other The other main problem with the race-not-stated category after the purpo8es to the NHDS. These data were NHDS race da~ lack of racial population-based adjustment. Thus, the often collected using the National information for Hispanic patient8, is also numbers and rates of discharges for Uniform Bill (UB-82 and UB-92), related to data collection forms. specific race categories, while probably which does not inclu& an item on race. Hospitals and data systems that use a more accurate, remain underestimated. One solution to this problem would combmed race/ethnicity item cannot Using either methor$ adjusted be for the NHDS to stop using supply the NHDS with information on numbers and rates of discharges for automated data collection. However, the race of Hispanic patients The white patients were significantly higher even before 1985, when all data wem Fe&ral standards for reporting racial than unadjusted estimates. Although collected manually using NHDS and ethnic statistics have been calculated differently, the numbem and abstracts, the proportion of discharges undergoing a wide-ranging review (19). rates of white dkchruges produced by with no race reported was a concern, It is uncertain whether one standard proportional adjustment and popuMion- ranging from 9-14 percent. In addition, approach to reporting will be 8 Advance Data No. 265 ● July 6, 1995 established, or whether it will continue more accurate estimate of white among children: 1979 to 1987. to be acceptable to report race and discharges, but because it is based on JAMA 264(13): 1688-92.1990. ethnicity either separately or in a the assumption that all racial groups 5. Saftlas AF, Olson DR, Franks AL, et combhmd format. have the same discharge rates, the al. Epidemiology of preeclarnpsia In 1990-92, the hospitals that did estimates of racial groups with higher and eclampsia in the United States, 1979-1986. Am J Obstet Gynecol not report race to the NHDS apparently rates would be underestimated to some 163(2): 460-65.1990. had a larger proportion of white patients extent, and comparisons between racial than the reporting hospitals. Estimates 6. Addiss DG, Shaffer N, Fowler BS, groups could be distorted. Tauxe RV. The epidemiology of based on racial distributions of At presen~ no ideal solution exists appendicitis and appendectomy in the d~chmges in previous years and on to eliminate the problem of United States. Am J Epidemiol racial distributions of county populations underreporting of race in the NHDS. 132(5): 910–25. 1990. both suggested that white patients made Therefore, the NHDS race data need to 7. Ford E, Cooper R, Castaner A, et al. up a larger share of discharges in be used cautiously and not Coronary arteriography and coronary nonreporting hospitals than in reporting bypass survey among whites and overinterpreted. The data can still be hospitals. The Hispanic patients not other racial groups relative to reported by race were also likely to be useful for some types of analyses. hospital-based incidence rates for white in larger proportions than all General inferences can be drawn if the coronary artery d~eawx Findings patients, based on the distribution of dfierences between racial groups are from NHDS. Am J Public Health 79(4): 43740.1989. those with a reported race and on the large. For example, the rate of HIV 8. Rodriguez JG, Sattin RW, Waxweiler raciaJ dMribution of the Hispanic hospitalizations for black patients was so much larger than the rate for white RJ. Incidence of hip fractures, United population. Therefore, discharges of States, 1970-83. Am J Prev Med patients that even if all the patients in white patients were probably 5(3): 175-81.1989. underestimated to a greater extmt than the race-not-stated category were added 9. Gillum RF. Idiopathic discharges of other racial groups. to the white category, the difference cardiomyopathy in the United States, Comparisons of NHDS data with would remain highly significant (2). 1970–1982. Am Heart J. 111(4): data from other sources supported the When white patients have a h@her 752-55.1986. hypothesis that white patients were rate than other racial groups despite the 10. U.S. Bureau of the Census. General disproportionately underestimated. The underestimate, such as for coronary population characteristics. 1990 National Health Interview Survey artery bypass grafts (20), it is reasonable Census of Population. vol CP l-2-r2P 1-52. Washington. U.S. Department estimated significantly larger numbers of to conclude that the rate for white of Commerce. 1992. wtilte discharges than the NHDS, but patients is higher. Research can also be 11. Office of Management and Budget. done on hospital use patterns withk similar numbers of black dkcharges. A Directive no. 15: Race and ethnic larger number of Medicare discharges racial groups, such as investigation of standards for Federal statistics and were white according to data from the major diagnostic categories for black adrnhistrative reporting. Statistical Health Care Financing Administration patients or sex differences in discharge Policy Handbook. U.S. Department than estimated by NHDS. However, the rates for white patients. In all these of Commerce, Office of Federal number of Medicare discharges of other areas, though, it must be recognized that statistical pOtiCy and Standards. races reported by these two sources the numbers and rates produced from 1978. were not significantly different. The the NHDS for specific racird groups will 12. U.S. Bureau of the Census. U.S. number of live btis that were white or be underestimated to an unknown population estimates, by age, sex, race, and Hispanic origin 19&0to black were huger than the NHDS extent. 1991. Current population reports, estimates of white or black women References series P-25, no. 1095. Washiugtorr hospitalized for deliveries, but U.S. Department of Commerce. differences were greater for the white 1. Wflcox LS, Koonin LM, Pokras R, et 1993. category. al. Hysterectomy in the United 13. Adams PF, Benson V. Current Because white patients are probably States, 1988-1990. Obstet-Gynecol. estimates from the National Health underreported to a greater extent than 83(4): 549-55.1994. Interview Survey, 1990. National patients of other races, proportional 2. Kozak LJ, McCarthy E, Moien M. Center for Health Statistics. Wtrd adjustment of NHDS data would not be Patterns of hospital use by patients Health Stat 10(181). 1991. expected to produce completely accurate with diagnoses related to HIV 14. Adams PF, Benson V. Current estimates of the number of discharges in infection. Public Health Rep 108(5): estimates from the National Health 571-81.1993. Interview Survey, 1991. National each race group. This adjustment would 3. Modan B, Wagener DK. Some Center for Health Statistics. Vital probably produce a more accurate epidemiological aspects of stroke Health Stat 10(184). 1992. estimate of white dkcharges, but it Mortality/morbidity trends, age, sex, 15. Benson V, Marano MA. Current would overestimate discharges of other race, socioeconomic status. Stroke estimates from the National Health races and would not affect comparisons 23(9): 1230-36.1992. Interview Survey, 1992. National between racial groups. The population- 4. Gergen PJ, Weiss KB. Changing Center for Health Statistics. Wrd based adjustment may also produce a patterns of asthma hospitalization Health Stat 10(189). 1994. Advance Data No. 265 ● July 6, 1995 9

16. Helblng C. Hospital insurance short-stay hospital benefits. Health Care Finan Rev. 1992 annual supplement. 55-96. 1993. 17. Ventura SJ, Martin JA, Taffel SM, et al. Advance report of final natality statistics, 1992. Monthly vital statistics repoti, vol 43 no. 5, suppl. Hyattsvillq Maryland National Center for Health Statistics. 1994, 18. Moore R. Report on HCFA data. Presented to the Subcommittee on Health Statistics for Minority and Other Special Populations, National Committee on Wal and Health Statistics. Sept 14. Washington, D.C. 1994. 19. Office of Management and Budget. Standards for classification of Federal data on race and ethnicity. No. 59. Federal Register. 29831.1994. 20. Graves EJ. National Hospital Discharge Survey annual summary, 1992. National Center for Health Statistics. Vital Health Stat 13(119). 1994. 21. SMG Marketing Group, Inc. Hospital Market Database. Chkago, Illinois: Healthcme Information Specialists. 1987. 22. SMG Marketing Group, Inc. Hospital Market Database. Chicago, Illinois: HealthCare Information Specialists. 1991. 23. Simmons WR, Schnack GA. Development of the design of the NCHS Hospital Discharge Survey. National Center for Herdth Statistics. Vital Health Stat 2(39). 1977. 24. Haupt BJ, Kozak LJ. Estimates from two survey designs: National Hospital Discharge Survey. National Center for Health Statistics. Vital Health Stat 13(111). 1992. 25. Shah BV. SESUDW Standard errors program for computing of standardii rates from sample survey data. Research Triangle Park, North Carolina Research Triangle htitllte. 1981. 10 Advance Data No. 265 ● July 6, 1995

Technical notes development of the original NHDS has numb% and medical information, been published (23). including dmgnoses and surgical and Survey methodology Beginning in 1988, the NHDS nonsurgical operations or procedures. sample included with certainty all Since 1977, patient ZIP Code, expected Source of data hospitals with 1,000 beds or more or source of paymentj and dates of surgery 40,000 discharges or more annually. The have also been collected. (The medical The National Hospital Discharge remaining sample of hospitals is based record number, bti date, and patient Survey covers discharges from on a stratified three-stage design. The ZIP Code are confidential information noninstitutional hospitals, except tirst stage consists of a selection of 112 and are not available to the public.) Federal, military, and Department of primary sampling units (PSU’S) that Veterans Affairs hospitals located in the comprise a probability subsample of Presentation of estimates 50 States and the DMrict of Columbki. PSU’S used in the 1985–94 National Only shofl-stay hospitals (hospitals with Health Interview Survey. The second The relative standard error of the an average length of stay for all patients stage consists of a selection of estimate and the number of sample of fewer than 30 days) or those whose noncertainty hospitals from the sample records on which the estimate is based specialty is general (medical or surgical) PSU’S. At the third stage, a sample of (referred to as the simple size) are used or children’s general are included in the discharges was selected by a systematic to identify esdmates with relatively low survey. These hospitals must also have random sampling technique. A detailed reliability. six beds or more stied for patient use. comparison of the old and new survey Because of the complex sample From 1988 through 1990, the designs has been published (24). design of the NHDS, estimates of less NHDS sampling tie consisted of No data collection procedures are than 5,000 are not presentex only an hospitals that were listed in the April used for the survey. The first is a asterisk (*) appears in the tables. These 1987 SMG Hospital Market Database manual system of sample selection and estimates generally have a relative (21), met the above criteriaj and began data abstmction. The second is an standard error of more than 30 percent accepting patients by August 1987. In automated method that involves the or are based on a sample of fewer than 1991 the sampling frame was updated to purchase of data tapes from abstracting include hospitals from the 1991 SMG 30 cases. Estimates based on fewer than service organizations, State data 60 cases are preceded by an asterisk (*) Hospital Database (22). The sample systems, or hospitals. Approximately consisted of 542 hospitals in 1990 and to indicate that they should not be one third of the respondent hospitals assumed to be reliable. These estima@ 528 hospitals in 1991 and 1992. In used the automated method in 1990 are generally 5,000 to 9,000. 1990, 23 of the sample hospitals were through 1992. found to be out of scope cmeligible) In the manual system, the sample because they went out of business or Sampling errors and rounding of selection and the transcription of numbers otherwise failed to meet the criteria for information from the hospital records to the NHDS universe. Seven hospitals abstract forms are performed at the The standard error is primarily a were out of scope in 1991, and 14 were hospitals. The completed forms, along measure of sampling variability that out of scope in 1992. In 1990, 474 of with sample selection control sheets, are occurs by chance because only a sample the 519 in-scope (eligible) hospitals forwarded to NCHS for coding, editing, rather than the entire universe is responded to the survey. In 1991, 484 of and weighting. Of the hospitals using surveyed. The relative standard error of 521 in-scope hospitals mspondecl and the manual system, about two-thirds had the estimate is obtained by dividing the 494 of 514 in-scope hospitals responded the work performed by their own standard error by the estimate itself and in 1992. medical records stafTin 1990 and 1991 is expressed as a percent of the estimate. and 58 percent in 1992. In the remrdning Sample design and data collection The resulting value is multiplied by 100, hospitals using the manual system, so the relative standard error is The NCHS has conducted the personnel of the U.S. Bureau of the expressed as a percent of the estimate. Census do the work on behalf of NCHS. NHDS continuously since 1965. The Estimates of sampling variability For the automated system, NCHS original sample was selected in 1964 were calculated with SESUDAAN from a frame of short-stay hospitals purchases tapes containing machine- software, which computes standard listed in the National Master Facility readable medical record data that are errors by using a first-order Taylor Inventory. That sample was updated systematically sampled by NCHS. approximation of the deviation of periodically with samples of newly The medical abstract form and the estimates tlom their expected values. A opened hospitals. Sample hospitals were automated data tapes contain items description of the software and the selected with probabilities ranging from relating to the personal chamcteristics of certainty for the largest hospitrds to 1 in the patients, including birth date, sex, approach has been published (25). 40 for the smallest hospitals. Within race, and marital status, but not name The constants for relative standard each sample hospital, a systematic and address; adminktrative information, error curves for estimates of discharges random sample of dkcharges was including admission and discharge dates, by race from the 1990-92 NHDS are selected. A report on the design and dkcharge status, and me&cal record presented in table I. The relative Advance Data No. 265 ● July 6,1995 11

Table 1.Estimated parameters for relative standard error equations for number of discharges, by race: National Hospital Discharge Suwey, 1991-S2

1990 1991 1892

Race a b a b a b

AIIracas ...... 0.00213 228.S34 0.00101 546.321 o.000e7 448.059 White ...... 0.00212 228.5S4 0.00234 927.094 0.00241 419.274 Black ...... 0.00537 264.999 0.005s9 273.3SS 0.00740 363.801 Another races ...... 0.02899 119.661 o.0288e 280.075 0.02271 182.649 Racenot atated ...... 0.02252 226-201 0.0166S 427.619 0.01496 301.892

standard emor~SE(X)] of an estimate Definitions of terms Patient-A person who is formally X maybe estimated from the formulz admitted to the inpatient service of a Discharge-The formal release of a short-stay hospital for observation, care, RSE(X) = 100 ~ patient by a hospital; that is the diagnosis, or treatment is a patient. The termination of a period of where x CLand b are detined in table I. terms “patient” and “inpatient” are hospitalization by death or by Estimates have been rounded to the u8ed synonymously. disposition to place of residence, nursing nearest thousand. For this reason, figures Population-The U.S. civilian home, or another hospital. The terms within tables do not always add to the population, which is the resident “discharges” and “patients discharged” totals. Rates and percents were population of the United States, calculated horn original, unrounded are used synonymously. excluding members of the Armed Dischargerate—The ratio of the figures and will not necessarily agree Forces, was used to compute rates. The number of hospital &charges during a precisely with rates or percents U.S. resident population was used to year to the number of persons in the calculated from rounded data. make population-based adjustments in civilian population on July 1 of that estimates of discharges by race. year. T-ts of significance Race—In ,jheNHDS, the race of Ethnici~In the NHDS, the discharges can be reported in six In general, statistical inference was ethnicity of d~charges can be reported categories, which are white, black based on the two-tailed t-test using the in time categories, which are Hispanic American Indirrn/Eskimo/Aleu~ Bonferroni criticrd values for post-hoc origb non-Hispanic, and not stated. Askm/Pscific Islander, other, and not multiple comparisons (0.05 level of Hospiral-All hospitals with an stated. signilkance). Critical values were average length of stay for all patients of determined for each set of comparisons, less than 30 days or hospitals whose that is within each table. For specialty is general (medical or surgical) comparisons of NHDS estimates with or children’s general are eligible for the Me&care data from the Health Care inclusion in the National Hospital Financing Administmtion (HCFA) and numbers of live births from birth Discharge Survey except Federal certificates, confidence intervals at the hospitals, hospital units of institutions, and hospitals with fewer than six beds 95 percent level (plus and minus 1.96 Symbols times the standard error) were stafkxl for patients’ use. --- Data not available constructed around the NHDS estimates. ● Reporting hospital-In this repofi a If the number of HCFA Medicaxe reporting hospital is one that reported . . . Category not applicable discharges or live bitths fell outside the race for 3–100 percent of d~charges. Quantity zero confidence interval, it was reported as ● Nonreportinghospital-In this repofi significantly different from the NHDS 0.0 Quantity more than zero but less a nonreporting hospital is one that estimate. than 0.05 reported race for less than 3 percent In this repom terms such as of discharges. z Quantity more than zero but less “higher” and “less” indicate that than 500 where numbers are dflerences are statistically significant. Live bitih-A live birth is the rounded to thousanda

Terms such as “similar” or “no complete expulsion or extraction from ● difference” mean that no statistically its mother of a product of cxmceptio% Figure does not meet standard of significant dtierence exits between the irrespective of the duration of the reliability or precision (see Technical notes) estimates brimg comprued. A kick of pregnancy, which, after separation, comment on the difference between any breathes or shows any evidence of life. # Figure suppressed to comply with two estimates does not mean that the Newborn infm—A newborn infant confidentiality requirements difference was tested and found to not is a patient admitted by bti to the be significant. hospital. 12 Advance Data No. 265 ● July 6, 1995

Suggested citation Copyright information Natfonal Center for Health SitatfatIca

Kozak LJ. Underreporting of raoe in the All material appearing in this” report is in the Acting Director National Hospital Discharge Survey. Advance public domain and may be reproduced or Jack R. Anderson data from vital and health statistic no 265. copied without permission; citation as to Acting Deputy Director Hyattsville, Maryland: National Center for source, however, is appreciated. Health Statistics. 1995. Jennifer H. Madans, Ph.D.

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DHHS Publication No. (PHS) 95-1250 5-1327 (6/95) Number 266 ● September 19, 1995 Advance i Data Ii9ii

From Vital and Health Statistics of the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

Urban and Rural Classification of National Health Provider Inventory Providers: United States, 1991 by Renee Delfosse, M.A., Divisionof Health Care Statistics

Highlights and use of health care. Table 1 compares as hospitals, homes for the blina &af, the total numbers of providers according mentally retarde~ and emotionrdly This report presents information to an urban-rural continuum. Subsequent disturbed in addition to nursing homes from the National Health Provider tables compare the total numbers of and board and care homes. The 1991 Inventory (NHPI) on the numbers of providers in urban and rural Iocations inventory includes nursing homes, board home health cam agencies, hospices, within Census DNisions (table 2) and and care homes, plus two providers, musing homes, and board and care within States (tables 3–5). home health care agencies, and homes classified according to their Previous inventories conducted by hospices, the large majority of whom kxation. These data are provided to aid the National Center for Health Statistic care for patienta in au outpatient setting, in studies of the differential availabiMy (NCHS) included health providers such the home (l).

Table 1. Number and percent of home health agencies, hospices, nursing homes, and board and care homes by rural-urban continuum codes: United States, 1991

Total Home health cars agerwlaa Hoa@cea Nursing homes Board and care homes RumMban continuum codes for metropolitan and norrmetfupolltan countlea Number Percent Nunber Perc8nt Nutrber Percent Nurrber Percent Nurrber Percent

United Sfates ...... 41,492 100.0 6,646 16.5 946 2.3 15,467 37.3 18,213 43.9

Metropolitan counties

Central countkm of 1 million population or more...... 14,403 100.0 2,098 14.6 253 1.8 4,791 33.3 7,261 50.4 Frfnge counties of 1 million population or more ...... 1,503 100.0 218 14.5 43 2.9 621 41.3 621 41.3 Countlas of 250,000 to 1 million population...... 9,027 100.0 1,409 15.6 176 1.9 3,071 %.0 4,371 48.4 Countfee of fewer then 250,000 population...... 3,615 100.0 813 17.0 106 2.9 i ,374 38.0 1,522 42.1

Nonmetropolften counties

Urban populeflon of 20,000 or more, adjacent to a metropolitan aree ...... 1,343 100.0 315 16.2 60 3.1 762 3S,2 806 41.5 Jrban population of 20,000 or more, not adfacent to a rrw’opolitsnarea...... 1,%5 100.0 245 18.2 66 4.3 5S9 40.1 495 36.6 Jrban popufatlon of 2,5oO 19,000, adjacent to a rnatropolltan area ...... 4,013 100.0 719 17.9 100 2.5 1,767 44.0 1,427 35.6 Jrben population of 2,500 19,000, not adjacent to a me~ropollten area ...... 3,663 100.0 781 21.3 107 2.9 1,620 44.2 t ,155 31.5 >ompfetefy rural or fewer than 2,500 urban population, adjacent to a malropoiftan area...... 702 100.0 139 19.8 6 0.9 %38 46.1 219 31.2 :ornplatefy rural or fewer than 2,500 utban population, not adjacent to a matropolffan area ...... 1,278 100.0 309 24.2 29 2.3 604 47.3 336 26.3

NOTES Excludes beard and care homes for the mentdy retarded. Excludmnonrespondingboardand owe homes.A totslof 85 placescouklnotk codedurberirural.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention National Center for Health Statistics CENTERSCDCFOR DISEASE CONTROL ANo PREVENTION 2 Advance Data No. 266 ● September19, 1995

Table 2. Number and percent distribution of home health agencies, hospices, nursing homaa, and board and oare homes in urban and rural locations by Census Division: United States, 1991

Total Home health cars agerrcka Hos@ces Nursing homes Board and care homes

Divklon Number Percent dktributlon Number Percent Number Percent Number Percent Number Percent

Allocations...... 44,577 100.0 6,853 16.5 951 2.3 15,511 37.3 18,262 43.9

New England ...... 2,666 100.0 433 18.2 75 2.8 1,166 44.6 970 36.4 Middle Atlantic ...... 4,734 100.0 638 17.7 62 1.7 1,604 33.9 2,210 46.7 Eaat North Central ...... 7,209 100.0 1,062 14.7 182 2.5 3,147 43.7 2,616 39.1 West North Central ...... 4,469 100.0 902 20.2 111 2.5 2,269 50.6 1,187 26.6 South Atlantic...... 6,819 100.0 1,129 16.6 164 2.7 1,968 26.9 3,536 51.9 Eaat South Central ...... 2,465 100.0 617 25.0 50 2.0 946 36.4 652 34.6 West South Central ...... 3,369 100.0 845 27.9 77 2.3 1,966 56.0 401 11.6 Mountahr...... 2,035 IOQ.o 414 20.3 69 3.4 703 34.5 649 41.7 Paclflc ...... 7,791 100.0 513 6.6 121 1.6 1,720 22.1 5,437 69.8

Urtmloeations ...... 31,836 100.0 4,898 15.4 704 2.2 11,158 35.0 15,076 47.4

New England ...... 2,271 100.0 390 17.2 56 2.5 1,066 47.0 757 33.3 Middle Atkmtlc...... 4,269 100.0 776 18.2 76 1.8 1,469 W.4 1,94s 45.6 East North Central ...... 5,437 100.0 802 14.8 126 2.3 2,364 43.5 2,145 39.5 West North Central ...... 2,128 100.0 377 17.7 56 2.7 1,004 47.2 689 32.4 South Atlantic ...... 5,244 100.0 854 16.3 144 2.7 1,479 26.2 2,767 52.8 Eaet South Central ...... 1,430 100.0 333 23.3 35 2.4 512 35.8 550 38.5 West South Central ...... 2,202 100.0 637 28.9 61 2.6 1,186 53.9 316 14.4 Mountain ...... 1,445 100.0 263 16.2 40 2.8 457 31.6 665 47.4 Paclfk ...... 7,410 100.0 466 6.3 108 1.5 1,619 21.8 6,217 70.4

Rural locfdkms...... 9,858 100.0 1,846 20.2 242 2.5 4,328 44.8 3,137 32.5

New Engiartd ...... 382 100.0 43 11.3 19 5.0 116 30.4 204 53.4 MkidleAtlantic...... 452 100.0 62 13.7 6 1.3 131 29.0 253 56.0 Eaat North Central ...... 1,766 100.0 259 14.7 56 3.2 762 44.3 669 37.9 West North Central ...... 2,334 100.0 524 22.5 53 2.3 1,263 54.1 494 21.2 South Atlantic ...... 1,562 100.0 273 17.5 37 2.4 467 31.2 765 48.0 East South Central...... 1,027 100.0 262 27.5 15 1.5 431 42.0 299 26.1 West South Central ...... 1,184 100.0 306 26.0 16 1.4 777 65.6 83 7.0 Mountain ...... 587 100.0 151 25.7 29 4.9 244 41.6 163 27.6 Pacific ...... 382 100.0 46 12.7 11 3.0 96 27.1 207 57.2

NOTES Excludesboard and care homaa for the mentally retarded. Excludas nonraqmnding bead and cam honwa. A total of 85 placaaccdd not be coded urbanhursl.

There were 18,262 board and care on the divisional level for all providers 4. National Center for Health Statistics. homes, 15,511 nursing homes, 6,853 (4), and on the State level for most National Home Health and Hospice home health care agencies, and 951 nursing homes and board and care Care Survey. Hyattsville, Maryland. 1992. hospices in the United States in 1991 homes (tables 6-7). 5. National Center for Health Statistics. (table 2). Of the 31,836 providers in References The Agency Reporting System for urban locations, 47 percent were board maintaining the national inventory of and care homes, 35percent were nursing 1. Delfosse R. Hospice and home health hospitals and institutions. Vkd homes, 15percent wer’ehomehealti agency characteristic~ 1991 National Health Stat 1(6). 1968. care agencies, and 2 percent were Health Provider Inventory. National 6. Institute of Medicine. Toward a hospices. In rural locations the Center for Health Statistics. Vital national health care survey, a data distribution differed: 45 percent of the Health Stat. In preparation. system for the 21st century. 9,656 providers were nursing homes, 2. Straban G. Overview of home health Washington: National Academy 33 percent were board and care homes, and hospice care patients Press. 1992. 20 percent were home health care Preliminary data from the 1992 7. Urban-rural continuum codes for metro and nonmetro counties, 1993. agencies, and 3 percent were hospices. National Home and Hospice Care USDA, ERS. The majority of patients served by Survey. Advance data from vital and health statistics; no 235. Hyattsville, the NHPI providers were elderly. Maryland National Center for Health Approximately 75 percent of home Statistics. 1993. health care agency and hospice clients, 3. Sirrocco A. Nursing homes and 92 percent of nursing home patients, and board and care homes. Advance data 68 percent of l-wardand care home from vital and health statistic no residents were 65 years and over (2,3). 244. Hyattsvilk Maryland National These percentages were found to hold Center for Health Statistics. 1994. Advance Data No. 266 ● September19, 1995 3

Tsble 3. Number and percent distribution of home heslth csre agencies, hospiq nursing homes, and bosrd snd care homes by Ststw United Ststes, 1991

Total Home health cam agencies Ho@es Nursing t1017WS Board and OSfehomae

State Number Pement dktributbn Nunlmr Percent Nun’ber Percent Nunber Pemsnt Number Percent

United states ...... 41,577 100.0 8,853 16.5 951 2.3 15,511 37.3 18,282 43.3

Alabama ...... 581 100.0 127 22.6 19 3.4 214 w.i 201 35.8 Alaska ...... 46 100.0 10 20.6 5 10.4 18 37.5 15 31.3 Arizona ...... 417 100.0 71 17.0 9 2.2 120 28.8 217 52.0 Arkansaa ...... 446 100.0 133 23.8 11 2.5 225 50.4 77 17.3 Callfomia ...... 5,316 100.0 333 6.3 83 1.6 1,178 22.2 3,722 70.0 Colorado ...... 515 100.0 101 19.6 19 3.7 191 37.1 204 =.6 Connaotbut ...... 462 100.0 110 22.8 9 1.9 244 50.6 119 24.7 Delaware ...... 741 100.0 19 13.5 3 2.1 47 33.3 72 5f.1 DlsMot at cohilllbh . . . . 144 100.0 18 12.5 3 2.1 18 12.5 105 72.9 Florkia...... 2,103 100.0 413 19.8 34 1.6 552 28.2 1,104 52.5 Georgia ...... 935 100.0 70 7.5 18 1.3 342 36.6 505 54.0 Hawaii ...... 360 100.0 18 4.7 8 2.1 54 14.2 3Q0 78.9 Idaho ...... 133 100.0 28 13.1 14 7.0 71 35.7 66 44.2 Illlnoie...... 1,267 100.0 309 24.4 49 3.9 613 64.2 96 7.6 Indiana ...... 744 100.0 150 20.2 13 1.7 531 71.4 50 6.7 lowa ...... 767 100.0 155 20.2 25 3.3 458 59.8 128 16.7 Kaneaa ...... 636 100.0 153 21.9 23 3.3 366 55.3 136 19.5 Kentucky ...... 728 100.0 112 15.4 19 2.6 287 39.4 310 42.6 Louisiana ...... 561 100.0 180 32.1 11 2.0 319 56.9 51 9.1 Maine ...... 403 100.0 35 8.7 15 3.7 138 34.2 215 53.3 M@and...... 560 100.0 36 16.6 25 4.3 219 37.8 240 41.4 Maaaaohuaat to...... 1,063 100.0 166 15.6 26 2.4 580 52.7 311 29.3 Mbhlgan...... 2,497 100.0 196 7.8 57 23 435 19.8 1,749 70.0 Minnesota...... 1,022 100.0 198 192 33 3.2 451 44.1 342 33.5 MbslseiIIP1...... 355 100.0 116 32.7 1 0.3 160 45.1 78 22.0 Missouri ...... 1,115 100.0 173 15.5 15 1.3 533 48.0 392 35.2 Montana ...... 225 100.0 43 21.6 12 5.3 98 43.6 66 28.3 Nebraska...... 335 100.0 75 19.0 6 1.5 229 56.0 65 21.5 Nevada...... 136 100.0 28 20.3 2 1.4 34 24.6 74 53.6 Naw HarnPehiIB ...... 295 100.0 60 20.3 13 4.4 87 28.5 135 46.6 Nawk’eey...... 762 100.0 111 14.6 19 2.5 319 41.9 313 41.1 Naw Maxioo ...... 250 100.0 45 18.0 3 1.2 68 27.2 134 53.6 New York ...... 1,304 100.0 470 21.5 35 1.8 535 31.3 664 45.4 Notth Carolina ...... 1,210 100.0 155 12.8 46 4.0 309 25.5 886 57.7 North Dakota ...... 200 100.0 70 36.0 2 1.0 65 42.5 43 21.5 Ohb...... 1,570 100.0 252 16.1 3s 2.5 877 55.3 402 25.6 Oklahoma ...... 532 100.0 75 14.1 13 2.4 ’38a 73.1 55 10.3 Oregon...... 1,203 100.0 71 5.9 14 1.2 191 15.9 927 77.1 Pennsylvania...... 2,088 100.0 317 15.3 26 1.4 630 33.4 1,033 50.0 Rhode lekmd...... 204 100.0 43 21.1 5 2.5 104 51.0 52 25.5 South Carolina ...... 506 100.0 101 20.0 13 26 140 27.7 252 49.6 3outh Dakota ...... 272 100.0 80 28.4 7 2.6 124 45.6 61 22.4 Tennaseae...... 621 100.0 262 31.9 11 1.3 285 34.7 263 32.0 Texan...... 1,850 100.0 557 30.1 42 2.3 1,033 55.8 218 11.8 Utah...... 793 100.0 53 27.5 4 2.1 90 46.6 46 23.6 Vermont ...... 219 100.0 19 8.7 7 3.2 55 25.1 136 83.0 Virglnla, ...... 766 100.0 188 24.5 28 3.6 227 26.8 340 43.1 Waehinglo n.,.....,, 844 100.0 81 9,6 11 1.3 279 33.1 473 56.0 We8tVirginia ...... 4+2 100.0 64 15.5 12 2.9 114 27.7 222 53.9 Wboonaln...,..,... 1,131 100.0 155 13.7 24 2.1 431 36.1 521 46.1 Wyoming, ...... 98 100.0 41 41.6 6 6.1 31 31.6 20 20.4

NOTESExcludeabomrdWtdoarotwmsfor thermntd~rdded. Exdudesapmsntage ofnonmqxmdimbcard ardcarekmms, 4 Advance Data No, 266 ● September 19, 1995

Table 4. Numbar and percsnt of home health agencies, hospices, nursing homes, and board and care homsa In urban araas: Unitad statsa, 1991

Total Home health w’s agencies Hofplces Nurelng homes Board and care homes

State Number Percent dlstrlbutlon Number Percent Number Percent Number Percent Number Percent

United States ...... 31,836 100.0 4,698 15.4 704 2.2 tl,156 35.0 15,076 47.4

Alabama ...... 366 100.0 72 16.7 14 3.6 141 36.5 159 41.2 Alaska...... 27 100.0 6 22.2 2 7.4 9 33.3 10 37.0 Arizona ...... 411 100.0 70 ‘t7.o 9 2.2 117 28.6 215 52.3 Arkansas .,,.....,.. 200 100.0 39 19.5 6 3,0 104 52.0 51 25.5 California ...... 5,187 100.0 320 6.2 75 1.4 1,151 22.2 3,641 70.2 Colorado ...... 374 100.0 69 76.4 10 2.7 129 34.5 186 44.4 Connedlcut ...... 460 100.0 110 22.9 9 1.9 244 50.8 117 24.4 Delaware ...... 104 100.0 12 11.5 2 1.9 33 31.7 57 54.8 Dlstrlct of Columbia . . . . 144 100.0 16 12.5 3 2.1 16 12.5 105 72.9 Florida ...... 1,963 100.0 377 19.2 33 1.7 515 26.2 1,036 52.9 Gsorgla...... 562 100.0 41 7.0 16 2.7 166 32.0 333 58.2 Hawall ...... 377 100.0 16 4.6 8 2.1 a 14.3 297 76.8 Idaho ...... 111 100.0 15 13.5 6 7.2 31 27.9 57 51.4 Illinois ...... 962 100.0 250 26 39 4,1 593 61.6 80 8.3 Indiana ...... 527 100.0 103 19.5 12 2.3 373 70.8 39 7.4 Iowa...... 298 100.0 56 16.8 9 3.0 177 59.4 56 18.8 Kansas ...... 351 100.0 74 21.1 14 4.0 159 45.3 104 29.6 Kentucky ...... 326 100.0 46 14.6 11 3.4 125 36.1 144 43.9 Louisiana ...... 412 100.0 124 32.5 9 2.2 223 E4.1 46 11.2 Maine ...... 275 100.0 25 9.1 9 3.3 89 32.4 152 55.3 Maryland ...... 532 100.0 84 15.6 23 4.3 199 37.4 226 42.5 Meeeachusefte ...... 1,053 100.0 164 15.6 24 2.3 557 52.9 308 23.2 Michigan ...... 1,810 100.0 135 7.5 27 1.5 376 20.9 1,270 70.2 Minnesota ...... 576 100.0 96 17.0 13 2.2 242 41.9 225 38.9 Mississippi ...... 172 100.0 42 24.4 1 0.6 68 39.5 61 35.5 Miesourl ...... 615 100.0 95 15.4 11 1.8 291 47.3 216 35.4 Montana ...... 66 100.0 12 13.6 4 4.5 30 34.1 42 47.7 Nebraetwi...... 175 100.0 31 17.7 5 2.9 65 48.6 54 30.9 Nevada ...... 117 100.0 21 17.9 2 1.7 25 21.4 69 59.0 NewHarnpshira ...... 217 100.0 45 20.7 9 4.1 66 30.4 97 44.7 NswJersey ...... 750 100.0 111 14.8 19 2.5 315 42.0 305 40.7 New Mexico ...... 166 100.0 30 17.9 3 1.6 47 28.0 88 52.4 New York...... 1,751 100.0 363 21.9 33 1.9 555 31.7 780 44.5 NorthCarollna ...... 766 100.0 95 12.1 28 3.6 206 26.5 456 57.9 Norlh Dakota ...... 48 100.0 13 26.5 2 4.1 20 40.6 14 28.6 Ohio ...... 1,367 100.0 214 15.7 31 2.3 750 54.9 372 27.2 Otdahoma ...... 277 100.0 43 15.5 11 4.0 197 71.1 26 9.4 Oregon ...... 1,056 100.0 49 4.6 13 1.2 163 15.4 831 78.7 Pennsylvania ...... 1,766 100.0 262 16.0 24 1.4 539 33.9 863 46.8 RhodeIsland ...... 199 100.0 43 21.6 5 2.5 101 50.6 50 25.1 SouthCarollna . . . 377 100.0 67 17.8 9 2.4 102 27.1 199 52.8 South Dakota...... 62 100.0 10 16.1 4 6.5 30 46.4 18 29.0 Tannee%e ...... 544 100.0 171 31,4 9 1.7 176 32.7 166 34.2 Texas ...... 1,313 100.0 421 32.1 35 2.7 662 50.4 195 14.9 Utah...... 146 100.0 32 21.9 2 1.4 70 47.9 42 28.8 Vermont ...... 47 100.0 3 6.4 11 23.4 33 70.2 Vlrglnla ...... 547 100.0 126 23.0 21 3.6 159 29.1 241 44.1 Waehlngton ...... 763 100.0 73 9.6 10 1,3 242 31.7 438 57.4 WestVlrglnia ...... 209 100.0 2-I 16.3 9 4,3 59 26,2 107 51.2 Wisconsin ...... 771 100.0 100 13.0 17 2.2 270 35.0 364 49.6 Wyoming ...... 30 100.0 14 46.7 2 6.7 8 26.7 6 20.0

NOTES: Excludes bcerd and care homes for the mentally reterded. Excludes nonresponding board and care homes. A total of 85 places coukl not be ooded urbatirural, Advance Data No. 266 ● September19, 1995 5

Table 5, Number and percent of home health agencies, hospices, nursing home% and board and care homes in rural areas: United statas,1991

Total Home haa#th care agendas HoqMcas Nurslw tlOMW Board and cam homes

State Number Pement dlsfrlbutlon Nu&r Percent Nurrbar Percent Nurriw Percent Number Percent

Unitad3fates ...... 9,656 100.0 1,948 20.2 242 2.5 4,329 44.8 3,137 32.5

Alabama ...... 167 100.0 53 31.7 5 3.0 70 41.9 33 23.4 Alaska ...... 17 100.0 3 17.6 1 5.9 9 52.9 4 23.5 Arizona ...... 5 100.0 1 20.0 2 40.0 2 40.0 Arkansas...... 246 100.0 84 38.2 5 2.0 121 49.2 26 10.6 Calitomla ...... 124 100.0 13 10.5 8 6.5 25 20.2 76 62.9 Colorado ...... 140 100.0 22 22.9 9 6.4 62 44.3 37 26.4 Connecfiout ...... Delaware ...... 36 100.0 7 19.4 1 2.8 13 36.1 15 41.7 Distriof of Columbla ...... Florida ...... 137 100.0 36 26.3 1 0.7 37 27.0 63 46.0 Georgia ...... 351 100.0 28 8.0 2 0.6 155 44.2 186 47.3 Hawsll ...... Idaho ...... 88 100.0 11 12.5 6 6.8 40 45.5 31 35.2 Illinois...... 305 100.0 59 19.3 10 3.3 220 72.1 16 5.2 Indlena ...... 217 100.0 47 21.7 1 0.5 158 72.6 11 5.1 Iowa ...... 466 100.0 33 21.2 16 3.4 281 60.3 70 15.0 Kansas ...... 345 100.0 78 22.6 9 2.6 227 65.6 31 9.0 Kentucky ...... 400 100.0 64 16.0 8 2.0 162 40.5 166 41.5 Louisiana...... 149 100.0 46 30.9 2 1.3 96 64.4 5 3.4 Maine ...... 126 100.0 10 7.9 6 4.8 4e 36.9 61 48.4 Maryland...... 47 100.0 12 25.5 2 4.3 20 42.6 13 27.7 Meesechusatts...... MlohlP ...... 662 100.0 60 e.8 30 4.4 117 17.2 475 83.6 Minnesota ...... 444 100.0 98 22.1 20 4.5 209 47.1 117 26.4 MlsskslI@ ...... 183 100.0 74 40.4 92 50.3 17 9.3 Mlssourt ...... 488 100.0 78 15.7 4 0.8 243 48.8 173 34.7 Montana ...... 137 100.0 37 27.0 6 5.8 66 49.6 24 17.5 Nebmsks...... 220 100.0 44 20.0 1 0.5 144 65.5 31 14.1 Nevada...... 21 100.0 7 33.3 9 42.9 5 23.6 New Hen@hs ...... 78 100.0 15 19.2 4 5.1 21 26.9 36 46.7 Naw Jaraey ...... Naw Mexko ...... 82 100.0 15 18.3 21 25.6 46 58.1 New York ...... 153 100.0 27 17.6 2 1.3 40 26.1 64 54.s North Carolina ...... 424 100.0 80 14.2 20 4.7 101 23.8 243 57.3 North Dakota ...... 151 100.0 57 37.7 65 43.0 29 192 Ohio ...... 203 100.0 38 18.7 8 3.9 127 62.6 30 14.8 Oklahoma ...... 255 100.0 32 12.5 2 0.8 192 75.3 2e 71.4 Oregon ...... 144 100.0 22 15.3 1 0.7 28 19.4 83 64.6 Pennsylvania ...... 233 100.0 35 11.7 4 1.3 91 30.4 169 56.5 Rhode lekand...... South Carolina ...... 125 100.0 33 26.4 3 2.4 38 30.4 51 40.6 -South Dakota ...... 210 100.0 70 33.3 3 1.4 84 44.8 43 20.5 Tennessee ...... 277 100.0 91 32.9 2 0.7 107 38.6 77 27.6 Texes ...... 534 100.0 136 25.5 7 1.3 366 66.9 23 4.3 Utah...... 46 100.0 21 45.7 2 4.3 19 41.3 4 8.7 Vermont ...... 172 100.0 16 9.3 7 4.1 44 25.6 105 61.0 Virglnie...... 233 100.0 67 28.0 5 2.1 68 26.5 es 41.4 Washington...... 77 100.0 6 10.4 1 1.3 36 48.8 a 41.6 WestVkgkria ...... 203 100.0 30 14.8 3 1.5 55 27.1 115 56.7 Wisconsin...... 359 100.0 55 15.3 7 1.9 160 44.6 137 38.2 Wyoming ...... 68 100.0 27 38.7 4 5.9 23 33.8 14 20.6

NOTES Excludes board andcarehomesfor Ihernentaliy rclarde.d. Exdudesn onreaponding boardandcarehorr&. AtotalotSSpleces couldno+beocded urbarirural, 6 Advance Data No. 266 ● September 19, 1995

Table 6. Number of residenta 65 years of age and over in board and care homes: United States, 1991

Realdents Residents Percent of all resident.4 State Residents with reported age 65 years of age and over 65 years of age and over

Number

United States ...... 302,820 267,514 182,469 68.2

Alabama ...... 2,545 2,351 1,328 56.5 Alaska ...... 149 146 15 10.3 Arizona ...... 3,692 3,150 2,291 72.7 Arkansas ...... 1,815 1,681 1,051 f.i2.5 California ...... 54,722 48,446 35,384 73.0 Colorado ...... 3,698 3,421 2,569 75.1 Connedlcut ...... 2,298 1,981 1,330 67.1 Delaware ...... 500 304 175 57.6 Dlstrlctof Columbia ...... 1,408 1,082 414 38.3 Florida ...... 27,529 22,617 17,953 7’9.4 Georgia ...... 4,532 3,978 2,728 68.6 Haweil ...... 2,267 1,289 849 65.9 Idaho ...... 1,429 1,135 835 73.6 Illinois...... 3,084 2,984 1,685 56.5 Indiana ...... 1,396 1,289 603 46.8 lowa ...... 4,340 3,861 1,637 42.4 Kansas ...... 810 754 245 32.5 Kentucky ...... 3,442 3,018 1,846 61.2 Louisiana ...... 697 841 67 10.5 Mehre ...... ,,,.. 2,768 2,541 1,834 72.2 Maryland ...... 2,373 2,233 1,318 59.0 Massachusetts ...... 5,767 5,538 3,023 54.6 Michigan ...... 18,190 16,331 10,579 64.8 Minnesota ...... 5,017 4,502 1,178 26.2 Mississippi ...... 1,131 930 554 59.6 Missouri ...... 7,556 6,887 4,237 61.5 Montana ...... 1,101 961 793 82.5 Nebraska ...... 2,005 1,942 1,349 69.5 Nevada ...... 812 612 400 65.4 NewHampehira ...... 1,329 1,204 831 74.0 NawJersey ...... 8,474 6,938 4,186 60.3 New Mexico ...... 1,501 1,412 520 36.8 New York...... 27,544 25,145 16,660 66.3 North Carolina ...... 15,321 13,589 10,099 74.3 North Dakota ...... 910 793 683 86.1 Ohio ...... 4,234 3,800 1,908 50.2 Oklahoma ...... 1,435 1,349 557 41.3 Oregon ...... 6,866 5,717 4,814 84.2 Pennsylvania ...... 23,811 21,210 16,271 76.7 RhodeIsland ...... 920 574 306 53.7 South Carolina ...... 4,810 4,146 2,704 65.2 South Dakota ...... 331 305 175 57.4 Tennessee ...... 3,799 3,440 2,507 72.9 Texas ...... 3,899 3,425 2,158 63.0 Utah ...... 1,250 962 816 #4.8 Vermont ...... 1,830 1,679 1,285 76.5 Virginia...... 10,296 9,558 6,810 71.3 Washington ...... 8,489 7,374 5,233 71.0 WestVlrglnla ...... 1,996 1,819 1,428 76.5 Wleconsln ...... 6,464 6,110 3,913 64.0 Wyoming...... 436 382 273 75.4

NOTES:Excludesboardand care hornmforthe mentaliyretarded.Excludesnonreapondingboardand care homes. Advance Data No. 266 ● September19,1995 7

Table 7. Number of residents 65 years of age and over in nursing homes: United Statee, 1991

Raafdants Rasidants Percent of al residents State Ras/dents Wh reported age 65 years of age and over 65 yearsof age and over

Number

United States...... ,.. 1,478,903 1,287,279 1,188,308 92.3

Alabama ...... 21,675 19,435 17,972 92.5 Alas ...... 808 657 517 78.7 Artzona ...... 12,103 10,806 9,931 91.9 Arkansas ...... 20,298 17,288 15,650 80.5 California ...... 98,885 89,420 79,388 8S.8 Colorado ...... 15,871 14,316 13,017 80.9 Connecticut ...... 27,921 22,366 20,651 92.3 Delaware ...... 4,308 3,680 3,378 92.3 DIaWc40fColumbia...... 2,881 2,408 2,246 93.3 Florfda ...... 58,878 52,276 48,628 84.9 Georgia ...... 24,728 31,324 28,407 90.7 Hawaii ...... 2,840 2,721 2,504 92.0 Idaho...... 4,871 4,408 3,997 90.7 Illlnols...... 67,540 74,418 66,207 69.0 Indiana ...... 46,231 40,765 37,140 91.1 lowa ...... 33,214 29,865 28,524 95.2 Kansas ...... 25,304 22,116 20,435 92.7 Kentuc~ ...... 24,966 22,020 20,283 92.1 Louisiana ...... 32,367 26,883 23,934 89.1 Mane...... 9,241 8,610 8,229 95.6 Maryland ...... 25,977 20,745 19,081 92.0 Maasachusatts ...... 48,276 42,620 39,s4s 93.5 Midrlgan ...... 46,196 40,087 36,643 91.5 Minnesota ...... 43,298 36,095 34,054 %.3 MisaPsippi ...... 14,819 11,145 10,355 92.9 Missouri ...... 45,745 38,302 35,866 93.1 Montana ...... 6,297 5,822 5,4s0 82.5 Nebraska ...... 17,779 16,752 15,736 93.9 Nevada ...... 3,043 2,765 2,434 88.0 NewHampshire ...... 7,523 7,202 6,S46 95.1 NewJersey ...... 40,068 34,619 X2,325 93.4 New Mexico ...... 5,634 5,003 4,602 92.0 NewYork ...... 99,372 88W 83,060 84.1 NorlhCarolina ...... 28,546 24,827 22,307 82.3 Nortfr Dakota ...... 6,784 5,365 5,868 95.4 Onto...... 77,676 68,252 62,560 91.7 Oklahoma ...... 27,456 24,984 23a 92.8 Oregon ...... 13,392 11,262 10,473 93.0 Pennsylvania ...... 83,107 71,095 66,824 84.0 Rhodeletend ...... 9,440 8,524 8,226 96.5 South Carolina ...... 13,089 11,807 11,026 92.6 SouIh Dakota ...... 8,192 7,378 7,0&4 95.7 Tennessee ...... 32,304 28,277 26,211 92.7 Texas ...... 90,405 77,246 71,875 83.0 Utah...... 5,544 5,037 4,357 86.5 Verrrwnt ...... 3,591 3,137 2,863 W.5 Virginia ...... 25,775 22,567 20,852 92.4 Washington ...... 24,525 20,985 19,321 92.1 West Virginia ...... 9,809 8,236 7,761 84.2 Wlsoonain ...... 46,838 40,150 36,772 91,6 Wyoming ...... 2,211 2,118 1,982 93.8 8 Advance Data No. 266 ● SeDtember 19, 1995

Technical notes overall agency response rate was have been classified as a musing home. 98.5 percent. The numerator is 7,804, As a result this tile contains 24 nursing Creating a mailing list the numkr of responding agencies. The homes that were also ICF–MR’S, and denominator is 7,920, the number of 11,204 board and care homes that were The 1991 NHJ?I was a mail survey responding agencies plus 116 rei%sing not ICF-MR facilities for the mentally conducted by NCHS. The inventory’s agencies and nonresponding agencies. retarded. The classification system used mailing list of home health me to separate nursing homes from board agencies and hospices contained 14,089 Nursing homes and board and and care homes relied heavily on criteria addressev the mailing list of nursing care homes such as the respondent’s categorization homes and board and care homes The facility response rate, excluding of the home, the home’s certification, (iicluding those for the mentally those board and care places not in the the number of beds setup and sta&d retarded) contained 73,106. Both the followup, was 99 percent (there were for use, the employment of registered agency and facility lists were 262 refusals). If the 8,578 were counted nurses or licensed practical nurses, the constructed using NCHS’s Agency in the calculation as in business and services provided, and the number of Reporting System, which is an ongoing nonresponses, the response rate for mentally retarded patients. system designed to update periodically facilities would be 84 percenh Because Note that a more detailed technical the NHPI listings (5). some of these 8,578 agencies were notes section for the 1991 NHPI is included in other reports (1,3). Mail survey either out of sco@ or out of business, the response rate was probably The Bureau of Census under an somewhat higher than 84 percenL Definitions interagency agreement with NCHS served as the data collection and Classification system Home health care agency-An agency providing health services to data-processing agent. Three individuals in their homes for the questionnaire mailouts plus a field Home health care agencies and purpose of (a) promoting, maintaining, followup were used to complete the hospices or restoring healti, or (b) maximizing inventory. At the end of the mail survey, NCHS classified the 7,804 agencies refusrds, postmaster returns, and the level of independence, while using the questionmdre item “type of minimizing the effects of disability and nonresponses were contacted by client.,” The client data were used illness (including terminal illness). telephone. Also contacted were places because they allowed for the Hospice—An agency providing who did not respond to questionnaire classification of the largest numbers of items considered critical for selecting specialized services for terminally ill agencies into either the home health people and their families, including samples for the Long-Term Care care agency category (6,797) or hospice medical services, social and emotional Component of the National Health Care category (943), with only 64 agencies support for patients and families, Survey (6). remaining in the category of agencies volunteer suppxl and bereavement Because of the large number providing both home health and hospice services for families following the death (17,156) of nonresponding board and care. Based upon additional information of the patient. care homes, resource constraints made it in an agency’s recorcl 56 of the homes— A nursing home is possible to follow up only one-half of Nursing agencies providing both home health a facility with three beds or more that is these non.mspondents. As a result, and hospice care are included with either licensed as a nursing home, nonresponding board and care homes home health agencies, and 8 are certified as a nursing facility under will not be included in the data included with hospices. Medicare or Medlcaidj identified as a presented in this report. nursing care unit of a retirement center, Nursing homes and board and or determined to provide nursing or Results of mail survey care homes medical care. Excluding the 8,578 nonrespondmg Board and care lzomes-This Home health care agencies and generic term describes a residentird hospices board and care homes and the 262 facilities that refused to participate, each setting that provides either routine Of the 14,089 agencies to which of the remaining facilities was classiikd general protective oversight or questionnaires were mailed, 7,804 as either a nursing home (15,511) or a assistance with activities necessary for responded and classified as home health boafd and care home (31,431). For independent living to physically limited agencies or hospices. Of tie remaining pwposes of this survey, no faciMies for persons (excludes those for the mentally 6,285, 116 agencies were the mentally retarded were classified as retarded). nonrespondents, and 6,169 agencies nursing homes. However, if a facility Rural-urban continuum codes for were out of scope or not in operation was primarily a nursing home and metropolitan and nonmetropolitan (questionnaks were returned by the happened to be certilied as an counties—These codes are based on the post office ancl/or field interviewers were intermediate care facility for the 1990 census. Rural counties included unable to locate by telephone). The mentally retarded (ICF–MR), it would nonmetropolitan counties that had an Advance Data No. 266 ● September 19, 1995 9 urbanpopulationfewer than 2,500. Diviswn States included south Delaware,District of Urban countiesincluded countiesnot Atlantic ColumbiajFlorim consideredrural. Nonmetmpolitan New Connecticut Maine, GeorgiajMarylandjNorth countiesare those countiesthat are not England Massachusetts,New Carolilq south Carolina consideredmetropolitan.Metropolitan Hampshire,Rhode Island Virgini%West Virginia areas, as definedby the Officeof Vermont Managementand Budget include core Eastsouth AlabamiLKentucky, countiescontaininga city of 50,000 or Mkldle New Jersey,New York, Centrrd Mississippi,Tennessee Atlantic Pennsylvania more people and a total area population west south Arkansas,Louisia@ of at least 100,000.Additionrd central OklahomajTexas contiguouscounties are included in East North Illinois, Indiana Central metropolitanareas if they are Michiga Ohio, Mountain Arizon%Colorado,Idaho, economicallyand sociallyintegrated Wisconsin Mon~ Nevac@New with the core county (7). Mexico, Utah, Wyoming Geographicdivisions-The U.S. West NortlI Iowa KW=, MiIUleSO@ Bureau of the Census groups the 50 Centml Missouri, Ne- Pacitic AlaSk& caIiforn@ States plus the District of Columbia”into North Dakott& South Hawaii, Oregon, the followingdivisions: Dakota Washington 10 Advance Data No. 266 ● September 19, 1995

Symbols --- Data not available

. . . Category not applicable

Quantity zero

● Figure does not meet standard of reliability or precision (more than 30-percent relative standard error in numerator of percent or rate)

*_ Figure does not meet standard of reliability and quantity zero Number 267 ● August 8, 1995 1 Advance Data From Vital and Health Statistics of the CENTERS FOR DISEASE CONTROLAND PREVENTION/National Center for Health Statistics

Office Visits to Neurologists: United States, 1991-92 by Susan M. Schappert, M.A., Division of Health Care Statistics

Introduction shows the Patient Record form, which is such, they are subject to sampling the sumey instrument used by variability. The Technical notes at the ‘ During 1991–92 an estimated 14.5 participating physicians to nxord end of this report dkcuss briefly the million visits were made in the United information about their patients’ office sample design, sampling errors, and States to nonfederrdly employed visits. guidelines for judging the precision of office-bssed physicians speeirdizing in Only visits to the offices of NAMCS estimates. Additional neurology, the diagnosis and treatment nonfederally employed physicians who publications summarizing NAMCS data of disor&rs of the nervous system-an were classified by the Ameriean Medical from 1991 and 1992 are available (5-7). average of 7.3 million visits per year. Association or the American Osteopathic This report summarizes data pertaining Association as “office-base~ patient Physician practice to office vM.s to neurologists in terms care” were included in the NAMCS characteristics of physician practice characteristics, sample. Viiits to private nonhospital- patient characteristics, and visit based clinks and health maintenance Onaverage, 2.9 visits per 100 “characteristics. organizations wem considered to be persons per year were ma& m The information presented in this within scope of the survey, but those neurologists during 1991 and 1992 report is based on data collected by the that took place in government-operated (tabIe 1). This specialty reeeived National Ambulatory Medical Care facilities wem not. Physicians 1.0 pereent of all office visits made to Survey (NAMCS), a national probability specializing in anesthesiology, ambulatory care physicians during the sample survey conducted by the pathology, or radiology were not 2-yem period. Division of Health Care StatisticS of the included in the sample, nor were v~lts Viiit rates did not differ by National Center for Health Statistics, to hospital-based physicians or gqraphic region, except that the West Centers for Dkase Control and physicians primarily engaged in training, had a higher annual vi.4t rate (3.8 visits Prevention. This survey was conducted resemch, or administration. Telephone per 100 persons) than did the Northeast yearly from 1973 through 1981, again in ccmtsets and visits made outside the (2.4 visits per 100 persons). The 1985, and has resumed an annual physician’s office were also excluded. majority of neurology visits schedule with the 1989 survey. The National Hospital Ambulatory (95.4 pereent) wexe made to doetms of The 1991 and 1992 NAMCS shared Medical Care Survey (NHAMCS) medlcirq 4.6 percent were made to identical survey instruments, definitions, collects patient and visit data horn doctors of osteopathy (table 2). and proeednres. The resulting 2 years of hospital-based outpatient departments data have been combmed to provide and emergency departments. Results Patient characteristics more reliable estimates, and the reader horn that survey are available in other should note that the estimates, percent published rOpOrtS(1+. Visks to neurologists are shown by distributions, and rates presented in this It is necessary to keep in mind that patient’s age, sex, and race in table 3. report reflect average annual estimates the estimates presented in this report are The visit rate was significantly higher based on the combined 1991 and 1992 based on a samplG rather than on the for pemons 25 years and over compmed dam unless otherwise stated. Figure 1 entire universe of office visits, and as with those under age 25. However, no

-u+/ #+ * U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service [ Centers for Disease Control and Prevention National Center for Health Statistics CENTERSCDCFOR DISEASE CONTROL L= 4 AND PREVENTION & -“.”,,”” ““.- m.”. -“. - n“~””. “, . ““”

As.u””oo .1 Oc.”nd,ml,litq-All Inhmatlon whlohWould P.mIU (a.nl,tic,tlan of ,. 0wm2m9nl of lhhh mnd Hummn&wlco* hdlvldud, ● oractlc., w.. balablhhnwntWI be hdo aonlldmtl.1, kin b. und only bV cont.,, 10, 01,9U* control pwaons●ngageaIn and far tha WP08.8 of Ihe S.W9Y ..6 w not b. dh.1.nd m Publk HeatthSwvlco rblm,.d to Bthw P8r.on ,0, us,d fc+anyathm,P“,Prme. NUIOMI OMtu for Hedkh8Ut18N0S ID

L DATEOF VISIT PATlENT RECORD OMB No. 0920-0234 ._/-& Explre8 4-30-93 Month Day NATIONAL AMBUIJiTORY MEDICAL CARE SURVEY CDC 64.21 D

2. DATE OF BIRTH 4. COLOR OR RAOE 5. =HNICITY & EXPECTED SOURCE(S) OF 7. WAS PATlENT S. 1STHIS VISIT PAYMENT [Check .!! rhar tlpp!y] REFERRED FOR INJURY RELATED? ~ 1❑ Wlllta THIS VISkT BY Hlspanio t ❑ HMO/olhW prepaid $ ❑ ~~=~al laYSa 2UN0 ~❑ afgl” ANOTHER I 2 ❑ Black PHYSICIAN? 2 ❑ Medicara 6 D Patient Pdd 9. DOES PATIENT Not 3. 95X *ian I PaoIfiIJ ❑ ❑ SMOKS ICIQARETTES? $ ❑ Idander 2 Hispanic 3 ❑ M,dlrxld 7 ❑ No charga 1 Y-s 1 ❑ Y46 1❑ Female 2 C Male Amarioan Indian I ❑ ❑ 20N0 3 ❑ Unknown 4 ❑ Eddmo / Almd ● Otfmr gowrnmant a Other 20N0

10. PA71EN7W COMPLAINTS) SYMPrOM S), 11. PHYSICIAN’S DkAGNOSES 12. HAVE YOU OR 13. ::~;:vnEENT OR OTHER REASON(S) iOh THIS VfS4 ANYONE IN YOUR . [h parient’s own tuords] PRACTICE SEEN !Check all tkt LW!J regardless of any entry - P$CbmdbCbm&/ PATIENT BEFORE? in itcm II] ,, MM1 lm#Oltnlt Wlmbnlos l~Y02 2DN0 i ❑ None of bdow

2 ❑ Daprasdon 1.min. h C+htc If yes, for the condition ❑ In it*m Ila? s Hypwtwmion 4 n Hypwcholzstwolamia 1 i-J Yes 2UN0 :- c.Ouwc 6 ❑ ObasKy

14. AMBULATORY SURGICAL 1S. OIA~NOSlfC / SCREENING SERVICES 16. THERAPEUTIC SERVICES PROCEDURE(S) [Check .// ordered or prov{dciff [Check all ordered nrprovt&d. Krc!ude tnrdication] [Record any ou#patic.t diognostm m T ❑ None 11 ❑ Pap teat rherapcudc proccdurc, For tkeprs#, ❑ ❑ ❑ check appropriate ties.] 2 elood pmre 12 StreP threat test I Norm en DruoabIM OTHER THERAPY 3 ❑ Urlm2tyds 13 ❑ HIV eerology 7 ❑ Atcohol abusa 13 ❑ P6ychetherapy 4 ❑ EKG - resting 14❑ Chdederd meaeura plmou;;G / 8 ❑ SmOIdng costion s ❑ EKG - exercise {5 ❑ Othdf lob ted !4 IJ Corractivz 1217263 8. ❑ ❑ I ❑ Soheduled 3 ❑ l-owl anedhszia ❑ ❑ 2 ebt is Hearing aid 0 Mamm0gr2m 16 Hemkng tsti ❑ 9 U Family/ SOdat ❑ 2 ❑ Performed 4 ❑ Regional an+sthosia 7 ❑ Che6t X-!lly 170 Vi21d 2@ity 3 E.XWC123 16 Phydothe.mpy 10❑ GIuwth / davalopmant ❑ ❑ I B❑ M3ntal 2katu3 exam ❑ s General anesthem 6 Other 7d0bgY 4 Cholesterol reduction ❑ !7 I_J Othm fhzmpy {SPCC(BJ 1S~ Other /Spc@y] t? Family planning 5 ❑ Wo&M mduoOon 9 ~ ASWJY tektrng ❑ 12 U 0th3r cowdlng b 10 Spirctm3by

17. MEDICATION if none, chook here ❑ a. N-w modlastlcm? la. DISPoslnON THIS ~~ 1S. &RATION [Check all that apply] [Re.ord all new Yax M THIs Vlsm or cnnfhnwd /Y’lmeactually medication I ❑ No fclow-up planmsd 1< spctttwl:h ordered or In 2CI ❑ physician] provldrd al z Ratiim m spccmed timrn thk vim’r. L%* 3 D Return If neadad, P.R.N. the ,sanw hnmd 2. II-J 2fl nameor generic 4 a Telephone follow-up plmnod name enterzd on 3. any R.x or @ice ~El 2C s ❑ Referred to afhor phyzician medtcal record. Include imnnmtmkr 6 ❑ Rztumed 10 roferfing physician and desensidzing 4. II--J 2E agents.] 7 ❑ Mmtt to hospital Mlnutek 5. lo 21-J 8 I-J Othzu[Spccfy]

..-. 4 m-as --• “---.J s-— significant dtierences were noted among rate of visits to neurologists (3.2 visits Visit characteristics visit rates for those in the age groups per 100 persons per ye@ than did black 2444 years, 45-64 years, 65–74 years, persons (1.6 visits per 100 pemons per Referral status and prior-visit and 75 years and over. In addition, visit year). status rates for persons under 15 years and Persons 254 years of age Nearly one-third (30.2 percent) of 15–24 yesrs of age did not dtier accounted for more than one-third office visits to neurologists ‘werethe significantly from eaeh other. Females (35.3 percent) of all offim visits to result of a refenal by another physician had a higher visit rate to neurologists neurologist& those 44 years and over than did males (3.3 visits per 100 amounted for slightly less than half of compared with 6.0 percent of the visits females per year compared with 2.5 the visits (46.1 percent). Females made a to all other physicians (figure 2). While visits per 100 males). Significant higher proportion of visits to 60.5 percent of neurology visits were differences were cotined to the age neurologists than did males, 58.0 percent made by patients returning for care of a group 25-44 years, with females in that and 42.0 percenq respectively. White previously treated problem, more than group making 4.0 visits per 100 persons made 91.1 pereent of the visits one-third (35.8 percent) were made by compared with 2.3 visits per 100 males. to this SpCCidty, and black pkXSOIIS new patients. In comparison, only White persons had a significantly higher accounted for 7.0 percent. 15.5 percent of the visits to all other Advance Data No. 267 ● August 8, 1995 3

Table 1. Annual number, percent distribution, and rate of office visits by physician symptomatic problem or complain4 with specialty, averaged over a 2-year period United States, 1991-92 the largest proportion of symptoms Nutrber of being those referable to the nervous Number of vk/ts per tisik fn Percent 100 parsons system (excluding sense organs) Phys/ckur speclatly thousands dktdbuf/on per yea+ (43.3 percent). Musculoskeletal

Allvisifs ...... 715,867 100.0 266.3 symptoms were listed at 22.9 percent of

Genersl and femify pracifoe ...... 192,051 26.8 76.8 the visits. Internal madidne ...... 101,598 14.2 40.6 Specific reasons for visit are listed Pediattisa ...... 65,387 11.9 34.1 in table 7. The single most frequently Obstettfos end gynecology...... 62,601 8.7 25.0 mentioned principal reason for visiting Ophthalmology ...... 43,864 6.1 17.5 Orthopedic surgery ...... 36,958 5.2 14.8 the neurologist was headaehe or pain in Dermatology ...... 2e,l 79 4.1 11.7 hea~ amounting for 18.4 percent of the Generafsurgety ...... 22,797 3.2 9.1 visits. A higher proportion of visits by Otoleryngology ...... 21,007 2.9 a.4 Paychlatry ...... 17,769 2.5 7.1 females were for this rea30n Urologicafsurgery ...... 13,857 1.9 5.5 (22.5 percent) compared with males Cerdioveecufardiseeees...... 13,146 1.8 5.3 (12.7 percent). Convulsions, mentioned Neurology ...... 7,253 1.0 2.9 Aflotherspecfaftfss ...... 66,382 9.6 27.3 at 9.1 percent of visits, was the second most frequent reason, followed by lBawd on U.S. Bureau of the Census estimates of the civilian, noninstifutimalized populaticm of the Unled States for Jup 1, 1991, and July 1, 1992, averaged over the 2-year period. disaubances of sensation (5.5 percent). It should be noted that estimates that differ in rank order may not be Table 2. Annual number, percent distribution, and rate of offfce visits to neurologists by selected physician praotice characteristics, averaged over a 2-yeer period United States, signiticzmtly dtierent fmm each other. 1991-92 Diagnostic services Physkfan pl%tdke Number of vkffs Percenf Number of Wslfsper characfetfstkx in thousands dkfribufion 100 persons peryea+ About one-third of all visits to Allvfaifs ...... 7,253 100.0 2.9 neurologists included no diagnostic or

Geographic region sermning seMces; 4 of every 10 visits

Northeast ...... 1,191 16.4 2.4 (42.2 pereent) included one semice. The Midwest ...... 1,815 25.0 3.0 most frequently mentioned speeilic South ...... 2,172 20.0 2.6 category was blood pressure check west ...... 2,076 28.6 3.8 which was reported at more thsn Professional fdentlfy one-third of the visits (37.3 percent). Dooforofmedklne ...... 6,921 95.4 2.8 Mental status exams were more Oostorofoskopathy ...... 332 4.6 0.1 likely to be ordered or provided at visits ‘Basedon U.S,Bureau oflheCensusestirnates ofthecivilian, noninstitutiinalimd pc.pu!@ionofthe UnitedStatesfor Ju&l, to neurologists compared with visits to 1S31, arxl July 1, 1SS2, averaged over the 2-year pericd. all other physicians (8.8 pereent and physicians were by new patients Patient’s principal reason for visit 1.1 pemen~ respectively), as waa “other (figure 3). Visits by referral statm and radiology” (radiology other than chest x prior-visit status are summarimd in Table 6 shows the patient’s ray). Unspecified diagnostic services table 4. principal reason for visiting the were reported at 29.6 percent of all physic@ according to the eight visits to neurologists. Table 8 displays vMs by the number and we of Expected sources of payment modules, or groups of reasons, outlined in A Reasonfor Visit Classi$catwnfor dmgnostic services ordered or provided. Ambulatory Care (WC) (8). Principal Private insurance was an expected Principal diagnosis source of payment at nearly one-half reason for visit (item 10s on the Patient (44.4 percent) of all visits to Record form) is the patient’s most Data on pMeipal diagnoses neurologists compared with one-third important complaint(s), symptom(s), or rendered at office visits are obtained (34.1 percent) of visits to all other other reason(s) for this visit expressed in from item 1la of the Patient Record specialties. Medicare was an expected the patient’s (or patient’s form where physicians are asked to pay soume at one-lifth of all neurology spokesperson’s) own words. Up to three record the prineipsl dkgnosis asoeiated visits (21.8 pereent). Data on expected rea30ns per visit may be coded based with the patient’s most importmt reason sources of payment are shown in upon the classification system found in for visit. Dhgnoses are classified and table 5. It should be noted that more the RVC. coded according to the lnternatitmal than one expected source of payment Eight out often visits to this Classi$catwn of Diseases, 9th Revisiofi could be reeorded per visit. specialty (81.1 pereent) were due to a ClinicalModification(ND-9-CM) (9). 4 Advance Data No. 267 ● August 8, 1995

Table 3. Annual number, percent distribution, and rate of offtoe visits to neurologists by neurology visits were migraine selected pattent characteristics, averaged over a 2-year period: United States, 1991-92 (10.3 percent) and symptoms involving Number of Welt rate head and neck (5,7 percent). A higher tidk In Percent per 100 proportion of visits by females listed Patient characteristic thousands distribution parsons’ diagnoses of migraine and symptoms AIIvIsIW...... 7,253 100.0 2.9 involving head and neck than did visits

Age by males. (Among visits with the latter Under 15years ...... 770 10.6 1.4 diagnosis, 97.1 percent were coded to 15-24 years ...... 577 8.0 1.7 ICD-9-CM subcategory 784,0, 25-44years ...... 2,559 35.3 3.2 headache). Parkinson’s dkease, which 45-64yeare ...... 1,663 26.1 4.0 accounted for 4.6 percent of the visits 65-74yeara ...... 820 11.3 4.5 overalL was listed at 6.6 percent of 75yesrsandover ...... 633 8.7 5.2 visita by males compared with Sex end age 3.1 percent of visits by females. The Female ...... 4,2i O 58.0 3.3 most tiquently reported diagnoses by Under15years ...... 329 4,5 1.2 age group are presented in table 11. 15-24yeafa ...... 312 4.3 1.6 X-44years...... 1,647 22.7 4.0 Inttxwtingly, one-fifth (19.8 percent) 45-64years ...... 1,071 14.8 4.3 of visits to neurologists were reported to 65-74yeare ...... 441 6.1 4.3 be injury related in item 13 of the 75yearaandover ...... 410 5.6 5.4 Patient Reeord form eompamd with Male ...... 3,044 42.0 2.5 about one-tentl (9.1 percent) of visits to Under15yeare ...... 442 6.1 1.5 all other physicians. This is not readfly 15-24years ...... 265 3.7 1.5 25+4years ...... 912 12.6 2,3 apparent from an examination of the 45-64yeers ...... 622 11.3 3.6 reported ICD–9-CM codes, however, as 65-74yeaIs ...... 380 5.2 4.6 only 6.7 percent of neurology visits 75yeemandover ...... 224 3.1 4.9 were classified to the “injury and Race poisoning” category of the ICD-9-CM. While ...... 6,605 91.1 3.2 Black ...... 508 7.0 1.6 Therapeutic services Asian/PacificIslander ...... 113 1.6 --- AmericanlndlaniEsldmo/Aleut...... “27 “0.4 --- Table 12 presents data on therapeutic services ordered or provided ‘Visit rates are besed on U.S. Bureau of tha Census esth’nates of the oMlien, noninstilufhalized U.S. population for July 1, 1991, and July 1, 1S32, averaged ovar the 2-year period. at visits to neurologists. Medication therapy was mentioned at nearly two-thirds of the visits (63.7 percent), More than one-third (36.1 percent) symptoms whose causes could not be and nonmedication therapy was ordered or provided at more than one-quarter of of allvisita toneurologktsr esultedina determined provisional diagnoses, cases the visits (27.9 percent). The most principal diagnosis that was clmsifiable referred elsewhere before a diagnosis frequently mentioned types of toadiseaseofthe nervoussystemand was made, cases in which a precise nonmedication therapy included “other senseorgans(table 9).Almutone-fifth diagnosis was unavailable for any other reason, and certain symptoms that counseling” (8.0 percent), exercise of the visits (21.3 percent) were represent important problems in medical counseling or education (7.1 percent), reeordedas “symptoms, signs, and care and that might be desired to physiotherapy (6.4 percent), and diet ill-defined conditions.” Dkasesofthe classify in addtion to a known cause. counseling or education (5.2 percent). musculoskeletal system andcmmective General symptoms (ICD-9-CM code Ambulatory surgery was scheduled or tissue accounted for 14.6 percent of the 780) may include any of the following performed at 1.3 percent of visits to visits. subcategories coma and stupor, neurologists, significantly less than the The top 20 principal diagnoses at hallucinations, SytlCOpe (fainting) and corresponding 6.1 percent of visits to all visits toneurologists areshownin collapse, convulsions, dizziness and other physicians. table 10. The mostfrequently listed giddiness, sleep disturbances, pyrexia Tables 13, 14, and 15 p~sent more specitic d~gnosis was “generrd (fever) of unknown origin, malaise and detailed drug data relating to neurology symptoms’’(ICD-9-CM code780), fatigue, hyperhidrosis (exeessive visi@ As used in the NAMCS, the term occurringat13.3 percentofvisits .This sweating), and other general symptoms. “drug” is interchangeable with the term catego~ falls within the larger Among the neurology visits reported “medication” and includes all new or classification of ’’symptoms, signs, and here, convulsions (ICD-9-CM code continued medications ordered or ill-defined conditions” ofthe ICW9– 780.3) accounted for more than provided at the visit. This includes both CM. This classification includes signs three-quarters of the “general prescription and nonprescription and symptoms for whlchno more symptoms” diagnoses. preparations, immunizing agents, and specilic dmgnosis can be made even The second and thiid most desensitizing agents. “Drug mentions” after investigation of the facts, transient frequently reported dmgnoses at refer to the total number of medications Advance Data No. 267 ● August 8, 1995 5

Wed in item 17 of the Patient Record Physician specialty form. Physicians may record more than Neurology 30.2 one medication per visi~ so that the total number of drug mentions may General surgery exceed the total number of visits. “Drug Orthopsdio surgery visits” refer to visits with at least one mention of medkation ordered or Otolaryngology provided by the physician. An earlier report destibes in detail the method and Urological surgery instruments used in the collection and

Ophthalmology processing of NAMCS drug data (10). Among visits to neurologists, there Dermatology was an average of 8.1 million drug Oardiovasular mentions per year for 1991 and 1992, dseaeas yielding 1.8 mentions per drug visit and Psychiatry 1.1 mentions per visit overall. Table 13 shows the number of drug mentions by Obstetrics and gynecology therapeutic classification, adapted from therapeutic categories used in the N&-onal Drug Code, 1985 edition (11). In cases where a particular drug was classifiable to more than one therapeutic category, it was listed under the Other category that ocamed with the greatest frequency. Necrologic drugs I 1 I I I 1 1 I (25.9 percent), drugs used for pain relief o 5 10 15 20 25 30 35 40 (22.4 percent), and psychopharmacologic percent of otica visits drugs (20.2 percent) were reported most fkquently, together accounting for abut lure 2. Percent of offfce visits that are referrals, according to physician specialty: Iited States, 1991-32 two-thirds (68.5 percent) of the drugs mentioned at visits to neurologists The generic substances used most frequently in medications ordered or Physician specialty provided at neurology visits are shown Neurology 35.8 in table 14. Acetaminophen was the most frequently occurring substance Otolafyngology (8.3 percent of mentions), followed by Orthopwlic surgery carbamazepine (6.0 pement) and amitriptyline (4.9 percent). It should be General surgery noted that drugs containing more than Dermatology one ingredient are listed in the data for each ingrdlenL For example, Urological surgery acetaminophen with codeine would be Ophthalmology listed both under the count for acetaminophen as well as the count for Psychiatry codeine. Obstetrics and gynecology Table 15 displays drug mentions General and family according to entry name, that is, the name recorded by the physician in item cwdo:~$e: 17 of the Patient Record form. This couId be a trade name, generic name, or Internal mediane simply a desired therapeutic effect. Pediitriis Tegretol was the specific entry listed most tkquently (6.0 percent of Other mentions), followed by Dikmtin I I I I (4.3 percent) and Sinemet (3.5 percent). o 10 20 24) 40 Dispositionof visit Percent of office visits Viits to neurologists were more Figure 3. Percent of offfce visits made by new patients, according to physician specialty: likely to include insfruetions to return at United States, 1991-92 6 Advance Data No. 267 ● August 8,1995

Table 4. Annual number end percent distribution of office visits to neurologists and to all aspecifictime (70.5percent)than were other physicians by patient’s referral status and prior-visit status, averaged over a 2-yaar period: United States, 1991-92 visit3toallother specialties (62.3 percent). Also, a higher proportion visits to neurologkts Vkifs to all other physicians of these visits resulted in inslructionsfor

Number of Nurrbar of the patient toreturn tothereferring vkffs In Percent vkifs in Percent physician (7.7 percent) compared with WI draracterktlc thousands dkfrfbuflon thousands dktributlon visita to all other physicians

AIIvMs...... 7,253 100.0 708,614 100.0 (0.9 percent). Thk is a reflection, to some degree, of thelargemtmberof Referral status referrakmade to this specialty relative Referred by another phyaldan...... 2,189 30.2 42,598 6.0 to other physician specialties. Data on Not raferred by another physklan...... 5,064 69.8 666,016 94.0 disposition of visit are displayed in Prior-visit status table 16. New patient ...... 2,597 35.8 109,4e4 15.5 Otdpatient, newprobfem ...... 269 3.7 159,512 22.5 Duration of visit Oldpatient, old problem ...... 4,386 60.5 439,608 62.0 About three-quarters (73.3 percent) of visits to neurologists lasted more than 15 minutes, compared with one-thiid Table 5. Annual number and percent distribution of office visits to neurologists and to all other physlchms by patient’s expected source(s) of paymen~ avemged over a 2-yaar (32.3 percent) of visits to all other period: United States, 1991-92 physicians. Average duration of neurology visita was 30.5 minutes Wts to rreut’ologkts Vkits to all other phyakkns compared with 17.2 minutes for all Number of Number of other visits. Average duration is based vkffs in Percent vklts In Percent E@eded source(s) of payment’ thouean& dkfrfbutlon thousands dktdbutlon on the time spent in direct face-to-face contact between the physician and the Allvtsits ...... 7,253 100.0 708,614 100.0 patient. It does not include visits of Private/commerdal lnsuranca ...... 3,220 44.4 241,927 34.1 “zero” minutes duration, that is, visits Medkefs ...... 1,581 21.8 145,086 20.5 in which the patient did not meet with Patient-paid ...... 983 13.5 150,664 21.3 HMO/otherprepaidpten ...... 827 11.4 122,833 17.3 the physician directly. Data on duration Medlcakf ...... 523 7.2 73,231 10.3 of visits are shown in table 17. Othergovemment ...... 221 3.1 14,795 2.1 Nocharge ...... 84 0.9 11,381 1.6 VMs to neurologists between 10.1 4.0 Other ...... 736 28,123 1975 and 1992 Unknown ...... 68 0.9 15,732 2.2

‘Tbtalmay excsedtotalnumbercf visitsbecausemomthanone categoryw ba reportedparvisit. The overall number of visits to neurologists increased by 283.3 percent

Table 6. Annual number and percent distribution of office visits to neurologists by patient’s principal reason for visitj averaged over a 2-year period: United States, 1991-92

Nutn5er of vklta Percent Prtnc@al reason for VISHand RVC code’ In thousands dktrfbrftlon

Allvidts...... 7,253 10CLO synyiommodul e ...... S001-S999 5,881 81.1 Syrr@cme referable tc the nervcus system (excluding sense organs) . . .S200-S259 3,141 43.3 Syn@ome referable to the musculoskeletal system...... S800-S999 1,662 22.9 Genarat symptoms ...... S001-S033 508 7.0 symptoms referable to paytiologkaf and mental dleorders...... S100+199 262 3.6 Symptornerefereble totheeyesand aars ...... S300+399 193 ;~,7 symptoms referable to the respiratory system...... S400-S499 51 ().7 Allothersymptoms2 ...... 65 ().9 Diaaase module ...... DOO1-0999 459 6.3 Dtsgnostlo, screening, end preventive modute ...... XIBX599 95 “1.3 Treatment module ...... TIOO-T899 362 5.3 Injury endadversee ffectsmodule ...... JOO%J993 83 “1.1 Teat resulta module ...... RIOO-R700 58 0.8 Admlnktratfvemodule ...... A1BA140 ●6 “0.1 Other ? ...... U930-U999 289 4.0

‘Baaed on A ReasonforWit CkssfioatkmforAr?iwktofyCam (WC) (8). %cludes symptomsreferableto the cardwascular and lymphaticsystem(S260-S299); aymptom$referabletothe d@st??esystem(S500-SS39);symptomsreferabletothe genitounnsrysystem S29~ and symptorrareferableto the skin,hair,and nails(8S30-8SS3). ?%=MMs, woMem,sndco~lain& n@ekeWretisfid, Mtiofmne,”andilkgibleetin-. Advance Data No. 267 ● August 8,1995 7

Table 7. Annual number and percent distribution of office vleits to neurologlets by the 20 from a 2-year total of 3.8 million in most frequently mentioned prlnclpal reasona for VISIL according to patlant’s sax, averaged over a 2-yaar period United States, 1991-82 1975-76 to 14.5 million in 1991-92. The 1975-76 toml represented Patient’ssex approximately 0.3 percent of all visit8 to Number of visits Prhro@a/mason for visitand RVG code’ in thousands Total Male Female office-based physicians during that time period. The1991-92 share, l.OpercenL Percent dletrbuflorr was signhicantly higher. According to Allvisifs ...... 7,253 100.0 100.0 100.0 data tiom the American Medical Headache, pahrhshead ...... S210 1,334 18.4 12.7 22.5 Association there were 6,257 Convulsions ...... S205 859 9.1 10.1 8.3 D18Wbenoes of .sensslion ...... S220 397 5.5 5.5 5.4 nonfederally employedr office-based Necksymptome ...... S900 374 5.2 3.8 6.1 neurologiws in the United State3 Backsymptoms ...... S905 344 4.7 5.2 4.4 (excluding possessions) in 1992 Vertigcdlzzinees ...... S225 256 3.5 3.9 3.2 compared with l,847in 1975, an Progrees visit, nototherwise spactfied...... T800 254 3.5 3.0 3.9 Legsymptome ...... S920 251 3.5 4.0 3.1 increase of 238.8 percent (12,13). Abnormal hsvoluntery movements...... S200 239 3.3 4.7 2.3 The rate of visits m neurologists Low backsymptoms ...... S910 198 2.7 3.2 2.4 increawif romanaverageof 0.9 visit3 Dieordersof motor functions...... S095 135 1.9 1.6 2.1 per 100 persons per year in 1975-76 to Viskrndysfuncfkm s ...... S305 131 1.8 1.3 2.2 Hsndandfinger symptome ...... S960 117 1.6 1.2 1.9 2.9 visits per 100 persons per year in Arrnsyrnptome ...... s945 113 1.6 1.7 1.4 1991–92. The age-adjusted visit rate for Dtsturbancas of memory ...... S215 105 1.4 1.3 1.6 1991–92 was 2.3 visits per 100 persons, Migraine headache ...... D385 85 1.2 ‘0.8 1.4 using the 1975-76 U.S. populations Shoukfersymptoms ...... S940 84 1.2 1.2 1.1 Ganeral weakness ...... S020 84 1.2 “0.6 1.6 the standard (figure 4). Wits to Disturbances ofslaep ...... S135 74 1.0 1.3 “0.8 neurologists during 1975–92 are shown Other diseases ofcantral nervous syetem . . . .D370 89 1.0 “1.1 0.9 by patient’s age in table 18. Allotherreasons ...... 1,951 26.9 31.8 23.4

‘Basad on A Reason for WI Classikatim forArriwfatov Care (WC) (8). References

Table 8, Annual number and percent distribution of office visits to neurologists and to all 1. McCaig LF. National Hospital other physicians by diagnostic services ordered or performed, averaged over a 2-yaar Ambulatory Mdlcal Cme Survey period: United States, 1991-92 1992 emergency department L&Its to S/l summary. Advance data ffom vital W?Jtsto naurologkfs ofharphyakiens and health statistics, no. 245. Hyattsvillq Maryland. National Nurnbarof Number of vfslfain Percent visitsin Percent Center for Health Statistics. 1994. UlaftctraracterktIc thouaanc% dMribufIon ftrousande d&sfdbufion 2. McCaig LF. National Hospital Ambulatory Medical Care Survey Allvisfts ...... 7,253 100.0 708,614 100.0 1992 outpatient department summary. Nurrbar of diagnostic Advance data from vital and health services ordared or performed statistics, no. 248. Hyattsville, None ...... 2,386 32.9 250,785 35.4 Maryland. National Center for Health One ...... 3,061 42.2 246,957 34.9 Two ...... 1,154 15.9 123,726 17.5 statistics. 1994. Three ...... 450 6.2 52,095 7.4 3. NeIson CR, Stussman BJ. AlcohoI- Four ...... 122 1.7 21,450 3.0 and drug-rclsted visits to hospital Fiveormcre ...... 78 1.1 13,621 1.9 emergency departments: 1992 National Hospital Ambulatory Diagnoatiosetvlces orderedorperformed’ Medical Care Survey. Advance data None ...... 2,W8 32.9 250,765 35.4 tkom vital and health stdistics, no. Blocdpreesurecheck ...... 2,702 37.3 307,770 43.4 251. Hyattsville, Maryland. National Urlnalysfs ...... o...... 130 1.8 95565 13.5 EKGrestin& ...... 86 1.2 21,419 3.0 Center for Health Statistics. 1994. Olherradkrlogy ...... 602 8.3 36,315 5.4 4. Burt CW. Injury-related visits to Cholesterol measure ...... 42 0.6 25,360 3.6 hospital emergency departments: Otherlabtest ...... 977 13.5 119,980 16.8 United States, 1992. Advance data Hearingtesl ...... 66 0.9 10,130 1.4 horn vital and health statistics, no. Visrralawify ...... 165 2.3 41,088 5.8 261. Hyattsville, Ma@md. National Menfalstsfusexsrw ...... 6S8 6.8 8,102 1.1 Otha# ...... 2,196 30.3 143,983 20.3 Center for Health Statistics. 1994. 5. Schappert SM. National Ambulatory ~Totalmayexcerrd totalnumberdvisifa baoausernorethan oneoatagoiymay baraporkfparvbit Medical Care Survey 1991 %KQiselectmoardiimm. %mf.lbwingdiagnostii serviceoategorbawara notraportadatviaiito naurdogiskalbrgytaeting, spironwt~andpaptaat. summary. Advance data from vital Thefolbwhmdmmmafii senrbcetaowiae wammoorbdatvbita tonaurolookfs.but wifhfrawenoieathat waratoolowto and health statistic no. 230. producerdi;bb&timataa: EKGaxekkm,mamrrw&am, atrapthmattes!c&f xrayandHIV(hunran irnmunodarkbmqvirua) aarobgy lleseaarvkea havebeaninoludad inthe’’other”osbgory. Unspe%hsddmgnoetic sarvicasacewnted for29,6parcemt Hyattsvilk+ Maryland National ofallrepxfadservkaa atvbiifoneurolog.bta. Center for Health Statistics. 1993. 8 Advance Data No. 267 ● August 8, 1995

Table 9. Annual number and percent distribution of office vlslta to neurologkrta by 6. Schappert SM. National Ambulatory principal diagnosis, averaged over a 2-year period: Unltad Stataa, 1991-92 Medical Care Survey: 1991 Nurnbar of summary. National Center for Healti visits In Perc3rrf Statistics. Vital and Healfh Stat Prlnc@al dlagnosia and ICD-9-CM code~ thousmds dktrfbutfon 13(116). 1994. AllvMts...... 7,253 100.0 7. Schappert SM. National Ambulatmy Infedlousand parasdtfcdlseaees ...... 001-139 65 0.9 Medical Care Survey: 1992 NeoPfaeme ...... - ...... 14~=9 60 0.8 summary. Advance data from vital Endocrfrre, nufritlonal andmatabollc dlaeaeas, SndlmmunifYdlmr*m. . ..240-279 75 1.0 andhealth statistic~ no. 253. Mentetdieorders ...... 290-319 602 8.3 Hyattsville, Maryland: National Dieeaeesof thenervous system and=msorgans ...... 320-339 2,616 36.1 Dleeaeeeof thecircufatory eyatem ...... -~9 344 4.7 Center for Health Statistics. 1994. Dieaaeesof thereeplmtory system...... 460-519 41 0.6 8. Schneider D, Appleton L, McLemore D!seaees of themuscufoekeletal system andconnectfVe tleeue ...... 710-738 1,060 14.6 T. A reason for visit classificsition for symptome, signs, andiil-deflned conditions ...... 780-7~ 1,544 21.3 ambulatory care. National Center for Injury andpoleoning ...... 800-999 464 6.7 Health Statistics. Vital and Health Suppkmwntaryc faeetficeticm...... VOI-V82 169 2.2 Allotherdlagnosesz ...... 71 1.0 Stat 2(78). 1979. Unknowns ...... 132 1.8 9. Public Health Service and Health Care Financing Administration. lBasadon the htternatimal C/a.sMicatim of Diaa8ses, Gfh Revisbn, C/inioal Mcd/fkatbn (lCD-%CM) (9). %dudss diseasesofthe bkmdand blind-formingorgans(280-263~ diaa.ms of the digastiiesyafam (520-S79); diaaassaof International Classification of the geniourinary system (SS&5291 complicationsof pragnan~, ohildbitih,andthe puerparium(6S0-876h diaassaaofthe skin Diseases, 9th Revision, clMcal andsubcutaneoustissue(630-709); mngenifalanomalies(740-75S); and carfainmndiins ofiginafinginMa pwinatalperiod modification. Washington: Public (#~~)blmkdiwnosas, unmdabkdagwes,andllleglbledmgnosm Health Service. 1980. 10. Koch H, Campbell W. The collection

Table 10. Annual number and percent distribution of oftlce visits to naurologlsta by tlm 20 and processing of drug infonuation. moat frequently mentioned principal dlagnosaa, according to patient’s 8.x, ●voragad over National Ambulatory Medkil Care a 2-vear mwlock Unltad Stataa, 1991-92 Survey, 1980. National Center for Health Statistics. Vital and Health Nrr&r of Patlent3 sex vlalfs in Stat 2(90). 1982. Prfnc#Ml dlsgnosfa and ICD-9-CM Codai thousands Totsf Mafe Fernak 11. Food aid Drug Administration. National Drug Code Directory, 1985 Percent dletrbtrtfon Edition. Washington Public Health Aflvtsits ...... 7,253 100.0 100.0 100.0 Service, 1985. 965 Genaref symptoms ...... --...760 13.3 15.8 11.5 12. Goodman LJ, Mason HR. Physician Convukfons...... 780.3 769 10.6 +3.1 8.8 Corns and stupor, helluclnatfons, eyncopa and collapse, dlzzfneee and distribution and medical licensure in gkktlnees, steep dkWtmncae, matatse and latlgue, other general the United States, 1975. American symptoms ...... 780.0-780.2,760.4-780.5, 780.7,760.9 195 2.7 2.7 2.7 Medical Association, Center for Migretne ...... 346 746 10.3 5.7 13.6 .symptomelnvolvin gheadandnec k...... 764 414 5.7 3.4 7.4 Health Services Research and Headache ...... 734.0 402 5.5 3.3 7.2 Development. Chicago, Illinois. ~heefa, other speech disturbance, other symbolic dyefunctfon, 1976. Spisfexis ...... 784.3.734.5-734.7 *12 “0.2 “0.1 “0.2 13. Roback G, Randolph L, Seidman B. Parkfnson’s dleease ...... -...... 332 331 4.6 6.6 3.1 Other and unepectfted dfeordere of back ...... 724 274 3.8 4.2 3.5 Physician characteristics and Mononeurifle of uppar limb and mononeurttls multlpkx ...... 354 268 3.7 2.5 4.6 distribution in the United States. Mutfiple ecteroefs...... 340 244 3.4 “0.6 5.2 American Medical Association, Spmfns and etrafns of other and unspecified parfe of back...... 647 231 3.2 3.2 3.5 Department of Physician Data 198 2.7 3.6 2.1 Other dtsordersof adtlfsaues ...... -...728 Services. Chicago, Illinoix 1993. Other dfsordereof oervlcafreglon ...... 723 197 2.7 3.1 2.5 Spedet eyn@orne or syndromes, not eleawhere cfaasMed ...... 307 152 2.1 1.3 2.7 EPIIsPSY ...... 345 150 2.1 1.9 2.2 Acute, butilldeflned, carabrovaWdmdke= ...... 436 131 1.8 2.2 1.5 Hyperldnatic eyndroma ofchlldhood ...... 314 121 1.7 3.0 ●0.7 Spondyfoefe andaflleddfsordara ...... 721 119 1.6 1.5 1.8 Intervertebral dlecdlaorcfefs ...... 722 115 1.6 *1.1 2.0 Other exfmpymrnklef diseSwad Anotimovemant dborrfef'e. ..333 114 1.6 1.6 1.6 Haredftery arfdldfopafhlc pa@hemfnauroPathy...... 356 106 1.5 1.6 1.4 Mononeuritfe oflowerllmb ...... 355 30 1.2 1.9 ‘0.7 Naurotlcdieordare ...... 300 79 1.1 “0.6 1.5 Atlotherdiagnoeae ...... 633 11.6 15.3 8.4

‘Based onthe /ntemafiofIa/Cksifiitkm of LMasfses,f3h Revisiw, Cfinioa/ Afcufifiitbn (lCO-SCM) (9). Advance Data No. 267 ● August 8, 1995 9

Table 11. Annual number and percent distribution of offioe visits to neuroiogista by the most frequently mentioned principai diagnoses, acwrding to patient’s age, averaged over a 2-year period: United States, 1991-92

Nuniw of vklfs Percent Cumulative Prfrro@al dhgnosls and ICD-9-CM code’ h thousands diatiibuflon percent

Under 15 years Allvisits ...... 770 100.0 . . . Generafsymptoms...... 780 287 37.3 37.3 ~erMnetlc~ndmm ofchlldhood ...... 3l4 102 13.3 50.6 Migralrre ...... 346 53 6.8 57.4 Symptomsinvohdngheadandneck ...... 764 41 5.4 62.8 Allolherdlagrroses ...... 287 37.2 100.0

15-24 years Atlvtdfs...... 577 100.0 . . . Generatsymp!oms...... 780 120 20.6 20.8 Mlgralne ...... 846 w 11.1 31.9 .Symptomslnvofvlngheadandneck ...... 764 57 9.8 4+.7 Spralnsandsfrainsof othersndunspeclfisd partsofback ...... 647 56 9.7 51.3 Aliotherdiagnoses ...... 281 46.7 100.0

25-44 years Aflvishs ...... 2359 100.0 . . . Migraine ...... 346 421 16.4 16.4 Generatsymptoma...... 780 256 10.0 26.4 .Syrnplomsinvoh4ngheadandneck...... 764 198 7.8 WI Multiplesderosls ...... 340 133 5.4 38.6 3prainsandslrahrsofothererrdunspecIfisdperfsofback ...... 847 126 4.9 44.5 Otherand unspsolfteddleordarsofbsck...... 724 120 4.7 49.2 Mononeuritts ofupper lbnband mononeurttis multiptax...... S54 100 3.3 53.1 Otherdlsordersofsofttissues...... 729 95 3.7 56.8 Otherdlsordarsofc=ervicalreglon...... 728 95 3.7 80.5 Epilepsy ...... 345 79 3.1 63.6 Allofherdlagnosas ...... 930 36.4 100.0

45-64 yeare Allvidts...... 1,893 100.0 . . . Generalsympfoms...... 76o 134 10.2 10.2 Migraine ...... W6 163 9.6 19.8 Otherandunepeclfteddlsordareof back...... 724 97 5.1 25.0 Syrr@omshrvofvIrrgheadandnaok...... 764 96 5.1 30.1 Mulfiplasdemds ...... 340 94 5.0 35.0 MononeurltieofupperIlmbandmononeuritlsmutfiplex...... 364 66 4.5 S9.6 Parkineon’sdisease ...... 332 83 4.4 44.0 Otherdlsordaraofsofttisaues...... 723 63 3.6 47.6 Olherdleordarsofcarvicalregion...... 723 69 3.8 51.2 Spondyloslsandallieddisordara...... 721 56 3.0 54.2 Allotherdiegnoses ...... 887 45.8 100.0

65 years and over Alivlaits ...... 1,454 100.0 . . . Paddnson’sdisaase ...... 332 246 16.9 16.9 Generatsympfoms...... 76o 106 7.4 24.3 Acute, butill-deflnsd,carebrovasoulardk@saa...... 436 88 5.8 30.2 MononeudtisofuppsrIlmband mononeurltismultiplex ...... 354 78 5.4 35.6 Heradifaiyand ldlopefhic peripheral neuropathy ...... 356 56 4.0 39.6 >thereM~ymMddwawad¬imwmentdhr~m . . ...333 53 3.7 43.2 Otherandunspeclfieddisordarsof back...... 724 53 3.6 46.8 Wotherdlagnoses...... 772 53.1 100.0

‘Basedonihe/r?tematima/ C/aasifiiationof/Xsaases,Wri?eviskwr,C/inlsa/A4cdifntkm(lC0-9-CM) (9). NOT= A maximumof 10 diagnosesware listedperege group.Onkrerible eatirmteswreindudud inthe table,sos~mf~r~s~havef~rthm 10dmgnosea. 10 Advance Data No. 267 ● August 8, 1995

Table 12. Annual number and percent distribution of office visits to neurologists and to all other physicians by therapeutic services ordered or provided, averaged over a 2-year period: United States, 1991-92

Vk/ts to neuro/og/sts VMa to all other physlsfans

Number of Number of visits Percent visits Percent Therapeutic service ordered or provided’ In thousands dkttibuflon in thousands dlstrfbutlon

Allvkils ...... 7,253 100.0 708,614 100.0

Medlcatlon therapy

Neworcontinued medication ...... 4,624 63.7 450,237 63.5 Nomedlcation reported ...... 2,629 36.3 256,377 36.5

Counseling, education, and other nonmedication therapy

None ...... 5,230 72.1 481,938 68.0 Diet ...... 379 5.2 82,639 11.7 Exerciaa ...... 513 7.1 54,426 7.7 Cholesterolreduction ...... 73 1.0 21,567 3.0 Weightreduction ...... 174 2.4 27,773 3.9 Drugabuse ...... 37 0.5 1,767 0.3 AtcoholsJ)uae ...... -17 “0.2 3,157 0.4 Smoktngceasation ...... 49 0.7 15,621 2.2 Famllykodal...... 152 2.1 13,574 1.9 Gruwttddevelopment ...... 90 1.2 17,145 2.4 Familyptennlng ...... “14 “0.2 6,220 0.9 Othercounsaiing ...... 579 8.0 58,119 6.2 Psychotherapy ...... 163 2.2 18,970 2.7 Correctlvelenses ...... 7,763 1.1 Hearingald ...... 432 0.1 Physiotherapy ...... 465 6.4 14,629 2.1 Other ...... 178 2.5 20,163 2.6

Ambulatorysurgery echeduledorpetforrned

Noprocadures ...... 7,159 98.7 665,389 93.9 Oneormoreprocedures ...... 94 1.3 43,225 6.1

'Total my M*dtotil number &visits because momthan onemtego~may berepotied psrvisit Advance Data No. 267 ● August 8, 1995 11

Table 13. Annual number and percent distribution of drug mentions at office visits to neurologists by therapeutic classification, averaged over a 2-year period: United States, 1991-92

Number of dmgmentiona Percerrf 7herapeufic claaaiffoation’ in thousands disfrfbufion

Atlmentions...... 8,143 100.0

Neurologlcdruge...... 2,109 25.9 Antlconvutsants...... 1,284 15.8 Drugs used to treat skeletalmusclehyperacltitly...... 419 5.1 Drugs used in extrapyremkfal movement disorders . . . . . 375 4.6 Drugeused inmyaathenlagrevis ...... ●2O “0.2 Drugeusedfor relief ofpein ...... 1,825 22.4 Generafenstgaab...... 910 11.2 Antterthritke ...... 612 7.5 Drugsusedto treat migraineand other headaches . . . . . 280 3.4 Other...... “23 ‘0.3 Psychopharmacologic digs ...... 1,642 20.2 Antkieprsssants...... 820 11.3 Antianxietydrugs ...... 269 3.3 Sedafiveeand hypnotice...... 2?24 2.7 Antipsychoticdruge...... 116 1.4 CNSstlmukmts,anorexiants ...... 113 1.4 Cardlovaecular-renaJdrugs...... 929 fl.4 Arrflhypertensiveegents...... 435 5.3 Antlarrhythmlcagents ...... 166 2.0 Dkrratka...... 137 1.7 Other...... 191 2.3 HormonesarrdagentsaffecMnghormonsl machardeme. . . . 310 3.6 Raef)iratorytraotdnrgs ...... 164 2.3 Anflmlorob[aldruga...... 176 2.2 Geatrolnteatirretdruge...... 145 1.8 Mefaboltoandnutrfentagents...... 127 1.6 Hernstologicdrugs...... 79 1.0 Ototogkdnrgs ...... 70 0.9 SkIn/mucousmembrance 55 0.7 Ofhe? ...... 66 0.8 Unc!aeeltlad, mlscelkmeous...... 423 5.2 l-rhempe~cda=fi~on &bawdonthesta@ard drugclaasikdbn usedintheNatiorM DrWCO&DiIWtOLM 19850d~cxI g:) (w desanesthetii, mdmphammticaWmntraS mda, onm~~, immunologicagants,ophthalmicdrugs,andantiparssifii agents. 12 Advance Data No. 267 ● August 8, 1995

Teble 14. Number and percent of drug mentions at office visits to neurologists by the 20 most frequently used generic substsncas, averaged over a 2-yaar period: United States, 1991-92

Number of occurrerws In Percent of Generic substance thousands’ ail dmg mention~

Allmantlons...... 10,186 . . .

Acetaminophen...... 673 8.3 Cerbernszeplne...... 491 6.0 AfnMptyline...... 3S6 4.9 Phenyloin ...... 352 4.3 Aspktn...... 345 4.2 Csffelne ...... 263 3.5 Levodopa ...... 281 3.5 Csrbidopa...... 281 3.5 Butsfbifsf...... 241 3.0 Neproxen ...... 230 2.6 Dhrefproexsodium ...... 216 2.7 Proprenolol ...... 213 2.6 Verapamil ...... 175 2.1 Dkhlorslantipyrfne ...... 162 2.0 Isornathaptenemucaf e...... 162 2.0 Noftrfpfyllne ...... 159 2.0 Phenobarbital ...... 147 1.6 Codeine ...... 139 1.7 Ibuprofen ...... 139 1.7 Cydobenzeprhre ...... 125 1.5

‘Frequencyofnmtiin combinessingla-ingredient agentswthmentmms oftheagentasan ingredientinacotination dreg. %sed on an average d 8,143,000 drug mentiins per year at otfIce VMS to neurobgbts during t 991-S2.

Table 15.Annual number, percent distribution, and therapeutic classification ofthe20drugs most frequently prescribed at office vislta to neurologists by entry name, averaged over a 2-year period: United States, 1991-92

Number of dNgNIWrf\OIrS Percent Entrynameofdmg’ in thousends dkttfbutlon Therapeutic ciaaelfi’catior+

Aflmanilons ...... 8,143 100.0 . . .

Tegretol ...... 481 6.0 Neurologlc drugs (entlconvulsante) Dilsntln ...... 352 4.3 Neurologlc drugs (entlconvufsarts) Sinemat ...... 281 3.5 Neurologlcdrugs (drugs usedinexfrapyrafnidal movement disorders) ElavI1 ...... 251 3.1 Psychopharmacologic drugs (entklapreseants) Dapakote ...... 216 2.7 Neurologlc druge(anticonvufeatrts) Indarsl ...... 211 2.6 Cardiovaecutar-renal drugs (antihypertensive agents) Midrib ...... 162 2.0 Drugausedforrellef ofpaln(drugsused totreatmigrelneend otherhasdaches) Pamakrr ...... 145 1.8 Psychopharmamlogic drugs (antldepreasants) Anaprox ...... 131 1.6 Drugs usad for relief of psln (antiarfhritics) Phenobarbltaf ...... 126 1.5 Psychophsrmecotoglc dmgs(sedstlvasand hypnotfca) Arnffrfpfyline...... 125 1.5 Psychophermecologfc drugs(antfdepreseants) Flexertl ...... 125 1.5 Neurologicdnrgs(drugs usadtofreatskelefal muadehyperscfivity) Cefen...... 113 1.4 Cerdlovsecular-renal druge(antiarrhylhmic agents) Prozac ...... 109 1.3 Psydwpharrnacologic drugs (antWprassante) Naprosyn ...... 98 1.2 Drugsusedforrellef ofpsin(sntlsrthrlfl=) Mysoline ...... 95 1.2 Necrologic drugs (anflconvulaants) Aspirin ...... 92 1.1 Drugsusedforrelief ofpefn(ganeraf anafgaah) Rifafin...... 92 1.1 Psychopharmacotoglc dregs (CNS stimulants, anorexiants) Darvocet-N ...... 90 1.1 Drugs used for relief of pain (general anafgeske) FIoricat ...... 85 1.0 Drugsusedforrellef ofpafn(genemtsnafgesi=) Another...... 4,754 56.4 . . .

‘The trade or generic name used by the physician on the prescription or other medical records. %herepeutic .Ie$sificetmn is based on the standard drug olassficatkm used in the Nafionel Drug Cccl+ Dkeotow t985 edtion (NDC) (11). Advance Data No. 267 ● August 8,1995 13

Table 16. Annual numbar and parcant distribution of offfco vfslts to nsurologista and to sfl other physicians by disposition of visit avsragad ovar a 2-yaar period: United Ststaa, 1991-32

Vleifsto nsumbglsts Visitsto all ofherphysMns

Number of Nuni)er of vfelfein Percent vislfein Peroerrt Dkipoelfkmof visit’ thormerro3 distifbuflon Ulormarrds dkfrfbuflon

Allvleit e ...... 7,253 100.0 708,814 100.0 Retumatapeoifla dtlrne...... 5,117 70.5 441,353 62.3 Retumtf needad ...... 627 11.4 163,582 23.1 Retumto referrirrgphyddan...... 560 7.7 6,285 0.9 No folbwup plenned...... 490 8.6 67,719 9.6 Telephonefolbwupplanned ...... 433 8.0 21,675 3.0 Refer tootherphysfdsn ...... 276 3.8 21,838 3.1 Admttto hospite l ...... 50 0.7 5,s70 0.6 Other dleposition...... 47 0.6 7,115 1.0

‘Total may axceed total number d viaifa bscauae rnora than ona categoiy may ba raported for aach visii.

Table 17. Annual numbar and parcent distribution of offfce visits to naurologlsta and to sfl othsr physicians by duration of visl~ avaragsd over a 2-yaar parlod: United Statae, 1991-62

Weltsto rreumlogkfs VWtsto afl otherphysldens

Nutir of Nrrn’barof VisttsIn PerOwt Vletlsin Percent Dwaffon of VM thouserrde dfsfrfbufion thousands Lwrfbuflon

Allots...... 7,253 100.0 708,614 100.0 Omlnufes’ ...... “9 *0.1 8,502 1.2 l-6minutes ...... *2O “0.3 57,600 8.2 6-10minutes ...... 369 5.5 166,473 26.3 11-15 minutes ...... 1,502 20.7 227,145 32.1 16-30 minutas ...... 2,384 40.9 179,206 25.3 31-60 mtnuf8e ...... 2,066 26.8 45,710 6.5 Morethen 60mkwfss...... 271 3.7 3,777 0.5

‘WJitain MM there was no fam-tefaoa wntact Imtwaan tha physician and ttw pdiant.

— Cruds rats — — /Qe-adjustsd rate

3.0 r 2.9

2.5 2.5 - 2.3

2.0 -

1.5 -

1.0 - 0.9 0.9 0.5 -

1975-76 1980-81 1985 1989-901991-82 Year NOTES: Sesadon2-year averages,excspt19S5.Aga-ac@stadestimatesare basedonthe 197576 U..%population.

Figure 4. Annual rata of office visits to neurologist Unitad States, 1975-92 14 Advance Data No. 267 ● August 8, 1995

Table 18. Number, percent distribution, and rate of office visits to neurologists, by patient’s age United States, 1975-82

Pat/errf’s age 1975-76 1980-81 1985 1988-.90 1991-92

Number of Welts in thousands’ Aflvisik ...... 1,892 3,013 4,992 6,167 7,253 Under 15years ...... -147 338 403 311 770 15-24years ...... 24s 311 500 542 577 26-44years ...... 663 991 1,567 2,341 2,659 45-64years ...... 577 1,029 1,454 1,812 1,883 66-74years ...... 173 M5 626 839 820 75yearesrrdover ...... 78 “176 422 521 633

Percent dlelrbuflon

Allvfsifs ...... 100.0 100.0 100.0 100.0 100.0

Under15yeare ...... 7.8 11.2 8.1 5.0 10.6 15-24yeafs ...... 13.1 10.3 10.0 8.8 8.0 25-44yeafe ...... 35.4 32.9 31.8 36.0 35.3 46-64yeare ...... 30.5 34.1 29.1 26.1 28.1 65-74years ...... 9.1 11.4 12.5 13.6 11.3 75yeereerrdover ...... “4.1 “5.5 8.5 8.4 8.7

Vish rate per 100 personsz

Allvlelt s ...... 0.9 1.4 2.3 2.5 2.9

Under15yesm ...... ‘0.3 0.7 0.6 0.6 1.4 15-24years ...... 0.6 0,8 1.3 1.5 1.7 25-44yeafs ...... 1.3 1.6 2.7 2.9 3.2 4%64yeafs ...... 1.3 2.4 3.3 3.5 4.0 65-74yeara ...... 1.3 2.2 3.8 4.7 4.5 75yemandover ...... “1.0 “2.0 4.1 4.5 5.2

‘Numbersare shownas 2-yesr aversgesexceptfor 1985. %ased on Bureau of the Census esfknales of the civilian noninsfifufiinalked pmpulafion for July 1 of each survey year. Rates for wmtimdyeaB are bmedonan average of thepopulafmn etimtesfor Julyl of each yeerofthe 2-year period. Suweyyears from1975-1985did notincludeAlssks orHswaii. Advance Data No. 267 ● August 8, 1995 15

Technical notes visits occurring during a randomly when interpreting diifenmces in race assigned l-week reporting period. data and individual physician specialties. Source of data and sample design Responding physicians completed Despite the difference in sample 33,795 Patient Record forms in 1991 sizes, the 1991 and 1992 surveys were The information presented in this and 34,606 Patient Record forms in identical in terms of survey instruments, report is based on data collected in the 1992. definitions, and procedures. The National Ambulatory Medical Care Charactefitics of the physician’s resulting 2 years of data have been Smvey (NAMCS) over the 2-year practice, such as primary specialty and combined to provide more reliable pericdfrom January 1991 through type of practice, were obtained from the estimates. All estimates, percent December 1992. The target universe of physicians during an induction distributions, and rates prqented here NAMCS includes office visits made in interview. The U.S. Bunizm of the unless otherwise notedj reflect 1991 and the United States by ambulatory patients Census, Housing Surveys Branch, was 1992 data that were averaged over the to nonfederally employed physicians responsible for the survey’s data 2-year period. who are principally engaged in office collection. Processing operations and practice, but not in the specialties of medical coding were performed by the Sampling errors anesthesiology, pathology, or tilology. National Center for Health Statistics, Telephone contacts and nonoffice visits Health Care Survey %ctiom Research The standard error is primarily a are excluded. Triangle Parkj North Carolina. measure of the sampling variability that A multistage probability sample For 1992, several changes were occurs by chance when only a sample, design is used in NAMCS, involving made in the sample design of the rather than an entire universe, is samples of primary sampling units NAMCS that should be considered in surveyed. The relative standard error of (PSU’S), physician practices within the interpretation of the survey results. an estimate is obtained by dividing the PSU’S, and patient visits within In an effort to even the precision of standard error by the estimate itse~ the physician practices. The PSU’S am estimates across each of the physician result is then expressed as a percent of counties, groups of counties, county specialty strata in the sample design, the the estimate. equivalents (such as parishes or decision was made to increase the Relative standard emors (RSE’s) for independent cities), or towns and proportion in the sample of specialists in estimated numbers of office visits, townships (for some PSU’S in New general surge~, psychiatry, expressed as 2-year averages for the England). For 1991, a sample of 2,540 otolaryngology, and neurology. Although period 1991-92, are shown in table I. nonfe&ral, office-based physicians was this would result in a corresponding Relative standad errors for estimated selected from master files maintained by decrease in the sample of the larger numbers of drug mentions, also the American Medical Association and physician specialties, most notably expressed as 2-year averages, are American Osteopathic Association. general and family practice, internal presented in hWe II. Standard errors for Physicians were screened at the time of medicine, and pedntrics, the precision estimated percents of visits and drug the survey to ensure that they were of these estimates tended to be much mentions are displayed in tables III-VI. eligible for survey participation. Of higher relative @ the smaller specialties, those screened, 1,887 physicians were and it was expected that the end result Alternatively, relative standard eligible (in-scope) to participate in the would be an acceptable balance of errom for 2-year averages may be survey. The remaining 653 physicians precK1on levels across all stxata calculated using the following general were ineligible .(out-of-scope) due to However, the reduced numbers of formuh where x is the average of reasons of being retiredj employed general practitioners, internists, and interest in thousands multiplied by 2 to primarily in teaching, research, or p~]atricians sampled in 1992, coupled obtain the 2-year total, and A and B are administration or other reasons. The with the high percents of sampled the appropriate coefficients from physician response rate for the 1991 physicians in these specialties who were table VII. The relative standard error NAMCS was 72 percent. determined to be ineligible (out-of- obtained in this way applies to both the For 1992, a sample of 3,000 scope) for survey participation, resulted 2-year total and the 2-year average. nonfe&ral, office-based physicians was in low numbers of survey respondents in selected from master files maintained by these categories and a lowering of the RSE(X) = d A+: .100 the American Medical Association and precision of these estimates relative to American Osteopathic Association. Of other survey years, especially when Similarly, relative standard errors those screenedj 858 physicians were duaggregated by other variables such as for percents may be calculated using the ruled ineligible (out-of-scope); 2,142 race. Because vMs made by black following general formula where p is were in-scope for the survey. The patients were often found to be clustered the percent of interest and x is the physician response rate for the 1992 among the sampled physicians and were denominator of the percent in thousands NAMCS was 71 percent. more likely to be made to general and (and the denominator is the 2-year Sample physicians were asked to family practitioners, which were aggregate estimate rather than the complete Patient Record forms (figure 1) undersampled in 1992, it is average itself), using the apprcyxiate for a systematic random sample of office recommended that caution be exemised coefficient from table VII. (The 2-year 16 Advance Data No. 267 ● August 8, 1995

Table L Approximate relative standard errors for estimated numbers of office visits by adjustmentwasealculated tominimim selected physician specialties: National Ambulatory Medical Care Survey, 1991-92 the impact of response on final estimates Estimated number of oflca visiis Physic/an qecial(y by imputing to nonrespondi.ng (expressed as annual average) in thousands All’ Naurolog~ physicians data from visits to similar physicians. For this purpose, physicians Relatlve standard error in percent werejudgedsimiku iftheyhadthe 25 ...... 110.8 34.7 same specialty desigmtion and practiced 35 ...... 93.7 30.0 50 ...... 78.4 25.9 inthesamePSU. 100 ...... 55.5 20.0 250 ...... 35.2 15.5 Testof significance and rounding 346 ...... 30.0 14.5 500 ...... 25.0 13.6 Inthisrepo%thedetermination of 1,000 ...... 17.8 12.6 statistica.linference isbasedonthe 2,500 ...... 11.6 11.9 5,000...... 8.5 11.7 two-tailedt-test. TheBonferrcfni 10,000 ...... 6.5 11.6 inequalitywasused toestablishthe 25,000 ...... 4.9 11.5 critic-rdvaluefor statisticrdl ysignifica.nt 50,000...... 4.2 11.5 100,000 ...... 3.6 11.5 differences (0.05 level of significance) 250,000 ...... 3.6 11.5 based on the number of possible 500,000...... 3.5 11.5 comparisons within aparticula.r variable

‘The smallest reliable estimate for visits to aggregated s~oialfias B 246,000 tisifs per year (or a 2-year total of 691 ,OCOvisits). or(combination ofvariables) ofinterest. Esfirnatas be!ew this figure have a relatMe standard emor greater than 30 percent and are d~med unreliable by NCHS standards. Terms relatingto dlfferencessuc has %he mkilast rallable estirnete for vkifs to neurdoglsts is 35,000 visits per year (or a 2-year total of 70,000 visk+. Eetimatas “greatert han’’or’ ’less than’’indicate be!-aw fhis fkmm have a relative standard error greater than 30 percent and are deemsd unreliable by NCHS standards. Grampb of use of table For visfis to neurok.gisfs, an estimate of 10 million vl=sik per year has a mlattie standard error of 11.6 thatthedii7erenceis statistically percent or a standard error of 1,160,000 visits (11.6 percent of 10 mullion). significant. Alack ofcommentregadng the difference between anyfsvo estimatesdoesnot meanthatthe Table ll.Approximate relative standard errora for aatimated numbers ofdrugmentlons by selected physician specialty=: National Ambulatory Mdical Care Suwey, 1991-92 dflerencewastested andfoundtobe nonsignificant. Estirrratadnunrber ofoffic%visits Phys/c/an specialty (expressad as annual average) In the tables, estimates of office in thousands Alil Netrro/og~ visits have been rounded to the nearest thousand. Consequently, estimates will RelalWe standard emor in percent not always add to tota18.Rates and 25 ...... 154.1 38.7 46 ...... 114.3 30.0 percents were calculated from original 100 ...... 77.2 22.2 unrounded figures and do not 250 ...... 48.9 17.1 necessarily agree with percents 500 ...... 34.7 15.0 674 ...... 30.0 14.5 calculated from rounded data. 1,000 ...... 24.7 13.9 2,500 ...... 16.0 13.1 Definition of terms 5,000 ...... 11.7 12.9 10,000 ...... 6.6 12.8 Ambulatory patient—An ambulatory 25,000 ...... 6.5 12.7 patient is an individual seeking personal 50,000 ...... 5.5 12.6 health services who is not cumently 100,000 ...... 4.9 12.6 250,000 ...... 4.6 12.6 admitted to any health care institution 500,000 ...... 4.4 12.6 on the premises. Drug mention—A drug mention is ‘The smallest reliable esfirnste of drug mentions at visks to aggregated speciatlies is 674,000 dmg merstiins per year (or a 2-year total of 1,S47,000 mantions). Estimstas below this figure have a ralative standard error greater than 30 percent and are the physician’s entry on the Patient desmed unreliable by NCHS standards. ‘Thesmallestreliable asfmwteofdrugn wntions atvisiisio neurologists ~4S,CsJOdrug rr_mntmnspmyear(ora2-yaar totalof Record form of a pharmaceutical 91,000 mentions), Estimatss be!ew this figure have a relative standard erm greater than 30 percent and are deermd unreliable agent—by any route of admini8tm- by NCHS standards.

Example of use of tab~ For neuro!agists, an esfimata of 25 tillicm drug mantions per year has a relatie standard error of 12.7 tion-for prevention, diagnosis, or percsnt or a standard error of ~1 75,000 drug mentions (12.7 percent of 25 millkm). treatment. Generic as well as brand- name drugs are included, as are aggregate is obtained by multiplying the Adjustments for nonresponse nonprestiption and prescription drugs. average estimate by 2.) EstimatesfiomNAMCS data were Along with all new drugs, the physician adjusted to account for sample also records continued medications if RSE(p) = d MH).lOO the patient was specifically instructed n.x physicians who were in-scope but did r -- during the visit to continue the notparticipate in the study. lhk Advance Data No. 267 ● August 8, 1995 17

Table Ill. Approximate standard errors of percents of estimated numbers of office visits to medication.Physicians mayreportupto aggregated specia[tfe= Natfonal Ambulatory Medical Care Survey, 1991-92 fivemedications per viWt. Base ofpercarrt (visits, Estimatedparsent Drugvisit-Adrug visitisavisitat ex$maaed as annual average,In thousands) 10r99 5or95 100r30 200r80 300r70 400r60 50 which medication wasprescrilxxi or provided by thephysiciau. Standard error In percentage points Neumlogist—As defined inthe 50 ...... 7.8 17.1 23.5 31.3 35.3 38.4 39.2 NAMCS, a neurologist is a physician 100 ...... 5.5 12.1 16.6 22.2 25.4 27.1 27.7 whohas self-designated the practice 250 ...... 3.5 7.6 10.5 14.0 16.1 17.2 17.5 500 ...... 2.5 5.4 7.4 9.9 11.4 12.1 +2.4 specialty ofneurology orchild 1,000 ...... 1.7 3.8 5.3 7.0 8.0 8.6 8.8 neurologyonthe American Medical 2,500 ...... 1.1 2.4 3.3 4.4 5.1 5.4 5.5 Association’s Physicians’ Professional 5,000 ...... 0.8 1.7 2.4 3.1 3.6 3.8 3.9 Activities Questionnaire. The 10,000 ...... 0.6 1.2 1.7 2.2 2.5 2.7 2.8 25,000 ...... 0.4 0.8 1.1 1.4 1.6 1.7 1.8 physician’sspecialty isalsoverified 50,000 ...... 0.3 0.5 0.7 1.0 1.1 1.2 1.2 duringtheNAMCS interview.l%e Ioo,ooo ...... 0.2 0.4 0.5 0.7 0.8 0.9 0.9 pmcticespecirdty ofneurologyis 250,000 ...... 0.1 0.2 0.3 0.4 0.5 0.6 0.6 delinedin the category of’’other 500,000 ...... 0.1 0.2 0.2 0.3 0.4 0.4 0.4 specialties’ ’bythe American Medical NOTE Emnple of use C4tabl.s An estimate of 20 percent bcsed cman mfimate d 25 rnllion vkiis per yam has a atendard error of 1.4 permnt or a rahtiie standard error of 7.0 percent (1.4 permnf dwkJedby 20 percent). Association (additional categories includefamily/generrd practke,medical specialties, andsurgkal specialties),and Table IV. Approximate standard errore of percents of estimated numbers of offfce visits to theAmericanBoard ofPsychiatryand neurologlste: National Ambulatory Medical Care Sunrey, 1991-92 Neurology cmiks physicians inthat specialty. Basa ofpercerrt(visits, Esthatedpercwrt qmsaad as annual Oflce-Anofficeis thespace average, In thousands) lor99 5or95 100r90 200r80 300r70 400r60 50 identiiiedbya physician asa location

Standarderrorlnparcentaga points forhisorherambukitory practice. Offices customarily include consultation, 50 ...... 2.3 5.1 7.0 9.3 10.6 11.4 11.6 100 ...... 1.6 3.6 4.9 6.6 7.5 8.0 8.2 examination,ortreatment spaces that 250 ...... 1.0 2.3 3.1 4.1 4.8 5.1 5.2 patients associate with theparticular 500 ...... 0.7 1.6 2.2 2.9 3.4 3.6 3.7 physician. 1,000 ...... 0.5 1.1 1.6 2.1 2.4 2.5 2.6 2,500 ...... 0.3 0.7 1.0 1.3 1.5 1.6 1.6 Physiciun-A physician is a duly 5,000 ...... 0.2 0.5 0.7 0.3 1.1 1.1 1.2 licensed doctor of medicine (M.D.) or 7,250 ...... 0.2 0.4 0.6 0.8 0.9 0.9 1.0 doctor of osteopathy @.O.) who is 10,000 ...... 0.2 0.4 0.5 0.7 0.8 0.8 0.8 currently in office-based practice and NOTEExarrpleot uaadtabloAneafiite of20percentbaaed onanmtimded 7,250,0Wneurokgy viskapxyaarhas a who spends some time caring for atandardermrof0.8 peroantoraralafiie standarderrorof4.O parmnt(O.8pwoant dwkfadby20parcent). ambulatory patients. Excluded fmm the NAMCS are physicians who are hospital Table V. Approximate standard errors of percente of estimated numbers of drug mentions base~ who specialize in anesthesiology, atvlslta toaggregated spacialtiee: National Ambulatory Medicaf Care Survey, 1991-92 pathology, or radiolog~ who are federally employed; who treat only B6seofpersent(tislts, Estirnatadparcmt expressedas annual institutionalized patients; or who are average, In thousmds) 10r99 50r95 100r90 200r60 300r70 400r60 50 employed full time by an institution and

Standard errorlnperoentaga points spend no time seeing ambulatory patients. 50 ...... 10.8 23.7 32.7 43.6 49.9 53.4 54.5 100, ...... 7.7 16.8 23.1 30.6 35.3 37.7 38.5 Wsit—A visit is a direct personal 250 ...... 4.9 10.6 14.6 19.5 22.3 23.9 24.4 exchange between an ambulatory patient 500 ...... 3,4 7.5 10.3 13.6 15.8 16.9 17,2 and a physician or a staff member 1,000 ...... 2.4 5.3 7.3 9,7 11.2 11.9 12.2 2,500, .,..,...... ,,, ...... 1.5 3.4 4.6 6.2 7.1 7.6 7.7 working under the physician’s 5,000 ...... 1.1 2.4 3.3 4.4 5.0 5.3 5.5 supervision, for the purpose of seeking 10,000 ...... 0.8 1.7 2.3 3.1 3.5 3.8 3.9 care and rendering personal health 25,000 ...... 0.5 1.1 1.5 2.0 2.2 2,4 2.4 semices. Excluded from the NAMCS 50,000 ...... 0.3 0.8 1.0 1.4 1.6 1.7 1.7 100,000 ...... <...... 0.2 0.5 0.7 1.0 1.0 1.2 1.2 are visits where medical care was not 250,000 ...... 0.2 0.3 0.5 0.6 0.7 0.8 0.8 provided, such as visits made to drop off 500,000 ...... 0,1 0.2 0.3 0.4 0.5 0.5 0.6 specimens, pay bilk, make

NOTE Example of uaa c1table: An eslimata cd20 percent based on an intimate & 10 rdliim drug mwrfions has a standard appointments, and wak-outs. error of3,1 pwoantc+aralatFFeafandarde rrorof15.5p arcent(3.t percent dMdedby20permnt). 18 Advance Data No. 267 ● August 8, 1995

Table W. Approximate standard errors of percents of estimated numbers of drug mentions at office visits to neurologists: National Ambulatory Medical Care Survey, 1991-92

Base of percent (vMs, Esflmated percent expressed as annual average, In thousands) lor99 5or95 100r90 200r80 300r70 400r60 50

Standard error In percentage points

50 ...... 2.6 5.6 7.6 10.3 11.8 12.7 12.9 100 ...... 1.6 4.0 5.5 7.3 6.4 9.0 9.1 250 ...... 1.2 2.5 3.5 4.6 5.3 5.7 5.8 500 ...... 0.6 1.8 2.5 3.3 3.7 4.0 4.1 1,000 ...... 0.6 1.3 1.7 2.3 2.7 2.8 2.9 2,600 ...... 0.4 0.8 1.1 1.5 1.7 1.8 1.8 5,000 ...... 0.3 0.6 0.6 1.0 1.2 1.3 1.3 8,000 ...... 0.2 0.5 0.6 0.8 0.9 1.0 1.0 10,000...... 0.2 0.4 0.6 0.7 0.8 0.9 0.9 25,000 ...... 0.1 0.3 0.4 0.5 0.5 0.6 0.6

NOTE ExanyYleof useoftableAn estimate of20percentbssed onanestlmateofS million drugmentk.ns peryearat neurologyvisitshes astsrwlarderrorof 0.8percentorarelstive stsndarderrorof 4.0peroent (O.8percent dividedby20 percent).

Table VII. Coefficients appropriate for determining relative standard errors by type of estimate and physician speolalt~ National Ambulatory Medical Care Survey, 1991-92

Coa~c/ent for usa with esthrratas In thousands

T~e of ast/mate and physician spec/ai7y A B

VMS

Overalltokds...... 0.001157131 61.31199983 Generaf sndfamilypractice ...... 0.007330504 54.54704362 Osteopathy ...... 0.01402452 18.13642054 Intemalmedicine ...... 0.006716567 55.2168744 Pediatrics ...... 0.007994388 35.33091768 Generafsurgery ...... 0.006685247 10.65103125 Ob~etrksandg ynecology...... 0.00919684 25.59982011 Orfhopedlcsurgery ...... 0.005641337 24.20372144 Csrdlovssculardisaasas ...... 0.01383253 12.5W.89271 Dermatology ...... 0.01275351 10.28301649 Urologkalsurgery ...... 0.008000282 11.92653664 Psychiatry ...... 0.008414736 12.86530675 Neurology ...... 0.01314774 5.36720616 Ophthafomology ...... 0.007938146 23.64517495 Ototaryngology ...... 0.007543396 8.0936265 Allotherspecle.ltles ...... 0.01537018 35.00317779

Drugmentlons

Overalltotals ...... 0.001863163 118.69462

Generslandfamilypractice ...... 0.009085669 100.96778 Osteopathy ...... 0.01658477 23.4733982 Intemalmedlclne ...... 0.01148498 103.21387 Pedlafrtos ...... 0.01245118 26.73517786 Generslsurgary ...... 0.03935224 6.06606796 Obstetftcs andgynecology...... 0.01454044 31.24058408 Orfhopedlcsurgety ...... 0.01566053 23.3838057 Cardlovasculardlseases ...... 0.01575914 24.23751806 Dermatology ...... 0.01299377 15.94507357 Urologicalsurgefy ...... 0.01867719 10.6886669 Psychiatry ...... 0.01430555 15.99374434 Neurology ...... 0.01593433 6.67244993 Ophthalmology...... 0.0251486 25.1381195 Otolaryngology ...... 0.008374063 12.25916054 Allotherspecislties ...... 0.0226229 57.79950436 Advance Data No. 267 ● August 8,1995 19

Symbols .-. Data not available

. . . Category not applicable

Quantity zero

0.0 Quantity more than zero but less than 0.05

z Quantity more than zero but less than 500 where numbers are rounded to thousands

* Figure does not meet standard of reliabilii or precision (see Technical notes)

# Figure suppressed to comply with confidentiality requirements 20 Advance Data No. 267 ● August 8, 1995

All material appearing in this report is in the public domain and may be reproduced or copied without permiasio~ citation aa to source, however, is appreciated.

Suggested citation Trade name disclaimer National Center for Health Statistics

Schappert SM. Office visita to neurologists: The usa of trade names is for identification Acting Director Unitad Statas, 1991-92. Advance data from only and does not imply endorsement by the Jack R. Andarson vital and health statistic; no 267. Hyatt.swille, Public Health Service, U.S. Department of Maryland National Cantar for Health Health and Human Services. Acting Deputy Director Statistic. 1995. Jennifer H. Madans, Ph.D.

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DHHS Publication No. (PHS) 95-1250 5-1394 (6/95) Number 268 . October 6, 1995 Advance i Data m

FromVital and Health Statisticsofthe CENTERS FOR DISEASE CONTROLAND PREVENTION/National Center for Health Statistics

National Hospital Ambulatory Medical Care Survey: 1993 Outpatient Department Summary Karen L. Lipkind, M.Ed., Division of Health Care Statistics

Introduction emergency department visits is Man/Pacific IslandeIs accounting for forthcoming (5). 22.4 percent and 3.2 percen~ During the 12-month period Because the estimates presented in respectively. The visit rate for black January-December 1993, an estimated this report are based on a sample rather persons was signhicantly higher than for 62.5 million visits were made to than on the entire universe of hospital white persons overall and in all age outpatient departments (OPD’S) of OPD visits, they are subject to sampling categories (figure 2). non-Federal, shofi-stay, and general variability. The Twhricsl notes at the hospitals in the United States-24.6 end of this report include a brief Outpatient department visit visits pm 100 persons. This was not overview of the sample design used in characteristics signitlcantly different from the 1992 rate the 1993 NHAMCS and an explanation of 22.5 visits per 100 persons. of sampling errors. A detailed Geographic region This report presents data on OPD description of the NHAMCS sample By region, the largest proportion of design and survey methodology has visits from the 1993 National Hospital OPD visits was made in the Northeast been published (6). Ambulatory Medical Care Survey (34.6 percent). Visit rates in the The OPD Patient Record form is (NHAMCS), a national probability Northeast (43.3 visits per 100 persons) used by hospitals participating in the survey conducted by the Division of and the Midwest (31. 1 visits per 100 NHAMCS to record information about Health Care Statistics, National Center persons) were higher than those in the patient visits. This form (figure 1) is for Healrh Statistics, Centers for Dkase West (10.3 visits per 100 persons). Control and Prevention. The survey was intended to serve as a reference for readers as they review the survey inaugurated in December 1991 to gather Clinic type findings presented in this document. and d~seminate information about the A clinic was defined as an health care provided by hospital administrative unit of the OPD where emergency and outpatient departments Patient characteristics ambulatory medical care is provided to the population of the United States. It OPD visits by patient’s age, sez under the supervision of a physician. is endorsed by the American Hospital and race are shown in table 1. There Clinics where only ancillary services, Association, the Emergency Nurses were no significant differences in OPD such as radiology, renal dialysis, and Association, and the American College visit rates among any of the age groups. pharmacy, were provided or other of Emergency Physicians. Females made 62.3 percent of all OPD settings in which physician services This report presents data on OPD visits and had a higher vKlt rate (29.8 were not typically provid~ were out of patient characteristics and visit visits per 100 persons) than males (19.1 scope for the survey. In addition, characteristics. Data from the 1992 visits per 100 persons) did. ambulatory surgery centers were out of NHAMCS have been published (l-4), WMte persons made 74.1 percent of scope since they are included in the and a report on 1993 NHAMCS all OPD visits, with black persons and National Survey of Ambulatmy Surgery.

Sun*. ~&’ % U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service ~< Centers for Disease Control and Prevention National Center for Health Statistics L.= CENTERScmFOR DIsEAsE CONTROL 4 AND PREVENTKIN 2 Advance Data No. 268. October 6, 1995

Department of Health and Human Services OMB No. 0920-027S Publk Health .servke, Centers for Disease Oontrol E@#&#S4 National Center for Health Statfetics

NDTtCE - Information contained on thbformwhich would permit idontiflcatbn of any individual or eafabllahmmtt hac bean coflected witha guaranteethatit willbe held fnatdotcordidenoa,willbeuaadonlyforpurpoaeaatatadforthisstudy,andwillnotbediaofoaador refaaeadtootherawithoutthesorwentoftheindividualortheeatabllahmrrm in accordancewith aacfbn WE@) of the Publlc Haafth $ervica &x (42 USC S42m). Pubtk reponing burdemfor thle phaaa of the survey la eetlmatad to average 3 mfrtutae per raaporw. If you have any oommenta regardingthe burden aatimata or any other aepad of this auway, Including suggestions for reducing this burden, sand them to fha PHS Reporte Cfaaramm - Ann: PRA HHH Bulfdfn~ Rm. ?$?t~ 200 lndepandanca Ave., S.W., Washington, DC 20S01,●nd to the Office of Management ●nd = paDwwork RaduoUonProieofOIWO-027StiWaah[noton.DC 2ftaOS.

NATIONAL HOSPITAL AMBULATORY 1. PATlENT NAME MEDICAL CARE SURVEY I OUTPATIENT DEPARTMENT 2. PATlENT RECORD NO. PATIENT RECORD 1993-94 =

3. DATE OF ViStT 5. SEX 6. RAOE 7. ~HNICiTY 8. EXPECTED SOURCE(S) OF “ 9. WAS PATIENT ❑ PAYMENT (checkelf tit wpfy) REFSRRED FOR ❑ * white THIS VISIT BY ~ , ~emale Hbpamc ❑ ❑ ❑ 10 origin 1 Private/ wmmwcial s ~$e~~pfepdd ANOTHER 2 Black ❑ ❑ PHYSICIAN? A6ian I Pacific 2 Medicare 6 PatiSnt paid L DATE OF BIRTH 2 ❑ MeJe No1 ❑ 30 l~~r ❑ I Yes 2 Hispanic 3 ❑ Medicaid 7 ❑ No oharge Amancan Indiirr - -i 40 Gf&no / Aleut

tO. PATtENT’S COMPLAINT(S), SYMPTOM(S), OR 11. PHYSICIAN’S DfAGNOSES 12. HAS PAWENT BSEI OTHER REASON(S) FOR THIS VISIT SEEN IN THIS (In porie.t’2 own werdr) CLfNIC BEFORE 8. Prind@ disgnceb / Pr&ema$eodated JDYea 2DN0 B. Matirmpatam Wth km loa

1 b. Orher: b. 0Pt6n [f yes, for the sondition h item 11a? I L Olhec: Gomar 11-JY66 2gNo

13. TESTS, SURGICAL AND NONSURGICAL’ PROCEDURES, AND THERAPIES Nona ❑ 14. COUNSELINGEDUCATION (CheIAafl or&red or prevkid) a. SELECTED b. ALL OTHER SERVICES t ❑ None SERVICES Inciudm Perfc6med Ordered (Cfrec%all erdered ● Teera ● knegings 2 a Exercle.e or prddedJ 1 In *D ● Surgerie8 and other procedure. a ❑ Chobeterd raductton t ❑ Bfood pressure ● OIhar therapies 2 10 20 . ❑ Weight reduction (stdras contact lenses, 2 ❑ Urmalyss ❑ P**w! 3 In 2U 5 Emrokingcessation or phye”otherepy) ❑ 6 ❑ Grcwth / davefopment 3 Spiromatry Exclude 4 ~n 20 ● Services in item 13a 7 ❑ injury preventkxr 4 a Allergy testing ● Cwn2eling / education s ❑ HIV transmission ● Madiifions 6 In ,D s n HIV serology ❑ (R220rdone on cod line 9 Cthaf Ho frwb51’nlSSorl 10 20 ❑ . ❑ Clher bfood test %%-$~j%~ 0’ 6 ,0 C6har - 15. MEDICATIONS / INJECTIONS None O 16. DISPOSITION THIS VISIT 17. PROVIDERS SEEN {rmechau 112U2apply) THtS VISIT lndwle ● Rx and OTC ● Meals ordered, ● New reeds (Gerk all #rat apply) . Immunkafiom auppfrad,or ● Continuingreads ❑ ● Alt*arrote administered (vdh 0, tillmul 1 No iObV-Up phflllad I ❑ Rasidentrlntwn ● Anaameks new orders) z D Return to dinio PRN 2 Q Sfeff phyaidan

I 3 ❑ Return to cfinic- appointment s uOlher phye!cian ❑ Phyeicienaaeisfanf/ 4 Telephone follow-up ptanned 4 ❑ Nurse practitioner 2 6 ❑ Return to referrfngphyddan s ❑ Registered nuree Licenseclpractical 3 s ❑ Refer to other @@iarrlolinio 60 nurea

7 ❑ Admit to howitai 7 ❑ Nurse’s aids 4 ❑ e.o-fSpe@J 8 Orner *ifl)

ptre 1. National Hospital Ambulatory Medioal Care Survey Outpatient Department Patient Record, Advance Data No. 268 ● October 6, 1995 3

Table 1. Numbar, parcent dlstrlbution, and annuai rate of outpatient department visits with corresponding standard errors by saiaotad patient and outpatient department characteristics: Unitad Stataa, Ist93

Number of Number of standard standard VISRSper standard visits In error In Percent error of 100persons error Patient and outpatient department ctwacterlstlcs thousanda Urousarrda dktrtbution percent w veari of rate

Allvisits ...... 62,534 7,330 100.0 . . . 24.6 2.9

Patient characterletic Age Under 15yeare ...... 12,927 1,930 20.7 2.0 22.6 3.5 15-24 yea fs ...... 8,512 1,248 13.6 0.9 24.8 3.6 2.5-44 yeats ...... 18,299 2,24a 28.3 1.0 22.4 2.8 45-64yeafa ...... 12,365 1,371 19.8 0.8 24.8 2.8 65-74yeare ...... 5,865 ee3 9.4 0.7 31.5 4.8 75yearaandover ...... 4,567 888 7.3 0.9 26.1 6.9

Sexandage: Femate ...... 38,935 4,646 62.3 0.9 29.6 3.6 Undar15yeare ...... 8,420 1,018 10.3 1.0 23.0 3.6 W5-24yeara...... 6,696 1,020 10.7 0.9 38.9 5.9 25-44yeara ...... 12,081 1S76 19.3 0.6 29.2 3.8 45-64yeara ...... 7,386 804 11.8 0.5 28.6 3.1 65-74years ...... 3,440 484 5.5 0.4 23.5 4.8 75yearaandover ...... 2,908 565 4.7 0.6 36.9 7.2

Male ...... 23,600 2,783 37.7 O.e 19.1 2.2 Under15yeara ...... 6,507 991 10.4 1.0 22.2 3.4 15-24years ...... 1,814 282 2.9 0.2 10.6 1.6 X-44years ...... 6,218 749 9.9 0.5 15.5 1.9 45-84yeafa ...... 4,977 805 8.0 0.4 20.6 2.5 65-74yeare ...... 2,426 424 3.9 0.4 2S.0 5.1 75yeareandover ...... 1,659 321 2.7 0.3 34.8 6.7

Raceandagw White ...... 6,519 74.1 2.2 21.9 3.1 Under15yeare ...... 9,026 1,576 14.4 1.5 19.3 3.5 15-24yeaE ...... 6,257 1,109 10.0 0s 22.8 4.0 2E-44yeafs ...... 13,449 1,939 21.5 1.0 19.9 2.9 45-84yeam ...... 9,156 1,191 14.6 0.7 21.4 2.8 65-74yeare ...... 4,676 827 7.5 0.7 28.3 5.0 75yeareandover ...... 3,772 644 6.0 0.9 33.0 7.4

Black ...... 14,015 1,320 22.4 2.1 43.8 4.1 Undar15yeare ...... 3,398 534 5.4 0.8 37.2 5.8 15-24years ...... 1,970 242 3.2 0.4 S8.3 4.7 25-44yeam ...... 4,159 429 6.7 0.7 41.9 4.3 45-e4yeara ...... 2,751 328 4.4 0.5 53.6 6.4 85-74year3 ...... 1,006 130 1.6 0.2 80.1 7.8 75yearsandover ...... 731 115 1.2 0.2 73.2 11.5

All other rams Aeian/Pactticlslander ...... 2,006 321 3.2 0.4 ...... AmeficanindianEskimo/Aleut...... 177 534 0.3 0.1 ......

Outpatient department characteristic

Geographic region: Northeast ...... 21,666 4,155 34.7 5.1 43.3 8.3 Midwest...... 17,684 5,140 28.3 5.8 28.5 8.3 South ...... 14,389 2,328 23.0 3.6 16.2 2.7 West ...... 8,783 2,150 14.0 3.1 15.5 3.8 lB-don U.S. Bureauofthe Cewus=timtes dthedvitian, nonintittimnaimd popuhtim ofthe Uni~SMt-as@Ju&l, 1%.

Clinicswereclassified into five care clinics. Pedatric, obstetricsand included such clinics aapsychiatqr and typeaaa presentedintable2. About half gynecology,and surgery clinics neurology,accountedfor 6.8percentof ofaUOPD visits (47.1percent) were accountedfor18.OpercenJ 14.7percen~ visit3. made to generalmedicine clinics that and13.4percent ofvisits, respectively. includedinternalmedicineand primary The ’’other’’cliniccategory,whlch 4 Advance Data No. 268. October 6.1995

Expected sources of payment White ~ Black Expected sources of payment were I - most often Medkaid (31.1 percent), I w 73.2 privatekommercial insurance (27.0 percent), and Medicare (16.9 percent) (table 3). “Patient paid” and “HMO/Other prepaid” were indicated at 12.1 and 8.8 percent of OPD visits, respectively. The patient- paid category includes the patient’s contribution toward “copayments” and “deductibles.”

Referral status and prior visit status Total Under 15 15-24 25-44 45-64 65-74 75 years Approximately one-fifth years years years years years end over (19.7 percent) of OPD visits were made Patient’s age as the result of a referral from another I loPcrisold patientdepartment. physician (table 4). About three-quarters (79.5 percent) of OPD visits were made Figure 2. Annual rate of outpatient department visits by pattent’s age and racw by patients who had been seen in the United States, 1993 clinic on a previous occasion, and more than half (63.7 percent) of all visits were made by persons who were returning to the cliiic for cafe of a previously Table 2. Number and percent distribution of outpatient department visits with corre- treated problem. One-fifth (20.5 percent) sponding standard errors by type of ollnk United States, 1993 of visits were made by new patients, Number of Standard Standard that is, patients who had not been seen v!sits In error in Percent error of in that clinic before. TW of C/lnlc thousands thousands distribution percent

62,5S4 7,330 100,0 Reason for visit Allvlstts ...... Generslmedlclne ...... 2e,443 4,265 47.1 2.9 In item 10 of the Patient Record surgery ...... 8,382 1,517 13.4 1.9 form, the patient’s (or patient Pedlatrlcs ...... 11,274 1,728 16.0 1.6 surrogate’s) “complaint(s), symptom(s), Obstetrics and gynecology...... 9,169 1,722 14.7 1.8 Other ...... 4,266 608 6.8 i .2 or other reason(s) for this visit in the patient’s own words” is recorded. Up to three reasons for visit are classified and coded according to A Reasonfor VW Classijicdionfor Ambulatoq Care (WC) (7). The principal reason is the problem, complain~ or reason listed in Table 3. Number and percent of outpatient department vislte with corresponding standard item 10a of the OPD Patient Record errors by patient’s expected source of paymenh United States, 1993 fonrl. Number of Stendatd Standard The RVC is divided into the eight vlslts In error /n error of thousands+ thousands Percent percent modules or groups of reasons dkplayed Expected source of payment in table 5. About 4 of every 10 visits Allvist is...,...... ,.. 62,534 7,330 . . . ,,. were made for reasons classified 8s 19,442 31.1 2.3 symptoms, with the diagnostic/screening Medicaid ...... 2,124 Private/commercial...... 16,906 3,390 27.0 2.6 and preventive module &d the treatment Medicare ...... 10,542 1,693 16.9 1.4 module each accounting for about one Pallent-paid ...... 7,692 966 12.1 1.1 fifth of the visits (19.5 and 18.7 percent HMO/other prepaid=...... 5,496 1,216 8.6 1.5 Other ...... 2,835 605 4.5 0.7 respectively). The 20 most frequently Other govemmenl ...... 2,755 557 4.4 0.7 mentioned principal reasons.for visi~ No charge ...... 1,392 431 2.2 0.6 representing 42.6 percent of all visits, Unspeclfled ...... 2,243 749 3.6 1.1 are shown in table 6. It is important to lNumbers may axcead total numkw of visitsbecsusemorethanone sourca of payment may be coded for each visit note that estimates differing in ranked 2HM0 b health maintenaneaorganization, Advance Data No. 268. October 6,1995 5

order may not be significantly W&ent Table 4. Numbw and percent distribution of outpatient deparhent visits with corresponding from each other. “Progress visit” was standard errors by referral status and prior visit status: Unikf States, 1393 the most frequently mentioned visit Nurrtrarof SWndard vktla in WrWkr Partwnf WW of (10.5 percent), reflecting the large W charadedsfic flrorlsands thorwands dsmuffm percd number of return visits for a pmriously treated problem. Five of the top 20 Allvisits ...... 62,534 7,330 100.0 . . .

reasons for visigwhich accounted for Retanal status 15 percent of all OPD visits, were Nc4rafermd byanotherphys#err ...... 50,1s5 6,261 80.3 1.6 classified in the diagnostic screening and Raferradby anotharphyaioian ...... 12,350 1,566 19.7 1.6 preventive module. The reasons were “Routine prenatal examination,” Prfor Waltstatus “General medical examination,” “Well Olctpafierlt...... 48,727 6,061 79.5 1.1 baby examination,” “Other and OIdprMam ...... 39,823 4,s5s 63.7 1.3 Newproblem ...... 9M 1,473 15.6 12 unspecified diagnostic tests,” and Newpatiant...... 12,s07 1,510 20.5 1.1 “Prophylactic inoculations.” “Stomach and abdominal pain, cramps and spasms,” and “Cough” were the most frequently mentioned reasons for visit in “Normal ~gn311Cy,” occurring at the symptom module each accounting diseasecategoriesspeciliedby the 7.9 pement of all visits. for 1.8 percent of the visits. ICD-9-CM. The supplementary Tests, surgical and nonsurgical classification is provided to deal with procedures, and therapies situations in which circumstances other Principal diagnosis than a disease or injury are recorded as Statistic3on various diagnostic The principal diagnosis or problem diagnoses. It accounted for 22.6 percent tests, surgical and nonsurgical associated with the patient’s most of all OPD visits, and was followed by prwedures, and therapies performed or important reason for visit and any other d~ears of the respirator system ordered by hospital strollduring an OPD significant current diagnoses are (8.7 percent). visit are shown in table 9. recoded in item 11. Up to three The 20 most frequently reported Approximately three quarters of all OPD diagnoses are coded and classified pMcipal diagnoses are shown in table 8. visits included one or more diagnostic according to the International These an? categorized at the three-digit or screening service. The most Classificatwn of Diseases, 9th Reviswn.j coding level of the ICD-9-CM and hequently mentioned checkbox category Clinical Modi@m”on (ICD-9-CM3 (8). accounted for more than one third (itim 13a) was blood pressure check, Displayed in table 7 are OPD visits by (35.2 percent) of all OPD vish,s. The recoded at 54.4 pement of visits. Other principal diagnosis using the major most commonly recorded diagnosis was frequently mentioned services included

Table 5. Number and percent distribution of outpatient defwtmant visits with corresponding standard errors by. .Patient’s .txindmd. rea80nfor vleit: Unitid States, 1993

Nunber of Sfarrdsrd SfSrrdard Vianein error in Peroenf error of Prlrrcpalreasonfor visitand RVC wdei urorwand2 fmmanda diafrbofforr per(wrrf

Allvisifs ...... 7,330 100.0 . . .

Syrnptommodule ...... S001-S893 24,S46 3,275 33.7 1.7 Generaf symptoms ...... S001-S033 3,419 420 5.5 0.5 symptoms referable to psychobgicaUmental disorders ...... S103-S133 2,191 42S 3.5 0.6 Symptoms referable to the nervous system (excluding sense organs). . . . . S200-S253 1,565 201 2.5 0.2 symptoms referable to the cardfovaeorrlarflytrphatlc syetem...... S260-.S233 187 43 0.3 0.1 Syrr@ornsreferable totheeyesand ears ...... S300-.S333 2,167 340 3.5 0.3 .symptomerefersbl etotherespirafor ysystem ...... 3400-3492 3,273 642 5.2 0.6 symptoms referable to the dlgeetlve system. , , ...... S500-S633 2,707 3s1 4.3 0.3 .Symptorns referable to the gankourfnmy system ...... S640-S82S 2,837 629 4.5 0.7 symptoms referable fo the skin, hair, and nails, ., ...... 3830-3899 2,318 522 3.7 0.5 Synptome referable to the musculoskeletsl system ...... Sr30&S389 4,102 686 6.7 0.7 Diaease module, ...... DW1-D383 8,078 825 9.7 0.8 Dlagno8tlo/8creenkrg and preventive module...... X1 OO-X5S8 12,223 1,785 19.5 1.4 Traatmsnt module ...... TIoo-T899 11,676 1,64s 18.7 1.7 Irrjurlasand adverae effeotsrrmdule ...... JOOld933 2,374 337 3.8 0.4 Test resutts module ...... ,,, ,.. .,, ...... R1OO-R7OO 777 127 1.2 0.1 Admlnlsttatlve module ...... AI WA140 431 13$ 0.8 0.2 Other ...... U960-U9B3 4,06s 654 6.5 1.0 lBawd onA Rewon for VisitCbwfhtbn forAtiu/dory Care (FPJC)(T). %cludes problermand complakrtanotelsewhereclassitkd,entrfesof “none”,blanks,and ilbgibb entries. 6 Advance Data No. 268. October 6, 1995

other blood tests (20.5 percent) and Table 6. Number and percent distribution of outpatient department visits with corre- urinalysis (13.9 percent). Readers should sponding standard errors by the 20 principal raaaons for visit moat frequently mentioned by patientw United States, 1993 note that for items 8, 13, 14, 16, and 17 on the OPD Patient Record form, Number of Standard Standatd vklts In eiror In Percent error of hospital staff were asked to check all of Reason for vklf and RVC Codei thousands thousands dlstffbutlon percent the applicable categories for that item. Therefoce, multiple responses could be Allvlsits ...... 62,534 7,330 100.0 . . .

coded for each visit., Progress visit ...... T800 6,593 1,254 10.5 1.8 Up to six entries for tests, surgical Routine prenatal examination ...... X2O5 3,900 818 6.2 1.0 and nonsurgical procedures, and General medical examination ...... Xl 00 3,140 506 5.0 0.5 Postoperative visit...... ,...... T205 1,394 278 2.2 0.3 therapies not listed in the checkbox Well baby examination ...... XI05 1.384 270 2.2 0.4 categories were made in item 13b. Stomach and abdominal pain, cramps and Results of the open-ended responses spasms ...... S545 1,121 178 1.6 0.2 were coded according to volume 3 of Cough ...... S440 1,119 264 1.6 0.3 Skirrraah ...... S660 808 143 1.3 0.1 the ICD-9-CM (8). There were an Fever ...... S010 795 201 1.3 0.3 estimated 33 miKlon procedures of this Earache or ear Infection ...... s355 726 131 1.2 0.1 type reported. Approximately two-thirds Backsymptoms ...... s905 716 147 1.1 0.2 Medication, othar and unspecified ., ...... TI15 655 122 1.0 0.1 of the procedures were reported as being Headceld ...... S445 622 155 1.0 0.2 performed (not just ordered) during the Headache, pairrin haad ...... S210 620 93 1.0 0.1 visit. The 20 most frequently reported Depression ...... S110 606 f43 1.0 0.2 procedures are shown in table 10. Other Counsal[ng, not otherwisa stated ...... T605 510 152 0.6 0.2 Other and unspacitied diagnostic teats . . . . . X370 500 215 0.6 0.3 individual psychotherapy, eye Prophylactic inoculations ...... x400 432 133 0.8 0.2 examinations, and Pap smears were Hyperfensiorr ...... D510 480 65 0.8 0.1 among the most frequently mentioned Knee symptoms ...... s925 479 85 0.6 0.1 procedures All other reasons ...... 35,692 1,701 57.4 0.6

Counseling/education lBased on A Reason for Visil C/assificsfbn forArrk5u/story Care (RVC) (7).

Ahnost half (46.6 percent) of all OPD visits included some form of counseling or education eifher ordered or provided (table 11). “Other” counseling was recorded at one-third of Table 7. Number and percent distribution of outpatient department viaite with corre- visits (36.9 percent), followed by sponding standard errors by principai diagnosi!x United States, 1993 counseling on growth/development Number of Standard Standard (5.3 percent of visits). visits in error in Percent error of Principal diagnosk and lCD-&CM Codaq thousands thousands dktrfbutfon percent Medications/injections All visits ...... 62,534 7,330 100.0

Hospital staff were instructed to Infectious and parasitic diseases ...... 001-139 1,696 236 3.0 0.3 record all new or continued medications Neoplasm ...... 140-239 3,760 813 6.0 1.0 ordered, suppli@ or administered at the Endocrtne, nutritional and metabolic diseases visi6 including prescription and and immunity disorders ...... 240-279 2,275 362 3.6 0.4 Mental dlsordere ...... 290-319 4,489 795 7.2 1.1 nonprescription preparations, and Diseases of the nervous system and sense immunizations and desensitizing agents. organs ...... 320-389 3,761 542 6.0 0.5 Up to five medications or drug mentions Diseases of the circulatory system ...... 390-459 3,595 531 5.7 0.5 Diseases of the respiratory syslem...... 460-519 5,461 993 8.7 0.9 were coded for each visit. As used in Diseases of the dlgastive system...... 520-579 2,091 239 3.3 0.4 the NHAMCS, the term “drug” is Diseases of the genifourinary system . . . . 580-829 3,678 727 5.9 0.7 interchangeable with the term Diseases of the skin and subcutaneous tiasua ...... 680-709 2,411 680 3.9 0.6 “medication”. The NHAMCS drug data Diseases of the musculoskeletal system and base permits classification by a wide connectlvetksue ...... , 710-739 3,401 569 5.4 0.6 range of variables, including specitic syn’ptoms, signs, and Illdeffned conditions ...... 780-799 3,590 386 5.7 0.3 drug entry name, trade name, generic Injury and poisoning...... 600-999 3,498 537 5.6 0.5 class, therapeutic category, prescription Supplementary classtiication...... VOI-V62 14,166 1,784 22.6 1.5 or nonprescription status, federally Another dlagnoses2 ...... “1,530 563 2.4 0.4 Unknowns ...... 2,902 373 4.6 0.5 controlled substance status, and composition status (that is, whether the 1Based on the htemaficrrd C/assificatiorr of Diseases, Wh Revision, C/inios/ kfdifioatbrr (ICD-9-CM) (8). ‘Includes dlsesses Ofthe bloodand blocd-f.ardngorgans(280-289); mmplicatiinsof pregnancy,childbirth,andthe drug is a single- or multiple-ingredient (630-S7S); mngentil anomahes (740-758); and certain mndflons originating in the perinetal period (760-779). product). A report describing the method 31ncludes blank diagnoges, uncodable diagrwaea, and illegible diagnoses. Advance Data No. 268 ● October 6,1995 7

and instruments used tn collect and Table 8. Number and percent distribution of outpatient department visits by the 20 prin- process drug information has been cipai diagnoses most frequently renderad by hospital staff United Statea, 1993 published (9). Number of standard S&rafSrd wits h error h Percerrf error of Medication was used at Prirrc@sl disgnos/s and ICD-9-CM Codst fholrssnds thousands disiiftwfion percent 57.1 percent of the outpatient department visits (table 12). Hospital Allvisifs ...... 62,534 7.s30 100.0 . . .

staff were instructed to record all new Nonnsfpregnancy ...... V22 4,923 913 7.3 1.1 or continued medications ordered or Hesfth supervision of infant or child ...... V20 1,676 345 3.0 0.5 provided at the visit including Essentlai hyparfenslon ...... 4oI 1,732 2= 2.8 0.3 prescription and nonprescription General rnadbl examination ...... V70 1,286 242 2.1 0.3 Suppurstive and unspedilad otifis media . . . . . 382 1,242 220 2.0 0.3 preparations, and immunizing and Acute upper respiratory infeef!ars of mulfipfe or desensittilng agents. As many as five urrspsciffed sites ...... 465 la 308 2.0 “ 0.3 medications or drug mentions could be Disbetes memfus...... 250 1,103 191 1.8 0.2 coded per visit. Asthma...... 493 1,022 267 1.6 0.3 Neuroflc disorders ...... 300 914 219 1.5 0.3 There was a total of 75.7 million Other posfsurglcal stafes...... v45 800 219 1.4 0.3 drug mentions, or an average of 1.2 Affedive psydroses ...... 296 603 201 1.3 0.3 drug mentions, per OPD visit. The 20 Malfgnsrrt neoplasm of fernefe breast ...... 174 &t6 190 1.0 0.3 General syrnptorns ...... 760 631 97 1.0 0.1 medications most frequently prescribed Other and urrspeolffsd disorders of back . . . . . 724 572 155 0.9 0.2 at OPD visits are shown in table 13 by Acufepharyngftis ...... 462 572 127 0.9 0.2 drug entry name and therapeutic Alcohol dapendenee syndrome ...... 303 “565 233 0.9 0.3 classification. The therapeutic Follow-up examination ...... V67 525 109 0.8 0.2 Chronic sinusitis ...... 473 503 127 0.6 0.1 classification is based on the therapeutic Other disorders of urethra and urfrraryW@. . . . 593 494 112 0.8 0.2 categories used in the National Drug Bronchltls, not spsdffed se acute or chronio . . . 490 492 106 0.8 0.1 Code Dmtory, 1985 edition (10). The Allofherdlagnosss ...... 40,497 4,762 64.8 1.5

top 20 medications account for lBaaad onthe IntamaticfrafClaaaifkstkmof DisazsasjSthRwisbtr, ClinicalAfcdh%atbn(lCO-Q-CM) (8). 23 percent of all drug mentions. Tylenol was the medication most frequently prescrib@ with 2.2 million mentions, or

2.9 pement of the total. It was followed Tabie 9. Number and percent of outpatient department visits with eorreaponding standard by prenatal vitamins (2.5 percent) and errors by sefeotad diagrtoatic servfcea performed or ordered: United Statea, 1393. amoxicillin (1.7 percent). Nurrber of Sterrded StSrrdani Selected dlsgrrosfic servicss performed or VIslta in etror h ordered by troeplta! stti ftrouesndsj thousands Disposition of this visit Pemnt p-d Allvfsifs ...... 62,534 7,330 ...... Apprmimately tWO-thiidS of OPD visits (65.6 percent) resulted in an Blood pressure ...... 34,013 4,012 54.4 1.9 Other bkmftest ...... 12,s43 1,515 20.5 1.0 appointment being made to return to the Urirrafysis...... 8,719 1,23s 13.9 1.2 clinic. This and the previously HIVserofo@ ...... 4ss 133 0.8 0.2 mentioned finding that most OPD Spirometry ...... *375 122 0.6 0.2 patients had been seen in the clinic Alfargytesting ...... “182 75 0.3 0.1 None ...... 14,627 1,821 23.4 1.3 before are indications of the continuous nature of care provided in the OPD lNumbars may aced tdal number of visii bacausa more Ihan one servka may ba raported par viaii, setting. For 17.9 percent of visits, the ‘HIV is human immunocfdciency virus. disposition was “Return to c~mic PRN” (as needed) (table 14). Only 1.5 percent of OPD visits resulted in hospital Additional reports utilizing References admission. NHAMCS data are forthcoming 1. McCsig LF. National Hospital in the Advance Data Jrom Etal and Providers seen this visit Arnbulatmy MtiIcal Care Survey: Health Statistics series. In addition, 1992 emergency department survey data will be available on A stalYphysician was seen at summary. Advance data from vital computer tape and CD-Rem horn the two-thirds of OPD visits (66.8 percent). and health statistic no. 245. National Technical Information Service in HyattsvilIe, Maryland National Conversely, one-thiid of the visits had early 1996. Questions regarding this Center for Health Statistics. 1994. patients who were NOT seen by a stalf repo@ future reports, or the NHAMCS 2. McCaig LF. National Hospital physician. Registered nurses were seen may be directed to the Ambulatory Ambulatory Medical Care Survey at 41.8 percent of visits and residents/ Care Statistics Branch by caUing 1992 outpatient department summary. interns were seen at one-quarter (301)436-7132. Advance data from vital and health (24.3 percent) of visits (table 15). statistics; no. 24S. Hyattsvillq 8 Advance Data No. 268 @October 6,1995

Table IO. Number and percent of outpatient department visits by the top write-in diagnostic tests, surgical and non-surgical procedures, or therapies most often performed or ordered in hospital outpatient departments: United States, 1993

Number of Standard Standard Percent dis ttibution Tests, surgical and non-surgical procedures visits in emor in emor of and therapies and ED-9-CM code1 thousands2 thousands Percent percent Total Performed Ordered Unknown3

All visits a ...... 62,534 7,330 ......

All vlslts with procedures wrltten In ...... 33,023 1,570 52.8 0.9 100.0 69.4 22.2 8.5

Other Individual psychotherapy ...... 94.39 2,045 563 3.3 5.3 100.0 89.2 0.9 9.9 Eye examination not otherwise specified ...... 95.09 1,793 608 2.9 5.7 100.0 90.0 1.6 8.4 Pap smear...... 91.46 1,744 379 2.8 5.7 100.0 83.0 9.1 7.9 Other nonoperative measurements and examinations ...... 89.39 1,548 526 2.5 6.1 100.0 93.3 2.2 4.5 Routine chest x ray ...... 87.44 1,386 216 2.2 6.5 100.0 55.3 34.5 10.2 Microscopic examination of specimen from female genital tract--culture ...... 91.42 1,074 209 1.7 7.4 100.0 87.1 7.4 5.6 Other mammography ...... 87.37 1,024 213 1.6 7.5 100.0 29.8 64.3 6.0 Electrocardiogram ...... 89.52 948 123 1.5 7.8 100.0 65.2 25.7 9.1 Diagnostic ultrasound of gravld uterus...... 88.78 825 185 1.3 8.4 100.0 52.6 43.5 3.9 Microscopic examination of specimen from ear, nose, throat and larynx-culture...... 90.32 574 130 0.9 10.1 100.0 85.9 10.8 3.3 Other diagnostic ultrasound ...... 88.79 557 185 0.9 10.3 100.0 55.5 39.3 5.2 Fetal monttortng, not otherwise specified ...... 75.34 531 267 0.8 10.5 100.0 94.9 2.1 3.0 Other physical therapy ...... 93.39 463 102 0.7 11.3 100.0 28.5 53.3 18.1 Skeletal x ray of anMe and foot ...... 88.28 375 71 0.6 12.5 100.0 73.3 19.2 7.5 Skeletal x ray of thigh, knee and lower leg ...... 88.27 357 93 0.6 12.8 100.0 74.5 19.0 6.4 Skeletal x ray of wrist and hand...... 88.23 353 115 0.6 12.9 100.0 89.0 8.5 2.5 Gynecological examination...... 89.26 321 89 0.5 13.6 100.0 85.0 10.6 4.4 X ray, other and unspecified ...... 88.39 310 60 0.5 13.8 100.0 73.9 19.7 6.5 Tonometry ...... 89.11 307 201 0.5 13.9 100.0 97.4 0.0 2.6 Other local excision or destruction of lesion or tissue of skin and subcutaneous tissue ..... 86.3 306 63 0.5 13.9 100.0 88.6 6.5 4.9

‘Based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) (8). *Numbers may exceed total number of visits because more than one procedure may be reported per visit. 3Not known whether ordered or pefformed.

Maryland: National Center for Health Statistics. 1994. Table 11. Number and percent of outpatient department visits with corresponding standard errors by counseiing~education services: United States, 1993 3. Nelson CR, Stussman BJ. Alcohol- and drug-related visits to hospital Number of Standard Standard emergency departments: 1992 Counseling/education ordered or visits in error in emor of provided by hospital staff thousands’ thousands Percent percent National Hospital Ambulatory Medical Care Survey. Advance data All visits ...... 62,534 7,330 . . a D. . from vital and health statis tics; no. 25 1. Hyattsville, Maryland: National Growth/development...... a . . a . 3,29 4 777 5.3 1.1 Center for Health Statistics. 1994. Exercise ...... e ...... D . 2,954 521 4.7 0.5 4. Burt CW. Injury-related visits to Injury prevention 0 D 0 a . . . . 0 e D mD "1,594 489 2.5 0.6 Weight reduction . . . 0 . . D. . . . a D 1,487 227 2.4 2.0 hospital emergency departments: Smoking cessation. e D. 0 D De D 0 . D 1,112 186 1.8 0.2 United States 1992. Advance data Cholesterol reduction 0 n . D . . . U . D 790 136 1.3 0.2 from vital and health statistics; no. Other STD transmission o ...... 761 157 1.2 0.2

26 1e Hyattsville, Maryland: HIV transmission. D q . e . . D . . q . D 722 166 1.2 0.2 National Center for Health Other ...... 23,051 3,121 36.9 1.7 Statistics. 1995. None ...... 33,397 3,937 53.4 2.0

5. Stussman BJ. National Hospital ‘Numbers may exceed total number of visits because more than one service may be reported per visit. Ambulatory Medical Care Survey: 1993 emergency department summary. Advance data from vital 7. Schneider D, Appleton L, McLemore modification, Washington: Public and health statistics. HyattsvilIe, T. A reason for visit classification for Health Service. 1980, Maryland: National Center for Health ambulatory care. National Center for 9. Koch H, Campbell W. The collection Statistics. 1995. To be published. Health Statistics. Vital and Health and processing of drug information. 6. McCaig LF, McLemore T. Plan and Stat 2(78). 1979. National Ambulatory Medical Care operation of the National Hospital 8. Public Health Service and Health Survey, 1980. National Center for Ambulatory Medical Care Survey. Care Financing Administration. Health Statistics. Vital Health Stat National Center for Health Statistics. International Classification of 2(90). 1982. Vital Health Stat l(34). 1994, Diseases, 9th Revision, clinical Advance Data No. 268. October 6, 1995 9

Table 12. Number and percent distribution of outpatient department visits with corre- 10. Food and Drug Administration. sponding standard errors by number of medication codas this vfsib United States, 1993 National Drug Code Dhe-ctory, 1985

Number of Standard standard Edition. Washington Public Health Number of vfatfain error in Percent error of Servicq 1985. medication sodes thousands thousands distribution percent 11. Shah BV, Barnwell BG, Hunt PN, La Vange LM. SUDAAN user’s manual Allvidls...... 62,534 7330 100.0 . . . release 5.50. Research Triangle Pink, None ...... 26,812 3716 42.9 i .9 North Carolinz Research Triangle 1 ...... 16,002 19s3 25.6 1.0 rnstitute. 1991. 2 ...... 9,118 1080 14.6 0.7 3 ...... 4,456 530 7.1 0.4 4 ...... 2,628 318 4.2 0.4 5 ormore ...... 3,518 466 5.6 0.6

Tabie 13. Number and percent distribution for the 20 drugs most frequantty prescribed at outpatient department visits with corresponding standard errors, by entry name of drug: United States, 1993

Number of Standard standard druge mentions error in Percent error of Entry name of drugt h thoussnda thousands disbfbutIon parcwt Therapeutic classlficatlorr2

Alldrug menWms...... 75.710 3,781 100.0 . . .

Tylenol ...... 2,191 326 2.9 0.4 Ganeralanalgaaks Pranakdvttamirss ...... 1,879 566 2.5 0.8 VWmins,mirrerals Amoxldllin ...... 1,307 227 1.7 0.3 Persidttlrrs Dlphiher&a& tetanus toxoids wlthpertusdav acdne ...... 934 173 1.2 0.3 Vacdnes and anllsarums Motrin ...... 879 148 1.2 0.2 Antiarthrttice Poliomyelitis vacdne...... 873 170 1.2 0.3 Vaodnas and antiserums Leak...... 795 126 1.1 0.1 Diuretics Prednisone ...... 743 119 1.0 0.2 AdrerreJcorticosteroids Zantac ...... 739 109 1.0 0.1 Agents used in dtsorders of upper GI tract Bacfrtm ...... 721 163 1.0 0.2 Antimlcrobiale Procardia...... 698 84 0.9 0.1 Aot!-snginal agents Ironpraparaflon ...... 685 211 0.9 0.3 Agents used to treat darldency anemias Ventolin...... 682 129 0.9 0.2 Bronchmtllators, anllasthmatks Proventil ...... 657 141 0.9 0.2 Bronchodkdore, antlasthmatics Hepatitis B ...... 657 127 0.9 0.2 vaccines and antiserums i-faemophllus Bcorrjugatevacdne ...... 656 139 0.9 0.2 Vaccines and antiserums Vssotec...... 616 85 0.8 0.1 Anthypertenslve agents Influenza vlrusvacclne ...... 567 161 0.8 0.2 Vaccines and antlsarums Bynthroid ...... 555 92 0.7 0.1 Agents used to treat thyroid disease vitamins...... 550 229 0.7 0.3 Vitamins, minerafs Another ...... 58,296 2,930 77.0 0.6

‘The entry made by the hospital staff on the prescription or other madiial remrds. This maybe a trade name, generic name, or desired thwapautic effect %serapeutii dassikation is based on the NatiorrafDrug COC4IYiredoM 1985 Edtiorr (10). [n cases where a drug had mere than one thempeutii use, rt was listed in the category that omurred withthegreatest fraquen~, 10 Advance Data No. 268. October 6, 1995

Table 14. Number and percent of outpatient department visits with corresponding standard errors by disposition of visik United States, 1993

Number of Standard Standatrl viaftaIn error in error of D@osltlon thousands thousands Percent percent

Allvlsifs ...... 62,534 7,330 . . . . .

Retumto clinic - appointment ...... 41,017 4,746 65.6 1.9 Retumto cl[nlc PRN2 ...... 11,163 1,933 17.9 1.4 Refer toother physlcian/clinlc ...... 4,625 595 7.4 0.8 Nolollow-up pkmned...... 2,805 483 4.5 0.5 Ralurnto referringphyslcian ...... 2,463 559 3.9 0.8 Telephonefollow-upplanned...... 2,079 564 3.3 0.8 Admltto hospital ...... 921 179 1.5 0.2 Other ...... 2,058 334 3.3 0.4 lNumbers may exceed total number of visits because more than one disposition may be reported per visit. 2PRN is as needed.

Table 15. Number and percent of outpatient department visits with corresponding standard errors by type of provider seen: UnitsdStatas,1993

Number of Standatd Standard vlslts In error In error of Type of provider thousandai thousands Percent percent

Allvleits ...... 62,534 7,330 ......

Ststfphysician ...... 41,786 5,720 66.6 2.4 Reglsterednurse ...... 26,155 2,567 41.8 3.3 Resldent/lntern ...... 15,223 2,363 24.3 2.2 Llcansedpracflcalnuree ...... “6,770 2,186 10.8 2.6 Nurse’saide ...... 5,254 998 8.4 1.3 Phyelcisn aesietsnWNuree practitioner ...... 4,547 892 7.3 1.0 Otherphysician ...... 2,145 555 3.4 0.6 Other ...... 11,053 2106 17.7 2.2

lNumbers may exceed total numbsr of visits because more than one provider may be reporfad per visfi.

Symbols --- Data not available . . . Category notapplioable Quantity zero 0.0 Quantity morethan zero but less than O.05 z Quantity morethan zero but less than 500 where numbers are roundedto thousands * Figure does not meet standard of reliabilityor precision Advance Data No. 268. October 6, 1995 11

and medical coding were performed by Table L Coefflciante appropriate for detar- Technical notes mlnlng relative standards errors: National Analytical Sciences Inc., Durham, North Hospital Ambulatory Medical Care Survey, Souroeof dataand sampledesign Carolina. 1993 Coe~oient for use Theinformation presented in this Samplingerrors withestfmstee report is based on data collected in the In thouesnds The standard error is primarily a 1993National Hospital Ambulatory measure of the sampling variability that TW of estlmste A B Medkal Care Survey (NHAMCS) ftom occurs by chance when only a sample, December 28, 1992 through December VMls...... 0.02082 5.924262 rather than an entire universe, is Dmg mentions . . . 0.02287 8.12S418 26, 1993. The data were adjusted to produce annual estimates. surveyed. The standard error also The @get universe of NHAMCS reflects part of the measurement emor, includes in-person visits made in the but does not measure any systematic United States by patients to emergency b-in the data. The chances are 95 departments (EDs) and outpatient out of 100 that an estimate fi-om the Adjustmentsfor hospital departments (OPD’S) of non-Federal, sample differs from the value that would nonrssponse short-stay hospitrds (hospitals with be obtained from a complete census by Estimatesfrom NHAMCS data average length of stays for all patients less than twice the standard error. were adjusted to account for sample of fewer than 30 days) or those whose The standard errors used in this hospitals that were in scope but dld not specialty is general (medcsl or surgical) report (including tests of significance) participate in the study. This adjustment or childnm’s general. The NHAIWS were approximated using SUDAAN was calculated to minimim the impact sampling flame consists of hospitals software. SUDA4N computes standard of response on final estimates by listed in the April 1991 SMG Hospital errors by using a first-order Taylor imputing to nonrespondmg hospitals Database. approximation of the deviation of data from visk to similar hospitals. For A four-stage probability sample estimates from their eqected values. A this purpose, hospitals were judged design is used in NHAMCS. The design description of the software and the similar if they were in the same region, includes Sillll@S of primary Samphlg approach it uses has been published ownership control group, and Units (ps~s), hospitals within PSU’S, (11). Standard errors for all estimates metropolitan statistical area control ED’s within hospitals and/or clinics are presented in each table. The relative group. within outpatient departments (OPD’S), standard error (RSE) of an estimate is and patient visits within ED’s and/or obtained by dividing the standard error Adjustmentsfor ED/clinic cIinics. The PSU sample consists of 112 by the estimate itself. The result is then nonrssponse PSU’S comprising a probability expressed as a percent of the estimate. subsample of the PSU’S used in the E8dmam8from NHAMCS data Appmtimate relative standard errors were adjusted to account for ED’s and 1985–94 National Health Interview for aggregate estimates may be Survey. The hospital sample for 1993 sample clinics that were in scope but calculated using the following general did not participate in the study. ‘His consisted of 489 hospitals. Of this formuk+ where x is the aggregate of group, 445 hospitals had either an ED or adjustment was calculated to mhdmize interest in thousands, and A and B are the impact of nonresponse on final OPD in 1993 to make them in scope or the appropriate coefficients tkom table I. eligible for the survey. During thii estimates by imputing to nonrespondmg perid 94 percent of the in-scope ED’s or clinics data flom visks to RSE (x) = A+:*IOO similar ED’s or clinics. For this purpose, hospitals participated. Based on the r ED’s or clinics were judged similar if induction intmview, 228 of the sample Similarly, relative standard emors for an hospitals had OPD’S. Hospital staff were they were in the same ED or clinic estimate of a percent maybe calculated group. asked to complete Patient Record forms using the following general formuk (figure 1) for a systematic random where p is the percent of interes~ Testof significanceand rounding sample of patient visits occurring during expressed as a proportion, and x is the Thedetermination of statistical a randomly assigned 4-week reporting denominator of the percent in thousands, period. The number of Patient Record using the appropriate coefficients from inference is based on the l-test. The forms completed for OPD’S was 2&357. Bonfemoni inequality was used to table I. Characteristics of the hospital, such establish the critical value for as owierahip and expected number of statistically significant dtierences (0.05 OPD visits, were obtained from the ‘SE(X)=e.’” level of significance over all analyses hospital administrator during an performed on estimates contained in a induction interview. The U.S. Buteau of The standard error for a rate maybe table). Terms relating to dtierences such the Census, Housing Surveys Branch, obtained by multiplying the relative as “higher than” indicate that the was responsible for the survey’s data standard error of the total estimate by difference is statistically signhicant. A collection. Data processing operations the rate. lack of comment regarding the 12 Advance Data No. 268 ● October 6, 1995 difference between any two estimates less than 30 days (short-stay) or hospital medical care is provided under the does not mean that the difference was whose specialty is general (medical or supervision of a physician. tested and found to be not significant. surgical) or children’s general. Federal Clim.c—An administrative unit of In the tables, estimates of OPD hospitals, hospital units of institutions, the outpatientdepartmentwhere visits have been rounded to the nearest and hospitals with less than six beds ambulatory medical me is provided thousand. Consequently, estimates will staffed for patient use are excluded. under the supervision of a physician. Emergency depa~ent—Hospital not always add to totals. Rates and The following are examples of the types facility for the provision of unscheduled percents were calculated from original of clinics excluded fmm the NHAMCS: unrounded figures and do not outpatient services to patients whose conditions require irnmedate care and ambulatory surgical centers, necessarily agree with percents that is staffed 24 hours a day. If an ED chemotherapy, employee health servke, calculated from rounded data. provided emergency servkes in dtierent renal dialysis, methadone maintenance, Definition of terms areas of the hospital, then all these areas and radiology. were selected with certainty into the Wsit—A direct.jpersonal exchange Patient—An individual seeking sample. Off-site emergency departments between a patient and a physician or personal herdth services who is not open less than 24 hours are inclu&d if other health cam provi&r working currently tiltted to any health care staffed by the hospital’s emergency qnder the physician’s supervision, for institution on the premises. department. the purpose of seeking care and Hospital-All hospitrds with an Outpatieti department-Hospital receiving personal health services. average length of stay for all patients of facility where nonurgent ambulatory

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Page Correction 2 Delete items 1 and 2 fkom the Patient Record form. 3 Table 1: Americau Indian/E&imo/AleuL Standard error in thousands: 53 [not 534] 9 Table 13: Vitamins, Number of drug mentions in thousamk “550 [not 550] 11 Paragraph 3 under “Source of data. . .“: Change “Based on the induction interview, [228] of the sample hospitals . . .“ to “Based on the induction interview, 255 of the sample hospitals . . .“

All materialappearing in this reportis in the Suggested citation public&main and may be reproduced or NationaI Center for Health Statistics copiedwithoutpermiseiorqdtation as to LipkindKL. National HospitalAmbulatory sourcxa,however,is apprsoiated. ActingDirector Medical Care Survey 1993 outpatient Jack R. Andarson departmentsummery.Advance date from vital and healthstatistioq no 266. Hyattsville, Tmde name discl~mar Acting Deputy Director Jennifer H. Macfans,Ph:D. Maryland NationalCenter for Health The use of trade names is for identification statistics. 1395. only and does not implyendorsementby the PublicHealth Service, U.S. Departmentof Health and Human SeM”oas.

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DHHS PublicationNo. (PHS) 95-1250-E 6-0020 (10/95) Number 269 . November 30, 1995 Advance Data From Vitaland Health Statisticsof the CENTERS FOR DISEASE CONTROLAND PREVENTION/National Center for Health Statistics

Characteristics of Prepaid Plan Visits to Office-Based Physicians: United States, 1991 David A. Woodwell, Division of Heafth Care Statistics

Introduction fee-for-service plans, which may result nonprepaid than prepaid plan visits were in inherently lower costs and atlects for patients over 65 years of age (16.2 This report presents data iiom the compruisons between plans (l–5). Much and 9.1 percen~ respectively), inclusion National Ambulatory Medical Care of the current literature compares of visits by the elderly would bias Survey (NAMCS) on visits to private prepaid plans and tmditional fee-for- comparisons. Prepaidplan visitsare office-based physicians at which the service plans in regards to health defined as those at which “HMO/other expected source of payment was a outcomes and quality of care (6-10). prepaid” was checked on the Patient health maintenance organization or other This report provides data on health care Record form, regardless of whether prepaid health care plan. The NAMCS delivery by private office-based another expected pay source was is a national probability sample survey physicians involved with patients checked as weIL NonPrepaidvisitsare of visits to nonfederally employet% seeking care under prepaid health defined as vi,shs for which “HMO/other office-based physicians conducted by the insurance plans. prepaid” was not checked as an Division of Health Care Statistics, Because the estimates presented in expected source of payment. An National Center for Health Statistics, this report am based on a sample rather Centers for Disease Control and expected source of payment was Prevention. l%ii survey is used to than on the entire universe of office unspecified in 2.1 percent of the visits. collect da~ on the demographic visits, they are subject to sampling These records are also excluded tlom characteristics, the medical problem(s), vaxiabilhy. The Technical notes at the this report. Visits by expected sources of and the medical treatment of patients end of this report include au ovemiew payment are shown in table 1. The making visits to private office-based of the sample design used in the 1991 expected sources of payment for physicians. The NAMCS was conducted NAMCS, an explanation of sampling nonprepaid vishs include patient-ptid annually ftom 1973 through 1981, again errors, and guidelines for judging the (31.4 percent), privatdcommercial in 1985, and resumed as an annual precK1on of the estimates. insurance (46.7 percent), Me@caid survey in 1989. The Patient Record form is (12.1 percent), and Medicare Health maintenance organizations reproduced in figure 1 and is iutended to (3.7 percent). @MO) were first developed in the early serve as a reference for readers as they To understand the usefulness and 1970’s with the passage of the HMO review the survey findings. For purposes limitations of these da@ two Act of 1973. This new initiative of this repo% visits made by patients 65 chamcteristics of the NAMCS should be provided grants and loans to enable the years of age and older were excluded noted. FirsG expected sources of development of HMO’s in an attempt to from analysis due to their high payment are not mutually exclusive. halt increasing health care costs. Since utilization and type of medical cam Because of co-payments, participation in then, HMO’s and other more recent received as compared with visits made governmental medical care programs, prepaid plans have attracted younger by patients younger than 65 years of and attiliations with other health and healthier enrollees than traditional age. Since a much larger proportion of insurance organizations, more than one

/+’’’’Q””’ U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service {< Centers for Disease Control and Prevention National Center for Health Statistics CENTERScmFOR DtSEASE CONTROL %=4 AND PREVENTION : nuwuo, usi? UUW.4 o-w. --w ------, -=--

Asmurance 01 Con f1d9ntloli2y-All Informmlo. wl!kh would permit Idmtlfiaat Ion of m D.PUWUM Of Health ●nd Hum.. ZWV1... lndlwldual,. pm.1,.., M.. .atabll.lun.nt Ml! be h.kl wnfldwwlu, ‘#Ill 60 ua.d only by C*nurs for 01.u*. Control pwons angq.d In m.d for tlw pnpoaae of the auf.ay ●nd will .01 be dlmloaed or Put.!k H“IUI Serti. ,,!.,,Mtooth.rP.m.”,m““d 63, ..Y OtMC PUT..”. Nmlo.al C..tw for H.zltlI Stmktlm ID

1. DATE OF VISIT PATlENTRECORD OMB No. 0920.0234 ____+&& ExPires 4-30-S3 NATIONALAMBUIJXTORYMEDICAL CARE SURVEY cDC 64.21 D

L DATE OF BIRTH 4. COLOR OR RACE 5. sTHNIC17Y & EXPECTED SOURCE(S) OF 7. WAS PATIENT S, IS THIS VISIT PAYMENT (Check afl that apply[ REFERRED FOR INJURY RELATED? ~ I ❑ Whit= -rHIs Vlsrr BY Hispanic * ❑ HMO/OIfW prepaid 5 m ~~$=f=ia, ?l-JYas 2DN0 ❑ 1 •l .nfgln ANOTHER 2 Black ❑ ❑ PHYSICIAN? z Medlczrz 6 Path-it paid 9. DOSS PA’rlENT Not 3. SEX Adnn I pacific ❑ SMOKE kXQARE77SS? 3 D Islander 2 HIsPmiG 8 ❑ Mediwdd 7 ❑ No charge t r-J Y*E I ❑ Fomz!4 2 ❑ Male 2~N0 ~ ~ :0* $ ❑ Lknkndwn ~ n ‘G:?;?%!” 1 . t ❑ Other government a U Other

10. PATIENT’S COMPLAINT S), SYMPTOM S), 11. PHYSICIAN’S DIAGNOSES 12. HAVE YOU OR 13. ~~SHPf#ENT OR OTHER REASON(S) illOR THIS VIS ANYONE IN YOUR [In patient’s own wor&/ PRACTICE SEEN [Cl[eck .// dlOl:pp{y . Pmg -Tdl PA71EN7 BEFORE? regardless of any enmy in Item J!] L 6!0s1,mpmmnl. WImUOmOk 1DY2B 2UN0 1 ❑ None of below

2 I_J Depression , O!Jw: b. Othm If yes, tor the condlhon ❑ In Item 1la? s Hyp6zt6rMon 4 I_J Hyparsholesterolemla t ❑ Yes 2DN0 :. cum ., Cxbc 5 ❑ Obzziiy

is. Dm2r40amc I SCREENING sERMcE5 T4. AMBULATORY SURGICAL 16.THERAPSU71C SERVICES PROCEDURE(B) [Check all ordcrcdorprovided] [Check all ordered or provided. ExcIude mzdicatimt] [Record my 0U1fMli

17. MEDICATION If nc+w, chzck hare ❑ a. Now nwdicaflon? la. DISposmON THIS vlsrr 19. ll#RA7iON [Check a!! that appiy] [Record all new Yea No -rHIs Visrr or conn”nutd Irllne Uctu.lly indications t ❑ No follow-uP plumed 1. spzni wldt ordered or in 20 ❑ phyxickm] prorided at 2 Raturn at 8pesMied time IIIITvisit, Ust 3 ❑ IIatwm If nz+ackad,P.R.N. the mm? brand 2. 10 20 nameor Reneric 4 ❑ Telephone fallow-up planned name zmertd on any RX or Ofice 3. lo 21-J 5 ❑ Refwred to other physician medical record. lnrlud~ Imnmnir,ng e n Returned to Feforring physfclan awd desenzftiring 4. lo 20 agent.,.] 7 ❑ Admft tohospitsl 8 ❑ Oth-2r[Specfi] Minuf6s s. in 20 t

...... Figure 1. Pauemtrecora lorm

expected source of payment is possible. by persons under 65 years of age that ● A higher proportion of pre]paid than In addition, a patient who has insurance had an expected source of payment of nonprepaid visits by new patients may have a visit with “patient ptid” “prepaid plan” almost doubled (10 were referrals (39 and 27 pereenc designated as the expcxXedsource of and 18 percen~ respectively) with a respectively). payment because of copayments or higher-.. tmmortion of 1991 VMS to ● The West represented 33 percent of deductibles. For these reasons all nonprirnary care specialties. all prepaid plan visits and 21 percent nonprepaid visits have been combined ● A higher proportion of prepaid than of nonpmpaid visits. Less lhan into one category. Second, the prepaid nonprepaid visits were to office-based 18 percent of prepaid visits were plan visits that are the subject of this physicians in the primary care made in the South compared with report cannot be analyzed aecordlng to specialties of general and knily 31 percent of nonprepaid visits. the type of prepaid plan because all practice, internal medicine, pediatics, . Prepaid and nonprepaid visits were preptid plans were grouped together and obstetrics and gynecology (70 similar with respect to the principal into a single C-ategowon the survey and 62 percen~ respectively). reason for visi~ physicians’ principal instrument, ● A higher proportion of prepaid visits diagnosis, and medications than nonprepaid visits to nonprhnary prescribed. Highlights care specialties were referrals from ● Excluding visits in which there was ● Between 1985 and 1991 the another physician (19 and 12 percen~ no face-to-face contact between proportion of physician office visits respectively). patient and physician, the average Advance Data No. 269. November30, 1995 3

duration of prepaid plan visits was Table 1. Number and percent of visits by expected sources of paymenfi similar to that of nonprepaid visits United States, 1991 (16 minutes vs. 17 minutes, Number of visitsIn respectively). @ratted sourcesofpaymenf thousands Percent ● After the exclusion of patients 65 years of age and older, the average Allvisitsz ...... 513,819 100.0

age of patients making prepaid plan Prepaid plans ...... 91,824 17.3 visits was 29.2 years compared with Nonprepaid plans ...... 421,335 82.1 31.4 years for patients making nonprepaid visits. Allnonprapakt ptenvisdts ...... 421,995 100.0 Medicare ...... 15,736 3.7 ● A significantly higher proportion of Medicaid ...... 51,055 12.1 prepaid plan visits had at least one Oihergovemment ...... 12,078 2.7 dmgnostic or screening test ordered Privste/commardal insurance ...... 197,046 46.7 Patiantpakf ...... 132,453 31.4 or performed (76 percent) compared Nodrarge ...... 8,635 2.0 with nonprepaid visits (70 percent) Other ...... 22,742 5.4 for patients 4544 years of age. ‘Numbersdo mat add to totsls because mare than one source of payment mey be repoitad par visit. 2An addiinal 155,870,0C0 visits wara for patients 65 yaars of aga and over and 10,384,000 VMS had no axpected sourca of Physician characteristics payment indicatad. These V!MS have been axcluded from this report.

In 1991, there were an estimated Table 2. Number and percent distribution of prepaid plan visits and percent distribution of 91.8 million visits to nonfederally nonprepaid visits by physician speciatty United States, 1991 employed office-based physicians at which a prepaid plan was an expected Prepaidptan vkr?s Notprspakl visits source of payment not includlng visit8 Nrrm5arof vMts in Peroent Percent made by patients 65 years of age and PhysicianWasialw thousands dkfdbution diatrtbution older. This is a significant increase from 1985 in which there were an estimated Allvldts ...... 91,824 100.0 100.0

51.4 million visits with an expected Pltmary care: source of payment of a pepaid plan. In General and femlly practice ...... 24,204 26.4 25.1 1991, about 18 percent of the vi&s by Infernal nwdldne ...... 14,335 15.7 11.9 pemonsunder 65yearsofagehada Ped?atrtcs ...... 15,247 -r6.6 14.4 -d Pkmas an expectedsourceof Obsfetrb and gynecology...... 10,095 11.0 10.6 payment compared with 10 percent in Other than primery care 1985. Orfhopedlc surgery ...... 5,331 6.5 5.6 Of the 91.8 million prepaid plan Dermatology ...... 3,081 3.3 4.2 office visits in 1991, about 70 percent Oto!aryngology ...... 2,774 3.0 3.1 were to primary care physicians- General surgary ...... 1,875 2.0 3.0 Urologkal suqery ...... 1$33 1.7 1.2 including general and family Csrdlovaecular diesaaaa ...... 1,282 1.4 0.3 practitioners, intmnists, pediiticians, Ophthalmology ...... 1,087 1.2 4.1 and obstetricians and gynecologists Psyohlarr)r ...... 1,340 1.5 3.2 (table 2). The percent of prepaid visits Neurology ...... 481 “0.5 i .2

to primary care physicians was down Allolherapaciaitlea ...... 8,540 9.3 11.6 tlom 77 Wment in 1985; the first year data wem collected on an expected source of payment. The decrease in the proportion of prepaid visits to primary nonprepaid visits horn 8 percent in 1985 requiring the patient to obtain a referml care physicians was due to a decline in to 12 percent in 1991. Sixty-two percent by their primary care specialist whereas the percent of visits to general and of the nonprepaid visits were to primary the requirements for a patient enrolled family practitioners fkom 35 percent in care physicians. in an open-ended plan are not as 1985 to 26 percent in 1991. The One possible explanation for the stringent. proportion of prepaid visits to increasing percent of prepaid plan visits Table 3 shows that the geographical obstetricians and gynecologists increased to nonprimary care specialties is the d~fribution of prepaid plan visits and from 7.6 percent in 1985 to 11.0 percent increased use of network models and nonprepaid visits differ. The West in 1991. Among nonprepaid visits, point-of-senricdopen-ended plans in accounted for the largest proportion of geneml and family practitioners also 1991 as compared with traditional prepaid plan visita (33.0 percent) while dropped as a percent of visit8, tiom HMO’s, which dominated the p~paid the South accounted for the smalleat 30 percent in 1985 to 25 percent in plan market in 1985 (11,12). Traditional proportion (17.9 pement). The 1991. Internist8 incmawd as a percent of HMO’s limit visita to specialists by distribution of nonprepaid visks was the 4 Advance Data No. 269 ● November 30, 1995

Table 3. Number and percent distribution of prepaid plan visits and percent distribution of reverse, with3 I.l percent occurring in nonprepaid visits by geographioai region: United States, 1991 theSouthand20.8 percentintheWest. Prepaldplan visfts Norprepaid VLsits Comparing thegeographical distribution

Number of ofprepaid plan visits overtime, visits In Percent Percent NAMCSdatashow thatin1985 the Region thousands dktribution dkfdbut/on Westhadthelargest munberofprepaid

Allvisns ...... 91,824 100.0 100.0 plan visits (20.1 million visits) and the Northeast had the smallest number of Northeast ...... 19,199 20.9 24.2 prepaid plan visits (7.4 million visits) Midwest ...... 25,930 28.2 24.0 South ...... 16,420 17.9 31.1 (figure 2). Wee ...... 30~76 33.0 20.6 Patient characteristics Approximately two-fifths (39.9 percent) of prepaid plan visits were made by patients 2544 years of 35 ■ 1985 ❑ 1991 age, and about one-quarter (26.2 percent) were made by patients 30 under 15 yearn of age. This pattern [ v//zi holds true for visits for nonprepaid sources of payment as well (table 4). However, patients 2544 years of age made up a relatively larger portion of prepaid plan visits compared with .-c nonprepaid viAts (39.9 vs. 35.4 percent). Correspondingly, patients 45--@ years of age made up a relatively smaller portion of prepaid plan visits compared with nonprepaid visits (21.9 vs. 28.1 percent). The majority of visits by persons with both prepaid and nonprepaid sources of payment were made by females, who “. south Northeast Midwest West accounted for a higher percent of visits than males in all age categories except Figure 2. Number of prepaid pian visits, by geographical region: United States, 1985 and under 15 years. 1991 As shown in table 5, the majority of prepaid plan visits were made by white persons (80.2 percent). Black Tabie 4. Number and percent distribution of prepaid pian visits and percent distribution of persons made 15.7 percent of these nonprepaid visits by patient’s age and sex United States, 1991 visits, with all other races a~counting Prepaid plan vktta Nonprepakf vfaffs for the remaining 4.0 percent. In all race categories, females made a higher Number of vklts In Percent Persant percent of visits than dld males. A A@ and sex thousands dktdbution dkttibution greater proportion of office-based

AIII.Hs ...... 91,624 100.0 100.0 prepaid plan visits were made by Under 15years ...... 24,058 26.2 24.4 black persons (15.7 percent) compared 15-24 yeaB ...... 11,009 12.0 12.1 with office-based nonprepaid visits 25-44 yesls ...... 36,65e 39.9 35.4 (8.5 percent). However, data from 45-84 yaals ...... 20,09e 21.9 26.1 1992 show that the percent of Male ...... 37,226 40.5 40.2 office-based visits by black persons Undar15ysam ...... 12,984 14.1 12.5 were stillar for prepaid and 15-24 ysars ...... 3,588 3.9 4.2 25-44 years ...... 12,235 13.3 12.0 nonprepaid visits based on that year 4S84yeare ...... 8,439 9.2 11.5 (see Discussion section).

Female...... 54,5ee 59.5 59.6 Visit characteristics Under 15years ...... 11,094 12.1 11.9 15-24 years ...... 7,421 S.1 8.0 Item 7 on the Patient Rword form 25-44yeam ...... 24,424 26.6 23.3 45-64yeam ...... 11,660 12.7 16.6 asks if the patient was referred by another physician for this visit. In Advance Data No. 269. November 30, 1995 5

Table 5. Number and percent distribution of prepaid plan visits and percent distribution of Prepaid plan visits were less likely nonprepald visits by patient’s race and sex: United States, 1991 to be associated with injuries compared Prepafdplan vkifs Nor!prapaid vkits with nonprepaid visits (table 7). Over all

Number of age groups, about 9 out of every 100 viaks in Percent Percent prepaid plan visits were injury related Race and sax thousands distifbution distribution (9.4 percent) compared with 12 out of Tohfvfetts...... 91,824 100.0 100.0 every 100 for nonprepaid visits (12.2 percent). The only age group to Black ...... 14,462 15.7 8.5 Male ...... 5,176 5.6 3.1 show a statistically significant Female ...... 9,286 10.1 5.4 dtierence, however, was for persons 25-44-years-okL For persons in this age White ...... 73,687 80.2 87.7 Male ...... 30,596 33.3 35.5 group, nonprepaid visits were 50 percent Female...... 43,091 46.9 52.2 more likely to be injury related

Other’ i ...... 3,675 4.0 3.8 compared with prepaid plan visits. Male ...... 1,454 1.6 1.6 Item 10 of the Patient Record form Female, ...... 2,222 2.4 2.2 aska for the patient’s (or patient’s surrogate) “complaint(s), symptom(s), hludes Asiin/Pacific Islander and American lndian/Eskim&Ueuf. or other reason(s) for this visit (In patient’s own words).” Up to three 8.2 percent of prepaid plan visits the were also observed for nonprepaid reasons for visit are coded and classified patienthadbeenreferred compared with visits. However, a higher proportion of according to A Reasonfor Wit 6.0pement ofthe nonprepaid visits prepaid than nonprepaid visits by new Ckmi$cation for Ambula.to~ Care (table 6). There was a significant persons were referrals (38.8 and (WC) (13). The principal reason is the difference in the refemal rate for primary 26.5 percent respectively). problem, complain~ or reason listed on care physicians compared with olher Patients that had au expected source item loa of the Patient Record form. specialists. Patients werereferredin of payment of a prepaid plan were less Approximately 61.0 percent of 3.4 percent of the prepaid plan visits for likely to smoke cigarettes compared prepaid plan visits were classified in the primary care physicians but were with those patienta that had another symptom module of the RVC, one of referred in 19.2percent ofvisits for expected source of payment. As shown the eight modules that makes up the other specialists. Notethatonly in table 7, about two-thirds of the visits classification (table 8). Of these 11.5 percent of the nonprepaid visits to with a prepaid plan source were made symptoms, 14.0 pment were classifiable other specialists were referrals. by patients who did not smoke to the respiratory system and ‘l?hemajori tyofpreptid plan visits cigarettes (68.5 percent), 8.4 percent 11.2 percent were classifiable to the were madeby patients whohadseen the were by patients who did smoke. In muaculoskeletal system. Nonprepaid physician previously for the same comparison, one-tenth of nonprepaid visits followed the same pattern. problem (54.9 percent). In addition, over visits were made by patients who smoke Table 9 shows the 20 most oneqnarter of the prepaid plan visits (11.7 percent) and three-fifths were frequently mentioned principrd reasons were made by “old patients” with a made by patients who dld not smoke for visi~ accounting for almost new problem (28.6 percent). New (62.1 percent). Smoking status of the 47 percent of the prepaid plan visits. patients made up less than one-tifth of patient was not spechied for about Note that estimates that differ in rauked the visits (16.5 percent). These patterns one-quarter of the visits. or&r may not be significantly different

Table 6. Number, percent distribution, and percent of visits referred by another physician by physioan specialty and vfsit status for prepaid plan and nonprepaid visits, Unitad-States, 1991

Prapaidplan visks NotwvwW V&tfS

Nudw Nurnbar Percent of Visns Percent Percent Percent lfl.sltcharacteffatics of vktts dkmbouon tsferrad fsferred ct%ttfbtion referred

Allvisits ...... 91,824 100.0 7,505 8.2 100.0 6.0

Primafy cara’ ...... 63,941 69.8 2,151 3.4 61.7 2.5 Other apecialtles ...... 27,864 30.4 5,354 19.2 36.3 11.5

Nawpaflent, ...... 15,111 16.5 5,660 36.8 18.8 26.5 Okfpatlent-new problem ...... 26,277 28.6 1,644 6.3 22.5 4.5 Oldpatlent-old prcblemz ...... 50,436 54.9 0.0 0.0 56.7 0.0 lPrimafy ewe spackdtias include geneml and family practice, infernal madicine, pediatrics, and cbatetrix/gynecology. %urvey odil spacificefions did not allow refemab for old patiint-old problam cases. 6 Advance Data No. 269. November 30, 1995

Table 7. Number and percent distribution of prepaid plan visits and percent distribution of and diseases of the nervous system and nonprepald visits by patient’s cigarette-smoking status and whether visit is injury reiated: United States, 1991 sense organs each representing about 8.0 percent of the visits. Nonpmpaid Prepaid pfan vfafts Norprapakt vlslta visits followed the same pattern. Number of Table 11 lists the 20 most tiequently vfslts In Percent Percent Visit chatacterfatics thousands dfstdbution distribution mentioned principal dmgnoses rendered by the physician at the three-digit AIIvMs...... 91,824 100.0 100.0 coding level of the ICD-9-CM. Doss patient smoke cigarettes? Approximately 40 pment of the visits

Yes ...... 7,709 8.4 11.7 are accounted for by the top 20 No ...... 62,878 68.5 62.1 principal diagnoses. Health supervision Unknown ...... 21,238 23.1 26.2 of infant or child was the most frequent

Is Walt Injury related? principal diagnosis, accounting for 4.9 percent of the prepaid plan visits. Yes ...... 8,613 9.4 12.2 No ...... 83,212 90.6 87.8 Health supervision of infant or child was followed by normal pregnancy and acute upper respirato~ infections of multiple or unspecified sites, accounting fromeachother.A general medical and is associated with the principal for 4.5 and 3.4 percent respectively. exam,accounting forabout5.2million reason for visit as recorded in item 10a. Comparing the principal diagnoses of visit8, 0r5.7percen4 was most The principal diagnosis was coded and the hvo types of visits, there is a ,frequently mentioned atpreptidplan classified according to rhe Intem.ational difference in the percent of visits for visits. Cough (4.5 percent), symptoms Classification of Di3eases, 9th Revision, health supervision of infant or child (4.9 referable to throat (3.7 percent), and ClinicaZModification (ICD-9-CM) (14). vs. 3.0 percent). This diagnosis prenatal examination (3.3 percent) The ICD-9

Tabie B. Number and percent distribution of prepaid pian visits and percent distribution of nonprepaid visits by patient’s rxincifIai. . reason for visit Unit&f Statas, 1991

Prapafd pkm vlaits NonprepaId visits

Number of visits In Percent Percent Prtnc@al reason for viatf modute and RVC coda+ thousands dlstrfbuflon dlsfdbtrtlon

Allvisifs ...... 91,824 100.0 100.0

Synptommodulfr ...... ’ ...... Sl~999 55,980 61.0 59.4 General symplome ...... Sool~099 6,358 6.9 6.9 symptoms referable to paychobglcal and mental dlaordera ...... S1OO-.S199 1,796 2.0 3.3 Symptoms referable to the nervous system (excluding sense organs). . . . . S200-S259 2,923 3.2 3.1 symptoms referable to the csrrllovascular and lymphatic system...... S260-S289 “487 “0.5 0.4 ~~tomrefer*le totheeyesmd earn ...... S300-3399 6,046 6,6 6,5 symptoms referable to the respiratory system ...... WXX3499 12,666 14.0 12.4 syr@oms referable to the dlgesfive syetem...... S5-639 3,500 3.8 4.0 synptoma referable to the genitourfnary system ...... SIMW8M 5,340 5.8 4.6 Systemereferable tolhealdn, nails, and hair ...... ~3rJ+899 6,337 6.9 6.6 symptoms referable to the muscutoskeletal system ...... 3900-S999 10,328 11.2 11.7 Dfeaase rnodula ...... -- ...... D1301-D999 7,314 8.0 7.5 Diagnostic, acraenlng, and preventive module...... Xl ~X599 15,593 17.0 16.0 Tmatmant module ...... TIOO-T899 7,102 7.7 8.8 Injury andadvems effecfs rnocfula ...... JOO14999 3,041 3.3 3.6 Allothermodufas2 ...... 2,795 3.0 4.9

1Ba8ed on A Raason for WitC/ant7ioatbn forAmbuMofy Care (IWC) (13). %dudrn test results meduh admini$treiiwe mcdule, unocdable and b!ank entries. Advance Data No. 269. November30, 1995 7

Table 9. Number, and percent distribution of prepaid plan visits and percent distribution 6.5 percent of prepaid plan visits, of nonprapald visits by the 20 principal reasons for visit most frequently mentioned by pattentrx United States, 1991 respectively. In contrastj nonprepaid visits recorded a signidcantly higher Prapaldplan VLSIYS NoryJriwak/ VtSffS percent of visits by patients suffering Nurnbar of vialts Percent Percent from depression 6.3 percenL as Prhc@Il fsason for Waltand RVC code’ In thousands disbfbofion dlstrfbuffon comprrred with 4.7P¢ for prepaid Allvtafts ...... 91,824 100.0 100.0 plans (table 12). However, when examining the differences at various age General nradbal examination ...... X1OO 5,247 5.7 4.3 Cough ...... S440 4,158 4.5 3.9 groups, only the patients between tbe symptoms referable to throsf ...... S455 3,377 3.7 3.2 ages of 15 and 24 yearn were more Prenatal examination, routine ...... X205 3;064 3.3 3.9 likely to have depression in the Well-baby examination ...... XlO5 2,966 3.2 2.4 Prograssvisif ...... T800 2,528 2.8 2.8 nonprepaid vWs (3.5 percent) compared Earache ore8rinfec&m...... S365 2,511 2.7 2.4 with prepaid plan visits (1.0 percent). Skin rash ...... S860 2,175 2.4 1.3 Past analysis of this question has shown Kneesymptoms ...... S925 1,833 2.0 1.2 that physicians seem to un&rreport Postopetatlve vlslt ...... T205 1,777 1.9 2.0 Stomach pahr, cr~s, and spasms...... S545 1,776 1.9 1.6 chronic conditions as diagnoses on item Fever ...... S010 1,726 1.9 2.0 11 of the Patient Record form (15). The Headache, pain lnhead ...... S210 1,703 1.9 1.7 same would hold true for visits to Nasslcongastlon ...... 3400 1,514 1.6 1.5 prepaid and nonprepaid sources of Head cofd, upper msphatoty infection...... S445 1,263 1.4 1.3 AIIww...... S090 1,277 1.4 0.8 payment Backsymptoms ...... S905 1,223 1.3 2.0 Diagnostic services performed or Asthma...... D625 1,000 1.1 0.4 or&rcd at the time of visit are shown in Shouktersymptoms ...... S840 992 1.1 1.0 Slnuspmbtems ...... S410 933 1.0 0.7 table 13. The most common service recorded at prepaid plan visits was a Afiotherreasons ...... 46,755 53.2 59.0 blood pressure testj 43.0 percenL A lBamed on A Rasson for Wit C/sss#iosYbn forA*/atoy Cm (WC) (13). urinalysis was performed or ordered in 13.9 percent while “all other diagnostic services” accounted for 34.7 percent. indkate if the patien~ at tie time of was reported as the patient dmguosis in Diagnostic serviees utilization rates in visit was aftlicted with any of tbe item 11. Obesity and hypertension were nonprepaid visits folIowed the same chronic conditions liste~ despite what checked most frequently, at 7.8 and pattern (table 14). Looking at age

Table 10. Number and percant distribution of prepaid plan visits and percent distribution of nonprepaid visits by principal diagnoshx Unitsd States, 1991

Prqafdplarr viaks Norpr.spati W&

Nurrirer of w“aifs Percent Percent Pffnc#Jsl diagnosk and ICL?-9-CM coda’ in thousands dfstrkxrffon distrhdfon

Allvwts...... ’...... 91,824 100.0 100.0

Infecflous arrdparasitio df.seases ...... 001-139 4,476 4.9 4.2 Ner@asms...... 140-238 2,438 2.7 2.5 Endocrfne, nufrifbnal, and metabolic. dbessessndimmunltydi borders...... 240-279 2,664 2.9 3.3 Mental diwrrders ...... 23+319 2,660 3.1 4.8 Dbeaaesoftfre nervous ayetemsrrd eansaorgans...... %?0-363 7,445 8.1 10.7 Dlseasssof thecfrculstory system ...... 390-459 3,577 3.8 4.3 Disaaaesof thereapbatorys ysfem...... 480-519 16,977 18.5 74.9 Dtseeaeaof fhedigastlve sysfam ...... 520-579 2,673 2.9 3.3 Diseaaesof thegenltourinary system...... 560-628 5,486 8.0 6.0 D-esofthe Mnmdsu&timmus tisue ...... *7m 5,320 5.6 6.0 Diseases of the muaculoakelatal system and mnnective tissue ...... 710-733 6,606 7.2 6.5 ~@om, s@ns, ~dll14flned mndklons ...... 7w7W 3,2SS 3.5 3.7 Injury endpcisonlng ...... 600-339 7,870 8.6 9.3 Supplarnsnfery clawdffcafiorr...... VO1-V82 16,838 18.3 17.5 Aflofherdiagnosea2 ...... 1,700 1.9 1.4 Unknown diagnoses3 ...... 1,639 1.8 1.7

‘Based on the Internstimd Clmafioatbn of Dksses, tlth Rwiskm, Clinicsl Mcdikatbn (ICD-9-OM) (14). %dud- rfisesses of the bbod-forming organs (28J-288); complba!bns of pregnancy, chiklbirth, and the puerparium (6sO+’8~ ccmgenitsl anomslbs (740-759); and mm-n conditbns origimstiig in the pe!indd Pried (7S4)-779). %duden blank d~noses, urscodabb diqpwms, and ih’egible dmgnoses. 8 Advance Data No. 269 ● November 30, 1995

Table 11. Number and percent of prepaid plan visits by 20 principal dlagnoaaa most frequently randarad by physicians: United SMaa, 1991

Prqraldplan vlsts Nonprepa\d vislte

Nurrber of vklts In Percent Percent Pr/nc/pa/dlagrrds and IGD-9-CM codet iflolreerrds cHrfbuf/on dlstrbutlon

Allvkifs ...... 91,824 100.0 100.0

HeaRheupewlsion ofinfantor child ...... V20 4,s31 4.9 3.0 Normal pregnancy ...... V22 4,091 4.5 3.9 Acute upper respiratory infections of mulfple or unspecified sites...... 465 3,160 3.4 3.0 Suppuretlve endunspeclfled otkismedla...... 382 2,917 3.2 3.0 Allerglc rhlnitis...... 477 2,670 2.9 1.5 Chronlcsinusifis ...... 473 2,659 29 1.9 Generelmedbalexarnlnetlon...... V71J 2,404 2.6 3.5 Essantlalhypertension ...... 401 2,150 2.3 2.3 Asthma ...... -...... 433 1,983 22 1.3 Acutepharyngifls ...... 462 1,602 2.0 2.1 Dbeasesofsabaceousglands...... 7IJ6 1,496 1.6 1.7 Bronchifis,note+ecitiedasaculeorchronic ...... ~0 1,392 1.5 1.6 Contec4dennefitisandothereczema ...... 692 1,221 1.3 1.1 Dlsbetesmelllttrs ...... -....250 1,098 1.2 1.2 Otherdlsordersofsynovlum,tendon, endbursa ...... 727 989 1.1 0.6 Actrfetonsillitis...... 483 S40 1.0 0.7 Certeinadverseeffecfsnotelsawhere classified...... 995 930 1.0 0.5 Perfpheralanthesqathlesandallledsyndrofnas...... 728 907 1.0 0.8 Sprafnsendsfralnsofother.andunspeMedpSftS ofback...... S47 848 0.9 1.1 Petsonethisforyofcertelnotherdkaasee ...... V12 782 0.9 0.6 Allofherdiagnoses ...... 52,858 57.6 84.6

lBasedon the/ntematima/ C/assifbatbn of Di=ases, 9fh Rsvistin, C/fni=/Mtiifkatbn (lCWM) (14).

differences, children under15yearsof Table 12. Number and percent of prepaid plan visits and percent of nonprepald visits by age were less likely to receive selected medical conditiorw United States, 1991 diagnostic tests compared with older age Prepaid plan vlsfts Nonprepaid visits groups in both types ofvisits(40 vs. Number of 72percentforprepaid planvisitsand37 vkits in vs.65 percentin nonpreptid visits). Medical condition’,2 thousands Percent Percent Persons 454 years ofage were more Allvlsite ...... 91,824 ...... likely to receive diagnostic testsin prepaid plan visits compared with Depression ...... 4,298 4.7 6.3 nonprepaid visits (76 vs.70percenC Hypertension ...... 5,987 6.5 7.0 Hypercholesterolemla...... 3,791 4.1 3.4 respectively). Obesity ...... 7,194 7.6 7.5 Viiitsatwhiehat leastone nonmedieation therapeutic service was 1Refers to question IS cm the Palient Record form 2Numbers do not sdd to totals because more than one medicsl condifkm msy be reported per visit and not aft wdegoriee are orderedorprovided represented on~thirdofthe totalprepaidplan visits, as shown in table 15. The most frequently checked therapeutic serviee Physicians were asked to record all new than one therapeutic application and in was diet cotmseling/education, reported or continued me&cations provided at the these cases, each drug was assigned to at 10.7 percent of the visits. Exercise visi$ including prescription and the category that occurred with the and growth development counseling/ nonprescription p~parations and greatest frequency. education followed with percents of 8.6 immunizing and desensitizing agents. As shown in table 17, antimierobd and3.8, re.spectively. “Another About one-third of both prepaid agents represented the largest share of therapeutic services” ordered or and nonprepaid visits included only the 95.1 million drug mentions in provided accounted for 14.8 pereent of one drug mention (35.4 and prepaid plan visits, 21.2 percent. Of tie visits. No significant differences 34.6 percenti respectively). The drugs these, penicillins were the largest group were found between prepaid and entered on item 17 of the Patient (7.9 percent). Of the drug mentions, nonprepaid visits. Record form are classified based on 14.7 percent were respiratory tract drugs, The majority of both types of visits the therapeutic categories used in the and drugs used for relief of pain were drug visits in which the patient National Drug Code Directo~, 1985 amounted for 12 percent. Two was given, prescribed and/or continued edition (16). The reader should significant differences were found on at least one medication (table 16). understand that some drugs have more between the prepaid and nonpmpaid Advance Data No. 269. November 30, 1995 9

visits in the distribution of drug Table 13. Number and percent of prepaid plan visits and percent of nonprepaid visits by mentions by therapeutic class. diagnostic and screening services ordered or provided: United States, 1991 Psychopharmacologic drugs represented Prapefdplerr VMS Notprspald visits a larger percent of drug mentions at Nurrbsr of nonprepaid vkks compared with prepaid Diagnostic end screening visits in plan visits (7.0 percent and 4.5 percen~ eervims ordered orprwided thouearr& Percent Percent

respectively). This strengthened the Total vistts~ ...... 91,824 ...... earlier finding that physicians involved in nonprepaid visits recorded a higher Blood preeaure ...... 33,4s5 43.0 39.9 Urinalysk ...... 12,771 13.9 13.3 percent of visits with a diagnosis of EKGresling ...... 1,s07 2.0 1.9 depression than did those involved EKGexerdse ...... -197 “0.2 0.4 with prepaid plan visits (item 13). Mammogram...... 1,636 1.s 1.7 Chest xray ...... 1,740 1.9 1.8 The only age group to show a Paptest ...... 4,737 5.2 5.0 significant difference, however, was 6trepthroat teet ...... 2,710 3.0 2.5 the 2544 years group. On the other Cholesterol measure ...... 3,389 3.7 3.2 hand respiratory tract drugs Hearlngtest ...... 1,723 1.9 1.8 Vkwdacuily ...... 2,030 2.2 4.8 represented a larger portion of drug Mental status exam ...... 1,254 ~.4 1.6 mentions at prepaid plan visits All other diagnostic sarvicae2 ...... 31,832 34.7 30.1 compared with nonprepaid visits for None ...... 33,350 38.3 39.6 persons in this same age group (15.2 vs. 9.9 percent). ‘Numbers do not edd to totals bemuse more than one service mey h reported per visii. ‘Includee other radiology, allergy tading, spiromsiry, HIV serob~, other Ieb tasfe, and dher. Table 18 shows the most tlequently occurring generic ingredients of the drug mentions at prepaid plans visits during Table 14. Number and percent distribution of prepaid plan visits and percent distribution of nonprapafd visits by number of diagnostic seNicea orderad or provided: United States, 1991. Note that drug products 1991 containing more than one ingrtilent are included in the data for each ingredient. Prspeidplen visRs Norprepahf visks For example, acetaminophen with Nurrber of codeine is included in both the count for Number of d.kagnoeticsenrfces Wts h Percent Percent ordered orprovidsd thousands dwwltion distribution acetaminopben and the count for codeine. Amoxicillin was the most Atlvfdte...... 91,824 100.0 100.0 frequently occurring generic ingredien~ None ...... 33,350 36.3 33.6 with 7.1 miWon mentiony it 1 ...... 31,754 34.6 32.1 represented 7.4 percent of the total. 2 ...... 14,7s9 16.1 16.4 3 ...... The second and third listed generic 7,142 7.8 7.5 4 ormore ...... 4,&39 5.3 4.5 ingredients were aceta.tninophen and erythromycin representing 4.3 and 2.7 percent, respectively. A report Table 15. Number and percent of prepaid plan visits and percent of nonprepald visits by describing the method and instructions nonmedication therapy ordered or provided: United Statee, 1991

used to collect and process drug Prspaidplsn v&b Norprepaid vis#s information for the NAMCS is available (17). Number of visits in More than one-half (57.7 percent) of Nonmsdicetion therapy thousands Percent Pefcent prepaid plan visits resulted in instructions for the patient to return at a .wwdtsj...... 91,824 ...... specific time (table 19), and about Blat ...... 9,655 10.7 11.2 one-quarter of the visits resulted in Exerdse ...... 7,SS8 6.6 8.1 Cholesterol reduction ...... instructions to return if needed 2,620 2.9 2.5 Welghtreductbn ...... 3,(KIO 3.4 3.9 (27.0 percent). These percents am not Atcohol abuee ...... “424 “0.5 0.8 significantly dilTerent hem the 1985 Smotdng cessation ...... 1,406 1.5 2.3 estimates for prepaid plan visits Family/sodaI ...... 1,944 2.1 2.3 Growth devekpment ...... 3,450 3.6 4.2 (55.3 percent and 26.6 percenq Farrrilypkuming...... 677 1.0 1.1 respectively) and follow the same Psychotherapy ...... 1,644 1.8 3.4 pattern as the nonprepaid visits. Physiotherapy ...... 1,913 2.1 3.0 Tale 19 also shows the duration of All other therepeuk servkes2...... 13,574 14.8 13.0 visit. Of the prepaid plan visits, None ...... 61,495 67.0 65.2 61.7 percent lasted between 6 and 15 lNumbera do not edd to tofala bmeuae mora than one type of rmmwdketion therapy msy ba raported per visit. minutes, 21.6 percent lasted 16 to 30 ‘Includes dmg abuse, dher munsalingl mrrective bnsaa, hearing sid, and other therapy 10 Advance Data No. 269. November 30, 1995

Table 16. Number and percent distribution of prepaid plan visits and percent distribution it appears that such visits aregenerally of nonprepald visits by number of medications provided or preacrlbed: United States, 1991 similar to nonprepaid visits for patients under 65years ofage with respect to Prepaid plan visfls Nonprepa/d vkffs the principal reason for visitj physicians’ Number of diagnosis, medications prescrib@ and vk=lts In Percent Percent duration of visit. This report focused Medketlon therapy’ thousands dktrtbution dktrfbution only on visits made by patients under Allvldts...... 91,824 100.0 100.0 the age of 65 to reduce the confounding effects of age and health conditions on Type of visit the characteristics examined. Fkepaid Nondrug vleit(O medications) ...... 35,176 38,3 38.3 visits were found to differ from DmgvieiF ...... 56,648 61.7 61.7 nonprepaid visits as follows Nurnberof medications relative to nonprepaid visits, a higher 1 ...... 32,514 35.4 34.6 2 ...... 14,890 16.2 18.3 proportion of prepaid visits wete to 3ormore ...... 9,244 10.1 10.9 physicians in the primary care specialties llnclud- prescription drugs, omr-th*munter preparations, immunmng agents, anddesenstizinga gents, %sits at which one or more drugs were provided or prescribed by the physician. HMO/other prepaid plans tend to have a higher proportion of visits with diagnostic tests performed or Table 17. Number and percent distribution of prepaid plan visits and percent distribution ordered but especially for persons ofnonprepaid vlsikfor drug mentions bytherapwtic classification: Unitd Sh~, 1991 between the ages of 45 and 64 years a hQher proportion of prepaid plan PrspaldpLarr visits Noryxepald vklts visits to nonprimruy care specialties Number of were referrals dN&? MeIIt\OtE Percwrt Percent Theiapeutfc classlfkatloni brthorreands disttfbutlon dktribuflon a lower proportion of prepaid plan visits were for patients over 65 years Alldrugmentlons ...... 95,104 100.0 100.0 of age

Antlmlcroblal agents ...... 20,191 21.2 16.8 a higher proportion of prepaid plan Penicillins ...... 7,546 7.9 6.1 visits were in the West Cephatoeporlns ...... 3,645 3.8 3.8 Erythromydnsand linccsarnldes...... 3,126 3.3 3.2 The comparisons of visit and patient Cardlovaecutar-renatdmge...... 7,181 7.6 8.8 characteristics between prepaid plan and Psychopharmacotogicdruga ...... 4,242 4.5 7.0 nonprepaid visk based on the 1991 Radiopharmaceuticatskontraat media 2,371 2.5 1.4 Gaetrointesllnal agents...... 2,912 3.1 3.9 NAMCS must be interpreted “with Metebolicarrd nutrlantagents...... 3,796 4.0 4.3 caution. This report focused on Hormones and agents affecting describing characteristics of prepaid plan honnonetmechantsms ...... 7,942 6.4 9.5 Immunologlcagents ...... 5,390 5.7 4.5 visits. For comparison purposes, the Skin/mucousmembrane ...... 6,024 6.3 6.7 eorreqmnding statistics for visits from Neurologlcdrugs ...... 1,716 1.8 2.5 other expeeted sourcee of payment were Ophthalmlcs ...... 1,750 1.8 2.6 presented. However, nonprepaid visits Drugausedforrellefofpaln ...... 11,187 11.8 10.9 Genera!anafgeeics ...... 5,364 5.7 5.5 are for a very diverse set of people with Antiarthritica ...... 5,448 5.7 5.1 respect to expected sources of payment. Reeplraforytmtdrugs ...... 13,956 14.7 11.3 For example, 12 percent of the Naeatdecongeslants ...... 3,823 4.0 3.1 nonprepaid vkits had an expected Arrtihk?tamine s ...... 3,600 3.8 2.4 Unctaeaified andmiacellaneous...... 3,797 4.0 4.5 source of payment identified as Allothers2 ...... 2,479 2.6 2.7 “Mdlcaid.” Thirty-one percent were identified as “patient paid.” Only lBasedon thestsndard drug classification used in the National DrWC4DimctoV, 1985 edtion (16). %dudes anesthetic drugs, antidotes, hematolcgic agents, c.ncolytics, otologic dregs, and antiparadk agents. 47 percent were identified as “private/ commercial.” In comparing tie statistics presented in thii repo~ one must minutes. Visits with a durationof nonprepaid visits (16minutes vs. 17 consider how the dhrsity of coverage “zero” minutes are those in which there minutes, respectively). in the nonprepaid group may ifiuence wasnoface-to-face contact between the prepsid and nonprepaid visit patient andphysician. In1991, Discussion comparisons. The results should not be 1.7percent of the visits hadaduration interpreted as a straight comparison ofzerominutes. Nonsignificant Indeseribingthepatient andvisit between HMO/other prepaid plans and ditTerence was found between the characteristicsof HMO/otkrprepaid fee-for-service plans. The reader must average durations ofprepaidand plan visits foundin the1991NAMCS, also consider that this report focuses on Advance Data No. 269. November30, 1995 11

describing patient and visit Table 18. Number and percent of drug mentions for prepaid plan visits and percent of drug mentions for nonprepaid visits for the 20 moat frquentty used generic substance= characteristics of prepaid plan visits to United Statea, 1991 office-based physicians and does not represent characteristics of all visits by Prq)afd@sn Vbu.s NorPrtwsW VfSffS persons who are insured with a prepaid Wnber of Percenf of Peroenf of health plan. The variable that drug nrenf/ons # O?ug S/l drug Generic subs fsrsce h ftroussndsj rnenfions mersfions differentiates the two comparison groups in this report is an expected source of Alldmgrnantions ...... 95,104 ......

payment for the visit. Persons insured in AmoxidUl n ...... 7,085 7.4 5.4 an HMO may pay out-of-pocket Acatsmhmphen...... 4,099 4.3 4.2 expenses to seek health care from a Erythromydn ...... 2,566 2.7 2.7 provider other than the HMO to obtain Phenylaphrfne ...... 2,469 2.6 1.9 Ibuprofen ...... 2,325 2.4 1.9 either noncovered health care or care Pheny@ro@nofamIrse...... 2,110 2.2 1.9 horn a provider that is not associated Pseudoaphadrhse...... 2,056, 2.2 1.0 with the prepaid plan. Guaifenssin ...... 1,834 2.0 1.5 Afbufeml ...... 1,640 1.9 1.5 TMs report does not include all Akohol...... 1,827 1.9 1.2 possible providers of physician services. Codeine ...... 1,722 1.8 2.0 Physicians in hospital-based practices Diph pertussls tetanus vaooine ...... 1,716 1.8 1.2 are not in-scope for the NAMCS, Vitamin A...... 1,685 1.6 1.7 Trhnathoprim...... 1,666 1.8 1.4 therefore, hospital-based managed care Srslfamethoxszola ...... 1,885 1.7 1.4 offices may not be included if the Ergocsldferol ...... ’ 1,614 1.7 t .5 physician indicated that helshe was Naproxen ...... 1,597 1.7 1.5 employed by a hospital. Similarly, vW1ts Terfenadlne ...... 1,442 1.5 0.8 Rboffavin ...... 1,3s0 1.5 1.5 to hospital outpatient clinics are not Cofactor ...... 1,338 1.5 1.5 included in fhis repofi For example, women seeking mammograms may use 1Frequency or msntb oombines single-ingradieti a~nta wih msntkms of the agent as an ktgmdiint in a combination dreg. mobde unit3 associated with radiology clinics of hospitals. Such sources would Table 19. Number and persent of prepaid pfan viaite and percsmt of nonprepaid vislta by not be included in the NAMCS. Data disposition and duration: United States, 1991 from population-based surveys may Prty?afd@sn VkS& NorpqssW Vkl?S obtain cWferentestimates of health care resource use compared with event-based Nurriw of VISM h surveys. The reader is encouraged to Wsif chwacferktic ftrouSerx&s Perusnf p8tW??f examine data horn the National Health Interview Survey for population-based Atlvlsifs ...... 91,824 ...... estimates of use of cancer screening by Dtspoafllont

women insured by an HMO or other No followup piannad ...... 7,797 8.5 11.4 prepaid health insurance plans (18). Retumaf spedffctime ...... 53,001 57.7 53.5 Examining data from the 1992 Retumit neadad ...... 24,791 27.0 23.8 NAMCS for cross-validation purposes Tefaphona foliowup planned...... 3,S37 3.7 3.6 Referred toofherphyafdan ...... 4,208 4.7 2.6 we found that some dtierences between Referred to referring phyaidan ...... 633 0.8 0.7 the 1991 prepaid plan and nonpmpaid Admit tohospifaf ...... 835 0.7 0.8 plan visits were not significant. These Other ...... 306 1.0 1.2

differences were noted where applicable. Duration All of the findings presented in the Omfnufesz ...... 1,595 1.7 1.1 Highlights section were replicated using l-5mhwfes...... 8,943 9.7 9.4 results horn the 1992 NAMCS. 6-10mkudes ...... 27,766 30.3 27.4 Examining 1992 data also allows us 11-15 minutas ...... 28,815 3+.4 a.9 to look at visits to hospital outpatients 18-30 rninutas ...... 19,853 21.6 23.7 31-60 minufas ...... 4,865 5.1 7.0 and emergency departments, which 80minrrtes andover ...... “161 “0.2 0.5 make up approximately 17 percent of lNumbaremay notaddto totsk bacsussnwra thanone dispositkmmaybe Iupted par visit the ambulatory care visits for persons %sits in whichtharawss nofaoe-to-faoaOo+Maofbahvaanpstii and @yeic&m. un&r the age of 65. The National Hospital Ambulatory Medical Care Survey (NHAMCS) tit collected data types of ambulatory care providers of pqxiid and nonprepaid visits (11.6 in 1992 from hospital providers to help (physician offices, hospital outpatients, vs. 135 percents respectively) (20,21). round out the description of ambulatory and emergency departments), black Figure 3 shows the 1992 distributions of care visits (19). Considering all three persons comprisedthe same proportion both prepaid plan and nonpn@d visits 12 Advance Data No. 269. November 30, 1995

fee-for-service patients. Arch Intern ■ Med 149:1185-8.1989. Physicians ~ Ho.spitalo.tpatient ~ Ernergencydapmtrne.t 8. Young GJ, Cohen BB. Inequities in I White patients hospital care, the Massachusetts experience. Inquiry 28:255+2. 1991. Prepaid plan 9. Carlisle DM, Siu AL, Keeler EB, McGlynn EA, KahrI KL, Rubenstein Nonprepaid LV, Brook RH. HMO vs fe&fm- service care of older persons with Black patients acute myocardial infarction. Am J Public Health 82:1626-30.1992. Prepaid plan 10. Greenwald HP, Henke CJ. HMO membership, treatment and nnortalily Nonprepaid risk among prostatic cancer patients. Am J Public Health 82 1099–1 104. I I I i I I 1992. o 20 40 60 80 100 11. Szilagyi PG, Roghrrraan KJ, Foye Percent of visits HR, Parks C, et al. Increased NOTE Excludesvisitsfor patients 65 years of age and over. ambulatory utilization in IPA plans among children receiving Figure 3. Percent distribution of visits to various providers for prepaid plan and hyposensitization therapy. Inquiry nonprepald visits by patient’s racexUnited States, 1992 29:467-75.1992. 12. Gemson DH, Freudenheim E, Senie RT, Elinson J, Fink R. Health to various providers. More of the References: promotion and dkease prevention in prepaid plan visits were to office- HMOS: A survey of newly based physicians rather than hospital 1. Roghrnann KJ, Gavett JW, Sorensen established JPAs in New York City. settings. Approximately 9 out of 10 AA, Wells S, Wersinger R. Who Am J Prev Med 6333-8.1990. prepaid plan visits made by black chooses prepaid rnedcal care Survey 13. Schneider D, Appleton L, McLemore patients were to office-based results from two marketing of three T. A reason for visit classification for ambulatory care. National Center for physicians whereas the corresponding new prepayment plans. Public Health Rep 90:516-27.1975. Health Statistics. Vital and Health number for nonprepaid visits is 7 out 2. Nycz GR, Wenz.el FJ, Lohrenz FN, Stat 2(78). 1979. of 10. For both races, the proportion Mitchell JH. Composition of the 14. Public Health Service and Health of total prepaid plan visits to subscribers in a rural prepaid group Care Financing Administration. emergency departments are lower than practice plan. Public Health Rep International Classification of for nonprepaid visits. The proportion 91:50L7. 1976. Diseases, 9th Revision, clirical of visits to emergency departments are 3. Jackson-Beeck M, Kleinman JH. modification. Washington Public approximately three times higher for Evidence for self-selection among Health Service. 1980. nonprepaid visits compared with health maintenance organization 15. Scbappert SM. National Ambulatory prepaid plan visits. The reader should enrollees. J Am Med Assoc Medical Care Survey 1991 note that the nonprepaid visits include 250:282629.1983. Summary. Advance data from vital 4. Lairson DR, Herd JA. The role of and health statistics no 230. visits made by people who have no health practices, health status, and Hyattsville, Maryland: National health insurance and it has been prior health care claims in HMO Center for Health Statistics. 1993. shown that such populations receive seleztion bias. Inquiry 24:276-84. 16. Food aod Dmg Administration. more primary care from emergency 1987. National Drug Code Directory, 1985 settings (22–2.4. 5. Llchtenstein R, Thomas JW, Watkins Edition. Washington Public IHealth In summary, results from this study B, Puto C, Lepkowski J, fhiams- Service. 1985. indicate that after controlling for age Watson J, Simone B, Vest D. HMO 17. Koch H, Campbell W. The collection dtierences between prepaid plan and marketing and selection bias. Med and processing of drug information. nonprepaid visits, prepaid plan visits Care 30:32945.1992. National Ambulatory Medkal Care dtier horn nonprepaid visits on referral 6. Ware Jr, JE, Rogers WH, Davies AR, Survey, 1980. National Center for Health Statistics. Vital Health Stat status, physicirm specialty, and regional Goldberg GA, et al. Comparison of health outcomes at a health 2(90). 1982. distribution. The visits are similar with maintenance organization with those 18. Makuc D, Freid VIM, Parsons PE. respect tQreason for visit+diagnosis, of fe~for-service care. Lancet Health insurance and cancer treatments ordered or provided, and 1017–22. 1986. screening among women. Advance duration. The proportion of office-based 7. Stern RS, Juhn PI, Gertler PJ, data from vital and health statistic physicians’ visits that has an expected Epstein AMA comparison of length no 254. Hyattsville, Maryland source of payment as “prepaid plan” of stay and costs for health National Center for Health Statistics. has increased since 1985. maintenance organization and 1994. Advance Data No. 269. November30,1995 13

19. McCaig LF, McLemoxe T. Plan and 22 Grumbach K, Keane D, Bindman A. 24. Schappert S. Race differences in operation of the National Hospital Primary care and public emergency hospital emergency department use. Ambulatory Medical Care Survey. overcrowding. Am J Public Health Stat Bull VO176 No 3.1995. National Center for Health Statistics. 83(3):3724. 1993. 25. Shah BV, Barnwell BG, Hunt PN, Vital Health Stat 1(34). 1994. 23. Kellerman AL. Nonurgent emergency LaVknge LM. SUDAAN user’s 20. Unpublished data horn the National department visits: Meeting an unmet manual, release 5.50. Research Ambulatory Me@cal C= Survey, need. J Am Med Assoc Triangle Park, North Carolina 1992. 271(M): 19534.1994. Research Triangle Institute. 1991. 21. Unpublished data from the National Hospital Ambulatory Medical Care Survey, 1992. 14 Advance Data No. 269. November 30, 1995

Technical notes National Center for Health Statistics, Table 1.Approximate relative standard Herdth Care Survey Section, Research errors for estimated numbers of ofttce visit= National Ambulatory Medical Care Source of data and Triangle ParlG North Carolina. Suwey, 1991 sample design Estimated number of Relative standard Sampling errors office vla/ts in thousands error In percent The information presented in this report is based on data collected by The standard error is primarily a 100 ...... 72.1 means of the National Ambulatory measure of the sampling variability that 200 ...... 51.1 occurs by chance when only a sample, 500 ...... 32.5 Medkal Care Survey (NAMCS) from 588 ...... 30.0 January 1991 through December 1991. rather than an entire universe, is 1,000 ...... 23.1 The target universe of NAMCS includes surveyed. The standard error also 2,000 ...... 16.6 office visits made in the United States reflects part of the measurement error 5,000 ...... 11.0 10,000 ...... 8.3 by ambulatory patienta to nonfederally but does not measure any systematic 20,000 ...... 6.6 employed physicians who are principally biases in the data. The chances are 95 50,000 ...... 5.3 engaged in office practice, but not in the out of 100 that an estimate from the 100,000 ...... ! 4.8 specialties of anesthesiology, pathology, sample differs from the value that would 200,000 ...... 4.5 500,000...... 4.3 or radiology. Telephone contacts and be obtained from a complete census by 700,000 ...... 4.3 nonoffice visits are excluded. less than twice the standard error. The standard errors that were used NOTES The smallest refiable estimate for visits to A multistage probability sample aggregated speclattias is 568,000 visits. Estimates bslow this design is used in NAMCS, involving in tests of significance for this report figure have a relatiie standard error greater than 30 parcant and are deemsd unrehable by NCHS standards. samples of primary sampling units were calculated using generalized linear Exampb of use of table: An aggregate estimate of 50 million visits has a refstiwe standard error of 5.3 parcant or a (PSU’S), physician practices within models for predicting the relative etamdard error of 2,653,000 visits (5.3 perormt of 50 million). PSU’S, and patient visits within standard error for estimates based on the physician practices. The PST-J’Sare linear relationship between the actual counties, groups of counties, county standard error, as approximated using Table Il. Approximate relative standard equivalents (such as parishes or SUDAAN software, and the size of the errors for aatlmated numbers of drug independent cities), or towns and estimate. SUDAAN computes standard mentfone: National Ambulatory Medical Care Survey, 1991 townships (for PSU’S in New England). errors by using a ficst-orkr Taylor For 1991, a sample of 2,540 nonfederal, approximation of the deviation of .Est/mated nurnbar of Relative skmdard office-based physicians was selected estimates from their expected values. A dmg M8nt10nS in thOUSSndS error /n percent from the master files maintained by the description of the software and the 100 ...... 78.1 American Medical Association and approach it uses has been published 200 ...... 66.8 American Osteopathic Association. (25). The relative standard error (RSE) 500 ...... 43.7 1,000 ...... 31.2 Physicians were screened at the time of of an estimate is obtained by dividing 1,063 ...... 30.0 the survey to ensure that they were the standard error by the estimate itself. 2,000 ...... 22.4 eligible for survey participation. Of The result is then expressed as a percent 5,000 ...... 14.8 those screened, 653 physicians were of the estimate. 10,000 ...... 11.2 20,000 ...... 8.9 ruled ineligible (out-of-scope). The Relative standard errors for 50,000 ...... 7.f remaining 1,887 physicians were emergency department estimates are 100,000...... 6.5 in-scope or eligible to participate in the shown in tables I and II. Standard errors 200,000 ...... 6.1 survey. The physician response rate for for estimates in percents of visits and 600,000 ...... 5.8 800,000 ...... 5.8 the 1991 NAMCS was 72 percent. drug mentions are shown in tables III Sample physicians were asked to and IV. MuMplying the estimate by the NOTES The smalleat refiable estimate for drug mantions is 1,0S3,000 mentions. Estimates balow this figure have a complete Patient Records (see figure 1) RSE will provide an estimate of the relatiie etandard error greater than 30 percent and are deenwd unreliable by NCHS standards. for a systematic random sample of office standard error for the estimate. Exampla of use of tsb!ei An aggregete aafimate of 50 milfkkn visits occurring during a randomly Alternatively, relative standard drug rrw.ntiins has a refafiie standard error of 7.1 percent or a standard error of 3,550,000 mantions (7.1 peroant of 50 assigned l-week reporting period. errors for aggregate estimates may be milhon). Responding physicians completed calculated using the following general 33,795 patient records. formulaj where x is the aggregate of Characteristics of the physician’s interest in thousands, and A and B are practice, such as primary specialty and the appropriate coefficients from table V. interest expressed as a proportion, and x type of practice, were obtained from the is the denominator of the percent in physicians during an induction RSE (X) = A+:*IOO thousands, using the appropriate interview. The U.S. Bureau of the T coefficients from table V. Census, Housing Surveys Branch, was Similarly, relative standard errors responsible for the survey’s data for an estimate of a percent maybe ~.(l-pjolm RSE (X) = collection. Processing operations and calculated using the following general p*x medicrd coding were performed by the formub where p is the percent of r Advance Data No. 269. November 30, 1995 15

Table Ill.Approximate standard errors for percents of estimated number of offloe visits: National Ambulatory Medical Csre Survey United States, 1991

Etiirrratedperoant Base of peroent (vkfk In thousands) 1 or 99 5 or 95 10 or 90 20 or 80 30 or 70 40 or 60 50

Standard errorhrpercentaga points

100 ...... 7.2 15.7 21.6 28.8 23.0 35.3 36.0 200 ...... ! ...... 5.1 11.1 15.3 20.4 23.3 24.9 25.5 500 ...... 3.2 7.0 9.7 12.9 14.8 ‘15.8 16.1 1,000 ...... 2.3 5.0 6.6 9.1 10.4 11.2 11.4 2,000 ...... 1.6 3.5 4.8 6.4 7.4 7.9 6.1 5,000 ...... 1.0 2.2 3.1 4.1 4.7 5.0 5.1 10,000 ...... 0.7 1.6 2.2 2.9 3.3 3.5 3.6 20,000 ...... 0.5 1.1 1.5 2.0 2.3 2.5 2.6 50,000 ...... 0.3 0.7 1.0 1.3 1.5 1.6 1.6 Ioo,ooo ...... 0.2 0.5 0.7 0.9 1.0 1.1 1.1 200,000 ...... 0.2 0.4 0.5 0.6 0.7 0.8 0.8 Soo,ooo ...... << ...... 0.1 0.2 0.3 0.4 0.5 0.5 0.6 1,060,000 ...... 0.1 0.2 0.2 0.3 0.3 0.4 0.4

Exampkrotuseot table:Anestimate of20perce.ntbassd onanaggragateestirrwe oflOmillionvisits hasastarrdard.wror d3.3parcentora relafiistandardermr ofll.Opercent(S.3 percant dwklad by 30).

Table IV.Approximate standard errors of percents of estimated numbers of drug mentions: National Ambulatory Medical Care Survey United States, 1991

Estirnatedpercent Base of percent (drugnrentlons In thousands) i or 99 5 or 95 10 or 90 20 or 80 30 or 70 40 or 80 50

Standard error In percentage points

100 ...... 9.6 21.1 29.1 38.8 44.4 47.5 48.5 200 ...... 6.8 14.9 20.6 27.4 31.4 33.6 3.3 500 ...... 4.3 9.5 13.0 17.3 19.9 21.2 21.7 1,000 ...... 3.1 6.7 9.2 12.3 14.0 15.0 15.3 2,000 ...... 2.1 4.7 6.5 8.7 9.9 10.6 10.8 5,000 ...... 1.4 3.0 4.1 5.5 6.3 6.7 6.9 10,000 ...... 1.0 2.1 2.9 3.9 4.4 4.8 4.9 20,000 ...... 0.7 1.5 2.1 2.7 3.1 3.4 3.4 50,0CS3 ...... 0.4 0.9 1.3 1.7 2.0 2.1 2.2 Ioo,ooo ...... 0.3 0.7 0.9 1.2 1.4 1.5 1.5 200,000 ...... 0.2 0.5 0.7 0.9 1.0 1.1 1.1 500,000 ...... 0.1 0.3 0.4 0.6 0.6 0.7 0.7 1,000,000 ...... 0.1 0.2 0.3 0.4 0.4 0.5 0.5

Exsmpb of usa of tabb An estimate of 20 parcant basad on an aggragata eafimate of 10 million Waii has a sfandani error d 3,9 pwcamt or a relative standard arror of 19.5 parcant (3,9 psrcant dhiiad by 20 parcant).

Adjustments for nonresponse t-test.TheBonferroni inequality was Definition of terms used to establish the critical value for lMimatesfromNAMCS datawere Ambulatory patient-An ambuMory adjustedtoaecount forsample statistical significantdflerences (0.05 level of confidence).Termsrelating to patient is an individual seekingpersonal physicianswho were in-scopebut did health services who is not currently not participatein the study.This d~erences such as “greaterthan”or adjustmentwas c.alculatedtominimize “less than” indicate that the diEerence admitted to any health care institution theimpactofresponse onfinalestimatm is statisticallysignificant on the premises. by imputing to nonresponding In the tables, estimatesof office Physician-A physician is a duly physiciansdatafrom visits to similar visits have been rounded to the nearest licensed doctor of medkine (MD) or physicians.Forthis purpose, physicians thousand.Consequently,estimateswilI doctor of osteopathy(DO) who is werejudgcdsimiiar iftheyhadthe not always add to totals.A lack of currentlyin office-basedpractice and samespecialty designationandpraeticed commentregardingany two estimates who spends some time earing for inthesatnePSU. does not mean that the diffemce was ambulatorypatients. Excluded from the NAMCS are physicians who me hospital Test ofsignificance and tested and found not to be significant. Rates and percents were calculatedfrom based; who specializein anesthesiology, rounding originrdunroundedfiguresand do not pathology,or radiology; who are Inthisrepofi the determinationof necessarilyagree with percents federallyemploye@who treat only statisticalinferenceisbasedonthe calculatedfrom rounded data. institutionalizedpatien@ or who are 16 Advance Data No. 269 ● November 30, 1995

Table V. Coefflclsnts appropriate for dotarmining relative standard errors by type of (HMO’s), independent practice sstfmate and physloian spsoialty National Ambulatory Msdlcal Cars Survey, 1991 organizations (IPA’s), and all other Coeffldent for use tn?heatlmataa In thowamk prepaid health care plans.

7Jpe of estimate andphyalclan epeclat/y A B Nonprepaid visit—A nonprepaid visit is a visit for wlich any expected VMS: source ofpayment with theexception of Overall total ...... 0.001744264 51.82697927 “HMO/otherprepaid” waschwlcedon item 60fthe Patient Record Mm. General mdfamiIypracfioe ...... 0.006617364 33.29640705 Osteopathy ...... 0.0163602 10.90230266 Internal medicine ...... 0.01573396 45.10067385 Pediatrtca ...... 0.0163602 10.90230286 Generafsurgary ...... 0.0163602 10.90230266 Obstettfcaandgynecotogy ...... 0.0163602 10.90230266 Orthopedicsurgery ...... 0.0163602 10S0230266 Cardlovaeoulardisaaees ...... 0.0163602 10.90230286 Dermatology...... 0.0163602 10.60230286 Urotogtcatsurgery ...... 0.0163602 10,60230286 Psychlatty ...... 0.0163602 10.90230266 Neurology ...... 0.0163602 10.90230266 Ophthalmology ...... 0.0163602 10.90230266 Otofsryngology ...... 0.0163602 10.90230286 Allotherepectaltles ...... 0.03340709 29.631108

Drug mentions Overatltotal ...... 0.003224617 93.92631667

Generetandfamilypracfice ...... 0.0122564 57.64543271 Osteopathy ...... 0.02764109 11.55212504 Intemalmedidne ...... 0.0122564 57.64543271 Pediatrics ...... 0.0122564 57.64543271 Generatsurgary ...... 0.0122W4 57.64543271 Obetetkssndgynecology ...... 0.0122584 57.64543271 Orthopedicsurgery ...... 0.0122664 57.64543271 Cardlovaaculardlaeases ...... 0.0122564 57.64543271 Dermatology...... 0.0122564 57.64643271 Urofogicalsurgety ...... 0.0122564 57.64543271 Psychiatry ...... 0.01225s4 57.64543271 Neurology ...... 0.0122564 57.64543271 Ophthalmology ...... 0.0122564 57.64543271 Otolaryngology ...... 0.0122564 57.64543271 Allotherspecialtie s...... 0.0463562 46.53697479

employedfr. dltimeby an institution and diagnosis, or treatment. Genericas well spend no time seeing ambulatory asbrand-name drugsareincluda as are patients. nonprescription and prescription drugs. Ojlce-Offices are the premises Along with all new drugs, thephysician physicians identi@ as locations fortheir alsorecordscondnued medieationsif ambulatory practicq these customarily the patient was specifically instructed include consultation, examination, or during the visit to continue the treatmentspaees thatpatients associate medication. with thepartictdar physician. Drug visit—A drug visit is a visit in Wsit—A visit is a direct personrd which medication wasprestibedor exchange between an ambtdatory patient provided by the physician. andaphysician (orastaffmember Prepaid plan visit—A prepaid plan working under thephysician’s visit is one for which “HMO/other supervision), for the purpose ofstx%ng prepaid plan” was checked as an care and rendering personal health expected source of payment in item6 of serviees. the Patient Record form. Instructions for Drug mention—A drug mentionis completing this item on the 1991 Patient the physician’s entry ofa Rex.mrdfonndefines “HMO/other pharmaceutical agent-by any routeof prepaid” as including visits covered administration-for prevention, under heath maintenance associations Advance Data No. 269 ● November 30, 1995 17

Symbols . . . Data not available . . . Categoty not applicable Quantity zero 0.0 Quantity more than zero but less than 0.05 z Quant”~ more than zero but less than 500 where numbers are rounded to thousands * Figure does not meet standard of reliabilityor preoision 20 Advance Data No. 269 ● November 30.1995

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Suggested cltatfon Copyright information National Center for Health Statistics

WoodWell DA. Characteristics of prepaid plan All material appearing in this report is in the Acting Director visita to office-baaed physicians Unitad public domain and may be reproduced or Jack R. Anderson States, 1991. Advance data from vital and copied without permission; citation as to health statisti~ no. 269. Hyattaville, Acting Deputy Director source, however, is appreciated. Maryland: National Center for Health Jennifer H. Madans, Ph.D. statistics. 1995.

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DHHS Publication No. (PHS) 96-1250 5-1604 (11/95) Number 270 . December 7, 1995 Advance Data m From Vital and Health Statistics of the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

National Ambulatory Medical Care Survey: 1993 Summary by David A. Woodwell and Susan M. Schappert, M.A., Division of Health Care Statistics

Introduction contacts and vish.s made outside the groups did not dtier significantly fkom physician’s office were also excluded. 1992 visit rates with the exception of During the 12-month period from Because the estimates presented in otolafyngologists. The rate of visits to January 1993 through December 1993, this report am based on a sample rather this specialty deereased fkom 9.1 visits an estimated 717.2 million visits were than on the entire universe of office per 100 persons in 1992 to 6.0 visits per made to nonfederally employ@ visits, they are subject to sampling 100 persons in 1993. However, the 1993 offiebased physicians in the United variability. The Technical notes at the figure is not significantly dfienmt from States, or 2.8 visits per person. This mte end of this report include an overview the corresponding rate of 7.7 visits per is not signilieantly dtierent from office of the sample design used in the 1993 100 in 1991. In fac~ the visit rate to visit rates observed since 1975 (l–5). NAMCS, an explanation of sampling otohuyngologists has ranged between ‘Ilk report presents data highlights errors, and guidelines for judging the 6.5 and 7.0 visits per 100 persons from the 1993 National Ambulatory precision of the estimates. between 1975 and 1990, so the 1992 Medical Care Survey (NAMCS), a The Patient Record form is used by figure appears to be an anomaly. national probability sample survey physicians partieipating in the NAMCS Doctors of osteopathy received 44.9 conducted by the Division of Health to record information about their million visits during 1993, or Care Statistics of the National Center patients’ office visits. This form is 6.3 pereent of all office visits. Visits to for Health Statistics, Centers for Disease reproduced in figure 1 and is intended to this specialty occurred at a rate of 17.7 Control and Prevention. Statistics are serve as a reference for readers as they per 100 persons, which was not presented on physician, patien~ and visit review the survey Iindmgs presented in significantly dtierent from the 1992 characteristics. this document. visit rate. Only visits to the offices of The physician sample for the Visits according to geograpldc NAMCS was selected with the chsxaeteristics of the physieiau’s nonfederally employed physicians cooperation of the Ameriean Medical practice are also displayed in table 1. (excluding those in the specialties of Association and the Ameriean Visit rates by region-NortheasL anesthesiology, rdlology, and Osteopathic Association. Their hfidwes~ South, and West

Smvlw, $N % U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service [ Centers for Disease Control and Prevention < National Center for Health Statistics %% CENTERSCKFOR DIsEAsE CONTROL 4ma AND PREVE~N 2 Advance Data No. 270. December 7, 1995

. . . 1 I 1. DAYS OF VISIT NATIONAL AMBULATORY MEDICAL CARE SURVEY OMB NO. 092302S4 +-#+ Ewkg4sf~: 1993-94 PATlENT RECORD --- . . ..

2. DA7E OF SIRTN 4. COLOR OR RACE S. ETHNICITY 0. Expuxm SOUROE(S) OF 7. WAS PATIEN7 8. Is THls VISIT PAYMENT lad dI AM w/y) RIWERRED FOR INJURY RSLATED? ~. , Dvlmt. THls VISIT BY 1❑ Privm / ccmmdr * a Yes MonU’I Doy Yew , •~l$ ~ so~y- ANOTHER ZONO 2rJekk PHYSICIAN? 2 a M8dkam *lg Palimtpaid 3. Ssx 9. I-S:AINWN=, ~❑g#k- *nYfm a.t& anlhdkaid ? ❑ No C3W@ IuFmele tahUb Anwicm In&n/ tnNo ?IJ **8 4 •EA~I~ 4(3cu12fwdnmwn2 Snomu a ❑ Unknonr 20 No

10. PATIENTW COMPLAINT 1i. PHYSICIAN% DIAGNOSES f..t $JUC@C~ PLUSibkJ 12. HAVE YOU OR 1% DOES PAmNY HAVE OR OTHER REASON(S) t%t%t%i’$fs)’ ANYONE IN YOUR [addntha6#yny@dkId /r* ptidnt’s owl Wwds] PRAOTICE SEEN qlq.tiry inUrn 11] PATIENT ❑EFORE? 3. Fll~ 1a Abihm2J a.um ❑ hloe+lut . * Inm 104. I Yes 2DN0 2 ❑ ciatuc2

1 sDHIV b. h b. Ohm If ye30for*O eancWOn 4 ❑ Obe* milwllIla? s•1 cMaq20fc4i3 e.02w com2r ,DY” ,Otdo I – ! I smNonsdlho@lwv8 14. TSSVS, SURGICAL AND NONSURGICAL PROCEDURES, AND THERAPISS Nomn

3. SELEOTEDSERVICES b. AU. OTHER SERWE3 ● SmJJtrfts●d @k??proc?dnru iitdda ● S2n@$ i~ itdm I& tc32tkd101dcmf 0rfimiridl Iir2wd. emmchhdc+tck -:: %LL%%%Lk aaiuaa hm k. ● GTw3uii~ / &adOn #2m w WdedJor 2’UA.J 14wfuydLukwy, w phphh2n@j) . k2k&mi0a3 !aelood Fm2aJm PweImad DIdwed Pwkmmdordered 2n Wind* to *!-J to an 3❑ .qxrolmby —— ——

an ID to 16. MEDICATIONS / INJECTIONS 17. apsFJitiiTloNJJs VISIT 18. :IRATN)N NOM ❑ THIS VISIT m*: amhleio!b?+tianmd i7iie ObYUdly ●xx MdOm , ● rmwamkdiau 2a Rdum3t2wdliedb3e $f%%; ● .ui## M*S J ~ Mum II needed, P.RN. ● Alld23iu 2 ● MdJ odcrd, ❑ S@34 or 4 Toio@molokww Pkmed odlhim?d ~ .Nmmd J I-J Fldlbrr4d20Ollw physicial ● cilnl!/ll@ d$ a ❑ Rdurmd b rzkring phyxick (wiho?wilhow , mu O?dem)] 713 Admi1201wpi291

—~ 5 a ❑ OGwr frprcrJ)y

Figure 1. Patient Record form during 1993 and accounted for a higher analyzed, at 6.1 visits per person. The the rate was higher for females 25-44 percent of visits than males in atl age pattern, however, was found to be years than for those 15–24, and categories except the youngest (under 15 slightly different for males and females. increased again for those 45-64 years years). Females also had significantly Among males, the visit rate for the age and 65–74 years of age. There was no higher visit rates than males in each age group 15–24 years was significantly significant dtierenee in visit rates category with the exception of the lower than for those under 15 years. But between females in the two oldest age youngest group (under 15 years) and the males in the age group 25-44 years had groups, 65–74 years and 75 years and two oldest groups (65–74 years and 75 a higher rate than those 15–24 years. over. years and over). These patterns were The rate increased with each successive The visit rate for the white also observed in the 1990-92 National age group, with males aged 75 years population was sigdkantly higher (3.0 Ambulatory Medical Care Surveys. and over having the highest rate of 6.2 visits per person) than the rate for the Visit rates were found to increase visits per person. black population (1.8 visits per person) with age after the age of 24. Persons There was no significant dtierence in 1993. Wit rates were higher for aged 75 years and over had the highest in the visit rates for females under 15 white persons in each age group visit rate of the six age categories years and those 15–24 years. However, compared with black persons, with the Advance Data No. 270 ● December 7, 1995 3

exception of those 75 years and over. Table 1. Annual number, parcant dlstrlbutlon, and rate of office vlalts by salaotad White persons made 88.2 percent of all physlclsn practice characterlstks: Unltad States, 1993 office visits, with black persons and Nwn!rer of Asians/Pachic Islan&rs accounting for Number of vMs per vfdtsin Perc8nt 100parwma 8.1 percent and 3.3 percent respectively. Phyalolanpracticecharacteriatk thousands distribution per yeari The visit rate for the black Allvlslfs ...... 717,191 100.0 282.0 population in 1993 was significantly lower than the 1992 rate (2.6 visits per Phyddan SpSCkffY person), but was not si@cantly General and famllypraotioe ...... 197,605 27.6 77.7 different from the 1991 mte (L9 visits Irrtemafmadidne...... 102,436 14.3 40.3 per person). The higher rates in 1992 Pediatrics ...... 76,982 10.7 30.3 Obstetricsarrdgynecology...... 64,030 6.9 ?27.2 may be the result of sampling variability Ophthalmology...... 38,373 5.5 15.5 rather than a true increase, as discussed Orthopedicsurgery...... 33,636 4.7 13.2 in a previous report (5). Dermatology...... 31,469 4.4 12.4 General surgery ...... 21,703 3.0 8.5 Psychiatry...... 20,469 2.9 8.0 Visit characteristics Urology...... 15,690 2.2 6.2 Otolaryngology...... 15,380 2.1 6.0 Cardlovaa@ardleeaces...... 12,178 1.7 4.8 Referral status and prior-visit Allergyandimmunolo~...... 10,605 1.5 4.2 status Neurology ...... 8,S93 1.2 3.3 Pulmonarydlseases3 ...... 4,251 0.8 1.7 Table 3 shows data on office visits Allotherspec!altles ...... 82,991 8.8 24.8 categorized by patient’s referral status Profesdonalidentity and prior-visit status. The distribution of visits by referral status and Dootorof medklne...... 672,306 83.7 264.4 Doctorof osteopathy ...... 44,865 8.3 17.7 prior-visit status according to physician specialty is shown in Geographicregion table 4. It is important to note tha~ in Northeast ...... 168,436 23.5 336.6 previous years, several data items Midwest...... 169,035 23.6 272.5 South...... 213,356 2S.7 250.0 were used to determine referral status. West ...... 1s6,363 23.2 292.7 Return visits made for treatment of an 1B3sed on U.S. Bureau of the Census estimates of the civikan noninsfikrtiinalized pepulafion of the United Stetes as or “old” problem were not considered July i, lS$@. referral visits even if the referral item 2The Vtit rate i3 4S.5 per 100 ferreks. on the Patient Record form had been 3These 3peciatties were sampled separately in 1993 onfy as part of a suppbnerrta[ date cdectiin project checked “yes” by the physician. This edit procedure was instituted on the assumption that if the physician had item on the Patient Record form will Also shown in table 3 are office seen the patient previously for be used to determine referral status. visits by prior-v~lt status. Eight out of treatment of the same problem The definition of a referred visit ten office visits (84.4 percent) were (defined as the current episode of consistent with past usage can be made by patients who had seen the care), that patient could not have been recreated using information available physician on a previous occasion, and referred for the current visit. on the public use data file. Recent more than half of all visits However, in recent years, increasing changes in the health care system may (63.1 percent) wem made by persons numbers of physicians in the NAMCS have altered the way referral status is returning to the physician for care of a sample have characterized visits as conceptualized and interpreted. previously treated problem. referrals an~ at the same time, as being Research is under way to improve the As e= the percent of referred made by “old” patients for “old” collection of this information in the visits reported by primary care problems. This apparent inconsistency NAMCS. specialties wa3 relatively low, 10 percent may have a number of possible When refened visits are restricted or less of the total visits to general and expkmationx some physicians may be to those made by new patients and those family practitioners, internists, reporting refereed patients as referred made by old patients for new problems, pe&atricians, and obsteticians- visi~ changes in referral patterns may their share of total visits is 6.6 percen~ gynec010gist8. In contras6 about half of have occurred dated to changes in not signidcantly difFerent than the 1992 all visits to neurologists (50.7 percent) insurance coveragq or physicians may NAMCS figure of 6.2 percent. Using the were reported to be referrals (table 4). be including patients seen before for number of referred visits reported by past episodes of care, rather than current physicians (which includes visits made Expected sources of payment episodes of care. by old patients for old problems), the Beginning with the 1993 survey percent of referred visits is 13.7 Data on expected sources of year, only data from the referral status (table 3). payment are shown in table 5. 4 Advance Data No. 270 ● December 7, 1995

Table 2. Annual number, percent distribution, and rate of office visits by patient’s age, million injury-related office visits in sex, and race United States, 1993 1993, representing 11.7 percent of all Number of offic.evisits. Corresponding figures for Number of vlslts per visits in Percent pereons 1992 were 65.6million and8.6percent Patient’s age, sex, and rsce thousands d/atfibut/on per yeeri of visits, nxpectively. About half of the injury visits (51.0 percent) were made Allvisb ...... 717,191 100.0 2.8 by males, and38.8percent weremade Age by persons 2544 years old. Under 15yeare ...... 129,279 18.0 2.3 The injury visit rate for males was 15-24 years ...... 62,346 8.7 1.8 not significantly higher than the rate for 25-44 years ...... 193,914 27.0 2.4 females in 1993 (34.6 visits per 100 45-84 years ...... 160,146 22.3 3.2 65-74 yaais ...... 93,673 13.1 5.0 males compared with 31.5 visits per 100 75yeera andover ...... 77,633 10.8 6.1 females), nor were there any diierences noted between males and females by Sex and age age. Female ...... 430,170 60.0 3.3 Among females, injury visit rates Under15yeers ...... 60,664 8.5 2.2 15-24yeara ...... 41,406 5.8 2.4 were not significantly different for 25-44years ...... 128,654 16.0 3.1 women in the age groups 2544, 45-64years ...... 96,011 13.4 3.7 45–64, 65–74, and75 years andover. 65-74yeafs ...... 55,215 7.7 5.4 However, the rates for these groups 75yesrsandover ...... 46,017 6.7 6.1 were significantly higher than for Male ...... 287,021 40.0 2.3 Undar15yesrs ...... 66,615 9.6 2.3 females under 15 years and 15–24 15-24years ...... 20,936 2.9 1.2 years of age. Males inthe age group 25-44yeats ...... 65,060 9.1 1.6 25-44 years had an injury visit rate 45-E4years ...... 84,135 8.9 2.7 higher than those aged under 15 years 65-74yeara ...... 36,656 5.4 4.6 75yearsandover ...... 29,616 4.1 6.2 and 15-24 years. However, the rate was not statistically difTerent for males Race and age in the 25-44, 45–64, 65–74, and 75 White ...... 632,500 88.2 3.0 years and over groups. Under15years ...... 113,506 15.8 2.5 The injury visit rate for black 15-24years ...... 53,650 7.5 2.0 25-44yeafa ...... 167,026 23.3 2.5 persons was 19.1 VMS per 100 persons 45-84years ...... 140,231 19.6 3,3 in 1993, significantly lower than the rate 65-74yeats ...... 86,204 12.0 5.2 of 35.6 injury visits per 100 white 75yaaraandover ...... 71,884 10.0 6.3 persons. Rates were not significantly Black ...... 58,154 8.1 1.6 dtierent between white males (36.8 per Under15yeers ...... 10,328 1.4 1.1 15-24years ...... 6,308 0.9 1.2 100) and white females (34.3 per 100), 25-44yeat3 ...... 16,946 2.4 1.7 or between black males (20.9 per 100) 45-64yeara ...... 14,399 2.0 2.8 and black femates (17.5 per 100) (data 65-74yaars ...... 5,381 0.8 3.2 not shown). 75yearsandovar ...... 4,793 0.7 4.8

All other races Patient’s cigarette-smoking

AslanPaclficlslander ...... 23,377 3,3 . . . status AmerbnlndlanrEsldmo/Alaut. . . . . 3,160 0.4 . . . Results from the 1993 survey ‘BasedonU.S. BureauoftheCensusestimatesoftheciviliannoninstrtulionalkedpopulationofthe UnhedSfeteaas ofJuiy1, 1963. showed that 67.7 million office visits, or 9.4 percent of he total, were made by patients who smoke cigarettes. However, Physicians were asked tocheck allof prepaid (19.3 percent), and patient-paid patient’s smoking status wa8 not the applicable payment categories for (15.0 percent). Medicaid was listed aa au reported for 27.0 percent of office visits. this survey item, with theresultthat expected source ofpaymentat Data on visits according to patient’s multiple payment sources could be 10.4percent ofvisits. cigarett&smoking status are presented in coded for each visit. The patient-paid tables 7 and 8. category includes thepatient’s Injury-related visits contribution toward “co-payments’’and Patient’s principal reason “deductibles.” Injury-relatedoffice visits are for visit Expected sourcesof payment were presented in terms of patient’s age, sex, most often private/commercial insurance andraceintable 6.Basedondata Item 10 of the Patient Record form (38.7 percent of visits), Medicare collectedinitem 8ofthePatient Record asks the physician to reccrrd the patient’s (22.1 percent of visits), HMO/other form, there were an estimated 84.0 (or patient surrogate’s) “complaint(s), Advance Data No. 270 ● December7, 1995 5

Table 3. Number and percent distribution of office visits by patient’s referral status, according to prior-visit status: United Statss, 1993

Prtor-vtsifstatus

New tlrdpatfent, Oldpetlenf, Refenal status All visits pstk?nt new pmbiem oldproblem

Number of vlsite in thousands

Allvielfs ...... 717,191 111,922 152,698 452,372

ReferradforthisvlQt ...... 98,159 37,066 10,063 51,028 Notrefemdforthlsvislt...... 619,022 74,854 142,635 401,344

Percantdfsfrbufion

Allvtsits ...... 100.0 100.0 100.0 100.0

Referradforthisvblt ...... 13.7 33.1 6.6 11.3 Notrefenedforthlsvtsit ...... 66.3 66.9 83.4 88.7

NOTE Numbers may not add to totals bwause ot rounding.

Table 4. Number and percent distribution of oMce visits by physician spaciaity, according to referral status imd prior-visit status: United states,1993

Referred for thisV/Sk Not rafarmdfor this vistt Nurr&r of Vidfain New OIdpat&rrt, Oldpatkti Naw Oidpatisrrt, Oldpaflanf, Physlciarrq)edaffy fhouaand$ Tofaf patlant nawpmblsm okfptilem pafkmf new pmbbm oidpr@Iam

Pamentdistrbutbn

Allvisit s ...... 717,191 100.0 5.2 1.4 7.1 10.4 19.9 56.0

General and famllypractloe ...... 197,605 100.0 0.9 1.1 1.9 11.3 30.3 54.6 Intemai medldne ...... 102,436 100.0 2.2 2.0 3.4 7.1 24.9 60.4 Pediatttce ...... 76,962 100.0 0.9 1.0 1.5 5.1 55.8 55.7 Obsfehfcs andgynecobgy ...... 64,030 100.0 3.0 1.5 5.9 13.1 15.0 81.5 Ophthslmol~ ...... 38,373 100.0 5.3 1.5 5.7 12.1 7.6 67.8 Orthopadlc surgery ...... 33,636 100.0 15.3 2.6 16,6 12.1 7.3 46.2 osrmatololJj ...... 31,463 100.0 6.1 1.4 8.5 17.3 12.1 54.5 General surgery ...... 21,703 100.0 16.3 3.0 18.7 9.9 9.1 42.9 Psychlatty ...... 20,463 100.0 5.0 “0.2 15.4 10.7 ●0.2 66.6 Urology ...... 15,880 100.0 14.6 1.8 17.4 6.5 3.4 58.2 Otokynfplogy...... i5,3eo 100.0 16.0 2.1 14.2 17.6 5.3 44.7 Cardlovaeculardlsaases ...... 12,17e 100.0 10.2 -1.4 16.8 6.4 4.7 60.4 Alfargyandimmunologyi ...... 10,605 100.0 6.7 “0.3 13.6 8.3 2.8 6s.3 Neurology ...... 8,393 100.0 28.3 2.1 19.7 7.6 3.5 36.2 Putmonarydbeaeaet ...... 4,251 100.0 9.e 1.1 9.1 11.2 6.3 62.4 Allotherapacbitias ...... 62,991 100.0 11.5 “0.8 16.8 12.6 9.7 46.4

lThaaespacMies waremmpkiseptwataly in19330ntyaspart cfasuppbmardsl datacolbctiinprojad.

symptom(s),or other mason(s) for thi8 The 20 most frequentlymentioned T-ts, procedures, and therapies vKlt in the patient’s own words.” Up to principalmasons for Visit representing threereasons for visit are classifiedand 42.2 percent of all visits, are shown in Statistic8on tests, procedure%and coded from the survey accordingto the table 10. Gener81medical examination thempies scheduledor performedby the Reasonfor VisitClassificationfor w33the most frequentlymentioned physiei.anduring the officeviAt are AmbulatoryCare (WC) (6). The reason for visit (5.3pement of the total), d~played in tables 11-13. The 1993 principal mason for visit is the problem, while cough w33the most frequently NAMCS Patient Record form combined eomplain~or reason listed in item 10a. mentionedreason related to illness or tests, surgicaland nonsurgical The RVC is divided into the eight injury (3.4percent). Nineteenof the top procedures,and therapies(except modules or groups of reasons displayed 20 reasons for officevisks in 1993 were eounselingkdueationand medication in table 9. More than half of all visits also listed among the 20 most frequently therapy)into a single item, with six were made for reasons classifiedas mentionedreasons in 1992,al~lt in checkboxesfor commonlyperformed symptoms (57.7pereent).Respiratory slightly differentorder.It should be services aud space to recod up to eight symptomsaccountedfor 11.6pereent of noted that estimates that difki in ranked additional services.Results of the all visits, and musculoskeletalsymptoms order may not be significantlydiEerent open-endedpart of the item were coded accountedfor 10.7percent, from each Other. accordingto the International 6 Advance Data No. 270. December 7, 1995 ● 7ablo 6. Number and percent of oftlco vialte by patient’a expected ourco(a) of paymatrk shown separately forthecheckbox items United States, 1993 (part a of item 14) and the open-en&d Number of Percent response categories (partb)inlkeeping vfslts In of all Eipected source(s) ofpayrnent’ thousands Vlslts with the format used on the Patient Record form. Allvlstls ...... 717,191 . . . Slightly less than three-quarters

Private/cx3mmercial insurance ...... 277,596 38.7 (73.0pereent) ofall officevisit3 Medicare ...... 15s,804 22.1 includedoneor more tests, procedures HMO/other prepal& ...... 138,3s7 19.3 or therapies (excluding counseling/ Patisnlpaid ...... 107,623 15.0 education and medication therapy that Medicaid ...... 74,712 10.4 Othergovemment .,.....,...... 11,946 1.7 are collected in separate data items) Nocharge ...... 9,623 1.3 (table 11). Blood pressure check was the Other...... 25,616 3.6 most tkquently mentioned checkbox Unknown ...... 14,0!X 2.0 category, recorded at half (49.8 percent) INumbarsrrwrynot addtotda!dbacause rnorathanoneaxpactad aourceofpaymant rnaybareportad pervtait, of the visits. Blood pressure checks ‘HMO Is health maintenance organizatbn. were ordered or provided at a significantly higher proportion of visits by females (54.3 percent) than at visits Table 6. Number, percent dlstrlbution, and annual rate of Injury-related office visits by by males (43.1 percent). pattent’s age, sex, and racw United States, 1993 Other frequently mentioned services

Number of were “other’’bloodtest (16.Opercentof Number of vtaltspar visits) and urinalysis (13.5 percent). HIV visits In Percent 100 persons PaUent%~, sax, andrace thousan~ distribution per yawl serology was ordered orpmvidedat 0.3 percent of office vi8its. Allln]ury-related visits ...... 83,980 100.0 33.0 The top 25 diagnostic and

Age therapeutic services (other than those

Under 15years ...... 11,018 13.1 19.2 reported in the checkbox categories on 15-24 yeara ...... 8,489 10.1 24.7 the Patient Record form) are shown in 25-44 years ...... 32,552 3S.8 39.9 table 12. Pap smear, electrocardiogram, 45-64years ...... 18,148 21.6 36.5 eye examinations, and routine chest x 65-74years ...... 7,297 8.7 39.2 75yearaandover ...... 6,476 7.7 51.2 rays were among the most frequently mentioned procedures. Table 13 presents Sex and age data on additional procedures that while Femete ...... 41,156 49.0 31.5 not among the top 25, were also of Under15years ...... 4,798 5.7 17.2 interest. 15-24years ...... 3,667 4.4 21.3 X-44years...... 14,979 17.8 36.2 45-64years ...... 8,982 10.7 34.8 Physician’s principal diagnosis 65-74years ...... 4,078 4.9 39.8 Item 11 of the Patient Record form 75yearsandover ...... 4,653 5.5 59.0 asks the physician to record the Mate ...... 42,824 51.0 34.6 principal diagnosis or problem Under15years ...... 6,220 7.4 21.2 16-24yeara ...... 4,822 5.7 26.2 associated with the patient’s most 25-44years ...... 17,573 20.9 43.7 important mason for the current visit as 45-64yeara ...... 8,166 10.9 38.3 well as any other significant current 65-74years ...... 3,219 3.8 38.5 diagnoses. Up to three diagnoses are 75yearsandover ...... 1,623 2.2 38.2 coded and claasitied according to the Race ICD–9-CM (7). Displayed in table 14 White ...... 75,140 89.5 35.6 are office visits by principal diagnosis Black ...... 6,102 7.3 19.1 using the major dlsea,se categories .-. Asianpaclfic islander ...... 2,299 2.7 specified by the ICD–9-CM. The ~edcanlndlmEsMm/AleM...... “439 ‘0.5 . . . supplementary classification, used for lBasedon U.S. Bureau dthe Cemus Mmt~ofthe civilian nonin3titionatized popubtionof the United States as of diagnoses that are not classifiable to Julyl, 19s3. injury or illness (for example, general medical examination, routine prenatal Classi$cation of Diseases, 9th revision, wouldresultin greater specificity of examination, and health supervision of Clinical Modi$catioq Volume3, responses, thereby clarifying the large an infant or child), accounted for Procedures Classijicatiotz (ICD-9-CM) numberofservices generally recorded in 15.6 percent of all office visits. Diseases (7). It was hoped that allowing the ’’other’’checkbox categoryin of the respiratory system (13.8 percent) physicians to record services in this way previous versions of thesumey. Data are and diseases of the nervous system and Advance Data No. 270. December7, 1995 7

Table 7. Number and parcant dldrlbutfon of office visits made by patients who smoke infantor child and general medical clgarattes by patient’s age, sexj and mew United Statea, 1993 examination, among others.) Of the 20 Nunimr of diagnoses shown in table 15, 18 also vfsik h Percent Patient’s age, sex, and race thousands dIstrfbutfon appeared on the li3t of the 20 most frequent diagnoses for 1992. All VLMSby patients who smoke dgereftes...... 67,720 100.0 Physician’s cheoldist of msdical Age conditions Under 15yesrs ...... “117 “0.2 VS-24years...... 6,121 9.0 In addition to the diagnostic data 25-44 year3 ...... 27,692 40.9 45-64 years ...... 22,541 33.3 reported in item 11 of the Patient S5-74years ...... 6,357 12.3 Record form, selected information on 75yeersand over ...... 2,831 4.3 the patient’s current health status was 38X collected in item 13. Physicians wem

Female ...... 38,928 59.0 given a list of common conditions and Male ...... 27,792 47.0 asked to record whether the patient now

Race has any of them, regardless of what was recorded as the cument diagnosis in item White ...... 59,262 87.5 Black ...... 6,369 9.4 11. The list of conditions was modtied Asian/Pactilclslander ...... 1,488 2.2 for the 1993 NAMCS and will be Amerbanlndlen/Eskhno/Aleut...... “551 “0.8 expanded in the 1995 NAMCS. Results from item 13 are shown in table 16. Slightly less than one-fifth sense organs (10.8 percent) were also essential hypertension, occurring at (18.9 percent) of the visits were made prominent onthe list. 3.9 percent of all visifs. Essential by patients who wem reported to have The 20mostfrequently reported hypertension has been the most one or more of the five conditions listed principaldiagnosm for1993areshown frequently reported morbidity-related on the survey form. Obes@ was intable15.These arecategorizedat the diagnosis in every survey year since the checked at 8.7 percent of the total, or threedigitcodiiglevel oftheICD–9– NAMCS began in 1973. (Morbidity- 62.7 milIion office visits. Diabetes CM,andaccmmted for35.5percentof related dmgnoses are those classifiable (5.6 percent), asthma (4.9 percent), and allofficevisMmade duringtheyear. to illness or injury. NonmorbIdity related osteoporosis (2.5 percent) were all The most frequent diagnosis rendered by diagnoses include routine prenatal recorded at a greater proportion of visits physicians at office visits in 1993 was examination, health supervision of an in this item than as a diagnosis in item

Table 8. Number and parcsnt disfributfon of oftlca visits by physician specialty, according to patient’s cigaretta-amofdng status: United States, 1993

Nuniw of Does pathmf smoke dgeretles? Visfts in Phya/dan q?edeh’y thousands Totaf Yes No Urrknownq

Percent dlstrbutbn

Allvieits ...... 717,191 100.0 9.4 63.5 27.0

Genarel end ferrdlypractk e...... 197,605 100.0 10.4 61.2 28.5 Internal medidne ...... ’... 102,436 100.0 13.6 70.9 15.3 Pedietrks...... 76,962 100.0 “0.6 84.1 5.3 Obsletrfoe endgynecobgy ...... 64,030 100.0 10.7 65.3 24.7 Ophthelmolq ...... 33,373 100.0 3.4 40.5 56.1 Orthopedic surgery ...... 33,636 100.0 11.7 40.0 43.4 Dermetobgy ...... 31,469 100.0 4.7 41.2 54.1 Generelsurgery ...... 21,703 100.0 11.7 51.3 36.9 Psychiatry ...... 20,469 100.0 19.3 60.1 20.5 Urobgy ...... 15,680 100.0 9.4 48.3 42.4 Otokuyrrgology...... <...... 15,380 100.0 8.3 71.9 19.8 Csrdlovascu!ar diseeess ...... 12,178 100.0 9.1 66.3 24.6 Allsrgy andimmunolo@ ...... 10,605 100.0 4.6 73.5 22.0 Neurology ...... 6,383 100.0 10.8 59.6 28.6 Pulmonary dtseeaes2 ...... 4,251 100.0 12.7 69.1 18.3 Allotherspaoleltbs ...... 62,991 100.0 11.3 62.7 26.0

%dudea entries01“unknown”and b!ank entries. %heae spda!lias ware sampled sapwataly in 1863 on~ as parl of a suppbrrwrrtd data collactiin projed 8 Advance Data No. 270. December 7, 1995

Table 9. Number and percent diatributfon of offfce visits by patient’s principal reason for visit United States, 1993

Number of viaii%h Percent f%lnc@al reason for visit and RVC Codeq thoueands dlsfrfbuflon

Allvisfts ...... 717,191 100.0

symplom module ...... sooI~999 414,163 57.7 Generaf symploma ...... sooI%099 46,990 6.6 Syrr@ome referable topsychologlceVmentef dkordere...... S100-S199 22,266 3.1 ~~tomrefetile tothenewous system (excluding senworgms) ...... S200-S259 22,556 3.1 SyMptOMS referable to the cardioveeculevlymphatic system. ., ...... S260-S299 3,748 0.5 Symptoma referable totheeyesandears...... S300-S399 51,514 7.2 symptoms refersble to the respiratory system ...... S400-S499 63,4s2 11.6 SyMptoms referebleto thedlgestivesystem ...... S50W639 32,454 4.5 Syn@oms referable tothegenitourinety ayetem...... S640-S829 31,370 4.4 syrnptoma referable tothesfdn, hafr, endnails ...... S830-S899 43,130 6.0 symptome referable tothemusculoskeletef syafem...... S900-S999 76,664 10.7 Diseeae modufe ...... DooI-D999 83,981 8.9 Dlagnoatlc/screening andprevantive module...... X1 OO-X599 115,728 16.1 Treatment module ...... TIoo-T899 67,537 9.4 Injurlas andadversa effecte module ...... Jo01A999 23,248 3.2 Teslresulte module ...... RIoo-R700 9,141 1.3 Adminlstraffve module ...... AIcwA140 7,93S 1.1 Othe~ ...... U990-U999 15,455 2.2

~Basedon,4 Reason for VW C/assificefbn for Afrbu/ab’y Care (WC) (6). %wludesproblem and somplamts not ekewhere olaesified, entries of “none,” b!anks, and illegible entnes.

Table 10. Number and percent distribution of office visits by the 20 principal reasons for visit most frequently mentioned by patients, according topatient’saex: United States, 1993

Number of Pat/errt’s aax vlelfs In Princ@ai reason for vlstt and RVG code~ thouaan& Total Female Male

Percent dietrbution

Atlvkite...... 717,191 100.0 100.0 100.0

General medicef examination ...... X1OO 38,185 5.3 5.7 4.7 Routine prenatal exeminaflon ...... x205 25,S93 3.8 6.0 . . . Cough ...... S440 24,842 3.4 2.9 4.3 Prograaa vieft, nototherwke specified...... T800 20,836 2.9 2.5 3.6 Postoperative visit ...... T205 18,129 2.5 2.4 2.7 Symptomaraferebletothroat...... s455 17,283 2.4 2.5 2.3 Earacheorearinfectlon .,...... s355 16,130 2.2 2.0 2.8 Wellbabyexaminatbn ...... XI05 14,023 2.0 i .7 2.3 Stomachpain,cramps,endspasms ...... S545 13,027 1.8 2.0 1.6 Backsymptoms ...... S805 12,78S 1.8 1.5 2.2 Vlslondysfuncflons ...... s305 12,416 1.7 1.9 1.4 Sklnraah ...... S660 12,138 1.7 1.5 1.9 Headacha,pafn lnhead ...... S210 10,736 1.5 1.8 1.0 Headcold, upperraeplratory infection (coryza) ...... S445 10,160 1.4 1.3 1.5 Fever, ...... so1o 10,006 1.4 1.2 1.7 Naeelcongestlon ...... s400 9,872 1.4 1.3 1.5 Chaetpalnandretetadsympfoms...... s050 9,535 1.3 1.2 1.5 Hypertension ...... D510 9,503 1.3 1.2 1.5 Kneeaymptoms ...... S925 S,824 1.2 1.1 1.5 Dapresslon ...... S110 8,758 1.2 1.3 1.0 Allotherreeaons ...... 414,347 57.8 57.0 59.2 lBasedon AH=sonfor Msil C/ass#imtbn forAtiu/afoy Care (RVC) (6).

11. It should be noted that in item 11, item 13thanby itemllmayindieate medlcationsordere~ supplied, or physicians are instructed to reeord up to thatchronic conditions are administeredatthe visit,including two additional diagnoses, if any (in underreported in item 11. prescription andnonprescription addition to the principal diagnosis), preparations, immunization and whetherornotthey areofdirect Medication therapy desensitizing agents, andanesthetics. As concern tothecumentvisit. l“hefact In item 16, physicians were used inthe NAMCS,theterm “drug”is that higher estimates were producedby instructedtorecordall neworeontinued interchangeable withthetenn Advance Data No. 270. December 7.1995

Table 11. Number and percent distribution of office visits by tests, surgical and nonsurgical procedures, and therapies ordered or provided, according to patient’s sex: United Statea, 1993

Number of Patient’s sex visits in WJt characteristic fhoussnds Total Female Male

Percent dlsfrbutlon

Allvfafts ...... 717,191 100.0 100.0 100.0

Number of aervlces ordered or provided

None ...... 191 ,s91 26.8 ;4.0 30.9 1 ...... 265,463 37.0 36.4 37.9 2 ...... 154,344 21.5 22.7 19.8 3 ...... 64,331 9.0 10.1 7.2 4 ...... 25,400 3.5 4.2 2.6 5 ...... <0,956 1.5 1.8 1.1 6ormore ...... 4,787 0.7 0.8 0.4

Percent of Waits

Sefecfed semrices2

Blood presstrre ...... 357,065 49.8 54.3 43.1 Urfnafysls ...... 96,674 13.5 15.8 10.0 spirometry ...... 4,577 0.6 0.6 0.7 Afferyytesting ...... 2,140 0.3 0.3 0.3 HlVserobgy3 ...... 1,825 0.3 0.3 “0.2 O!herbksodteef ...... 114,904 16.0 16.5 15.3

‘Includeaihesix checkboxcategorias forselsotsdservhs anduptoeightothar sarvkesrecordsd ~thephysiciinin ihespscas~ovidsd onfhePatiantRemrd form.llm.saindude kssfs, imaging%, surgarks and other procedures, andtherap’es with fheexmpfion c4aducatiin/counesling and medicafiin. %dumbers may not add to totals because rn-ora than one service maybe reported per visit. %IIV is human irnmuncdeficierwy virus.

Tabie 12. Number and percent of office visits by the 25 write-in diagnostic and therapeutic “rnedkation,” and the term procedures most often ordered or performed: United States, 1993 “prescribing” is used broadly to mean

Number of Percent ordering or providing any medkation, Diagnostic and therapeutic procedures vials in of all whether prescription or over-the-counter. ofdered orperfonrred and ICD-9-CM Codef thousands Visns Visits with one or more drug mentions Allvisits ...... 717,191 . . . are termed “drug visits” in the NAMCS. Up to five medications, or Papsrnear ...... 91.46 19,613 2.7 Elecfrocardlogrsm ...... W.52 18,539 2.6 drug mentions, were coded per drug other nOnOp8rStiVe measurements and examlnatkms . . . 89.39 18,268 2,5 visit. Eye examination, not otherwise specitfed ...... 95.o9 17,179 2.4 The NAMCS drug data base Rouline chest bray ...... 67.44 14,015 2.0 Other local exdsion or destruction of Iesfon or tissue of permits classification by a wide range of skkrand suboufaneous tissue...... 86.3 13,881 1.9 variables, including speeific product Mlcrossopic examination of specimen from ear, nose, name, generic class, entry form chosen throat, andlarynx-cuflure ...... 30.32 12,392 1.7 Other Individual psychotherapy ...... 94.39 11,570 1.6 by the physician (that is, brand name, Tonometry ...... 89.11 10,267 1.4 generic name, or the desinxl thera~utic Llmttedeye exarninatlon ...... 95.oI 9,659 1.3 effect), pre,seription status (that is, Other mammography...... 87.37 9,363 1.3 Other phydcaltherepy ...... 93.39 7,313 1.0 whether the product is prescription or General phydoaiexamhsatlon ...... 69.7 6,562 1.0 nonprescription), fedemlly controlled Gynecological WSISSinatiOn ...... 89.26 5,6SJJ 0.8 substance status, composition status (that Other dlegnosflc ultrasound ...... 88.79 4,506 0.6 is, single or multiple ingredient Audiometry ...... 95.41 4~f8 0.6 Diagnostic utlreeound of gravid uterus ...... 86.78 4,198 0.6 product), and therapeutic category. A Skeletal xrayofwttefand hand ...... 88.23 4,149 0.6 report describing the method and Skeletal x ray of thigh, knee, and lower leg ...... 68.27 3,976 0.6 insbnunents used to colleet and process Skeletal xrayofankfeandfoot ...... 88.28 3,881 0.5 drug infotition for the NAMCS is Removal of other therapeutic device ...... 97.89 3,355 0.5 Fundusphotography ...... 95.11 3,331 0.5 available (8). Manual examination of breasl ...... 63.36 2,964 0.4 Data on mediation therapy are Fetal monitoring, not otherwise specified ...... 75.34 2,943 0.4 shown in tables 17-21 and figure 2. Xray, other andunepecifled ...... 88.39 2,873 0.4 Medkation therapy was the most lBased on the hbmationd C/assWcatiofrof Dksases, 9fh RevL$brr,C/inks/ Mcdifiiatbn (ICD-3-CM) (7). commonly mentioned therapeutic service 10 Advance Data No. 270. December 7, 1995

Table 13. Number and percent of office visits by selected diagnostic and therapeutic thatsome chugs have more than one procedures: United States, 1993 therapeutic application. In these cases, Number of Percent the drug was listed under the NDC Selected prucadures and viaifs in of all ICD-9-CM codei thousands wt.?! classification that occurred with the greatest frequency. All visits ...... 717,191 . . . Cardiovascular-renal drugs Ophthalmoscopy ...... 16.21 1,690 0.2 (14.0 percent), antimicrobial agents Other endoscapy ofsmalllnlestine ...... 45.13 1,709 0.2 (13.9 percent), and drugs used for pain Colonosmpy, ...... 45.23 955 0.1 Flexible slgmoldoecopy ...... 45.24 1,446 0.2 relief (11.0 pereent) were listed most Othercystoscopy ...... 57.32 1,730 0.2 frequently.. About onethird (31.6 Clozsdblopsyof uterus ...... 68.16 1,259 0.2 pereent) of all mentions of antimicrobial Vaglnoscopy ...... 70.21 1,057 0.1 Injecffon of therapeuflc substance into joint or agents wem at visits made by persons ligament ...... 81.92 1,368 0.2 unkr 15 years, and about two-thirds Othsr Inclslon with drainage of skin and subcutaneous (69.4 percent) of the mentions of tkSUe...... 86.04 1,340 0.2 Biopayof sldnand subcutaneous tksue ...... 86.11 2,687 0.4 immunologic agents were at visits by Appllcatlonofothercast ...... 93.53 1,323 0.2 this age group. Four of every 10 Applicatlonofsplint ...... 93.54 1,514 0.2 necrologic drug mentions (41.1 percent) Irrfgatlonofear ...... 96.52 2,745 0.4 occurred at visits by persons 2544 lBasedon the/nfemsfiona/ C/asiftitbn of Di*ases, 9th Revisbn, Cflnimf Mdifmatbn (lC&WM) (~. y-s. The 20 most frequently used Table 14. Number and percent distribution of office visits by physician’s principai generic substances for 1993 are shown diagnosis: United States, 1993 in table 20. Drug products containing Number of more than one ingredient (combination Prlncpal dlagnosls and visits In Percent ICD-5LCM codei thouaarr& diatdbufIon products) are included in the data for each ingredient. For example, Allvklts ...... 717,191 100.0 acetaminophen with codeine is included lnfectlousandparaslllc dfeeaaea...... 001-138 21,828 3.0 in both the count for amtaminophen and Neoplasm...... 140-239 21,878 3.1 the count for codeine. Amoxicillin was Endocttne, nutrklonal andmetabolicdkeases and Immunltydlaordera ...... 240-279 25,428 3.5 the generic ingredient most frequently Mentaldkorders...... 290-319 33,613 4.7 used in drugs ordered or provided by Diseasesotthe newous syatemandsensa the physician at office visits in 1993 (as organs ...... 320-389 77,737 10.8 Dlseasssofthecirculatorysystem ...... 390-459 57,584 8.0 well as in 1990-92), occurring in 3.9 Dkeaaeeoftherespirsfory system ...... 460-519 99,114 13.8 percent of drug mentions. Dkeasesofthedigestive system ...... 520-579 27,851 3.9 Table 21 presents the 20 Diseases of thegenttourinary system ...... 580-829 41,281 5.8 Dkeases of the skin and subcutaneous medications most ti’equently mentioned tissue ...... 680-709 6.0 by physicians in the NAMCS, aceordmg Dkeases of the musculoskeletal system and connectivetksue ...... 710-739 51,910 7.2 to the enuy name of drug. Entry name symptoms, signs, andill-defined conditions . . . . 780-799 32,503 4.5 refers to the actual designation used by Injuryandpoiscming ...... 800–999 46,161 6.4 the physician on the Patient Record Supplementary classification ...... VOI-V82 112,087 15.6 Allotherdiagnosesz ...... 8,554 1.2 form and may be a trade name, generic Unknown...... 17,112 2.4 name, or simply a desired therapeutic effect. Amoxicillin was the medication lBasedon the/ntemafiona/ C/&ifhatbn of Diseases, 9fh Revisbn, C/inim/MMifkatbn (lC~M) (~. 21ncludm dis=ses of the blood and blod-forfing organs (28&289) mmplicatkms ofpregnancy, childbirth, andthepuerperrum most frequently reported by physicians, (630-67S); congenital anomalies (740-759); and oertain conditions originating m ttw perinatsl period (780-779). 31ncludes bknkdisgnoses, unmdable diagnoses, and illegible diagnoses, with 19.2 million mentions (2.1 percent of the total). It was followed by ~lenol, Premarin, Lasix, Amoxil, and in 1993, reported at467.3 million office shown intable 18. Nine ofevery 10 Prednisone, each amounting for visits or 65.2 percent of the totat visits to allergists and immunologists 1.2 percent of the total. All of these (table17). included atleastonedmg mention, as were among the top 10 drug entry Therewere913.5miUion drug did80fevery10 visits to internists. names mentioned in 1992. mentionsatvisits toofiiee-based Drug mentions are displayed by physiciansduting 1993.This yieldsan therapeutic class in figure2 and table 19. Counseling and education average ofl.3 drug mentions per oftice This classification is based on the visi40r2.Odmg mentions per drug visit. therapeutic categories used in the Data on counseling and education Data on numberof drug visits and National Drug Code Directory, 1985 services ordered or provided at drug mentions byphysician specialty are edition (NDC) (9). It should be noted physicians’ office visits were collected Advance Data No. 270. December 7, 1995 11

Tabl@ 15. Number and porcant distribution of office visite by the 20 principal diagnoaoc most fraquontiy randared by physician, aocording to patfant’a smc United Statec, 1993

Number of Patient’ssex vialtsin Prlncpal diagnoslaand ICD-9-CM Codei thrxLsan& Total Female Male

Percent dbtrbufton

AflvIslts ...... Ibo.o 100.0 100.0

Eeaerrtlal hypertension ...... 401 26,124 3.9 3.9 3.9 Normalpregnancy...... V22 26,4S8 3.7 6.2 . . . Suppuratfveandunspedtbd otifiemedla ...... 382 19,309 2.7 2.0 3.7 Generaf msdbstexamlnatfon ...... V70 19,066 2.7 2.4 3.0 Healfheupsrvbfonofinfantorc held...... V20 18,50S 2.6 2.2 3.2 Acute upparrespiratoryhrfectbnsof mulllpteor unspedfbd sites ...... 465 17,557 2.4 2.2 2.8 Diabetee mellltus ...... 250 12,997 1.8 1.7 2.0 Chronlcslrrusftb...... 473 11,594 1.6 1.8 1.3 Asthma ...... 433 17,%0 1.6 1.6 1.5 Bronchitis,notspedfbd asacuteorchronlo ...... 430 10,093 1.4 1.3 1.5 Altergicrtdnltls ...... 477 9,637 1.3 1.4 1.3 Acutepharyngitis ...... 462 9,576 1.3 1.3 1.3 Dlseaaeeofssbaceousglands...... 706 9,193 1.3 1.3 1.3 Neuroticdleorders...... 300 8,532 1.2 1.1 1.3 Otherpoatsurgbafstates...... V45 7,ss0 1.1 1.2 1.0 Aftecthfepsychosss...... 236 7,351 1.0 1.1 0.9 3psctallnvestigatlonsertdexsmlrrstions...... V72 7,111 1.0 1.5 0.3 Contaddarmatltlsendothereczeme ...... 692 6,919 1.0 0.8 1.2 Oefsoarthrwbendailbddisordara ...... 715 6,890 1.0 1.0 0.9 Cataract ...... 366 6,739 0.9 1.0 0.8 Allotherdiagnosss ...... 462,287 64.5 63.0 66.6

%asedonthelntematicml C/mifmtionofDisasses, 9thRevi$br, Ciisioal hfodifik4vr(lCD-3-CM) (7).

Tabie16.Number and percantofoffice vlsitsbyselected medical conditions, according topatient’s ageandsex:United Statea,1993

Patient’s age Patferrf’ssav

All ages, Under 15-24 25-44 45-64 65-74 75 years Madksf condftfon’ bothS8X8S 15yests years yews years years and over Female Mafe

Nurnberofvtdtaln thousands

Allvfsfts ...... 717,191 129,279 62,346 193,914 160,146 33,873 77,633 430,170 267,021

Obaany...... 62,707 2,2s6 3,580 16,S96 23,50s 11,145 5,231 43,171 19,536 Diabetes ...... 40,35s “223 “765 4,632 14,366 12,496 7,610 22,382 17,366 Asthma ...... 35,154 9,098 2,771 6,946 7,214 4,258 2,665 20,634 14,520 Osteoporosla...... 17,752 *262 ●6 *593 2,3SS 5,331 8,766 15,043 2,703 Hl~ ...... 1,343 . . . “120 933 ●21 2 73 . . . “503 S40 Noneofthesbove ...... 561,632 117,672 55,416 164,9s6 120,028 67,012 56gm3 23s,407

Percent of Wefts

Allvtslts ......

Obsslfy...... 6.7 1.6 5.7 6.7 14.7 11.e 6.8 10.0 6.8 Diabetes ...... 5.6 “0.2 “1.2 2.4 9.0 13.3 10.1 5.3 6.1 Asthma ...... 4.9 7.0 4.4 4.6 4.5 4.5 3.7 4.8 5.1 Osteoporosis ...... 2.5 *0.2 “0.0 “0.2 1.5 6.3 11.3 3.5 0.3 Hl~ ...... 0.2 . . . “0.2 0.5 “0.1 “0.1 . . . “0.1 0.3 Noneoftheabove ...... 61.1 91.0 6s.9 85.1 74.9 71.4 72.8 79.8 63.1

‘Numbers may not add to totals because more than one condtiin rmaybe reported per visit %IIV is human immuncdeficiencyvirus. initem 15 of the Patient Record form. (9.0 percent), weight reduction notincludedin oneofthenine Asshownintable 2Zeounselingand (5,7 percent), and growth/development checkbox categories. education services wererecordedat (4.2percent) werementioned most ‘llecounselingand education abouthalf(48.5pereent) ofalIoffiee frequently. One-third ofvisits (34.2 eategoriee ofinjury prevention, HIV visits during 1993. Exereise percent) included “other” counseling transmission, and other STD 12 Advance Data No. 270. December 7.1995

Table 17. Number and percent distribution of office visits by medication therapy and number of medications provided or prescribed, according to patient’s sex: United States, 1993

Number of Patient’s sax vkits In W/t chamcterktlc thousends Total FemsJe Male

Percent distrhdfon

Medlcaflon therspyi

Aflvkdts...... 717,191 100.0 100.0 100.0

Dmgvlslts2 ...... 467,301 85.2 65.0 65.5 Vfdts without mention of medication ...... 249,890 34.8 35.0 34.5

Number of medications provided or prescribed by physlclarr

Allvisifs ...... 717,191 100.0 100.0 100.0

249,890 34.8 35.0 34.5 226,541 31.6 30.6 32.8 124,624 ~7.4 17.4 17.4 56,803 7.9 7.9 7.9 28,328 4.1 4.5 3.5 28,984 4.2 4.4 3.9

‘Indudee preswiptkm drugs, over-lhe-oxmter preparations, imrrunizing agents, and desensitizing agents. %lts at which one or mom drugs were provided or prescribed by the physiciin.

Table 18. Number and percent distribution of drug visits and drug mentions by physician spaclal~. United States, 1993

Number of Nurr@erof Percent dmg VISIW Percent dmg merrtfons Percent of dtug Physlclan qeclaHy in thousendsl dfstrfbutlon In thousands dlefrfbutfon Vlaw

Alispedallles ...... 467,301 100.0 913,503 100.0 65.2

Generaf and family practice, .,....,...... 147,257 31.5 296,201 32.4 74.5 Internal medicine...... ,...... 81,874 17.5 187,379 20.5 79.9 Pediatrics ...... 64,773 11.7 88,594 9.6 71.2 Obetetrtcs. endgynecofogy ...... 28,736 6.4 44,818 4.9 46.4 Dermatology ...... 21,255 4.5 36,635 4.2 67.5 Ophthalmology...... 19,230 4.1 33,686 3.7 48.8 psychiatry ...... 15,161 3.2 30,379 3.3 74.7 Orthopedlcsurgery ...... 11,783 2.5 17,656 1.9 35.0 Allergyandimmunology3 ...... 9,861 2.1 20,738 2.3 93.0 Cerd[ovasculardlseases ...... 8,614 1.6 24,800 2.7 70.7 Otola~ngology ...... 7,949 1.7 12#345 1.4 51.7 Generafsurgery ...... 7,189 1.5 12$08 1.4 33.1 Urology ...... 6,350 1,4 8,611 0.9 40.5 Neurology ...... 4,953 1.1 9,356 1.0 59.0 Pulmonarydlseases3 ...... 3,312 0.7 9,743 1.1 77.9 Allotherspeciaftfes ...... 38,006 6.1 76,054 8.3 60.3 lVisits at which one or more drugs were provided or prescribed by the physician. 2Number ofdrugvMsd Midedbyn umberofo fficev!sttsrm uitlplied by 100. %hese speoiatties were ssmpled separately in 1993 on~ as pati of a aupplemeniai data mlhmiion projecl.

Wtnsmissionwem addedtothe1993 One-quarter (23.3 percent) ofoffice visit refers m the amount of time spent Patient Record form. Such services were visits included instructions to returnif in face-to-face contact between the orderedorprovided at2.6percentj needed.Lessthan lpercentofvisits physician and the patient. This time is 1.3percent, and 1.4percent of visits, resulted in a hospital admission. estimated and recorded by tk physician respectively. Table 23 displays data on disposition of and does not include time spent waiting office visits. to see the physician, time spent Disposition of visit receiving care from someone other than Duration of visit Two-thirds of ofice visits the physician without the presence of (66.7 percent) included a scheduled Data on the duration of office visits the physician, or time spent by the f’ollowup visitor telephone call in1993. is presented in table 24. Duration of physician in reviewing patient records Advance Data No. 270. December7, 1995 13

Table 19. Number and percent distribution of drug mentions by patient’s age, according to therapeutic classification: United States, 1993

Patient’s age Number of dmg mentions Under 15 15=24 25-44 45-64 65-74 75 years 7tretapeuf\c ofaseelficetkmq in ftrouewrds Total years years yeare yeara years and over

Percantdiefribtrfion

Alldrug rnardions...... 913,503 100.0 15.1 6.7 22.8 24.7 15.9 14.9

Cardiovaaculsr-rsnsl drugs ...... 127,549 100.0 “0.7 “0.7 7.7 28.3 28.2 33.4 Antlmlcroblal agente ...... 127,130 100.0 31.6 10.6 25.7 18.6 8.0 5.6 Drugs used forreliefofpaln ...... 100,838 100.0 9.0 52 28.9 26.6 15.7 13.6 Reef)lratorytracfdrugs ...... 87,751 100.0 26.3 8.7 26.6 21.2 10.1 7.2 Horrrwnesendagenfssffeoflnghonnonal mechanisms ...... S5,421 100.0 4.2 5.2 21.3 36.6 20.1 12.7 Peychophartnecobgiodrugs ...... 62,532 100.0 5.6 4.9 33.1 31.0 14.5 10.9 Skin/mucousmerWane...... 54,551 100.0 14.5 16.5 23.7 20.9 10.1 8.2 Metebolicsndnufrfentagenta ...... 43,427 100.0 8.3 11.2 25.8 19.5 17.1 18.2 Immunologicagenfe ...... 39,732 100.0 69.4 2.3 6.2 6.8 7.6 7.7 Gaatrointestinalagents ...... 38,658 100.0 4.3 4.3 23.5 28.4 21.4 18.1 Ophthalmicdruge ...... 31,320 100.0 8.9 “3.6 13.9 19.0 23.9 30.6 NeurologIcdruge ...... 20,418 100.0 “3.5 “5.0 41.1 27.5 10.9 12.0 Hernstoiogfcagente ...... 16,219 100.0 “3.2 . 12.2 16.6 18.6 20.6 26.7 Otherand unckrseMe& ...... 77,777 100.0 16.6 7.6 23.8 28.2 13.7 12.0

%sedonthestandwd drugcbdfkatiin usedintheAfationa/ DrugCodaDimctory#1985edtion(NDC) (9). %dudesanesthestim, atid@-, mdnphamwtimaWmntM rmdia,oncotylii, ot.logica, anti~~ti=, andund-fitimkwlknwus drugs.

and/or test results. In cases where the Table 20. The 20 most frequently occurring generic substances in drug mentions at office patient received care from a member visits by number of occurrences and percent of all drug mentions: Unitwt States, 1993 of thephysician’s staff but dld not Nunhw of Percent of actually see the physician during the Occurrancas aif drug Generic substance in #ousarrds* Merltlonaz visit, duration was recorded as “O” minutes. Allgenerfc substances ...... 1,0s0,98s .. . Nearly two-thirds (63.5 percent) of Arnoxidllkr ...... 35,2W 3.9 physicians’ office tilts had a duration Acetarnlnophen ...... 34,277 3.8 of 15 minutes or less in 1993. The mean Hydmchlorothiszkfe...... 15,217 1.7 duration time for all visits was 18.4 Albuterol ...... 14,343 1.6 minute8. Corresponding numbers for Ibuprofen ...... 14,405 1.6 Mulfivitamhw+feneral ...... 14,064 1.5 1992 were 66.6 pereent and 17.6 Eryfhrornydn ...... 13,459 1.5 minutes, respectively. Aaplrtn ...... 13,233 1.5 Additional reports utilizing 1993 Phenyiqhrine ...... 12,588 1.4 NAMCS data are forthcoming in the Guelfenesln ...... 11,727 1.3 Estrogens ...... 11,ss0 1.3 Advance data horn Vhal and Health Furoeemkla ...... 11,212 1.2 Statistics series. Data from the 1993 Predrrisone ...... 10,833 1.2 NAMCS will be available on computer Codeine ...... 10,153 1.1 tape and CD-ROM from the National Digoxln ...... 9,9s4 1.1 Trimathoprlm ...... 9,886 1.1 Technical Information Service in Dlillszem ...... 9,541 1.0 early 1996. Questions regarding this Hydrwortlsone...... 9,516 1.0 repcu%future reports, or the NAMCS Pheny~ropanolernine ...... 9,435 1.0 Ranitkfine ...... 9,325 may be directed to the Ambulatmy 1.0 Care Statistics Branch by calling 1Fraquency or mentkm conbines single-ingredient agents with nmnticws or the agent as an ingredient in a mmbination dreg. (301) 436-7132. 2Bssed on an estimated 913,508,cYXl drug rmrdions in 13$3.

References 1. Nelson C, McLemore T. The National Ambulatory Medkal Care Summary. National Center for Health Hyattsville, Maryland National Survey. United States, 1975-81 and Statistics. Vital and Health Stat Center for Health Statistics. 1992. 1985 trends. National Center for 13(110). 1992. 4. Schappe~ SM, National Ambulatory Health Statistics. vital Health Stat 3. Schapper~ SM. National Ambulatory Medicsl Care Survey: 1991 13(93). 1988. Medical Care Survey: 1990 Summary. National Center for Health 2. Schapper$ SM. National Ambulatory Summary. Advance data from vital Statistics. ~lti snd Health Stat Medical Care Survey: 1989 and health statistics no. 213. 13(116). 1994. 14 Advance Data No. 270. December 7, 1995

Table 21. Number, percent distribution, and thempeutfc classlffcatfon for tfte 20 druge most fmquentiy prescribed at office vlslta, by entry name of drug: United States, 1993

Number of dmg mentions Perc4vrt Entry name of dNg7i In thousands dlstrfbutlon Therzpeuf/c clasalfkathm2

Alldfug mentions ...... 913,503 100.0 . . .

Amoxfdllln ...... 19,212 2.1 Penicillins Tylenol ...... i 1,225 1.2 General analgealoa Premartn ...... 10,675 1.2 Estrogens and progestins Leak...... 10,578 1.2 Dluretlca Amoxfl ...... 10,569 1.2 Penicillins Prednfsone ...... 10,562 1.2 Adrenaf wrtioosterokfe Zanlac ...... 9,303 1.0 Agantsusadindisordera ofupparGltrac4 Cardizem ...... 6,977 1.0 Antianginaf agenta Allergy ralleforshots ...... 8,029 0.9 DlagnoafIcs, nonradioacftve and radiopaque Influenzavirusvaccine ...... 7,685 0.8 Vaccines and antiserums Procardia ...... 7,575 0.8 Antlanglnafagents Lanoxfn ...... 7,177 0.8 Cardfacglyoosfdes SynthroId ...... 7,169 0.8 Agents used to treat thyroid dfsaaae Vasotec ...... 7,032 0.8 Antihypertenefve agents DlphtheriWTetanusToxoida/Perfusais ...... 6,994 0.8 Vacdresandan tfaerums Ventolhf ...... 6,940 0.8 Bronchodffatom,antfasthmatfca Prenatelforrmrla(vltamlns) ...... 6,902 0.8 Vitamins, mlnerafs Naprosyn ...... 6,769 0.7 Anfiafthrtlfce Proventll ...... 6,626 0.7 Bronchodllatora,antfasthmallcs Prozac ...... 6,462 0.7 Antldapreaaants Another...... 737,042 80.7 . . .

%eentrymade bythephysiekn onthe.prescription orothermadical reoords.l%isrnsy beatrsdenama, ganericnsme,or desiradtherapautic effac+. 2Basedon the Nafiond Dr~MD/~to~, 1985 Ediimn(NDC) (9). Incases where adrug had morathan onetherapeutic use, it was MedundertheN DCeategc+yt hatocewredwkhthe hghest frequency,

5. Schappefi SM. National Ambulatory MedicalCareSurvey 1992 Summary.Advance datafromvital Cardiovascular-renal 14.0 andhealtb statistics no. 253. b Antimicrobial 13.9 Hyattaville, Marykmd National Pain relie! Center for Health Statistics. 1994. Respiratory trad 6. Schneider D, Appleton L, McLemore Hormones and rale agentt T. A reason for visit classification for Peychopharmacologit ambulatory care. National Center for Skitimusous membrerw Health Statistics.Vital endHeakh Stat 2(78).1979. g 7.Public Health Service and Heelth Gastrointestma Care Financing Administration. E Ophthalmh Neurologi, International Classification of Hematologil_: Diseases, 9thRevision, clinical Other and utiassifiid 8,5 modltication. Washington: Public 1 1 1 1 1 I 1 1 I Health Service. 1980. o 2 4 8 a 10 12 14 16 S.Koch H, Campbell W. The collection Percent of mentiins and processing of drug information. SOURCE Ssmd on the standarddrugdasdfkatbn used intha)4atkm/D~Co&a Directory 196Sedkvr (NDC)(9). Nationrd Ambulatory Medical Care Survey, 1980. National Center for Figure 2. Peroant distribution of drug mentions at offioe visits by therapeutic classification: United States, 1993 Health Statistics. Wal Health Stat 2(90). 1982. 9. Food and Drug Administration. National Drug Code Directory, 1985 Edition. Washingtorx Public Herrlth Service. 1985. 10. Shah BV, Barnwell BG, Hunt PN, La Vange LM. SUDAAN User’s Manual, Release 5.50. Research Triangle Institute. Research Triangle Psrk, NC. 1991. Advance Data No. 270. December 7, 1995 15

Table 22. Number and percent of office visits by counselingkfucation ordered or provided: United States, 1993

Number of Pat/erft’s sex fdeifs in CounseIin~education ordered orprovid.d thouaamds Total Female Male

Percent of vkiis

Atlvldts ...... 717,191 ......

None ...... 369,4e4 51.5 50.4 53.2 Exerdsa ...... 64$?57 9.0 8.9 9.0 Welghtreduotkrn ...... 40,715 5.7 5.9 5.3 Growth/development ...... 30,255 4.2 4.2 4.3 Cholesterolreducfkrn ...... 27,063 3.8 3.7 3.9 Smotrkrgcessetion ...... 22,674 3.2 3.1 3.3 Injurypreventlon ...... 21,786 3.0 2.6 3.8 STDtransmiaeion (exceptHlV)z3 ...... 10,216 1.4 1.8 0s HlVWutsmisaion3...... 9,114 1.3 1.5 1.0 Other ...... 245,281 34.2 35.4 32.5

lNumbemmaynot addtototelsbacsuse morethanonefype ofmunsalingred ucatiorr rrmybempctfed perviaif. 2STD is Saxualp tmnsmilted diseases. %-N/is human immunodafrcierwy virus.

Table 23. Number and percent of oftlce visits by disposition of vlsib United States, 1993

Number of Percent Vwfs in of an D!-spoaltfonl fhouaarrde VMts

Allvrsits ...... 717,191 . . .

Retumatspecifiedtime ...... 447,169 62.4 Retumifneedsd ...... 168,947 23.3 Nofolknvupptersned ...... 61,687 8.6 Tele+shonefollowuppkmned...... 30,937 4.3 Referredtootherphyetdan ...... 26,411 3.7 Admittohos@tef...... 6,022 0.8 Refumedto refefrlngphyelcien ...... 8,360 1.2 Other ...... 13,954 1.9 lNumberamsynot addtototabbecauae momthanonedlspoaifiin tswybemported pervisif.

Table 24. Number and percent distribution of office visits by duration of visik United states, 1993

Nurrber of Vfattsfrf Percerrf Duraflon ftrouaarr& dkfribufion

Allviatte ...... 717,191 100.0

Omlnufesi ...... 17,4s4 2.4 l-5mkrutes ...... 40,611 5.7 6-10mtmutaa ...... 177,641 24.8 11-15mlnutas ...... 219,418 30.6 16-30minutes ...... 204286 28.5 31 mInutesandover ...... 57,540 8.0 lVisita in which there was no faetefsce ccmtasf batwaan patient and ptsysidan. 16 Advance Data No. 270. December 7, 1995

Technical notes interview. The U.S. Bureau of the Table L Approximate relative standard errors for estimated numbers of ofttce Census, Housing Surveys Bmnch, was visits: National Ambulatory Medical Care Source of data and sample responsible for the survey’s data Suwey, 1993 collection. Processing operations and design Estimated Relatlve medical coding were performed by the number of standard The information presented in this office visits error in National Center for Health Statistics, In thousands penxrt report is based on data collected by Health Care Survey Section, Research means of the National Ambulatory Triangle Park North Carolina. 100 ...... 83.2 Medical Care Survey (NAMCS) from 200 ...... 58.9 January 4, 1993, through kmuary 2, 500 ...... 37.4 Sampling errors 787 ...... 30.0 1994. The target universe of NAMCS 1,000 ...... 26.6 includes office visits made in the United The standard emor is primarily a 2,000 ...... 19.0 States by ambulatory patients to measure of the sampling variabiMy that 5,000 ...... 12.3 nonfederrdly employed physicians who occurs by chance when only a sample, 10,000 ...... 9.1 20,000 ...,...... ,.. 7.0 are principally engaged in office rather than an entire universe, is 50,000 ...... 5.3 practice, but not in the specialties of surveyed. The standard error also 100,000 ...... 4.6 anesthesiology, pathology, or radiology. reflects part of the measurement error, 200,000 ...... 4.2 500,000 ...... 3.9 Telephone contacts and nonoffice visits but does not measure any systematic 1,000,000 ...... 3.8 are excluded. biases in the data. The chances are 95 A multistage probability sample NOTE The smallest reliable estimate for visfis to aggregated out of 100 that an estimate from the specislt”es s 781,030 visis. Estimates below this figure have design is used in NAMCS, involving a relattie standard error greater than 30 percent and are sample diflers from the value that would deenmd unrafiabla by NCHS efandards. samples of primary sampling units be obtained from a complete census by Example of use of tabkx An aggregate estlmtde of 10 million (PSU’S), physician practices within visits has a re!afiie standard error of 9.1 parcent or a less than twice the standard error. standard error of 910,000 visits (9.1 peroent of 10 million). PSU’S, and patient visita within The standard errors used in tests of physician practices. The PSU’S are significance for this report were Table IL Approximate relative standard counties, groups of counties, county calculated using generalized Iinem equivalents (such as parishes or errors for estimated numbers of drug models for prWlcting the relative mentions: National Ambulatory Madioal independent cities), or towns and standard error for estimates based on the Care Survey, 1993 townships (for some PSU’S in New linear relationship between the actual Estimated Re/at/ve England). For 1993, a sample of 3,400 standard error, as approximated using number of standard nonfederal, office-based physicians dNg M8f7t10nS etror In In thousands percent was selected from master files SUDAAN sofhvare, and the size of the estimate. SUDAAN computes standard maintained by the American Medkzd 100 ...... 114.4 Association and American Osteopathic errors by using a first-order Taylor 200 ...... 81.0 Association. Physicians were screened approximation of the deviation of 500 ...... 51.4 estimates from their expected values. A 1,000 ...... 36.5 at the time of the survey to ensure that 1,496 ...... 30.0 they were eligible for survey description of the software and the 2,000 ...... 26.1 participation. Of those screened, 936 approach it uses has been published 5,000 ...... 17.0 (10). The relative standard error (RSE) 10,000 ...... 12.5 physicians were ruled ineligible 20,000 ...... 9.6 (out-of-scope) due to reasons of being of an estimate is obtained by dividing 50,000 ...... ! ...... 7.3 retired, employed primarily in the standard error by the estimate itself. 100,000 ...... 6.3 teaching, research, or administration, The result is then expressed as a percent 200,000 ...... 5.6 500,000 ...... 5.4 or other reasons. The remaining 2,464 of the estimate. 1,000,000 ...... 5.3 physicians were in-scope, or eligible Relative standard errors (RSES) for to participate in the survey. The estimated numbers of office visits in NOTE The smallest refiible estimate of drug mentions for 899re9ated speoiailks is 1,46S,000 mentions Estimates physician response rate for the 1993 1993 are shown in table L relative below this figure have a relative standard error greater than 30 percard arrd are deemed unreliable by NCHS standards. NAMCS was 73.0 percent. standard errors for estimated numbers of Example of use of table An aggragsfe estimate of 100 million drug mentions haa a relafiie standard -error of 8.3 perosnt or Sample physicians were asked to drug mentions are presented in table II. a standard arror C46,300,000 mentions (6.3 percent of 100 complete Patient Record forms (figure 1) Standard errors for estimated percents of million). for a systematic random sample of office visits and drug mentions are displayed visits occurring during a randomly in tables III and IV. MuMplying the assigned l-week reporting period. estimate by the RSE will provide an interest in thousands, and A and B are Responding physicians completed approximation of the standard error for the appropriate coefficients from table V. 35,978 Patient Record forms. the estimate.

Characteristics of the physician’s Alternatively, relative stzmdard RSE (X) = A+:*1OO practice, such as primary specialty and errors for agfyegate estimates may be r type of practice, were obtained from the calculated using the following general Similarly, relative standard errors physicians during an induction formu~ where x is the aggregate of for percents may be calculated using the Advance Data No. 270. December 7, 1995 17

Table Ill.Approximate standard errors of percents of estimated numbers of office visik Nationai Ambulatory Medical Care Survey, 1993

EWnatadpercent Baaa of pemnt (b4Ms In thousands) 1 or 99 5 or 95 10 or90 20 or 80 30 or 70 40 or 60 50

100...... 8.3 18.1 25.0 33.3 36.1 40.7 41.6 200 ...... 5.9 12.8 17.6 23.5 27.0 28.8 29.4 500 ...... 3.7 8.1 11.2 14.9 17.0 18.2 16.6 1,000 ...... 2.6 5.7 7.9 10.5 12.1 12.9 13.2 2,000 ...... 1.9 4.1 5.6 7.4 8.5 9.1 9.3 5,000 ...... 1.2 2.6 3.5 4.7 5.4 5.6 5.9 10,000 ...... 0.8 1.8 2.5 3.3 “ 3.8 4.1 4.2 20,000 ...... 0.6 1.3 1.8 2.4 2.7 2.9 2.9 50,000 ...... 0.4 0.8 1.1 1.5 1.7 1.8 1.9 Ioo,ooo ...... 0.3 0.6 0.8 1.1 1.2 1.3 i .3 200,000 ...... 0.2 0.4 0.6 0.7 0.9 0.9 0.9 500,000 ...... 0.1 0.3 0.4 0.5 0.5 0.6 0.6 1,000,000 ...... 0.1 0.2 0.3 0.3 0.4 0.4 0.4

NOTE Example of use of table An estimate of SOpercent baaed on an aggragata estimate of 10 miliiin viaita has a standard errcf of 3.5 percent or a refstiie standard error of 11.7 parcent (3.5 percent divided by 30 parcant),

TabielV. Approximate standard errore ofpercentaof estimated numbers ofdrugmentions: Nationai Ambulatory Medical Care Survey, 1993

Eatirnetedparcant Base ofpercent @#fslnthousands) 1 or 99 5 or 95 10 or90 20 or 80 30 or 70 40 or 60 50

Sktrrdarderrorht parcantagepoints

100 ...... 11.4 24.9 34.3 45.7 52.4 56.0 57.1 200 ...... 8.0 17.6 24.2 32.3 37.0 S9.6 40.4 500 ...... 5.1 11.1 15.3 20.4 23.4 25.0 25.6 1,000 ...... 3.6 7.9 10.6 14.5 16.6 17.7 18.1 2,000 ...... 2.5 5.6 7.7 10.2 11.7 12.5 12.8 5,000 ...... 1.8 3.5 4.9 6.5 7.4 7.9 8.1 10,000 ...... 1.1 2.5 3.4 4.6 5.2 5.6 5.7 20,000 ...... 0.8 1.8 2.4 3.2 3.7 4.0 4.0 50,000 ...... 0.5 1.1 1.5 2.0 2.3 2.5 2.6 Ioo,ooo ...... 0.4 0.8 1.1 1.5 1.7 1.6 1.8 200,000 ...... 0.3 0.6 0.8 i .0 1.2 1.3 1.3 500,000 ...... 0.2 0.4 0.5 0.7 0.7 0.8 0.8 I,ooo,ooo ...... 0.1 0.3 0.3 0.5 0.5 0.6 0.6

NOTEExarr@eof usecitableAn estiite of30parcentbasad onanaggregataaetirnate of100milfiindrug manfiins hasaatandard errwofl.7p.wc.ant waralafiiastandard errorof5.7 pe-t (1.7 percant dtidad ty 30 parcent),

following general formul~wherep is by imputing to nonrespondmg (or combination of variables) of interest. thepercent ofinterest expressedasa physicirtns data from visits to similar Terms relating to differences such as proportion, andxis the denominatorof physicians. For this propose, physicians “greater than” or “kxs than” indicate thepereentin thousands, using the were judged similar if they had tie that the difference is statistically appro@atecoefficient flomtableV. same specialty designation and practiced significant. A lack of comment regarding in the same PSU. the difference between any two estimates does not mean that the Test of significance and ‘SE(’)=c“’” dtierence was tested and found to be rounding not significant. In thi8repofi the determination of In the tables, estimates of office Adjustments for nonresponse statistical inferenee is based on the visits have been rounded to the nearest Estimates horn NAMCS data were two-tailed t-test. The Bonferroni thousand. Consequently, estimates will adjusted to account for sample inequality was used to establish the not always add to totals. Rates and physicians who were in-scope but did critical value for statistically significant percents were calculiwed from original not participate in the study. This differences (0.05 level of significance) unrounded figures and do not adjustment was calculated to minimize based on the number of possible necesmrily agree with percents the impact of response on iinal estimates comparisons within a particular variable calculated from rounded data 18 Advance Data No. 270. December 7, 1995

Table V. Coefficients appropriate for determining relative standard errora by type of who spends sometime earing for estimate and physician spasialt~ National Ambulatory Medical Care Survey, 1993 ambulatory patients. Excluded from the Coefficient for use wlfh estimates In thousands NAMCS are physicians who am hospital Type of estimate and basal, who specialize in anesthesiology, phyaiclan apec/a/iy A B pathology, or radiology; who are W#rs federally employ~ who treat only Overall total ...... 0.001402906 63.14391s63 institutionalized patients; or who are employed full time by an institution and Generel andlamily practice ...... 0.00967743 82.86427569 Osteopathy ...... 0.009634146 21.982533 spend no time seeing ambulatory Intemai medicine ...... 0.009613634 66.930512SS patients. Pedlatrica ...... 0.01497736 43.04423824 Wsit—Avisit is a direct personal Ganeral surgary ...... 0.004562476 6.1 S923111 exchange between an ambulatory patient ObsteUfoaendgynecology...... 0.01215806 45.17522836 Orthopedic surgery ...... 0.01 S47372 30.1373659 and a physician or a staff member Cerdiovescukar dlseeaaa ...... 0.01842725 13.330613S4 working under the physician’s Dermatology ...... 0.01300847 14.22174725 supervision, for the purpose of seeking Urology ...... 0.01462425 10.21006093 care and rendering personal health Psychiatry ...... 0.011116SS 6.36650241 Neurology ...... 0.01062749 4.46207203 services. Excluded from the NAMCS Ophthelomology ...... 0.01360671 23.79903861 are visits where medkal care was not Otolsryngology ...... 0.01584593 7.10113491 providd such as visits made to drop off Allargysndlmmunologyt ...... 0.02015721 3.3591506s specimens, pay bills, make Pulmonerydiaaaaaa’ ...... 0.01604307 2.76807823 Aliotherapecialties ...... 0.0118534s 45.14667567 appointments, and walk-outs.

Drug mentions

Overelltotel ...... 0.002655818 130.60816

Generalsndfsmllypracfice ...... 0.01454036 153.42208 Osteopathy ...... 0.014s2355 34.91826215 Intemalmadiclne ...... 0.01501777 127.67927 Pedistrfcs ...... 0.0212S038 29.86328192 Generelsurgery ...... 0.02674708 6.25933055 Obstetrfcaandgynecology ...... 0.0283S093 47.78~72168 Orthopedlcsurgery ...... 0.03130595 31 .2701S391 Cerdiovseculardiaeaaes ...... 0.02412645 26.653378 Dermatology ...... 0.020s4168 14.43471796 Urology ...... 0.03026505 10.123550s Psychiatry ...... 0.02554631 11.76240189 Neurology ...... 0.01978151 5.29S00076 Ophthalomolcqy ...... 0.02642952 39.03224336 Otokwyn@ogy...... 0.03147744 6.66505135 Allergyandlmmunology’ ...... 0.02579986 6.30451913 Pulrnonerydlaeeaeal ...... 0.02283235 5.93S3W04 AllotherspecfeltIee ...... 0.02135922 59.19073373

~Physicianstrataaddedas a supplementto the 1993 NAMCSoniy.

Definition ofterms specificallyinsawted duringthevisit to eontinuethemedkation. Physicians may Ambulatorypatient-An ambulatory report up to five medications per visiL patient isanindividurd seeking personal Drug visit—Adrug visit is a visit at hcalthsemiceswho isnotcurrently which medication was prescribed or admittedto anyhealth care institution provided by the physician. onthepremises. Ojice-An office is the space Drug mention—Adrug mentionis identified by a physician as a location the physieian’s entry on the Patient for his or her ambulatory practice. Recordfon.nofa pharmaceutical Offices customarily include consultation, agent-by any route ofadministration— examimtion, ortreafment spaces that forprevention, diagnosis, or treatment. patients associate with the particular Genericaswellas brand-namedrugs are physician. includ~ as are nonpnxcription and Physician—Aphysician is a duly pre3eription drugs. Along with allnew licensed doctor of medkine (M.D.) or drugs, thephysician also records doctor of osteopathy @.O.) who is continued medications ifthepatientwas’ currently in office-based practice and Advance Data No. 270. December 7, 1995 19

Symbols --- Data not available . . . Category not applicable Quantity zero 0.0 Quantity more than zero but less than 0.05 z Quantii more than zero but less than 500 where numbers are roundedto thousands * Figure does not meet standard of reliabilityor precision 20 Advance Data No. 270. December 7, 1995

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Suggested citation Copyright Information National Center for Health Statfatfce

Wcodwell DA, Schappert SM. National All material appearing in this report is in the Acting Director Ambulatory Medical Care Survey: 1993 public domain and may be reproduced or Jack R. Anderson summary. Advance data from vital and health copied without permission; citation as to Acting Depu~ Director statistics; no. 270. Hyattsville, Maryland: source, however, is appreciated. Jennifer H. Madsns, Ph.D. National Center for Health Statistics. 1995.

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Special analyses by cause of death, age, other reports of major committees concerned with vital and health demographic variables, and geographic and trend analyses statistics and documents such as recommended model vital are included. registration laws and revised birth and death certificates. SERIES 21. Date on Natality, Marriage, and Divorce-These reports SERIES 5. International Vital and Health Statistlca Repo~These contain statistics on natality, marriage, and divorce that are reporta are enslytkal or descriptive reports that compare U.S. not included in regular, annual, or monthly reports. Special vital and health statistics with those of other countries or analyses by health and demographic variables and present other international data of relevance to the health geographic and trend analyses are included. statistics system of the United States. SERIES 22. Data From the Natfonal Mortality and Natality Surveya- SERIES 6. Cognition and Survey Meaeurement—These reports are Oiscontinued in 1975. Reports from these sample surveys, from the National Laboratory for Collaborative Research in based on vital records, are now publishad in Series 20 or 21. Cognition and Survey Measurement. They use methods of SERIES 23. Data From the National Survey of Family Growth— cognitive science to design, evaluate, and test survey These reports contain statistics on factors that affect birth instmments. rates, including contraception, infertility, cohabitation, SERIES 10. Data From the National Health Interview Survey-These marriage, dworce, and remarriage adoption; usa of medical reports contain statistics on illness; unintentional injuries; care for family planning and infertility and related maternal disabilii use of hospital, medml, and other health servi~ and infant health topics. These statistics are based on and a wide range of special current health topics covering national surveys of childbearing age. many aspects of health behaviors, health status, and health SERIES 24. Compilations of Data on Natality, Mortality, Marriage, care utilization. They are based on data collected in a Divorce, and Induced Terminations of Pregnancy— continuing national household interview survey. These include advance reports of births, deaths, marriages, SERIES 11. Data From the National Health Examination Survey, the and divorces based on final data from the National Vital National Hsalth and Nutrition Examination Surveys, and Statistics System that ware published as supplements to the the Hispanic Health and Nutrition Examination Survey- Monthly Vi Ststisi7csRqwrt (MVSR). These reports provide Data from direct examination, teatktg, and measurement on highlights and summaries of detailed data subsequently representative samples of the civilian noninstitutionalized published in Vita/ Statistics of the United States. Other population provide the basis for (1) medically defined total supplements to the MVSR published here provide selected prevalence of specific diseases or conditions in the United findings based on final data from the National Vial StstLW”ca States and the distribti”ons of the population W-W respect to System and may be followed by detailed reports in Series 20 physical, physiological,and psychologicalcharacteristics, and or 21. (2) analyses of trends and relationships among various For answers to questions about this report or for a list of reports published measurements and between survey periods. in these series, contact SERIES 12. Data From the Instltutlonalized Population Surveya- Data Dissemination Branch Discontinued in 1975. Reports from these surveys are National Center for Health statistics included in Series 13. Centers for Disease Control and Prevention SERIES 13. Data From the National Health Care Survey-These Public Health Servka reports contain statistics on health resources and the public’s 6!525 Belcrest Road, Room 1064 use of health care resources including ambulatory, hospital, Hyattsville, MD 20762 and long-term care services based on data collected directly (301) 436-6500 from health care providers and provider records. E-mail: nchsquery@nchlOa. em.cdc.gov Internet http://www.crk..gonchswsnchshmemMmMm DEPARTMENT OF PRESORTED SPECIAL HEALTH & HUMAN SERVICES FOURTH CLASS RATE Public Health Service POSTAGE & FEES PAID Centers for Disease Control and Prevention PHS/NCHS National Canter for Health Statistics PERMIT NO,,G-281 6525 Belcrest Road Hyattaville,Maryland 20782

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DHHS Publication No. (PHS) 96-1866, Series 16, No. 27 6-0231 (4/96)