DOCUMENT RESUME

ED 096 516 CB 002 146

TITLE National Ambulatory Medical Care Survey: Backgroundand Methodology. United States-1967-72. Vital andHealth Statistics. Data Evaluation and MethodsResearch. Series 2, No. 61.

INSTITUTION National Center for Health Statistics (DHEW),Rockville, Md.

REPORT NO DHEW-HRA-74-1335PUB DATE Apr 74NOTE 85p.AVAILABLE FROM Superintendent of Documents, U. S. Government

Printing Office, Washington, D. C. 20402 ($1.25)

EDRS PRICE MF-$0.75 HC-$4.20 PLUS POSTAGEDESCRIPTORS Data Collection; Feasibility Studies; Medical

Research; *Medical Services; *National Surveys;*Research Design; *Research Methodology; StatisticalData; *Tablet (Data)

IDENTIFIERS *Ambulatory Health Care

ABSTRACTThe report describes the initial destgn and the

preliminary backgrouna exploration, subsequent development, andfeasibility testing of methods for conducting a continuing NationalAmbulatory Medical Care Survey (VMS). Selected feasibility studyfindings are presented to illustrate collected data and suggest kindsof information that may be expected when substantive survey resultsbecome available on a continuing national basis. NAMCS was authorizedto gather and disseminate statistical information about ambulatoryhealth care provided by office-based physicians to the population ofthe United States. Ambulatory health care is defined as healthservices rendered individuals under their own cognizance. at a timewhen they are not in a hospital or other health care institution.Thirteen pages of detailed tables present the survey resultsregarding annual volume (1967-1972) and rates of patient visits forpopulation groups, medical specialty groups, and geographic areas.Quantitative descriptions of visit characteristics includetabulations of patient's problems, reasons for visit, diagnoses,services, treatment, and subsequent disposition. The 40-page appendixpresents the data collection forms for the survey and field tests.(AG)

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Library of Congress Cataloging in Publication Data

National ambulatory medical care statistics.

(Data evaluation and methods research, series 2, no. 61) (DHEW publication no.(HRA) 74-1335)

"Prepared for the Division of Health Resources Statistics, National Center for HealthStatistics."

Supt. Docs. no.: HE 20.6209: 2/61Includes bibliographical references.1. Medical statistics. 2. Medical careUnited StatesStatistics: I. White, Kerr L., joint

author. II. Williamson, John W., joint author. III. United States. National Center for HealthStatistics. Division of Health Resources Statistics. IV. Title. V. Series: United States.National Center for Health Statistics. Vital and health statistics. Series 2: Data evaluationand methods research, no. 61. VI. Series: United States. Dept. of Health, Echo:ation, andWelfare. DHEW publication no. (HRA) 74-1335. [DNLM: 1. Ambulatory careStatistics.2. Health surveysU.S. WB16 T298n 1967.721RA409.U45 no. 61 312'.01'82s [362.1'0973] 73-20225

For sale by the Superintendent of DocurrAmts. U.S. Government Printing 011ie*, Washington, D.C. 20102-Price $1.25

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ATA EVALUATION AND METHODS RESEARCH Series 2. .4.0

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National AmbulatoryMedical Care Survey:

Background and Methodology

United States-1967-72

A report on feasibility studies of methods developed for collecting nationalambulatory medical care data from practicing office-based physicians in theUnited States, 1967.72, prepared ror the Division of Health ResourcesStatistics, National Center for Health Statistics, Health Resources Adminis-tration, U.S. Department of Health, Education, and Welfare.,

DHEW Publication No. (HRA) 74-1335

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

Health Resources AdministrationNotional Center for Health Statistics

Rockville, Md. April 1974

NATIONAL CENTER FOR HEALTH STATISTICS

EDWARD B. PERRIN, Ph.D., Director

PHILIP S. LAWRENCE, Sc.D., Deputy DirectorDEAN E. KRUEGER, Acting Associate Directorfor Analysis

GAIL F. FISHER, Associate Director for the Cooperative Health Statistics SystemELIJAH L. WHITE, Associate Director for Data Systems

IWAO M. MORIYAMA, Ph.D., Associate Director for International Statistical ProgramsEDWARD E. MINTY, Associate Director for ManagementROBERT A. ISRAEL, Associate Director for Operations

QUENTIN R. REMEIN, Associate Directorfor Program DevelopmentPHILIPS. LAWRENCE, Sc.D., Acting Associate Director for Research

ALICE HAYWOOD, Information Officer

DIVISION OF HEALTH RESOURCES UTILIL-.TION STATISTICS

SIEGFRIED A. HOERMANN, Acting DirectorPETER L. HURLEY, Acting Deputy Director

JAMES F. DELOZIER, Acting Chief, Ambulatory Cale Statistics BranchWILLIAM F. STEWART, Chief, Family Planning Statistics Branch

ABRAHAM L. RANOFSKY, Cnief, Hospital Disci...irk. Survey Branch

Vital and Health Statistics-Series 2-No. 61

DHEW Publication No. IHRA) 74-1335

Library of Congress Catalog Card Number 73-20225

PREFACE

This report describes the initial design and the preliminarybackground exploration, subsequent development, and feasibilitytesting of methods for conducting a continuing National AmbulatoryMedical Care Survey (NAMCS). The purpose of NAMCS is to gatherand disseminate statistical information on the provision and use ofambulatory health car.: services in the United States. The workreported here was accomplished from 1967 through 1972, butgerminal planning for these methodologic studies stemmed from thereport of the Subcommittee on National Morbidity Survey of theU.S. National Committee on Vital and Health Statistics published in1953.1 In the 20-year interim, social and technologic changes as wellas the efforts of interested organizations, involved individuals, andfarsighted leaders contributed to the inauguration of the 1973NAMCS. Principal contributors during the period of this report wererepresentatives from endorsing medical organizations; the NAMCSTechnical Advisory Panel; the contracting organizationsLea, Inc.,and the National Opinion Research Center; the Department ofMedical Care and Hospitals of The Johns Hopkins University; andboth the National Center for Health Services Research and Develop.ment and the National Center for Health Statistics, of the HealthServices and Mental Health Administration, U.S. Department ofHealth, Education, and Welfare.

The principal national sources of statistical information aboutambulatory medical care are the practicing, office -based physicians.Without their cooperation this research would not have beenpossible. Major medical organizations that endorsed the NAMCSproject early were as follows: American Medical Association;National Medical Association; American Academy of Dermatology;American Academy of Family Physicians; American Academy ofNeurology; American Academy of Orthopaedic Surgeons; AmericanAcademy of Pediatrics; American Association of Neurologic Sur-geons; American College of Obstetricians and Gynecologists; Ameri-can College of Physicians; American College of Preventive Medicine;American College of Surgeons; American Osteopathic Association;American Proctologic Society; American Psychiatric Association;American Society of Internal Medicine; American Society of Plasticand Reconstructive Surgeons; American Uro logic Association; andAs ociation of American Medical Colleges.

the NAMCS 'technical Advisory Panel of individuals with ambula-tory health care interests and expertise served as a committee ofconsultants to the feasibility study from its beginning. Committeemembers were the following: Theodore R. Ervin; Todd M. Frazier;

and Drs. Barbara Bates, Robert J. Haggerty, Jean I.. Harris, HowardII. I halt, Robert R. Huntley, Hugh II. Hussey. R. Robert Kalinowski,Chester F. Keefer (deceased), Charles E. Lewis, Kenneth D. Rogers,Paul J. Sanazaro, Patrick B. Storey, and Kerr I.. White. Consultantsfrom the Department of Medical Care and Hospitals of the JohnsHopkins University School of Hygiene and Public Health inBaltimore were Drs. James B. Tenney, Kerr I.. White, and John W.

National Center for Health Statistics provided sponsorship,supervision, and technical staff support for the entire NAMCSmethodologic development project. Siegfried A. Hoermann, Directorof the Division of Health Resources Statistics, was Project Adminis-trator and Supervisor; James E. DeLozier has been the ProjectOfficer for the study since 1969; and E. Earl Bryant, of the Office ofStatistical Methods, gave consultation and expert assistance foraspects of sampling ,ind survey design.

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CONTENTS

Page

Preface iii

IntroductionAmbulatory Nledical Care 1

Definition and OrientationNeeds and Uses for Information 2

National Center for Health Statistics Program 2Authority and Purpose 2Current Survey Operations 3

National Ambulatory Medical Care Survey 3Purpose and Scope 3Sample Design 3Survey Methods 4

Fie!d Procedures 4Data Collection 4

Data Processing and Results 5

Background and Methodology 5Exploratory Studies 6

Literature Summary 6Office Records Survey 6Initial Forms Design 7

Feasibility Studies: Field Test: Phase I, 1968-69 7Purpose and Design 7Survey Results 8Conclusions 8

Feasibility Studies: Field Test: Phase II, 1970-71 9Purpose and Design 9Survey Results 11Conclusions 12

Illustrative Feasibility Study Findings 13Introduction and Methods 13Data Source and Volume 13Age and Sex of Patients 14Problems and Diagnoses 15Selected Characteristics of Visits 16

Summary and Conclusion 17

References 19

List of Detailed Tables 20

CONTENTS -Con.

Appendix 1. Data Collection Forms, 1973 National Ambulatory

Page

Medical Care Survey 35

Patient Log and Patient Record, Sampling Every Patient 35

Patient Log and Patient Record, Sampling Every Second Patient ';G

Patient Log and Patient Record, Sampling Every Third Patient '36

Patient Log and Patient Record, Sampling Every Fit th Patient 37

Induction Interview Schedule 38

Appendix II. Introductory Letters, 1973 National AmbulatoryMedical Care Survey 46

Appendix 111. Data Collection Forms, Field Test: Phase I 48Long Form Patient Data 48Short Form-Patient Data 49Induction Interview Schedule 50Patient Form Evaluation Interview Schedule 54

Appendix IV. Data Collection Forms, Field Test: Phase II 60Short Form and Patient Log for Nonsampliog Procedure 60Short Form With Patient Log for Sampling; Procedure 61

Miniform and Patient Log for Nonsampling Procedure 69Miniform With Patient Log for Sampling Procedure 63Miniform Without Patient Log; for Nonsampling Procedure 64Enlistment Interview Schedule 65

Evaluation Interview Schedule 69

Data not available

SYMBOLS

Category not applicable

Quantity zero

Quantity more than 0 but less than 0.05

Figure does not meet standards ofreliability or precision

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NATIONAL AMBULATORY MEDICAL CARE SURVEY:

BACKGROUND AND METHODOLOGY

,Jaincs B. Tenney, NHL, 1)r. P.11.; Kerr L. Whit.!, Ni.D.; and John W. Williamson, NI.D.a

INTRODUCTION

In April 1973 the National Center for flealthStatistics inaugurated the National AmbulatoryNledical Care Survey to gather and disseminatestatistical information about ambulatory healthcare provided by office-based physicians to thepopulation of the United States. It is thepurpose of the present report to relate thecurrent survey design characteristics and todes, ribe the background and methodology fordeveloping the National Ambulatory MedicalCare Survey. Selected feasibility study findingsare presented to illustrate collected data andsuggest kinds of information that may be ex-pected when substantive survey results becomeavailable on a continuing national basis,

AMBULATORY MEDICAL CARE

Definition and Orientation

Ambulatory medical ( arc is the predominantpathway for the provision and use of proles-

Dr. Tenney is Assistant Protesser and Drs. White andWilliamson are Profess4rs 41. the .14.hiss Hopkins UniversitySchool 4)1 Dvgiene and Public Health. Department ol MedicalCare And lialum4)re. Nlatyland.

sional medical services in the United States. It isdefined as health services rendered individualsunder their own cognizance, at a time when theyare not in a hospital or other health careinstitution. These services, for the largest part,fall under the category of primary care. Primarycare is characterized by direct personal contactbetween patients seeking help for their healthproblems, and physicians or other health profes-sionals who try to provide it. Secondary ortertiary care applies to services provided ambula-tory patients who arc referred to specialists ofconsultant physicians.2 By definition ambulatory medical care does not include secondary-and tertiary-level care provided hospital in-patients, or lay services given outside formalhealth care systems.

Ambulatory care takes place in many settings,from patients' homes, neighborhood health cen-ters, and public clinics to hospital outpatientdepartments and emergency rooms. However,the largest volume of ambulatory care in thiscountry is provided at the doctor's office.3 It isthere that people go when sick, in distress, orout of sorts, and it is there physicians attendthem. Approximately 7 of every 10 Americansconsult a physician 1 time or more annually, and7 of every 10 physicians engaged in patient-care

activities do so principally in office-based prat--tice.4.5 According to unpublished data from the1972 National Health Interview Survey, exclud-ing elephone calls, 80 percent of all physicianvisits take place in the doctor's office; 13percent at hospital clinics and emergency rooms;and 7 percent at homes, on jobs, or elsewhere.

NEEDS AND USES FORINFORMATION

Important needs for and uses of statisticaldata on the volume and characteristics of healthcare provided in physicians' offices are manifest.Vet the apparent importance of population useand professional practice of ambulatory medicalcare is not reflected in currently availableknowledge. Five broad areas for application areparticularly prominent:

t. Nutimia/ statistics--'the summary account-ing of events affecting the Nation's governmen-tal as well as public interestshould have con-tinuing data input for surveillance to reflect theambulatory care component of the Nation'shealth services systems. Specifically, the infor-mation given should be useful in comparing theuse of ambulatory services among differentgroups of the population over time and inassessing the kind and magnitude of effectsassociated with changes that occur in health caresystems.

2. Professioncd educationThe systematicpreparation of physicians and other health per-sonnel to meet the health care requirements ofthe public--needs regular reliable data on thehealth problems of ambulatory and institutional-ized patients and on the professional care theyreceive. The information would be useful indeveloping educational priorities and in planningdesirable curriculum changes in medical andother health care schools. This would insure thatgraduates are prepared for the tasks they arccalled to perform or the medical problems theywill be encountering.

3. Health policy formulationThe selection,at all levels of care, of alternative directions foradministration, management, and implementa-tion in personal health services systemsneedsrelevant data about ambulatory and institutional

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services to evaluate sound choice and rationaldecisions. The information would be useful inassessing alternative plans for modifying healthservices organizations and delivery systems.

-I. Medical practice managementThe admin-istration and implementation of decisions af-fecting the planning and conduct of ordinaryoffice practice and patient careneeds regionaland national data reflecting contemporarytrends in use of services and treatment ofpatients. The information would be useful inassuring the maintenance of standards and incomparing the effects of alternative proceduralpatterns and manpower organizationaldistributions.

5. Quality assuranceThe systematic effortto assess and improve the effectivene- andefficiency of medical careneeds ambulatorycare data to develop basePnes for implementingprograms of professional standards review. Theinformation would be particularly useful inestablishing priorities for research and develop-ment of quality assessment standards, instru-ments, guidelines, and methods.

THE NATIONAL CENTER FOR HEALTHSTATISTICS PROGRAM

Authority and Purpose

The National Center for Health Statistics(NCHS) is the principal Federal agency withcorn, .ehensive responsibility for compilation,analysis, and dissemination of health statistics;and it serves as a recognized focal point fornational leadership in developing coordinateddata collection systems to meet public andprivate needs. Established in 1960 by authoriza-tion under both the Public Health Service andNational Ilealth Survey Acts, the Center is aseparate rganizational part of the Health Re-sources Administration in the U.S. Departmentof Health, Education, and Welfare. Its majormission is "... to develop and maintain systemscapable of providing reliable general purpose.national, descriptive health statistics on a contin-uing basis, and to publish these statistics for theuse of the health and related professions and

industries, both public and private."5 Accord-ingly, VMS is fundamentally concerned withthe need for, and has a clear mandate to developand provide national statistics regarding, ambula-tory medical care in the United States.

Current Survey Operations

The Center operates a number of nationalstatistical data collection systems: the nationalvital statistics of births, deaths, fetal deaths,marriages, and divorces; surveys based on sam-ples of the birth and death records; a continuingnationwide survey of households by interviews;

NATIONAL AMBULATORY

The National ,mbulatory Medical Care Sur-vey (NAMCS) is the contemporary data collec-tion system constituting the outcome of NCHS'concern with developing objective and reliablequantitative information to measure and de-scribe ambulatory health care services for theU.S. population.? The initial (1973) NAMCSdesign is presented here. The features are en-dorsed by major organizations within the medi-cal profession listed in the preface and are theresult of decisions based on experience from thebackground investigation and methodologic de-velopment described in subsequent sections ofthe report.

PURPOSE AND SCOPE

The purpose of the NAMCS is to meet needsand demands for statistical information aboutthe provision and use of ambulatory medicalcare services in the United States. Initially, thetarget population consists of all office visitswithin the coterminous United States made byambulatory patients to physicians who are prin-cipally engaged in office-based practice but notin the specialties of anesthesiology, pathology,and radiology or in Government service. Tele-phone contacts and nonoffice visits arc ex-cluded. When resources permit feasible surveymethods to be developed, the target populationwill also include visits to other locations andprofessionals, thus encompassing the remaining

a series of national surveys based on physicalexaminations of population samples; periodicsurveys of nursing homes, hospitals, and otherhealth ,..are facilities and their patients or resi-dents; a continuous national sampling of short-stay hospital records; and surveys of variouscategories of health manpower based on licenserenewals, reports from establishments, or othersow.,:es. Results arc published in several series ofstatistical :sports and are also provided inreference to specific special requests for statis-tical data or technical assistance.6 A constantprogram is maintained to improve these systemsand to develop new ones in response to changingneeds and demands.

MEDICAL CARE SURVEY

fraction of ambulatory medical care initially notwithin its scope. Complex sampling and re-porting problems must be resolved to producereliable statistical information from hospitaloutpatient departments and emergency rooms, amost important component of this remainder.

SAMPLE DESIGN

The only objective and reliable sources ofdata about physicians' services rendered toambulatory patients during office visits are thephysicians themselves and members of theiroffice staffs. The survey population for theNAMCS' multistage probability sample, there-fore, includes all physicians in office-basedpractice responsible for ambulatory patient care,excluding those in anesthesiology, pathology,and radiology or in Government service. Thesampling frame is a list of licensed physician. inoffice-based practice compiled from files thatare classified and maintained by the AmericanMedical Association (AMA) and the AmericanOsteopathic Association (AOA). These files arecontinuously updated by the AMA and AOA,making them as current and correct as possibleat the time of sample selection.

The first-stage sample was designed and se-lected by the National Opinion Research Center(NORC), a nonprofit research organization affil-iated with the University of Chicago, whichcontracted to carry out all phases of NAMCS

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field work. A modified probability- proportional-to -size procedure using separate samplingframes for standard metropolitan statistical areas(SMSA's) and for nonmetropolitan counties wasemployed. After sorting and stratifying by size.region, and demographic characteristics, eachframe was divided into sequential zones of 1million residents, and a random number w sdrawn to determine which primary samplingunit (PSU) came into the sample from eachzone. The final first-stage sample contained 87PSIT's, corresponding to individual counties orsmall groups of contiguous counties across thecountry.

The second-stage sample was selected fromthe list of physicians located in sample PSU'sordered by major specialty categories, so thatthe overall probability for including any individ-ual was the reciprocal of the number of physi-cians in the frame at the time of selection. Afinal sample of 1,705 office-based physicianswas thus drawn and assigned by random meth-ods to one of the 52 one-week periods in theyear for data collection. Samples for subsequent)4 ars will exclude with certainty physiciansincluded within the previous 2 years. In subse-quent years larger samples may be employed formore precise estimates or more detailed repre-sentation of ambulatory medical care informa-tion. Reliability will continue to require preserv-ing strict statistical sampling procedures,unsubstituted collection period assignments, andhigh participation levels among samplephysicians.

SURVEY METHODS

Field Procedures

To maximize participation levels and mini-mize data collection requirements, assuring ob-jective and reliable information as a result,NAMCS field procedures uniformly emphasizeand accommodate the individual circumstancesof sample physicians. After receiving introduc-tory letters from NCHS and AMA or AOA,sample physicians are telephoned by informedand trained NORC interviewers who explain thesurvey briefly and arrange personal appoint-ments to relate more detailed instructions. When

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interviewers visit, they determine samplephysicians' eligibility, ascertain their coopera-tion, deliver survey materials with printed in-structions, and assign predetermined Monday-through-Sunday data collection periods. A shortinterview concerning basic practice characteris-tics, such as estimated numbers of patients to beexpected, is administered. Office staff who willassist with data collection are invited to attendor are offered separate instruction sessions.Sample physicians are informed of support forthe NAMCS by their respective specialty socie-ties. State and local medical societies arc madeaware of the survey through communicationsfrom the AMA a° well as from interviewers andfield staff supervisors.

Before the beginning and again during theweek assigned for data collection, interviewerstelephone sample physicians to answer possiblequestions and to insure that procedures aregoing smoothly. At the end of the survey week,participating physicians mail finished surveymaterials to interviewers who edit the forms forcompleteness before transmitting them for cen-tral data processing. Problems at this stage areresolved by interviewer telephone calls to samplephysicians; if there are no problems, fieldprocedures are complete with respect to thesample physicians' participation in the NAMCS.Missing information is generally obtained fromthe patient's medical record by the physician'sstaff or provided from memory by thephysician.

Data Collection

The actual data collection for the NAMCS iscarried out by participating physicians, aided bytheir office assistants when possible. They arerequested to complete data collection formsconcerning ambulatory patient visits takingplace during assigned I -week periods in theiroffice practices. Based on their own estimates ofthe numbers of patients expected to visit duringthe survey period, physicians are assigned to usean "every-patient" or a "patient-sampling" pro-cedure. All procedures are designed so thatencounter forms for approximately 10 patientvisits be completed each day. Physicians expect-ing 10 or fewer visits daily record data for all ofthem, while those expecting more than 10 visits

record data after every second, or third, or fifthvisit, observing the same predetermined samplinginterval continuously. These procedures mini-mize the workload of data collection and main-tain equal reporting levels among sample physi-cians regardless of the size of their practices.Each form requires 1-2 minutes to complete, sothat approximately 15 minutes are required ondays when ambulatory patients are attended intheir offices.

Two data collection forms are employed bythe participating physicians: the Patient Log andthe Patient Record. The Patient Log is asequential list of patients visiting throughout thesurvey week that serves to indicate at whichvisits data should be recorded. The PatientRecord is an encounter form which requires 12items of data about a visit: date and duration ofthe visit; patient's birthdate, sex, color, andprincipal problem; physician's estimate of theseriousness of the problem, and whether thepatient has been seen for it before; majorcategorical reasons for the visit; diagnoses; treat-ment or services; and disposition. Together theseitems constitute a brief but informative generalaccount of an ambulatory patient visit. ThePatient Log and the Patient Record are separate,or attached only by perforation so that samplephysicians can keep the Log and mail the PatientRecord back to the interviewer after comple-tion, tvithout any indication of patient names toprotect confidentiality. Copies of the variousPatient Logs and Patient Records are shown inappendix I.

DATA PROCESSING AND RESULTS

Edited NAMCS Patient Records and physicianinterview information are mailed by the inter-viewers to NORC for further editing, subsequentcoding, and entry on magnetic tapes. Anyremaining information identifying individualambulatory pat:ents is positively deleted. Allinformation that would permit identification ofa physician, a practice, or an establishment isheld in strict confidence for use only by personsengaged in and for the purposes of the survey,secure from disclosure or release to other per-sons or use for other purposes.

Initial NAMCS results in the form of sum.mar/ statistical tabulations of national andregional estimates for numbers of visits, percentdistribution, and population rates of use arepublished as soon as each annual cycle of thecontinuing NAMCS is complete. More detailedtabulations of visit characteristics by majorphysician specialties, patient. groups, diagnosticcategories, treatment provided, and dispositionarranged will follow. Cross-tabulations of lesscommon visit characteristics will be publishedwhen sufficient data about them are available tomeet practical standards of precision. In addi-tion, research findings on the reliability andvalidity of NAMCS methods, the means toimprove and extend them, and on statisticsrelated to specific questions from States orprofessional specialty groups are underdevelopment.

BACKGROUND AND METHODOLOGY

In 1967 the National Center for HealthStatistics began planning the project from whichthe current NAMCS design and methods ulti-mately developed. NCIIS staff members enteredinto discussions with consultants, practicingphysicians, statisticians, and potential contrac-tors to identify ambulatory care data collectionproblems and prospective approaches to solu-tions. Contract proposals were solicited for a"pilot study on a survey of physician's records"to develop methods for expanding "... thehealth records program to include samples from

records of private physicians." The request wasintended to elicit as many proposals and ideas aspossible since the prospect appeared more diffi-cult than any the Center had attempted previ-ously, and a heuristic problem-solving approachseemed indicated. After numerous inquiries, halfa dozen proposals were finally submitted; theone by Lea, Inc., of Ambler, Pennsylvania, wasselected as most likely to succeed on the basis ofthat company's prior experience and existingresources for surveys involving collection of datafrom ambulatory medical practice. A technical

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advisory group of individuals with nationallyrecognized interest or experience was named.Initial discussions established a tentative proto-col that called for periodic meetings of aworking group comprised of the Director of theNCHS Division of Health Resources Statistics,the Project Officer and staff, the contractor'srepresentatives, and a consultant group fromThe Johns Hopkins University in Baltimore.After several working group meetings and pre-liminary exploratory investigations, the purposeof the project became clear: a methodologicstudy was needed to determine the feasibility ofcollecting ambulatory care data from office-based physicians on an ongoing national surveybasis. It %you'd require developing alternativeinstruments and procedures for data collection,testing them by application among samples ofphysicians, and evaluating the results accordingto criteria for feasibility. The NANICS methodo-logic study design subsequently evolved in threestages: first, a stage of exploratory studiesfollowed by two stages of feasibility studies.Field Test: Phase I and Field Test: Phase II, eachwith specific objectives related to the project'spuyosc.

EXPLORATORY STUDIES

Objectives of the exploratory stage were todefine operationally the boundaries and com-ponents of the ambulatory care data problemfor research and to formulate alternative meth-ods and procedures for subsequent testing andevaluation. The international literature was re-viewed, a sample of practicing physicians wasinterviewed, and individuals with identified in-terests or experience in the subject wereconsulted.

Literature Summary

Published accounts of ambulatory care stud-ies, particularly those involving data collectionfrom office-based physicians, documented therelative lack of existing information or broadexperience with methods of population-basedmedical practice surveys outside hospitals orinstitutions. Since the earliest account in 1842,occasional individuals or small groups of physi-cians have reported studies of morbidity en-countered and services rendered in home and

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office settings, based principally on analysis ofexisting records.° Reports were reviewed frommany countries, including Great Britain, Canada,Australia, Denmark, Germany, Holland, Nor-way, and the United States.9 The Royal Collegeof General Practitioners and the General Regis-ter Office of the United Kingdom carried out animportant survey of 171 physicians from 106general practices in England and Wales over a1-year period in 1955.56. It was undertakenafter lengthy preliminary explorations of record-keeping techniques following the advent of theNational Health Service there.1° In the UnitedStates, relatively extensive studies were re-stricted to selected groups of practices; notableones included the surveys reported by Standishet al., by Peterson et al., by the Chronic IllnessProject, Inc., and by Kroeger et al.11-14 Ambu-latory care services and utilization among pre-paid insurance plan populations had been stud-ied by Weissman and by Denson et al., and frominsurance claim form data by Avnet.15-17 Thesole existing source for continuing, profession-ally defined ambulatory care statistics identifiedin this country was National Disease and Thera-peutic Index by Lea, Inc.. a commercial surveyconducted principally for pharmaceutical mar-keting research purposes among a quota-samplepanel of private physicians." The literaturerevealed the need for developing uniform termi-nology, common units of measurement, widelyaccepted definitions, and for agreeing on prac-tical classifications of patients' problems anddiagnostic conditions encountered in ambula-tory practice. Information from all the availableaccounts was sought to help in formulatinginitial NAMCS methods and feasibility studydesign.

Office Records Survey

A direct personal interview survey was con-ducted by Lea, Inc., among a random sample ofphysicians in private practice, in accordancewith contract provisions to explore possibleapplications of existing office records as a sourceof national ambulatory care information. Acommercial list of physicians was stratified bymedical specialty group and geographic region ofthe country to provide the sampling frame; 358interviews were successfully completed among

the 400 physicians who were selected as thesample. Results revealed that whereas nearly allrespondents kept records, variations in theirform, style, content, completeness, and accessi-bility were extensive. The use of illegible terms,abbreviations, and symbols precluded their useby anyone but the recording physician in 20percent of cases, and alphabetic filing systemsprecluded ready relation to defined time periodsin 80 percent. Examination of specimen records,which were obtained from two-thirds of therespondents, substantiated the interview find-ings. It was concluded that practicing physiciansalone could provide a range of informationconcerning ambulatory patient visits in theiroffices, provided that confidentiality and ano:nymity were preserved. Since existing recordswere not a feasible source for data collection, adhoc encounter forms of some sort, designed forthe purpose, became necessary.

Initial Forms Design

Different styles and versions of modifiedencounter forms were drafted to facilitate thecollection of ambulatory patient visit data byphysicians. Basic precepts were to minimizeworkload or practice interference due to record-keeping and to maximize usefulness of the datato be gathered. Form designs were revisedrepeatedly after consultation with survey re-search specialists and again after pretesting themamong 22 selected physicians practicing in alarge metropolitan area. Interviews followingtheir pretest experience suggested that physi-cians preferred shorter (i.e., 2 days quarterly)instead of longer (i.e., 1 week or I month) datacollection periods, as well as shorter instead oflonger data collection forms as an initial ap-proach to field testing. Most of these explora-tory study results were incorporated in thedesign of subsequent stages of feasibility studiesfor the NAMCS project.

FEASIBILITY STUDIES:FIELD TEST: PHASE 1,1968 -69

Purport and Design

The purpose of the first phase of feasibilitystudy field testing was to evaluate ambulatory

patient visit data collection by a national sampleof physicians, using two different data collectionforms and three different methods to enlist theirparticipation. The objective was to determinewhether any combination of the forms andmethods was more feasible as to the proportionsof sample physicians agreeing to participate in anational ambulatory medical care survey andlater satisfactorily completing data collectionforms as requested.

The two forms employed to determine thequantity of data that was feasible for physiciansto collect are shown in appendix III. The longerform required about 3 minutes per patient visitto complete. and the shorter one about 1

minute. Both forms requested entries for thepatients' purpose or problem, diagnosis, age,race, sex, marital status, and prior visit status, aswell as the location and duration of contact,diagnostic procedure, treatment, and disposi-tion. In addition, the longer form requestedentries for the patient's socioeconomic, health,and referral status; the physician's estimate ofthe seriousness of the problem; and more spe-cific diagnostic test details. If physicians wishedto retain completed records, the forms weredesigned so that contact-sensitive code sheetsbeneath each one could be detached and re-turned alone.

The three methods of enlisting sample physi-cians to participate in the survey which wereevaluated for feasibility in the Phase I field testwere ( I) telephone contact by a physician inresidency training, (2) telephone contact by alay interviewer, and (3) personal visit contact bya lay interviewer. Since each approach wasemployed to enlist physicians for data collectionusing the long form and the short form, therewere six different form-approach combinationsfor comparison.

The sampling frame was constructed from acommercially maintained list to represent thesurvey population of all non-Federal, patientcare-oriented physicians in office-based practicein the continental United States, excludingspecialists in anesthesiology, pathology, andradiology. It was stratified by physician's agegroup, medical specialty group, and geographicregion; and a systematic sample was selectedcontaining 899 doctors of medicine or osteop-athy. Each physician was randomly assigned to

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one of the six form-approach combinations forthe data collection field test.

First, introduCtory letters were sent to all

sample physicians from the Director of theNCI'S, which briefly explained the purpose ofthe study and advised them of the forthcomingcall by a representative of the Center. Thenefforts were made to contact each physicianaccording to the assigned procedures and toenlist participation of those who were ascer-tained to be within the predefined scope of thestudy. Eligible physicians were defined as thosewho provided care for any ambulatory patientsin their practice. Home, office, hospital clinic, oremergency room visits and telephone contactswere included to establish feasibility. They wereasked to participate for an assigned 2-day periodof data collection, which would recur quarterlyfor a year. An enlistment interview to elicit

practice characteristics, provide instructions, andanswer questions was held beforehand, andsurvey materials with printed instructions weresupplied. Finally, after completing data collec-tion forms concerning ambulatory patient visits,participating sample physicians returned themby mail to a central location for tabulation anddescribed their experience at a postsurvey eval-uation interview conducted by telephone.

Survey Results

Results of the feasibility study's first phase offield testing are shown in table 1. Of 899physicians in the total sample at the time it wasdrawn, 679 (76 percent) were still eligible andavailable at the time the field test was con-ducted; they constituted the effective or targetiample that was actually approached and askedto participate. Others could not be located, hadleft practice by death or retirement, did notprovide services for ambulatory patients, wereunavailable during the survey period, or theywere not requested to participate. The relativelylarge number of ineligible or unavailable physi-cians was attributed in part to the 6-monthperiod elapsing between drawing the sample andconducting the field test. Of the effective sampleapproached, nearly three-fourths (74 percent)were enlisted or agreed to participate, and morethan one-half (55 percent) did so by completingand returning data collection forms. Differences

between samp!c proportions using and complet-ing the long form and the proportions using andcompleting the %Lott form were negligible. Theexpected dif ferent... in response for the twoforms was not reali;,..1, perhaps because bothforms seemed long to respondents using onlyone of them. 'Hie ditr-rent approaches alsoappeared to have slight ov.rall effect, althoughtelephone contact by resia-nt physicians wasslightly more successful than !idler methods ofenlistment, and personal contact by lay inter-viewers was marginally more successful forcompletion.

Item completion, the proportion of returneddata collection forms on which Aida weresupplied as requested for each specric item,ranged from 90 to 99 percent for items on theshort form, and from 85 to 99 percent for itemson the long form. Nonresponse to some itemswas attributed to their relatively inconspicuousposition on the forms; for others it seemed morerelated to the increased time required to makenecessary judgments for reply. Hospital emer-gency room or clinic visit and telephone contactdata were relatively underrccorded.

Interviewing at the time of enlistment pro-vided data about practice characteristics thatfacilitated interpretation of the field test results.Postsurvey interviewing gathered impressions ofthe physicians' experience and their suggestionsfor improving survey methods. Reducing theworkload for participating physicians and in-creasing their awareness of the purposes of themethodologic study were the most frequentlymentioned practical suggestions to improve fu-ture participation.

Conclusions

Conclusions from Field Test: Phase I offeasibility studies for the NAMCS methodologicproject were tentative. Ambulatory medical caredata collection instruments and procedures hadbeen designed and tested among a nationalsample of office-based physicians. The results in,terms of sample proportions enlisting for parti-cipation in the study and actually completingdata collection assignments suggested that anational ambulatory medical care survey usingsuch instruments and procedures was potentiallyfeasible. Revisions and improvements appeared

necessary- to assure that coktiniting, nationalstatistical inftnniation based on methods fordata collection ptactu ing physicians wouldalso meet required NCIIS standards of qualityand (nnpleteness of respons.

FEASI61LiTY STUDIES:FIELD TEST: PHASE II, 1970-71

Purpose and Design

The purpose of the second phase of feasibilitystudy field testing was to develop iurd evaluateat»bulatory patient visit data collection methodsfurther. I mproemen is suggested by Phase I fieldtest experience were incorporated in the design,which was aimed specific ally at reducing datacollection workload and practice interference,increasing the participants' awareness of thepurposes of the stave}, and strengthening pre-viously established levels of professional interestand support. A subcontract was arranged for theNational Opinion Research Center (NORC) toassist with the design and to conduct all surveyfield work. The scope of the survey was limitedto ambulatory patient visits to physicians intheir offices, since other methods would berequired for outpatient clinics and telephonecontacts. Objectives were to increase the propor-tions of sample physicians agreeing to partici-pate in the survey and satisfactorily completingassigned data collection procedures.

Two data collection forms again were tested:a "short" one required about ! minute per visitto complete, and a "mini" one required onlyseconds per visit. The short form correspondedto the shorter form used in Field Test: Phase 1;and the miniform embraced an irreducible mini-mum of useful data, requesting only the pa-tient's age and see: and the physician's diagnosisand type of treatment. The miniform was usedprimarily to test whether the size of the formwould have any effect on physicians' willingnessto participate in the survey. The detachablerecord and code sheet feature of Phase I formshad not proved useful and was discontinued.

A patient sampling procedure was devised totest this method for reducing the data collectionworkload of participating physicians. Instead ofcompleting a form for every patient visit, those

using the sampling procedure were to recorddata for only every third patient visit. Acomplete list of every patient visit was needed toinsure that the sequence was observed; it wouldprovide a patient sampling frame and afford theadded benefit of relative assurance that the datacollection process was complete. The number ofmissed patient visits would he minimized andbecome measurable in part by this method.Accordingly, a "log" was devised for use inaudition to data collection forms, for listingpatients visits in the sequence of their arrival inthe office, or in any systematic order that fittedusual office procedures and assured complete-ness. The additional procedure made it necessaryto design the field test so as to assess the effectof the log as well as that of the different forms.

One uniform approach to enlisting samplephysicians to participate in the survey wasadopted as a result of the Phase I experience. Acombined telephone-personal-contact methodusing lay interviewers was employed. The tele-phone contact served to determine a samplephysician's eligibility and availability and tomake an appointment for an interviewer's sub-sequent personal contact. At that time participa-tion was enlisted, data collection requirementsand survey procedures were explained, and aninterview concerning practice characteristics washeld. Sample physicians were encouraged toassign office assistants, secretaries, receptionists,or nurses to help with data collection as much aspossible and to maintain the log of patientsvisiting.

Five data collection form/procedure combina-tions were tested in Field Test: Phase II of thefeasibility study:

1. Short form, log, no sampling2. Short form, log, sampling3. Miniform, log, no sampling4. Miniform, log, sampling5. Miniform, no log, no sampling

Appendix IV shows copies of these forms andlogs.

Survey participation was again enlisted for a2-day period that would recur quarterly within ayear. Six pairs of consecutive days were identi-fied so that sample physicians could be assignedrandomly to one of them; for feasibility study

9

purposes, however, a preselected second paircould be assigned if a physician were unavailableon the first. The same sample of physicians wascontacted within 6 months after the initial datacollection assignment period to repeat theprocess in a second quarter in order to estimateexpectable attrition if the same methods becamefeasible to employ for a continuing nationalsurvey.

Perhaps the single most important aspect ofPhase II field testing was to develop methods ofmaking the medical profession at large andparticularly the sample physicians requested toparticipate more aware of the purpose andsignificance of an ambulatory medical caresurvey. Endorsement was first provided by theAMA, and a letter from its Executive Secretarywas sent to all sample physicians before aninterviewer's telephone call indicating full organ-izational and professional support for the re-quest to participate. Nineteen medical and pro-fessional specialty societies subsequentlyendorsed the survey in principle. Their supportwas indicated in the introductory letter sent toall sample physicians from the Director of NCHSto introduce the survey and describe needs anduses for the information expected to result.(Copies of the AMA and the NCIIS introductoryletters arc given in appendix II.) An informativeNCHS press release was used by a number ofmass-circulation and medical specialty journals,increasing the possibility that physicians wouldknow of the survey. Just before initial telephonecontact, supervisory interviewers also called lo-cal medical society executives to inform themabout the nature and purpose of the survey andto tell them sample physicians in their vicinitywould be asked to participate. All these methodswere applied to achieve the increased awarenessof the survey considered necessary to attain highenlistment and completion rates among a na-tional sample of office-based physicians.

A multistage, stratified national probabilitysample was selected from a survey populationcontaining all office-based doctors of medicinepracticing in the coterminous United States,excluding anesthesiologists, pathologists, andradiologists. Physicians were defined and classi-fied for survey purposes as they are representedon the AMA master list, from which the finalsampling frame was constructed. First the pre-selected sample of PSU's maintained and staffed

10

by NORC was stratified by geographic regionand physician population size, and a subsampleof PSU's was selected with probability propor-tional to the number of physicians practicing ineach one. Next the AMA list of physicians in thesample PSU's was stratified by age and specialtygroup, and individuals were systematically se-lected with a probability inversely proportionalto the number practicing in their PSU to formthe total sample of 831 physicians. Finally, eachsample physician was randomly allocated to oneof the five survey form and procedure combina-tions, to one of the six pairs of consecutive daysfor data collection, and to one of the inter-viewers assigned to work in his PSU.

Contacts with physicians began about 3 weeksbefore the survey period. Letters from both theNCI'S Director and the AMA Executive Directorwere sent to all sample physicians. Efforts weremade to telephone physicians by trained layinterviewers who ascertained their eligibility,i.e., whether they provided services for ambula-tory qfients from offices where they wereprimarily responsible for the care of such pa-tients over time. The interviewers tried toarrange personal visits with eligible physicians,to explain survey procedures to them and to anydesignated office assistant whose help could beexpected. Data collection forms and printedsurvey materials were delivered at that time, anda structured enlistment interview was adminis-tered to obtain information about anticipatednumbers of ambulatory patient visits and otherpractice characteristics. Later, just before thefirst data collection days, interviewers tele-phoned physicians again to remind them of thesurvey and answer any questions arising in themeantime. When the data collection period wasfinished, participating physicians mailed surveymaterials to interviewers, who edited them forcompleteness and telephoned the participant fora brief postsurvey evaluation interview to obtaininformation about his experience. All completeddata collection forms and interview returns weremailed to a central location for editing, coding,and data processing for analysis. Appendix IVcontains copies of the two interview schedules.

At the second-quarter data collection period 6months later, the same physicians were re-minded by letters, contacted by telephone, andsent survey materials by mail, except in in-stances whet- additional instructions or answers

to questions required personal visits. Interviewsconducted with participants after the data col-lection period were abbreviated at this stage.

Data processing was oriented toward analysisof survey enlistment and data collection formcompletion for feasibility study test purposes.Since analysis of the substantive content ofpatient visit record forms was secondary, surveyparticipation factors were emphasized in codingand tabulation. Information was amalgamatedfrom the interviewers' control folders regardingcontacts with physicians, from the enlistmentinterviews regarding practice characteristics,from the data collection forms regarding mien,visits, and from the postsurvey evaluat'on inter-views regarding the data collection process itself.All was coded, entered, and stored on magnetictape for subsequent computer tabulation andanalysis. Weighting factors corresponding to thereciprocal of their probability of selection in thesample were calculated for each physician andemployed for interpreting enlistment and com-pletion rates, which constituted the principalfeasibility study results.

Survey Result

Results of the second phase of feasibilitystudy field testing are shown in table 2. Of 831physicians in the total sample at the time it wasselected, 746 (90 percent) were both eligible andavailable to participate at the time of the surveyand constituted the effective or target samplefor study. The remainder could not be locatedafter persistent attempts, had died or retired, didnot have primary responsibility for ambulatorypatient care in their offices, or would not beavailable during the survey period. Eighty-threepercent (621) of the effective sample of physi-cians enlisted or agreed to participate, and 80percent (595) actually completed forms andreturned them following the first-quarter datacollection period. If the same proportions arecalculated using the weighting factors to adjustfor the probability of selection into the sample,86 percent enlisted and 83 percent completedassigned data collection procedures. The propor-tion of sample physicians participating in thePhase II survey calculated with or withoutweighting factors is substantially greater thanthe 55-percent completion achieved in the PhaseI field test. Higher proportions of miniform

users than of short form users participated in thesurvey. Little difference was observed betweenproportions enlisting in the survey and proportions actually completing data collection foreither farm. Similarly, negligible differenceswere noted between proportions of samplephysicians using the work-reducing, patient-sampling procedures and those listing everypatient and completing forms fur each one.There was also little noticeable effect on re-sponse by use of the Patient Log; completionrates were 86 and 85 percent, respectively, forphysicians using the miniform with the log andthose using the miniform without the log.Differences between completion rates by geo-graphic region, specialty, or age group were notsignificant.

Results after the second quarter of the PhaseII field test show that 79 percent of the effectiveor target sample of 721 physicians agreed toparticipate, and 73 percent of them actually didso. The difference between the effective samplent4rnbers in the two quarters reflects changesamong the sample physicians over the intervalthat affected their eligibility or availability.Additional members left practice, could not belocated, or were no longer directly responsiblefor ambulatory patient care; a few not availablethe first quarter were eligible to participate inthe second, however. Eightr.six percent of thosephysicians who actually completed data collec-tion forms in the first quarter also completedforms in the second quarter. An overall attritionof 7 percent between quarters was thereforeobserved. The decrement was slightly greateramong physicians listing and recording data forall patients than for those using work-savingsampling procedures.

The quality of data collection represented bythe enlistment and completion rates reached inField Test: Phase II of the feasibility studies isindicated by the record form item completion,and by the proportion of their ambulatoryoffice patients the sample physicians includedduring their assigned data collection periods.Item completion on Field Test: Phase II first-quarter record forms ranged from 95 to 98percent for the four miniform items, and from83 to 99 percent for the 17 variably applicableshort form items; the rates were higher than hadbeen achieved in Field Test: Phase 1. Samplephysicians completing forms were asked whether

they recalled not recording data concerning anyambulatory patients attended in their officesduring their assigned periods; 93 percent wereconfident all were included, and only 2 percentthought more than two patients might have beenmissed. The number of patients represented byreturned data collection forms was consistentlyabout 85 percent of the number of patientsthese physicians previously had expected wouldvisit, regardless of the data collection form orprocedure used. This difference may be due toambulatory patient visits in nonofficc locations,such as hospital emergency rooms, outpatientclinics, or patient's homes, which did occur asthe physicians recalled at the postsurvey evalua-tion interview but were excluded from the scopeof siucly.

The majority (73 percent) of the 595 samplephysicians participating in the first quarter ofthe feasibility study's Field Test: Phase 11 surveycollected data concerning ambulatory patientvisits during the randomly preselected 2-dayperiod first assigned to them. Altcrrative periodswere assigned to another 15 percent who wereinitially interviewed after the first preselectedperiod had iw :sed, and to 9 percent more whoexpected to see no ambulatory patients in thefirst preselected period. These reasons weresufficient for alternative data collection periodassignments for feasibility study purposes; alter-native periods would be unnecessary for pur-poses of a continuing survey using similarmethods because physicians could be inter-viewed early and could record zero visits onnonpractice days.

Postsurvey evaluation interviews after the firstquarter of Field Test: Phase II showed thatmethods designed to int.rease awareness of thesurvey and its potential benefits had beeneffective and warranted. More than half theresponding sample physicians indicated that theintroductory letters they received beforehandfavorably influenced their decision to partici-pate. The proportions were 63 percent for theAMA letter and 56 percent for the NCIIS letter;the remainder indicated they were uninfluenced

12

by or did not recall receiving either letter. Halfthe NCHS letters were sent by certified mail,with no discernible effects on recall or participa-don. Only a few respondent physicians con-sulted local medical society officials or discussedsurvey participation with colleagues. Otherfavorable factors cited were the worthwhilepurpose of the survey and the persuasiveness ofthe interviewers. Forms, procedures, and surveymaterials presented no consistent problems forthese participants, although a number of mini-form users questioned the usefulness of thesmall amount of data they collected for poten-tial ambulatory care statistics.

Conclusions

Based on the foregoing results and accruedexperience after Field Test: Phase II of thefeasibility studies, the maturing methods andprocedures developed and tested to date wereconsidered feasible for application when thecontinuing NAMCS was inaugurated. Extensiveand improved levels of participation by prac-ticing office-based physicians, in terms of sampleproportions collecting patient visit data underfield trial conditions, supported this conclusion.Nevertheless, the critical importance of main-taining high levels of participation also war-ranted variation and testing of methods andprocedures to refine them further under actualcontinuing survey conditions. Short data collec-tion forms and simple patient sampling pro-cedures were found to be practicable. Advanceinformation about the survey's nature, purpose,and significance appeared to be a prerequisitefor success; and support from organized medi-cine, professional societies, and publications atnational and local levels proved to be a practicalmeans of increasing physician response. Thecompleteness and quality of patient visit datacollection as estimated in the field trial seemedsufficient to support feasibility study results,but procedural reliability and content validityremain to be established after the NAMCS hascommenced.

ILLUSTRATIVE FEASIBILITY STUDY FINDINGS

INTRODUCTION AND METHODS

The purposes of both field phases of theNAMCS feasibility studies described in thisreport were methodologic, by design. Thesesurveys were conducted to develop and test, andsubsequently improve and test, instruments andprocedures for ambulatory care data collectionby practicing office-based physicians on a con-tinuing national basis. The instruments andprocedures that were developed and the resultsof their feasibility testing have been related inforegoing sections. It is through the application,continuing evaluation, and refinement of suchmethods that the goal of statistical informationreflecting the important but relatively under-represented ambulatory component of healthcare services for the population may be realized.

As a byproduct of Field Test: Phase II of thefeasibility studies, a volume of data collectedfrom actual ambulatory patient visits to practic-ing office-based physicians regarding the pa-tients' visits and the services they were providedbecame available. These data are subject toimportant limitations by virtue of their by-product nature and cannot be presented eitheras a quantitatively precise or statistically ac-curate representation of the subjects containedwithin them. Participation by physicians was lessthan complete and it varied within and betweenquarters. Five different form-procedure com-binations were employed for data collection,and substitution for preassigned recordkeepingperiods was permitted for feasibility study pur-poses. The amount of data collected at ambula-tory patient visits concerning different charac-teristics varied because of the different formlengths and patient sampling procedures thatwere required. For these reasons as well as thecosts that would be incurred, the feasibilitystudy data were not adjusted for nonresponse orweighted to reflect the national population basisfor the probability samples of PSU's as well asphysicians. The small sample size and volume ofdata and the lack of uniform content or collec-tion methods also precluded calculating usefulestimates of national utilization rates or otheroffice-based ambulatory medical care param-eters. Statistical information of the necessary

kind and quality still depends on results of thecontinuing NAMCS.

At the same time, these data have inherentinterest for potential users of NAMCS infor-mation. Selected summary findings may indicatekinds of information to be expected or suggestuseful analyses or tabulations for practical ap-plication when continuing survey results may beobtained. The authors therefore undertook alimited exploration of the Field Test: Phase IIbyproduct data, with permission, cooperation,collaboration, and support from NCHS. Undertheir direction a group of summer apprentice-ship-traineeship medical and dental students,supervised by preceptors, applied standardizedcomputer programs to tabulate and analyze themagnetic-tape-stored data. Additional codingand key punching for patient problem anddiagnosis data were accomplished by exper-ienced staff from the Center. The proportionaldistributions, ranked frequencies, and cross-tabulations that follow are the findings from thisanalysis. Wherever bias may appear due toaggregation or subdivision of entries, it is aconsequence of described data limitations andthe authors' judgment and does not necessarilyreflect the style or format of subsequentNAMCS results or tabulations.

The data are presented here with onlyminimal discussion, which represents commentsthat could accompany similar data from theNAMCS. The reader is CAUTIONED, however,that these data are not to be considered repre-sentative of national statistics and should beregarded only as illustrative of tabulations ex-pected in the future from the NAMCS.

DATA SOURCE AND VOLUME

Office-based physicians participating in FieldTest: Phase II of the feasibility study and thepatient visits from which they collected data foranalysis and presentation here are shown in table3 by number and percent according to specialtygroups.

The numbers of physicians shown in the firstcolumn of table 3 used short form procedures inthe first and/or second quarters of the survey torecord patient visit data. Although the short

13

form procedures provided over four times asmany items of data per visit as miniforms andproduced the only survey data that were col-lected about a number of visit characteristics.they constituted only two of the five surveyprocedures. The number of physicians assignedshort form procedures was correspondinglysmall compared to the overall number of partici-pating physicians. For these reasons, subsequentanalyses of data provided by short forms alonedid not include characterization by the specialtygroups listed in table 3, but were limited to thephysicians' type of practice, either specialty orgeneral and family practice. The numbers ofphysicians in each type of practice may beascertained by reference to this table.

The percent distribution of participatingphysicians using all survey procedures, shown inthe third column of table 3, was compared withthe corresponding distribution calculated fromthe numbers of all office-based physicians (ex-cluding anesthesiologists, pathologists, and radi-ologists) in the United States and possessions atthe end of December 1971.19 Differences ex-ceeding approximately 2 percent were found fortwo specialty groups; 4.4 percent more partici-pating than all office-based physicians were ingeneral surgery. and 8.2 percent fewer were inthe "remaining other specialties" category.

The percent distribution of participatingphysicians is less similar to the percent distribu-tion of patient visits, also shown in table 3, inseveral respects. Physicians in primary carespecialties reported relatively more patient visitsand those in secondary/tertiary care specialtiesreported relatively fewer patient visits thanmight be expected on the basis of their propor-tions among the participants. Physicians ingeneral and family practice comprised a quarterof those participating and reported a third of thevisits; pediatricians comprised 4.7 percent andreported 8 percent. Psychiatrists and neurolo-gists, who made up 6.8% percent of all partici-pants, reported 3.1 percent of all visits.

AGE AND SEX OF PATIENTS

Tables 4 and 5 show the ambulatory visits to-each specialty group of office-based physiciansaccording to the age group and sex of patientsvisiting, respectively. Table 6 shows the distribu-

14

tion of all visits by both sex and age group ofpatients visiting. Together these tables provide aquantitative description of two major demo-graphic variables for the entire group of ambula-tory care visits, as well as for visits to physiciansin major specialty groups providing ambulatorymedical care services.

The first row of table 4 displays the percentdistribution of all ambulatory patient visitsreported during Field Test: Phase 11 amongbroad age groups of patients. By comparison,proportionately more visits to physicians inprimary care specialties were made by youngerpatients. A small percentage of visits to pediatri-cians was made by patients over the age of l4,and a still smaller percentage of visits to generalinternists was made by patients of 14 years orless. The age distribution of patients visitingphysicians in general and family practice resem-bles that of all patient visits. By contrast,relatively fewer patient visits to secondary/tertiary care physicians were made by theyounger patients. The bulk of visits to obstetri-cian-gynecologists were, of course, by patients intheir childbearing years; this is also true forpatient visits to psychiatrists-neurologists, forreasons that are less obvious.

The sex of patients visiting physicians indifferent specialty groups is shown in table 5.The majority of ambulatory patient visits aremade by females, but not in pediatric ororthopedic surgery practices. The distributionsby sex of visits to physicians in primary and insecondary/tertiary care specialties are similar,although, as expected, females made nearly allvisits to obstetrician-gynecologists.

Table 6 shows the overall number and percentdistribution of all Field Test: Phase II officevisits by patient sex and age group. The majorityare made by females, but males predominateslightly at ages 65 years and over. By compari-son with a similar distribution constructed forthe estimated total U.S. population in 1971, theproportion of office visits by females is 5percent greater than the proportion of femalesin the U.S. population." For the youngest agegroup, the proportions of visits and of thepopulation are similar: but for the age group5-14 years, the proportion of visits is approxi-mately half their proportion of the total. Visitsby women aged 25.44 years make up more than

16 percent of all visits, though women of thisage group constitute 12 percent of the entirepopulation. Additional data will afford a closerexamination of such characteristics whenNAMCS results are available.

PROBLEMS AND DIAGNOSES

The most common patient problems encoun-tered by the office-based physicians using shortform procedures are shown in table 7, and themost common diagnoses and the major classes ofdiagnoses recorded at all ambulatory patientvisits during both quarters of Field Test: Phase11 are shown in tables 8 and 9.

These three tables represent results of codingusing the Eighth Revision International classifi-cation of Diseases. .Idapted for Use in theUnited States (ICDA), with its supplementaryclassification for "Special Conditions and Exam-ination Without Sickness."2 I Individuals experi-enced in using the classification for codinghospital discharge abstracts and death certificatediagnoses were employed to apply its rules andprocedures for entries recorded after the ambu-latory patient visits. Entries for the patients'purpose, problem, or chief complaint could notbe coded for 2.6 percent of the short formprocedure visits, and entries for the most impor-tant diagnosis accounting for the visit could notbe coded for 8.5 percent of all the visits. In partthis was because these items were not completedby the data-collecting physicians and in partbecause entries that were made could not beassigned to any categories of the classification.The ICDA, which was designed to code andclassify well-defined diseases and causes ofdeath, was difficult and unwieldy to apply formany of the relatively ill-defined symptoms,problems, complaints, and clinical impressionsthat label conditions which ambulatory patientspresent in office-based medical practice. Follow-ing recommendations of the Chicago Conferenceon Ambulatory Medical Care Records, NCHShas subsequently been participating actively inthe development of improved classifications forpatients' problems and conditions encounteredin ambulatory medical care.22

Common patient problems within the diag-nostic categories listed in table 7 were reasonsfor the majority of these ambulatory patient

visits. Examinations of essentially well personsand followup care for others were most promi-nent. Lower on the list but still within the first15 categories were such nonspecific and well-known conditions as sore throat, nervousness,backache, common cold, and obesity, whichbring numbers of patients to visit doctors andrequire a proportion of the ambulatory healthcare services they provide. Essential benignhypertension, elsewhere a specific diagnosis,here reflects visits for the purpose of havingbood pressure checked. The common reasonspatients present for ambulatory care visits areprincipally classified in broadly defined, non-specific, and residual ICDA categories.

The diagnostic categories listed in table 8contain the common diagnoses or disease labelsparticipating office-based physicians assigned tothe patients' conditions that they thought ac-counted for each ambulatory care visit duringthe survey. Relatively few of the 872 ICDAthree-digit categories include a good many of thediagnoses they assigned; none of the remaindercontained diagnoses made at more than I

percent of the visits. Although nonspecific,residual, and combined categories appear on thelist, many contain well-defined disease entitiessuch as hypertension, chronic ischemic heartdisease, diabetes, obesity, otitis media, acutepharyngitis, bronchitis, hay fever, and acutetonsillitis. Visits for diagnoses under followupcare, examination, and prenatal care categoriesarc as prominent in order of frequency as thesecategories were found to be among the patientproblems in table 7. In part, this finding mayreflect agreement between physicians' views ofpatients' purposes or reasons for visiting and oftheir own professionally defined diagnostic la-bels for their patients' conditions. The firstlisted category of unassigned diagnoses in partreflects the measure of uncertainty with whichspecific diagnoses arc often made in office-basedpractice. Provisional treatment for expecteddisease and early management of undiagnosedand still-undifferentiated symptoms or symp-tom complexes in ambulatory patients iscommonplace.

Table 9 lists the major ICDA classes ofdiagnostic categories in the rank order of theirfrequency as reasons for the ambulatory patientvisits included in Field Test: Phase II. Compari-

15

son Of this ranked list with similar ones forhospital discharge diagnoses and for causes ofdeath in the United States facilitates inter-pretation.2 .2 4 The supplementary class,"Special conditions and examinations withoutsickness," leads the ambulatory visit list, fol-lowed by "Diseases of the respiratory system"and the class of conditions for .vhich nodiagnostic category was assigned. The classcontaining conditions responsible for the largestnumber of deaths in this country, "Diseases ofthe circulatory system," appears fourth on thelist for visits. "Neoplasms," second in order as acause of death and seventh as a cause ofhospitalization, is 15th as a cause for ambula-tory patient visits here, followed by classes ofconditions for which fewer than 1 percent of thevisits were made. "Diseases of the digestivesystem," the second most common cause ofhospitalization and fifth of deaths, is 14th intable 9. "Accidents, poisonings, and violence"and "Diseases of the respiratory system" arcclasses accounting for relatively large propor-tions of ambulatory visits as well as of hospitali-zations and deaths. The differences and similari-ties observed between ranked classes ofdiagnostic categories accounting for ambulatoryvisits, for hospital-treated morbidity, and formortality suggest the potential utility of suchstatistical information to provide perspective furestablishing priorities and policy for health careservices.

SELECTED CHARACTERISTICS OFVISITS

Tables 10-18 show distributions of Field Test:Phase II ambulatory patient visits to office-basedphysicians in two broad types of practice,according to selected characteristics related topatients visiting, services and treatment pro-vided, dispositions arranged, and durations ofvisits. Data concerning these characteristics werecollected by physicians using the two short formsurvey procedures, and thus the majority ofthese analyses and tabulated findings are basedon the subsample of visits they reported. Dataon treatment provided at visits were also col-lected by physicians using miniform procedures,and table 16 is consequently based on all visitsduring the survey.

16

The color and current marital status ofpatients visiting arc presented in tables 10 and11. Over 90 percent were white, about 3 percentmore than the proportion of white persons inthe resident United States population.25 In part,this is because larger proportions of personsother than white than of white persons may visitless frequently, or attend hospital clinics andemergency rooms instead of physicians' offices,for ambulatory health care services. More thanhalf the patients were married, and aboutone -third were single.

The findings presented in table 12 show thatless than one in five visits were made by patientsnew to the physician. About 63 percent ofpatients visiting physicians in specialty practicehad previously been seen for the same problem,and about 16 percent for other problems. Bycontrast, 49 percent of patients visiting physi-cians in general and family practice had beenseen before for the same problem, and about 30percent for other problems.

The extent to which histories wen: taken andphys ..al examinations performed at ambulatorypatient visits is shown in table 13. histories wereobtained in about 87 percent of visits; thesewere limited in extent about twice as frequentlyas they were general. The proportion of visits tophysicians in specialty practice at which nohistory was taken exceeds the comparable pro-portion in general and family practice.

Examinations followed the same pattern ashistories. An examination was performed at 9 of10 visits, and more than twice as many werelimited as were general in nature. Proportions ofvisits including general examinations were lower,and limited examinations higher, in general andfamily practice than in specialty practice. Visitsat which examinations were not performed at allwere more frequent among physicians in spe-cialty than in general and family practice.

Table 14 shows the distribution of ambula-tory patient visits according to whether diag-nostic tests were ordered, and for what purposethey were intended. laboratory procedures,X-ray examinations, and other diagnostic proce-dures were not ordered for any reason at a largemajority of visits, and at others physicians didnot know or did not record whether tests wereordered or their intent. Visits to physicians inspecialty practice included laboratory procc-

dures for screening more commonly than visitsto physicians in general and family practice. Theproportion of i:s at which diagnostic test datawere incomplete or unknown may reflect themiddle position his item occupied on the datacollection form, or uncertainty by physicians asto how to classify the purpose of tests that wereordered or performezl.

Diagnostic specimens such as blood, urine,and other samples needed for diagnostic testswere not taken at approximately two-thirds ofthese ambulatory patient visits, as shown intable 15. At the remainder, specimens weretaken less commonly by physicians themselvesthan by office staff or others, particularly inspecialty practice, where they were obtained at31 percent of visits. The proportions of visits atwhich specimens were taken arc similar to thoseat which laboratory procedures were ordered, oncomparison with percentages shown in table 14.

Table 16 presents findings from all Field Test:Phase II ambulatory patient visits and showstheir distribution according to broad types oftreatment provided by the office-based physi-cians. At more than half of the visits drugs ofsome type were prescribed, administered, dis-pensed, or advised; drug therapy was providedmore commonly in general and family practicethan in specialty practice. No treatment wasconsidered needed at 17 percent of the visits,and advice concerning diet, exercise, or habitchanges was given at 12 percent Therapeuticlistening or psychotherapy was recorded as atype of treatment employed at almost 8 percentof the visits. This 8 percent may be an under-estimate, since it included visits at which themodality was purposefully pursued, but notothers at which it may have gone unrecognizedas part of the therapeutic exchange between thepatient and the physician. Other treatment wasprovided at one-fourth of the visits; it wasproportionally more prominent among visits tophysicians in specialty types of practice, asmight be expected. In contrast to the findingsconcerning diagnostic tests and specimens intables 14 and 15, treatment was unknown orunrecorded at less than 1 percent of visits.

Disposition and followup plans after visits tophysicians using short form survey proceduresare presented in table 17. Appointments forreturn visits were specifically arranged followingthe majority, and less specific directions toreturn if necessary were given at one-fourth ofthe visits. Relatively fewer specific appointmentsand more general arrangements were made aftervisits to physicians in general and family practicethan in specialty practice. No further followupor telephone followup was planned after 9 and 7percent of these visits, respectively. Patientswere referred for admission to hospital afterapproximately 4 percent of visits, predomi-nantly to remain under the same physician's carethere. Patients were referred to another physi-cian after 2 percent of visits, and directed toreturn to another referring physician or agencyafter 1 percent. The different proportionaldistributions observed between visits to physi-cians in specialty and in general and familypractice are expected, as these broad types ofpractice differ with respect to the patientsserved, conditions treated, and services provided.

Table 18 shows the volume and distributionof ambulatory patient visits by their duration inminutes spent in face-to-face or other directcontact between patients and physicians. Nearlyhalf the visits were completed within 10 minutesor less, and only a small minority lasted morethan 30 minutes. Shorter visits predominated ingeneral and family practice, longer ones inspecialty practice.

From the illustrative findings contained inthis section of the report, an impression may begained concerning the ambulatory care datagathered by office-based physicians during FieldTest: Phase II of the NAMCS Feasibility Study.The same kinds of data, modified, refined, andmultiplied, are expected to be collected duringthe ongoing NAMCS. Results will make variedand detailed analyses possible, and quantitativestatistical information concerning office-basedambulatory health care services provided for theU.S. population will become available.

SUMMARY AND CONCLUSION

In 1973 the National Ambulatory Medical Center for Health Statistics to gather data andCare Survey was inaugurated by the National promulgate statistical information concerning

17

the provision and use of ambulatory health careservices for the population of the United States.A national probability sample of office-basedphysicians now collects data from ambulatorypatient visits during 1-week periods in theirpractices. Processing and analysis of the resultsprovide national and regional estimates of theannual volume and rates of ambulatory patientvisits for population groups, medical specialtygroups, and geographic areas. Quantitativedescriptions of visit characteristics include tabu-lations of patient's problems, reasons forvisiting, medical diagnoses, services, treatment,and subsequent disposition.

The background and development of methodsemployed for the NAMCS required exploratoryand feasibility studies conducted over a periodof 6 years. Literature review and consultationdocumented needs and potential uses for na-tional ambulatory medical care statistic-;. Infor-mation regarding accepted definitions, uniformterminology, procedural experience, or practicalclassifications for the problems and conditionsencountered in irnbulatory care settings wasfound to be limited. First, data collection formsand procedures were developed and tested bysample physicians in a national field survey,which demonstrated the difficulty of achievinghigh levels of participation. Refined data collec-

18

tion forms and improved procedures were fur-ther tested by a second sample of physicians inan extensive national survey lasting over 2quarters in 1 year. Results demonstrated theusefulness of professional endorsement, proce-dural efficiency, and minimal work requirementsin achieving physician-participation levels ex-ceeding 80 percent.

As a byproduct of the latter phase of feasibil-ity studies, a volume of ambulatory visit databecame available. It was analyzed and presentedto illustrate kinds of information NAMCS resultswill provide. Subject to described limitations ofthe data, percent distributions of 23,407 ambu-latory patient visits to a national probabilitysample of office-based physicians are shown bycategories of patients, specialty groups of physi-cians, and characteristics of visits. Commonpatient problems and physician diagnoses areranked in order of their frequency. Thesefindings may suggest potential applications forNAMCS results, whic:: will supplement existingNCHS programs with information from ambula-tory patient visits in office-based practice. Theadded NAMCS results will assure that a morecomprehensive range of statistical information isavailable concerning the entire spectrum ofhealth care services for the population of theUnited States.

REFERENCES

1National Health Center for Health Statistics: Origin, pro-gram and operation of the United States National Health Survey.Vita/ and Malt,: Statastu-%. PITS Pub. No. 1000.S4 nes 1-No. I .Publit Health Service. Washington. U.S. Government PrintingOffice, Aug. 1963.

-White, h.: Patterns of medical practice. In Clark, D., andMcMahon, B. (eds.), Preventive Medicine. Boston, Little,Brown, and Co.. 1967.

3National Center fen Health Statistic- Physician visits,volume and interval since last visit, United States, 1969. Vital

and Health Statistics. Series 10. No. 75. DIIEW Pub. No.(HS1)4)72-10E4. Health Services and Mental Health Administra-tion. Washington. U.S. Government Printing Office, July 1972.

4National Center for Health Statistics: Current estimatesfrom the Health Interview Survey. United States. 1971. Vitaland lkalth Statistics. Series 10. No. 79. DI-IEW Pub. No.(HM1)73-1505. Health Services and Mental Health Administra-tion. Washington. U.S. Government Printing Of:ice. Feb. 1973.

"National Center for Health Statistici: Health Resources

Statistics. Health Manpower and health Facilities. 1971. DHEWPub. No. OW072-1509. Wald) Services and Mental HealthAdministration. Washington. U.S. Government Printing Office,

Feb. 1972.6National Center for Health Statistics: The Mission and

Policies of the National Center fu, Health Statistics. DHEW Pub.No. (HS10)73-1201. Health Services and Mental Health Adminis-tration. Rockville,

7Hoermann, S.: The national ambulatory medical caresurvey. Med.Care I I :(Suppl.) 196.205 (Mar.-Apr.), 1973.

9Cowan, C.: Report of private medical practice for 1840.J.R.Stat.Soc. 5: 81.86 (Apr.), 1842.

9Tenney, J.: The Content of Medical Practice: A ResearchBibliography. Baltimore, The Johns Hopkins University Schoolof Hygiene and Public Health, Department of Medical Care andHospitals, 1968.

°Logan W., and Cushion, A.: Morbidity Statistics FromGeneral Practice. Vol. Illustrated (Gr:at Britain). Gencral Regis-ter Office. Studies on medical and population subjects No. 14.London, Her Majesty's Stationery Office, 1958.

11Standish, S., Bennett, B., White, K., et al: Why PatientsSee Doctors. Seattle. University of Washington Press, 1955.

"Peterson, 0.. Andrews, LL, Spain, R., et al.: An analyticalstudy of North Carolina general practice 1953.1954. J.Med.

Educ. 31 (Part 2):1 -:65, (Dec.) 1965.13Chronic Illness Project, Inc.: Physician reporting morbidity

survey report. Miami, Ha., Chronic Illness Project in DadeCounty, 1963.

14Kroeger, H., Altman, I., Clark, D., et al.: The officepractice of internists. JAMA 193:371-376, 667.672, 916.922:and 194:177.181, 533-538, 1965.

"Weissman, A.: Morbidity study of Permanente health planpopulation; a preliminary report. Permanente Found.Med.Bull.9:1-17. (Jan.) 1951.

16Densen, P., Balainuth, E., and Deardorff, N.: Medical careplans Is a source of morbidity data. The prevalence of illness andassociated volume of service. Milbank Mm.Fund Quart.38:48-101, (Jan.) 1960.

17Avnet, Physician service patterns and illness rates: aresearch report on medical data retrieved from insurance records.New York, Group Health Insurance, 1967.

19Lea, Inc.: Annual report. A continuing study of morbidityin private medical practice in the United States: National disease

and therapeutic index. Ambler, Pa., Lea (undated).19American Medical Association, Center for Health Services

Research and Development: 1972 Reference data on the profileof medical practice. Chicago, American Medical Association,1972.

29U.S. Bureau of the Census: Estimates of the population ofthe United States by age and sex: July 1, 1971 (PreliminaryReport). Current Population Repots: Populations Estimates andProjection.s. Series P-25, No. 466. Washington. U.S. GovernmentPrinting Office, Sept. 1971.

21Nztional Center or Health Statistics: Eighth RevisionInternational Classification of Diseases. Adapted for Use in the

United States. PHS Pub. No. 1693. Public Health Service.Washington. U.S. Government Printing Office, 1967.

22Conference on ambulatory medical care records: In J.H.Murnaghan (ed.), Ambulatory Medical Care Data: Report of theConference on Ambulatory Medical Care Records, held atChicago, III. Apr. 18.22, 1972. Philadelphia, J.B. Lippincott,1973, pp. 10.12.

23National Center for Health Statistics: Inpatient utilizationof short-stay hospitals by diagnosis. United States, 1968. Vitaland Health Statistics. Series 13, No. 12. DREW Pub. No.(ISM)73-01763. Health Services and Mental Health Administra-tion. Washington. U.S. Government Printing Office, Mar. 1973.

24National Health Center for Health Statistics: Provisionalstatistics. Annual summary for the United Stags, 1971: Births,deaths, marriages, and divorces. Vital and Health Statistics.Monthly Vital Statistics Report Series, Vol. 20, No. 13. DREW

Pub. No. (HSM)73-1121. Health Services and Mental HealthAdministration. Washington. U.S. Government Printing Office,Aug. 1972.

25U.S. Bureau of the Census: Statistical Abstract of theUnited States: 1971. (92d edition). Washington. U.S. Govern-ment Printing Office, 1971.

19

LIST OF DETAILED TABLESPape

Table 1. Number of physicians in sample and percent enlisting in and completing forms for Field Test: Phase I. NAMCSFeasibility Study, by enlistment method and length of form: United States, 1969

2. Number of physicians in sample and percent enlisting in and completing forms for Field Test: Phase II, NAMCSFeasibility Study, by data collection form and procedure. United States, 1971 23

3. Number and percent distribution of 645 office-based physicians participating in Field Test: Phase II, NAMCSFeasibility Study and of 23,407 embulatory patient visits, by specialty of physicians: United States, 1971 24

4. Number and percent distribution of 23,407 ambulatory patient visits to office-based physicians participating in FieldTest: Phase II, NAMCS Feasibility Study, b., age of patients and specialty of physicians: United States, 1971 . . . . 25

5. Number and percent distribution of 23.407 ambulatory patient visits to oftice-based physicians participating in FieldTest: Phase I', NAMCS Feasibility Study. by sex of patients and specialty of physicians: United States. 1971 . . . 26

6. Number and percent distribution of 23,407 ambulatory patient visits to office-based physicians participating in FieldTest: Phase II. NAMCS Feasibility Study, by sex and age of patients: United States, 1971 26

7. Number, percent, and cumulative percent of 7,514 ambulatory patient visits franked in decreasing frequency) tooffice-based physicians participating in Field Test: Phase II, NAMr..S Feasibility Study, by the 20 most commonthree-digit ICDS categories assigned for patient's purpose, problem, or chief complaint: United States, 1971 . . . . 27

8. Number, percent, and cumulative percent of 23,407 ambulatory patient visits franked in decreasing frequency) tooffice-based physicians participating in Field Test: Phase II. NAMCS Feasibility Study, by the 20 most commonthree-digit ICDA categories assigned for their most important diagnosis: United States, 1971

9. Number and percent distribution of 23,407 ambulatory patient visits franked in decreasing frequency) to office-basedphysicians participating in Field Test: Phase Il, NAMCS Feasibility Study, hythe 19 major ICOA classes ontainingtheir most important diagnosis: United States, 1971

28

29

10. Number and percent distribution of 7,514 ambulatory patient visits to office-based physicians participating in FieldTest: Phase II, IJAMCS Feasibility Study, by type of physician practice and color of patiints: United States. 1971 . 29

11. Number and percent distribution of 7,514 ambulatory patient visits to office-based physicians participating in F .endTest: Phase II, NAMCS Feasibility Study, by type of physician practice and marital status of patients: United States,1971

12. Number and percent distribution of 7,514 ambulatory patient visits to off icetesed physicians participating in FieldTest: Phase II, NAMCS Feasibility Study, by type of physician practice and by whether patient had been seen beforeby same physician: United States, 1971

13. Number and percent of 7,514 ambulatory patient visits to office-based physicians participating in Field Test: PhaseII, NAMCS Feasibility Study, by type of physician practice and extent of history taken and examination made atvisit: United States, 1071

20

30

30

31

LIST OF DETAILED TABLESCon.

Table 14. Number and percent distribution of 7,514 ambulatory patient visits to office-based physicians participating in FieldTest: Phase II. NAMCS Feasibility Study, by type of physician practice and laboratory procedure, X-rayexaminations, end other diagnostic procedures ordered: United States, 1971

15. Number and percent distribution of 7,514 ambulatory patient visits to office-based physicians participating in FieldTest: Phase II, NAMCS Feasibility Study, by type of physician practice and diagnostic specimen taken: UnitedStates, 1971

16. Number and percent distribution of 23,407 ambulatory patient visits to office-based physiciansparticipating in FieldTest: Phase II, NAMCS Feasibility Study, by type of physician practice and treatment provided for patients: UnitedStates, 1971

17. Number and percent distribution of 7,514 ambulatory patient visits to office-based physicians participating in FieldTest! Phase II, NAMCS Feasibility Study, by type of physician practice and disposition following patientvisit: United States, 1971

Page

32

33

33

34

18. Number and percent distribution of 7,514 ambulatory patient visits to office-based physicians participating in FieldTest: Phase II. NAMCS Feasibility Study, by type of physician practice and duration of visit: United States, 1971 . . 34

21

Table 1. Number of physicians in sample and percent enlisting in and completing forms for Field Test: Phase I, NAMCS FeasibilityStudy, by enlistment method and length of form: United States, 1969

Enlistment method and form lengthNumber ofphysicians'

Percentenlistinc

Percentcompleting

Total, all methods and forms 679 74 55

Total, long forms 351 73 54

Total, short forms 328 75 56

Telephone contact by resident physician

Total 224 80 54

Long forms 118 78 50

Short forms 106 82 58

Telephone contact by lay interviewer

Total 241 73 47

Long forms 122 73 50

Short forms 119 74 54

Personal contact by lay interviewer .

Total 214 70 61

Long forms 111 75 65

Short forms 103 64 57

' Effective or target sample number is given; it excludes 220 (24 percent) of 899 total sample physicians, who were unavailable or

ineligible according to prior survey definitions, and hence were not requested to participate or complete forms.

22

Table 2. Number of physicians in sample and percent enlisting in and completing forms for Field Test: Phase II, NAMCS FeasibilityStudy, by *data collection form and procedure: United States, 1971

First quarter

Data collection form and procedure

Total, all forms and procedures

Total, short formTotal, miniform

Log and sampling procedures

Total

Short formsMiniforms

Log, no sampling procedures

Total

Short formsMiniforms

Miniforms

No log, no sampling procedure

Number ofphysicians'

746

301445

Percentenlisting

Percentcompleting

83 80

285

7887

84

7484

78

143142

310

8286

81

7680

78

158152

151

7488

87

7286

85

quarter

Number ofPhysicians'

Percentenlisting

Percentcompleting

721 79 73

291 74 67430 82 78

278 81 73

141 79 72137 83 74

298 74 69

150 68 62148 80 77

145 83 82

' Effective or target sample numbers are given; they exclude 85 (10 percent) of 831 total sample physicians the first quarter, and 56(7 percent) of 777 the second quarter, who were unavailable or ineligible according to prior survey definitions, and hence were notrequested to participate or complete forms.

23

Table 3. Number and percent distribution of 645 office-based physicians participating in Field Test: Phase II, NAMCS FeasibilityStudy and of 23,407 ambulatory patient visits, by specialty of physicians: United States, 1971

Specialty of physicians

Participating physicians Patient visits

Number ofshortformprocedures

Number ofall study

procedures

Percentdistribution of

all studyprocedures

Number ofall study

procedures

Percentdistribution of

all studyprocedures

Total, all specialties 246 645 100.0 23,407 100.0

Primary care specialties

Total 101 283 43.9 12,538 53.6

General and family practice 62 166 25.7 7,932 33.9

General internal medicine 27 87 13.5 2,723 11.6

General pediatrics 12 30 4.7 1.883 8.0

Secondary/tertiary care specialties

Total 145 362 56.1 10,869 46.4

General st:rgery 39 92 14.3 2,512 10.7

Obstetrics-gynecology 23 52 8.1 1,873 8.0

Orthopedic surgery . 16 38 5.9 1,507 6.4

Other surgical specialties 32 84 13.0 2,421 10.3

Psychiatry-neurology 11 44 6.8 718 3.1

Other medical specialties 19 40 6.2 1,461 6.2

Remaining other specialties 5 12 1.9 377 1.6

24

Table 4. Number and percent distribution of 23.407 ambulatory patient visits to office based physicians participating in Field Test:

Phase II. NAMCS Feasibility Study. by age of patients and specialty of physicians: United States, 1971

Specialty of physiciansNumber of

patientsAltages

0-14years

15-44years

4564years

65 yearsand over

Notstated

Percent distribution

Total, all specialties 23,407 100.0 19.1 43.0 I 25.7 12.7 1.5

Primary care specialties

Total 12,538 100.0 26.9 36.6 22.1 12.9 1.5

General and family practice 7,932 100.0 192 43.7 22.7 12.7 1.8

General internal medicine 2,723 100.0 2.8 38.1 35.0 22.7 1.3

General pediatrics 1,883 100.0 94.0 4.9 0.5 0,6

Secondary/tertiary care specialties

Total 10,869 100.0 10.1 50.4 25.5 12.4 1.5

General surgery 2,512 100.0 10.3 45.6 29.9 12.4 1.8

Obstetricsiynecology 1,873 100.0 0.9 84.7 11.0 1.9 1.6

Orthopedic surgery 1,507 100.0 20A 42.7 27.3 8.8 0.9

Other surgical specialties 2.421 100.0 15.2 35.1 30.8 17.9 1.0

Psychiatry- neurology 718 100.0 5.3 73.4 17.1 1.9 2.2

Other medical specialties 1,461 100.0 7.1 37.4 27.4 26.7 1.3

Remaining other specialties 377 100.0 1.9 48.5 35.5 9.8 4.2

Table 5. Number and percent distribution of 23.407 ambulatory patient visits to office-based physicians participating in Field Test:Phase II, NAMCS Feasibility Study, by sex of patients and specialty of physicians: United States. 1971

Specialty of physiciansNumber ofpatients

Both s Male

AIL

FemaleNot

stated

Percent distribution

Total, all specialties 23.407 100.0 41.6 1 56.6 1.8

Primary care specialties

Total 12.538 100.0 43.1 1 55.1 1.8

General and family practice 7,932 100.0 41.3 56.7 2.0

General internal medicine 2,723 100.0 40.4 58.0 1.7

General pediatrics 1,883 100.0 54.8 44.2 1.0

Secondary/tertiary care specialties

Total 10,869 100.0 39.9 58.3 1.8

General surgery 2,512 100.0 47.6 50.8 1.6

Cbstetrics-gynecology 1.873 100.0 1.7 96.1 2.2

Orthopedic surgery 1,507 100.0 51.6 47.4 1.0

Other surgical specialties 2.-121 100.0 47.9 50.7 1.4

Psychiatry-neurology 718 100.0 40.5 57.1 2.4

Other medical specialties 1,461 100.0 43.8 54.5 1.7

Remaining other specialties 377 100.0 65.3 30.0 4.8

Table 6. Number and percent distribution of 23,407 ambulatory patient visits to office-based physicians participating in Field Test:Phase i I, NAMCS Feasibility Study, by sex and age of patients: United States, 1971

Age of patients

Both sexes Male Female Not stated

NumberPercent

distribution

-Number

Percentdistribution Number

Percentdistribution

Number

- .

Percentdistribution

Total, ail ages . 23A07 100.0 9,749 41.6 13,243 56.6 415 1i

04 years 1.993 8.5 1,044 4.5 930 4.0 19 0.1

5.14 yaws 2A77 10.6 1,310 5.6 1,148 4.9 19 0.1

15.24 years 3,908 16.7 1.505 6A 2.376 102 27 0.1

26.44 years 6.166 26.3 2,280 9.7 3,839 16.4 47 0.245.64 years 5,537 23.7 2,398 10.2 094 13.2 45 0.265 years and over 2,973 12.7 1,158 9.9 1,798 7.7 17 0.1

Not stated 353 1.5 54 0.2 68 0.2 241 1.0

26

Table 7. Number, percent. and cumulative percent of 7,514 ambulatory patient visits (ranked in decreasing frequency) to office-basedphysicians participating in Field Test: Phase II. NAMCS Feasibility Study, by the 20 most common three-digit ICDA categoriesassigned for patient's purpose, problem, or chief complaint: United States, 1.971

(Diagnostic groupings and code number inclusions are based on the Eighth Revision International Classification of Diseases. Adaptedfor Use in the United States. 19651

Rank ICDA categoriesNumber

ofvisits

Percentof

visits

Cumulativepercent

1 Medical or special examination YOO 966 12.9 12.9

2 Medical and surgical aftercare Y10 898 12.0 24.8

3 Prenatal care Y06 412 5.5 30.3

4 Symptoms referable to respiratory system 783 336 4.5 34.8

5 Other general symptoms 788 283 3.8 38.5

6 symptoms referable to limbs and joints 787 281 3.7 42.3

7 Diagnostic category (and 3digit ICDA code) not assigned 198 2.6 44.9

8 Acute pharyngitis 462 178 2.4 47.3

9 Symptoms referable to abdomen and lower gastrointestinal tract 785 174 2.3 49.6

10 Nervousness and debility 790 155 2.1 51.7

11 Vertebrogenic pain syndrome 728 149 2.0 53.6

12 Acute nasopharyngitis (common cold) 460 141 1.9 55.5

13 Persons receiving prophylactic inozutation and vaccination Y02 135 1.8 57.3

14 Other ill-defined and unknown causes of morbidity and mortality '96 133 1.8 59.1

15 Obesity not specified as of endocrine origin 277 122 1.6 60.7

16 Essential benign hypertension 401 121 1.6 62.3

17 Injury, other, and unspecified Ni96 t20 1.6 63.9

18 Othes eczema and dermatitis 692 118 1.6 65.5

19 Follow-up examination with no need for further care or need for onlylimited care Y03 89 1.2 66.7

20 Symptoms referable to genitourinary system 786 81 1.1 67.7

Other specified diagnostic categories (with 3digit ICDA codes assigned) 2,424 32.3 100.0

27

Table 8. Number, percent, and cumulative percent of 23,407 ambulatory patient visits (ranked in decreasing frequency) tooff icebased physicians participating in Field Test: Phase II, NAMCS Feasibility Study, by the 20 most common threedigit ICOAcategories assigned for their most important diagnosis: United States, 1971

(Diagnostic groupings and code number inclusions are based on the Eighth Revision International Classification of Diseases, Adaptedfor Use in the United States, 19651

1

Rank ICOA categories

.

Numberof

visits

Percentof

visits

Cumulativepercent

1 Diagnostic category (and 3digit ICOA code) not assigned 1,982 8.5 1 8.52 Medical and surgical aftercare Y10 1,878 8.0 16.5

3 Medical or special examination Y00 1,423 6.1 22.64 Prenatal care Y06 751 3.2 25.85 Essential benign hypertension 401 699 3.0 28.8

6 Acute upper respiratory infection of multiple or unspecified sites 465 662 2.8 31.67 Neuroses 300 558 2.4 34.08 Chronic ischemic heart disease . . . . 412 445 1.9 35.99 Diabetes mellitus 250 362 1.6 37.4

10 Obesity not specified as of endocrine origin 277 346 1.5 38.911 Otitis media without mention of mastoiditis 381 324 1.4 40.312 Other eczema and dermatitis 692 314 1.3 41.613 Acute pharyngitis 462 313 1.3 43.014 Follow413 examination with no need for further care or need for Only

limited care Y03 285 1.2 44.215 Bronchitis, unqualified 490 283 1.2 45.416 Hay fever 507 276 1.2 46.617 Sprains and strains of other and unspecified parts of back N847 270 1.2 47.718 Acute tonsillitis 463 249 1.1 48.819 Other viral diseases 079 223 0.9 49.720 Diseases of sebaceous glands . . 706 212 0.9 50.7

20 Synovitis, bursitis, and tenosynovitis 731 212 0.9 51.6

Other specified diagnostic categories (with 3digit ICOA codes assigned) 11,340 48.4 100.0

28

Table 9. Number and percent distribution of 23,407 ambulatory patient visits franked in decreasing frequency) to office-basedphysicians participating in Field Test: Phase II, NAMCS Feasibility Study, by the 19 major ICDA classes containing their most

important diagnosis: United States, 1971

(Diagnostic groupings and code number inclusions are based on the Eighth Revision International Classificationof Diseases. Adapted

for Use in the United States, 19651

Rank Major ICDA classes

Numberof

visits

Percentof

visits

Total, all visits 23,407 100.0

1 Supplementary classification: Special conditions and v...4.-ninations without sickness YO0 -Y13 4,779 10.1

2 VIII. Diseases of the respiratory system 460-519 3,056 13.1

3 Unknown diagnoses (with no code assigned) 1,982 8.5

4 VII. Diseases of the circulatory system 390458 1,927 8.2

5 XVII. Accidents, poisonings, and violence N800-N999 1,879 8.0

6 VI. Diseases of the nervous system and sense organs 320389 1,195 5.1

7 X. Diseases of the genitourinary system 580629 1,191 5.1

8 XI II, Diseases of the musculoskeletal system and connective tissue 710.738 1,144 4,9

9 XII. Diseases of the skin and subcutaneous tissue 680.709 1,053 4.5

10 V. Mental disorders 290.315 988 4211 IR. Endocrine, nutritional, and metabolic diseases 240.279 980 4212 XVI. Symptoms and ill-defined conditions 780.796 878 3.8

13 I. Infective and parasitic diseases 000.136 801 3.4

14 IX. Diseases of the digestive system 520-577 777 3.3

15 II. Neoplasms 140.239 397 1.7

16 IV. Di$01111$ of blood and blood-forming organs 280.289 183 0.8

17 XI V. Congenital anomalies 740-759 136 0.6

18 XI. Complications of pregnancy, childbirth, and the puerperium 630678 56 0.2

19 XV. Certain causes of perinatal morbidity and mortality 760.779 5 0.0

Table 10. Number and percent distribution of 7,514 ambulatory patient visits to off ice-hased physicians participating in Field Test:

Phase II, NAMCS Feasibility Study, by type of physician practice and color of patients: United States, 1971

Color of patients

Total, all typesof practice

General andfamily practice

Specialtypractice

Number1 Percent

distributionNumber

Percentdistribution

NumberPercent

distribution

Total, all visits

WhiteM otherNot stated

7,514 100.0

_..,

2,592 100.0 4,922 100.0

6,82764344

90.98.80.6

2.343233

16

90.49.00.6

m

4,484410

28

91.18.30.6

29

Table 11. Number and percent distribution of 1,514 ambulatory patient visits to officebased physicians participating in Field Test:Phase II. NAMCS Feasibility Study. by type of physician practice and meritsl status of patients: United States, 1971

Marital status of patients

Total, an typesof practice

General and lfamily practice

SweatyprectIce

NumberPercent

distributionNumber

Percentdistribution

NumberPercent

distribution

Total, all visits 7,514 100.0 2,592 100.0 4,922 100.0

Single 2.58 34.6 823 31.8 1,775 36.1

Married 3,892 51.8 1,375 53.0 2,517 51.1

Widowed 442 5.9 157 6.1 ?R5 5.8

Separated/divorced 237 32 113 4.4 124 2.5

Unknown 345 4.6 124 4.8 221 4.5

Table 12. Number and percent distribution of 7,514 ambulatory patient visits to office -based physicians participating in Field Test:

Phase II. NAMCS Feasibility Study, by type of physician practice and by whether patient had been seen before by same Physician:

United States, 1971

mmeaseserTotal, all types

of practiceGeneral and

family practiceSpecialtypractice

Patient seen before by same physician ,

Number1 Percent

distributionNumber

Percentdistribution

NumberPeramt

distribution.

Total, all visits 7,514 100.0 2,592 100.0 4.922 100.0

Seen before 6.172 82.1 2.106 81.3 4,088 82.8

For present problem 4,377 58.3 1261 48.6 3,116 83.3

Not for present problem 1,571 20.9 789 29.7 802 16.3

Unknown whether for present problem 224 3.0 76 2.9 148 3.0

Not seen before 5,308 17A 489 18.1 830 17.0

Unknown whether seen before 34 0.5 17 0.7 17 0.3

30

Table 13. Number and percent of 7,514 ambulatory patient visits to office-based physicians participating in Field Test: Phase II,NAMCS Feasibility Study, by type of physician practice and extent of history taken and examination made at visit: United States,1971

History taken and examination made at visit

Total, all types Icf practice

General andL family practice

Specialtypractice

Number Percent Number Percent Number Percent

Total, all visits 7,514 100.0 2,692 100.0 4.922 100.0i

I

Total, history taken 6,510 86.6 2.338 90.2 4,172 84.8

General history 2,121 28.2 722 27.9 1.3.49 28.4

Limited history 4,389 58.4 1,616 62.3 2,773 56.3

Total, history not taken 964 12.8 245 9.5 719 14.6

Total, unknown history 40 0.5 9 0.3 31 0.6...qg

Total, examination made 6,783 90.3 2,399 92.6 4,384 :,:.

General examination 2,109 28.1 678 26.2 1,431 29.1

Limited examination 4,674 62.2 1,721 66.4 2,953 60.0

Total, examindtiwg not made 641 8.5 174 6.7 467 9.5

Total, unknown examination 90 1.2 19 0.7 71 1.4

31

Table 14. Number and percent distribution of 7,514 ambulatory patient visits to office-based physicians participating in Field Test:Phase II. NAMCS Feasibility Study, by type of physician practice and laboratory procedure, X-ray examinations, and otherdiagnostic procedures ordered: United States, 1971

Diagnostic tests ordered at visit

-

Total, all typesof practice

General and

family practiceSpecialtypractice

NumberPercent

distributionNumber I Percent

distribution NumberPercent

distribution

Total, all visits 7.514 100.0 2,592

,

100.0 4,922 100.0

Lab rocedures

Total 1,991 26.5 523 202 1,468 29.8

1,000 13.3 222...,

8.6 778 15.8Fo- screeningFor diagnosis 574 7.6 217 8.4 357 7.3For followup 417 5.5 84 32 333 6.8None ordered 5.095 67.8 1,821 70.3 3,274 66.5Unknown 428 5.7 248 9.6 180 3.7

X-ray ( *erns

Total 710 9.4 220 8.5 490 10.0

For screening 176 2.3 52 2.0 124 2.5For diagnosis 402 5.4 147 5.7 255 5.2For followup 132 1.8 21 0.8 111 2.3None ordered 6,040 80A 2.072 79.9 3,968 80.6Unknown 764 102 300 11.6 464 9.4

Other diagnostic procedures

Total I 565 7.5 112 4.3 453 92

For screening 192 2.6 42 1.6 150 3.0For diagnosis 170 2.3 47 1.8 123 2.5For followup 203 2.7 23 0.9 180 3.7None ordered 6,104 812 2,159 83.3 3,945 80.2Unknown 845 11.2 321 12.4 524 10.6

32

Table 15. Number and percent distribution of 7,514 ambulatory patient visits to office-based physicians participating in Field Test:

Phase II, NAMCS Feasibility Study, by type of phytiruan practice and diaunostic specimen taken: United States, 1971

Diagnostic specimen taken at visits

Total, all typesof practice

General andfamily practice

Specialtypractice

1

NumberPercent

distributionNumber

Percentdistribution

NumberPercent

disc: bution

Total, all visits 7.514 100.0 2,592 100.0 4,922 100.0, ,

----

Total, specimen taken 2,128 28.3 594 22.9 1,534 31.2

By physician 910 12.1 283 10.9 627 12.7

3y staff 1.077 14.3 271 10.5 806 16.4

By other persons 141 1.9 40 1.5 101 2.1

No specimen taken 4,991 66.4 1.784 68.8 3.207 65.2

Unknown whither specimen taken 395 5.3 214 8.3 181 3.7

Table 16. Number and percent distribution of 23,407 ambulatory patient visits tooff icebased physicians participating in Field Test:

Phase II, NAMCS Feasibility Study, by type of physician practice and treatment provided for patients: United States, 1971

Total, all typesof practice

General andfamily practice

Specialtypractice

Treatment provided for patients

NumberPercent

distributionNumber

Percentdistribution

NumberPercent

distribution,

Total, all visits' 23,407 100.0 7,932 100.0 15,475

.

100.0

None required 3,986 17.0 1,015 12.8 2 .971 19.2

Drug therapy 12,065 51.5 5,399 68.1 6,666 43.1

Office surgical treatment 1,908 8.2 486 6.1 1,422 9.2

Therapeutic listening and/or psychotherapy 1,754 7.5 400 5.0 1,354 8.7

Advised diet, exercise, or habit changes 2,825 12.1 999 12.6 1,826 11.8

Family planning 293 1.3 90 1.1 203 1.3

Other treatment 5,872 25.1 1,394 17.6 4,478 28.9

Unknown treatment 194 0.8 63 0.8 131 0.8

8 The sum of column entries exceeds column totals since more than 1 type of :reatment may have been provided per visit.

33

Table 17. Number and percent distribution of 7,514 ambulatory patient visits to office-based physicians participating in Field Test:Phase II, NAMCS Feasibility Study, by type of physician practice and disposition, following patient visit: United States, 1971

Disposition following patient visit

Total, all typesof practice

General andfamily practice

Specialtypractice

NumberPercent

distributionNumber

Percentdistribution

NumberPercent

distribution

Total, all visits' 7,514 100.0 2.592 100.0 4.922 100.0

No further followup planned 670 8.9 293 11.3 377 7.7Telephone followup planned 510 6.8 174 6.7 336 6.8Return to same physician anytime, pro re nata 1,884 25.1 779 30.1 1,105 22.5Return to same physician at specified time or

interval 4,423 58.9 1,274 49.2 3,149 64.0Referred for diagnostic tests only 72 1.0 21 0.8 51 1.0Referred to another physician for consultation,

diagnosis or treatment 181 2.4 71 2.7 110 2.2Referred for hospital admission under same

physician's care 236 3.1 45 1.7 1?.1 3.9Referred for hospital admission, under another

physician's care 69 0.9 19 0.7 50 0.1

Returned to referring physician/sgency 67 0.9 3 0.1 64 1.3

Other disposition 65 0.9 12 0.5 53 0.1

' The sum of column entries exceeds column totals since more than 1 kind of disposition may have been arranged per visit.

Table 18. Number and percent distribution of 7,514 ambulatory patient visits to ''icebased physicians participating in Field Test:Phase II, NAMCS Feasibility Study, by type of physician practice and duration of visit: United States, 1971

Duration of visit in minutes

® .Total, all types

of practiceGeneral and

family practiceSpecialtypractice

NumberPercent

distributionNumber

Percentdistribution

fNumber

Percentdistribution

Total, all visits 7,514 100.0 2,592 100.0 4,922 100.0

0-5 minutes 1,294 17.2 521 20.1 773 15.76.10 minutes 2,229 29.7 898 34.6 1,331 27.011.15 minutes 2,033 27.1 785 30.3 1.248 25.41630 minutes 1,529 20.3 330 12.7 1,859 37.83160 minutes 321 4.3 28 1.1 293 6.061 minutes and over 28 0.4 5 0.2 23 0.5Unknown duration 80 1.1 25 1.0 55 1.1

Median, minutes 11.0 f 9.8 11.9

34

APPENDIX I

DATA COLLECTION FORMS

1973 NATIONAL AMBULATORY MEDICAL CARE SURVEY

PATIENT LOG AND PATIENT RECORD, SAMPLING EVERY PATIENT

PATIENT LOGOATS 19

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35

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36

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ON NEXT PAGE

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37

CONFIDENTIAL*NORC-4155Feb., 1973

TIDEBEGAN:

AMPM

INDUCTION INTERVIEW SCHEDULE

NATIONAL AMBULATORY MEDICAL CARE SURVEY

INDUCTION INTERVIEW

Form Approved.OMB No. 068-S72106Expires: June 30,1974

(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 minimalamount 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.)

YesNo . (ASK A) . 2

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

(Name of Specialty)

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

practice, or an establishment will be held confidential, will be used only 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.

38

-2-

2. Do you have a solo practice, or are you associated with other physiciansin a partnership, in a group practice, or in some other way?

Solo 1

Partnership . . . (ASK A). . 2

Group . . . ;ASK A) 3

Other . (SPECIFY AND ASK A) . 4

A. 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's a (that's aMonday) through Sunday)

month date month date

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

Yes . . . (GO TO Q. 4) . . . 1

No (ASK A) . . . 2

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

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 leave these forms with you anyway--just in caseyour plans change. I'll 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 A PATIENT RECORD FORMS AND GO TO Q. 10, P. 6.

39

-3-

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

BDr. has primeresponsibility

(in scope)

Inst. has primeresponsibility(out-of-scope)

(1) 1

1

1(3)

1(4)

C. Is that all of the office locations at which you expect to see ambulatorypatients during that week?

Yes

No 2

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

IF ALL LOCATIONS ARE OUT-OF-SCOPE (CODE "0" IN Q. 4B), THANK THE DOCTOR AND LEAVE.

40

5. A.

-4-

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

to see in your office practice? (DO NOT COUNT PATIENTS SEEN AT LOUT -OF -SCOPE

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 manyllyi do you

expect to see any ambulatory patients? COUNT EACH DAY IN WHICH DOCTOR EXPECTS

TO SEE ANY PATIENTS AT AN IN-SCOPE OFFICE LOCATION.

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

DETERMINE PROPER PATIENT LOG FORK FROM CHART BELOW. READ ACROSS ON

"TOTAL PATIENTS" LINE UNDER "A" AND CIRCLE LETTER IN APPROPRIATE

"DAYS" COLUMN UNDER "B."

THIS LETTER TELLS YOU WHICH OF THE FOUR PATIENT LOG FORKS (A, B, C, D)

SHOULD BE USED BY THIS DOCTOR.

LOG FORM DESCRIPTION

A.

Expected totalpatients duringsurvey week.

A--Patient Record is to becompleted for ALLpatients listed on 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 listed.on Log.

ENTER TOTAL FROMQ. 5-A.

B.

Total 1212 in practiceduring week.

ENTER TOTALFROM Q. 5 -B. DAYS

1- 10 PATIENTS

1 1 2 13 1415

16I7

11-20

21- 30

31-40

41-50

A A A A A A A

B A A A A A A

C BA A A A A,C BB A A A A

D CBB A A A

51-60

61- 70

71-80

D C B B B A A

D DCBBB AD DCBBBB81- 90

91-100

101-110

111-120

D 1) C B B B B

D D C C B B BD DCCBBBD DDCBBB

121-130

131-140

141-150

151-160

161-170

171-180

181-190

D D D C C B B

D DDCCCBD DDDCCCD DDDCCCD DDDDCC,DDDDDCCD DDDDCC

191-200 D DDDDDC200- + V D D D D D D D

*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 are to draw an X or lineon line 5 on every other page of the two folio pads, starting with page 1 of the pad.

41

-5-

6. FIND PATIENT LOG FOLIO WITH APPROPRIATE LETTER AND ENTER LETTER AND NUMBEROF THIS FORM HERE.

-111,(Folio Number)

1. NAND DOCTOR HIS FOLIO AND EXPLAIN HOW FORMS ARE TO BE FILLED OUT. SHOW DOCTORIII INSTRUCTIONS ON POCKET OF FOLIO TO WHICH HE CAN REFER AFTER YOU LEAVE.

UCORD VERBATIM BELOW ANY CONCERN, PROBLEMS OR QUESTIONS THE DOCTOR RAISES.

8. IF DOCTOR EXPECTS TO SEE AMBULATORY PATIENTS AT MORE THAN ONE IN-SCOPE LOCATIONDURING ASSIGNED WEEK, TELL HIM YOU WILL DELIVER THE FORMS TO THE OTHER LOCATION(S).ENTER THE FORM LETTER AND NUMBER(S) FOR THOSE LOCATIONS BELOW, BEFORE DELIVERINGFORM(S).

Location Patient Record Form Letter & Number

9. During the survey week (REPEAT EXACT DATES), will anyone be available to helpyou in filling out these records (at each IN-SCOPE location)?

Yes . . . (ASK A) . I

No 2

A. IF YES: Who would that be?

RECORD NAME, POSITION AND LOCATION.

Name I position ILocation

B.*INTERVIEWER: WASPERSON BRIEFED BYYOU?

Yes No

*

42

INTERVIEWER SHOULD BRIEF SUCH PERSON IF POSSIBLE.

1 2

1 2

1 2

1 2

-6-

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-tame (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 NUMBER 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 personaregularly employed who are now on vacation, ill, etc. Do not includeother physicians. RECORD ON TOP LINE OF COLUMN B BELOW.

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

Employees1

A.Full -time

B.Part-time

(35 or more hours/week) (Less than 35 hours/week)

(1) Registered Nurs.

(2) Licensed PracticalNurse

(3) Nursing Aide

(4) Physician Assistant

(5) Technician

(6) Secretary orReceptionist

(7) Other (Specify)

TOTAL: TOTAL:

43

-7-

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

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

11. TIME INTERVIEW ENDED

12. DATE OF INTERVIEW

44

(Month) (Day) (Year)

COMPLETE ITEMS ON LAST PAGE

IMMEDIATELY AFTER THE INTERVIEW

-8-

I. How much interest do you think the II. How confident are you that the

doctor has in the survey? doctor wiii complete the forms?

Great interest . . . . . I Definitely will . . . . 1

Some interest 2 Probably will 2

Little interest . . . . 3 Doubtful 3

No interest 4

Can't tell 5

INTERVIEWER NUMBER INTERVIEWER'S SIGNATURE

J 1 I

45

APPENDIX II

INTRODUCTORY LETTERS

1973 NATIONAL AMBULATORY MEDICAL CARE SURVEY

En icing Or gar : atlonS

DEPARTMENT OF HEALTH. EDUCATION. AND WELFAREPUBLIC HEALTH SERVICE

HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATIONROCKVILLE MAR YLANO 20152

AnNISICIK Medical ARC litahonE B H000wd, M 0E c um/ Viso Prourfent

N. ,one. Mickel Auoc.at.onH. _rtE nisutove Vwa PlesbileAt

American Academy of D.rnystotayFrederic A J Kinqery MSecret.av l'reasurer

American Academy of fame. PhysiciansAnger Z usiE recutive !suet tut

American Aiwierny of NeurotogyStrerieciv A Neer.,E Net V; Set ..ljtyMott. an Academy of 11 .-vetrelic

SurgeonsChalet. V Heck ME 'we Does ter

American Academy of PeckatriCsHubert G Fro et MExecutive Driest,American Assoctaburi of

Neurological SimmonsGordon van can Noon. MSecretary

American College of Obstetriciansend GynecoRgssts

Michael NOVIttlfl MDirer. to

American College of PhysiciansEriwarn C Strivanuvrr. Jr mEiecut.ve vice Pr...dent

American College of PreventiveMedicerve

WardE C .rector

amen College of SwgeoosC Boihni Hanlon ME net uIrre D.,ecItv

MY/Man Chtflopatenc AssociationE oared P Crowed (..)

E.scui. Offal MI

American Pi otologit Society.1041n E Ray MUPistuderit

American Psycheatrec ASiOcalhonWalter E Berton 16,1sat dice+ Clitectio

American Society of Internal MedicineR Ramsey

E *c u t nal Director

Amerman Society of Plastic andReconstruct...4 Surgeons. Inc

Dallas F WhaleyE isculive V,ce President

thOlOileC Association'Nyland T laadbettet MPreadent

WROCIattOel Of American Medical CollegesJohn A 0 Cont. q M 0 Pti ErPendent

46

NATIONAL CENTER FORHEALTH STATISTICS

Dear Dr.

The National Cftnter for Health Statistics, as part of itscontinuing program to provide information on the healthstatus of the American people, is conducting a NationalAmbulatory Medical Care Survey (NAMCS).

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

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

Many organizations and leaders is the medical professionhave expressed their support for this survey, includingthose shown to the left. In particular, your own specialtysociety has reviewed the NAMCS program and supports thiseffort (see enclosure). They join me in urging yourcooperation in this important research.

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

Enclosure

Sincerely yours,

Edward B. Perlin, Ph.D.Acting Director

,

AMERICAN MEDICAL ASSOCIATION

ERNEST R. NOWARD. M.D.Eascutive Vice Mutant

535 NORTH DEARBORN STREET CHICAGO, ILLINOIS 60610 PHONE (312) 527.1500 TWX 910.221.0300

Dear Doctor

The National Center for Health Statistics is conducting a survey tocollect data on office-based ambulatory medical care. We urge you to co-operate in this survey from which we expect to obtain data of value tothe medical profession in planning and organizing health services,' inplanning for the efficient utilization of health facilities and manpower,and in determining desirable modifications in medical education programs.

The American Medical Association is keenly interested in having ac-curate information about medical care services provided by physiciansin private practice and was represented on the Technical Advisory Panelwhich was consulted about the type and amount of patient information tobe collected and the survey procedures to be used. The survey has beendesigned to require a minimal amount of recordkeeping and to ensure con-fidentiality of information on patients from physicians. Data from thesurvey will be presented in summary form.

If you wish more details about the survey or the amount of time itwill involve, please contact Mr. Theodore Woolsey, Director, National Cen-ter for Health Statistics, 5600 Fishers Lane, Rockville, Maryland 20852.

I believe the data to be collected will be of value to the medicalprofIssion and urge you to support the study by providing the informa-tion requested.

Sincerely,

Ernest B. Howard, M. D.

47

.rerun* seers 40PG:MAAJ

APPENDIX III

DATA COLLECTION FORMSFIELD TEST: PHASE I

LONG FORM-PATIENT DATA

SURVEY OF AMIULATORY MEDICAL CARE PHYSICIAN i COPY 96426S IMMS 101 INS COPRACI

Pel Wwe IN pew.,. thee IONisir,

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inuA'Alaj00000

PATIENT CHARACTERISTICS DIAGNOSTIC PROCEDURES MANAGEMENTaaa

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00

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wow06,4114UmweiNone

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48

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togs M ime amelied Gm r ilorod

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II los Or pwrw.f Ihe maw god Iola moi hetothril at nW.rd other pumas at wed Mr dyewho porp000

:=11res.=i

1111.0 MANZ IOPT01410

SHORT FORM-PATIENT DATA

SURVEY OF AMBULATORY MEDICAL CARE

YAWN NATIO CONTACT

Prow t promo gweiblees cbiok eerapIeel

MM .wooer cOoro 1E0s or orcroornog

Offor Arrow

PATIENT CHARACTERISTICS

Nene* (*tm/

Nebo

hoar00

CCAOS OS IA=

%nu.

Nara

cow OO

masa AURAL STATUS

*wood cmdp.aosai

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0

PAMIR NON SY YOU WOW

Y.

No

00

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No

00

49416PHYSICIAN'S COPY

LOCATION OP Colt CO TACT

Mr offico e. clookTolephose Whet Ob.. INC

leeteNtry°ANON* that (toorlf

of poorOAN (wear!

100110Nso wee0111

MANAGEMENTTRIATIAINT rthrod. roorribot doroort

ororoPeroil Or orrAlri

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0

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One Arrow

Socraior prosorres r trarrols (rotifyi

DIAGNOSTIC PROCEDURESTor. 1000.

Gorr.'INTOST Wow! 0

Nom 0

Corer 0SILAMINATION Word 0

Nor 0

eeewbs o eibeems

Aborimirolive preceeeei

0100 bededH-- -

NAOPICIPIC tart ammo U.S VISI via NA 0

IP TN. PUIPON Of TUTS

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woman manor 0 0Sear leA1101001110 0 0 0WNW 1410011000 0 0

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blew. le 80 0 operml bee a leagbel

kkgrod for diewoom ram sily

&Awed a smoker 010610 Is. gawkAmposis

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Nor 0 Ploorr 0 Sir, O are 0

a frooror

Solorroll for Morel orrorsWeer by aweOWN 080004010ber

Sleobee le easeb0 phylkime *peaakahpacoM

CONFIDENTIAL AN rforroo odoch ovoll overt olooroAroo ofArvolool or so marorworo .18 Ise hold rookrosol.orr be rod

.My by tenons roped eg eed for rfo worst r re WNW, OW *INAel be Error or roloord To rho wow or rod for ow OWpurple.

NeD#00.4Uwe me 0 =

49

03500

INDUCTION INTERVIEW SCHEDULE

INDUCTION INTERVIEW -

SURVEY OF AMBULATORY MEDICAL CARE

ED

1 - 4

5

6 - 7

8

9

FOR CODFRS

DATE OF INTERVIEW: INTERVIEWER'S NO:

CITY WHERE INTERVIEWED:

I NTFR VI EWER'S COMMENTS - RECORD ALL SI GNI FI CANT OBSERVAT:ONSRELATING TO YOUR CONTACT WITH THIS DOCTOR:

RESPONDENT:( Prinl Last Name

( Pri nt

( Pri nt City

Fi rst Name I ni ti al )

Street Address)

I NTER VI EWER' S NAME

50

Siatt Zip)

Form Approved - BudgetBureau No. 68-S68099

SANC INDUCTION QUESTIONNAIRE

Doctor, I would like to ask you a few questions to make sure we haveidentified you properly.

1. First, you are a (SPECIALTY) , is that right?

( ) Yes ( ) No - What is your specialty, doctor?

2a. Do you practice ( ) solo or ( ) in a. group or partnership?(Check one)

b. (IF GROUP OR PARTNERSHIP) How many physicians are associated with you?

111MINI. 111=1111. physicians

3. Do you treat any ambulatory patients in your practice?

( ) Yes (CONTINUE INTERVIEW)

( ) No - I treat no ambulatory patients (TERMINATE INTERVIEW)

( ) No - I am no longer in practice (TERMINATE INTERVIEW)

4a. Would you tell me about how many hours you spend in a typical week indirect patient Care and counseling?

hours

b. How many hours each week in other professional activity such asteaching, research, administration and continuing education?

c. How many weeks per year do you usually practice?

hours

weeks

51

5. (REFER TO QUESTION 4a)

You indicated you spend a total of hours per week in directpatient care and counseling. I would like to find out the differentways in which you spend your patient care time. I am particularlyinterested in how you divide it among five areas. Let me read themall first and then go over them one at a time. They are:

Face to face contact with patients in your own officeor clinic.

On the telephone.

In a hospital emergency room, in its outpatient clinic orwith its bed patients.

Now, to start again, how much time per week do you usually spend in

(a) Face to face contact with patients inyour own office or clinic?

(PROBE) About how many minutes do youspend with each patient?

(b) How much time per week on the telephonewith patients?

(PROBE) About how many minutes witheach patient?

(c) How much time per week in the hospitalemergency room?

(PROBE) About how many minutes witheach patient?

(d) How much time per week in a hospitaloutpatient department?

Hours or Percent

=111,MIOMMID

min.

min.

min.M11__r____

(PROBE) About how many minutes witheach patient? min.

(e) How much time per week with yourhospitalized patients? .1111111

(PROBE) About how many minutes witheach patient? min.

52

(f) Are there any other places where you carry out orpursue patient care in a typical week?

( ) Yes ( ) No

(IF YES, ASK) What .are they? (ASK, FOR EACH)How much time is spent?

Place Hours or Percent

0111

6. How many people work for you in your practice, including personsshared with other doctors?

Full time (35 hours or more per week) people

Part-time (less than 35 hours per week) people

7. (ASK ONLY OF SOLO PRACTITIONERS. DO NOT READ CHOICES, BUT RECORDPHYSICIAN'S ANSWER.)

What office facilities do you share with other doctors'

( ) None

( ) Reception room

( ) Examining rooms

( ) Consultation rooms

( ) Laboratory

( ) X-Ray

( ) Other, (please specify)

8. In a typical week, how many ambulatory patient contacts do you have,those seen in person and those contacted by telephone?

patients per week

53

03500

PATIENT FORM EVALUATION INTERVIEW SCHEDULE

SAMC FORM EVALUATION INTERVIEW -

SURVEY OF AMBULATORY MEDICAL CARE

ED

I - 4

5

6 - 7

8

9FOR CODERS

DATE OF INTERVIEW: INTERVIEWER'S NO:

CITY WHERE INTERVIEWED:

INTERVIEWER S COMMENTS - RECORD ALL SIGNIFICANT OBSERVATIONSRELATING T() YOUR CONTACT WITH THIS DOCTOR:

RESPONDENT:

54

(Print

(Print

(Print

Last Name First Name Initial)

Street Address)

City

INTERVIEWER'S NAME:

State Zip)

Form Approved - BudgetBureau No. 68-S68099

ti

SAMC FORM EVALUATION INTERVIEW

(To be administered to participating physicians afterthey have completed one quarterly assignment)

1. When were the patient record forms usually filled out? (Check one only)

( ) After each patient visit

( ) From time to time during the day, as time allowed

( ) All at once at end of each reporting day

( ) All at once at end of the reporting period

( ) Other.

2. About how many minutes did it take to fill out each form? min. /form.

3. Who usually filled out the forms?

Was anyone else involved? ( ) Yes(IF YES) Who?

( ) No

What part did she (he, you) play in filling out the forms?

4. From what sources did you draw the information requested on she form?(DO NOT READ CHOICES, BUT RECORD PHYSICIAN'S ANSWER)

( ) Doctor's memory

( ) Nurse's or aide's memory

( ) Patient's medical record

( ) Bills/statements

( ) Other

66

5. Did you encounter any inconsistencies on the form?

( ) Yes ( ) No

(IF YES) What were they?

6. Was there any information not requested in the patient record formwhich you think should be added for the sake of completeness?

( ) Yes ( ) No

(IF YES) What information?

7. What design or format changes can you suggest which you feel wouldmake the form more useful or easier to fill out?

(IF NONE) Then, you are generally satisfied with its layout as itstands?

) Yes

( ) No - Why cot?

56

8. Did you find that the use of the forms was helpful to you,.ig any way?

( ) Yes - How?

( ) No

9. What did you do with your copies of the form? (DO NOT READ CHOICES, BUTRECORD PHYSICIAN'S ANSWER)

( ) Filed them in patient's record jackets

( ) Kept them all together in a file

( ) Sent them back

( ) Threw them away

( ) Other

10. Was your patient load during your reporting days unusual in any waywith respect to number of patients, location of contacts, or timeout of the office?

( ) Yes - In what way?

( ) No

11. From what you know of this study. do you think that other physicianswould participate in it?

( ) Yes

( ) No - Why not?

12. With regard to the annual reporting schedule, would you prefer toreport one day each month rather than two consecutive days each quarter?

( ) Yes ( ) No ( ) No preference

57

13. What would you suggest be done to increase the likelihood ofparticipation by other physicians?

(IF MONEY OR COMPENSATION IS MENTIONED, ASK) How much?

(IF MONEY OR COMPENSATION IS NOT MENTIONED, ASK)

Would monetary compensation help?

( ) No

( ) Yes

(IF YES, ASK) How much?

14. There are some situations that a few physicians have been uncertain

about including in this survey. Thinking back over the days duringwhich you.participated, do you recall seeing any patients who were

ambulatory, perhaps at home or in an.emergency room prior tohospitalization, that you did not report on?

( ) Na

( ) Yes - Where did these contacts take place?

Now many contacts were involved?

58

15. Do you keep any kind of daily list of patients contacted? ( ) Yes ( ) No

(IF YES) Does it include: Yes No If no, proportionincluded

a. All office patients? ( ) ( )

b. All telephone calls? ( ) ( ) .c. All hospital patients? ( ) ( )

d. All emergency room patients? ( ) ( )

e. All home visit patients? ( ) ( )

Does it exclude any patients?

( ) No

( ) Yes, specify

1

59

APPENDIX IV

DATA COLLECTION FORMS

FIELD TEST: PHASE II

SHORT FORM AND PATIENT LOG FOR NONSAMPLING PROCEDURE

PATIENT LOGOAT( i9

vw.e.. MS mime

I. MI._ And rm... renswrdmely sanlord pr... r

F1T 1414PATIENT'S NAME- -

11

12

13 1

14

15

16 1

17

18

19

20

PHYSICIAN S COPY

I ves - we 10f.er, Vser.

60

bT 19coo.. 2.

NATIONAL AMBULATORY MEDICAL CARE SURVEY

PATIENT RECORDmmnm 1 9 115ID

0 REASONS FOR THIS VISITArabian dr ehrl a ;wrier.

Are* vereerm1.50.41.1lINIwo r eo*...41;

0 COLOR OR RACE

Alto. C ow...0 Noree C Ur .

(it CURRENT NARITA!. STATUS

Oleee. (..elelle ch. Wood!

a Men.. CD LIZtti. t: Ilwwanw

0 PATIENT SEEN RT YOUIf MET

13 Yes ".

IP YES, FOR THEPRESENT PEOS4 E1fit

I 17, Tes tan, H.

Garr&HISTORY r: L....1

11.

Gemmel

IIIIANNATIONI N.

DIAGNOSTIC TESTS 0101110 THIS VISIT Id..i .11 thot A141/1

kallellATOO ftactowa a .i 11 re er1o0. Ot0111.1rerPC Irateralt

' C ScrenreC. Drew..C1 New*

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DIAGNOSTIC SPECIMENTAKEN THIS VISIT IT

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NANO .. -.Orr rat. - 011.117101141.1. Warr.coo, EMI 1111 IEN 0 MIME I I I I

SHORT FORM WITH PATIENT LOG FOR SAMPLING PROCEDURE

26859

NATIONAL AMBULATORY MEDICAL CARE SURVEY

PATIENT RECORD 26859

PATIENT LOG 0611

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'ln AWNS FOR !NM 'NUT

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; TINS OfPATIENT'S NAME

I VISIT

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7

DIAGNOSTIC TESTS ORDERED THIS VISIT 1.46 .. ch 300,, 6Egt,1. or.n .3.$ a.5 s (.63% .0 M16 M116,4t

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CONTINUE LISTING PATIENTS ON THE NEST `AGE

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IInTHIS vISIT (*ack 11 ea loptc)

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61

MINIFORM AND PATIENT LOG FOR NONSAMPLING PROCEDURE

PATIENT LOGDATE 19

As each pat,ont orr,voo, reord hs nom* on rholag below, r.mil console, the correspondingly num.beied patgnt record to rho "ph,.

NATIONAL AMBULATORY MEDICAL CARE SURVEY

PATIENT RECORDAGE

Yrs.

SEX

i 0 Mole

a Feleal

DATE 19

Ttsicrnuuscw

5 9 8f011orMos.

DIAGNOSIS THIS VISIT

pAT,ENTPATIENT'S NAME

Molt important diagnosis (definite or provio.onol)

31

32

33

34

35

36

37

38

39

40

PHYSICIAN'S COPY

roe. s oorto Oboe No. ilaaysaao[a 0,80,71

62

°the. diagnoses

TREATMENT THIS VISIT (check all that opply1

1 None required Advised diet, exercise or habit changes

2 0 Drug therapy a Family planning

0 Office surgical treatment 7 Other (specify)

Thimopoutic listoning and /or psychotherapy

CONFIDENTIAL All information which would permit identification of an individual or on StOlb.lishmont will be hold canfidontiel, will be used only by persons engaged in end for the PhIr0011 of thesurvey and will not be disclosed*, released to other parsons or used for any other purpose.

room o 0Ove0 SuaCia Guotu No. 01-5700aecan o/psrrs

MINIFORM MTH PATIENT LOG FOR SAMPLING PROCEDURE

85154NATIONAL AMBULATORY MEDICAL CARE SURVEY 85154

PATIENT RECORD

PATIENT LOG

DATE 19

As ach patient wr.ves, record name, time of irisit, ego and serion the log bolo.. Fat the patient entered on line 3. also completethe patient record to the

PATIENT'S NAMEDIME OF

VISIT

AGEYes.er

Mos.

SEX

0.111 O PAYrs.

O. Mos. 0 F

0.10. OM2

p.m. 0 FMa s.

3

0.0%. Yrs. OM

Record diognosis and treatment fortt .s por,nt, Mos

OF

CONTINUE LISTING PATIENTS ON THE NEXT PAGE

DIAGNOSIS THIS VISIT

Most important diagnosis (definite or proviional)

Other diagnoses

TREATMENT THIS VISIT (check 11 that apply)

t 0 Nene required

Drug therapy

3 0 Office surgical treatment

0 Therapeutic listening and/or psychotherapy

llajwisod dist, exercise or habit choose

e Family planning

7 Other (specify)

CONFIDENTIAL All information which would permit identification of in individual or an stablishment will be held confidential, will be used only by persons engaged in and for thepurposes of the survey and will not be disclosed at released to other persons or used for any

other porpoe. roar. MMOVSO 850057 scam, MO. 011-57001111g 0/11/71

63

MINIFORM WITHOUT PATIENT LOG FOR NONSAMPLING PROCEDURE

NATIONAL AMBULATORY MEDICAL CARE SURVEY

PATIENT RECORDAGE

Yrs.

SEX

1 Male

2 Female

DATE 19

PATIENT/WAIEA

5 9 7g1:or

Mos.

DIAGNOSIS THIS VISIT

Most important diagnosis (definite or provisional)

Other diagnoses

TREATMENT THIS VISIT (check all that apply)

1 None required 5 Advised diet, exercise or habit changes

2 Drug therapy 6 Family planning

3 Office surgical treatment 7 Other {specify)

4 0 Therapeutic listening and/or psychotherapy

CONFIDENTIAL All information which would permit identification of an individual or an stab.lialiment will be held confidential, will be used on!y by persons engaged in and for the purposes of thesurvey and will not be disclosed or released to other persons or used for any other purpose.

room o xliemovto-111110Glit tINEAU NO. 1170065CIIIP. 11/31/71

64

ENLISTMENT INTERVIEW SCHEDULE

CONFIDENTIAL*

Time AMRegan: PM

Form approved.

Budget Bureau No. 68-570065

February 1971

NATIONAL OPINION RESEARCH CENTER

University of Chicago

NATIONAL AMBULATORY MEDICAL CARE SURVEYSurvey No. 4118

INDUCTION INTERVIEW

(Phys. ID Number)

1 halti on tht. phone he other day, Dr. , I have a few questions to

ask hetore we discus the reporting procedures.

First, about your practice . .

1. You are d Is that right?

(ENTER :q'L('IALTY FROM CODE ON FACE SHEET LABEL.)

Yes

No (ASK A) 2

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

(Name of Specialty)

2. Do you practice solo, or are vou associated with other physicians in a

partnership, in a group practice, or in some other way?

Solo 1

Partnership (ASK A) 2

Group . . . (ASK A) 3

Other (SPECIFY AND ASK A) 4

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

(# of Physicians)

ars.

All information which would permit identification of en individual or an

establishment will be held confidential, will be used only by persons engaged in

and for the purposes of the survey, and will not be disclosed or released to other

persons or used for any other purpose.

65

-2-

Now I'll take a few minutes to discuss with you the physician's role in the NationalAmbulatory Medical Care Survey. To understand this better, I should give you a little

background about the origin of this survey.

There is a general lack of any systematic information about the characteristics andcomplaints of people who consult physicians in their offices. Such information is bad-

ly needed by medical educators and persons concerned with medical manpower needs.

In response to this need, NCHS (National Center for Health Statistics), in coopera-tion with representative of the medical profession has developed this survey ofAmbulatory Medical Care. The information for this survey can be provided only by

office-based physicians who provide care for ambulatory patients.

The task is simple, carefully designed, and should not take much of your time. Es-

sentially it consists of your participation on two randomly selected consecutivedays in each of four quarters. Your participation consists of filling out a minimal

amount of information for each patient seen by you during that two-day period. Let

me show you the form(s) involved now. TAKE OUT FOLIO AND SHOW FORM(S) TO THE DOCTOR.

EXPLAIN HOW FORMS ARE TO BE FILLED OUT. SHOW DOCTOR THE INSTRUCTIONS ON POCKET OFFOLIO TO WHICH HE CAN REFER AFTER YOU LEAVE.

RECORD VERBATIM ANY CONCERNS, PROBLEMS, OR QUESTIONS THE DOCTOR RAISES IN CONNECTIONWITH THE EXPLANATION OF THE SURVEY OR THE COMMITMENT FOR FOUR QUARTERS.

Doctor, now that you know what the task is, let me tell you that your reporting days

for this quarter are: READ DAYS OF WEEK AND DATES WHICH YOU CIRCLED FROM PAGE 3 OF

CONTROL FOLDER.

M T W Th F Sa

and

M T W Th F Sa, March and

3. Are you likely to see au ambulatory patients on those days?

IF NO:

A. Why is that?

OS

Yes 1

No . . . (ASK A & B) . . 2

-3-3. Continued

IF NO TO 3:

B. Your alternate days would be (READ NEXT PAIR OF DAYS). Are you at alllikely to see an ambulatory patients on those two days?

(1) IF NO TOB : Would you pl,:ase selecton which you

Yes 1

No . . . [ASK (1)J 2

any two consecutive days betweenwould be likely to see 22x ambulatory

Yes (RECORD SELECTED DAYS ANDDATES IN BOX)

No (OFFER CHOICE OF ANY 2 DAYSBETWEEN MARCH 22 PND APRIL 2AND RECORD SELECTED DAYS ANDDATES IN BOX) 2

March 8 and March 20patients?

SELECTED REPORTING BAYS ARE:

and

M T W Th F Sa

andM T W Th F Sa, March/April

RECORD VERBATIM ANY COMMENTS DOCTOR MAKES WITH REFERENCE TO THE SELECTION OF RE-PORTING DAYS. IF REPORTING DAYS ARE UNACCEPTABLE FOR OTHER REASONS THAN ABOVE,RECORD VERBATIM HERE.

4. A. At which office location will you be seeing ambulatory patients during the2-day reporting period? RECORD UNDER A BELOW AND ASK B WHEN INDICATED.

B. IF HOSPITAL EMERGENCY ROOM, OUT-PATIENT CLINIC, OR OTHER INSTITUTIONAL LO-CATION 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?

.

Office Location

.

Dr. has primeresponsibility

(in-scope)

Inst. has primeresponsibility(out-of-scopq)

( 1 ) 1 0

0(2) 1

0(3) 1

67

-4-

5. During your 2-day reporting period (REPEAT EXACT DATES), will anyone be availableto help in the survey reporting process (at each IN-SCOPE location)?

Yes . . . (ASK A) . I

No 2

A. IF YES: Who would that be?

RECORD NAME, POSITION, AND LOCATION.

Name Position Location

B. INTERVIEWER: WASPERSON BRIEFED BYYOU?

'es No

1 2

1 2

1 2

1 2

Now I have just a few more questions about your practice during a typical week.

6. " During a typical week, approximately how many hours do you spend each day caringfor ambulatory patients? RECORD IN COLUMN A.

B. And about how many ambulatory patient visits do you have each day, during atypical week? RECORD IN COLUMN B.

Day of the weekA.

Estimated hoursB.

Estimated No. of patients

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

BEFORE YOU LEAVE, STRESS THAT EACH AMBULATORY PATIENT SEEN BY THE DOCTOR DURING THE 2-

DAY PERIOD AT ALL IN-SCOPE LOCATIONS (REPEAT THEM) IS TO BE INCLUDED IN THE SURVEY.

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

free to call me. My phone number is written in on the folio. I'll call you the day

before your reporting days just to remind you.

10 1- 1 I

Month Date

TimeEnded.

AMPM

J.TEMS I & II ARE TO BE COMPLETED BY THE INTERVIEWER AFTER THE INTERVIEW.

I. How much interest to you think the doctor II. How confident are you that the

has in the survey? doctor will complete the forms?

Tntetviewer ib

j

68

Great interest . . . 1

Some interest . . . 2

Little interest . 3

No interest 4

Can't tell 5

Interviewer's Signature:

Definitely will . . . 1

Probably will . . . . 2

Doubtful . 3

EVALUATION INTERVIEW SCHEDULE

CONFIDENTIAL* NATIONAL OPINION RESEARCH CENTERUniversity of Chicago

TimeBegan:

}h

searchDr.

AMPM

NATIONAL AMBULATORY MEDICAL CARE SURVEY

Survey No. 4118

SURVEY EVALUATION INTERVIEW

Iiirm approved.

Budget Bureau No.:68-S70065Feb. 1971

1 I I

(Phys. ID Number)

.This is (YOUR NAME) from the National Opinion Re-

Center (. f the University of Chicago). I called to thank you very much

for your cooperation in the National Ambulatory Medical Care Survey. To com-

plete your participation, I hope you will answer a few questions now to help

us evaluate the survey.

NOTE: IF PROCEDURE V WAS USED BY THIS DOCTOR, BEGIN THIS INTERVIEW WITH Q. 2.

1. You will recall that two forms were used--the Patient Log and the Patient

Record.

A. First, tellthe Patient

me about the Patient Log--who, in your office, completed

Log (for the most part)?

B. At what point were

Doctor himself 1

Assistant who wasbriefed by interviewer .

Someone else (SPECIFY) . .

2

3

the patients' names (usually) entered on the log?

DO NOT READ CATEGORIES.

When patients :.necked in with re-cerLionist or nurse 1

When patients saw doctor 2

Other (SPECIFY) 3

2. Now, tell me about the Patient Record. You may recall that there were two

kinds of information requested on the Patient Record--personal and clinical.

A. Who usually completed the items asking for clinical information?

Doctor himself 1

Assistant who wasbriefed by interviewer . 2

Someone else (SPECIFY) . . 3

B. Who usually completed the items asking for personal information?

Doctor himself 1

Assistant who wasbriefed by interviewer . 2

Someont. else (SPECIFY) . 3

*All information which would permit identification of an individual oran establishment will be held confidential, will be used only by persons en-

gaged in and for the purposes of the survey, and will not be disclosed or re-

leased to other persons or used for any other purpose.

-1-

69

-2-

2. Continued

C. Was anyone chit! involved in completing any part of the PatientRecords?

IF YES TO C:

(1) Who was that?

Yes . [ASK (1) & (2)) . . . 1

No . (GO TO 3) 2

(Name) (Position)

(2) What part of the form did (you/he/she/they) complete?

Clinical items 1

Personal items 2

Other (SPECIFY) 3

3. At what point in the process was the clinical information on the PatientRecord filled out? DO NOT READ CATEGORIES

At the time patient saw doctor 1

At the end of each day (ASK A) 2

At the end of reporting period (ASK A) 3

Other (SPECIFY AND ASK A) 4

A. IF NOT AT TIME

PATIENT SAW DOCTOR: Was the clinical information entered mostly frommemory, mostly from the patient's mediea: record,or mostly from something else?

Mostly memory

Mostly patient's medical record 2

Mostly something else (SPECIFY) 3

4. How long did it usually take to complete a Patient Record?

minutesorseconds

5. When filling out the Patient Records, were there any items or instructionsthat you had trouble with?

Yes . (ASK A) 1

No 2

A. IF YES: What were they?

70

ASK Q'S 6 AND 7 ONLY OF DOCTORSTO Q. 8.

6. Did vou(OR PERSON) have anythe Patient Log?

A. IF YES: What was the trouble?

-3-

ASSIGNED PROCEDURES II OR IV' FOR OTHERS SKIP

trouble filling out Yes . (ASK A) . 1

No 2

7. Did you (or the person filling out the forms) have any difficulty follow-

ing the survey procedures because a Patient Record was completed for only

every third patient? Yes . (ASK A) . . I

No

A. IF YES: What difficulties?

ASK EVERYONE:

8. We are trying to get some notion of how complete the information is which

we have collected. We know t'at many things could have occurred to pre-

vent you from keeping records on the two reporting days. How confident

are you that the records you sent to us include every ambulatory patient

seen by you during the 2-day reporting period--would you say you are con-

fident that every patient was included, or that you got all except one or

two, or that more than that were missed, for one reason or another?

Every patient was included . . . I

Got all except one or two . . . 2

Missed more than that (ASK A) 3

Can't recall 4

A. IF MISSED MORE THAN TWO: Why was that?

11

-4-

9. what- changes do you suggest in order to make any of the forms more usefulor easier to complete? RECORD IN APPROPRIATE COLUMN.

Patient Records

amM

Patient Loll

ASK Q. 10 ONLY IF "NO CHANGES" SUGGESTED IN Q. 9.

10. Are you generally satisfied with the forms as they are?

Yes

No (ASK A) 2

A. IF NO: Why not?

11. With regard to the overall survey operation in your office, did you findthat the procedures we asked you to follow were reasonable and easilyadaptable to your office routine?

Yes 1

No . (ASK A) . . . 2

A. IF NO: What changes in procedures do you suggest that would makeyour participation easier?

72

-5-

Now, about your practice.

12. Was your practice during the 2-day reporting period (GIVE DATES) unusual

in any way?

IF YES:

A. Was your patient load lighter thanusual, heavier than usual, or about

the same?

B. How about the amount of timespent in caring for ambulatorypatients--was that less thanusual, more than usual, orabout the same?

Yes . . (ASK A-C) I

No 2

Lighter than usual . 1

Heavier than usual . 2

About the same . . . 3

Less than usual . . 1

More than usual . . 2

About the same . 3

C. In what (other) ways was your practice unusual during your reporting

period?

13. Doctor, we would like to get an idea of your total ambulatory patient load

during the two-day reporting period, including telephone calls and patient

contacts made outside of your office.

A. First, how many ambulatory patientcontacts would you estimate tookplace by telephone during the two- Number of patient

day period--not including calls contacts by

for appointments? telephone.

B. How many ambulatory patient con-tacts were not included in thesurvey because they took place

outside of your office during thetwo-day period, such as in a hos-pital emergency room, in a patient'shome, in an wit-patient clinic, atthe !-:ene of an accident, or elsewhere?

Number of outsidepatient contacts:

1.4. What suggestions do you have for us to encourage participation in this sur-

vey by other physicians? (IF MONEY IS MENTIONED, PROBE FOR AMOUNT.)

73

1

-6-

15. A letter was sent to you by Mr. Theodore Woolsey of the National Center forHealth Statistics (NCHS) urging you to participate. Did you receive thatletter?

Yes . (ASK A) 1

No 2

A. IF YES: Did it influence your decision to participate?

Yes 1

No 2

16. There was also a letter from Dr. Howard, Executive Director of AMA urgingyou to take part in the study. Did you receive that letter?

Yes . (ASK A) 1

Nc 2

A. IF YES: Did it influence your decision to participate?

Yes

No 2

17. Did you happen to discuss the survey with anyone from your (local or)state medical society or one of your colleagues before you participated?

Yes, local or state medical society (ASK A) . .

Yes, colleague . . . . (ASK A) . 2

No, neither 3

A. IF YES: Did (that/those) discussion(s) influence your decision to par-ticipate?

Yes 1

No 2

18. Were there any (other) specific factors which influenced your decision toparticipate?

A. IF YES: What were they?

Yes . (ASK A)

No 2

-7-

19. We initially requested your participation in this survey during four quarter-

ly 2-day periods. After having participated for the first period, how do

you feel about participating during the other 2-day periods - -wc Id defi-

nitely participate, probably participate, probably not participate, or defi-

nitely not participate?

Definitely would 1

Probably would . . 2

Don't care one way or the other . 3

Probably would not (ASK A-D) . 4

Definitely would not (ASK A-D) . 5

Don't know 6

IF PROBABLY NOT OR DEFINITELY NOT:Imeig

A. Why would you (probably) not participate?

B. (PROCEDURES I AND II ONLY): Would you be willing to participate if the

Patient Record was different?Yes 1

No 2

C. (PROCEDURES T. III, AND V): Would you be willing to participate if

you were asked to complete cnly about ten Patient Records for each of

the two days?Yes

No 2

D. Are there any (other) conditions under which you would participate

again?Yes [ASK (1)] . . 1

No

(1) IF YES TO D: Under what conditions?

That's all the questions I have, Doctor. The information ycu have given us to-

day will be most useful in evaluating our survey procedures. Thank you very

much for all your help and cooperation.

FILL OUT ITEMS ON BACK COVER AFTER INTERVIEW.

TimeEnded:

AMPM

75

-8-

ITEMS BELOW ARE TO BE COMPLETED BY THE INTERVIEWERAFTER THE INTERVIEW

1. HOw do you think the doctor feels about participating during the otherthree quarters?

Definitely would

Probably would 2

Probably would not . . . . 3

Definitely would not . . 4

Can't tell 5

II. Was doctor cooperative during this evaluation interview?

Yes 1

No . . (ANSWER A) . . . . 2

A. IF NO: Why do you think he wasn't cooperative?

Was Lhis interview conducted on the telephone? Yes 1

No (ANSWER A) . . 2

A. IF NO: Where was it conducted, and why were you not able to conductit on the telephone?

Please record here any other comments or insights of your own which mighthelp us in the evaluation of this survey.

Interviewer's Signature:

Date of Interview:

76

01 I

Month Date

(Interviewer fi)

VITAL AND HEALTH STATISTICS PUBLICATION SERIES

Formerly Public Health Services Publication No. 1000

lirograms and collection procedures, Reports which describe the general programs of the National

;enter for Health Statistics and its offices anddivisions, data collection methods used, definitions,

end other material necessary for understanding the data.

:Data evaluation and methods research.Studies of new statistical methodology including: experi-

Oiental tests of new survey methods, studies of vital statistics collection methods, new analytical

ichniques, objective evaluations of reliability of collected data, contributions to statistical theory.

Inalvtical studies Reports presenting analytical or interpretive studies based on vital and health

aitatlstics, carrying the analysis further than the expository types of reports in the other series.

Documents and committee reports.Final reports of major committees concerned with vital and

taealth statistics, and documents such as recommended model vital registration laws and revised

birth and death certificates.

Data from the Health Interview Survey.Statistics on illness, accidental injuries, disability, use

of hospital, medical, dental, and other services, and other health -related topics, based on data

collected in a continuing national household interview survey.

Data from the Health Examination Survey. --Data from direct examination, testing, and measure-

ment of national samples of the civilian, noninstitutional population provide the basis for two types

of reports: (1) estimates of the medically defined prevalence of specific diseases in the United

States and the distributions of the population with respect to physical, physiological, and psycho-

logical characteristics; and (2) analysis of relationships among the various measurements without

reference to an explicit finite universe of persons.

Data from the Institutional Population Surveys Statistics relating to the health characteristics of

persons in institutions, and their medical, nursing, and personal care received, based on national

samples of establishments providing these services and samples of the residents or patients.

Data from the Hospital Discharge Survey. Statistics relating to di scharged patients in short-stay

hospitals, based on a sample of patient records in a national sample of hospitals.

-Data on health resources: manpower and facilities.Statistics on the numbers, geographic distri-

bution, and characteristics of health resources including physicians, dentists, nurses, other health

occupations, hospitals, nursing homes, and outpatient facilities.

Data on mortality.Various statistics on mortality other than as included in regular annual or

monthly reportsspecial analyses by cause of death, age, and other demographic variables, also

geographic and time series analyses.

Data on natality, marriage, and divorce.--Var.3us statistics on natality, marriage, and divorce

other than as included in regular annual or monthly reportsspecial analyses by demographic

variables, also geographic and time series analyses, studies of fertility.

Data from the Natioaal Natality and Mortality Surveys, Statistics on characteristics of births

and deaths not available from the vital records, based on sample surveys stemming from these

records, including .uch topics as mortality by socioeconomic class, hospital experience in the

last year of life, medic,1 care during pregnancy, health insurance coverage, etc.

of titles of reports published in these series, write to: Office of InformationNational Center for Health StatisticsPublic Health Service, HRARockville, Md. 20832