the national ambulatory medical care surveylibrary of congress cataloging in publication data...

Data from theNATIONAL HEALTH SURVEY

Series 13Number 21

The National AmbulatoryMedical Care Survey:1973SummaryUnited States, May 1973-April 1974

Statistics are presented on the utilization of office-based physi-cians by ambulatory patients based on data provided by physiciansin the 1973 National Ambulatory Medical Care Survey. The num-ber of office visits and annual rate of office visits are shown byphysicians’ specialty, type of practice, and geographic location,and by the patient’s age, sex, and race. Also shown are the numberof office visits by patients’ medical problems, and physicians’ diag-noses, treatment, and disposition decisions.

DHEW Publication No. (HRA) 76-1772

US. DEPARTMENT OF HEALTH, EDUCATION, AND WELFAREPublic Health Service

Health Resources AdministrationNational Center for Health StatisticsRockville, Md. October 1975

Library of Congress Cataloging in Publication Data

DeLozier, James ENational ambulatory medical care survey, 1973 summary, United States, IWy 1972-

April 1974.

(Vital and health statistics: Series 13, Data from the National Health Survey; no. 21)(DHEW publication; no. (HRA) 76-1772)

Biblio~aphy: p.1. Physician services utilization–United States–Statistics. 2. Ambulatory mediczd carc-

United States. 3. Health surveys–United States. 4. United States–Statistics, Mediczl. 1.Gagnon, Raymond O., joint author. II. United States. National Center for Health Statistics.III. Title. IV. Series: United States. National Center for Health Statistics. Vital and healthstatistics: Series 13, Data from the National Health Survey Data from the hospital clischar~cosurvey; no. 21. V. Series: United States. Dept. of Health, Education, and Welfare. DHE~Vpublication; no. (HRA) 76-1772. [DNLM 1. Ambulatory care–Statistics. W2 A N 148vm no.21]RA407.3.A349 no. 21 [RA41O.7] 362.1’1’0973sISBN 0-8406 -0057-7 [362.1’0973] 75-35700

NATIONAL CENTER FOR HEALTH STATISTICS

HAROLD MARGULIES, M.D., Acting Director

ROBERT A. ISRAEL, Acting Deputy Director

GAIL F. FISHER, Associate Director for the Cooperative Health Statistics System

ELIJAH L, WHITE, Associate Director for Data Systems

EDWARD E. MINTY, Associate Director for Management

PETER L. HURLEY, Acting Associate Director for Operations

JAMES M. ROBEY, Ph.D., Associate Director for Program Development

ALICE HAYWOOD, Information Officer

DIVISION OF HEALTH RESOURCES UTILIZATION STATISTICS

SIEGFRIED A, HOERMANN, Director

WILLIAM F. STEWART, Acting Deputy Director

W. EDWARD BACON, Ph. D., Chiei Hospital Care Statistics Branch

JAblES E. DeLOZIER, Chief Ambulatory Care Statistics Branch

MANOOCHEHR K. NOZARY, Chief, Technical Services Branch

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

Vital and Health Statistics Series 13-No. 21

DHEW Publication No. (HRA) 76-1772Library of Congress Catalog Card Number 75-35700

PREFACE

This is the first of a series of reports from the National Center forHealth Statistics presenting results from the National AmbulatoryMedical Care Survey (NAMCS). It is appropriate to acknowledge atthis time a number of individuals and organizations outside of theNational Center for Health Statistics that assisted in and contributedto the development and implementation of the NAMCS.

First and foremost to be acknowledged are the contributions of themany physicians and their staffs who have graciously given their timeand effort to provide these data. As the only reliable source of theinformation presented here, their voluntary participation in the studywas crucial.

The contribution of Kerr L. White, M. D., who has been the primemotivator of this study since its conception, cannot beoveremphasized. He and his colleagues at the Johns HopkinsUniversity, Drs. John Williamson and James B. Tenney (currentlyHealth Director, Buncombe County, North Carolina), and Ms. JaneMurnaghan, provided inspiration as well as consultation through theseveral years of the NAMCS development.

The American Medical Association (AMA) and the AmericanOsteopathic Association (AOA) provided constructive consultationduring the formative years of planning the survey and shared with theCenter their many years of experience in surveying physicians. TheAMA and AOA also provided data files from which the NAMCSsample was selected and assisted in the selection process. Mr. ChrisTheodore and Mrs. Gene Roback of the AMA and Dr. EdwardCrowell of the AOA have provided assistance in these and otheractivities.

Under contractual arrangements, the National Opinion ResearchCenter has acted as the Center’s field agent in the NAMCS. Theirsurvey expertise and, ‘in particular, the professionalism of theirinterviewing staff have been major factors in the NAMCS success.

A number of individuals with ambulatory care interest andexpertise have served as technical advisors to the NAMCS. Providingoverall guidance and direction to the NAMCS at key pointsthroughout its development were:

Leland B. Blanchard, M.D. Charles E. Lewis, M.D.Lynn P. Carmichael, M.D. C. H. Ruhe, M.D.Theodore R. Ervin Herbert ShermanTodd M. Frazier Patrick B. Storey, M.D.Robert J. Haggerty, M.D. James B. Tenney, M. D., Dr. P.H.Jean Louise Harris, M.D. Kerr L. White, M.D.James Hudson, M.D. John W. Williamson, M.D.Hugh H. Hussey, M.D.

...Ill

Nineteen major national medical organizations have given theirofficial endorsement to the NAMCS and have actively participated inthe survey’s development and implementation. Without theirassistance and strong support this research would not have beenpossible. The organizations which have endorsed the NAMCS are:

American Academy of DermatologyAmerican Academy of Family PhysiciansAmerican Academy of NeurologyAmerican Academy of Orthopedic SurgeonsAmerican Academy of PediatricsAmerican Association of Neurological SurgeonsAmerican College of Obstetricians and GynecologistsAmerican College of PhysiciansAmerican College of Preventive MedicineAmerican College of SurgeonsAmerican Medical AssociationAmerican Osteopathic AssociationAmerican Proctologic SocietyAmerican Psychiatric AssociationAmerican Society of Internal MedicineAmerican Society of Plastic and Reconstructive Surgeons, Inc.American Urologic AssociationAssociation of American Medical CollegesNational Medical Association

CONTENTSPage

Preface ........................................................................................................ i

Highlights .................................................................................................... 1

Introduction ............................................................................................... 1Background ............................................................................................ 1Scope .................................................................................................... 2Source and Limitation of Data ............................................................... 2

Survey Findings in Brief ............................................................................ 3Population Utilization Patterns .............................................................. 3Physician Utilization Patterns ................................................................ 4Patient Problems, Diagnoses .................................................................... 5Characteristics of Visits ......................................................................... 7

References ......................0......................................................................... 9

List of Detailed Tables ............................................................................... 10

Appendix I. Technical Notes on Survey Design and Procedures ................Sample Design ........................................................................................physician Universe and Sample Size ......................................................Data Collection ......................................................................................Data Processing ......................................................................................Estimation Procedures ............................................................................Reliability of Estimates ..........................................................................Population Figures ................................................................................Systematic Bias ......................................................................................

454545464747485050

Appendix II. Definitions of Certain Terms Used in This Report ................ 52General Terms Relating to the Survey .................................................... 52

Selected Terms Used on the Patient Record .......................................... 53

Appendix III. Survey Instruments .............................................................. 56Patient Record and Patient Log ............................................................. 57Induction Interview Form ...................................................................... 58

v

SYMBOLS

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

Category

Quantity

Quantity

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

zero ---------------------------------------------- -

more than O but less than 0.05 ----- 0.0

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

vi

NATIONAL AMBULATORY MEDICAL CARESURVEY

James E. DeLozier, M. S., and Raymond O. Gagnon,

Division of Health Resources Utilization Statistics

HIGHLIGHTS

There were an estimated 644.9 million“encounters”, or “visits”, in the ofilces of“ofilce-based” physicians in the United Statesduring the period May 1973-April 1974. Bydefinition, these were visits for the purpose ofseeking or receiving care that involved a directpersonal exchange between the patient and thephysician or a member of his staff, Femalesaccounted for three of every five visits. Whitepersons accounted for nearly 9 of every 10 visits.The average person made 3.1 visits during the1-year period.

General and family practitioners accounted for40.4 percent of all visits; medical specialties, 26.3percent; and surgical specialties, 28.5 percent.More than 60 percent of all visits were by patientsseen previously for the same problem; and about20 percent were for problems considered seriousor very serious by the physician. During 63percent of all visits, the patient expressed a“symptomatic” problem or complaint as themajor reason for the visit. “Nonsymptomatic”problems accounted for 18 percent of all visits.Either a disease of the respiratory system or adisease of the circulatory system was thediagnosis in about one of every four visits.

Drug therapy was part of the treatmentprescribed at half of all visits. Laboratory tests

were ordered nearly 20 percent of the time as wasan injection or immunization. No treatment wasconsidered necessary at 5 percent of all visits. For61.2 percent of the visits, the patient wasinstructed to return at a specified time. Nofollowup was planned at 12.7 percent of thevisits.

INTRODUCTION

In May 1973, the National Center for HealthStatistics inaugurated the National AmbulatoryMedical Care Survey (NAMCS) to provide basicnational statistics concerning the public’sutilization of ambulatory medical services in theUnited States. As a continuing nationalprobability sample survey of ambulatory medicalencounters, the NAMCS represents the firstsurvey of its kind to be conducted successfully. Itis also the first major survey to incorporate thedimension of perceived need for seeking medicalcare as expressed by the patient in his own words.This information, related directly to thephysician’s diagnosis, treatment, and dispositiondecision, presents a broad picture of theambulatory patient, the problems for which heseeks care, and the physician’s interpretation andtranslation of those problems into medical termsand actions.

The NAMCS is the newest of the nationalsurveys conducted by the Division of HealthResources Utilization Statistics (DHRUS) of theNational Center for Health Statistics (NCHS)under authority of Public Law 93-393. TheDHRUS is responsible for a series of integratedsurveys designed to provide data concerning awide range of health resources. Along with theNAMCS, the DHRUS program includes theNational Hospital Discharge Survey, theNational Nursing Home Surveys, and theNational Family Planning Reporting System.These programs, together with the NCHS HealthInterview Survey, Health and Nutrition Exami-nation Survey, and Health Manpower andFacilities Surveys, constitute the National HealthSurvey program which, since 1956, has beenproviding basic national statistics measuring anddescribing the health status of Americans.

It is the purpose of this report to present abroad summary of NAMCS results from the firstyear (19 73) of operation. Additional tabulationsand more detailed analysis wiIl foIlow in sub-sequent reports.

Background

Until recently, the hospital and the hospitalinpatient have provided the principal focus forresearch into the provision of medical care in thiscountry. The last few years, however, have seenconsiderable resources invested in the study ofthe ambulatory care segment of the nationalhealth care system. It has been recognized thatthe sheer volume of ambulatory encounters farexceeds that of inpatient services, and thatambulatory medical care commands a significantshare of the total resources expended for healthcare. In addition, the roles of public clinics andhospital outpatient and emergency departmentsare being redefined and reorganized, and newand innovative ambulatory facilities are beingintroduced and tested in a wide range of settingsthroughout the country.

Greatly increased needs and demands for datahave accompanied the increased interest inambulatory care. As a result, the National Center

for Health Statistics has developed the NAMCSto meet some of these needs by providing basicstatistical documentation of the public’sutilization of ambulatory services.

Several years of testing and developmentpreceded the inauguration of this survey. Threemajor field tests and several smaller studies wereconducted between 1968 and 1973 to develop andrefine survey methods and instruments. A majorconsideration during that time was thedevelopment of procedures whit’h wouldminimize the time and work required ofindividual physicians while still obtainingsufllcient data to meet a wide range of needs. Inthis regard, an important aspect of the sampledesign is the categorical exclusion of physiciansselected in a NAMCS sample from possibleselection for the succeeding 2 years. In this way,no physician can be selected more frequentlythan once every 3 years.

Throughout the development of the NAMCS,every effort has been made to make it responsiveto the needs of the medical profession and toprovide the various interests in the medicalcommunity with means for input to the study.Toward this end, practicing physicians, adminis-trators, academicians, and researchers inmedical care delivery were (and continue to be)consulted at each step of the survey’sdevelopment. Liaison was established betweensurvey ofilcials and many major nationalmedical organizations; 19 national organizationswere asked for their support and assistance.These organizations have given their strongsupport, cooperation, and ofilcial endorsementto the NAMCS. A complete description of thebackground and methodological development ofthe NAMCS has been published. 1

SCOPE

The basic sampling unit for the continuingNAMCS is a physician-patient encounter. Onlyencounters, or visits, in the offices of physiciansclassified by the American Medical Associationfi~~] o:sthe American Osteopathic Association

“office-based, patient care” wereincluded in the 1973 NAMCS. (“Encounter” and“visit” are used interchangeably in this report.)Major ambulatory encounters not included in the

2

1973 NAMCS were those made by telephone,those made outside of the physician’s office (e.g.,in the patient’s home), those made in hospitaland institutional settings, and those made withphysicians not classified by the AMA or AOA asdescribed above. Though the scope of the 1973NAMCS included an estimated 70 percent of allambulatory encounters, important segments ofambulatory care were obviously omitted.

According to the Health Interview Survey,more than 10 percent of all ambulatoryencounters occur in hospital outpatient depart-ments and emergency rooms, and 13 percentoccur by telephone. It is planned to extend theNAMCS to include these encounters in the futurethough some very complex methodological andsampling problems must be resolved first.

The precise definitions of ofilce, physician,and patipnt eligible for the NAMCS arepresented in appendix II.

Source and Limitations of Data

The data presented in this report wereprovided by a national probability sample ofoffice-based physicians. A sample of 1,695physicians were contacted during the period May1, 1973, through April 30, 1974, of which 1,441were found to be eligible for the NAMCS andwere asked to participate. A total of 1,103 physi-cians (76.5 percent) participated in the study,providing data concerning a random sample ofabout 30,000 patient visits.

During a randomly assigned 7-day period, thesample physicians maintained a listing of’ allpatient visits in their offices. For a systematicrandom sample of visits, data were recorded onan encounter form provided for that purpose.Specially trained interviewers visited thephysicians prior to their designated week,provided survey materials, and thoroughlyinstructed each physician and. staff member inthe methods and definitions to be used.

Since the information in this report is derivedfrom a sample survey, readers are urged to reviewthe three appendixes to this report which provideinformation necessary for proper interpretationof the statistics presented. Appendix I contains ageneral description of the survey methods, thesample design used, and the data collection and

processing procedures. Imputation methods,estimation techniques, and estimates of samplingvariation are also presented. Since the statisticsin this report are based on a sample ofambulatory visits rather than on all visits, theyare subject to sampling errors. Therefore,particular attention should be paid to the sectionin appendix I entitled “Reliability of Estimates.”The sample size fkom the first year of datacollection is relatively small and, therefore, manyof the estimates shown in the detailed tables havesomewhat high relative standard errors. Chartsof relative standard errors and instructions fortheir use are given in appendix I.

Definitions of the terms used in this report andin the survey operation are presented in appendixII. A thorough review and understanding of thisinformation is also essential for the fullunderstanding and interpretation of these data.The letters and questionnaires used in theNAMCS are reproduced in appendix III.

The National Center for Health Statistics hascollected and published data on physician visitssince the initiation of the Health Interview Surveyin 1957.2 There are basic differences in theambulatory care statistics available from thatSurvey and in those from the National~mbulatory Medical Care Survey. The HealthInterview Survey collects information from anational sample of individuals concerning theirambulatory visits during a prior 2-week period.The NAMCS collects medical statistics onphysician visits directly from the attendingphysician. There are also differences in thephysician populations covered, in data collectiontechniques, and in the definitions of terms usedin the two surveys. As a result, there aredifferences in the estimates of patient visitsderived from both surveys, but the differences arenot substantial and are reconcilable.

SURVEY FINDINGS IN BRIEF

Population Utilization Patterns

There were an estimated total of 644.9 millionpatient visits in the United States to office-basedphysicians, or 3.1 visits per person, during theperiod May 1973 through April 1974. Visits byfemales accounted for 60 percent of all visits,

3

with more visits by females than males at all agesexcept under 15 years (table 2). Visits by femalespredominated for all specialties except pediatrics(table 4).

The utilization or visit rate for females, 3.7visits per person, was 50 percent higher than therate for males (table 1). An examination of visitrates by age and sex shows that this differenceexists largely because the rate for females in theage group 15-45 iyears is almost double thecorresponding rate for males. These rates, itshould be remembered, represent only visits tooffice-based physicians. Other studies, includingthe Health Interview Survey (HIS), indicate anannual rate of about 4.5 visits per person to allambulatory care sources (exclusive of telephonecontacts).

The visit rates for both sexes generally increasewith age, as do the rates for the white and allother groups. The rate for white persons is higherthan that of all other persons (3.2 and 2.6,respectively). When age is considered, however,the higher rate for the white group exists only forpersons under 15 and for persons over 64. Thereis no significant difference in the visit ratesbetween the white and all other groups in anyother age category. Data from the HIS show that23 percent of visits to hospital outpatient clinicsand emergency rooms are by persons other thanwhite as compared with 10 percent of visits toofl-ice-based physicians. The visit rates by ageand color, therefore, may change substantiallywhen the full universe of ambulatory care isconsidered.

Although the South Region had the largesttotal number of visits and the West had thefewest (table 2), the overall utilization rates showno differences among regions. Table 3 shows thatfor each region, there were about three visits perperson per year. This similarity in utilizationamong regions is consistent among all agegroups. There is a difference in rates, however,between the Northeast and all other regions whenphysician specialty is considered (table 7). Therates among the North Central, South, and Westare not significantly different for any specialty. Inthe Northeast, however, the rate for general andfamily practice is significantly lower and the ratefor medical specialists is higher than thecorresponding rates in the other regions.

There was also a difference in the visit ratesfor metropolitan and nonmetropolitan areas,with the rate being one-third greater in metro-politan areas. The higher visit rate for metro-politan areas is generally true for all age and sexcategories (table 3).

Physician Utilization Patterns

General practice physicians accounted for 260million, or 40 percent of all office visits duringthe survey year (table A). Pediatricians andgeneral practitioners on the average had largerpractices than physicians in other specialties(table 8). Pediatricians had an average of 139office patient visits per week. General and familypractitioners averaged 118 visits while theaverage for all office-based physicians was 91ofl-lce visits per week. The average number ofvisits per week varied somewhat by type ofpractice as well. For nearly all specialties,physicians in solo practice averaged fewer patientvisits than physicians in partnership or grouppractice.

Table A. Number and percent distribution of visits to office-based physicians by physician specialt y: United States, Mriy1973 -ApriI 1974

Physician Specialty

AH specialties . . .

General/Family practice . .

Medical Specialties . . .Internal Medicine . . .Pediatrics . . . . .Dermatology . . . .Other medical specialties .

Surgical Specialties . . . .General surgery . . . .Obstetrics and Gynecology.Ophthalmology . . . .Orthopedic surgery . . .Otorhinolaryngology . .UroIogy . . . . . .Other surgical specialties .

Psychiatry . . . . . .

All other specialties . . . .

Numbervisits inhousands

644,893

260,310

169,31674,69353,65915,68125,283

183,78844,84650,71528,01422,17920,48411,074

6,476

20,300

11,180

Percentdistribution

100.0

40,4

26.311.6

8.32.43.9

28.57.07.94.33.43.2

;::

3.1

1.7

It should be noted that no attempt has beenmade to examine such factors as size andcomposition of staff, hours spent seeing patients,

4

I

and certain other factors which are importantconsiderations when analyzing differences be-tween types of practices. The weekly visit ratespresented here are generally consistent with thosefrom other sources, including the AmericanMedical Association (AMA), though these figuresare generally lower than those of the AMA. Mostof the differences are likely the result of differentdata collection methods, different definitions ofvisit, and sampling variability.

Patient Problemsr Diagnoses

There were two major sources of informationconcerning the conditions which caused patientsto make ofilce visits, The first is the “patient’sprincipal problem, complaint, or symptom” asreported in the patient’s own words. The secondis the “principal diagnosis” representing thephysician’s best description of the patient’scondition at the time of the visit. It may be aworking, provisional, or definitive diagnosis.

Patients’ problems, complaints, or symptoms(these terms hereafter used interchangeably) havebeen coded and classified according to a systemspecifically developed for the NAMCS.3 Princi-pal diagnoses have been coded and classifiedaccording to the Eighth Revision of theIntwwational Classljication oj”Diseases Adaptedjor Use in the United States (ICDA).4 A maxi-mum of three problems and three diagnoseswere coded for each patient visit. On the averagethere were slightly less than 1.5 diagnostic codesand 1.5 problem codes assigned for each visit.The data presented in this report represent onlythe tirst listed or principal problems andprincipal diagnoses. Tabulations and analysis ofsecond and third listed problems and diagnoseswill be included in subsequent reports.

Patient problem data are presented in tables 9through 15. In table 9 are listed the 60 mostfrequent problem categories. Though they arelisted in order of the estimated total number ofvisits, the ranking is somewhat superficial sincemany estimates are not statistically differentfrom other near estimates because of samplingvariability.

As shown in table 9, the first 16 listed prob-lem categories account for half of all visits,and the first 40 account for 75 percent of thevisits. Prominent among the most frequent

symptoms presented by patients are problems(pain, sprain, swelling, fracture, and so forth) ofthe upper extremities, lower extremities, andback, which are three of the first six problemcategories. There were 63.7 million visits forthese three problems, which is nearly 10 percentof all visits. The common complaints of sorethroat, cough, and cold were also prominentamong the most frequent problem categories,accounting for 52.5 million visits, or more than 8percent of all visits.

The first listed problem category, progressvisit, contains 75 million visits and includes thosevisits for which the patient’s principal problemwas recorded as a followup or progress visit.There were, however, a total of 396.7 millionfollowup visits. This figure may be derived fromtable 22 which shows that 61.5 percent of the644.9 million visits were by patients seen beforefor the current problem. For all but 75 million ofthese, the patient’s problem was expressed interms of a symptom, complaint or other reasonfor visit and was coded and classified as a symp-

tomatic or nonsymptomatic problem.

In tables 10 through 15 are shown the 27 mostfrequent problem categories grouped accordingto “symptomatic,” “nonsymptomatic” and“other” problems. Because progress visits cannotbe categorized as either symptomatic ornonsymptomatic, they are included in the “otherproblems” category. Also contained in the“other” category is problem code 990,“Problems, complaints, symptoms, and reasonsfor visit, not elsewhere classified.” There were37.1 million visits in this category (out of the 40.2million shown in the 30th category of tables10-15). These were largely diagnostic terms givenby the patients as their problems which theNAMCS Classification System was not designedto code with specificity. As shown in table 12,these were some of the most seriously ill persons.This deficiency in the coding system has beenrectified somewhat by modifications introducedfor the 1975 NAMCS.

Symptomatic problems accounted for 63.5percent of all visits, the remainder being evenlydivided between nonsymptomatic problems andthe somewhat amorphous “other problems”category (table B). The predominance of femalevisits holds for nearly all of the most frequent

5

patient problem categories, with male visits morefkequent only for three symptomatic and threenonsymptomatic problems (table 10).

Nonsymptomatic problems, consisting largelyof routine examinations, were usually considerednot serious while symptomatic problems weremore frequently considered serious or veryserious (table 12). More than 30 percent of visitsfor high blood pressure and fatigue wereconsidered serious or very serious, as were 40percent of visits for chest pain. Cold, allergic skinreaction, and earache were least often serious.

Table B. Number and percent distribution of visits to office-Irased physicians, by patient’s principal prbblem: UnitedStates, May 1973-April 1974

Number of PercentPatient’s principal problem tilts in distribution

thousands

Att problems . . . 644,893 100.0

Symptomatic . . . . 409,840 63.5Nonsymptomatic . . . 119,230 18.5Other ..,.... 115,823 18.0

Broad classes of treatment and dispositiondecisions for the most frequent patient problemsare presented in tables 14 and 15. Drug therapywas the most frequent method of treatment,being all or part of the treatment at about half ofthe visits. For nearly all of the leadingsymptomatic problems, drugs were prescribedmore than half the time. In 9 of the first 19symptomatic problem categories, drug therapywas prescribed more than 70 percent of the time.For only three problems were drugs ordered lessthan half the time.

Laboratory tests were ordered or providedmost often for fatigue and chest pain. Aninjection or immunization was most frequentlyprovided for sore throat, cold, fatigue and skinwounds (about 30 percent of the visits for each).

Information concerning physician principaldiagnosis is shown in tables 16 through 21. The60 most frequent diagnoses classified in ICDA3-digit categories are shown in table 16. As withtable 9, the ordering shown is superficial becausesample variation makes the differences betweenmany adjacent positions in the list statisticallyinsignificant.

In table 16, the first 23 diagnoses account forhalf of all visits. The next 37 categories add only

17.5 percent to the cumulative dktribution.. Themajor classifications of principal diagnoses arepresented in table C. These data are consistentwith the patient problem data and provide detailand insight into the sometimes’ indeterminateproblem expressions. As might be predicted ftomthe problem data, the largest group of diagnosesis “special conditions and examinations withoutillness,” which constitutes 17 percent of all visits.Of the remaining major classification groups,diseases of the respiratory, circulatory, andnervous systems are the three most frequentdiagnostic categories, being the categories ofdiagnosis for 32 percent of the visits.

Table C. Number and percent distribution of visits to office-basedphysicians by principrd diagnosis: United States, May 1973-April 1974

Principal diagnosis classified by major ICDAcategory 1

Alldiagnoses Oaoo. ce.

Infective and parasitic diseases . . ooo-136Neoplasms. . . . . . . ; 140-239Endocrine, nutritional and

metabolic diseases . . . . 240-279Mental disorders . . . . . . 290.315Diseasesof nervous system and

sense organs . . . . . . 320-389Diseases of circulatory system . . 390458Diseases of respiratory system . . 460-519Diseases of digestive system. . . 520-577Diseases of genitourinary system . 580-629Diseases of skin and subcutaneous

tissue . . . 680-709Diseases of mulculosLleLl ;yst;m. 710-738Symptoms and ill-defiled conditions 780-796Accidents, poisoning and violence ~ 800-999 ISpecial conditions and examinations

without sickness . . . . . YOO-Y13(ltherandunknown . . . . . . . .

Numbexvisits in1,000’s

;44.893

25,23312,713

26,09929,064

50,84159,24097,38323,82637,744

34,09934,37034,25147,609

.10,20322,218

‘ercentlistri-wtion

00.0

3.92.0

:::

7.9

1?::3.75.9

5.35.35,37.4

17.13.4

lDiagnostic groupings and code number inclusions are basedon the Eighth Rev&on~ International C’k@%ation of Dieeases,Adapted for Use in the United States, 1965.

As with the data concerning patient problems,table 17 shows that visits by females predominatein all but a few diagnosis categories. This tablealso shows the major ICDA classes and selectedspecific diagnosis categories. There were moremale than female visits only for diagnoses ofotitis media and the broad category of accidents,poisonings, and violence.

Treatment and disposition decisions for the 20most frequent diagnosis categories (3-digit ICDAcategories) are shown in tables 20 and 21.

6

Laboratory tests were ordered most frequentlywhen the diagnosis was diabetes (67.5 percent ofvisits) and chronic ischemic heart disease (40.3percent of visits). Visits for hay fever, othereczema and acute tonsillitis most often resultedin an injection or immunization. Drug therapywas part of the treatment prescribed for 80percent or more of visits for acute upperrespiratory infection, acute pharyngitis, acutetonsillitis, and bronchitis.

Disposition decision generally follows predict-able lines. No followup was planned mostfrequently when the patient was diagnosed ashaving an acute, self-limiting condition or a“nonillness” condition such as a routineexamination. Instructions to return at a specifiedtime were given for diagnoses of chronicconditions and conditions which are oftenserious.

Characteristics of Visits

The majority of visits (61 percent) concernedproblems or conditions for which the patient hadpreviously been seen by the same physician. Only16 percent were visits by “new” patients — i.e.,first visits to physicians who had never treatedthe patient before (table 22). Males were morefrequently new patients than were females, andpersons other than white were new patients moreoften than white persons. The proportion of newpatient visits. varied among the four majorspecialty groups as may be seen in table 23,although the pattern for general and familypractice physicians was similar to that formedical specialists. Surgical specialties have ahigher proportion of new patients than any of theother specialty groups.

For about 81 percent of the visits, physiciansevaluated the patients’ problems as not serious oras slightly serious m terms of the extent ofimpairment that might result if no care weregiven. Proportionally more visits by males wereconsidered serious than by females, and theproportion of serious problems increased withage of patient (table 24).

During nearly all visits, one or more treatmentor service was ordered or provided to the patient.In only 5 percent of the visits was no treatment orservice considered appropriate by the physician

(table 26). (See appendixes II and III forcomplete listing and definitions of Treatmentand Service Categories.) Drug therapy, theprovision of a prescription or nonprescriptiondrug, was the most frequent treatment. It wasordered or provided at 49.4 percent of visits.Medical counseling and laboratory tests wereeach provided about 20 percent of the time aswas an injection or immunization.

The average (median) length of time that apatient spent under the direct care of hisphysician was 12 minutes (table D). It isimportant to understand that “duration of visit”represents the time spent by the patient inface-to-face contact with the physician. This timeit is estimated by the physician after the visit, andit does not include “waiting” time, time spent inthe care of the patient by the physician’s staffwithout the presence of the physician, or timespent by the physician in the care of the patientbefore or after the face-to-face contact (e.g.,time spent reviewing charts and test results,writing instructions, or maintaining records).The category, “zero minutes” represents thosevisits for which thq physician spent no time withthe patient and care was provided by a staffmember under the physician’s direct supervi-sion. In many instances (75 percent of the visits)the duration of visit was reported in 5-minuteintervals (5, 10, 15 minutes) since precisemeasurements of time were not possible. Despitethe lack of absolute precision in the estimatedtime figures, the relative values are thought toprovide useful and valuable information. Intables 13 and 19, for example, time spent duringvisits for various problems and diagnosticconditions provides an indication of theirseriousness and complexity.

Table D. Percent and cumulative percent distribution of visits tooffice-based physicians by duration of visit: United States,Mav 1973-Anril 1974

Duration of visit Percent Cumulativedistribution percent

I ITotal visits . . . 100.0 100.0

Zero minutes . . . . 2.0 2.0l-5 minutes . . . . , 15.0 17.06-10 minutes . . . . 32.3 149.311-15 minutes . . . , 25.7 75.016-30 minutes . . . . 18.9 93.931 minutes or more . . . 6.1 100.0

1Median duration of visit: 12 minutes; mean, 14 minutes.

7

Table 28 shows time spent according tophysician specialty. Nearly half of all visits werecompleted in 10 minutes or less and only a smallproportion lasted more than 30 minutes. Shortervisits predominate in general and family practice,longer ones in specialty practices.

Disposition and followup plans after the visitare shown in tables 30 and 31. Appointments forreturn visits at specified times were arrangedfollowing 61 percent of the visits, and less specific

directions to return if necessary (PRN) were givenat one-fifth of the visits. The instruction to returnat a specified time was given more frequently byphysicians in specialty practice than by those ingeneraI and family practice. This specificfollowup instruction was also more frequentlygiven to older patients than to younger ones, Nofollowup or telephone followup was planned after12 and 3 percent of the visits, respectively, andpatients were referred for admission to a hospitalafter 2 percent of the visits.

REFERENCESlN~tiona] centerfor Health stati~tic~:National ambulatory medical care survey: background and

methodology, United States. Vital and Health .Stafisfics. Series 2. No. 61. DHEW Pub. No. (HRA)74-1335. Health Resources Administration. Washington. U. S. Government Printing Otlice, Mar. 1974.

2Nationalcenterfor Hea]th Statistics: Physician visits, volume and interval since last visit, UnitedStates, 1971. Vital and Health Statistics. Series 10, No. 97. DHEW Pub. No. (HRA) 75-1524. HealthResources Administration. Washington. U. S. Government Printing Office, Mar. 1975.

3Nationalcenterf(>r Health Statistics: The National ambulatory medical care survey: SymptmnClassification, United States. Vital and Health Statistics. Series 2, No. 63. DHEW Pub. No. (HRA)74-1337. Health Resources Administration. Washington. U. S. Government Printing Office, May 1974.

4Nationalcenterfor Hea]th Statistics: Eighth Revision IntemationaI Class@ation of” Disswstw.Adaptedfbr Use in the United States. PHS Pub. No. 1693. Public Health Service. Washington. U. S.Government Printing Office, 1967.

8

c

LIST OF DETAILED TABLES

Table 1, Number, percent distribution, and annual rate of office visits by age of patient, according to patient’s sex and color:

United States, May1973-April 1974. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2, Number and percent distribution ofoffice visits by~eographic region andmetropolitan andnonmetropolitan areas,according toage, sex, andcolor of patient: United States, May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . , .

3, Annual rate of office visits by age of patient, according to geographic region, metropolitan and nonmetropolitan

areas, andsexof patiant: Unitad States, May1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4, Numbar and percent distribution of office visits bysex, color, andageof patiant, according to physician specialtyandtype ofpractice: United States, May1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5, Annual rataof office visits bysex, color, andageof patient, according tophysician specialty, andtype of practice:United States, May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6, Number and percent distribution ofoffice visits bygeographic region andmetropolitan andnonmetropolitan areas,according to physician specialty and type of practice: United States, May 1973-April 1974 . . . . . . . . . . . . . . . . .

7. Annual rate of office visits by geographic region, metropolitan and nonmetropolitan areas, according to physicianspecialty, and typa of practica: United States, May 1973-April 1974. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8, Mean number of office visits per week, by type of practica and physician specialty: United States, May 1973-April

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9, Number, percent distribution, and cumulative parcent of visits to office-based physicians for the 60 most frequent

patient problems: United States, May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10, Number and percent distribution of office visits bysex, color, and age of patient, according topatient’s principalproblem, complaint, orsymptom: United States, Mayl973-Aprill974. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11. Numbar and percent distribution of office visits by physician specialty andtypeof practice, according topatient’s

principal problem, complaint, orsymptom: United States, Mayl973-Aprill974 . . . . . . . . . . . . . . . . . . . . . . .

12, Number andpercent distribution of office visits byseriousness ofpatient’s principal problem, according topatient’s

principal problem, complaint, or symptom: United States, May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . .

13, Number and percent distribution of office visits by time actually spant with physician, according to patiant’sprincipal problem, complaint, or symptom: United States, May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . .

14, Number and percent of office visits by treatments and services ordered or provided, according to patient’s principalproblem, complaint, or symptom: United States, May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15. Numbar and percent of of fica visits by disposition of visit, according to patient’s principal problem, complaint, orsymptom: United States, May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16, Number, percent distribution, and cumulative percent of visits to office-based physicians, by the 60 most common

ICDA three-digit categories containing the principal diagnosis: United States, May 1973-April 1974 . . . . . . . . . . .

17, Number and percent distribution of office visits by sex, color, and aga of patient, according to principal diagnosis:United States, May1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18, Number and percant distribution of office visits by physician specialty, according to principal diagnosis: United

States, May1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19, Number and percent distribution of office visits by time actually spent with physician, according to principal

diagnosis: United States, May1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20, Numbar and parcent of office visits by treatments and services ordered or provided, according to the 20 mostfrequent diagnoses: United States, May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Page

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

29

31

32

9

List of Detailed Tables-Con.

Table 21, Numbar and parcent of office visits by disposition of visit, according tothe20most frequant diagnoses: UnitedStates, May1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..”. .- . . . . . . . . . . . . . . ..s. s

22. Numbar and percent distribution of office visits by prior visit status, according to age, sex, and color of patient:United States, May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. o . . . . . . ..s . . . . ..o o.100

23. Number and percent distribution of office visits by prior visit status, according to physician specialty andtypeofpractice: United States, May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24. Number and percent distribution of offica visits by seriousness of patient’s principal problem, according to sex,color,and ageofpatient: United States, May1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25. Number and percent distribution of office visits by seriousnessof patient’s principal problem, according tophysi-cianspecialty andtype of practice: United States, May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26, Number and percent ofoffice visits bytreatmants andservices ordered orprovided, according tosex, color, and ageofpatient: UnitedStatas,May 1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27. Number and percent of office visits by treatments and services ordared or providad, according to physicianspecialty, andtype ofpractice: United States, Mayl973-April 1974. . . . . . . . . . . . . . . . . . . . . . . . . . 0. . . . .

28. Number and percent distribution of offica visits by time actually spent with physician, according to physicianspecialty andtypeofpractica: United States, May1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29. Number and percent distribution of office visits bytima actually spent with physician, according toage, sex, andcolor ofpatiant: United States, May 1973 -Aprii 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30. Number and percent of office visits by disposition of visit, according to sex, color, and age of patient: UnitedStates, May1973-April 1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...o....,000......000

31. Number and percent of office visits by disposition of visit, according to physician specialty, andtype of practice:United States, May1973-April 1974. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. s . . . . . ... .

33

34

35

36

37

38

39

40

41

42

43

10

I Table 1, Number, percent distribution, andannual rate Ofoffice tisitsby age Ofpatient, according topatient's sex andcolor: United States, May 1973-April 1974

Sex and color

All patientsMaleFemale

WhiteMsleFemale

All otherMaleFemale

All patientsMaleFemale

WhiteMdeFemale

fNl other

MaleFemale

Number 01visits inthousands

644,893253,285391,608

575,881228,577347,304

69,01324,70944,304

644,893253,285391,608

575,881228,577347,304

69,01324,70944,304

Total,sll ages

Under 15 15-24 25-44 45-64 65 yearsyears years years years and over

100.0100.0100.0

100.0100.0100.0

100.0100.0100.0

3.1 )2.53.7

3,22.63.7

2.62.03.2

19.426.115.1

19.526.215.0

18.624.415.4

Percent distribution

15.4 24.713.6 20.116.6 27.8

15.113.616.1

18.213.720.8

24.119.727.1

29.823.533.4

24.925.424.6

25.125.225.0

22.926.720.7

Number of visits per person per year

t

2,3 2.62.3 1.92.2 3.4

2.4 2.72.5 2.02.3 3.4

i.s 2.41.4 1.31.6 3.3

3.22.14.2

3.12.14.1

3.42.1

3.83.24.3

3.83.24.3

3.73.4

15.514.916.0

16.215.216.8

10.411.79.7

4.94.55.2

5.04.65.3

4.03.7

4.3I

4.0 I 4.2

11

Table 2. Number and percent distribution of office vkits by geographic regicm and metropolitan and nonmetropolitanareas, according to age, sex, and color of patient: United States, May 1973-April 1974

Age, sex, and colorII

—

AUpatients

All agesUnder 15 years15-24 years2544 years45-64 years65 years and over

Sex—

MaleUnder 15 years15-24 years2544 years45-64 years65 years and over

FemaleUnder 15 years15-24 years25-44 years45-64 years65 years and over

Q&r

WhiteUnder 15 years15-24 years2544 years45-64 years65 years and over

All @herUnder 15 years15-24 years2544 years45-64 years65 years and over

Number ofvisits in

thousands

644,893125,07799,581

159,551160,435100,249

253,28566,00734,41950,82564,28237,752

391,60859,07065,161

108,72696,15362,497

575,881112,22987,003

138,960144,64593,044

69,01312,84812,57820,59215,7907,204

100.0100.0100.0100.0100.0100.0

100.0100.0100.0100.0100.0100.0

100.0100.0100.0100.0100.0100.0

100.0100.0100.0100.0100.0100.0

100.0100.0100.0100.0100.0100.0

23.823.923.924.324.422.0

23.924.725.622.624.521.5

23.823.023.025.224.322.4

24.824.725.125.125.323,0

16.116.515.419.015.7

*

26.627.326.925.626.127.7

26.226.027.026.624.727.5

26.828.626.825.127.127.9

27.528.828.426.026.728.8

18.413.716.422.520.6

*

South‘est lMe~~anlNOn


31.534.331.431.230.530.5

32.335.031.531.831.230.8

31.033.531.330.929.930.3

30.333.128.830.629.429.1

42.244.649.235.340.549.0

18.114.617.918.919.119.8

17.714.216.019.019.620.3

18.414.918.918.918.719.4

17.513.417.818.318,619.1

23.325.219.023.223.227.9

74.770.774.179.976.170.0

73.169.572.178.175.269.8

75.872.075.180.776.770.1

74.370.574.079.275.669.9

78.272.874.485.080.270.8

25.329.325.920.123.930.0

26.930.527.921.924.830.2

24.?.28,024.919.3~3a3

29.9

25.730,026.o20.924.430.1

21.827,225.615.119.929.2

12

Table 3, Annual rate of office visits by age of patient, according to geographic region, metropolitan and nonmetropol-itan areas, and sex of patient: United States, May 1973-April 1974

Geographic region,location of physician’s

practice and sex of patient

All regions

NortheastNorth centralSouthwest

Location and sex

Metropolitan areaMaleFemale

Nonmetropoiitan areaMaleFemale

Total,all

ages

3.1

3.13.03.13.2

3.42.74.0

2.52.22,9

IIUnder 15 15-24years years

2.3

2.42.22.41.9

2.32.42.3

2.12.21.9

2544 45-64 65 yearsyears years and over


2.6

2.82.62.62.6

2.82.03.7

2.21.62.8

3.2

3.33.03.23.3

3.62.34.7

2.21.62.8

3.8

3.63.63.84.2

4.23.54.8

2.92.53.2

4.9

4.34.94,86.2

5.45.05.6

4.13.64.5

13

Table 4. Number and percent distribution of office visits by sex, color, and age of patient, according to physician specialty

Physician specialtyand type of practice

AUspechdities

General and familypractice

Medical specialtiesInternal medicinePediatricsOther

Surgical specialtiesGeneral surgeryObstetrics and

gynecologyOther

Other specialtiesPsychiatryOther

mu eofu ractice

soloOtherl

Number ofvisits in

thousands

644,893

260,310

169,31674,69353,65940,964

183,78744,846

50,71588,227

31,48120,30011,180

386,208258,685

and type of practice: United States, May 1973.Apri3 1974 - - -

I Sex I Color I &e

Total, All Under 15 15-24 2544 45-64 65 years533 WMte other years years years years and over)ersons


100.0

100.0

100.0100.0100.0100.0

100.0100.0

100.0100.0

100.0100.0100.0

100.0100.0

39.3

40.8

44.439.652.941,8

31.639.4

45.2

44.043,844.3

39.139.6

60.7

59.2

55.660.447.158.2

68.460.6

100.054.8

56.056.255.7

60.960.4

89.3

88.0

88.487.389.988.6

91.190.9

87.992.9

94.395.791.7

88.390.8

10.7

12.0

11.612.710.111.4

8.99.1

12.17.1

5.7**

11.79.2

,19.3

16.6

34.52.6

93.515.0

10.09.3

*

15.5

16.417,813.4

17.222.8

15.4

16.8

11.110.64.4

20.6

18.013.4

31.612.6

12.913.911,0

15.515.4

24.7

23.5

15.721.4

*

25.0

32.525.7

54.223.4

38.248.020.3

25.024.3

24.9

26.4

22.736.1

*

27.0

25.433.6

11.229.4

20.917.627.1

26.222.9

15.5

16.8

16.029.3

*

12,4

14.018.0

*

19.2

11.8*

28.3

16.214.6

lkcludes prutnership and group practices.

,

14

Table 5. Annual rate of office visits by sex. color, and age of Datient. according to physician specialty, and type of


All specialties

General and family practice


Surgical specialtiesGeneral surgeryObstetrics and gynecologyOther


Type of practice

SclloOtherl

pra&ice; United State;, Ma+ 1973:April 197~ - - - - “

Sex Color Age.

Total, All Under 15 15-24- 2544 45-64 65 years11persons Male Female WMte other years years years years and over

-.


3.1

1.3

0.80.40.30.2

0.90.20.20.4

0.20.10.1

1.91.3”

2.5

1.1

0.80.30.30.2

0.60.20.00.4

0.10.10.0

1.5,1.0

3.7

1.4

0.90.40.20.2

1.20.30.50.5

0.20.10.1

2.21.5

3.2

1.3

0.80.40,30.2

0.90.20.20.5

0.20.10.1

1.91.3

2.6

1.2

0.70.40.20.2

0.60.20.20.2

0.1**

1.70.9

2.3.—

0.8

1.10.00.90.1

0.30.1

*

0.2

0.10.10.0

1.21.1

2.6

1.2

0.50.20.10.2

0.90.20.40.3

0.10.10.0

1.61.1

3.2

1.2

0.50.3

*

0.2

1.20.20.50.4

0.20.20.0

1.91.2

3.8

1.6

0.90.6

*

0.3

1.10.40.10.6

0.20.10.1

2.4

1.4

4.9

2.1

1.31.1

*

0.2

1.30.4

*

0.8

0.20.00.2

3.11.9

lInchrdes partnership and group practices

15

Table 6. Number and percent distribution of office visits by geographic region and metropolitan and nonmetropolitan areas,according to physician specialty and type of practice: United States, May 1973-April 1974


AUspecialties


MedicalspecialtiesInternal medicinePediatricsOther

SurgicalspecialtiesGeneral surgeryObstetrics end gynecology

Other


Type of practice

solootherl

Number ofvisits in

thousands

644,893

260,310

169,31674,69353,65940,964

183,78744,84650,715

88,227

31,48120,30011,180

386,208258,685

Total,all Northeast North Central South

~=t Metropolitan Nomnetropolitan

regions areas areas


100.0

100.0

100.0100.0100.0100.0

100.0100.0100.0

100.0

100.0100.0100.0

100.0100.0

23.8

17.3

33.335.326.937.8

22.615.529.8

22.1

34.342.219.9

28.516.9

26.6

30.4

25.124.230.020.5

23.233.321.7

19.0

22.411.841.5

25.328.5

31.5

34.1

26.024.630.223.3

33.331.532.5

34.7

29.829.430.6

31.631.5

18.1

18.3

15.615.913.018.4

20.919.716.0

24.3

13.516.6

*

14.723.2

74.7

62.1

83.283.175.094.0

82.674.089.9

82.7

87.696.471.7

74.075.8

25.3

37.9

16.916.925.16.0

17.426.010.1

17.3

12.4*

28.3

26.024.2

lhrcludes partnership and group practices.

16

Table 7. Annual rate of office visits by geographic region, metropolitan and nonmetropolitan areas, according to physicianspecialty, and type of practice: United States, May 1973-April 1974


AUspecialties

Oeneral and family practice




Type of practice

soloOthcrl

J%dNO’tie=tI ‘orticentidI ‘oufiI ‘“t

3.1

1.3

0.80.40.30.2

0.90.20.20.4

0.20.10.1

1.91.3

3.1

0.9

1.20.50.30.3

0.80.10.30.4

0.20.20.0

2.30.9

Number of visits per 1

3.0

1.4

0.70.30.30.1

0.70.30.20.3

0.10.00.1

1.71.3

3.1

1.4

0.70.30.20.1

0.90.20.30.5

0.10.10.1

1.91.3

son per :

3.2

1.3

0.70.30.20.2

1.10.20.20.6

0.10.1

*

1.61.7

Metropolitan I NomnetrOpolitanareas I areas

r

3..4

1.1

1.00.40.30.3

1.10.20.30.5

0.20.10.1

2.01.4

2.5

1.5

0.40.20.20.0

0.50.20.10.2

0.1*

0.0

1.51.0

lIncludes partnership and group practices.

17

Table 8. Mean number of office visits per week, by type of practice and physician specialty: United States, May 1973-

Physician specialty

All specialties


Medical specialtiesInternrd medicinePediatricsOther



1.Includes partnership andg’roup practices.

April 1974

Total,all practices

91

118

9982

139100

72608872

524482

solo

88

113

9581

133101

68578270

504091

Other 1

95

132

10383

14299

77659574

595666

2-Includes those physicians who saw one ormorepatients during their week of participation in the survey.

18

Table9. Number, percent distributioII, andcumuIative percent oftiltst ooffice-base dpbysiciansforthe60mostfiequent patient problems: Utited States, Wy1973-Aptil974

Patient’sprincipal problem classifiedbyNAMCSsymptom dar.sificatiOnl

1.2.3.4.5.

6.7.8.9.

10.

11.12.13.14.15.

R18.19.20.

21.22.23.24.2.5.

26.27.28.29.30.

31.32.33.34.35.

36.37.38.39.40.

41.42.43.44.45.

46,47.48.49.50.

51.52.53.54.55.

56.57.58.59.60.61.

Total, all problems

ProgressvisitsProblemsof lower extremityPregnancyexaminationThroat sorenessProblemsof upper extremity

Problemsof backcoughAbdominalpainGeneralphysicalexaminationCold

GynecologicexaminationVk,itfor medicationNmreHeadacheFatigue

Pabrbr chestRequiredphysicalexaminationWeU-babyexanrirrationFeverAllergicskin reaction

Problemsof face, neckVisiondysfunction,except b~mdrressWeightgainVertigoEarache

WoundsHighblood precsureSbmtness of breathNasalcongestionSwelling,maw of skin

Skin irritation (nonaffergic)Anus,rectafproblemsSymptomsof nervousnessSynrptamsof deprassirorVaginald~charge

NauseaPain, irritation of eyeMenstrualdisordersAcnePainfulurination

DiarrheaHearbrgdysfunction,except deafnessMenopausalsymptomsSituationc3problemsSymptomsof anxiety

NoctoriaLaboratory testbrgSwelliig or mass,site rmspecifiedStomachupsetPain,site unspecifkd

Lumpin breastSkinmolesIrregularheartbeatwartsSinusproblem

PelvicdisorderWeakuess,numbnessof extremityHmmmessBlockedfeelingof carWdvard~orderAUotlrerproblems

9g0,985400905520405

415311540900312

904910997056004

322901906002112

410701010069735

116205306301115

113560810807662

572705653100604

555731650941800

601920015570013

680109200111304

660420325737663

Residual

Numberofvisitsin

thousands

644,893

75,67325,94425,94220,72618,956

18,8X18,34716,41815,02213,460

13,15413,10313,04312,31411,768

11,35011,09510,6999,8229,45LI

9,3279,2198,9997,6067,466

7,3917,0146,8586,6756,158

6,1445,2544,7674,7614,687

4,2694,1824,1784,0613,5S2

3,0922,9542,7292,4882,369

2,3092,2792,2342,2122,150

2,1462,0261,9711,8911,814

1,7121,6521,6431,5591,503

114,445

Percentof

visits

100.0

11.74.04.03.22.9

2.92.82.52.32.1

2.02.02.01.91.8

1.81.71.71.51.5

1.41.41.41.21.2.

1.11.11.11.01.0

1.00.80.70.70.7

0.70.70.70.60.6

0.50.50.40.40.4

0.40.40.40.30.3

0.30.30.30.30.3

0.30.30.30.20.2

17.7

Cumrdativepercent

100.0

11.715.819.823.025.9

28.931.734.236.638.7

40.742.744.846.748.5

50.352.053.655.256.6

Sg.159.560.962.163.2

64.465.566.567.668.5

69.570.371.071.872.5

73.273.874.575.175.6

76.176.677.077.477.8

78.178.578.879.279.5

79.880.180.480.781.0

81.381.5gl.882.082.3

100.0

lsymptomatic gmupbrgsand code numberinclusiorrcare based on a symptom classificationdevelopedfor usein the NAbfCS.

19

..SoIiE>.o.z’

6

————

20

****++

******+

**+

****q

********.qq

mm

d-m

Ooooqooooooo

Oqoooooo

Oooooqoo

qq

Gtio”OOO”

156006‘s&

odtiG

d&ti

00000000000000000000&&o&&o&o

00

00

00

00

00

00.

.-+4..,-!..

.-+d.

,+ti...

..d...s

44.++

.d+

21

Table 12. Number and percent distribution of Office visits by seriousness of patient’s principal problem, according topatient’s principal problem, complaint, or symptom: United States, May 197&April 1974.

Patient’s principal problemclassified by NAMCSsymptom classification 1

Total, all problems

Symptomatic problems -001-899

1.2.3.4,5.6.7.8.9.

10.11.12.13.14.15.16.17.18.19.20.

Problems of lower extremityThroat sorenessProblems of upper extremityProblems of backcoughAbdominal painColdHeadacheFatiguePain in chestFeverAllergic skin reactionProblems of face, neckVision dysfunction (except blindness)Weight gainVertigo-dizzinessEaracheWounds of skinHigh blood pressureOther symptomatic problems

Norrsymptomatic problems -900-979

21. Pregnancy exam22. General medical exam23. Gynecologic exam24. Visit for medication25. None26. Required physical exam27. Well-baby exam28. Other nonsymptomatic problems

~er problems -000, 980-999

400520405415311540312056004322002112410701010069735116205

Residual

905900904910997901906

Residua

980,985

Wrmber of,isits inhousands

44,893

25,94420,72618,95618,82418,34716,41813,46012,31411,76811,3509,8229,4589,3279,2198,9997,6067,4667,3917,014

65,431

25,94215,02213,15413,10313,04311,09510,69917,172

75,67340,151

Seriousness of patient’? principal problemII I I

--lTotal Serious and Slightly Notvery serious serious serious


100.0

100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

100.0100.0100.0100.0100.0100.0100.0100.0

100.0100.0

19.2

20.511.418.718.816.927.0

7.118.930.640.415.4

*

20.022.211.524.0

*

19.633.023.6

***

7.613.7

**

18.8

19.635.6

30.4

29. Progress visits 51.830. All other problems 000,990,998,999 33.4

lSymptomatic groupings and code number inclusions are based on a symptom classification developed for use irr the NAMCS.

40.238.938.842.538.841.232.737.533.232.641.835.639.223.938.741.151.039.241.535.3

*

8.1*

11.614.6

**

17.9

28.631.0

50.5

39.349.742.638.844.331.860.343.636.227.142.856.440.853.949.835.036.941.225.441.1

93.786.294.980.871.697.498.563.3

22

Table 13. Number and percent distribution of office visits by time actually spent with physician, according to patient’sprincipal problem, complaint, or symptom: United States, May 1973-April 1974

Patient’s principalproblemclassifiedby NAMCSsymptom classification

Total, all problems

Symptomatic problems-001-899

1.2.3.4.

::7.8.9.

10.11.12.13.14,15.16,17,18,19.20,

Problemsof lower extremityThroat sorenessProblemsof upper extremityProblemsof backCoughAbdominaf painColdHeadacheFatiguePain in chestFeverAllergicskin reactionProblems of face, neckVkion dysfunction (except blindness)WeightgainVertigo-dizzinessEaracheWounds of skinHigh blood pressureOther symptomatic problems

400520405415311540312056004322002112410701010069735116205

Residual

Nonsymptomatic problems -900-979

21. Pregnancy exam 90522. General medical exam 90023. Gynecologic exam 90424. Visit for medication 9102s. None 99726. Required physical exam 90127. Well-babyexam 90628, Other nonsymptomatic problems Residual

Other problems -000, 980-999

29, Progressvisits 980,98530. All other problems 000,990,998,999

Number oivisits in

thousdand}

44,893

25,94420,72618,95618,82418,34716,41813,46012,31411,76811,3509,8229,4589,3279,2198,9997,6067,4667,3917,014

65,431

25,94215,02213,15413,10313,04311,09510,69917,172

75,67340,151

Total

100.0

100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0100.0

100.0100.0100.0100.0100.0100.0100.0100.0

100.0100.0

Time actually spent with physician

I IUnder 6 6-10 11-15 16 minutesminutes minutes minutes and over


17.0

13.621.214.19.5

16.38.2

25.19.3

12.9*

19.225.7

**

16.114.415.726.7

*

14.0

27.5**

70.220.014.9

*

18.4

22.718.8

32.3

31.646.334.930.640.329.437.932.227.227.744.435.432.320.539.526.741.929.338.931.0

42.622.323.518.726.829.647.416.9

34.330.4

25.7

28.023.227.526.428.531.724.030.329.827.926.225.427.622.517.333.529.823.526.125.3

17.636.434.2

*

24.927.337.619.6

25.623.9

25.0

26.89.3

23.433.514.930.613.128.230.136.5

*

13.531.553.427.225.3

*

20.522.729.6

12.435.836.6

*

28.328.2

*

45.1

17.326.9

lSymptomatic groupings and code number inclusions are based on a symptom classitlcation developed for use in theNAMCS.

23

wm+

24

Table 15, Number and percent of office visits by disposition oftisit, according topatient's pficipal problem, complatit, orsymptom: United States, May1973-April 1974

Patient’s principal problemclassified by NAMCSsymptom claasificatiOnl

Total, all problems

Symptomatic problems -001-899

1. Problems of lower extremityThroat soreness

? Problems of upper extremity4. Problems of back5. cough

Abdominal pain!: Cold8. Headache9. Fatigue

Pain in chest;1 Fever12. Allergic skin reaction13. Problems of face, neck14. Vision Dysfunction (except blindness)15. Weight gain

Vertigo-diaziness:;: Earache18. Wounds of skh

High blood pressure;: Other symptomatic problems

400520405415311540312056004322002112410701010069735116205

Residual

Nonsymptomatic problems -900-979

21. Pregnancy exam22. General medical exam23. Gynecologic exam

Vk.it for medication;$ None26. Required physical exam27. Well-baby exam28. Other nonsymptomatic problems

Other problems -000,980-999

29. Promess visits

9059009C4910997901906

Residual

980,98530. AU;tlrer problems 000,990,988,999

Number ofVwltsinthousands

644,893

25,94420,72618,95618,82418,34716,41813,46012,31411,76811,3509,8229,4589,3279,2198,9997,6067,4667,3917,014

165,431

25,94215,02213,15413,10313,04311,09510,69917,172

75,67340,151

Deposition of visitNo Return at

follow-up specfled Return if 0ther2planned time needed

12.7

lU10.75.9

14.38.8

23.910.9

*

12.;13.913,223.1

*

1::+22.2

3.210.2

24.;14.526.220.580.1

*

14.9

13.37.8

Percent3

61.2

63.030.562.759.336.154.528.558.676.162.930.745.552.146.692.372.448.756.588.961.1

92.054.763.860.96S.210.590.260.9

71.870.1

lsymptomatic goup~gs ~d code number inclusions are based on a symptom class~lcation develOP@ ‘or

use in the NAMCS.

21.4

21.747.321.128.645.624.644.825.112.624.647.938.224.424,3

*20.932.517.510.121.7

7.317.419.412.912.9

*

15.;

13.816.7

9.4

14.19.1

E!12.717.3

*

12.510.011.612.7

13.;**

;:;

1.;12.3

3.97.3

*****

11.3

4.69.7

‘Includes telephone followup planned, referred to other physician, returned to referring physician,admit to hospital, and aff other dispositions.

3Percents will not add to 100 because some patient visits had more than one disposition.

25

Table 16. Number, percent distribution, and cumr.dative percent of visits to office-based physicians, by the60 most common ICDA threedlgit categories containing the principal diagnosis: United States,May 1973-April 1974

60 most common ICDA ikligit categories

k3.4.5.6.7.8.9.

10.11.12.13.14.15.16.17.18.19.20.21.22.23.24.25.26.27.28.29.30.31.32.33.34.35.36.

41.42.

2

:::

%49.so.51.52.53.54.55.56.57.58.59.60.61.

AU visits

Medicalor specialexaminationMedicaland surgicalafter carePrenatal careEssentirdbenignhypertensionAcute upper respiratory infection, site rrnspecfledNeurosesObservation,without need for medical careChronic ischemicheart diseaseHay feverOtitis mediaAcute pharyngitisObesityRefractive errorsOther eczemaand dermatitisDiabetes mellitusAcute tonsillitisDiagnosisgivenas “None”Diseasesof sebaceousglandsOther viral diseasesBronchitis, unquslitledOsteoarthritisSynovitis,bursitisAsthmaInoculations and vaccinationsSprains and strains of back, unspec~ledDiarrheal diseasesCystitisMenopausalsymptomsInfluenza, unquaMedOther rheumatismAcute bronchitisChronic sinusitisDnorders of menstruationArthritis, unspecitledSprains, strains of sacroiliacregionSymptomatic heart diseaseInfective diseasesof uterus, vagina,vulvaConjunctivitisand ophthabniaAcute nasopharyngitis(common cold)Rheumatoid arthritisOpen wound of fingerCataractHemorrhoidsDkplacement of intervertebral discOtitis extemaEmphysemaStreptococcal sore throatPersonality disordersSchuophreniaGastritis and duodenitisNervousness,and debilityFunctional disorder of intestinesDiseasesof parametriumChronic cystic diseaseof breastUlcer of duodenumGlaucomaPostpartum ObservationAcute SinusitisMyxedemaChronic pharyngitisAUother dwgnosis

YooYloY06401465300793412507381462277370692250463. ..

706079490713731493Y02847009595627470717466503626715846427622360460712883374455725380492034301295535790564616610532375Y07461244502

Residual

Number ofvisitsin thousands

644,893

39,61332.34525,35922,75221,51416,57015,89315,48712,16610,52310,41510J369,1759,1528,9048,2348,0197,9686,9576,9126,4036,2126,1176,0345,9125,2965,1825,1544,9764,8374,2454,0794,LM93,6323,5383,5223,2612,9662,8502,8402,7552,7232,7112,6992,6682,6272,5082>4872,4712,4612,3102,2782,1391,9591,9591,9411,9161,8861,8131,715

209,667

Percentof

visits

100.0

6.15.03.93.53.32.62.52.41.91.61.61.61.41.41.41.31.21.21.11.11.0

::;0.90.90.80.80.80.80.80.70.60.60.60.50.50.50.50.40.40.40.40.40.40.40.40.40.40.40.40.40.40.30.30.30.30.3

E

3:::

CumrdativePercent

100.0

6.111.215.118.622.024.527.029.431.332.934.536.137.538.940.341.642.844.145.246.247.248.249.150.151.051.852.653.454.254.955.656.256.857.458.058.559.059.559.960.460.861.261.662.062.562.963.263.664.064,464.865.165.465.766.166.466.666.967.267.500.0

1Diagnosticgroupingsand code number inclusionsare baaed on the E&hthRevisionInternationalClassificationof Diseases,Adapted for Usein the UnitedStates, 1965.

26

mmi!

27

s

5!

00

000

00

0000qoo

o000

0000

c&

o&

&o

&o

00

0000000

00

0000

0000

‘s00

0000

0000

c000

0000

c1+

*!-IT

-l!+.4!-(

*d&d

.+!-l&

*dd*

.-l,+

,+,-(

.

29

%%*

**C

.+d,+

i*

*N

******

mm

.t+

Tisblc 19. Number and percent distribution of office visits by time actually spent with physician, according to principal diagnoses:Llnited states, May 1973-Anril 1974.-.

Principal diagnosis classified byICDA catcgoryl

Aff diagnoses

Infective and parasitic diseases

Ncriplasms

Endocrine, nutritional and metabolic diseasesDiabetes mellitusObesity

MentalduordersNeuroses

Dise&vcsM nervous systcm mrdsense organsDiseasesand conditions of the eye

Refractive errmeOtitis media

Disemmof circulatory systemEssential benign hypertensionChronic ischemic heart disease

Diseases of respiratory systemAcute respiratory hrfcction (except influenza)InihrenmHay fever

Diseasesof digestivesystem

Diseasesof gmritourbrarysystemDiseasesof female genital organs

Diseasesof skm and subcutaneous tissue

Disea.msof musculmkclctd systemArthritis and rbcumatism

Symptams mrdill-dc!hredconditions

Accidents, poisoning, and violenceFractureDislocation, sprainLacerations

Spcckdcmrdftionsand cxamimrtionswithout ilhresshiedicafand special examsPrenatal carehfedical and surgfcrdaftercare

Other dkrgnmes2

Diagnosisgivenm “None”

Dkmrosisunknown3

000-136

140-239

240-279250277

290-315300

320-389360-379

370381

390458401412

460-519460466470474

507

520-577

580-629610-629

680-709

710-738710-718

7S0-796

800-999800-829830-348870-907

YOO-Y13YooY06Ylo

... .....Number ofvisits inthousands

644,893

25,233

12,713

26,0998,904

10,136

29,06416,570

50,84115,248

9,17510,523

59,24022,75215,487

97,38350,859

5,19912,138

23,826

37,74421,895

34,099

34,37018,463

34,251

47,6097,934

15,4089,131

110,20339,61325,35932,345

8,630

8,019

5,569

Tme actuafly spent with physicianTotal Under 6 1 6-10 I 11-15 I 16 minutes

II ‘-”minutes I minutes I minutes I and over

100.0

100.0

100.0

100.0100.0100.0

100.0100.0

100.0100.0

100.0.100.0

100.0100.0100.0

100.0100.0100.0100.0

100.0

100.0100.0

100.0

100.0100.0

100.0

100.0100.0100.0100.0

100.0100.0100.0100.0

100.0

100.0

100.0

17.0

17.2

19.6

14.914.417.6

5.5*

12.415.6

*18.7

11.414.110.2

22.220.820.042.8

12.7

11.811.4

22.8

12.413.1

8.7

19.215.511.327.9

22.610.529.125.3

17.7

37.6

28.2

Percent di

32.3

38.0

23.3

33.432.037.9

14.616.6

31.532.2

17.542.7

30.836.426.4

39.445.644.421.3

27.1

31.130.1

36.9

30.930.2

25.8

32.327.237.729.8

34.432.742.035.0

34.1

23.7

29.8

25.7

26.0

23.7

23.727.116.8

16.318.7

26.426.7

22.228.3

31.229.330.6

23.524.425.714.3

32.5

29.027,6

23.6

26.425.7

31.6

24.227.224.320.9

25.133.715.924.1

24.2

17.8

21.3

25.0

18.7

33.4

27.926.627.7

63.659.5

29.925.5

58.610.2

26.620.232.8

15.09.1

*21.7

27.8

28.231.0

16.8

30.231.0

33.8

24.330.226.721.5

17.823.113.015.6

24.0

20.9

20.6

lDlagn05ticgroup~85 and code number ~clu5iOn5~e b~ed “n tbe Eighth Repi~~n Infernafionul Cla.rsij?cationof Diseases,Adapted

#r fh in t{le UrtitcdStutes, 1965.280-289, Dlscaaesof Oroblood cnd blood-formingorwrra; 630-678, Complications of pregnmcy, childbti, and Orepucrperium;740-759, Cmrgmritafarmmafics;760-779, Certain causes of perirratalmmbldity and mmtelity.

3fjlankdf3gn&s,nmrcodablediagnosis, illegiblediagnosis.

31

————

-J7@

—

ra.

h-.

Table 21. Number and percent of office tisitsby deposition ofvisit, according tothe20 most frequent dia~oses: United States,Ma

20 most frequent diagnosesclassified by ICDA category I

k:;5.6,7.8.9.

10.11.

;:14,

;::17.18.

;;

Other

AB diagnoses

Medical and special exemsMedicct and surgical aftercsrePrenatal careEssential benign hypertensionAcute upper respiratory infectionNeurosesObservationChronic ischemic heart dkeaseHay feverOtitis mediaAcute pharyngitisObesityRet’ractive errorsOther eczemaDiabetesAcute tonsillitisDiagnosis given as “None”Diseases of sebaceous glandsOther vfraf diseasesBronchitis, unqualitled

Y1 oY06401465300793412507381462277370692250463

. . .

706079490

1$lT%kmg

Number ofvisits inthousands

644,893

39,61332,34525,35922,75221,51416,57015,89315,48712,16610,52310,41510,136

9,1759,1528,9048,2348,0197,9686,9576,912

346,800

74

Disposition of visit

No folkkvup Return at Return if 0ther2planned specitled time needed

Percent3

12.7

32.516.3

**

**

10.620.8

*

37.812.4

*

13.728.0

*

18.9*

10.4

61.2

54.467.093.487.624.874.136.390.478.156.529.387.533.053.891.828.358.172.345.038.9

59.7

21.4

13.114.86.09.2

49.216.622.2

8.716.927.941.8

*

28.034.4

*

49.613.3

*34.250.5

22.4

lDitrgnosti g p . gc rou in s and code number inclusionsare based on the Eighth Revision International Classification of Diseases, Adapted.&r Use in the Umted States, 1965.

9.4

3.6

:::3.87.46.9

::;*

10.911.8

****

15.6***

22.6

12.2

‘Includes telephone folfowup planned, referred to other physician, returned to referring physician, admit to hospital, andSafl other dispositions,

Percents will not add to 100 because some patient visits had more than one disposition.

33

Table 22. Number and percent distribution of office visits by prior visit status, according to age, sex, andcolor of patient: United States, May 1973-April 1974

Age, sex, and color

All patients

M ages

Under 15 years15–24 years25–44 years45 –64 years65 years and over

Jxz-

Male

Under 15 years15–24 years25–44 years45–64 years65 years and over

Female

Under 15 years15–24 years25-44 years45–64 years65 years and over

Color

White

Under 15 years15–24 years25–44 years45–64 years65 years and over

All other

Under 15 years15–24 years25-44 years45–64 years65 years and over

Number ojvisits inthousands

644,893

125,07799,581

159,551160,435100,249

253,285

66,00734,41950,82564,28237,752

391,608

59,07065,161

108,72696,15362,497

;75,881

112,22987,003

138,960144,645

93,044

69,013

12,84812,57820,59215,7907,204

Prior visit statusPatient seen Patient seen before

Total for the For current For anotherfirst time problem problem

100.0

100.0100.0100.0100.0100.0

100.0

100.0100.0100.0100.0100.0

100.0

100.0100.0100.0100.0100.0

100.0

100.0100.0100.0100.0100.0

100.0

100.0100.0100.0100.0100.0

15.6

16.722.819.011.8

7.5

17.5

16.425.726.113.37.7

14.3

17.121.315.710.87.5

14.9

16.021.818.211.6

7.5

21.0

23.030.024.114.0

*

61.5

48.552.359.169.278.8

58.4

49.845.553.366.478.5

63.6

47.055.861.871.178.9

62.4

48.853.360.269.778.9

54.6

44.945.251.264.576.4

22.9

34.825.022.019.013.7

24.1

33.828.720.720.313.8

22.1

35.923.022.618.113.6

22.7

35.225.021.618.713.6

24.4

32.124.824.721.615.1

34

Table 23. Number and percent distribution Of Office visits by prior visit status, according to physician specialty and typeof practice: United States, May 1973-April 1974

Physician specifllty andtype of practice

All specialties





Type of practice

soloOtherl


644,893

260,310

169,31674,69353,65940,964

183,78744,84650,71588,227

31.48120,30011,180

386,208258,685

Total

Prior visit statusPatient seen

IF

Patient seen beforefor the or current For another

fiist time rxoblem Droblem

100.0

100.0

100.0100.0100.0100.0

100.0100.0100.0100.0

100.0100.0100.0

100.0100.0


15.6

12.8

13.814.610.017.4

21.817.714.128.2

11.98.6

18.1

14.617.1

61.5

57.3

60.463.045.775.0

65.562.970.664.0

79.586.367.0

62.360.5

22.9

29.9

25.822.544.4

7.7

12.719.415.3

7.8

8.65.1

14.9

23.222.5

1Includes partnership and group practices.

35

Table 24. Number and percent distribution Of Office visits by seriousness of patient’s principal problem, according tosex, color, and age of patient: United States, May 1973-April 1974

—

Sex, color, and age

All patients

Sex—

MaleFemale

Color

WhiteAU other

A&e

Under 15 years15–24 years25–44 years45-64 years65 years and over


644,893

253,285391,608

575,88169,013

125,07799,581

159,551160,435100,249

Seriousness of patient’s principal problem

Total Very Slightly Notserious Serious serious serious

100.0 3.2

100.0 3.8100.0 2.8

100.0 3.1100.0 3.3

100.0 1.5100.0 1.7100.0 2.7100.0 3.9100.0 6.3

Percent d

16.0

18.114.6

15.718.2

10.210.714.020.125.1

ribution

30.4

31.929.4

30.529.5

29.426.029.432.234.7

50.5

46.253.2

50.649.0

58.961.654.043.933.9

36

Table 25. Number and percent distribution of office visits by seriousness of patient’s principal problem,according to physician specialty and type of practice: United States, May 1973-April 1974


MI specialties



Surgical specialtiesGeneral surgeryObstetrics and gynecologOther


Type of practic~

soloOtherl

Wmber of‘isits inhousands

i44,893

!60,310

[69,31674,69353,65940,964

[83,78744,84650,71588,227

31,48120,30011,180

)86,208~58,,685

Seriousness of patient’s principal problemVery I Slishtlv 1 Not

Total II serious I Serious “y-serrous I serious

Percent dk.tribution

100.0

100.0

100.0100.0100.0100.0

100.0100.0100.0100.0

100.0100.0100.0

100.0100.0

3.2

2.3

3.65.1

*

4.8

2.63.8

*

3.2

10.514.9

*

3.13.3

16.0

15.3

17.123.4

7.418.3

13.014.74.1

17.1

33.242.217.0

16.315.5

30.4

32.2

32.733.029.935.6

25.428.815.029.6

32.028.139.0

30.330.4

50.5

50.1

46.638.561.941.3

59.052.780.150.1

24.314.941.4

50.350.8

1Includes partnership and group practices.

37

CQ

m

—

ym

——

0)mm.

v)

wm.

I

Table 28. Number and percent distribution of office visits by time actually spent with physician, according to physicianspecialty and type of practice: United States, May 1973-April 1974


All specialties


MedicalspecialtiesInternal medicinePediatricsOther

Surgical specialtiesGeneral surgeryObstetrics and gynecolcOther

Other speciakiesPsychiatryOther

Type of practice

soloOtherl

{umber ofWitsinhousands

i44,893

!60,310

.69,31674,69353,65940,964

.83,78744,84650,71588,227

31.48120,30011,180

186,208!58,685

Time actually spent with physician1 I 1 I I I 31

Total Zero 1–5 I 6-10 11–15 16-30 minutes‘-minutes mbmtes minutes minutes minutes or more

100.0

100.0

100.0100.0100.0100.0

100.0100.0100.0100.0

100.0100.0100.0

100.0100.0

2.0

2.0

3.82.9

2;

0.7***

***

1.72.5

Percen

15.0

20.1

9.95.8

12.713.6

13.716.912.512.7

6.9*

16.4

14.415.7

32.3

35.4

31.424.442.529.5

31.935.832.029.9

13.79.3

21.8

32.332.2

25.7

23.7

29.530.931.624.1

26.626.425.527.2

16.914.122.2

25.625.8

18.9

15.6

19.426.5

9.619.5

23.317.325.725.0

17.313.025.2

19.617.9

6.1

3.1

6.09.5

6.;

3.8

E4.7

44.561.813.1

6.35.9

l~cludes~~nerWp and grOuPPractices

40

Table 29. Number and percent distribute

Sex, color, and age

All patients

Sex

MaleFemale

Color

WhiteOther

Age

Under M years15–24 years25-44 years45-64 years65 years and over

and color_— —.


644,893

253,285391,608

575,88169,013

125,07799,581

159,551160,435100,249

of office visits by time actually spent with physician, accordiug to age, sex,f patient: United States, May 1973-April 1974

Time actually spent with physician31

Total Zero 1–5 6–10 11–15 16–30 minutesminutes minutes minutes minutes minutes or more

.100.0

100.0100.0

100.0100.0

100.0100.0100.0100.0100.0

2.0

2.02.0

2.2*

2.51.41.72.22.3

Perc(

15.0

16.014.3

14.915.7

19.218.114.811.712.0

it distributi(

32.3

31.532.8

31.737.3

39.133.530.129.730.2

——

25.7

26.225.4

25.924.1

26.423.524.026.728.2

18.9

17.919.6

19.117.2

10.518.620.322.821.3

6.1

6.46.0

6.33.9

2.45.0

::;5.8

41

Table 31. Number and percent of office visits by disposition of visit, according to physician specialty, and type ofpractice: United States, May 197 3-April 1974


AHspecialties





Type of practice

solo0ther3


644,893

260,310

169,31674,69353,65940,964

183,78744,84650,71588,227

31.48120,30011,180

386,208258,685

Disposition of visit

No followup Return at Return if Otherlplanned specWled time needed

Percent2

12.7

16.1

10.810.013.9

8.4

10.611.24.6

13.7

13.112.1

61.2

54.8

63.467.048.177.0

65.361.976.160.9

76.984.363.5

60.562.1

21.4

25.8

20.717.732.510.9

17.217.114.418.9

12.07.1

20.9

22.020.4

9.4

6.6

12.114.112.4

8.4

11.213.99.8

10.8

7.9*

14.3

9.010.4

*Includes telephone followup planned, referred to other physician, returned to referring physician, admit to hospital,andall other dispositions.

:Pcrccnts will not add to 100 because some patient visits had more than one dispositionIncludes partnership and group practices.

43

APPENDIX I

TECHNICAL NOTES ON SURVEY DESIGNAND PROCEDURES

Sample Design

The NAMCS utilizes a multistage probabilitydesign that involves probability samples ofprimary sampling units (PSU’S), physicianpractices within PSU’S, and patient visits withinphysician practices. The first stage sample,consisting of 87 PSU’S, was selected by theNational Opinion Research Center (NORC), theorganization responsible for field operationsunder contract to the National Center for HealthStatistics (NCHS). A PSU is generally a county, agroup of adjacent counties, or a standardmetropolitan statistical area. The United Statesis divided into approximately 1,900 PSU’S. Thedetails of the methodology used in selecting thissample are contained in an unpublishedtechnical memorandum prepared by the NORC.

The second stage consists of a probabilitysample of practicing physicians selected from themaster physician files maintained by theAmerican Medical Association and the AmericanOsteopathic Association. Within each l?SU, alleligible physicians were arranged by four broadspecialty groups: general and family practice,nwdicaJ specialties, surgical specialties, and“other” specialties, Within each specialty group,the tile was arranged by specific individualspecialty. Then, within each PSU, a systematicnmdom sample of physicians was selected insuch a way that the overall probability ofselecting any physician in the United States wastipproximately constant.

The final stage was the selection of patientvisits within the annual practices of samplephysicians. “This involved two steps. First, the

total physician sample was divided into 52random subsamples of approximately equal size,and each subsample was randomly assigned toone of the 52 weeks in the survey year. Second, asystematic random sample of visits was selectedby the physicians during the assigned week. Thesampling rate varied for this final step from a100-percent sample for very small practices to a20-percent sample for very large practices asdetermined in a presurvey interview. (Themethod by which the sampling rate wasdetermined is described in the InductionInterview Form displayed in appendix III.)

Physician Universe and Sample Size

Table I shows the distribution of physicians inthe universe used for selection of the 1973NAMCS sample, and the distribution of thesample by physician specialty. The total universe(184,386) was composed of all physicianscontained in the master files maintained by theAmerican Medical Association (AMA) andAmerican Osteopathic Association (AOA) as ofNovember 1, 1972, who met the followingcriteria:

a. Office based, as defined by AMA and AOAb. Principally engaged in patient care activitiesc. Nonfederally employedd. Not in the specialties of anesthesiology,

pathology, clinical pathology, forensicpathology, radiology, diagnostic radiology,pediatric radiology and therapeutic radi-ology.

45

Physicians selected in the sample were furtherscreened to assure that they met all of the abovecriteria at the time of the survey. Of the 1,695physicians selected in the 1973 NAMCS grosssample, 254 did not meet all of the above criteriaand were, consequently, ruled out-of-scope(ineligible) for the study. The most frequentreasons for being out-of-scope were that thephysician was retired, deceased, and employed inteaching, research, or administration andconsequently no longer in practice. Of the 1,441sample physicians in-scope (eligible) for thesurvey, 1,103 (76.5 percent) participated in thesurvey while the remaining 338 declined to do so.The response patterns by specialty are shown intable I.

III). The Patient Log, a sequential listing ofpatients, served as a sampling frame to indicatethe visit for which data were to be recorded. ThePatient Record is an encounter form on which 12items of data about the visit were recorded.

Physicians recorded, in sequence on the log, allpatients seen in their offices from Mondaymorning through Sunday night of their assignedsurvey week. Based on the physician’s ownestimate of the number of patients expected tovisit his office(s) during the survey period, thephysician was assigned a patient sampling ratio.These sampling ratios were designed so thatabout 10 Patient Records were completed eachparticipating physicians: The Patient Log(appendix III) and the Patient Record (appendix

Table I. Distribution of physicians in the universe (AMA and AOA) and in the 1973 Nationel AmbulatoryMedical Care Survey sample by physician specialty, United States, May 1973-April 1974

Physician specialty

All specialties



Surgical specialtiesGenersl surgeryObstetrics and gynecologyOther

Other specialtiespsychiatryO&er -

Universe

84,386

55,530

47,03624,81711,63410,585

63,49819,40614,67229,420

18,32212,2436,079

-Grosstotal

1695

507

439223103113

579178140261

17010664

-out of

scope

254

82

68302315

6115

;;

4316

I 27

NetTotal

1441

425

371193

8098

518163125230

1279037

Non-{esponse

338

114

:1519

125423251

::3

Response

1103

311

2891456579

393121

93179

1107634

~Response

Rate -.. .

76.5

73.2

77.975.181.380.6

75.974.274.477.8

86.684.491.9

Of the 1,103 physicians who participated in the day of practice. Physicians expecting 10 or fewerNAMCS, 146 (10 percent) saw no patients duringtheir assigned ;eporting period because o~vacations, illness or other reason for beingtemporarily not in practice.

Data Collection

The actual data collection for the 1973NAMCS was carried out by physicians aided bytheir ofllcecollection

46

assistants when ‘po_ssible.forms were employed

Two databy the

vis;ts e~ch day re;orded da;a for ‘all of them,while those expecting more than 10 visits per dayrecorded data for every second, third, or fifthvisit, based upon the predetermined samplinginterval. These procedures were designed tominimize the workload of data collection andmaintain somewhat equal reporting levels amongsample physicians regardless of the size of theirpractice. For physicians assigned a patient-sampling procedure, a random start wasprovided on the first page of the log.

Predesignated sample visits on each succeedingpage of the log provided a systematic randomsample of patient visits during the reportingperiod.

Data Processing

All Patient Records were clerically edited forcompleteness and consistency. To the extentpossible, missing information was obtained fromparticipating physicians by telephone follow-back. Nonresponse rates for data items on thePatient Records are considered insignificant, lessthan 2 percent for all items except “color orrace” which was 5 percent.

Information contained in item 5 of the PatientRecord (patient’s problem) was coded accordingto a special classification system developed forthat purpose.? Diagnosis information, item 9 ofthe Patient Record, was coded according to theEighth Revision of the International Classlj7ca-tion qfDiseases, Adapted fir Use in the UnitedStates [lCDA]. A maximum of three problemsand three diagKoses were coded. All coding wasveritled 100 percent by independent coding anddifferences were adjudicated by the NationalCenter for Health Statistics. The medical codingand verification were performed by the AmericanMedical Records Association under contract tothe National Opinion Research Center (NORC).

All information was keypunched (with100”percent verification, and subsequentlyconverted to computer tape for further edit andconsistency checks.

Estimation Procedures

Statistics produced from the 1973 NationalAmbulatory Medical Care Survey (NAMCS) werederived by a complex estimating procedure. Theprocedure used produces essentially unbiasednational estimates and has basically threecomponents: (1) inflation by reciprocals of theprobabilities of selection, (2) adjustment fornonresponse, and (3) a ratio adjustment to fixedtotals. Each of these is described briefly below.Exact formulae and estimation procedures areavailable in unpublished form upon request.

Injlation by reciprocals of sampling probabil-ities — Since the survey utilizes a three-stage

sample design, there were three probabilities: (a)the probability of selecting the PSU, (b) theprobability of selecting a physician within thePSU, and (c) the probability of selecting a patientvisit within the physician’s practice. The lastprobability was defined to be the number ofPatient Records completed divided by the exactnumber of office visits during the physician’sspecified reporting week. All weekly estimateswere inflated by a factor of 52 to derive annualestimates.

Adjustment for nonresponse — All estimatesfrom NAMCS data were adjusted to account forsample physicians who did not participate in thestudy. This was done in such a manner as tominimize the impact of nonresponse on finalestmates by imputing to nonrespondent physi-cians the practice characteristics of similarrespondents. For this purpose, similar physicianswere judged to be physicians having the samespecialty designation and residing in the samePsu.

Ratio adjustment — A post-stratificationadjustment was used in the estimation process tobring the number of physicians estimated fromsurvey results into close agreement with thenumber of physicians in each of nine specialtygroups known from the AMA and AOA data.The adjustment is made by using a multiplierfactor obtained by taking the difference betweenthe universe total number of physicians and thetotal estimated to be out-of-scope and dividingthat difference by the estimated in-scopephysicians for the particular specialty group.

Reliability of Estimates

Since the statistics presented in this report arebased on a sample, they will differ somewhatfrom the figures that would have been obtained ifa complete census had been taken using the sameschedules, instructions, interviewing personneland procedures. As in any survey, the results arealso subject to reporting and processing errorsand errors due to nonresponse. To the extentpossible, these types of errors were kept to aminimum by methods built into the surveyprocedures.

47

The standard error is primarily a measure ofsampling variability, that is, the variations thatmight o~cur by cha-nce because only a sample ofthe-population is surveyed. As calculated f& thisreport, the standard error also reflects part of thevariation which arises in the measurementprocess. It does not include estimates of anysystematic biases which might be in the data. ‘I’hechances are about 68 out of 100 that an estimatefkom the sample would differ from a completecensus by less than the standard error. Thechances are about 95 out of 100 that thedifference would be less than twice the standarderror and about 99 out of 100 that it would be lessthan 272 times as large.

The relative standard error of an estimate isobtained by dividing the standard error of theestimate by the estimate itself, and is expressedas a percentage of the estimate. For this report,asterisks are shown for any data table cell withmore than a 25 percent relative standard error.In order to derive standard errors that would beapplicable to a wide variety of statistics and couldbe prepared at a moderate cost, severalapproximations were required. As a result, therelative standard errors shown in figure I andthe standard errors of percentages shown intable II should be interpreted as approximaterather than precise for any specific estimate. ,

1“

.

The standard errors (and relative standarderrors) shown in this appendix are not directlyapplicable to differences between two sampleestimates. The standard error of a difference isapproximately the square root of the sum of thesquares of each standard error consideredseparately. Although it is only a roughapproximation in most other cases, this formulawill represent the standard error quite accuratelyfor the difference between separate and uncor-related characteristics.

The precision of an estimated rate orpercentage computed by using sample data forboth numerator and denominator depends uponthe sampling variability of both the numeratorand denominator. Table II shows approximatestandard errors of estimated percentages whenthe characteristic used to form the numerator ofthe percentage is a subclass of the denominator.The reliability of an estimated rate where thedenominator is the total U.S. population can bedetermined by using the relative standard errorof the numerator obtained from figure I.

Population Figures

The base populations used in computingannual natioiai visit rates are provisionalestimates for the civilian, noninstitutionalpopulation as of October 1,1973, provided by the

Table II. Approximate standard errors of percentages for estimated numbers of patient visits

Base of percent(Number of patientvisits in thousands)

10002000300040005000

10000200003000040000

50000100000600000

Estimated percent

lor991 5or951 100190 1 20 or 80 1 30 or70 I 50

Standard error expressed in percentage points

3.32.31.91.61.5

1.00.70.60.5

0.50.30.1

7.15.04.13.63.2

2.31.61.31.1

1.00.70.3

9.86.9

U4.4

3.12.21.81.6

1.41.00.4 ~

13.19.37.56.55.9

4.12.92.42.1

1.9

;:

15.010.6

8.77.56.7

4.73.42.72.4

16.411.6

9.48.27.3

5.23.73.02.6

I-1-EExample of use of Table II: An estimate of 20 percent (read at top of table) based on an estimateof 10 million (read from left side of table) has a standard error of 4.1 percent. The relativestandard error is equal to 4.1 percent + 20 percent or 20.5 percentage points. For estimatedpercents not shown on table, linear interpolation will provide a good approximation to thestandard error..

48

Figure 1. Approximate relative standard error of estimated numbers of patient visits shown in this report.‘?

lm 10,OOO 100,OOO 650,000

SIZE OF ESTIMATE IN THOUSANDS

Examdc of use of ikure 1: An estimate of‘ rekkve ;tandar~ k;or of 11 percent (read

(11 percent of 10,000,000).

10,000,000 patient visits (read from scale at bottom of chart) has afrom scale at left side of figure) or a standard error of 1.1 million

49

U.S. Bureau of the Census (table III and IV).Although these estimates are consistent withestimates of the civilian resident populationpublished in Current Population Reports by theBureau of the Census, they are presented heresolely for the purpose of providing denominatorsfor rate computations and are not to beconsidered as oftlcial population estimates.

Rounding of Numbers

Estimates relating to patient visits have beenrounded to the nearest thousand. Percents andrates were calculated on the basis of original,unrounded figures and, therefore, will notnecessarily agree with rates and percents whichmight be calculated from rounded data.

Systematic Bias

There have been no attempts to determinesystematic biases in the data reported here or tomeasure the impact of any biases. There areseveral factors, however, that the user of thesedata should understand, all of which indicatethat these data underrepresent the total officevisits to office-based physicians. These factorsare:

1. The sampling universe for the 1973 NAMCSwas the files of “office-based, patient-care”physicians maintained by the AMA andAOA. There are certainly physicians not soclassified which, at the time of the survey,would have met the criteria for that

Table III. Estimates of the civilian noninstitutional population of the United States by age, color and sex,as of November 1, 1973

(used in the calculation of rates for tables 1 and 5)

1Age

Color and sexAu Under 15 15-24 25-44 45-64 65 years and

ages years years years years over

All colors . . . 206,422 55,347 37,643 50,407 42,631 20,395

Male . . . . . . . 99,546 28,208 18,385 24,326 20,201 8,426Female . . . . . . 106,877 27,139 19,257 26,081 22,430 11,969

Wide. . . . . . 180,222 46,592 32,357 44,280 38,402 18,591

Male . . . . . . . 87,224 23,815 15,886 21,598 18,278Female . . . . . . 92,998

7,64722,776 16,472 22,682 20,124 10,943

Another . . . . . 26,201 8,755 5,285 6,127 4,229 1,804

Male . . . . . . . 12,322 4,393 2,500 2,728 1,923 778Female . . . . . . 13,879 4,362 2,786 3,399 2,306 1,026

50

2.

34

classification. Visits to these physicians arenot represented in these data.A frequent reason for not participating inthe NAMCS was given as “too busy” or“too busy right now.” This is an indicationthat the busier physician was not as likelyto participate as the less busy physician.An assessment of this problem isunderway, but if these indications are cor-rect, some bias would result.Physicians who participated in the NAMCSdid a thorough- and conscientious job. Inkeeping the Patient Log, however, theprobability a patient was accidentallyomitted from the survey is much greaterthan the probability that a patient wasincluded who did not make a visit. This

factor could also introduce a slight bias.

Studies to measure the impact of theseproblems are either planned or underway. Thebest estimate at this time of underrepresentationof total ofi-lcevisits by the NAMCS comes from acomparison with the national Health InterviewSurvey (HIS) data. Data ftom the HIS show totaloffice visits during calendar 1973 to be about 715million. Although the HIS and NAMCS data arenot totally comparable, they are sufficientlycompatible to allow rough approximations.Based on this comparison, it is estimated that the1973 NAMCS data underrepresent the actualtotal visits to office-based physicians by 60 to 70million visits, or by about 10 percent of the totalvisits.

Table IV, Estimates of the civilian noninstitutioanl population of the United States by geographic region, metropolitan and nonmetro.politan area, and sex and age, as of November 1, 1973

(used in the calculation of rates for tables 3 and 7)

——

AgeGeographicregion,metropolitan and

nonmetropolitan area, and sexAll Under 15 15-24 2544 45-64 65 yearsages years years years years and over

I Number in thousands

Allregions . . . . , . 206,422 55,347 37,643 50,407

Northeast . . . 48,862 12,521North central” : : : : . . .

8,395 11,86656,658 15,480 10,414 13,566

south . . . . . . . . . . 64,926 17,718 12,095 15,790West . . . . . . . . . . 35,977 9,628 6,738 9,186

Metropolitan area . . . , 141,620 37,814 25,891 35,687

Male . . . . . .. o.. 67,976 19,254 12,515 17,187Female, . . . . . . . . 73,650 18,560 13,379 18,501

Nonmetropolitan area . . . 64,803 17,533 11,751 14,720

Male, . . . . . . . . . . 31,570 8,954 5,870 7,138Female . . . . . . . . .— 33,227 8,579 5,878 7.581

42,631

10,94911,51612,949

7,217

29,194

13,77415,421

13,438

6,4277,009

20,395

5,1315,6826,3743,209

13,085

5,2667,823

7,310

3,1604.146

51

APPENDIX II

DEFINITIONS OF CERTAIN TERMS USEDIN THIS

General Terms Relating to the Survey

1,

2.

3.

Oj5ce(s): Premises which the physicianidentifies as a location for his ambulatorypractice. Responsibility, over time for patientcare and professional services rendered thereresides with the individual physician ratherthan with any institution.Ambulatory patient: An individual present-ing for personal health services, neitherbedridden nor currently admitted to anyhealth care institution on the premises.Physician:a. In-scope — All duly licensed Doctors of

Medicine and Doctors of Osteopathycurrently in practice who spend some timein caring for ambulatory patients at anoffice location.

b. Out-of-scope — Those physicians whotreat patients only indirectly, includingspecialists in anesthesiology, pathology,forensic pathology, radiology, therapeuticradiology, and diagnostic radiology, andthe following physicians:

physicians in military service

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

physicians employed fill time by anindustry or institution and having noprivate practice (e.g., physicians whowork for the V.A., the Ford MotorCompany, etc.)

REPORT

physicians who spend no time seeingambulatory patients (e.g., physicianswho only teach, are engaged in research,or retired)

4. Patients:a. In-scope —

physician oroffice(s).

b. Out-of-scope

All patients seen bymember of his staff in

— Patients seen by

thehis

thephysician !& a hospital, nursing home, or~ther extended c&e institution, or thepatient’s home. Note: If the doctor has aprivate office (which fits definition of“oftice”) located in a hospital, theambulatory patients seen there would beconsidered “in-scope.”—Patients seen by the physician in anyinstitution (including out-patient clinics ofhospitals) for which the institution has theprimary responsibility for the care of thepatient over time;—Patients who call on the telephone andreceive advice from the physician;—Patients who come to the office only toleave a specimen, pick up insurance forms,or pay their bills;—Patients who come to the ofilce only topick up medications previously prescribedby the physician.

5. Visit: A direct, personal exchange betweenambulatory patient and the physician (ormembers of his staff) for the purpose ofseeking care and rendering health services.

6. Physician Specialty: Principal Specialty

52

(including general practice) as designated bythe physicians at the time of the survey.Those physicians for which a specialty wasnot obtained were assigned the principalspecialty recorded in the Master Physiciantiles maintained by the AMA or AOA.

7. Medical Specialists — Includes specialists infollowing and related specialties:

AllergyCardiovascular diseasesDermatologyGastroenterologyInternal MedicinePediatricsPediatric allergyPediatric cardiologyPulmonary diseases

8. Surgical Specialty — Includes specialists inthe following and related specialties:

General surgeryNeurological surgeryObstetrics and GynecologyOphthalmologyOtolaryngologyPlastic SurgeryColon and rectal surgeryThoracic surgeryUrology .

9. “Other” Specialty — Includes specialists inthe following and related special~ies:

PsychiatryNeurologyPreventive MedicineGeriatricsPublic health

10. Geographic region — The four major regionsof the United States (excluding Alaska andHawaii) as defined by the U.S. Bureau of theCensus,

1L Metropolitan, nonmetropolitan — Refers tothe location of a physician’s practice as beingwithin a Standard Metropolitan StatisticalArea (SMSA) or not. SMSA’S are established

and defined by the U.S. OffIce ofManagement and Budget.

Selected Terms Used on the Patient Record

1. Color or Race: In this report, color or raceincludes four categories: white, Negro/black,

other, and unknown. The physician wasinstructed to mark the category which in hisjudgment was most appropriate for the patientbased upon observation and/or prior know-ledge of the patient. “Other” was restricted toOrientals, American Indians, and othernonwhite, non-Negro races.

2. Patient’s Principal Problem[sJ Complaint[s~or Symptom[s] — [In Patient’s Own Words]:The patient’s principal problem, complaint,s~ptom or reason for the visit as expressed bythe patient. Physicians were instructed torecord key words or phrases verbatim to theextent possible, listing that problem firstwhich in the physician’s judgment was mostresponsible for the patient making the visit.

3. Sen”ousness ofProblem in Item 5-A: This item

4.

includes fou; categories: very serious, serious,slightly serious, and not serious. The physicianwas instructed to check one of the fourcategories according to his own evaluation ofthe seriousness of the patient’s problemcausing this visit. Seriousness refers tophysician’s clinical judgment as to the extentof the patient’s impairment that might result ifno care was given.Major reason[s] jbr this visit: The physician’sclassification of the patient’s major reason(s)for the visit into one or more of the followingcategories:a. Acute problem — A condition or illness

having a relatively sudden or recent onset(i.e., within three months of the visit).

b. Acute problem .followup — A return visit

c.

d,

primarily for cc%tinued medical care of apreviously treated acute problem.Chronic problem-routine —’ A visitprimarily to receive regular care orexamination for a preexisting chroniccondition or illness (onset of condition wasthree months or more beforeChronic problem--are-up

this visit).— A visit

53

primarily due to a sudden exacerbation of apreexisting chronic condition.

e. Preriatal care — Routine obstetrical careprovided prior to delivery.

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

g. Postoperative care — A visit primarily forcare required following surgical treatment.Includes changing dressing, removingsutures or cast, advising on restriction ofactivities or routine after surgery checkup.

h. Well adult/child examination — Generalhealth maintenance examinations androutine periodic examinations of presum-ably healthy persons, both children andadults. Includes annual physicals, well-childcheckups, school, camp and insuranceexaminations.

i. Family planning — Services or advice whichenable patients to determine the numberand spacing of their children. Includes bothcontraception and infertility services.

j. Counseling/advice — Information of ahealth nature which would enable thepatient to maintain or improve his physicalor mental well-being. Included would beadvice regarding diet, changing habits orbehavior, and general information regard-ing a specific problem.

k. Immunization — Administration of anyinoculation of specific substances to‘produce a desired immunity, including oralvaccines. (Allergy shots are not included inthis category, but are entered in “Other.”)

L Referred by another physician/agency —Medical attention prompted by advice orreferral for consultation or treatment, fkomanother physician, hospital, clinic, healthcenter, school nurse, minister, pharmacist,etc. Does not include self-referral or referralby family or friends.

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

n. Other — The reason for this visit is notcovered in the preceding list.

5. Principal diagnosis: The physician’s diagnosisof the patient’s principal problem orcomplaint. In the event of multiple diagnoses,

the physician was instructed to list them inorder of decreasing importance, and “prin-cipal” refers to the first listed diagnosis. Thediagnosis represents the physician’s bestjudgment at the time of the visit and may betentative, provisional or definitive.

6. “Other Diagnosis”: The diagnosis of any othercondition known to exist for the patient at thetime of the visit. Other diagnoses are generallynot related to the reason for that visit.

7. Treatments and Services Ordered or Provided:a. General history/exam — History and/or

physician examination of a comprehensivenature including all or most systems.

b. Laboratory procedure/test — One or morelaboratory procedures or tests includingexamination of blood, urine, sputum,smears, exudates, transudates, feces andgastric content, and including chemistry,serology, bacteriology, pregnancy test, ECG,EKG.

c. X-ray — Any single or multiple x-rayexamination for diagnostic or screeningpurposes. Does not include radiationtherapy.

d. Injection/immunization — Administrationof immunizing, desensitizing or therapeuticsubstances via any route, e.g., needle,syringe, oraL

e. Oflce surgical treatment — Any surgicalprocedure performed in the office this visit;includes suture of wounds, reduction offractures, application/removal of casts,incision and draining of abscesses, applica-tion of supportive materials for fracturesand sprains, and all irrigations, aspirations,dilatations and excisions.

f. Prescription drugs — Drugs, vitamins,hormones or other medications that maybedispensed only with the authorization of aphysician.

g. Nonprescription drug — Drugs, vitamins,hormones or other medications that maybedispensed without the authorization of aphysician (“over the counter”).

h. Psychotherapy/therapeutic listening — AUtreatments designed to produce a mentalresponse through suggestion, persuasion,reeducation, reassurance and support.Includes such techniques as hypnosis andpsychoanalysis.

54

i, Medical counseling/advice — Instructionsand recommendations regarding any healthproblems (e.g., diet, changing habits orbehavior).

j. Other — Treatment or services renderedwhich are not listed or indicated in thepreceding categories.

8, Disposition: Eight categories are provided todescribe the physician’s disposition of the casedefined as follows:a. No jbllowup planned — No return visit or

telephone contact is scheduled for thepatient’s problem on this visit.

b. Return at specljied time — The patient wastold to schedule an appointment or wasinstructed to return at a particular time.

c. Reiurn ~~ needed, P. R. IV. — No futureappointment was made~e patient wasinstructed to make an appointment with thephysician if the patient considers itnecessarv.

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

e. Referred to other physician/agency — Thepatient was instructed to consult or seekcare from another physician or agency. Thepatient may or may not return to thisphysician at a later date.

f. Returned to refeming physician — Patientwas referred to this physician and was nowinstructed to consult again with thephysician or agency which referred him.

g. Admit to hospital — Patient was instructedthat further care or treatment will beprovided in a hospital. No further officevisits are expected prior to that admission.

h. Other — Any other disposition of the casenot included in the above categories.

9. Duration of visit: Time the physician spentwith the patient, but does not include the timepatient spent waiting to see the physician, anddoes not include the time patient spentreceiving care from someone other than thedoctor without the presence of the physician.In the event a patient was provided care by amember of a physician’s staff but did not seethe physician during the visit, “duration ofvisit” was recorded as zero minutes.

55

APPENDIX Ill

SURVEY INSTRUMENTS

1I

—

—F

..

..

..

..

57

CONFIDENTIAL*NORC-4155Feb., 1973

NATIONAL

E

I

AMBULATORY MEDICAL CARE SURVEY

INDUCTION INTERVIEW I(Phys. ID Number)

BEFORE STARTING INTERVIEW

1. ENTER PHYSICIAN I.D. NUMBER IN BOX TO RIGHT, ABOVE

2. ENTER DATES OF ASSIGNED REPORTING WEEK IN Q. 3, P.2

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

Although ambulatory medical care accounts for nearly 90 per cent of all medicalcare received in the United States, there is no systematic information aboutthe characteristics and problems of people who consult physicians in theiroffices. This kind of information has been badly needed by medical educatorsand others concerned with the medical manpower situation.

In response to increasing demands for this kind of information, the NationalCenter for Health Statistics has conducted a series of feasibility studies todetermine whether a workable data collection method could be developed. Inclose consultation with representatives of the medical profession, this NationalAmbulatory Medical Care Survey was designed and tested.

Your own task in the survey is simple, carefully designed, and should not takemuch of your time. Essentially, it consists of your participation during aspecified 7-day period. During this period, you simply check off a minimal ‘amount of information concerning the patients you see.

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

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

Yes . . . . . . . 1No .(ASKA). . 2

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

(Nsme of Specialty)

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

practice, or an establishinentwill be held confidential, will be used onlY bypersons engaged in and for the purpose of the-survey, and will not be disclosedor released to other persons or used for any other purpose.

58

2. Doin

A,

you have a solo practice, or are you associated with other physiciansa partnership, in a group practice, or in some other way?

solo. . . . . . . .. . . . . . .1

Partnership . . . (ASK A). . . 2

Group . . . (AsKA) . . . . . .3

Other . (SPECIFY AND ASKA) . . 4

IF PARTNERSHIP, GROUP, OR OTHER: How many other physicians are associ-ated with you?

(//of Physicians)

3. NOW, doctor, this study will be concerned with the ambulatory patientsyou will see in your office during the week of (READ REPORTING DATES ENTEREDBELOW .)

(that’a a (that’s aI Monday) through / Sunday)

month date month date

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

Yes . . . (GOTOQ. 4) .

No . . . . . (ASKA) .

A. IF NO: Why is that? RECORD VERBATIM, THEN READ PARAGRAPH BELOW

that week?

. . 1

. . 2

Since it’s very important, doctor, that we include any ambulatorypatients that you do happen to see in your office during thatweek, I’d like to ~ave these forms with you anyway--just in caseyour plans ~hange. 1’11 plan to check back with your office justbefore (STARTING DATE) to make sure, and I can explain them indetail then, if necessary.

GIVE DOCTOR THE ~PATIENT RECORD FORMS AND GO TO Q. 10, P. 6.

59

4. A. At what office location will you be seeing ambulatory patients during that7-day period? RECORD UNDER A BELOW AND ASK B WHEN INDICATED.

B. IF HOSPITAL EMERGENCY ROOM. OUT-PATIENT CLINIC, OR OTHER INSTITUTIONALLOCATION IN A: Thinking about the ambulatory patients you see in (PLACE IN

A), do you, yourself, have primary responsibility for theircare over time, or does (INSTITUTION IN A) have primaryresponsibility for their care over time? CODE UNDER B BELOW.

A.

Office Location

~

(1) 1 0

(2) 1 0

(3) 1 0

(4) 1 0

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

Yes. . . . . 1

No. . . . .2

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

IF ALL LOCATIONS ARE OUT-OF-SCOPE (CODE “O” IN Q. 4B), THANK THE DOCTOR AND LEAVE.—

60

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

to see in your office practice? (DO NOT COIJNTpATIENTS SEENAT [OuT-OF-5cOPE

LOCATIONS] CODED IN 4-B.)

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

B. And during those seven days (REPEAT DATES IF NECESSARY), on how many ~ do you

expect to see any ambulatory patients? COUNT EACH DAY IN WHICH DOCTOR EXPECTSTO SEE ANY PATIENTS AT AN IN-SCOPE OFFICE LOCATION.

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

DETERMINE PROPER PATIENT LOG FORM FRCM CHART BELOW. READ ACROSS ONt!ToTALpATI~TSlt LINE UNDER llA1tAND CIRCLE LETTER IN APPROPRIATEIIMySII coL~ UNDER “B.”

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

LOG FORM DESCRIPTION

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

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

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

*D--patient Record is to becompleted for everyFIFTH patient listedon Log,

Expected total Total ~ in practicepatients during during week.survey week.

ENTER TOTALENTER TOTAL FROM FROM Q. 5-B. DAYSQ. 5-A.

1 2 3 4 5 6 7

1- 12 PATIENTS AAAAAAA

13- 25 BAAAAAA

26- 39 CBAAAAA

40- 52 CBBAAAA

53- 65 ! I DCBBAAA

66- 79 DCBBBAA

80- 92 DDCBBBB

93-105 DDCBBBB

106-118 DDCCBBB

119-131 DDCCBBB

132-145 DDDCCBB

146-158 DDDCCBB

159-171 DDDcCcc

EEEw‘In the rare instance the physician will see more than 500 patients during his

assigned reporting week, give him two D Patient Log Folios and instruct him to completea patient record form for only every tenth patient. Then you sre to draw an X or lineon line 5 on every other page of the two folio pads, starting with page 1 of the pad.

61

6. FIND PATIENTLOG FOLIOWITH APPROPRIATELETTERAND ENTER LETTERAND NUM8EROF THIS FORM HERE.

(FolioNumber)

7. HAND DOCTORHIS FOLIOAND EKPLAINHOW FORMSARE TO BE FILLEDOUT. SHOWDOCTORTHE INSTRUCTIONSON POCKETOF FOLIO TO WHICH HE CAN REFERAJ?TERYOU LEAVE.

RECORDVERBATIMBELOW ANY CONCERN,PROBLEMSOR QUESTIONSTHE DOCTORRAISES.

8. IF DOCTOREKPECTSTO SEE AMBULATORYPATIENTSAT MORE THAN ONE IN-SCOPELOCATIONDURINGASSIGNEDWEEK, TELL HIM YOU WILL DELIVERTHE FORMSTO THE OTHERLOCATION(S).ENTER THE FORM LETTER AND NUNBER(S) FOR THOSE LOCATIONS BELOW, BEFORE DELIVERINGFORM(S).

Location PatientRecordForm Letter& Number

9. Duringthe surveyweek (REPEATEXACT DATES), will anyonebe availableto helpyou in fillingout theserecords(at each IN-SCOPE location)?

Yes . . .(ASKA) ..1

No . . . . . . . . .2

A. IF YES: Who would thatbe?

RECORD NAME, POSITION AND LOCATION.

Name I Position I Location I Yes No I

-k

I 1 2

‘“INTERVIEWERSHOULD BRIEF SUCH PERSON IF POSSIBLE.

,

62

10. NOW I have just one more question about your practice. (NOTE: IF DOCTORPRACTICES IN LARGE GROUP, THE FOLLOWING INFORMATION CAN BE OBTAINED FROMSOMEONE ELSE.)

A. What is the total number of full-time (35 hours or more per week) em-ployees of your (partnership/group)practice? Include persons regularlyemployed who are now on vacation, temporarily ill, etc. Do not includeother physicians. RECORD ON TOP LINE OF COLUMN A BELOW. —

1) How many of these full-time employees are . . . (READ CATEGORIESBELOW AS NECESSARY AND RECORD NOMBER OF EACH IN COLUMN A.)

B. And what is the total number of part-time (less than 35 hours per week]employees of your (partnership/group)practice? Again, include personsregularly employed who are now on vacation, ill, etc. Do not includeother physicians. RECORD ON TOP LINE OF COLOMN B BELOW.

1) How many of these part-time employees are . . . (READ CATEGORIESAS NECESSARY AND RECORD NOMBER OF EACH IN COLUMNB.)

Employees

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Registered Nurse

Licensed PracticalNurse

Nursing Aide

Physician Assistant

Technician

Secretary orReceptionist

Other (Specify) .

A.Full-time

(35 or more hours/week)

roTAL:

B.Part-time

(Less than 35 hours/week)

TOTAL:

63

BEFOREYOU LEAVE,S7RESSTHAT~ AMBULATORYPATIENTSEEN BY THE DOCTORDURINGTHE 7-DAY PERIOD AT ALL IN-SCOPE OFFICE LOCATIONS (REPEAT THEM) IS TO BE IN-CLUDED IN THE SURVEY~i’HAT EACH PATIENT IS TO BE RECORDED ON THE LOG, AND ONLYTHE APPROPRIATE NUMBER OF PATIENT RECORDS COMPLETSD.

Thank you for your time, Dr. . If you have any (more) questions,please feel free to call me. My phone number is written in the folio. I’llcall ~ on Monday morning of your survey week just to remind you.

11. TIME INTERVIEW ENDED . . . . . . . . . AMPM

12. DATE OF INTERVIEW . . . . . . . .az3nz

(Month) (Day) (Year)

I COMPLETE IIEMS ON LAST PAGE

IMMEDIATELY AFTER TRE INTERVIEWI

64

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

Great interest . . . . . 1

Some interest . . . . . 2

Little interest . . . . 3

NO interest . . . . . . 4

Can’t tell . . . . . . . 5

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

Definitely will . . . . 1

Probably will . . . . . 2

Doubtful . . . . . . . 3

IN’JJIRVIEWERhWER

I

INTRRVIEWRR’S SIGNATURE

irrrrl’* U. S. GCWESNMENT PR2NTING OFFICE :1975 210-981/26

65

VITAL AND HEALTH STATISTICS PUBLICATION SERIES

Originally I%{blic Health Service t% blico tiorz No. f 000

S,ri,s 1. Pvo&’ams and collection fivoceduves.— Reports which describe the general programs of the NationalCenter for Health Statistics and its offices and divisions, data collection methods used, definitions,and other material necessary for understanding the data.

S1”VtC’S2. Dak2 ewluation and methods vesewch. — Studies of new statistical methodology including: experi-mental tests of new survey methods, studies of vital statistics collection methods, new analyticaltwhniqttes, objective evaluations of reliability of collected data, contributions to statistical theory.

S ri~,.!.?. .-lnal~ticaz stwdies. -Reports presenting analytical or interpretive studies based on vital and healthstatistics, carrying the analysis further than the expository types of reports in the other series.

S( ‘Yi{w ~!, Docum cnts and committee vefiovts. — Final reports of major committees concerned with vital andheulth statistics, and documents such as recommended model vital registration laws and revisedbirth and death certificates.

S&~i,s 10. Pa tu jjmm the Health In tevview .%wve v. —Statistics on illness, accidental injuries, disability, usecii Ilospital, medical, dental, and other services, and other health-related topics, based on data

CO1Iected in a continuing national household interview survey.

Stri~c.<11. Data j>cim the Health Examination Swvey. —Data From direct examination, testing, and measure-ment of national samples of the civilian, noninstitutional population provide the basis for two typesof reports: (1) estimates of the medicaHy defined prevalence of specific diseases in the UnitedSt.mss imd the distributions of the population with respect to physical, physiological, and psycho-lo~,ical characteristics; and (2) analysis of relationships among the various measurements withoutr~d’~’rcmceto an explicit finite universe of persons.

S(k-i,s j2. Pa 10j%m the Institutional Population Swveys —Statistics relating to the health characteristics ofpmmw in institutions, and their medical, nursing, and personal care received, based cm nationalwropks of establishments providing these services and samples of the residents or patients.

S,.-fit ,S ]3. Pa la from tke Hospital Dischm-ge Swvey. —Statistics relating to cii~ch.wged patients in short-stayhospitals, based on a sample of patient records in a national sample of hospitals.

S, vi,s 1.!. Data on health vesowces: manpower and facilities. —Statistics on the numbers, geographic distri-bution, and characteristics of health resources inch.tding physicians, dentists, nurses, other healthoccupations, hospitals, nursing homes, and outpatient facilities.

S8Fit x 20. Datd on movtality.- Various statistics on mortality other than as included in regular annual ormonthly reports —special analyses by cause of death, age, and other demographic variables, also!yoLq-spMC and time series analyses.

t?, vi, ‘x Z’J. .lMia on natality, mawiage, and divorce. —Various statistics on natality, marriage, and divorceother than as included in regular annual or monthly reports-special analyses by demographicvariables, also geographic and time series analyses, studies of fertility.

S ‘rif’s 2;. Data j>om the National Natality and Mentality Suweys. — Statistics on characteristics of birthswtd deaths not available from the vital records, based on sample surveys stemming from these“records , including such topics as mortality by socioeconomic class, hospital experience in thekt year of Iife,.meclical care during pregnancy, health insurance coverage, etc.

For ,1 li:-,t d titles of reports published in these series, write to: Scientific and Technical Information BranchNational Center for Health StatisticsPublic Health Service, HRARockviLle, Md. 20S52

the national ambulatory medical care surveylibrary of congress cataloging in publication data...

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