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Pastor PN, Makuc DM, Reuben C, Xia H.
Chartbook on Trends in the Health of Americans.
Health, United States, 2002. Hyattsville, Maryland:
National Center for Health Statistics. 2002.
Library of Congress Catalog Number 76–641496
For sale by Superintendent of Documents
U.S. Government Printing Office
Washington, DC 20402
Department of Health and Human Services

Tommy G. Thompson
Secretary
Centers for Disease Control and Prevention

Julie Louise Gerberding, M.D., M.P.H.
Director
National Center for Health Statistics

Edward J. Sondik, Ph.D.
Director
Preface
Preface Earlier editions of Health, United States may present data for
additional years that are not included in the current printed
report. Where possible, these additional years of data are
The Chartbook on Trends in the Health of Americans is an available in Excel spreadsheet files on the Health, United
excerpt from Health, United States, 2002 and includes States home page. Tables with additional data years are
highlights and appendixes I and II from the complete listed in Appendix III.
report.
Racial and Ethnic Data

Health, United States, 2002 is the 26th report on the health
status of the Nation, and is submitted by the Secretary of the Many tables in Health, United States present data according
Department of Health and Human Services to the President and to race and Hispanic origin consistent with Department-wide
Congress of the United States in compliance with Section 308 of emphasis on expanding racial and ethnic detail when
the Public Health Service Act. This report was compiled by the presenting health data. Trend data on race and ethnicity are
National Center for Health Statistics (NCHS), Centers for Disease in the greatest detail possible, after taking into account the
Control and Prevention (CDC). The National Committee on Vital quality of data, the amount of missing data, and the number
and Health Statistics served in a review capacity. of observations. The large differences in health status by race
and Hispanic origin documented in this report may be
The Health, United States series presents national trends in
explained by several factors including socioeconomic status,
health statistics. Major findings are presented in the highlights
health practices, psychosocial stress and resources,
section. The report includes a chartbook, trend tables,
environmental exposures, discrimination, and access to health
extensive appendixes, and an index.
care. New standards for Federal data on race and ethnicity
are described in Appendix II under Race.
Chartbook
The Chartbook on Trends in the Health of Americans Changes in This Edition
assesses the Nation’s health by presenting trends and current
information on selected determinants and measures of health Each volume of Health, United States is prepared with the
status. Determinants of health considered in the chartbook goal of maximizing its usefulness as a standard reference
include demographic factors, health insurance coverage, source while maintaining its continuing relevance.
health behaviors and risk factors, and preventive health care. Comparability is fostered by including similar trend tables in
Measures of health status include mortality and limitations of each volume. Currency is maintained by adding new tables
activity due to chronic health conditions. Many measures are each year to reflect emerging topics in public health and
shown separately for persons of different ages because of the improving the content of ongoing tables. New to Health,
strong effect of age on health, as well as differences in United States, 2002 is a table on the 10 Leading Health
causes of morbidity and mortality across the age span. Indicators and associated measures from the Healthy People
Selected figures also highlight differences in determinants and 2010 goals and objectives for improving the health of the
measures of health status by such characteristics as sex, Nation (table 52). Table 64 on use of selected substances,
race, and Hispanic origin. based on data from the redesigned National Household
Survey of Drug Abuse (NHSDA), has been reformatted to
include additional substances. A new table provides data on
Trend Tables the proportion of the population with health insurance
The chartbook section is followed by 147 trend tables coverage through health maintenance organizations by private
organized around four major subject areas: health status and insurance, Medicaid, and Medicare, based on the National
determinants, health care utilization, health care resources, Health Interview Survey (NHIS) (table 132). State health
and health care expenditures. A major criterion used in expenditure data from National Health Accounts were added in
selecting the trend tables is availability of comparable national the following new tables: per capita expenditures for total
data over a period of several years. The tables report data personal health care, hospital care, physician services, nursing
for selected years to highlight major trends in health statistics. home and home health care, and drugs (table 140); and
Chartbook on Trends in the Health of Americans Health, United States, 2002 iii
Preface
expenditures for Medicare (table 141) and Medicaid (table 142) The Index to Trend Tables is a useful tool for locating data by
as a percent of total personal health care expenditures. topic. Tables are cross-referenced by such topics as Child
and adolescent health, Women’s health, Elderly population,
The use of the Tenth Revision of the International
Nutrition-related data, State data, American Indian, Asian,
Classification of Diseases (ICD–10) for classifying and coding
Black, and Hispanic origin populations, Education, Poverty
cause-of-death starting with 1999 data introduced
status, Disability, and Metropolitan/nonmetropolitan data.
discontinuities in mortality trends between 1998 and 1999.
Discontinuities due to differences in classification between
ICD–9 and ICD–10 were minimized for some causes of death Electronic Access
(ischemic heart disease and unintentional injuries in table 30, and Health, United States may be accessed on the World Wide
cerebrovascular diseases in tables 30 and 38) by using ICD–9 Web at www.cdc.gov/nchs/hus.htm. From the Health, United
codes that more closely resemble the codes for ICD–10 and States home page, one may also subscribe to the Health,
revising the corresponding death rates for 1980–98. Starting with United States listserv.
this edition of Health, United States, 1980–98 death rates for
these three causes of death differ from previous editions. To Health, United States, 2002, the chartbook, and each of the
facilitate evaluation of mortality change between 1998 and 1999, 147 individual trend tables are available as separate Acrobat
comparability-modified rates for 1998 were added to each .pdf files on the Web. Individual tables are downloadable as
mortality trend table for comparison with 1999 death rates Excel spreadsheet files. Pdf and spreadsheet files for selected
(tables 30, 31, 35, 37–43, and 45–48). tables will be updated on the Web if more current data become
available near the time when the printed report is released.
The table on occupational disease deaths (table 49) was expanded Readers who register for the listserv will be notified of these
to include both males and females 15 years of age and over and table updates. Previous editions of Health, United States and
the number of occupational diseases was increased. chartbooks, starting with the 1993 edition, also may be accessed
from the Health, United States home page.
Appendixes Health, United States is also available, along with other
Appendix I describes each data source used in the report and NCHS reports, on a CD-ROM entitled ‘‘Publications from the
provides references for further information about the sources. National Center for Health Statistics, featuring Health, United
Appendix I is reorganized with data sources listed States, 2002,’’ vol 1 no 8, 2002. These publications can be
alphabetically within two broad categories: Government viewed, searched, printed, and saved using Adobe Acrobat
Sources and Private and Global Sources. software on the CD-ROM.
Appendix II is an alphabetical listing of terms used in the report.

It also presents standard populations used for age adjustment
Copies of the Report
(tables I, II, and III); ICD codes for causes of death shown in Copies of Health, United States, 2002 and the CD-ROM may
Health, United States from the Sixth through Tenth Revisions and be purchased from the Government Printing Office through
the years when the Revisions were in effect (tables IV and V); links to GPO on the Health, United States home page.
comparability ratios between ICD–9 and ICD–10 for selected
causes (table VI); ICD–9–CM codes for external cause-of-injury,
Questions?
diagnostic, and procedure categories (tables VII, IX, and X);
industry codes from the Standard Industrial Classification Manual For answers to questions about this report, contact:
(table VIII); and sample tabulations of NHIS data comparing the

Data Dissemination Branch
1977 and 1997 Standards for Federal data on race and Hispanic National Center for Health Statistics
origin (tables XI and XII). Centers for Disease Control and Prevention
Appendix III lists tables for which additional years of trend 6525 Belcrest Road, Room 1064
data are available electronically in Excel spreadsheet files on Hyattsville, Maryland 20782
Phone: 301–458-INFO
the Health, United States home page and CD-ROM,

E-mail: [email protected]
described below under Electronic Access.

Internet: www.cdc.gov/nchs
iv Chartbook on Trends in the Health of Americans Health, United States, 2002

Acknowledgments
Acknowledgments Bysheim, Jacqueline M. Davis, Gail V. Johnson, Zung T. Le,
Sharon L. Ramirez, Thelma W. Sanders, Tammy M.
Overall responsibility for planning and coordinating the content Stewart-Prather, and Patricia A. Vaughan.
of this volume rested with the Office of Analysis,
Data and technical assistance were provided by staff of the
Epidemiology, and Health Promotion, National Center for
following NCHS organizations: Division of Data Services:
Health Statistics (NCHS), under the general direction of Diane
Margaret C. Avery; Division of Health Care Statistics:
M. Makuc and Jennifer H. Madans.
Catharine W. Burt, Donald K. Cherry, Barbara J. Haupt, Lola
The Chartbook on Trends in the Health of Americans was Jean Kozak, Karen L. Lipkind, Nghi Ly, Linda F. McCaig,
prepared by Patricia N. Pastor, Diane M. Makuc, Cynthia Susan M. Schappert, Alvin J. Sirrocco, Genevieve W.
Reuben, and Henry Xia. Data and analysis for specific charts Strahan, and David A. Woodwell; Division of Health
were provided by Margaret D. Carroll of NCHS, Jo Anne Examination Statistics: Margaret D. Carroll, Rosemarie Hirsch,
Grunbaum and Sherry Everett Jones of the National Center and Clifford L. Johnson; Division of Health Interview Statistics:
for Chronic Disease Prevention and Health Promotion. Viona I. Brown, Pei-Lu Chiu, Robin A. Cohen, Richard H.
Technical assistance was provided by John M. Aberle-Grasse, Coles, Nancy G. Gagne, Cathy C. Hao, Kristina Kotulak-Hays,
Barbara M. Altman, Robert N. Anderson, Patricia M. Barnes, Susan S. Jack, Jane B. Page, Eve Powell-Griner, Charlotte A.
Alan J. Cohen, Catherine R. Duran, Lois A. Fingerhut, Virginia Schoenborn, Mira L. Shanks, Anne K. Stratton, and Luong
M. Freid, Richard J. Klein, Kenneth D. Kochanek, Ellen A. Tonthat; Division of Vital Statistics: Robert N. Anderson,
Kramarow, Ji-Eun Lee, Andrea P. MacKay, Elsie R. Pamuk, Thomas D. Dunn, Donna L. Hoyert, Kenneth D. Kochanek,
Kate Prager, Louise Saulnier, Charlotte A. Schoenborn, Diane Marian F. MacDorman, Joyce A. Martin, T.J. Mathews, Arialdi
S. Shinberg, Felicity Skidmore, Thomas C. Socey, Melissa S. M. Minino, William D. Mosher, Sherry L. Murphy, Gail A. Parr,
Tracy, Marie Pees of the Census Bureau, Howell Wechsler Harry M. Rosenberg, Manju Sharma, Betty L. Smith, and
and Steven A. Kinchen of the National Center for Chronic Stephanie J. Ventura; Office of Analysis, Epidemiology and
Disease Prevention and Health Promotion. Health Promotion: John Aberle-Grasse, Lois A. Fingerhut,
Health, United States, 2002 highlights, trend tables, and Deborah D. Ingram, and Richard J. Klein; and Office of
appendixes were prepared under the leadership of Kate International Statistics: Juan Rafael Albertorio-Diaz and
Prager. Trend tables were prepared by Alan J. Cohen, Francis C. Notzon.
Margaret A. Cooke, La-Tonya D. Curl, Catherine R. Duran, Additional data and technical assistance were also provided
Virginia M. Freid, Andrea P. MacKay, Mitchell B. Pierre, Jr., by the National Center for HIV, STD, and TB Prevention,
Rebecca A. Placek, Anita L. Powell, Kate Prager, Laura A. CDC: Tim Bush, Sharon Clanton, Melinda Flock, and Luetta
Pratt, and Henry Xia, with assistance from Ji-Eun Lee, Kelly Schneider; Epidemiology Program Office, CDC: Samuel L.
Lubey, and Louise Saulnier of TRW Corporation. Production Groseclose and Patsy A. Hall; National Center for Chronic
planning and coordination of appendixes and index to trend Disease Prevention and Health Promotion, CDC: Jo Anne
tables were managed by Anita L. Powell. Production planning Grunbaum, Sherry Everett Jones, Steven A. Kinchen, Joy
and coordination of trend tables were managed by Rebecca Herndon, and Lilo T. Strauss; National Immunization Program,
A. Placek. Administrative and word processing assistance CDC: Emmanuel Maurice and Dave Sanders; National
were provided by Carole J. Hunt, Lillie C. Featherstone, and Institute of Occupational Safety and Health, CDC: Rochelle
Anne E. Cromwell. Althouse and Robert M. Castellan; Agency for Health Care
Publications management and editorial review were Research and Quality: Joel Cohen, Steven Machlin, and
provided by Thelma W. Sanders and Rolfe W. Larson. The Joshua Thorpe; Health Resources and Services
designer was Sarah M. Hinkle. Graphics were supervised by Administration: Evelyn Christian; Substance Abuse and Mental
Stephen L. Sloan. Production was done by Jacqueline M. Health Services Administration: Joanne Atay, Judy K. Ball,
Davis and Zung T. Le. Printing was managed by Joan D. Joseph C. Gfroerer, Ronald Manderscheid, Lucilla Tan,
Burton and Patricia L. Wilson. Richard Thoreson, and Deborah Trunzo; National Institutes of
Health: Ken Allison, James D. Colliver, Deborah Dawson, and
Electronic access through the NCHS Internet site and Lynn A.G. Ries; Centers for Medicare & Medicaid Services:
CD-ROM were provided by Christine J. Brown, Michelle L. Gerald S. Adler, Cathy A. Cowan, Frank Eppig, David A.
Chartbook on Trends in the Health of Americans Health, United States, 2002 v

Acknowledgments
Gibson, Leslie Greenwald, Helen C. Lazenby, Katharine R.

Levit, Anna Long, Madie W. Stewart, and Carter S. Warfield;
Office of the Secretary, DHHS: Mitchell Goldstein; Census
Bureau: Joseph Dalaker; Bureau of Labor Statistics: Alan
Blostin, Kay Ford, Daniel Ginsburg, and Peggy Suarez;
Department of Veterans Affairs: Laura O’Shea; Alan
Guttmacher Institute: Rebecca Wind; Association of Schools
of Public Health: Karen L. Helsing; InterStudy: Richard
Hamer; University of Michigan: Patrick O’Malley; Cowles
Research Group: C. McKeen Cowles; and CSR Incorporated:
Gerald D. Williams.
vi Chartbook on Trends in the Health of Americans Health, United States, 2002

Contents
Contents Appendixes
Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
I. Data Sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
II. Definitions and Methods . . . . . . . . . . . . . . . . . . . . 110
List of Chartbook Figures. . . . . . . . . . . . . . . . . . . . . . . . viii
Geographic Regions and Divisions of

the United States. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Highlights
Health Status and Determinants. . . . . . . . . . . . . . . . . . . 3
Health Care Utilization and Resources . . . . . . . . . . . . . . 7
Health Care Expenditures . . . . . . . . . . . . . . . . . . . . . . . 9
Chartbook on Trends in the Health of

Americans
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Race and Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Low Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Health Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . 28
Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Preventive Health Care . . . . . . . . . . . . . . . . . . . . . . . . . 32
Prenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Adult Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Limitation of Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Child Limitation of Activity . . . . . . . . . . . . . . . . . . . . . 36
Adult Limitation of Activity . . . . . . . . . . . . . . . . . . . . . 38
Chronic Health Conditions . . . . . . . . . . . . . . . . . . . . . 40
Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Life Expectancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Infant Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Child and Young Adult Mortality . . . . . . . . . . . . . . . . . 47
Adult Mortality: 25–44 Years of Age . . . . . . . . . . . . . . 49
Adult Mortality: 45–64 Years of Age . . . . . . . . . . . . . . 51
Adult Mortality: Elderly . . . . . . . . . . . . . . . . . . . . . . . . 53
Data Tables for Figures 1–28 . . . . . . . . . . . . . . . . . . . . . 54
Chartbook on Trends in the Health of Americans Health, United States, 2002 vii
List of Chartbook Figures
List of Chartbook Figures Limitation of Activity

15. Limitation of activity caused by 1 or more chronic
Population health conditions among children by sex and age:
United States, 1998–2000 . . . . . . . . . . . . . . . . . . 37
1. Total and elderly population: United States, 16. Limitation of activity caused by 1 or more chronic
1950–2050 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 health conditions among adults by age: United States,
2. Percent of population in 3 age groups: United States, 1998–2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
1950, 2000, and 2050 . . . . . . . . . . . . . . . . . . . . 19 17. Selected chronic health conditions causing limitation
3. Percent of population in selected race and of activity among adults by age: United States,
Hispanic origin groups by age: United States, 1998–2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
1980–2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
4. Low income population by age, race, and Hispanic
origin: United States, 2000 . . . . . . . . . . . . . . . . . 23 Mortality
18. Life expectancy at birth and at 65 years of age by
Health Insurance sex: United States, 1901–99 . . . . . . . . . . . . . . . . 43
19. Infant, neonatal, and postneonatal mortality rates:
5. Health insurance coverage among persons under 65 United States, 1950–99 . . . . . . . . . . . . . . . . . . . 44
years of age: United States, 1984–2000 . . . . . . . 24 20. Infant mortality rates by detailed race and Hispanic
6. No health insurance coverage among persons origin of mother: United States, 1997–99 . . . . . . . 45
under 65 years of age by selected characteristics: 21. Death rates for leading causes of death among
United States, 2000 . . . . . . . . . . . . . . . . . . . . . . 25 persons 1–24 years of age: United States,
1950–99 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
22. Percent of deaths due to leading causes of death
Health Risk Factors among persons 1–24 years of age: United States,
7. Cigarette smoking among men, women, high 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
school students, and mothers during pregnancy: 23. Death rates for leading causes of death among
United States, 1965–2001 . . . . . . . . . . . . . . . . . . 27 persons 25–44 years of age: United States,
8. Overweight and obesity by age: United States, 1950–99 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
1960–99 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 24. Percent of deaths due to leading causes of death
9. High school students not engaging in recommended among persons 25–44 years of age: United States,
amounts of physical activity (neither moderate nor 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
vigorous) by grade and sex: United States, 25. Death rates for leading causes of death among
2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 persons 45–64 years of age: United States,
10. Adults not engaging in leisure-time physical activity by 1950–99 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
age and sex: United States, 2000 . . . . . . . . . . . . 31 26. Percent of deaths due to leading causes of death
among persons 45–64 years of age: United States,
1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Preventive Health Care 27. Death rates due to leading causes of death among
persons 65 years of age and over: United States,
11. Early prenatal care among mothers: United States, 1950–99 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
1970–2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 28. Percent of deaths due to leading causes of death
12. Early prenatal care by detailed race and Hispanic among persons 65 years of age and over:
origin of mother: United States, 2000 . . . . . . . . . 33 United States, 1999 . . . . . . . . . . . . . . . . . . . . . . . 53
13. Influenza and pneumococcal vaccination among
adults 65 years of age and over: United States,
1989–2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
14. Influenza and pneumococcal vaccination among
adults 65 years of age and over by race and
Hispanic origin: United States, 2000 . . . . . . . . . . 35
viii Chartbook on Trends in the Health of Americans Health, United States, 2002
Highlights
Highlights 72.5 per 1,000, after having declined steadily over the past
decade, and the birth rate for unmarried Hispanic women
increased for the second year to 97.3 per 1,000 (table 9).
Health Status and Determinants
Health Behaviors and Risk Factors
Population characteristics
Health behaviors and risk factors have a significant effect on
Important changes in the U.S. population will shape future health outcomes. Cigarette smoking increases the risk of lung
efforts to improve health and health care. Two major changes cancer, heart disease, emphysema, and other respiratory
in the demographic characteristics of the U.S. population are diseases. Overweight and obesity increase the risk of death
the growth of the elderly population and the increasing racial and disease as well as the severity of disease. Regular
and ethnic diversity of the Nation. physical activity reduces mortality, lessens the risk of disease,
and enhances physical functioning. Heavy and chronic use of
From 1950 to 2000 the proportion of the population that is
alcohol and use of illicit drugs increase the risk of disease
elderly rose from 8 to 12 percent. By 2050 it is projected that
and injuries. Environmental exposures also affect health. For
one in five Americans will be 65 years of age or over
example, poor air quality contributes to respiratory illness,
(figure 2).
cardiovascular disease, and cancer.
The racial and ethnic composition of the Nation has
Since 1990 the percent of adults who smoke cigarettes has
changed over time. The Hispanic population and the Asian
declined only slightly. In 2000, 26 percent of men and
and Pacific Islander population have grown more rapidly than
21 percent of women were smokers. Cigarette smoking by
other racial and ethnic groups in recent decades. In 2000
adults is strongly associated with educational attainment.
more than 12 percent of the U.S. population identified
Adults with less than a high school education were almost
themselves as Hispanic and almost 4 percent as Asian or
three times as likely to smoke as those with a bachelor’s
Pacific Islander (figure 3).
degree or more education in 2000 (figure 7 and tables 61
In 2000 the percent of Americans living in poverty dropped to and 62).
11.3 percent overall. However, the poverty rate differs
The percent of high school students who smoke cigarettes
significantly among population subgroups. More than
increased in the early 1990s. Since 1997 the percent of
one-quarter of black and Hispanic children lived in poor
students who smoke has declined. In 2001, 29 percent of
families in 2000 (figure 4 and table 2).
high school students reported smoking during the past month
(figure 7).
Fertility
Cigarette smoking during pregnancy is a risk factor for
Birth rates for teens have continued to decline, while birth poor birth outcomes such as low birthweight and infant death.
rates for women 20–44 years of age increased in 2000. The In 2000 the proportion of mothers who smoked cigarettes
overall fertility rate increased for the third year in 2000 after during pregnancy declined to 12 percent, down from
dropping each year during 1990–97. 20 percent in 1989. Smoking rates for mothers ages 18–19
years decreased in 2000, after increasing each year since
The birth rate for teenagers declined for the ninth
1995. Mothers in this age group remained more likely to
consecutive year in 2000, to 48.5 births per 1,000 women
smoke during pregnancy than mothers at other ages (figure 7
aged 15–19 years, an all-time low for the Nation. Between
and table 11).
1991 and 2000 the teen birth rate declined more for 15–17
year olds than for 18–19 year olds (by 29 percent compared The prevalence of overweight and obesity among adults
with 16 percent) (table 3). has increased substantially since 1976–80. In 1999 an
estimated 61 percent of adults 20–74 years of age were
The birth rate for unmarried women increased 2 percent in
overweight with 27 percent obese, based on preliminary data
2000 to 45.2 births per 1,000 unmarried women ages 15–44
(figure 8).
years, but was still 4 percent below its high in 1994. The birth
rate for unmarried black women increased slightly in 2000 to
Health, United States, 2002 3

Highlights
The prevalence of overweight among children and the incidence of specific diseases, injury-related emergency
adolescents rose from 1976–80 to 1999. In 1999 an department use, and suicide attempts.
estimated 13 percent of children 6–11 years of age and
Limitation of activity due to chronic health conditions occurs
14 percent of adolescents 12–19 years of age were
about twice as often among boys as girls and is significantly
overweight, based on preliminary data (figure 8).
higher among school-age children than preschoolers. Among
Almost 40 percent of adults reported that they did not engage children 5–17 years, 9 percent of boys and 5 percent of girls
in physical activity during leisure time in 2000. The had an activity limitation in 1998–2000 with the majority
percent of adults who were physically inactive increased with classified as having a limitation based on participation in
age, and at most ages women were more likely to be inactive special education (figure 15).
than men (figure 10).
Limitations in handling personal care needs such as bathing
Among current drinkers, 43 percent of men and 19 percent of (activities of daily living or ADLs) and routine needs such
women reported drinking five or more alcoholic drinks in a as shopping (instrumental activities of daily living or
day on at least one day in the past year in 2000. This level IADLs) increase sharply with age among the
of alcohol consumption was most common among young noninstitutionalized population. Among adults 75 years of age
adults 18–24 years of age (table 67). and over, nearly 10 percent reported ADL limitations and
nearly 20 percent reported IADL limitations in 1998–2000
The prevalence of illicit drug use within the past 30 days
(figure 16 and table 58).
among youths 12–17 years of age remained essentially
unchanged between 1999 and 2000 at about 10 percent. The The relative importance of different chronic conditions as
percent of youths reporting illicit drug use increased with age, causes of activity limitation differs by age. Among younger
ranging from 3 percent among those 12–13 years to over adults 18–44 years the most frequently mentioned chronic
16 percent among those 16–17 years in 2000 (table 64). conditions causing limitations were arthritis and other
musculoskeletal conditions and mental illness in 1998–2000.
The number of cocaine-related emergency department
Among adults 45 years of age and older arthritis and other
episodes per 100,000 population for persons 35 years and
musculoskeletal conditions and heart and other circulatory
over increased steadily throughout the 1990s to 68 per
conditions outranked other conditions as causes of activity
100,000 in 2000. Among those 26–34 years, the age group
limitation (figure 17).
with the highest episode rate, the 2000 rate (155 per
100,000) declined for the second year in a row. The same The percent of noninstitutionalized adults reporting fair or
patient may be involved in multiple drug-related episodes poor health increases substantially through middle and old
(table 66). age. In 2000 about 1 in 10 persons 45–54 years of age
reported fair or poor health status compared with 1 in 5
In 2000 about one-half of substance abuse clients in
persons ages 55–64 years, 1 in 4 persons ages 65–74 years,
specialty treatment units were receiving treatment for both
and 1 in 3 persons 75 years of age and older (table 59).
alcoholism and drug abuse (table 86).
Of the more than 40,000 new AIDS cases in 2000, 3 out of
The presence of unacceptable levels of ground-level ozone is
4 were male. New AIDS cases dropped more for men than
the largest source of air pollution. In 2000 approximately
for women in 2000. Among males 13 years of age and over,
42 percent of the U.S. population lived in areas designated as
11 percent fewer new AIDS cases were reported in 2000 than
nonattainment areas for established health-based standards
in 1999 while among females in the same age group,
for ozone (table 52).
4 percent fewer cases were reported (table 54).
Morbidity Syphilis facilitates transmission of HIV disease. The

incidence rate of primary and secondary syphilis in 2000 (2.2
Limitation of activity due to chronic health conditions and cases per 100,000 population) was the lowest since national
self-assessed (or family member-assessed) health status are reporting began in 1941. However, the average annual rate of
two summary measures of morbidity presented in this report. decline in primary and secondary syphilis slowed to 8 percent
Additional measures of morbidity that are presented include between 1998 and 2000, following average reductions of
4 Health, United States, 2002

Highlights
more than 20 percent per year since the last major syphilis over. In 1999–2000 falls was the most often cited reason for
epidemic peaked in 1990 (table 53). injury-related ED visits among persons 45 years of age and
older (tables 83 and 84).
Gonorrhea causes infertility and also facilitates transmission
of HIV disease. In 1998–2000 gonorrhea incidence was Between 1993 and 2001 the percent of high school students
relatively stable at 132 cases per 100,000 population, who reported attempting suicide (8–9 percent) and whose
following an average annual decline of 11 percent between suicide attempts required medical attention (about 3 percent)
1990 and 1997 (table 53). remained fairly constant. Girls were more likely than boys to
consider or attempt suicide and were also more likely to
In 2000 the reported rate for chlamydial infection was 257
make an attempt that required medical attention. However, in
cases per 100,000 persons. Rates of reported chlamydial
1999 adolescent boys (15–19 years of age) were five times
infection have been increasing annually since the late 1980s
as likely to die from suicide as were adolescent girls, in part
when public programs for screening and treatment of women
reflecting their choice of more lethal methods, such as
were first established to avert pelvic inflammatory disease and
firearms (tables 47 and 60).
related complications (table 53).
Incidence rates for all cancers combined declined in the Mortality Trends
1990s for males but not for females. Between 1990 and 1998
age-adjusted cancer incidence rates declined on average Life expectancy and infant mortality are measures often used
more than 2 percent per year for non-Hispanic white males to gauge the overall health of a population. Over the past 50
and Hispanic males and almost 2 percent for black males. years overall mortality has declined substantially among
Although there was no significant change in cancer incidence Americans of all ages.
for females overall, among Hispanic females rates decreased
In 2000 life expectancy at birth for the total population
on average 1 percent per year, and among Asian or Pacific
reached a record high of 76.9 years, based on preliminary
Islander females rates increased almost 1 percent per year
data. In 1999 life expectancy was 76.7 years (table 28).
(table 56).
During the 20th century life expectancy at birth increased
The most frequently diagnosed cancer sites in males are
from 48 to 74 years for males and from 51 to 79 years for
prostate, followed by lung and bronchus and colon and
females. Life expectancy at age 65 rose from 12 to 16 years
rectum. Cancer incidence at these sites is higher for black
for men and from 12 to 19 years for women (figure 18).
males than for males of other racial and ethnic groups. In
1998 age-adjusted cancer incidence rates for black males In 2000 the infant mortality rate declined to a record low of
exceeded those for white males by 64 percent for prostate, 6.9 infant deaths per 1,000 live births, based on preliminary
43 percent for lung and bronchus, and 11 percent for colon data. In 1999 the infant mortality rate was 7.1 per 1,000
and rectum (table 56). (table 23).
Breast cancer is the most frequently diagnosed cancer Between 1950 and 1999 the infant mortality rate declined
among females. Breast cancer incidence is higher for by about 75 percent. Substantial declines occurred in mortality
non-Hispanic white females than for females in other racial during the first month of life (neonatal) as well as after the
and ethnic groups. In 1998 age-adjusted breast cancer first month of life (postneonatal) (figure 19 and table 23).
incidence rates for non-Hispanic white females exceeded
Since 1950 mortality among children and young adults
those for black females by 27 percent, for Asian or Pacific
(ages 1–24 years) has declined by more than one-half.
Islander females by 46 percent, and for Hispanic females by
Overall mortality at ages 1–24 years has declined, in part,
78 percent (table 56).
due to decreases in death rates for unintentional injuries,
Injuries accounted for 37 percent of all visits to emergency cancer, heart disease, and infectious diseases. Homicide and
departments (ED) in 1999–2000. The proportion of ED visits suicide rates generally increased over this period, but have
that were injury-related declined with age from 41 percent for declined since the mid-1990s (figures 21 and 22).
children and adults under 45 years of age to 33 percent for
Between 1950 and 1999 mortality among adults 25–44
persons 45–64 years and 26 percent for those 65 years and
years declined by more than 40 percent overall. Death rates

Highlights
for unintentional injuries, cancer, heart disease, and years in 1990 to 5.5 years in 1999 and 5.4 years in 2000
tuberculosis decreased substantially during this period. (preliminary data) (table 28).
Suicide rates rose through 1980 and have since declined

During the 1990s mortality from lung cancer declined for
slightly. HIV disease was the leading cause of death in this

men and increased for women. Although these trends
age group in the mid-1990s; with decreasing HIV disease

reduced the sex differential for this cause of death, the
death rates, it dropped to the fifth leading cause of death in

age-adjusted death rate for lung cancer was still 89 percent
1999 (figures 23 and 24).

higher for men than for women in 1999 and 84 percent higher
Since 1950 mortality among adults 45–64 years has in 2000 (preliminary data) (table 40).
decreased by nearly 50 percent overall. During this period

During the 1990s mortality from chronic lower respiratory
death rates for heart disease, stroke, and unintentional injury
diseases remained relatively stable for men while it
decreased while cancer mortality rose slowly through the

increased for women. These trends reduced the gap between
1980s and then declined. Cancer is the leading cause of

the sexes for this cause of death. In 1990 the age-adjusted
death for 45–64 year olds, accounting for more than one-third
death rate for males was more than 100 percent higher than
of deaths in this age group in 1999 (figures 25 and 26).

for females. In 1999 the difference between the rates had
During the past 50 years mortality among elderly persons been reduced to 52 percent, and in 2000, to 45 percent
65 years of age and over has dropped by about one-third. (preliminary data) (table 42).
During this period death rates for heart disease and stroke
Between 1990 and 2000 life expectancy at birth increased
have declined sharply while the death rate for cancer rose
more for the black than for the white population, thereby
until 1995 and has since decreased slightly (figure 27).

narrowing the gap in life expectancy between these two racial
groups. In 1990 life expectancy at birth was 7 years longer
Disparities in Mortality for the white than for the black population. By 1999 the
difference had narrowed to 5.9 years and by 2000, to 5.6
Despite overall declines in mortality, racial and ethnic

years (preliminary data) (table 28).
disparities as well as gender disparities in mortality persist.

The gap in life expectancy between the sexes and between Overall mortality was one-third higher for black Americans
the black and white populations has been narrowing. than for white Americans in 1999, compared with 37 percent
higher in 1990. In 1999 age-adjusted death rates for the
Infant mortality rates have declined for all racial and ethnic
black population exceeded those for the white population by
groups, but large disparities remain. In 1997–99 the infant

38 percent for stroke, 28 percent for heart disease,
mortality rate was highest for infants of non-Hispanic black

27 percent for cancer, and more than 700 percent for HIV
mothers (13.9 deaths per 1,000 live births) and lowest for
disease (table 30).
infants of Chinese mothers (3.3 per 1,000 live births)

(figure 20 and table 20). The 5-year survival rate for black females diagnosed in
1989–97 with breast cancer was 15 percentage points lower
Infant mortality increases as mother’s level of education

than for white females. In 1999 breast cancer mortality was
decreases. In 1999 the mortality rate for infants of mothers

35 percent higher for black females than for white females,
with less than 12 years of education was 57 percent higher

compared with 15 percent higher in 1990 (tables 41 and 57).
than for infants of mothers with 13 or more years of

education. This disparity was more marked among Homicide rates among young black males 15–24 years of
non-Hispanic white infants, for whom mortality among infants age and among young Hispanic males were nearly
of mothers with less than a high school education was more 50 percent lower in 1999 than in the early 1990s when
than twice that for infants of mothers with more than a high homicide rates peaked for these groups. In spite of these
school education (table 21). downward trends, homicide was still the leading cause of
death for young black males and the second leading cause
Life expectancy at birth increased more for males than for

for young Hispanic males in 1999, and homicide rates for
females between 1990 and 2000, reducing the difference in

young black and Hispanic males remained substantially higher
life expectancy between the sexes. The difference in life

than for young non-Hispanic white males (table 46).
expectancy between males and females narrowed from 7

Highlights
Since 1995 death rates for HIV disease declined sharply for 1980. Pneumoconiosis deaths are largely associated with
black males and Hispanic males 25–44 years of age. In occupational exposures and can be prevented through
spite of these declines, HIV disease was still the leading effective control of worker exposure to occupational dusts
cause of death for black males 25–44 years of age and the (table 49).
third leading cause for Hispanic males 25–44 years of age in
1999, and HIV death rates remained much higher for black
and Hispanic males than for non-Hispanic white males in this
Health Care Utilization and Resources
age group (table 43).
Preventive Health Care
In 1999 the death rate for motor vehicle-related injuries for
young American Indian males 15–24 years of age was Use of preventive health services helps reduce morbidity and
almost twice the rate for young white males, and the suicide mortality from disease. Use of several different types of
rate for young American Indian males was double the rate for preventive services has been increasing. However, disparities
young white males. Death rates for the American Indian in use of preventive health care by race and ethnicity and by
population are known to be underestimated (tables 45 and family income remain.
47).
Between 1990 and 2000 the percent of mothers receiving
Between 1990 and 1999 death rates for stroke declined for prenatal care in the first trimester of pregnancy increased
white males 45–54 and 55–64 years of age but not for Asian from 76 to 83 percent. Although increases occurred for all
American males in these age groups. In 1999 death rates racial and ethnic groups, in 2000 the percent of mothers with
for stroke were 31–40 percent higher for middle-aged Asian early prenatal care still varied substantially, from 69 percent
American males than for middle-aged white males. Death for American Indian mothers to 91–92 percent for Japanese
rates for the Asian American population are also known to be and Cuban mothers (figures 11 and 12 and table 6).
underestimated (table 38).
In 2000, 76 percent of children 19–35 months of age received
the combined vaccination series of 4 doses of DTP
Occupational Health (diphtheria-tetanus-pertussis/acellular pertussis) vaccine, 3
Improvements in workplace safety constitute a major public doses of polio vaccine, 1 dose of measles-containing vaccine,
health achievement in the 20th century. Despite important and 3 doses of Hib (Haemophilus influenzae type b) vaccine.
accomplishments, preventable injuries and deaths continue to Children living below the poverty threshold were less likely to
occur. have received the combined vaccination series than were
children living at or above poverty (71 percent compared with
In 1999–2000 the occupational injuries with lost workdays 78 percent) (table 73).
rate, 2.8 per 100 full-time equivalents (FTEs) in the private
sector, was at its lowest level in 2 decades. The industries Annual influenza vaccination can prevent complications of
reporting the highest injury rates in 2000 were transportation, influenza illness and one dose of pneumococcal vaccine
communication, and public utilities (4.1 per 100 FTEs), and can reduce the risk of invasive pneumococcal disease.
construction and manufacturing (both reporting 4.0) (table 51). Between 1989 and 2000 the percent of elderly adults
reporting influenza vaccination within the past year doubled to
Between 1992 and 2000 the occupational injury death rate 65 percent and the percent ever receiving a pneumococcal
decreased 17 percent to 4.3 deaths per 100,000 employed vaccine increased from 14 to 53 percent (figure 13).
workers. Mining, the industry with the highest death rate in
2000 (30 per 100,000), accounted for less than 3 percent of Between 1987 and 2000 the percent of women 40 years of
all occupational injury deaths. Construction, with a death rate age and over who reported a mammogram within the past 2
of 13 per 100,000, accounted for 20 percent of all years more than doubled from 29 to 70 percent. Women with
occupational injury deaths in 2000 (table 50). less than a high school education are much less likely than
those with some college education to report a recent
A total of 2,739 pneumoconiosis deaths, for which mammogram (58 percent compared with 76 percent in 2000)
pneumoconiosis was the underlying or nonunderlying cause of (table 82).
death, occurred in 1999, compared with 4,151 deaths in

Highlights
Uninsurance and Access to Health Care 1999–2000 (47 percent compared with 11 percent). Men in
this age group were twice as likely as women to be without a
Access to health care is important for preventive care and for usual source of health care (24 percent compared with
prompt treatment of illness and injuries. Indicators of access 12 percent) (percents are age adjusted) (table 78).
to health care services include having a usual source of
Emergency department (ED) use among nonelderly adults
health care, having a recent health care contact, and use of
18–64 years of age is greater among those covered by
the emergency department. Health insurance coverage is a
Medicaid than among the privately insured or uninsured.
major determinant of access to health care.
Forty-two percent of nonelderly adults with Medicaid reported
The percent of the nonelderly population with no health at least one ED visit in 2000 compared with 18 percent of the
insurance coverage (either public or private) fluctuated around privately insured and 20 percent of the uninsured (percents
16–17 percent between 1994 and 2000. Among the nonelderly are age adjusted) (table 79).
population, poor and near poor persons are much more likely
Use of dental care is greater among persons with higher
than others to be uninsured (figures 5 and 6 and table 129).
family incomes. In 2000 almost three-quarters of persons with
The likelihood of being uninsured varies substantially among higher family income (at least twice the poverty level) had a
the States. In 2000 the percent of the nonelderly population dental visit in the past year compared with about one-half of
with no health care coverage varied from less than 10 percent persons with family income less than twice the poverty level
in New Hampshire, Rhode Island, Pennsylvania, and (percents are age adjusted) (table 80).
Wisconsin to more than 20 percent in Florida, Louisiana,
Oklahoma, Texas, New Mexico, Montana, and Alaska Outpatient Care
(table 147).
Twelve percent of children under 18 years of age had no Major changes continue to occur in the delivery of health care
health insurance coverage in 2000. Children with low family in the United States, driven in large part by the need to rein
income were more likely than higher income children to lack in rising costs. Use of inpatient services has decreased while
coverage (26 percent among those with family income 1–1.5 use of outpatient services, such as outpatient surgery, home
times the poverty level compared with 6 percent among those health care, and hospice care, has increased.
with income at least twice the poverty level) (table 129). In 2000, 63 percent of all surgical operations in community
Seven percent of children under 18 years of age had no hospitals were performed on outpatients, up from 51 percent
usual source of health care in 1999–2000. Uninsured in 1990 and 16 percent in 1980 (table 96).
children were substantially more likely to be without a usual Between 1996 and 2000 use of home health care by
source of care than insured children (29 percent compared persons 65 years of age and over declined from 547 to 276
with 4 percent) (table 76). per 10,000 population, after increasing steadily between 1992
Thirteen percent of children under 18 years of age had no and 1996. The recent decline was a result of the Balanced
health care visit to a doctor or clinic within the past 12 Budget Act of 1997, which imposed stricter limits on the use
months in 1999–2000. Uninsured children were nearly three of home health services funded by Medicare and interim
times as likely to be without a recent visit as insured children limits on Medicare payments to home health agencies from
(30 percent compared with 11 percent) (table 75). October 1997 until a prospective payment system was
implemented for Medicare home health agencies in October
One in 5 children under 18 years of age had an emergency 2000 (data are age adjusted) (table 88).
department (ED) visit within the past 12 months in 2000.
Children with Medicaid coverage were more likely than those Use of hospice care by persons 65 years of age and over
with private coverage to have had an ED visit within the past increased by 83 percent to 25 patients per 10,000 population
12 months (29 percent compared with 18 percent) (table 77). during the period 1994–2000. Among the elderly use of
hospice services was slightly higher for males than for
Among adults 18–64 years of age, the uninsured were more females (27 compared with 23 patients per 10,000 in 2000).
than 4 times as likely as those with health insurance Cancer was the most common diagnosis among hospice
coverage to have no usual source of health care in patients (data are age adjusted) (table 89).

Highlights
Inpatient Care and Resources 7 percent. The United States continues to spend more on
health than any other industrialized country.
Use of hospital inpatient services has declined, as has the
In 2000 national health care expenditures in the United
number of beds in community hospitals. Nursing home use
States totaled $1.3 trillion, increasing 6.9 percent from the
has also declined.
previous year compared with a 5.7 percent increase in 1999.
Between 1985 and 2000 the hospital discharge rate In the mid-1990s annual growth had slowed somewhat,
declined 24 percent, from 151 to 115 discharges per 1,000 following an average annual growth rate of 11 percent during
population, while average length of stay declined 1.7 days, the 1980s (table 113).
from 6.6 to 4.9 days (data are age adjusted) (table 91).
The rate of increase in the medical care component of the
Use of hospital inpatient care is greater among the poor Consumer Price Index (CPI) rose to 4.6 percent in 2001
than among those with higher family income (at least twice from 3.4 percent per year during 1995–2000. During the last
the poverty level). In 2000 among nonelderly persons, the two years, the CPI for hospital services showed the greatest
hospital discharge rate for the poor was more than twice the price increases (6.6 percent in 2001 and 6.0 percent in 2000)
rate for those with higher family income (172 and 82 per compared with other components of medical care (table 114).
1,000 population). Average length of stay was 1.3 days longer
In 2000 health expenditures as a percent of the gross
for poor than for higher income persons (4.7 and 3.4 days)
domestic product (GDP) increased to 13.2 percent, up from
(data are age adjusted) (table 90).
13.1 percent the previous three years (table 113).
Between 1990 and 2000 the number of community hospital
The United States spends a larger share of the GDP on
beds declined from about 927,000 to about 824,000.
health than any other major industrialized country. In 1998
Community hospital occupancy, estimated at 64 percent in
the United States devoted 13.1 percent of the GDP to health
2000, has been relatively stable since the mid-1990s, after
compared with 10.3–10.4 percent each in Switzerland and
declining from 67 percent in 1990 and 76 percent in 1980
Germany and 9.3–9.4 percent in Canada, France, and
(table 107).
Norway, countries with the next highest shares (table 112).
In 1999 there were almost 1.5 million elderly nursing home
residents 65 years of age and over. More than one-half of Expenditures by Type of Care and Source
the elderly residents were 85 years of age and over and
of Funds
almost three-fourths were female. Between the mid-1970s and
1999, nursing home utilization rates increased for the black During the last few years expenditures for prescription drugs
population and decreased for the white population (table 97). have grown at a faster rate than any other type of health
In 2000 there were 1.8 million nursing home beds in expenditure. The sources of funds for medical care differ
facilities certified for use by Medicare and Medicaid substantially according to the type of medical care being
beneficiaries. Between 1995 and 2000 nursing home bed provided.
occupancy in those facilities was relatively stable, estimated Expenditures for hospital care accounted for 32 percent of
at 82 percent in 2000 (table 111). all national health expenditures in 2000. Physician services
accounted for 22 percent of the total in 2000, prescription
Health Care Expenditures drugs for 9 percent, and nursing home care for 7 percent
(table 116).
National Health Expenditures From 1995–2000 the average annual rate of increase for
prescription drug expenditures (15 percent) was higher
After 25 years of double-digit annual growth in national health than for any other type of health expenditure. During the first
expenditures, the rate of growth slowed during the 1990s. At half of the decade expenditures for home health care
the end of the decade the rate of growth started edging up increased more rapidly (19 percent per year) than other types
again. In 2000 health expenditures increased by almost of expenditures (table 116).

Highlights
In 2000 prescription drug expenditures increased Publicly Funded Health Programs

17 percent and prescription drugs posted a 4.4 percent rate of
price increase in the Consumer Price Index. In 2001 the price The two major publicly funded health programs are Medicare
of prescription drugs increased 5.4 percent (tables 114 and and Medicaid. Medicare is funded by the Federal Government
116). and reimburses elderly and disabled persons for their health
care. Medicaid is funded jointly by the Federal and State
In 2000, 46 percent of prescription drug expenditures were
Governments to provide health care for the poor. Medicaid
paid by private health insurance (up from one-quarter at the
benefits and eligibility vary by State.
beginning of the decade), 32 percent by out-of-pocket
payments (down from 59 percent in 1990), and 17 percent by In 2000 the Medicare program had 40 million enrollees and
Medicaid. Although Medicare is the Federal program that expenditures of $222 billion (table 134).
funds health care for the elderly, and the elderly are the In 2000 hospital insurance (HI) accounted for 59 percent of
highest per capita consumers of prescription drugs, only Medicare expenditures. Expenditures for home health agency
2 percent of prescription drug expenses were paid by care decreased to 3 percent of HI expenditures in 2000, down
Medicare in 2000 (table 117). from 14 percent in 1995 (table 134).
In 1998, 88 percent of elderly persons in the civilian In 2000 supplementary medical insurance (SMI) accounted
noninstitutionalized population had a prescribed medicine for 41 percent of Medicare expenditures. One-fifth of SMI
expense. The average annual out-of-pocket prescribed expenditures in 2000 were payments to managed care
medicine expense per elderly person with expense was $531 organizations and the remainder were payments for
(table 118). fee-for-service utilization (table 134).
In 1998, 95 percent of elderly persons in the civilian Of the 29 million Medicare enrollees in the fee-for-service
noninstitutionalized population reported medical expenses program in 1999, 13 percent were 85 years of age and over
averaging $6,300 per person with expense. Fifteen percent of and 13 percent were under 65 years of age. Among elderly
expenses were paid out-of-pocket, 14 percent by private fee-for-service Medicare enrollees, payments increased with
insurance, and 68 percent by public programs (mainly age from an average of $4,000 per year per enrollee for
Medicare and Medicaid) (table 118). those aged 65–74 years to $7,400 for those 85 years and
In 2000, 33 percent of personal health care expenditures over. Average payments per fee-for-service enrollee declined
were paid by the Federal Government and 11 percent by in 1998 and 1999 (table 135).
State and local government; private health insurance paid In 1998, 82 percent of Medicare beneficiaries were
35 percent and consumers paid 17 percent out-of-pocket non-Hispanic white, 9 percent were non-Hispanic black, and
(table 117). 7 percent were Hispanic. Some 21–24 percent of Hispanic
In 2000 the major sources of funds for hospital care were and non-Hispanic black beneficiaries were persons under 65
Medicare (31 percent) and private health insurance entitled to Medicare through disability compared with
(33 percent). Physician services were also primarily funded by 11 percent of non-Hispanic white beneficiaries (table 136).
private health insurance (48 percent) and Medicare In 1999 Medicare payments per enrollee varied by State,
(21 percent). In contrast, nursing home care was financed ranging from less than $4,000 in Hawaii, Montana, Utah,
primarily by Medicaid (48 percent) and out-of-pocket payments North Dakota, South Dakota, Idaho, and Iowa to more than
(27 percent) (table 117). $6,200 in New York, New Jersey, Maryland, the District of
In 1999 the average monthly charge per nursing home Columbia, and Louisiana (table 144).
resident was $3,891. Residents for whom the source of In 1998 Medicaid vendor payments totaled $142 billion for 41
payment was private insurance, family support, or their own million recipients (table 137).
income paid close to the average charge, compared with an
average monthly charge of $5,800 when Medicare was the In 1998 children under the age of 21 years accounted for
payor and $3,500 when Medicaid was the source of payment 47 percent of Medicaid recipients but only 16 percent of
(table 123). expenditures. Aged, blind, and disabled persons accounted for

Highlights
26 percent of recipients and 71 percent of expenditures decreased by 16 percent, to 541 plans during these 2 years
(table 137). (table 132).
In 1998, 22 percent of Medicaid payments went to nursing In 2001 the percent of the population enrolled in HMOs
facilities, 15 percent to inpatient general hospitals, 14 percent varied among the States, from 0 in Alaska to 44 percent in
to prepaid health care, and 10 percent to prescribed drugs Massachusetts and 53 percent in California. Other States with
(table 138). 38 percent or more of the population enrolled in HMOs in
2001 included New Hampshire, Connecticut, and Maryland
In 1999 spending on health care by the Department of

(table 146).
Veterans Affairs was $17.9 billion. Fifty-four percent of

inpatients and 40 percent of outpatients were low-income In 2000, 38 percent of children had health insurance coverage
veterans without a service-connected disability (table 139). through a private, Medicaid, or Medicare HMO compared
with about one-third of adults 18–64 years of age and
Private Health Insurance one-quarter of the elderly. Nine percent of children
(12 percent of those under 6 years of age) were in a
More than 70 percent of the population under 65 years of age Medicaid HMO compared with less than 3 percent of
has private health insurance, most of which is obtained nonelderly adults. Fifteen percent of the elderly were in a
through the workplace. The share of employees’ total Medicare HMO and 13 percent in a private HMO (table 131).
compensation devoted to health insurance had been declining The proportion of the elderly population enrolled in Medicare
in recent years, but increased in 2000 and again in 2001 due HMOs in 2000 ranged from 8 percent in the Midwest to
to increases in health insurance premiums. 31 percent in the West (table 131).
Between 1995 and 2000 the age-adjusted proportion of the

population under 65 years of age with private health State Health Expenditures
insurance fluctuated between 71 and 73 percent after
declining from 77 percent in 1984. More than 90 percent of Total personal health care per capita expenditures and its
private coverage was obtained through the workplace (a components vary substantially among the States.
current or former employer or union) in 2000 (figure 5 and
Personal health care per capita expenditures averaged
table 127).
$3,800 in 1998, but varied among the States from $2,700 in
In 2001 private employers’ health insurance costs per Utah to $4,800 in Massachusetts. Higher expenditures were
employee-hour worked increased to $1.28 up from $1.09 in clustered in the New England and Mideastern States with
2000. Among private employers the share of total lower per capita expenditures in the Rocky Mountain,
compensation devoted to health insurance was 6.2 percent in Southwestern, and Far West States (table 140).
2001, up from 5.5 percent in 2000 (table 120).
The components of personal health care expenditures also
vary significantly by State. Hospital care per capita
Health Maintenance Organizations (HMOs) expenditures in 1998 ranged from $1,030 in Utah to $1,800 in
New York. Physician and other professional services per
An HMO is a prepaid health plan delivering comprehensive
capita expenditures varied from $760 in Utah to $1,350 in
care to members through designated providers. Almost
Minnesota. Per capita expenditures for nursing home care
30 percent of all persons in the United States are enrolled in
ranged from $90 in Alaska to $860 in Connecticut (table 140).
HMOs.
Twenty-one percent of all personal health care expenditures
Enrollment in HMOs totaled 80 million persons or 28 percent
were paid by Medicare in 1998, up from 17 percent in 1991.
of the U.S. population in 2001. HMO enrollment varied from
The Medicare share of State health expenditures in 1998
21–22 percent in the Midwest and South to 35 percent in the
varied from 8 percent in Alaska to 25–27 percent in
Northeast and 41 percent in the West. HMO enrollment
Mississippi, Louisiana, and Pennsylvania and 28 percent in
increased steadily through 1999 but declined by nearly 2
Florida (table 141).
million between 1999 and 2001. The number of HMO plans

Introduction
Chartbook on Trends in the Health People 2010 (2,3). Connections to the Leading Health
Indicators are specified in the notes to the appropriate
of Americans figures. Further information on the Leading Health Indicators
is presented in Health, United States, 2002, table 52 and in
As the Nation considers health policies and programs for the Appendix II, Leading Health Indicators.
21st century, it is important to examine recent trends in health
and health care. Fashioning effective policies and programs
depends on knowledge of past achievements and Organization of the Chartbook
understanding of current health problems. During the 20th
century, the health of Americans improved significantly. Figures in the chartbook have been grouped into six sections
Achievements of the past century include sizeable increases covering selected health determinants and outcomes. The first
in life expectancy, reflecting sharp decreases in infant section (figures 1–4) presents major demographic, economic,
mortality and important declines in death rates at other ages. and social factors influencing health: growth and aging of the
Effective public health efforts, improved health care, and national population, changing patterns of racial and ethnic
economic prosperity have all contributed to declines in diversity, and low income. The second section (figures 5–6)
mortality (1). Policies and programs that have controlled describes trends over time in health insurance coverage and
infectious disease, improved safety in workplaces and homes, characteristics of the uninsured. The third section
educated Americans about healthier lifestyles, and increased (figures 7–10) focuses on specific risk factors associated with
access to health care are only a few of the ways public increased risk of disease and death: cigarette smoking,
health efforts have enhanced health. Ensuring healthier and overweight and obesity, and lack of physical activity. The
safer lives in the 21st century will require continuing efforts to fourth section (figures 11–14) presents trends in use of two
monitor health outcomes and the myriad of factors affecting types of preventive health care: prenatal care beginning
health and health care. during the first trimester of pregnancy and vaccination for
influenza and pneumococcal disease among the elderly. The
The Chartbook on Trends in the Health of Americans fifth section (figures 15–17) shows the percent of children and
assesses the current state of the Nation’s health by adults who have limitation of activity caused by chronic health
describing trends in selected determinants and measures of conditions, and the prevalence of specific chronic health
health status. It also examines differences in health outcomes conditions causing activity limitation. Finally, the sixth section
and risk factors for major groups within the national (figures 18–28) describes trends over time in mortality by
population. Selection of the measures used in the chartbook showing changes in life expectancy at birth and at 65 years
was difficult because no single, limited set of measures can of age since 1901, changes in infant mortality since 1950,
fully summarize the health of a large and diverse population. and age- and cause-specific death rates for children and
Any set of health measures involves some arbitrary choices adults since 1950.
and a good case could be made for including a number of
other measures of health. In selecting measures for the Many measures are shown separately for persons of different
chartbook, several factors were considered: whether the ages because of the strong effect age has on most health
measure was commonly used by health researchers and outcomes. Selected figures in the chartbook also highlight
policy makers, whether the measure was understood by a current differences in health and health determinants by
wide range of users, and whether information was available variables such as sex, race, and Hispanic origin. Some
over time. As a group, the measures featured in the estimates are age adjusted using the age distribution of the
chartbook were selected to cover major topics of public health 2000 standard population. Time trends for some measures
concern. In addition to sociodemographic information that are shown on a logarithmic scale to emphasize the rate of
provides the context within which to interpret health change and to enable measures with large differences in
measures, the topics covered include: health insurance magnitude to be shown on the same chart (figures 1, 19, 21,
coverage, health-related risk factors, use of preventive care, 23, 25, and 27). Other trends are shown on a linear scale to
limitation of activity caused by chronic health conditions, and emphasize absolute differences over time (figures 3, 5, 7, 8,
mortality. Several figures in the chartbook are related to the 11, 13, and 18). Time trends for some measures are not
topics covered by the Leading Health Indicators in Healthy presented because of the relatively short amount of time that
Chartbook on Trends in the Health of Americans Health, United States, 2002 15

Introduction
comparable national estimates are available (physical activity, part, because of decreases in death rates for unintentional
figures 9 and 10; and limitation of activity caused by chronic injuries, cancer, and heart disease. Declines in deaths due to
health conditions, figures 15–17). infectious diseases, which did not rank among the leading
causes of death in 1999, also contributed to the decrease in
Following the figures in the chartbook is a section containing
child mortality. Among younger (25–44 years) and older
data tables for each figure that show the data points graphed.
(45–64 years) working-age adults, decreases in death rates
For some measures, standard errors for the data points are
for unintentional injuries, heart disease, and stroke (for those
provided and data not shown in the figures may be included.
45–64 years) have lowered the overall risk of death. Finally,
Additional information about the health measures is included
among the elderly, marked decreases in death rates for heart
in the notes to each data table as well as in Appendix II.
disease and stroke have increased the average number of
Finally, the 147 trend tables in the body of Health, United
years Americans can expect to live after age 65.
States, 2002 supplement the broad picture of the Nation’s
health presented in the chartbook by providing detailed data Recent declines in death rates for many leading causes of
for many groups within the United States. Additional death reflect the influence of healthier life styles, greater use
measures of health status and determinants as well as of preventive care, public health efforts, and advances in
information on health care use, health care resources, and medicine. Decreased cigarette smoking among adults is a
health care expenditures are presented in these trend tables. prime example of a risk factor for disease and death that has
contributed to recent declines in mortality. Improvements in
medical care and increased use of preventive health care
Chartbook Data Sources have contributed to increases in life expectancy at all ages.
The increasing percent of mothers who report beginning
Health-related and demographic data presented in this
prenatal care during the first trimester of pregnancy and the
chartbook are from several national data systems. These are
increasing percent of elderly persons who have been
listed below and described in Appendix I.
vaccinated against influenza and pneumococcal disease
Population counts and projections are from the U.S. Census illustrate the role for preventive health care throughout the life
Bureau. Poverty rates are based on data from the Current span. Public health and private efforts to improve motor
Population Survey. The National Health Interview Survey vehicle transportation safety, as well as safety in homes and
supplied data on health insurance coverage, adult cigarette workplaces, have contributed to lower death rates due to
smoking, adult physical inactivity, adult vaccination, and unintentional injuries for children and adults. Finally, the
activity limitation due to chronic health conditions. The Youth decline in the death rate for HIV disease in the 1990s
Risk Behavior Survey provided data on smoking and physical demonstrates how new medical treatments can dramatically
activity among high school students. The National Health and decrease the number of deaths caused by a particular
Nutrition Examination Survey was the source of data on disease.
overweight and obesity. Data from the National Vital Statistics
For some important determinants of health, recent trends
System were used to estimate life expectancy, death rates,
have not been favorable. Increases in overweight and obesity,
and use of early prenatal care. The National Linked File of
and high levels of physical inactivity among adults are
Live Births and Infant Deaths provided data for estimates of
significant risk factors for chronic disease that have not
infant mortality according to the race and Hispanic origin of
shown improvement. The rising prevalence of overweight in
the mother.
children and adolescents, and the high percent of adolescents
not engaging in recommended amounts of physical activity
Conclusions raise additional concerns for future health outcomes.
During the 20th century, the health of Americans significantly Another measure of the health of Americans is the percent of
improved. Trends in the age-specific death rates for the children and adults limited in their everyday activities because
leading causes of death in 1999 indicate that the rates for of chronic health conditions. Among community-dwelling
many causes have declined since 1950. Among children and children and adults, the percent reporting activity limitation
young adults (1–24 years of age), mortality has declined, in caused by a chronic health condition increases markedly with
age. Less than 10 percent of children have an activity
16 Chartbook on Trends in the Health of Americans Health, United States, 2002

Introduction
limitation. In contrast, nearly one-half of adults 75 years of References
age and over report an activity limitation. The chronic health
1. Fielding JE. Public health in the twentieth century: Advances
conditions that cause limitation of activity among younger and and challenges. Annu Rev Public Health (20):xiii–xxx. 1999.
older adults differ. Among adults 45 years of age and over,
2. U.S. Department of Health and Human Services. Healthy
arthritis and other musculoskeletal conditions, and heart People 2010. 2nd ed. With understanding and improving health
disease (including other circulatory conditions) are most often and objectives for improving health. 2 vols. Washington, DC:
mentioned as causes of activity limitation. Among younger U.S. Government Printing Office. November 2000.
adults (18–44 years of age) the two most frequently 3. U.S. Department of Health and Human Services. Leading
mentioned causes of activity limitation include arthritis and Health Indicators: 2002 annual report for the Nation.
other musculoskeletal conditions, and mental illness. Forthcoming.
4. Keppel KG, Pearcy JN, Wagener DK. Trends in racial and
Efforts to improve health in the 21st century will be shaped ethnic-specific rates for the health status indicators: United
by important changes in the U.S. population. The fraction of States, 1990–98. Healthy people statistical notes, no. 23.
the population 65 years of age and over is increasing. With Hyattsville, Maryland: National Center for Health Statistics.
this increase, there will be more elderly Americans living January 2002.
longer with chronic health conditions. As Americans meet this
challenge, it will be in the context of a Nation that is growing
more racially and ethnically diverse. Socioeconomic and
cultural differences among racial and ethnic groups in the
United States will likely continue to influence patterns of
disease, disability, and health care use in the future. Finally,
persons living in poverty and near-poverty remain a segment
of the national population at higher risk for worse health
outcomes and in need of greater access to health care.
Despite impressive gains in health for the Nation as a whole,
large differences in health and health care use among racial
and ethnic groups remain (4). This chartbook illustrates
important racial and ethnic differences in use of early prenatal
care and infant mortality rates, for example, as well as
differences in vaccination rates among the elderly and health
insurance coverage among the nonelderly. Many of the 147
trend tables that follow the chartbook section provide
information on racial, ethnic, and socioeconomic disparities in
other measures of health and health care. Future progress in
improving the health of the Nation will require sustained
efforts to eliminate these disparities, such as the Health and
Human Services Initiative to Eliminate Racial and Ethnic
Disparities in Health. Continued collection and dissemination
of reliable and accurate information about health and health
care will be critical for monitoring these disparities and
charting future trends in the health of Americans.

Population
Age The aging of the population has important consequences for
the health care system (1). As the elderly fraction of the
From 1950 to 2000 the total resident population of the United population increases, more services will be required for the
States increased from 150 million to 281 million representing treatment and management of chronic and acute health
an average annual growth rate of 1 percent (figure 1). During conditions. Providing health care services needed by
the same time period, the elderly population (65 years of age Americans of all ages will be a major challenge in the 21st
and over) grew twice as rapidly. Projections indicate that the century.
total population will increase more slowly over the next 50
years and the elderly population will increase more rapidly. Reference
During the past 50 years, the U.S. population has grown 1. Wolf DA. Population change: Friend or foe of the chronic care
older (figure 2). From 1950 to 2000 the percent under 18 system? Health Aff 20(6):28–42. 2001.
years of age fell from 31 percent to 26 percent while the
percent elderly rose from 8 percent to 12 percent. From 2000
to 2050 a small decline in the percent of the population under
18 years of age is anticipated while a sizeable increase in the
percent elderly is expected. As the ‘‘baby boom’’ generation
turns 65, beginning in 2011, the size of the elderly population
will grow substantially. By 2050 it is projected that one in five
Americans will be elderly.

Population
Race and Ethnicity

Changes in the racial and ethnic composition of the
population have important consequences for the Nation’s
health since many measures of disease and disability differ
significantly by race and ethnicity (Health, United States,
2002, trend tables). One of the overarching goals of U.S.
public health policy is elimination of racial and ethnic
disparities in health.
Diversity has long been a characteristic of the U.S.
population, but the racial and ethnic composition of the Nation
has changed over time. In recent decades the percent of the
population of Hispanic origin and Asian or Pacific Islander
race has risen (figure 3). In 2000 over a quarter of adults and
more than a third of children identified themselves as
Hispanic, as black, as Asian or Pacific Islander, or as
American Indian or Alaska Native.
In the 1980 and 1990 decennial censuses, Americans could
choose only one racial category to describe their race (1). In
2000 the question on race was modified to allow the choice
of more than one racial category. Although overall a small
percent of persons of non-Hispanic origin selected two or
more races in 2000, a higher percent of children than adults
were described as being of more than one race. The number
of American adults identifying themselves or their children as
multiracial is expected to increase in the future (2).
In 2000 the percent of persons reporting two or more races
also varied considerably among racial groups. For example,
the percent of all persons reporting a specified race who
mentioned that race in combination with one or more other
racial groups was 3 percent for white persons and 40 percent
for American Indians and Alaska Natives (3).
References
1. Grieco EM, Cassidy RC. Overview of race and Hispanic origin.
Census 2000 Brief. United States Census 2000. March 2001.
2. Waters MC. Immigration, intermarriage, and the challenges of
measuring racial/ethnic identities. Am J Public Health
90(11):1735–7. 2000.
3. Jones NA, Smith AS. The two or more races population: 2000.
Census 2000 Brief. United States Census 2000. November
2001.

Population
Low Income
Children and adults in families with incomes below or near
the Federal poverty level have worse outcomes on many
measures of health than those with higher incomes (see
Appendix II, Poverty level for a definition of the Federal
poverty level). Although, in some cases, illness can lead to
poverty, more often poverty causes poor health by its
connection with inadequate nutrition, substandard housing,
exposure to environmental hazards, unhealthy lifestyles, and
decreased access to and use of health care services (1).
In 2000 the overall percent of Americans living in poverty
dropped to 11.3 percent, the lowest level since 1973. Recent
declines in poverty have included persons of all ages and
most racial and ethnic groups (2). However, in 2000 the
percent of persons living in poverty continued to differ
significantly by age, race, and ethnicity (figure 4).
For the population as a whole, children were more likely than
either working-age adults or elderly persons to be poor. But
both children and elderly persons were more likely than
working-age adults to be poor or near poor. At all ages, a
higher percent of black and Hispanic persons than
non-Hispanic white persons were poor or near poor. In 2000
more than a quarter of black and Hispanic children were poor
and more than one-half were either poor or near poor. Also
more than one-half of elderly black and Hispanic persons
were either poor or near poor.
References
1. Pamuk E, Makuc D, Heck K, Reuben C, Lochner K.
Socioeconomic Status and Health Chartbook. Health, United
States, 1998. Hyattsville, Maryland: National Center for Health
Statistics. 1998.
2. Dalaker J. Poverty in the United States: 2000. Current
population reports, series P-60 no 214. Washington, DC:
U.S. Government Printing Office. 2001.

Health Insurance
Health Insurance Reference

1. Institute of Medicine. Committee on the
Health insurance coverage is an Consequences of Uninsurance.
important determinant of access to health Coverage matters: Insurance and health
care (1). Uninsured children and care. Washington, DC: National
Academy Press. 2001.
nonelderly adults are substantially less
likely to have a usual source of health
care or a recent health care visit than
their insured counterparts (Health, United
States, 2002, tables 72, 75, 76, and 78).
The major source of coverage for
persons under 65 years of age is private
employer-sponsored group health
insurance. Private health insurance may
also be purchased on an individual
basis, but it costs more and generally
provides less coverage than group
insurance. Public programs such as
Medicaid provide coverage for many
low-income children and adults.
Between 1994 and 2000 the
age-adjusted percent of the nonelderly
population with no health insurance
coverage fluctuated between 16 and
17 percent, after rising from 14 percent in
1984 (figure 5).
In 2000 over 40 million Americans under
65 years of age reported having no
health insurance coverage. The percent
of nonelderly adults without health
insurance coverage decreases with age.
In 2000 adults 18–24 years of age were
most likely to lack coverage and those
55–64 years of age were least likely
(figure 6). Persons with incomes below or
near the poverty level were almost four
times as likely to have no health
insurance coverage as those with
incomes twice the poverty level or
higher. Hispanic persons and
non-Hispanic black persons were more
likely to lack health insurance than
non-Hispanic white persons. Persons of
Mexican origin were more likely to be
uninsured than non-Hispanic black
persons or other Hispanics.

Health Risk Factors
Smoking References
1. Centers for Disease Control and Prevention. Tobacco
As the leading cause of preventable death and disease in the use—United States, 1900–1999. MMWR 48(43):986–93. 1999.
United States, smoking is associated with significantly 2. U.S. Department of Health and Human Services. Preventing
increased risk of heart disease, stroke, lung cancer, and tobacco use among young people: A report of the Surgeon
chronic lung diseases (1). During pregnancy smoking General. Atlanta, Georgia: Centers for Disease Control and
contributes to elevated risk of miscarriage, premature delivery, Prevention. 1994.
and having a low birthweight infant. Preventing smoking 3. Centers for Disease Control and Prevention. Trends in
cigarette smoking among high school students—United States,
among teenagers is critical since smoking usually begins in
1991–2001. MMWR 51(19):409–12. 2002.
adolescence (2). Decreasing cigarette smoking among
4. Mathews TJ. Smoking during pregnancy in the 1990s. National
adolescents and adults is a major public health objective for
vital statistics reports; vol 49 no 7. Hyattsville, Maryland:
the Nation. National Center for Health Statistics. 2001.
Among adult men and women, cigarette smoking declined
substantially following the first Surgeon General’s Report on
smoking in 1964 (figure 7). Since 1990, though, the decline in
the percent of adults who smoke has slowed. In 2000,
25 percent of men and 21 percent of women were smokers.
Cigarette smoking by adults continues to be strongly
associated with educational attainment. Among adults,
persons with less than a high school education were almost
three times as likely to smoke as those with a bachelor’s
degree or more education (Health, United States, 2002,
table 62).
Among high school students, the percent reporting recent
cigarette smoking decreased between 1997 and 2001 after
increasing in the early 1990s. During the last decade, a
similar percent of male and female students reported
smoking. In 2001 white and Hispanic students were more
likely than black students to report current smoking (3).
Among mothers with a live birth, the percent reporting
smoking during pregnancy declined between 1989 and 2000
(4). Twelve percent of mothers with a live birth in 2000
reported smoking during pregnancy. Maternal smoking
declined for all racial and ethnic groups in the 1990s, but
differences among these groups persist (Health, United
States, 2002, table 11). In 2000 the percent of mothers
reporting smoking during pregnancy was highest for American
Indian or Alaska Native mothers (20 percent) and lowest for
Chinese mothers (0.6 percent).

Health Risk Factors
Overweight and Obesity References

1. Allison DB, Fontaine KR, Manson JE, et al. Annual deaths
Many epidemiologic and actuarial studies have shown that attributable to obesity in the United States. JAMA
increased body weight is associated with excess mortality (1). 282(16):1530–8. 1999.
Among adults, overweight and obesity substantially elevate 2. U.S. Department of Health and Human Services. The Surgeon
the risk of illness from heart disease, diabetes, and some General’s call to action to prevent and decrease overweight
types of cancer. Overweight and obesity are also factors that and obesity. Rockville, Maryland: U.S. Department of Health
and Human Services, Public Health Service, Office of the
increase the severity of disease associated with hypertension,
Surgeon General. 2001.
arthritis, and other musculoskeletal problems (2). Among
3. Dietz WH. Health consequences of obesity in youth: Childhood
children and adolescents, obesity increases the risk of high predictors of adult disease. Pediatrics 101(3 Pt 2):518–25.
cholesterol, hypertension, and diabetes (3). Diet, physical 1998.
activity, genetic factors, and health conditions contribute to
overweight in children and adults.
Results from a series of national health examination surveys
indicate that the prevalence of overweight and obesity
changed little between the early 1960s and 1980 (figure 8).
Findings from the 1988–94 survey, however, showed
substantial increases in overweight and obesity among adults.
The upward trend in overweight reflected primarily an
increase in the percent of adults who were obese. Preliminary
estimates from the 1999 survey indicate that overweight and
obesity have continued to increase. In 1999, 61 percent of
adults were overweight with 27 percent obese.
The prevalence of overweight and obesity vary by sex. In
1988–94, 61 percent of men were overweight in comparison
to 51 percent of women. Among overweight men a third were
obese; among overweight women about one-half were obese
(Health, United States, 2002, table 70).
The percent of children (6–11 years of age) and adolescents
(12–19 years of age) who are overweight has also risen.
Among children and adolescents, the percent overweight
increased after the mid-1970s. Preliminary estimates from the
1999 survey indicate that 13 percent of children and
14 percent of adolescents were overweight. In contrast to
adults, the percent of overweight children and adolescents in
1988–94 did not differ by sex (Health, United States, 2002,
table 71).

Health Risk Factors
Physical Activity
Many epidemiologic and clinical studies have shown the
benefits of regular physical activity for reducing mortality,
preventing cardiovascular disease, and enhancing physical
functioning (1). Regular physical activity lessens the risk of
heart disease, diabetes, colon cancer, high blood pressure,
osteoporosis, and arthritis. It also improves symptoms
associated with mental health conditions such as depression
and anxiety. Although vigorous physical activity produces the
greatest cardiovascular benefits, moderate amounts of
physical activity are associated with lower levels of mortality.
Among the elderly, even small amounts of physical activity
may improve cardiovascular functioning (2).
In 2001, 38 percent of female high school students and
24 percent of male high school students reported a level of
physical activity that did not meet the criteria for the
recommended amount of either moderate or vigorous physical
activity (figure 9). The percent reporting a lack of moderate
and vigorous physical activity was lower among students in
9th grade than among students in 10th–12th grade. Between
1999 and 2001 the percent of students reporting a lack of
moderate and vigorous physical activity remained stable.
In 2000, 39 percent of adults reported that they did not
engage in physical activity during leisure time (figure 10),
about the same as in 1997 (3). Among men and women, the
percent of adults who were physically inactive increased with
age. Among noninstitutionalized elderly persons 75 years of
age and over, more than one-half indicated being physically
inactive during leisure time. At most ages, women more often
reported being physically inactive than men.
References
1. U.S. Department of Health and Human Services. Physical
activity and health: A report of the Surgeon General. Atlanta,
Georgia: Centers for Disease Control and Prevention. 1996.
2. Mensink GB, Ziese T, Kok FJ. Benefits of leisure-time physical
activity on the cardiovascular risk profile at older age. Int J
Epidemiol 28(4):659–66. 1999.
3. National Center for Health Statistics. Prevalence of sedentary
leisure-time behavior among adults in the United States.
Available from www.cdc.gov/nchs/products/pubs/pubd/hestats/
3and4/sedentary.htm accessed on 3/12/02.

Prenatal Care Japanese and Chinese women had the 2. Rowland D, Salganicoff A, Keenan PS.
The key to the door: Medicaid’s role in
highest levels of early prenatal care.
improving health care for women and
Prenatal care that begins in the first children. Annu Rev Public Health
trimester and continues throughout References 20:403–26. 1999.
pregnancy reduces the risk of maternal
1. Lewis CT, Mathews TJ, Heuser RL.
morbidity and poor birth outcomes. Prenatal care in the United States,
Attitudes toward pregnancy, lifestyle 1980–94. National Center for Health
factors, and cultural beliefs have been Statistics. Vital Health Stat 21(54).
suggested as reasons women delay 1996.
prenatal care. Financial and health
insurance problems are among the most
important barriers to such care (1).
Expansion of Medicaid coverage for
pregnancy-related services has increased
availability and use of prenatal care by
low-income women (2).
During the last 30 years, the percent of
mothers reporting early prenatal care has
risen (figure 11). This upward trend reflects
increases during the 1970s and the 1990s.
By 2000, 83 percent of mothers reported
receiving early prenatal care.
Increases in use of early prenatal care
have been observed among mothers in
all major racial and ethnic groups.
Increases in use of prenatal care in the
1990s were greatest for those with the
lowest rates of care: Hispanic,
non-Hispanic black, and American Indian
or Alaska Native women (Health, United
States, 2002, table 6).
There continue to be important racial and
ethnic differences in the percent of
mothers reporting early prenatal care
(figure 12). In 2000 the percent was
higher for non-Hispanic white women
than for non-Hispanic black women,
American Indian or Alaska Native
women, and most groups of Hispanic
women. For Hispanic and Asian mothers,
the percent with early prenatal care
varied among subgroups. Among
Hispanic mothers, Cuban women had the
highest levels of early prenatal care;
among Asian or Pacific Islander mothers,

Adult Vaccination References 2. Centers for Disease Control and

Prevention. Influenza, pneumococcal,
1. Centers for Disease Control and and tetanus toxoid vaccination of
In the United States influenza epidemics Prevention. Influenza and adults—United States, 1993–1997.
result in the death of more than 18,000 pneumococcal vaccination levels among MMWR 49(SS-9):39–62. 2000.
persons 65 years of age and over each persons aged ≥ 65 years—United
States, 1999. MMWR 50(25):532–37.
year (1). Pneumococcal disease
2001.
accounts for more deaths than any other
vaccine-preventable bacterial disease.
Annual influenza vaccination and one
dose of pneumococcal polysaccharide
vaccine can lessen the risk of illness and
subsequent complications among elderly
persons. Medicare has covered the cost
of influenza and pneumococcal
vaccination since 1993 (2).
Between 1989 and 2000 the percent of
noninstitutionalized adults 65 years of
age and over who reported an influenza
vaccination within the past year more
than doubled to 65 percent (figure 13).
During the same period the percent of
elderly adults ever having received a
pneumococcal vaccine also increased
sharply from 14 percent to 53 percent.
Several factors have been suggested as
contributing to these increases: greater
acceptance of preventive health care by
consumers and practitioners, improved
Medicare coverage for these vaccines,
and wider delivery of this care by health
care providers other than physicians (2).
The level of coverage varied significantly
by race and Hispanic origin in 2000
(figure 14). Among elderly non-Hispanic
white adults, 67 percent were vaccinated
against influenza and 57 percent against
pneumococcal disease. Among elderly
non-Hispanic black and Hispanic adults,
slightly over one-half were vaccinated
against influenza, and about a third
against pneumococcal disease.

Limitation of Activity
Child Limitation of Activity solely by participation in special education. About 7 percent of
school-age and adolescent boys and 3–4 percent of girls were
Limitation of activity due to chronic physical, mental, or classified as having activity limitation only by their
emotional disorders or deficits is a broad measure of health participation in special education.
and functioning. Among children chronic health conditions that

limit activity include, but are not restricted to, hearing, visual, References
and speech problems; learning disabilities; mental retardation
1. Newacheck PW, Strickland B, Shonkoff JP, et al. An
and other developmental problems (such as cerebral palsy); epidemiologic profile of children with special health care needs.
mental and emotional problems; and a variety of chronic Pediatrics 102(1):117–21. 1998.
health conditions (such as asthma). The long-term impact of 2. Jans L, Stoddard S. Chartbook on women and disability in
activity limitation in children can often be ameliorated by use the United States: An InfoUse report. Washington, DC: U.S.
of health care and educational services. National Institute on Disability and Rehabilitation Research.
1999.
The identification of activity limitation in children is sometimes
uncertain because children are learning and mastering new
activities as they develop. As a result some variation in
children’s activities may be due to differences in the pace of
development. Estimates of the number of children with an
activity limitation vary depending on the type of disabilities
included and the methods used to identify them (1).
The National Health Interview Survey (NHIS) identifies
children with activity limitation in two ways: by asking about
specific limitations in play, self-care, walking, memory, and
other activities and by determining if a child receives special
education or early intervention services. Comparable national
data on activity limitation have been available since 1997
(see Appendix I, National Health Interview Survey). Between
1997 and 2000 levels of activity limitation among children
remained about the same (Health, United States, 2002,
table 58).
In 1998–2000 limitation of activity due to chronic health
conditions occurred twice as often among boys as among
girls (figure 15). Among preschoolers (under 5 years of age),
4 percent of boys as compared with 2 percent of girls had an
activity limitation. Among school-age children (5–11 years of
age) and adolescents (12–17 years of age), 9 percent of boys
had an activity limitation compared with about 5 percent of
girls. Physiological, maturational, behavioral, and social
differences between boys and girls have been suggested as
explanations for the higher prevalence of activity limitation in
boys (2).
The percent of children with activity limitation was significantly
higher among school-age children and adolescents than
among preschoolers. For boys and girls, the higher percent of
school-age children and adolescents with activity limitation
was largely explained by the number of children identified

Adult Limitation of Activity Reference

1. Guralnik JM, Fried LP, Salive ME. Disability as a public health
Measuring limitations in everyday activities due to chronic outcome in the aging population. Annu Rev Public Health
physical, mental, or emotional problems is one way to assess 17:25–46. 1996.
the impact of health conditions on self-care and social
participation (1). Chronic health conditions can alter the ability
of adults to lead independent lives by affecting a person’s
capacity to carry out a variety of activities. The effect that
chronic health conditions have on activity limitation may vary
with the availability of supportive and health care services.
In the National Health Interview Survey (NHIS), limitation of
activity in adults includes limitations in handling personal care
needs, activities of daily living (ADLs), and routine needs
instrumental activities of daily living (IADLs). For both sets of
activities, limitation is defined as needing the help of another
person to do an activity. Limitation of activity in NHIS also
includes limitations in having a job outside the home, walking,
remembering, and other activities. Comparable national data
on activity limitation have been available since 1997 (see
Appendix I, National Health Interview Survey). Between 1997
and 2000 the age-adjusted percent of adults reporting any
activity limitation caused by a chronic health condition
declined by about 13 percent (Health, United States, 2002,
table 58).
Limitations in ADLs among noninstitutionalized adults are
more prevalent among the elderly than among adults of
working age (figure 16). Less than 1 percent of adults 18–44
years of age report an ADL limitation in contrast to nearly
10 percent of persons 75 years of age and over.
Limitations in IADLs, as well as limitations in any activity,
affect a higher percent of noninstitutionalized elderly adults
than adults of working age. Among persons 75 years of age
and over, nearly one-fifth of adults report needing the help of
other persons to do routine activities such as household
chores and shopping (IADLs) and nearly one-half say their
activities are limited in some way due to a chronic physical,
mental, or emotional problem.
Limitations in ADLs, IADLs, and any activity are higher among
poor elderly persons than nonpoor elderly persons. In
1998–2000 the percent of elderly persons with an IADL
limitation, for example, was substantially higher among poor
(22 percent) than nonpoor persons (9 percent) (for related
data, see Health, United States, 2002, table 58).

Chronic Health Conditions

Health surveys that measure limitation of activity have
typically asked about the conditions causing these restrictions.
Limitation of activity may be caused by more than one health
condition. Health conditions usually refer to broad categories
of disease and impairment rather than medical diagnoses and
reflect the understanding the general public has of factors
causing disability or limitation of activity (1). Despite
differences among various health surveys conducted in
Western industrialized countries, several chronic conditions
are consistently mentioned as important causes of disability.
Among these, arthritis and other musculoskeletal conditions
and circulatory conditions are often identified as leading
causes of disability.
Chronic health conditions causing limitation of activity are
generally more common among elderly than among younger
adults (figure 17). In 1998–2000 the prevalence of arthritis
and other musculoskeletal conditions causing activity
limitation, for example, was 22 per 1,000 adults 18–44 years
of age in contrast to 193 per 1,000 adults 75 years of age
and over. Other leading causes of activity limitation such as
heart and other circulatory problems, difficulties with vision
and hearing, diabetes and respiratory problems, were also
more prevalent among the elderly than among working-age
adults. Disabling mental illness, however, followed a different
pattern. The highest rates of mental illness causing activity
limitation were reported by adults 45–64 years of age.
The relative importance of various chronic conditions causing
limitation of activity differed for adults of various ages. Among
younger adults 18–44 years of age, the most frequently
mentioned chronic conditions causing limitations in activity
were arthritis and other musculoskeletal conditions, and
mental illness. Among adults 45 years of age and over,
arthritis and other musculoskeletal conditions, and heart and
other circulatory conditions outranked other conditions as
causes of activity limitation.
Reference
1. Fujiura GT, Rutkowski-Kmitta V. Counting disability. In: Albrecht
GL, Seelman KD, Bury M, eds. Handbook of disability studies.
Thousand Oaks, California: Sage Publications, 69–96. 2001.

Mortality
Life Expectancy
Life expectancy is a measure often used to gauge the overall
health of a population. As a summary measure of mortality,
life expectancy represents the average number of years of life
that could be expected if current death rates were to remain
constant. Shifts in life expectancy are often used to describe
trends in mortality. Life expectancy at birth is strongly
influenced by infant and child mortality. Life expectancy later
in life reflects death rates at or above a given age and is
independent of the effect of mortality at younger ages (1).
During the 20th century, life expectancy at birth increased
from 48 to 74 years for men and from 51 to 79 years for
women (figure 18). Improvements in nutrition, housing,
hygiene, and medical care contributed to decreases in death
rates throughout the lifespan. Prevention and control of
infectious diseases had a profound impact on life expectancy
in the first half of the 20th century (2).
During the last century, life expectancy at age 65 also
increased. Among men, life expectancy at age 65 rose from
12 to 16 years and among women from 12 to 19 years. In
contrast to life expectancy at birth, which increased sharply
early in the century, life expectancy at age 65 improved
primarily after 1950. Improved access to health care,
advances in medicine, healthier lifestyles, and better health
before 65 are factors underlying decreased death rates
among the elderly (3).
Longer life expectancies at birth in many other developed
countries suggest the possibility of improving longevity in the
United States (Health, United States, 2002, table 27).
Decreasing death rates of less advantaged groups could raise
life expectancy in the United States (Health, United States,
2002, table 28).
References
1. Arriaga EE. Measuring and explaining the change in life
expectancies. Demography 21(1):83–96. 1984.
2. Centers for Disease Control and Prevention. Achievements in
public health, 1900–1999: Control of infectious diseases.
MMWR 48(29):621–9. 1999.
3. Fried LP. Epidemiology of aging. Epidemiol Rev 22(1):95–106.
2000.

Mortality
Infant Mortality References 2. American Academy of Pediatrics Task

Force on Infant Positioning and SIDS.
1. Anderson RN. Deaths: Leading causes Positioning and SIDS. Pediatrics
Infant mortality, the risk of death during for 1999. National vital statistics reports; 89(6):1120–6. 1992.
the first year of life, is related to the vol 29 no 11. Hyattsville, Maryland:
underlying health of the mother, public National Center for Health Statistics.
2001.
health practices, socioeconomic
conditions, and availability and use of
appropriate health care for infants and
pregnant women. Disorders related to
short gestation and low birthweight, and
congenital malformations are the leading
causes of death during the first month of
life (neonatal mortality). Sudden Infant
Death Syndrome (SIDS) and congenital
anomalies rank as the leading causes of
infant deaths after the first month of life
(postneonatal mortality) (1).
Between 1950 and 1999 the infant
mortality rate declined by about
75 percent (figure 19). Substantial
declines occurred for both neonatal and
postneonatal mortality. In 1999 the infant
mortality rate was 7.1 deaths per 1,000
live births with two-thirds of all infant
deaths occurring during the neonatal
period. Declines in infant mortality have
been linked to improved access to health
care, advances in neonatal medicine,
and educational campaigns such as the
‘‘Back to Sleep’’ campaign to curb
fatalities caused by SIDS (2).
Infant mortality rates have declined for all
racial and ethnic groups, but large
disparities remain (Health, United States,
2002, table 20). During 1997–99 the
infant mortality rate was highest for
infants of non-Hispanic black and
American Indian or Alaska Native
mothers (figure 20). Infants of Chinese
mothers had the lowest infant mortality
rate. Among Hispanic mothers, the infant
mortality rate was highest for Puerto
Rican mothers and lowest for Cuban
mothers.

Mortality
Child and Young Adult Death rates for the other leading causes Reference
of death, cancer and heart disease, have
Mortality also declined with the greatest decline in
1. Hoyert DL, Arias E, Smith BL, Murphy
SL, Kochanek KD. Deaths: Final data
cancer mortality occurring during for 1999. National vital statistics reports;
During the past 50 years mortality 1960–95 and the greatest decline in vol 49 no 8. Hyattsville, Maryland:
among children and young adults (1–24 heart disease mortality during 1950–70. National Center for Health Statistics.
years of age) has declined by more than In 1999 cancer and heart disease 2001.
one-half. In 1999 the five leading causes together accounted for about 10 percent
of death for this age group were related of deaths among persons 1–24 years of
to either injury or chronic diseases. In age.
1950, in contrast, two of the five leading
causes of death were infectious diseases
(influenza/pneumonia and tuberculosis).
Unintentional injuries have been the
leading cause of death for children and
young adults throughout the past 50
years. Death rates for unintentional
injuries have been declining since 1970
(figure 21). In 1999 more than 40 percent
of all deaths to persons 1–24 years of
age resulted from unintentional injuries
(figure 22). Nearly three-quarters of these
deaths occurred to persons 15–24 years
of age (1).
Homicide and suicide were the second
and third leading causes of death in this
age group in 1999. Most of these deaths
were among persons 15–24 years of
age: 86 percent of homicides and
94 percent of suicides in this age group
occurred to persons 15–24 years of age.
Between 1960 and the mid-1990s,
homicide and suicide rates among
persons 1–24 years of age increased.
Since the mid-1990s homicide and
suicide rates have declined.
Homicide and suicide rates vary by age,
sex, and race. Males 15–24 years of age
are at substantially higher risk of
homicide and suicide than younger
persons or females. Among males 15–24
years of age, homicide rates for black
males were eight times as great as for
white males in 1999 (Health, United
States, 2002, tables 46 and 47).

Mortality
Adult Mortality: 25–44 introduction of new antiretroviral Reference
therapies.
Years of Age 1. Centers for Disease Control and
Prevention. HIV and AIDS—United
HIV disease death rates among persons
25–44 years of age vary substantially by States, 1981–2000. MMWR
Since 1950 mortality among adults 50(21):430–4. 2001.
25–44 years of age has declined by sex, race, and Hispanic origin. The risk
more than 40 percent. Underlying the of death is higher for males than females
overall decline in the death rate have and is much higher for black persons
been both favorable and unfavorable and Hispanic persons than for those in
trends in the leading causes of death other racial and ethnic groups. The HIV
(figure 23). Four of the five leading disease death rate for black females, for
causes of death in 1999 were also example, was 12 times the rate for white
leading causes of death in 1950. But females in 1999 (Health, United States,
tuberculosis, which was one of the top 2002, table 43).
five causes of death in 1950, is no
longer a significant cause of death for
adults 25–44 years of age.
Mortality from heart disease has declined
by more than 60 percent since 1950,
with most of the decrease occurring by
1990. Mortality from unintentional injury
and cancer has also declined, with most
of the decrease occurring after 1970.
Altogether unintentional injury, cancer,
and heart disease, the three leading
causes of death among persons 25–44
years of age in 1999, accounted for
about one-half of all deaths in this age
group (figure 24).
In contrast to the declines for the top
three causes of death, the suicide rate
among persons 25–44 years rose
between 1950 and 1980 but has
declined slightly since 1980. Suicide, the
fourth leading cause of death among
young working-age adults in 1999, was
responsible for 9 percent of deaths in
this age group.
The fifth leading cause of death in 1999,
human immunodeficiency virus (HIV)
disease, has been an important cause of
mortality among persons 25–44 years of
age since the late 1980s (1). After rising
rapidly in the late 1980s and the early
1990s, the HIV disease death rate began
to fall sharply in the late 1990s with the

Mortality
Adult Mortality: 45–64 as high as the rate for adults with more
than a high school education in 1999 (2).
Years of Age
References
Death rates for persons 45–64 years of
age have declined substantially over the 1. Centers for Disease Control and
past 50 years. Since 1950 mortality in Prevention. Achievements in public
health, 1900–1999: Decline in deaths
this age group has decreased by nearly
from heart disease and stroke—United
50 percent overall. Four of the five States, 1900–1999. MMWR
leading causes of death in 1999 were 48(30):649–56. 1999.
also the leading causes of death in 2. Hoyert DL, Arias E, Smith BL, Murphy
1950. Tuberculosis, which ranked in the SL, Kochanek KD. Deaths: Final data
top five causes in 1950, was the cause for 1999. National vital statistics reports;
of only a small number of deaths in vol 49 no 8. Hyattsville, Maryland:
National Center for Health Statistics.
1999.
2001.
The death rates for heart disease and
stroke among persons 45–64 years of
age declined substantially between 1950
and 1999 (figure 25). During this period
the death rate for heart disease declined
by almost 70 percent and the death rate
for stroke by nearly 80 percent.
Advances in the prevention and
treatment of heart disease and stroke
rank among the major public health
achievements of the 20th century (1).
In contrast to the large declines in heart
disease and stroke mortality, the death
rate for cancer among persons 45–64
years of age rose slowly through the
1980s and then declined. Cancer was
the leading cause of death among
persons 45–64 years of age, accounting
for more than one-third of the deaths in
this age group in 1999 (figure 26).
In 1999 cancer, heart disease, stroke,
and chronic lower respiratory diseases
together accounted for nearly 70 percent
of all deaths in this age group. Both
biological and socioeconomic factors are
strongly associated with death among
older working-age adults. Men had a
higher death rate than women, and
adults with a high school education or
less had a death rate more than twice

Mortality
Adult Mortality: Elderly Reference
1. Office of the Surgeon General, U.S.
Three-quarters of all deaths in the United Public Health Service. The health
States occur among persons 65 years of consequences of smoking: Chronic
age and over (Health, United States, obstructive lung disease. Rockville,
Maryland: U.S. Department of Health
2002, table 33). During the past 50 years
and Human Services. 1984.
overall death rates have declined by
about one-third for older persons.
Chronic diseases have caused most of
the deaths among the elderly throughout
the 50-year period.
The death rate for heart disease among
the elderly declined between 1950 and
1999 by more than 50 percent and the
death rate for stroke by more than
60 percent (figure 27). Trends in the
other leading causes of death among the
elderly varied. The death rate for cancer,
the second leading cause of death for
the elderly in 1999, rose between 1950
and 1995 and has decreased slightly
since 1995. The death rate for the fourth
leading cause of death, chronic lower
respiratory diseases, has increased since
1980 reflecting, in large part, the effects
of cigarette smoking (1).
The large difference in the death rate
due to influenza and pneumonia between
1998 and 1999 reflects, in large part,
changes in the coding of this cause of
death. A comparison of the comparability-
modified 1998 rate with the 1999 rate
indicates a decline of only 3 percent (see
data table for figure 27 and Appendix II,
Comparability ratio).
In 1999 the underlying cause in over
one-third of the deaths to persons 65
years of age and over was heart disease
(figure 28). The second leading cause of
death, cancer, accounted for about a fifth
of all deaths. Each of the other leading
causes of death (stroke, chronic lower
respiratory diseases, and influenza and
pneumonia) accounted for less than
10 percent of deaths to the elderly.

Data Tables for Figures 1–28
Data table for figure 1. Total and elderly population:

United States, 1950–2050
65 years and
Year Total over
Number in thousands
1950 . . . . . . . . . . . . . . . . . 150,216 12,257
1960 . . . . . . . . . . . . . . . . . 179,326 16,207
1970 . . . . . . . . . . . . . . . . . 203,212 20,066
1980 . . . . . . . . . . . . . . . . . 226,546 25,549
1990 . . . . . . . . . . . . . . . . . 248,710 31,242
2000 . . . . . . . . . . . . . . . . . 281,422 34,992
2010 . . . . . . . . . . . . . . . . . 299,862 39,715
2020 . . . . . . . . . . . . . . . . . 324,927 53,733
2030 . . . . . . . . . . . . . . . . . 351,070 70,319
2040 . . . . . . . . . . . . . . . . . 377,350 77,177
2050 . . . . . . . . . . . . . . . . . 403,687 81,999
NOTES: Data are for the resident population. Data for 1950 exclude Alaska
and Hawaii. See Appendix II, Population.
SOURCES: U.S. Census Bureau, 1980 Census of Population, General
Population Characteristics, United States Summary (PC80-1-B1)
[includes data for 1950–80]; 1990 Census of Population, General Population
Characteristics, United States Summary (CO-1-1); 2000 Census of
Population, Profiles of General Demographic Characteristics, United States,
www.census.gov/prod/cen2000/dp1/2kh00.pdf accessed on September 27,
2001; Projections of the Total Resident Population by 5-Year Age Groups,
and Sex with Special Age Categories: Middle Series, 2006 to 2010 through
2050 to 2070, www.census.gov/population/projections/nation/summary/np-t3-c.txt
to np-t3-g.txt accessed on September 27, 2001.
Data table for figure 2. Percent of population in 3 age groups: United States, 1950, 2000, and 2050
Year All ages Under 18 years 18–64 years 65 years and over
Percent
1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 31.3 60.6 8.2
2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 25.7 61.9 12.4
2050 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 23.7 56.0 20.3
NOTES: Data are for the resident population. Data for 1950 exclude Alaska and Hawaii. See Appendix II, Population.
SOURCES: U.S. Census Bureau, 1980 Census of Population, General Population Characteristics, United States Summary (PC80-1-B1) [includes data for
1950]; 2000 Census of Population, Profiles of General Demographic Characteristics, United States, www.census.gov/prod/cen2000/dp1/2kh00.pdf accessed on
September 27, 2001; Projections of the Total Resident Population by 5-Year Age Groups, and Sex with Special Age Categories: Middle Series, 2050 to 2070,
www.census.gov/population/projections/nation/summary/np-t3-g.txt accessed on September 27, 2001.

Data table for figure 3. Percent of population in selected race and Hispanic origin groups by age: United States, 1980–2000
All ages Under 18 years 18 years and over
Race and Hispanic origin 1980 1990 2000 1980 1990 2000 1980 1990 2000
Percent
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Hispanic or Latino . . . . . . . . . . . . . . . . . . . . 6.4 9.0 12.5 8.8 12.2 17.1 5.5 7.9 11.0
Not Hispanic or Latino
White . . . . . . . . . . . . . . ..... .... . . . . 79.7 75.6 69.1 74.0 68.9 60.9 82.0 78.0 72.0
Black or African American ..... .... . . . . 11.5 11.7 12.1 14.5 14.7 14.7 10.3 10.7 11.2
Asian or Pacific Islander . ..... .... . . . . 1.6 2.8 3.7 1.7 3.1 3.5 1.5 2.7 3.8
American Indian or Alaska Native ... . . . . 0.6 0.7 0.7 0.8 1.0 0.9 0.5 0.6 0.7
Other race . . . . . . . . . . . ..... .... . . . . 0.1 0.1 0.2 0.2 0.2 0.3 0.1 0.1 0.1
2 or more races . . . . . . . ..... .... . . . . ... ... 1.6 ... ... 2.6 ... ... 1.3
. . . Category not applicable.

NOTES: Data are for the resident population. Persons of Hispanic origin may be of any race. Race data for 2000 are not directly comparable with data from
1980 and 1990. Individuals could report only one race in 1980 and 1990, and more than one race in 2000. Persons who selected more than one race in 2000
are shown as having two or more races and are not included in any other racial category; persons in single race categories in 2000 selected only one race. In
2000 the category, Asian or Pacific Islander, includes Asian and Native Hawaiian or Other Pacific Islander. See Appendix II, Hispanic origin and Race.
SOURCES: U.S. Census Bureau, 1980 Census of Population PC80-1-C1, tables 100, 121, 131, and 167; 1990 Census of Population 1990-CP-1-1, table 3; and
Census 2000 Redistricting Data (P.L. 94–171), www.census.gov/population/cen2000/phc-t1/tab01.pdf, accessed on August 17, 2001.

Data table for figure 4. Low income population by age, race,

and Hispanic origin: United States, 2000
Age, race, and Hispanic origin Poor Near poor
Percent
All races and origins
All ages . . . . . . . . . . . . . . . . 11.3 17.9
Under 18 years . . . . . . . . . . 16.1 21.3
18–64 years . . . . . . . . . . . . 9.4 14.8
65 years and over . . . . . . . . 10.2 27.1
White, not Hispanic or Latino
All ages . . . . . . . . . . . . . . . . 7.5 14.7
Under 18 years . . . . . . . . . . 9.3 16.3
18–64 years . . . . . . . . . . . . 6.7 11.6
65 years and over . . . . . . . . 8.3 26.0
Black or African American
All ages . . . . . . . . . . . . . . . . 22.0 24.4
Under 18 years . . . . . . . . . . 30.6 28.2
18–64 years . . . . . . . . . . . . 17.4 21.3
65 years and over . . . . . . . . 22.4 32.3
Hispanic or Latino
All ages . . . . . . . . . . . . . . . . 21.2 30.1
Under 18 years . . . . . . . . . . 28.0 34.2
18–64 years . . . . . . . . . . . . 17.4 27.0
65 years and over . . . . . . . . 18.8 36.8
NOTES: Data are for the civilian noninstitutionalized population. Black race
includes persons of both Hispanic and non-Hispanic origin. Persons of
Hispanic origin may be of any race. Poor is defined as family income less
than 100 percent of the poverty level and near poor as 100–199 percent of
the poverty level. See Appendix II, Poverty level. See related Health, United
States, 2002, table 2.
SOURCES: Dalaker J. Poverty in the United States: 2000. Current
population reports, series P-60 no 214. Washington, DC: U.S. Government
Printing Office. 2001; Table 2. Age, Sex, Household Relationship, Race and
Hispanic Origin by Ratio of Income to Poverty Level: 2000,
ferret.bls.census.gov/macro/032001/pov/new02_001.htm to new02_006.htm
accessed on March 26, 2002.

Data table for figure 5. Health insurance coverage among persons under 65 years of age: United States, 1984–2000
Health insurance coverage
Private Medicaid Uninsured
Year Percent SE Percent SE Percent SE
1984 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77.1 0.6 6.7 0.3 14.3 0.4

1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76.2 0.4 7.1 0.2 15.3 0.3
1994 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70.3 0.4 11.0 0.3 17.3 0.3
1995 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.6 0.4 11.3 0.2 15.9 0.2
1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.5 0.5 10.9 0.3 16.5 0.3
1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70.9 0.3 9.6 0.2 17.4 0.2
1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.3 0.4 8.8 0.2 16.5 0.2
1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.9 0.3 9.0 0.2 16.1 0.2
2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.7 0.3 9.4 0.2 16.8 0.2
SE Standard error.
NOTES: Data are for the civilian noninstitutionalized population. Percents are age adjusted to the 2000 standard population using three age groups: under 18
years, 18–44 years, and 45–64 years. Medicaid includes other public assistance through 1996; includes State-sponsored health plans starting in 1997; and
includes Child Health Insurance Program (CHIP) starting in 1999. Uninsured persons are not covered by private insurance, Medicaid, CHIP, public assistance
(through 1996), State-sponsored or other government-sponsored health plans (starting in 1997), Medicare, or military plans. Percents do not add to 100
because the percent of persons with Medicare, military plans, and other government-sponsored plans is not shown and because persons with both private
insurance and Medicaid appear in both categories. See Appendix II, Age adjustment and Health insurance coverage. See related Health, United States, 2002,
tables 127–129.
SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey.

Data table for figure 6. No health insurance coverage among

persons under 65 years of age by selected characteristics:
United States, 2000
Characteristic Percent SE
Age
Under 18 years . . . . . . . . . . . . 12.4 0.3
18–24 years . . . . . . . . . . . . . . 29.7 0.7
25–34 years . . . . . . . . . . . . . . 22.7 0.5
35–44 years . . . . . . . . . . . . . . 16.8 0.4
45–54 years . . . . . . . . . . . . . . 12.8 0.3
55–64 years . . . . . . . . . . . . . . 12.5 0.4
Percent of poverty level

Below 100 percent . . . . . . . . . . 34.2 0.8
100–149 percent . . . . . . . . . . . 36.5 1.0
150–199 percent . . . . . . . . . . . 27.3 0.9
200 percent or more . . . . . . . . 8.7 0.2
Hispanic or Latino
Mexican . . . . . . . . . . . . . . . . . 39.9 0.9
Puerto Rican . . . . . . . . . . . . . . 16.4 1.3
Cuban . . . . . . . . . . . . . . . . . . 25.2 2.2
Other Hispanic . . . . . . . . . . . . 32.7 1.4

White only . . . . . . . . . . . . . . . 12.5 0.3
Black or African American only . 20.0 0.6
SE Standard error.
NOTES: Data are for the civilian noninstitutionalized population. Percents by
poverty level, race, and Hispanic origin are age adjusted to the year 2000
standard population using three age groups: under 18 years, 18–44 years,
and 45–64 years. Persons of Hispanic origin may be of any race. Uninsured
persons are not covered by private insurance, Medicaid, Child Health
Insurance Program (CHIP), State-sponsored or other government-
sponsored health plans, Medicare, or military plans. Percent of poverty level
was unknown for 26 percent of sample persons under 65 years of age in
2000. See Appendix II, Age adjustment, Health insurance coverage,
Poverty, and Race. See related Health, United States, 2002, table 129.
SOURCE: Centers for Disease Control and Prevention, National Center for
Health Statistics, National Health Interview Survey.

Data table for figure 7. Cigarette smoking among men, women, high school students, and mothers during pregnancy:
Mothers
during
Men Women High school students pregnancy
Year Percent SE Percent SE Percent SE Percent
1965 . . . . . . . . . . . . . . . . . . . . . . . . . . 51.2 0.3 33.7 0.3 --- --- ---

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . 42.8 0.5 32.2 0.4 --- --- ---
1979 . . . . . . . . . . . . . . . . . . . . . . . . . . 37.0 0.5 30.1 0.5 --- --- ---
1983 . . . . . . . . . . . . . . . . . . . . . . . . . . 34.8 0.6 29.4 0.4 --- --- ---
1985 . . . . . . . . . . . . . . . . . . . . . . . . . . 32.2 0.5 27.9 0.4 --- --- ---
1987 . . . . . . . . . . . . . . . . . . . . . . . . . . 30.9 0.4 26.5 0.4 --- --- ---
1988 . . . . . . . . . . . . . . . . . . . . . . . . . . 30.3 0.4 25.7 0.3 --- --- ---
1989 . . . . . . . . . . . . . . . . . . . . . . . . . . --- --- --- --- --- --- 19.5
1990 . . . . . . . . . . . . . . . . . . . . . . . . . . 28.0 0.4 22.9 0.3 --- --- 18.4
1991 . . . . . . . . . . . . . . . . . . . . . . . . . . 27.6 0.4 23.5 0.3 27.5 1.4 17.8
1992 . . . . . . . . . . . . . . . . . . . . . . . . . . 28.1 0.5 24.6 0.5 --- --- 16.9
1993 . . . . . . . . . . . . . . . . . . . . . . . . . . 27.3 0.6 22.6 0.4 30.5 1.0 15.8
1994 . . . . . . . . . . . . . . . . . . . . . . . . . . 27.6 0.5 23.1 0.5 --- --- 14.6
1995 . . . . . . . . . . . . . . . . . . . . . . . . . . 26.5 0.6 22.7 0.5 34.8 1.1 13.9
1996 . . . . . . . . . . . . . . . . . . . . . . . . . . --- --- --- --- --- --- 13.6
1997 . . . . . . . . . . . . . . . . . . . . . . . . . . 27.1 0.4 22.2 0.4 36.4 1.2 13.2
1998 . . . . . . . . . . . . . . . . . . . . . . . . . . 25.9 0.4 22.1 0.4 --- --- 12.9
1999 . . . . . . . . . . . . . . . . . . . . . . . . . . 25.2 0.5 21.6 0.4 34.8 1.3 12.6
2000 . . . . . . . . . . . . . . . . . . . . . . . . . . 25.2 0.4 21.1 0.4 --- --- 12.2
2001 . . . . . . . . . . . . . . . . . . . . . . . . . . --- --- --- --- 28.5 1.0 ---
SE Standard error.
- - - Data not available.
NOTES: Data for men and women are for the civilian noninstitutionalized population. Percents for men and women are age adjusted to the 2000 standard
population using five age groups: 18–24 years, 25–34 years, 35–44 years, 45–64 years, and 65 years and over. Cigarette smoking is defined as follows: among
men and women 18 years and over, those who ever smoked 100 cigarettes in their lifetime and now smoke every day or some days; among high school
students (grades 9–12), those who smoked cigarettes on 1 or more of the 30 days preceding the survey; and among mothers with a live birth, those who
smoked during pregnancy. See Appendix II, Age adjustment and Cigarette smoking. See related Health, United States, 2002, tables 11 and 61.
SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey (data for men and women);
National Vital Statistics System (data for mothers during pregnancy); National Center for Chronic Disease Prevention and Health Promotion, Youth Risk
Behavior Survey (data for high school students).

Data table for figure 8. Overweight and obesity by age: United States, 1960–99
Children, 6–11 years Adolescents, 12–19 years Adults, 20–74 years
Overweight Overweight Obesity
Year Percent SE Percent SE Percent SE Percent SE
1960–62 . . . . . . . . . . . . . . . . . . . . . . . . --- --- --- --- 44.8 1.0 13.3 0.6

1963–65 . . . . . . . . . . . . . . . . . . . . . . . . 4.2 0.4 --- --- --- --- --- ---
1966–70 . . . . . . . . . . . . . . . . . . . . . . . . --- --- 4.6 0.3 --- --- --- ---
1971–74 . . . . . . . . . . . . . . . . . . . . . . . . 4.0 0.5 6.1 0.7 47.7 0.7 14.6 0.5
1976–80 . . . . . . . . . . . . . . . . . . . . . . . . 6.5 0.6 5.0 0.6 47.4 0.8 15.1 0.5
1988–94 . . . . . . . . . . . . . . . . . . . . . . . . 11.4 1.0 10.5 0.9 56.0 0.9 23.3 0.7
1999 . . . . . . . . . . . . . . . . . . . . . . . . . . 13.0 --- 14.0 --- 61.0 --- 27.0 ---
SE Standard error.
NOTES: Data are for the civilian noninstitutionalized population. Percents for adults are age adjusted to the 2000 standard population using five age groups:
20–34 years, 35–44 years, 45–54 years, 55–64 years, and 65–74 years. Overweight for children is defined as a body mass index (BMI) at or above the sex-
and age-specific 95th percentile BMI cut points from the 2000 CDC Growth Charts: United States. Overweight for adults is defined as a BMI greater than or
equal to 25 and obesity as a BMI greater than or equal to 30. Data for 1966–70 are for adolescents 12–17 years, not 12–19 years. Pregnant adolescents were
excluded beginning in 1971–74. Pregnant women 20 years of age and over were excluded in all years. 1999 data are preliminary estimates from the 1999
National Health and Nutrition Examination Survey (NHANES). 1999 data are limited in sample size and geographic coverage and, therefore, are subject to more
sampling error than multi-year NHANES. As a result, annual prevalence estimates may fluctuate more than those from multi-year NHANES. See Appendix II,
Age adjustment and Body mass index (BMI). See related Health, United States, 2002, tables 70 and 71.
SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Examination Survey and National Health and
Nutrition Examination Survey.
Data table for figure 9. High school students not engaging in recommended amounts of physical activity (neither moderate nor
vigorous) by grade and sex: United States, 2001
All students Male students Female students
Grade Percent SE Percent SE Percent SE
Grade 9 . . . . . . . . . . . . . . . . . . . . . . . . 24.3 1.4 20.1 1.6 28.1 1.9

Grade 10 . . . . . . . . . . . . . . . . . . . . . . . 29.6 0.9 23.6 1.1 35.6 1.7
Grade 11 . . . . . . . . . . . . . . . . . . . . . . . 34.4 1.2 24.4 1.3 44.2 1.6
Grade 12 . . . . . . . . . . . . . . . . . . . . . . . 38.9 1.4 29.5 2.1 47.9 1.2
All grades . . . . . . . . . . . . . . . . . . . . . . . 31.2 0.7 24.2 0.8 37.9 1.2
SE Standard error.
NOTES: The recommended amount of moderate physical activity for high school students is at least 30 minutes of activities, which do not cause sweating or
hard breathing, on 5 or more of the past 7 days. The recommended amount of vigorous physical activity is at least 20 minutes of activities, which cause
sweating and hard breathing, on 3 or more of the past 7 days. The recommended amounts of physical activity for high school students are based on the
Healthy People 2010 objectives 22–6 and 22–7 (moderate and vigorous activity in adolescents).
SOURCE: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Youth Risk Behavior Survey.

Data table for figure 10. Adults not engaging in leisure-time physical activity by age and sex: United States, 2000
Total Men Women
Age Percent SE Percent SE Percent SE
18–24 years .... . . . . . . . . . . . . 30.7 1.0 25.9 1.4 35.5 1.4

25–44 years .... . . . . . . . . . . . . 33.8 0.6 31.6 0.8 36.0 0.7
45–64 years .... . . . . . . . . . . . . 41.0 0.7 40.6 1.0 41.5 0.8
65–74 years .... . . . . . . . . . . . . 46.2 1.1 42.0 1.6 49.7 1.3
75 years and over . . . . . . . . . . . . 59.4 1.2 52.6 2.0 63.7 1.3
SE Standard error.
NOTES: Data are for the civilian noninstitutionalized population. Leisure-time physical inactivity is defined as not engaging in at least 10 minutes of physical
activity which causes an increase in sweating, breathing, or heart rate.
Data table for figure 11. Early prenatal care among mothers: Data table for figure 12. Early prenatal care by detailed race
United States, 1970–2000 and Hispanic origin of mother: United States, 2000
Year Percent Race and Hispanic origin

of mother Percent
1970 . . . . . . . . . . . . . . . . . . . . . . . . . . 68.0
1975 . . . . . . . . . . . . . . . . . . . . . . . . . . 72.4 White, not Hispanic or Latino . . . . . . . . ...... 88.5
1980 . . . . . . . . . . . . . . . . . . . . . . . . . . 76.3 Black or African American, not Hispanic
or Latino . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74.3
1985 . . . . . . . . . . . . . . . . . . . . . . . . . . 76.2
Hispanic or Latino . . . . . . . . . . . . . . . . . . . . . . 74.4
1990 . . . . . . . . . . . . . . . . . . . . . . . . . . 75.8
Cuban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.7
1993 . . . . . . . . . . . . . . . . . . . . . . . . . . 78.9
Puerto Rican . . . . . . . . . . . . . . . . . . . . . . . . 78.5
1994 . . . . . . . . . . . . . . . . . . . . . . . . . . 80.2
Central and South American . . . . . . . . . . . . . 77.6
1995 . . . . . . . . . . . . . . . . . . . . . . . . . . 81.3
Other and unknown Hispanic or Latino . . . . . . 75.8
1996 . . . . . . . . . . . . . . . . . . . . . . . . . . 81.9
Mexican . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.9
1997 . . . . . . . . . . . . . . . . . . . . . . . . . . 82.5
Asian or Pacific Islander . . . . . . . . . . . . . . . . . . 84.0
1998 . . . . . . . . . . . . . . . . . . . . . . . . . . 82.8
Japanese . . . . . . . . . . . . . . . . . . . . . . . . . . 91.0
1999 . . . . . . . . . . . . . . . . . . . . . . . . . . 83.2
Chinese . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87.6
2000 . . . . . . . . . . . . . . . . . . . . . . . . . . 83.2
Filipino . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84.9
NOTES: Early prenatal care begins during the first trimester of pregnancy. Other Asian or Pacific Islander . . . . . . . . . . . . 82.5
See related Health, United States, 2002, table 6. Hawaiian . . . . . . . . . . . . . . . . . . . . . . . . . . . 79.9
SOURCE: Centers for Disease Control and Prevention, National Center for American Indian or Alaska Native . . . . . . . . . . . 69.3
Health Statistics, National Vital Statistics System.
NOTES: Early prenatal care begins during the first trimester of pregnancy.
Hispanic origin categories include persons of any race. The race groups,
Asian or Pacific Islander and American Indian or Alaska Native, include
persons of Hispanic and non-Hispanic origin. See related Health, United
States, 2002, table 6.

Data table for figure 13. Influenza and pneumococcal vaccination among adults 65 years of age and over: United States, 1989–
2000
Influenza vaccination Pneumococcal

during past 12 months vaccination ever
Year Percent SE Percent SE
1989 . . . . . . . . . . . . . . . . . . . . . . . . . . 31.0 0.5 14.3 0.4

1990 . . . . . . . . . . . . . . . . . . . . . . . . . . --- --- --- ---
1991 . . . . . . . . . . . . . . . . . . . . . . . . . . 42.3 0.7 21.5 0.6
1992 . . . . . . . . . . . . . . . . . . . . . . . . . . --- --- --- ---
1993 . . . . . . . . . . . . . . . . . . . . . . . . . . 52.3 0.9 28.5 0.8
1994 . . . . . . . . . . . . . . . . . . . . . . . . . . 55.6 0.9 29.9 0.8
1995 . . . . . . . . . . . . . . . . . . . . . . . . . . 58.8 0.9 34.5 0.9
1996 . . . . . . . . . . . . . . . . . . . . . . . . . . --- --- --- ---
1997 . . . . . . . . . . . . . . . . . . . . . . . . . . 63.5 0.7 42.6 0.7
1998 . . . . . . . . . . . . . . . . . . . . . . . . . . 63.6 0.7 46.3 0.8
1999 . . . . . . . . . . . . . . . . . . . . . . . . . . 65.9 0.8 49.9 0.8
2000 . . . . . . . . . . . . . . . . . . . . . . . . . . 64.5 0.7 53.2 0.8
SE Standard error.
NOTES: Data are for the civilian noninstitutionalized population and are age adjusted to the 2000 standard population using two age groups: 65–74 years and
75 years and over. See Appendix II, Age adjustment.
Data table for figure 14. Influenza and pneumococcal vaccination among adults 65 years of age and over by race and Hispanic
origin: United States, 2000
Influenza vaccination Pneumococcal

during past 12 months vaccination ever
Race and Hispanic origin Percent SE Percent SE

White only . . . . . . . . . . . . . . . . . . . . . 66.7 0.8 56.9 0.8
Black or African American only . . . . . . 48.2 2.3 30.8 2.1
Hispanic or Latino . . . . . . . . . . . . . . . . . 55.6 2.6 30.5 2.7
SE Standard error.
NOTES: Data are for the civilian noninstitutionalized population and are age adjusted to the 2000 standard population using two age groups: 65–74 years and
75 years and over. Hispanics may be of any race. See Appendix II, Age adjustment and Race.

Data table for figure 15. Limitation of activity caused by 1 or more chronic health conditions among children by sex and age:
Limitation of activity indicated

by participation in special
education or early intervention All other limitation Any limitation
services only of activity of activity
Sex and age Percent SE Percent SE Percent SE
Boys
Under 5 years . . . . . . . . . . . . . . . . . . 2.2 0.2 1.6 0.2 3.8 0.2
5–11 years . . . . . . . . . . . . . . . . . . . . 6.5 0.2 2.4 0.2 8.9 0.3
12–17 years . . . . . . . . . . . . . . . . . . . 6.8 0.3 2.5 0.2 9.3 0.3
Girls
Under 5 years . . . . . . . . . . . . . . . . . . 1.1 0.1 1.1 0.1 2.2 0.2
5–11 years . . . . . . . . . . . . . . . . . . . . 3.7 0.2 1.2 0.1 4.8 0.3
12–17 years . . . . . . . . . . . . . . . . . . . 3.4 0.2 1.8 0.2 5.2 0.3
SE Standard error.
NOTES: Data are for noninstitutionalized children. Children with limitation of activity caused by chronic health conditions may be identified by enrollment in
special programs (special education or early intervention services) or by some other activity limitation. The category, all other limitation of activity, may include
children receiving special education or early intervention services. In 1998 data cover only July–December due to an error with the computer-assisted personal
interview (CAPI) during January–June. See Appendix II, Limitation of activity.
Data table for figure 16. Limitation of activity caused by 1 or more chronic health conditions among adults by age: United States,
1998–2000
ADL limitation IADL limitation Any limitation of activity
Age Percent SE Percent SE Percent SE
18–44 years .... . . . . . . . . . . . . . . . . . 0.4 0.0 1.0 0.0 6.2 0.1

45–64 years .... . . . . . . . . . . . . . . . . . 1.2 0.1 2.9 0.1 16.2 0.2
65–74 years .... . . . . . . . . . . . . . . . . . 3.2 0.2 6.5 0.2 27.5 0.4
75 years and over . . . . . . . . . . . . . . . . . 9.6 0.3 19.6 0.4 46.0 0.6
SE Standard error.
NOTES: Data are for the civilian noninstitutionalized population. Limitation of activity is assessed by asking respondents a series of questions about limitations
in their ability to perform activities usual for their age group because of a physical, mental, or emotional problem. Respondents are asked about limitations in
activities of daily living (ADLs), instrumental activities of daily living (IADLs), limitations in work, walking, memory, and other activities. Persons may report
limitations for an ADL, an IADL, and some other activity. Any limitation of activity may include limitations in ADLs and IADLs. For adults identified as having
limitation of activity, the causal health conditions are determined and respondents are considered limited if one or more of these conditions is chronic. In 1998
data cover only July–December due to an error with the computer-assisted personal interview (CAPI) during January–June. See Appendix II, Activities of daily
living, Instrumental activities of daily living, and Limitation of activity. See related Health, United States, 2002, table 58.

Data table for figure 17. Selected chronic health conditions causing limitation of activity among adults by age: United States,
1998–2000
Number of persons with limitation of activity caused by

selected chronic health conditions per 1,000 population
18–44 years 45–64 years 65–74 years 75 years and over
Type of chronic health condition Rate SE Rate SE Rate SE Rate SE
Mental illness . . . . . . . . . . . . . . . . . . . . . . . 10.4 0.4 18.6 0.8 11.4 1.0 10.7 1.0
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6 0.2 18.5 0.7 38.4 1.8 42.5 2.0
Fractures/joint injury . . . . . . . . . . . . . . . . . . 6.8 0.3 15.9 0.7 25.4 1.4 48.6 2.2
Vision/hearing . . . . . . . . . . . . . . . . . . . . . . . 4.2 0.3 13.8 0.6 31.2 1.6 82.5 3.0
Heart/other circulatory . . . . . . . . . . . . . . . . . 5.4 0.3 45.5 1.2 110.8 3.0 170.9 4.1
Arthritis/other musculoskeletal . . . . . . . . . . . . 22.0 0.6 73.2 1.5 117.8 3.1 193.1 4.3
SE Standard error.
NOTES: Data are for the civilian noninstitutionalized population. Selected chronic health conditions include the three leading causes of activity limitation among
adults in each age category. Conditions refer to response categories in the National Health Interview Survey; some conditions include several response
categories. ‘‘Mental illness’’ includes depression, anxiety or emotional problem, and other mental conditions. ‘‘Heart/other circulatory’’ includes heart problem,
stroke problem, hypertension or high blood pressure, and other circulatory system conditions. ‘‘Arthritis/other musculoskeletal’’ includes arthritis/rheumatism,
back or neck problem, and other musculoskeletal system conditions. Persons may report more than one chronic health condition as the cause of their activity
limitation. In 1998 data cover only July–December due to an error with the computer-assisted personal interview (CAPI) during January–June. See Appendix II,
Activities of daily living, Instrumental activities of daily living, and Limitation of activity.
Data table for figure 18. Life expectancy at birth and at 65 years of age by sex: United States, 1901–99
At birth At 65 years
Year Male Female Male Female
Life expectancy in years

1900–02 . . . . . . . . . . . . . . . . . . . . . . . . 47.9 50.7 11.5 12.2
1909–11 . . . . . . . . . . . . . . . . . . . . . . . . 49.9 53.2 11.2 12.0
1919–21 . . . . . . . . . . . . . . . . . . . . . . . . 55.5 57.4 12.2 12.7
1929–31 . . . . . . . . . . . . . . . . . . . . . . . . 57.7 60.9 11.7 12.8
1939–41 . . . . . . . . . . . . . . . . . . . . . . . . 61.6 65.9 12.1 13.6
1949–51 . . . . . . . . . . . . . . . . . . . . . . . . 65.5 71.0 12.7 15.0
1959–61 . . . . . . . . . . . . . . . . . . . . . . . . 66.8 73.2 13.0 15.8
1969–71 . . . . . . . . . . . . . . . . . . . . . . . . 67.0 74.6 13.0 16.8
1979–81 . . . . . . . . . . . . . . . . . . . . . . . . 70.1 77.6 14.2 18.4
1989–91 . . . . . . . . . . . . . . . . . . . . . . . . 71.8 78.8 15.1 19.0
1997 . . . . . . . . . . . . . . . . . . . . . . . . . . 73.6 79.4 15.9 19.2
1998 . . . . . . . . . . . . . . . . . . . . . . . . . . 73.8 79.5 16.0 19.2
1999 . . . . . . . . . . . . . . . . . . . . . . . . . . 73.9 79.4 16.1 19.1
NOTES: Life expectancies prior to 1997 are from decennial life tables based on census data and deaths for a 3-year period around the census year. Beginning
in 1997, the annual life tables are complete life tables based on a methodology similar to that used for decennial life tables. Alaska and Hawaii were included
beginning in 1959. For decennial periods prior to 1929–31, data are limited to registration States: 1900–02 and 1909–11, 10 States and the District of Columbia;
1919–21, 34 States and the District of Columbia. Deaths to nonresidents were excluded beginning in 1970. See Appendix II, Life expectancy. See related
Health, United States, 2002, table 28.
SOURCES: Anderson RN. United States life tables, 1997. National vital statistics reports; vol 47 no 28. Hyattsville, Maryland: National Center for Health
Statistics. 1999 (data for 1900–97); Anderson RN. United States life tables, 1998. National vital statistics reports; vol 48 no 18. Hyattsville, Maryland: National
Center for Health Statistics. 2001 (data for 1998); Hoyert DL, Arias E, Smith BL. Deaths: Final data for 1999. National vital statistics reports; vol 49 no 8.
Hyattsville, Maryland: National Center for Health Statistics. 2001 (data for 1999).

Data table for figure 19. Infant, neonatal, and postneonatal Data table for figure 20. Infant mortality rates by detailed race
mortality rates: United States, 1950–99 and Hispanic origin of mother: United States, 1997–99
Post- Race and Hispanic origin Infant deaths

Year Infant Neonatal neonatal of mother per 1,000 live births
Deaths per 1,000 live births White, not Hispanic or Latino . . . . . . . 5.9
1950 . . . . . . . . . . . . . . 29.2 20.5 8.7 Black or African American, not Hispanic
or Latino . . . . . . . . . . . . . . . . . . . . . 13.9
1960 . . . . . . . . . . . . . . 26.0 18.7 7.3
Hispanic or Latino . . . . . . . . . . . . . . . 5.8
1970 . . . . . . . . . . . . . . 20.0 15.1 4.9
Puerto Rican . . . . . . . . . . . . . . . . . 8.0
1980 . . . . . . . . . . . . . . 12.6 8.5 4.1
Other and unknown Hispanic or
1985 . . . . . . . . . . . . . . 10.6 7.0 3.7 Latino . . . . . . . . . . . . . . . . . . . . . 6.7
1990 . . . . . . . . . . . . . . 9.2 5.8 3.4 Mexican . . . . . . . . . . . . . . . . . . . . 5.6
1995 . . . . . . . . . . . . . . 7.6 4.9 2.7 Central and South American . . . . . . 5.1
1996 . . . . . . . . . . . . . . 7.3 4.8 2.5 Cuban . . . . . . . . . . . . . . . . . . . . . . 4.6
1997 . . . . . . . . . . . . . . 7.2 4.8 2.5 Asian or Pacific Islander . . . . . . . . . . . 5.1
1998 . . . . . . . . . . . . . . 7.2 4.8 2.4 Hawaiian . . . . . . . . . . . . . . . . . . . . 8.6
1999 . . . . . . . . . . . . . . 7.1 4.7 2.3 Filipino . . . . . . . . . . . . . . . . . . . . . 6.0
Other Asian or Pacific Islander . . . . . 5.2
NOTES: Infant is defined as under 1 year of age, neonatal as under 28
days of age, and postneonatal as between 28 days and 1 year of age. See Japanese . . . . . . . . . . . . . . . . . . . 4.1
related Health, United States, 2002, table 20. Chinese . . . . . . . . . . . . . . . . . . . . . 3.3
SOURCE: Centers for Disease Control and Prevention, National Center for American Indian or Alaska Native . . . . 9.1
NOTES: Infant is defined as under 1 year of age. Hispanic origin categories
include persons of any race. The race groups, Asian or Pacific Islander and
American Indian or Alaska Native, include persons of Hispanic and
non-Hispanic origin. See related Health, United States, 2002, table 20.
Health Statistics, National Vital Statistics System, National Linked Birth/
Infant Death Data Sets.

Data table for figure 21. Death rates for leading causes of death among persons 1–24 years of age: United States, 1950–99
1–24 years 15–24 years
All Unintentional Heart All Unintentional Heart

Year causes injuries Homicide Suicide Cancer disease causes injuries Homicide Suicide Cancer disease
Deaths per 100,000 population Deaths per 100,000 population

1950 . . . . . . . . . . . . 100.8 38.1 2.7 1.9 8.3 3.9 128.1 54.8 5.8 4.5 8.6 6.8
1960 . . . . . . . . . . . . 81.2 36.3 2.6 2.3 8.1 2.4 106.3 56.0 5.6 5.2 8.3 4.0
1970 . . . . . . . . . . . . 83.6 41.8 5.3 3.7 7.2 1.8 127.7 68.7 11.3 8.8 8.3 3.0
1980 . . . . . . . . . . . . 70.7 35.8 7.2 5.2 5.1 2.0 115.4 61.7 15.4 12.3 6.3 2.9
1985 . . . . . . . . . . . . 58.6 28.3 5.7 5.6 4.3 1.9 94.9 47.9 11.7 12.8 5.4 2.8
1990 . . . . . . . . . . . . 58.4 25.2 9.1 5.7 3.9 1.7 99.2 43.9 19.7 13.2 4.9 2.5
1995 . . . . . . . . . . . . 55.2 22.1 9.3 5.8 3.5 1.8 95.3 38.5 20.0 13.3 4.6 2.9
1996 . . . . . . . . . . . . 52.1 21.6 8.3 5.2 3.4 1.7 89.6 38.1 17.9 12.0 4.5 2.7
1997 . . . . . . . . . . . . 49.9 20.8 7.7 5.0 3.5 1.8 86.2 36.5 16.6 11.4 4.5 3.0
1998 . . . . . . . . . . . . 47.8 20.3 6.9 4.9 3.4 1.7 82.3 35.9 14.6 11.1 4.6 2.8
1998 (Comparability-
modified) . . . . . . . . . 47.8 20.9 6.9 4.9 3.4 1.7 82.3 37.0 14.6 11.1 4.6 2.8
1999 . . . . . . . . . . . . 47.0 20.2 6.3 4.5 3.4 1.6 81.2 36.2 13.2 10.3 4.6 2.8
NOTES: Death rates for 1–24 years of age are age adjusted to the year 2000 standard population using three age groups: 1–4 years, 5–14 years, and 15–24
years. Causes of death shown are the five leading causes of death among persons 1–24 years of age in 1999. 1950 death rates are based on the sixth revision
of the International Classification of Disease (ICD–6), 1960 death rates on the ICD–7, 1970 death rates on the ICDA–8, and 1980–98 death rates on the ICD–9.
1998 (Comparability-modified) death rates use comparability ratios to adjust the rate to be comparable to records classified according to the ICD–10. 1999
death rates are based on the ICD–10. Comparability ratios for selected ICD revisions are available at www.cdc.gov/nchs/data/comp2.pdf. Homicide refers to
deaths due to assault. Suicide refers to deaths from intentional self-harm. Suicide is not a cause of death for children under 5 years of age. Cancer refers to
malignant neoplasms. See Appendix II, Age adjustment, Cause of death, and Comparability ratio. See related Health, United States, 2002, tables 36, 37, 39, 46,
and 47.
SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System.
Data table for figure 22. Percent of deaths due to

leading causes of death among persons 1–24 years of age:
United States, 1999
Cause of death 1–24 years 15–24 years
Percent
Unintentional injuries . . . . . . 42.9 44.5
Homicide . . . . . . . . . . . . . . 13.4 16.3
Suicide . . . . . . . . . . . . . . . . 9.5 12.7
Cancer . . . . . . . . . . . . . . . . 7.3 5.6
Heart disease . . . . . . . . . . . 3.5 3.5
Other causes . . . . . . . . . . . 23.5 17.3
NOTES: 1999 deaths are coded according to the tenth revision of the
International Classification of Disease (ICD–10). Homicide refers to deaths
due to assault. Suicide refers to deaths from intentional self-harm. Suicide is
not a cause of death for children under 5 years of age. Cancer refers to
malignant neoplasms. See Appendix II, Cause of death. See related Health,
United States, 2002, tables 37, 39, 46, and 47.

Human
immuno-
deficiency
All Unintentional Heart virus (HIV)
Year causes injuries Cancer disease Suicide Year disease
Deaths per 100,000 population Deaths per 100,000 population

1950 ................. .. . . 276.9 45.7 43.3 55.9 11.9 1987 ................. .. . . 13.0
1960 ................. .. . . 229.8 41.9 41.4 47.8 12.3 1988 ................. .. . . 16.0
1970 ................. .. . . 243.1 49.7 39.9 41.6 15.6 1989 ................. .. . . 21.0
1980 ................. .. . . 185.9 41.4 32.7 28.1 15.7 1990 ................. .. . . 23.9
1985 ................. .. . . 169.8 34.6 31.0 24.6 14.9 1991 ................. .. . . 27.1
1990 ................. .. . . 185.0 33.9 29.3 20.6 15.3 1992 ................. .. . . 30.6
1995 ................. .. . . 195.6 33.2 27.4 21.3 15.3 1993 ................. .. . . 33.6
1996 ................. .. . . 178.3 32.4 26.9 20.4 15.0 1994 ................. .. . . 37.4
1997 ................. .. . . 163.1 32.5 26.5 20.2 14.8 1995 ................. .. . . 37.4
1998 ................. .. . . 158.7 32.7 26.0 20.4 14.7 1996 ................. .. . . 26.2
1998 (Comparability-modified) . . . 158.7 33.7 26.1 20.1 14.6 1997 ................. .. . . 13.4
1999 ................. .. . . 157.9 32.8 25.2 20.2 14.0 1998 ................. .. . . 10.4
1998 (Comparability-modified) . . . 12.0
1999 ................. .. . . 10.9
NOTES: Death rates are age adjusted to the year 2000 standard population using two age groups: 25–34 years and 35–44 years. Causes of death shown are
the five leading causes of death among persons 25–44 years of age in 1999. 1950 death rates are based on the sixth revision of the International Classification
of Disease (ICD–6), 1960 death rates on the ICD–7, 1970 death rates on the ICDA–8, and 1980–98 death rates on the ICD–9. 1998 (Comparability-modified)
death rates use comparability ratios to adjust the rate to be comparable to records classified according to the ICD–10. 1999 death rates are based on the
ICD–10. Comparability ratios for selected ICD revisions are available at www.cdc.gov/nchs/data/comp2.pdf. Cancer refers to malignant neoplasms. Suicide
refers to deaths from intentional self-harm. See Appendix II, Age adjustment, Cause of death, and Comparability ratio. See related Health, United States, 2002,
tables 36, 37, 39, 43, and 47.
Data table for figure 24. Percent of deaths due to leading

causes of death among persons 25–44 years of age:
United States, 1999
Cause of death Percent
Unintentional injuries . . . ............... . . . 20.8

Cancer . . . . . . . . . . . . . ............... . . . 15.9
Heart disease . . . . . . . . ............... . . . 12.8
Suicide . . . . . . . . . . . . . ............... . . . 8.9
Human immunodeficiency virus (HIV) disease . . . 6.9
Other causes . . . . . . . . ............... . . . 34.8
International Classification of Disease (ICD–10). Cancer refers to malignant
neoplasms. Suicide refers to deaths from intentional self-harm. See
Appendix II, Cause of death. See related Health, United States, 2002,
tables 37, 39, 43, and 47.

Chronic lower
Heart Unintentional respiratory
Year All causes Cancer disease injuries Stroke diseases
Deaths per 100,000 population

1950 ................. .. . . . . . 1,265.3 259.8 504.8 60.0 119.0 ---
1960 ................. .. . . . . . 1,140.7 263.4 454.9 53.4 87.7 ---
1970 ................. .. . . . . . 1,094.9 277.0 401.0 57.3 70.8 ---
1980 ................. .. . . . . . 883.5 280.6 303.5 40.4 40.9 22.7
1985 ................. .. . . . . . 823.7 281.9 267.4 33.7 34.5 25.0
1990 ................. .. . . . . . 757.6 273.1 217.5 31.3 30.2 24.7
1995 ................. .. . . . . . 717.2 249.8 194.2 30.6 28.8 24.0
1996 ................. .. . . . . . 700.6 243.4 189.5 31.1 28.7 23.7
1997 ................. .. . . . . . 679.4 237.5 182.5 31.6 27.7 23.3
1998 ................. .. . . . . . 662.0 231.1 174.3 31.9 26.7 22.6
1998 (Comparability-modified) . . . . . . 662.0 232.7 171.8 32.9 28.3 23.7
1999 ................. .. . . . . . 660.9 228.8 167.1 31.9 25.6 24.3

NOTES: Death rates are age adjusted to the year 2000 standard population using two age groups: 45–54 years and 55–64 years. Causes of death are the five
leading causes of death among persons 45–64 years of age in 1999. 1950 death rates are based on the sixth revision of the International Classification of
Disease (ICD–6), 1960 death rates on the ICD–7, 1970 death rates on the ICDA–8, and 1980–98 death rates on the ICD–9. 1998 (Comparability-modified)
death rates use comparability ratios to adjust the rate to be comparable to records classified according to the ICD–10. 1999 death rates are based on the
ICD–10. Comparability ratios for selected ICD revisions are available at www.cdc.gov/nchs/data/comp2.pdf. Death rates for chronic lower respiratory diseases
are not available prior to 1980 because of changes in medical terminology and the classification of these terms in the relevant ICD revisions. Cancer refers to
malignant neoplasms. Stroke refers to cerebrovascular diseases. See Appendix II, Age adjustment, Cause of death, and Comparability ratio. See related Health,
United States, 2002, tables 37, 38, 39, and 42.

causes of death among persons 45–64 years of age:
United States, 1999
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34.6
Heart disease . . . . . . . . . . . . . . . . . . . . . . . . . 25.3
Unintentional injuries . . . . . . . . . . . . . . . . . . . . 4.8
Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.9
Chronic lower respiratory diseases . . . . . . . . . . 3.7
Other causes . . . . . . . . . . . . . . . . . . . . . . . . . 27.7
neoplasms. Stroke refers to cerebrovascular diseases. See Appendix II,
Cause of death. See related Health, United States, 2002, tables 37, 38, 39,
and 42.

Data table for figure 27. Death rates due to leading causes of death among persons 65 years of age and over: United States,
1950–99
Chronic lower Influenza

Heart respiratory and
Year All causes disease Cancer Stroke diseases pneumonia
Deaths per 100,000 population

1950 ................. .. . . . . . 7,933.3 3,613.3 952.4 1,188.8 --- 273.0
1960 ................. .. . . . . . 7,536.4 3,503.6 950.9 1,225.9 --- 317.7
1970 ................. .. . . . . . 6,717.5 3,089.4 971.0 1,015.5 --- 243.9
1980 ................. .. . . . . . 5,900.2 2,652.9 1,060.2 675.3 180.7 215.8
1985 ................. .. . . . . . 5,694.0 2,431.0 1,091.2 532.6 225.5 242.9
1990 ................. .. . . . . . 5,395.9 2,108.8 1,149.3 453.1 246.8 260.7
1995 ................. .. . . . . . 5,313.8 1,946.1 1,161.6 443.3 273.5 239.7
1996 ................. .. . . . . . 5,265.9 1,893.6 1,150.4 437.9 277.9 235.5
1997 ................. .. . . . . . 5,226.6 1,844.0 1,137.9 428.8 282.9 238.4
1998 ................. .. . . . . . 5,181.4 1,794.8 1,124.8 412.4 288.0 247.4
1998 (Comparability-modified) . . . . . . 5,181.4 1,769.4 1,132.5 436.7 301.8 172.8
1999 ................. .. . . . . . 5,237.5 1,771.5 1,132.8 434.0 314.6 167.5

NOTES: Death rates are age adjusted to the year 2000 standard population using three age groups: 65–74 years, 75–84 years, and 85 years and over. Causes
of death shown are the five leading causes of death among persons 65 years of age and over in 1999. 1950 death rates are based on the sixth revision of the
International Classification of Disease (ICD–6), 1960 death rates on the ICD–7, 1970 death rates on the ICDA–8, and 1980–98 death rates on the ICD–9. 1998
(Comparability-modified) death rates use comparability ratios to adjust the rate to be comparable to records classified according to the ICD–10. 1999 death
rates are based on the ICD–10. Comparability ratios for selected ICD revisions are available at www.cdc.gov/nchs/data/comp2.pdf. Death rates for chronic lower
respiratory diseases are not shown prior to 1980 because of changes in medical terminology and the classification of these terms in the relevant ICD revisions.
Cancer refers to malignant neoplasms. Stroke refers to cerebrovascular diseases. See Appendix II, Age adjustment, Cause of death, and Comparability ratio.
See related Health, United States, 2002, tables 36, 37, 38, 39, and 42.

causes of death among persons 65 years of age and over:
United States, 1999
Heart disease . . . . . . . . . . . . . . . . . . . . . . . . . 33.8

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.7
Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3
Chronic lower respiratory diseases . . . . . . . . . . 6.0
Influenza and pneumonia . . . . . . . . . . . . . . . . . 3.2
Other causes . . . . . . . . . . . . . . . . . . . . . . . . . 27.0
neoplasms. Stroke refers to cerebrovascular diseases. See Appendix II,
Cause of death. See related Health, United States, 2002, tables 37, 38, 39,
and 42.

Appendix Contents
Appendix Contents Nurse Supply Estimates . . . . . . . . . . . . . . . . . .
Online Survey Certification and Reporting
102
Database. . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
I. Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Population Census . . . . . . . . . . . . . . . . . . . . . 103
Government Sources . . . . . . . . . . . . . . . . . . . . . 76
Population Estimates . . . . . . . . . . . . . . . . . . . 104
Abortion Surveillance . . . . . . . . . . . . . . . . . . . . 76
Surveillance, Epidemiology, and End Results
Aerometric Information Retrieval System. . . . . . 76

Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
AIDS Surveillance . . . . . . . . . . . . . . . . . . . . . . 77
Survey of Occupational Injuries and
Census of Fatal Occupational Injuries. . . . . . . . 77

Illnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Consumer Price Index . . . . . . . . . . . . . . . . . . . 78

Youth Risk Behavior Survey . . . . . . . . . . . . . . . 105
Current Population Survey . . . . . . . . . . . . . . . . 79

Private and Global Sources . . . . . . . . . . . . . . . . 106
Drug Abuse Warning Network. . . . . . . . . . . . . . 79

Alan Guttmacher Institute Abortion Survey . . . . 106
Employer Costs for Employee

American Association of Colleges of Osteopathic
Compensation . . . . . . . . . . . . . . . . . . . . . . . . 79
Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Employment and Earnings . . . . . . . . . . . . . . . . 80

American Association of Colleges of
Inventory of Mental Health Organizations . . . . . 80

Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Medicaid Data System . . . . . . . . . . . . . . . . . . . 81

American Association of Colleges of Podiatric
Medical Expenditure Panel Survey . . . . . . . . . . 81

Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Medicare Current Beneficiary Survey . . . . . . . . 82

American Dental Association . . . . . . . . . . . . . . 106
Medicare National Claims History Files. . . . . . . 82

Annual Census of Hospitals . . . . . . . . . . . . . . 107
Monitoring the Future Study . . . . . . . . . . . . . . . 83

Annual Survey of Hospitals . . . . . . . . . . . . . . . 107
National Ambulatory Medical Care Survey . . . . 83

Association of American Medical Colleges . . . . 107
National Health Accounts . . . . . . . . . . . . . . . . . 84

Association of Schools and Colleges of
Estimates of State Health Expenditures. . . . . . 85

Optometry . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
National Health and Nutrition Examination

Association of Schools of Public Health . . . . . . 108
Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Demographic Yearbook . . . . . . . . . . . . . . . . . . 108
National Health Interview Survey . . . . . . . . . . . 87

National Health Maintenance Organization
National Health Provider Inventory (National

Census . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Master Facility Inventory) . . . . . . . . . . . . . . . . 89

National League for Nursing. . . . . . . . . . . . . . . 108
National Home and Hospice Care Survey. . . . . 89

Organization for Economic Cooperation and
National Hospital Ambulatory Medical Care

Development Health Data . . . . . . . . . . . . . . . 109
Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Physician Masterfile . . . . . . . . . . . . . . . . . . . . . 109
National Hospital Discharge Survey . . . . . . . . . 90

World Health Statistics Annual . . . . . . . . . . . . . 109
National Household Survey on Drug Abuse . . . 91
National Immunization Survey . . . . . . . . . . . . . 92
National Medical Expenditure Survey . . . . . . . . 93

II. Definitions and Methods . . . . . . . . . . . . . . . . 110
National Notifiable Diseases Surveillance
System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Appendix Tables
National Nursing Home Survey. . . . . . . . . . . . . 94
I. Projected year 2000 U.S. population and
National Patient Care Database . . . . . . . . . . . . 95
proportion distribution by age for age adjusting
National Survey of Ambulatory Surgery. . . . . . . 95
death rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
National Survey of Family Growth . . . . . . . . . . 96
II. Numbers of live births and mother’s age groups
National Survey of Substance Abuse Treatment
used to adjust maternal mortality rates to live
Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
births in the United States in 1970 . . . . . . . . . . . . 111
National Vital Statistics System . . . . . . . . . . . . 97
III. Projected year 2000 U.S. resident population and
Birth File . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
age groups used to age adjust survey data . . . . . 112
Mortality File. . . . . . . . . . . . . . . . . . . . . . . . . 99
IV. Revision of the International Classification of
Multiple Cause of Death File. . . . . . . . . . . . . 101
Diseases (ICD) according to year of conference
National Linked File of Live Births and Infant
by which adopted and years in use in the
Deaths . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Compressed Mortality File. . . . . . . . . . . . . . . 102
Appendix Contents
V. Cause-of-death codes, according to applicable

revision of International Classification of
Diseases (ICD) . . . . . . . . . . . . . . . . . . . . . . . . . . 115
VI. Comparability of selected causes of death between
the Ninth and Tenth Revisions of the International
Classification of Diseases (ICD) . . . . . . . . . . . . . . 117
VII. Codes for first-listed external causes of injury from
the International Classification of Diseases (ICD)
Ninth Revision, Clinical Modification . . . . . . . . . . . 120
VIII. Codes for Industries, according to the Standard
Industrial Classification (SIC) Manual . . . . . . . . . . 125
IX. Codes for diagnostic categories from the International
Classification of Diseases, Ninth Revision, Clinical
Modification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
X. Codes for procedure categories from the International
Classification of Diseases, Ninth Revision, Clinical
Modification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
XI. Current cigarette smoking by persons 18 years of
age and over, according to race and Hispanic origin
under the 1977 and 1997 Standards for Federal data
on race and ethnicity: United States, average annual,
1993–95 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
XII. Private health care coverage for persons under 65
years of age, according to race and Hispanic origin
under the 1977 and 1997 Standards for Federal
data on race and ethnicity: United States, average
annual 1993–95. . . . . . . . . . . . . . . . . . . . . . . . . . 137

Appendix I — Data Sources
Appendix I their impact on the data. Where possible, table notes
describe the universe and method of data collection, to
enable the user to place his or her own evaluation on the
Data Sources data. In many instances data do not add to totals because of
rounding.
This report consolidates the most current data on the health Some information is collected in more than one survey and
of the population of the United States, the availability and use estimates of the same statistic may vary among surveys
of health resources, and health care expenditures. The because of different survey methodologies, sampling frames,
information was obtained from the data files and/or published questionnaires, definitions, and tabulation categories. For
reports of many Federal Government and private and global example, cigarette use is measured by the National Health
agencies and organizations. In each case, the sponsoring Interview Survey, the National Household Survey of Drug
agency or organization collected data using its own methods Abuse, the Monitoring the Future Survey, and the Youth Risk
and procedures. Therefore, the data in this report vary Behavior Survey.
considerably with respect to source, method of collection,
definitions, and reference period. Overall estimates generally have relatively small sampling
errors, but estimates for certain population subgroups may be
Although a detailed description and comprehensive evaluation based on small numbers and have relatively large sampling
of each data source are beyond the scope of this appendix, errors. Numbers of births and deaths from the vital statistics
users should be aware of the general strengths and system represent complete counts (except for births in those
weaknesses of the different data collection systems. For States where data are based on a 50-percent sample for
example, population-based surveys obtain socioeconomic certain years). Therefore, they are not subject to sampling
data, data on family characteristics, and information on the error. However, when the figures are used for analytical
impact of an illness, such as days lost from work or limitation purposes, such as the comparison of rates over a period, the
of activity. These data are limited by the amount of number of events that actually occurred may be considered
information a respondent remembers or is willing to report. as one of a large series of possible results that could have
Detailed medical information, such as precise diagnoses or arisen under the same circumstances. When the number of
the types of operations performed, may not be known and, if events is small and the probability of such an event is small,
so, will not be reported. Health care providers, such as considerable caution must be observed in interpreting the
physicians and hospitals, usually have good diagnostic conditions described by the figures. Estimates that are
information but little or no information about the unreliable because of large sampling errors or small numbers
socioeconomic characteristics of individuals or the impact of of events are noted with asterisks in selected tables. The
illnesses on individuals. criteria used to designate unreliable estimates are indicated in
The populations covered by different data collection systems notes to the applicable tables.
may not be the same, and understanding the differences is Descriptive summaries of the data sets that follow provide a
critical to interpreting the data. Data on vital statistics and general overview of study design, methods of data collection,
national expenditures cover the entire population. Most data and reliability and validity of the data. The agency or
on morbidity and utilization of health resources cover only the organization that sponsored the data collection is specified.
civilian noninstitutionalized population. Such statistics do not More complete and detailed discussions are in the
include data for military personnel who are usually young, for publications and Web sites listed at the end of each
institutionalized people who may be any age, or for nursing summary. The entries are listed alphabetically by dataset
home residents who are usually old. name.
All data collection systems are subject to error, and records
may be incomplete or contain inaccurate information. People
may not remember essential information, a question may not
mean the same thing to different respondents, and some
institutions or individuals may not respond at all. It is not
always possible to measure the magnitude of these errors or

Government Sources Director, Division of Reproductive Health, NCCDPHP, CDC,

Atlanta, GA 30341; or visit the NCCDPHP surveillance and
research Web site at www.cdc.gov/nccdphp/drh/surveil.htm.
Abortion Surveillance
Centers for Disease Control and Prevention Aerometric Information Retrieval System (AIRS)
National Center for Chronic Disease Prevention
and Health Promotion Environmental Protection Agency
In 1969 CDC’s National Center for Chronic Disease The Environmental Protection Agency’s Aerometric Information
Prevention and Health Promotion (NCCDPHP) began abortion Retrieval System (AIRS) compiles data on ambient air levels
surveillance to document the number and characteristics of of particulate matter smaller than 10 microns (PM-10), lead,
women obtaining legal induced abortions, monitor unintended carbon monoxide, sulphur dioxide, nitrogen dioxide, and
pregnancy, and assist efforts to identify and reduce tropospheric ozone. These pollutants were identified in the
preventable causes of morbidity and mortality associated with Clean Air Act of 1970 and in its 1977 and 1990 amendments
abortions. For each year from 1973–97 abortion data have because they pose significant threats to public health. The
been available from 52 reporting areas: 50 States, the District National Ambient Air Quality Standards (NAAQS) define for
of Columbia, and New York City. Beginning in 1998, abortion each pollutant the maximum concentration level (micrograms
data are available only from 48 reporting areas coming from per cubic meter) that cannot be exceeded during specific time
central health agencies. The total number of legal induced intervals. Data shown in this publication reflect percent of the
abortions is available for all reporting areas; however, not all population living in nonattainment areas that exceed the
areas collect information on the characteristics of women who NAAQS for a pollutant in a calendar year and population data
obtain abortions. Furthermore the number of States reporting from the Bureau of the Census. For 1996 and later years,
each characteristic and the number of States with complete estimates of the population in the year 2000 are used for this
data for each characteristic varies from year to year. State calculation.
data with more than 15 percent unknown for a given Nonattainment areas may include single counties, multiple
characteristic are excluded from the analysis of that counties, parts of counties, municipalities, or combinations of
characteristic. the preceding jurisdictions. When an area is designated as
For 48 reporting areas, data concerning the number and ‘‘nonattainment,’’ it retains this status for 3 years, regardless
characteristics of women who obtain legal induced abortions of annual changes in air quality. Nonattainment areas may
are provided by central health agencies such as State health also include jurisdictions in which the source of the pollutants
departments and the health departments of New York City is located, even if that jurisdiction meets all NAAQS. The
and the District of Columbia. In general the procedures are areas monitored may change over time to reflect changes in
reported by the State in which the procedure is performed. air quality or the pollutants being monitored.
However, two reporting areas (the District of Columbia and The EPA’s ambient air quality monitoring program is carried
Wisconsin) report characteristics of abortions only for out by State and local agencies and consists of three major
area/State residents; characteristics for out-of-area/State categories of monitoring stations, State and Local Air
residents are unavailable. Monitoring Stations (SLAMS), National Air Monitoring Stations
The total number of abortions reported to CDC is about (NAMS), and Special Purpose Monitoring Stations (SPMS),
10 percent less than the total estimated independently by the that measure the criteria pollutants. Additionally, a fourth
Alan Guttmacher Institute (AGI), a not-for-profit organization category of a monitoring station, the Photochemical
for reproductive health research, policy analysis, and public Assessment Monitoring Stations (PAMS), which measures
education. See AGI Abortion Survey in Appendix I below. ozone precursors (approximately 60 volatile hydrocarbons and
carbonyl) has been required by the 1990 Amendments to the
For more information, see Centers for Disease Control and Clean Air Act.
Prevention, CDC Surveillance Summaries, May 2002.
Morbidity and Mortality Weekly Report 2002;51 (NoSS-3), SLAMS consist of a network of about 4,000 monitoring
Abortion Surveillance—United States, 1998; or contact: stations whose size and distribution is largely determined by

the needs of State and local air pollution control agencies to
of new treatments, which prevent or delay the onset of AIDS
meet their respective State implementation plan requirements.
and premature death among HIV-infected persons, and result
The NAMS (1,080 stations) are a subset of the SLAMS
in an increase in the number of persons living with HIV and
network with emphasis being given to urban and multi-source
AIDS. A growing number of States require confidential
areas. In effect they are key sites under SLAMS, with
reporting of persons with HIV infection and participate in
emphasis on areas of maximum concentrations and high
CDC’s integrated HIV/AIDS surveillance system that compiles
population density. SPMS provide for special studies needed
information on the population of persons newly diagnosed and
by the State and local agencies to support State
living with HIV infection.
implementation plans and other air program activities. SPMS
For more information on AIDS surveillance, see: Centers for

are not permanently established and can be adjusted easily
Disease Control and Prevention. HIV/AIDS Surveillance

to accommodate changing needs and priorities. SPMS are
Report, published semiannually; or contact: Chief,

used to supplement the fixed monitoring network as
Surveillance Branch, Division of HIV/AIDS Prevention—

circumstances require and resources permit.
Surveillance and Epidemiology, National Center for HIV, STD,

For more information, write: Office of Air Quality Planning
and TB Prevention (NCHSTP), Centers for Disease Control
and Standards, Environmental Protection Agency, Research
and Prevention, Atlanta, GA 30333; or visit the NCHSTP
Triangle Park, NC 27711; or visit the EPA Office of
home page at www.cdc.gov/nchstp/od/nchstp.html.
Air Quality Planning and Standards home page at
www.epa.gov/oar/oaqps.
Census of Fatal Occupational Injuries (CFOI)
Bureau of Labor Statistics
AIDS Surveillance
Centers for Disease Control and Prevention The Census of Fatal Occupational Injuries (CFOI),
National Center for Chronic Disease Prevention administered by the Bureau of Labor Statistics (BLS) in
and Health Promotion conjunction with participating State agencies, compiles
comprehensive and timely information on fatal work injuries
Acquired immunodeficiency syndrome (AIDS) surveillance is occurring in the 50 States and the District of Columbia. To
conducted by health departments in each State, territory, and compile counts that are as complete as possible, the BLS
the District of Columbia. Although surveillance activities range census uses diverse sources to identify, verify, and profile
from passive to active, most areas employ multifaceted active fatal work injuries. Key information about each workplace
surveillance programs, which include four major reporting fatality (occupation and other worker characteristics,
sources of AIDS information: hospitals and hospital-based equipment or machinery involved, and circumstances of the
physicians, physicians in nonhospital practice, public and event) is obtained by cross-referencing the source records.
private clinics, and medical record systems (death certificates, Work relationship is verified for each work injury fatality by
tumor registries, hospital discharge abstracts, and using at least two independent source documents. For a
communicable disease reports). Using a standard confidential fatality to be included in the census, the decedent must have
case report form, the health departments collect information been employed (that is, working for pay, compensation, or
that is then transmitted electronically to CDC without personal profit) at the time of the event, engaged in a legal work
identifiers. activity, or present at the site of the incident as a requirement
of his or her job. These criteria are generally broader than
AIDS surveillance data are used to detect epidemiologic
those used by Federal and State agencies administering
trends, to identify unusual cases requiring followup, and for
specific laws and regulations. Fatalities that occur during a
semiannual publication in the HIV/AIDS Surveillance Report.
person’s commute to or from work are excluded from the
Studies to determine the completeness of reporting of AIDS
census counts.
cases meeting the national surveillance definition suggest
reporting at greater than or equal to 90 percent. Data for the CFOI are compiled from various Federal, State,
and local administrative sources—including death certificates,
Decreases in AIDS incidence and in the number of AIDS
workers’ compensation reports and claims, reports to various
deaths, first noted in 1996, have been ascribed to the effect
regulatory agencies, medical examiner reports, and police

reports—as well as news reports. Diverse sources are used consumers has risen from $100 in 1982–84 to $177.10 in
because studies have shown that no single source captures 2001.
all job-related fatalities. Source documents are matched so

The current revision of the CPI, completed in 2000, reflects
that each fatality is counted only once. To ensure that a

spending patterns based on the Survey of Consumer
fatality occurred while the decedent was at work, information

Expenditures from 1993 to 1995, the 1990 Census of
is verified from two or more independent source documents

Population, and the ongoing Point-of-Purchase Survey. Using
or from a source document and a followup questionnaire.

an improved sample design, prices for the goods and
States may identify additional fatal work injuries after data services required to calculate the index are collected in urban
collection closeout for a reference year. In addition, other areas throughout the country and from retail and service
fatalities excluded from the published count because of establishments. Data on rents are collected from tenants of
insufficient information to determine work relationship may rented housing and residents of owner-occupied housing
subsequently be verified as work related. States have up to 1 units. Food, fuels, and other goods and services are priced
year to update their initial published State counts. monthly in urban locations. Price information is obtained
Occupational fatalities and rates shown in this report are through visits or calls by trained BLS field representatives
revised, except for the most recent year, and may differ from using computer-assisted telephone interviews.
original data published by CFOI. Increases in the published

The earlier 1987 revision changed the treatment of health
counts based on additional information have averaged less

insurance in the cost-weight definitions for medical care items.
than 100 fatalities per year, or less than 1.5 percent of the
This change has no effect on the final index result but
total.
provides a clearer picture of the role of health insurance in
For more information, see: Bureau of Labor Statistics, the CPI. As part of the revision, three new indexes have been
National Census of Fatal Occupational Injuries, 2000. created by separating previously combined items, for
Washington, DC. U.S. Department of Labor. August 2001; or example, eye care from other professional services and
visit the CFOI Internet site at stats.bls.gov/oshfat1.htm. inpatient and outpatient treatment from other hospital and
medical care services.
Consumer Price Index (CPI) Effective January 1997 the hospital index was restructured by
Bureau of Labor Statistics combining the three categories—room, inpatient services, and
outpatient services—into one category, hospital services.
The Consumer Price Index (CPI) is a monthly measure of the Differentiation between inpatient and outpatient and among
average change in the prices paid by urban consumers for a service types are under this broad category. In addition new
fixed market basket of goods and services. The all-urban procedures for hospital data collection identify a payor,
index (CPI-U) introduced in 1978 covers residents of diagnosis, and the payor’s reimbursement arrangement from
metropolitan areas as well as residents of urban parts of selected hospital bills.
nonmetropolitan areas (about 87 percent of the U.S. A new geographic sample and item structure were introduced
population in 2000). in January 1998 and expenditure weights were updated to
In calculating the index, price changes for the various items 1993–95. Pricing of a new housing sample using computer-
in each location were averaged together with weights that assisted data collection started in June 1998. In January
represent their importance in the spending of all urban 1999 the index was rebased from the 1982–84 time period to
consumers. Local data were then combined to obtain a U.S. 1993–95.
city average. For more information, see: Bureau of Labor Statistics,
The index measures price changes from a designated Handbook of Methods, BLS Bulletin 2490, U.S. Department of
reference date, 1982–84, which equals 100. An increase of Labor, Washington, DC. April 1997; Revising the Consumer
22 percent, for example, is shown as 122. Change can also Price Index, Monthly Labor Review, Dec 1996. U.S.
be expressed in dollars as follows: the price of a base period Department of Labor, Bureau of Labor Statistics, Washington,
‘‘market basket’’ of goods and services bought by all urban DC; IK Ford and D Ginsburg, Medical Care and the
Consumer Price Index, National Bureau of Economic

Research, Research Studies in Income and Wealth vol. 62; or consequences and other health hazards. Estimates reported
visit the BLS home page at www.bls.gov. in this publication are from the hospital ED component of
DAWN.
Current Population Survey (CPS) Hospitals eligible for DAWN are non-Federal, short-stay
general hospitals that have a 24-hour emergency department.
Bureau of the Census
Since 1988 the DAWN emergency department data have
The Current Population Survey (CPS) is a household sample been collected from a representative sample of these
survey of the civilian noninstitutionalized population conducted hospitals located throughout the coterminous United States,
monthly by the U.S. Bureau of the Census for the including 21 oversampled metropolitan areas. Within each
Department of Labor, Bureau of Labor Statistics (BLS). CPS facility, a designated DAWN reporter is responsible for
provides estimates of employment, unemployment, and other identifying eligible drug-abuse episodes by reviewing
characteristics of the general labor force, the population as a emergency department records and abstracting and
whole, and various other population subgroups. submitting data on each reportable case. To be included in
DAWN, the patient presenting to the ED must meet all of the
The CPS survey is conducted by the Bureau of the Census following four criteria: (a) patient was between ages 6 and 97
for the Department of Labor. The CPS sample is located in years and was treated in the hospital’s ED; (b) patient’s
754 sample areas, with coverage in every State and the presenting problem(s) for the ED visit was induced by or
District of Columbia. Beginning with 2001 estimates are based related to drug use, regardless of when drug use occurred;
on interviews of an expanded sample of 60,000 households (c) episode involved use of an illegal drug or use of a legal
per month. Prior to 2001 estimates were based on 50,000 drug or other chemical substance contrary to directions; (d)
households per month. In an average month the nonresponse patient’s reason for using the substance(s) was dependence,
rate is about 6–7 percent. In 1994 major changes were suicide attempt or gesture, and/or psychic effect.
introduced, which included a complete redesign of the
questionnaire and the introduction of computer-assisted The data from the DAWN sample are used to generate
interviewing for the entire survey. In addition, there were estimates of the total number of emergency department
revisions to some of the labor force concepts and definitions. drug-abuse episodes and drug mentions in all eligible
hospitals in the coterminous United States and in the 21
The estimation procedure used involves inflation by the metropolitan areas. Overall, a response rate of 81 percent of
reciprocal of the probability of selection, adjustment for sample hospitals was obtained in the 2000 survey.
nonresponse, and ratio adjustment. Beginning in 1994 new
population controls that were based on the 1990 census For further information, see Substance Abuse and Mental
adjusted for the estimated population undercount were used. Health Services Administration, Office of Applied Studies.
Emergency Department Trends from the Drug Abuse Warning
For more information on the CPS, visit the BLS home page Network, Preliminary Estimates January–June 2001 with
at www.bls.gov/cps. Revised Estimates 1994 to 2000, DAWN Series D-20, DHHS
Publication No. (SMA) 02–3634, Rockville, MD. 2002 or write:
Drug Abuse Warning Network (DAWN) Office of Applied Studies, Substance Abuse and Mental
Health Services Administration, Room 16–105, 5600 Fishers
Substance Abuse and Mental Health Services
Lane, Rockville, MD 20857; or visit the SAMHSA home page
Administration
at www.drugabusestatistics.samhsa.gov.
The Drug Abuse Warning Network (DAWN) is a large-scale,
ongoing drug abuse data collection system based on Employer Costs for Employee Compensation
information from hospital emergency departments (EDs) and
Bureau of Labor Statistics
from medical examiner facilities. The major objectives of the
DAWN data system include monitoring of drug-abuse patterns Employer costs for employee compensation cover all
and trends, identification of substances associated with occupations in private industry, excluding farms and
drug-abuse episodes, and assessment of drug-related households and State and local governments. These cost

levels are published once a year with the payroll period Inventory of Mental Health Organizations (IMHO)
including March 12th as the reference period.
The cost levels are based on compensation cost data Administration (SAMHSA)
collected for the Bureau of Labor Statistics Employment Cost
Index (ECI), released quarterly. Employee Benefits Survey The Survey and Analysis Branch of SAMHSA’s Center for
(EBS) data are jointly collected with the ECI data. Cost data Mental Health Services conducted a biennial Inventory of
were collected from the ECI’s March 1993 sample that Mental Health Organizations and General Hospital Mental
consisted of about 23,000 occupations within 4,500 sample Health Services (IMHO/GHMHS) from 1986 until 1994. The
establishments in private industry and 7,000 occupations core questionnaire included versions designed for specialty
within 1,000 establishments in State and local governments. mental health organizations and another for non-Federal
The sample establishments are classified industry categories general hospitals with separate psychiatric services. The
based on the 1987 Standard Industrial Classification (SIC) response rate to most of the items on the inventory was
system, as defined by the U.S. Office of Management and relatively high (90 percent or better). However, for some
Budget. Within an establishment, specific job categories are inventory items, the response rate may have been somewhat
selected to represent broader major occupational groups such lower.
as professional specialty and technical occupations. The cost
IMHO/GHMHS has been the primary source for Center for
levels are calculated with current employment weights each
Mental Health Services data included in Health, United
year.
States. The data system was based on questionnaires mailed
For more information, see: U.S. Department of Labor, Bureau every other year to mental health organizations in the United
of Labor Statistics, Employment Cost Indexes 1975–99, States, including psychiatric hospitals, non-Federal general
Bulletin 2532, Oct. 2000; or visit the BLS home page at hospitals with psychiatric services, Department of Veterans
www.bls.gov. Affairs psychiatric services, residential treatment centers for
emotionally disturbed children, freestanding outpatient
Employment and Earnings psychiatric clinics, partial care organizations, freestanding
day-night organizations, and multiservice mental health
Bureau of Labor Statistics organizations, not elsewhere classified.
The Division of Monthly Industry Employment Statistics and IMHO/GHMHS was a redesign of three previous inventory
the Division of Employment and Unemployment Analysis of systems with more complicated data collection procedures. In
the Bureau of Labor Statistics publish data on employment 1998 the IMHO/GHMHS was replaced by the Survey of
and earnings. The data are collected by the U.S. Bureau of Mental Health Organizations, General Hospital Mental Health
the Census, State Employment Security Agencies, and State Services, and Managed Behavioral Health Care Organizations
Departments of Labor in cooperation with BLS. The major (SMHO). A brief 100% inventory of organizations was
data source is the Current Population Survey (CPS), a conducted by postcard and used to provide basic information
household interview survey conducted monthly by the U.S. on all organizations and as a sampling frame from which to
Bureau of the Census to collect labor force data for BLS. The draw a sample for a more in-depth sample survey. The
CPS is described separately in this appendix. Data based on sample survey questionnaire differed from the previous core
establishment records are also compiled each month from questionnaires mainly by inclusion of questions relating to
mail questionnaires by BLS, in cooperation with State managed behavioral health care organizations.
agencies. Other surveys conducted by the Survey and Analysis Branch
For more information, see: U.S. Department of Labor, Bureau are the Client/Patient Sample Survey and the Inventory of the
of Labor Statistics, Employment and Earnings, Jan. 2002, vol Juvenile Justice System. The Client/Patient Sample Survey
49 no 1, Washington, DC. U.S. Government Printing Office. encompasses patients admitted to State and county mental
Jan. 2002; or visit the BLS home page at www.bls.gov. hospitals, private mental hospitals, multiservice mental health
organizations, the psychiatric services of non-Federal general
hospitals and Department of Veterans Affairs medical centers,

residential treatment centers for emotionally disturbed The number of recipients and eligibles reported on the
children, and freestanding outpatient and partial care HCFA-2082 are referred to as ‘‘Unduplicated,’’ which simply
programs. The Inventory of the Juvenile Justice System means that each person is counted once based on their
provides data on the number of organizations providing eligibility grouping (for example, Aged or Blind or Disabled)
services to inpatients, outpatient and residential treatment when they first receive medical services.
clients. The purpose of these surveys is to determine the The Medicaid data presented in Health, United States are
sociodemographic, clinical, and treatment characteristics of contained in the Medicaid statistical system (HCFA-2082
patients served by these organizations. Report and the MSIS tapes). Data reported on the quarterly
For more information, write: Survey and Analysis Branch, Medicaid financial report (HCFA-64) submitted to CMS by
Division of State and Community Systems Development, States for reimbursement may differ from the Medicaid
Center for Mental Health Services, Room 15C-04, 5600 statistical report, primarily because the HCFA-64 includes
Fishers Lane, Rockville, MD 20857. For further information on disproportionate share hospital payments, payments to health
mental health and data from the 1997 Client/Patient Sample maintenance organizations and Medicare, and quarterly
Survey, see: Center for Mental Health Services, Mental payment adjustments.
Health, United States, 2000. Manderscheid R, Henderson MJ,
For further information on Medicaid data, see Medicaid
eds. DHHS Pub. No. (SMA) 01–3537. Washington, DC; or
Statistics, Program and Financial Statistics, Fiscal Year 1997,
visit the Center for Mental Health Services home page at
HCFA Pub. No. 10129, Health Care Financing Administration,
www.samhsa.gov/cmhs/cmhs.htm.
Baltimore, MD. U.S. Government Printing Office, May 1999;
or call the Medicaid Hotline at 410-786-0165. For additional
Medicaid Data System information and data visit the CMS Web site at www.hcfa.gov.
Centers for Medicare and Medicaid Services
Medical Expenditure Panel Survey (MEPS)
Many State Medicaid agencies continue to submit data
annually to the Centers for Medicare & Medicaid Services Agency for Healthcare Research and Quality
(CMS) (formerly known as Health Care Financing
The 1996 and 1997 Medical Expenditure Panel Surveys
Administration (HCFA)) using the Form HCFA-2082, Statistical
(MEPS) update the 1987 National Medical Expenditure
Report on Medical Care: Eligibles, Recipients, Payments, and
Survey (NMES). MEPS is designed to understand how the
Services. However, the majority of Medicaid data are derived
growth of managed care and other changes in the health
from the Medicaid Statistical Information System (MSIS).
care delivery system affect the use, type, and costs of health
States participating in MSIS provide CMS with a larger
care. MEPS consists of four components:
database through submission of computer tapes. CMS then
extracts comparable data to produce a mirror copy of the The Household Component (HC) is a nationally
HCFA-2082 report. The Federal reporting period is between representative survey of the civilian noninstitutionalized
October 1 and September 30 of the fiscal year. population drawn from a subsample of households that
participated in the prior year’s National Health Interview
The following information may help when using Medicaid
Survey conducted by the National Center for Health Statistics.
data:
The sample sizes for HC are approximately 10,000 families in
CMS performs many statistical edits to ensure 1996 and 1998–2000, 13,500 families in 1997 and 2001, and
consistency and identification of aberrant and missing data. 15,000 families annually beginning in 2002. The panel design
CMS may substitute cell values only when necessary in order of the survey features several rounds of interviewing covering
to maintain consistency. two full calendar years. Data are collected on health status,
Medical Vendor Payments exclude lump sum adjustments health insurance coverage, health care use and expenditures,
(such as payments to disproportionate share hospitals). and sources of payment for health services.
States must adjust payments to qualified hospitals that The Nursing Home Component (NHC) gathered
provide inpatient services to a disproportionate number of information from a sample of approximately 800 nursing
Medicaid recipients and/or other low-income persons. homes and more than 5,000 residents in 1996. Data were

collected on characteristics of the facilities and services personal interviewing (CAPI) survey instruments. Because
offered, expenditures and sources of payment on an long-term care facility residents often are in poor health,
individual resident level, and resident characteristics, including information about institutionalized patients is collected from
functional limitation, cognitive impairment, age, income, and proxy respondents such as nurses and other primary care
insurance coverage, and the availability and use of givers affiliated with the facility. The sample is selected from
community-based care prior to nursing home admission. the Medicare enrollment files with oversampling among
Data are collected in the Medical Provider Component disabled persons under age 65 and among persons 80 years
(MPC) to improve the accuracy of expenditure estimates of age and over.
derived solely from the Household Component (HC). MPC is Medicare claims are linked to survey-reported events to
particularly useful in obtaining expenditure information for produce the Cost and Use file that provides complete
persons enrolled in managed care plans and Medicaid expenditure and source of payment data on all health care
recipients. MPC collects data from hospitals, physicians, and services, including those not covered by Medicare.
home health providers that were reported in HC as providing
care to the MEPS sample persons. Sample sizes for MPC For more information about MCBS, see: A profile of the
vary from year to year depending on the HC sample size and Medicare Current Beneficiary Survey, by GS Adler. Health
the MPC sampling rates for providers. Care Financing Review, vol 15 no 4. Health Care Financing
Administration. Washington, DC. Public Health Service. 1994.
The Insurance Component (IC) consisted of two
For further information on the MCBS, visit the CMS home
subcomponents. The household sample collected detailed
page at www.hcfa.gov.
information from employers and union officials on the health
insurance held by and offered to respondents to the MEPS
HC. The list sample collected data on the types and costs of Medicare National Claims History Files
workplace health insurance from 40,000 business
establishments and governments.
The Medicare Common Working File (CWF) is a Medicare
For further information on MEPS, visit the AHRQ home page
Part A and Part B benefit coordination and claims validation
at www.meps.ahrq.gov.
system. There are two National Claims History (NCH) files,
the NCH 100 percent Nearline File, and the NCH Beneficiary
Medicare Current Beneficiary Survey (MCBS) Program Liability (BPL) File. These NCH files contain claims
records and Medicare beneficiary information. The NCH
100 percent Nearline File contains all institutional and
The Medicare Current Beneficiary Survey (MCBS) is a physician/supplier claims from CWF. It provides records of
continuous survey of a nationally representative sample of every claim submitted, including all adjustment claims. The
about 18,000 aged and disabled Medicare beneficiaries NCH BPL file contains Medicare Part A and Part B
enrolled in Medicare Part A (hospital insurance), or Part B beneficiary liability information (such as deductible and
(medical insurance), or both, and residing in households or coinsurance amounts remaining). These records include all
long-term care facilities. The survey provides comprehensive Part A and Part B utilization and entitlement data. Records for
time-series data on utilization of health services, health and 1999 were maintained on more than 39 million enrollees and
functional status, health care expenditures, and health 48,735 institutional providers including 6,162 hospitals, 14,991
insurance and beneficiary information (such as income, skilled nursing facilities, 9,029 home health agencies, 2,289
assets, living arrangement, family assistance, and quality of hospices, 3,002 outpatient physical therapy facilities, 543
life). The longitudinal design of the survey allows each comprehensive outpatient rehabilitation facilities, 3,580
sample person to be interviewed 3 times a year for 4 years, end-state renal dialysis facilities, 3,515 rural health clinics,
whether he or she resides in the community or a facility or 1,000 community mental health centers, 2,742 ambulatory
moves between the two settings, using the version of the surgical centers, and 1,882 federally qualified health centers.
questionnaire appropriate to the setting. Sample persons in Over 1 billion claims were processed in fiscal year 1999.
the community are interviewed using computer-assisted

Data from the NCH files provide information about enrollee Approximately 44,300 8th, 10th, and 12th graders in 424
use of benefits for a point in time or over an extended period. schools were surveyed in 2001. In 2001 the annual senior
Statistical reports are produced on enrollment, characteristics samples comprised roughly 13,300 seniors in 134 public and
of participating providers, reimbursement, and services used. private high schools nationwide, selected to be representative
of all seniors in the continental United States. The 10th-grade
For further information on the NCH files see: Centers for
samples involved about 14,300 students in 137 schools in
Medicare and Medicaid Services, Office of Information
2001, and the 2001 eighth-grade samples had approximately
Services, Enterprise Data Base Group, Division of Information
16,800 students in 153 schools. Response rates of
Distribution, Data Users Reference Guide; or call the
82 percent, 88 percent, and 90 percent for 12th, 10th, and
Medicare Hotline at 410-786-3689. For further information on
8th-graders in 2001 have been relatively constant across
Medicare, visit the CMS home page at www.hcfa.gov.
time. Absentees constitute virtually all of the nonrespondents.
Monitoring the Future Study (MTF) For further information on Monitoring the Future Study,
see: National Institute on Drug Abuse, National Survey
National Institute on Drug Abuse Results on Drug Use from the Monitoring the Future Study,
1975–2000, Vol. I, Secondary School Students, NIH Pub. No.
Monitoring the Future Study (MTF) is a large-scale
01–4924, Bethesda, MD: Public Health Service, printed
epidemiological survey of drug use and related attitudes. It
August 2001; or visit the NIDA home page at
has been conducted annually since 1975 under a series of
www.nida.nih.gov or the Monitoring the Future home
investigator-initiated research grants from the National
page at www.monitoringthefuture.org.
Institute on Drug Abuse to the University of Michigan’s
Institute for Social Research. MTF is composed of three
substudies: (a) annual survey of high school seniors initiated National Ambulatory Medical Care Survey
in 1975; (b) ongoing panel studies of representative samples (NAMCS)
from each graduating class that have been conducted by mail Centers for Disease Control and Prevention
since 1976; and (c) annual surveys of 8th and 10th graders National Center for Health Statistics
initiated in 1991.
The survey design is a multistage random sample with stage The National Ambulatory Medical Care Survey (NAMCS) is a
one being selection of particular geographic areas, stage two continuing national probability sample of ambulatory medical
selection of one or more schools in each area, and stage encounters. The scope of the survey covers physician-patient
three selection of students within each school. Data are encounters in the offices of non-Federally employed
collected using self-administered questionnaires conducted in physicians classified by the American Medical Association or
the classroom by representatives of the Institute for Social American Osteopathic Association as ‘‘office-based, patient
Research. Dropouts and students who are absent on the day care’’ physicians. Patient encounters with physicians engaged
of the survey are excluded. Recognizing that the dropout in prepaid practices—health maintenance organizations
population is at higher risk for drug use, this survey was (HMOs), independent practice organizations (IPAs), and other
expanded to include similar nationally representative samples prepaid practices—are included in NAMCS. Excluded are
of 8th and 10th graders in 1991. Statistics that are published visits to hospital-based physicians, visits to specialists in
in the Dropout Rates in the United States: 1999 (published by anesthesiology, pathology, and radiology, and visits to
the National Center for Educational Statistics, Pub. No. NCES physicians who are principally engaged in teaching, research,
2001–022) stated that among persons 15–16 years and 17 or administration. Telephone contacts and nonoffice visits are
years of age, 3.4 percent have dropped out of school, while excluded, also.
the dropout percent increases to 4.7 percent of persons 18 A multistage probability design is employed. The first-stage
years of age, and to 11.1 percent for persons 19 years of sample consists of 84 primary sampling units (PSUs) in 1985
age. Therefore, surveying eighth graders (where dropout rates and 112 PSUs in 1992 selected from about 1,900 such units
are much lower than for high school seniors) should be into which the United States has been divided. In each
effective for picking up students at higher risk for drug use. sample PSU, a sample of practicing non-Federal office-based

physicians is selected from master files maintained by the vision products and other medical durables purchased in retail
American Medical Association and the American Osteopathic outlets are based on estimates of personal consumption
Association. The final stage involves systematic random expenditures prepared by the U.S. Department of
samples of office visits during randomly assigned 7-day Commerce’s Bureau of Economic Analysis, U.S. Bureau of
reporting periods. In 1985 the survey excluded Alaska and Labor Statistics/Consumer Expenditure Survey; the 1987
Hawaii. Starting in 1989 the survey included all 50 States. National Medical Expenditure Survey and the 1996 Medical
Expenditure Panel Survey conducted by the Agency for
In 1999 a sample of 2,499 physicians was selected, 1,728
Healthcare Research and Quality; and spending by Medicare
were in scope and 1,087 participated in the survey for a
and Medicaid. Those durable and nondurable products
response rate of 63 percent. Data were provided on 20,760
provided to inpatients in hospitals or nursing homes, and
records. In the 2000 survey a sample of 3,000 physicians
those provided by licensed professionals or through home
was selected, 2,049 were in scope and 1,388 participated for
health agencies are excluded here, but are included with the
a response rate of 68 percent. Data were provided on 27,369
expenditure estimates of the provider service category.
records.
Nursing home expenditures cover care rendered in
The estimation procedure used in NAMCS has three basic
establishments providing inpatient nursing and health-related
components: inflation by the reciprocal of the probability of
personal care through active treatment programs for medical
selection, adjustment for nonresponse, and ratio adjustment to
and health-related conditions. These establishments cover
fixed totals.
skilled nursing and intermediate care facilities, including those
For more detailed information on NAMCS, see: Cherry DK. for the mentally retarded. Spending estimates are primarily
National Ambulatory Medical Care Survey: 2000 summary. based upon data from the U.S. Bureau of the Census
Advance data from vital and health statistics; no. 328. Services Annual Survey and the quinquennial Census of
Hyattsville, MD: National Center for Health Statistics. 2002; or Service Industries.
visit the NHCS section of the NCHS home page at
Expenditures for construction include those spent on the
www.cdc.gov/nchs.
erection or renovation of hospitals, nursing homes, medical
clinics, and medical research facilities, but not for private
National Health Accounts office buildings providing office space for private practitioners.
Centers for Medicare and Medicaid Services Expenditures for noncommercial research (the cost of
commercial research by drug companies is assumed to be
Estimates of expenditures for health based on National Health imbedded in the price charged for the product; to include this
Accounts are compiled annually by type of expenditure and item again would result in double counting) are developed
source of funds by the Office of the Actuary. The American from information gathered by the National Institutes of Health
Hospital Association (AHA) data on hospital finances are the and the National Science Foundation.
primary source for estimates relating to hospital care. The
Source of funding estimates likewise come from a multiplicity
salaries of physicians and dentists on the staffs of hospitals,
of sources. Data on the Federal health programs are taken
hospital outpatient clinics, hospital-based home health
from administrative records maintained by the servicing
agencies, and nursing home care provided in the hospital
agencies. Among the sources used to estimate State and
setting are considered to be components of hospital care.
local government spending for health are the U.S. Bureau of
Expenditures for home health care and for services of health
the Census’ Government Finances, and the National Academy
professionals (for example, doctors, chiropractors, private duty
of Social Insurance reports on State-operated Workers’
nurses, therapists, and podiatrists) are estimated primarily
Compensation programs. Federal and State-local expenditures
using a combination of data from the U.S. Bureau of the
for education and training of medical personnel are excluded
Census Services Annual Survey and the quinquennial Census
from these measures where they are separable. For the
of Service Industries.
private financing of health care, data on the financial
The estimates of retail spending for prescription drugs are experience of health insurance organizations come from
based on household and industry data on prescription drug special Centers for Medicare & Medicaid Services analyses of
transactions. Expenditures for other medical nondurables and private health insurers, and from the Bureau of Labor

Statistics’ survey on the cost of employer-sponsored health U.S. territories and military and Federal civilian employees
insurance and on consumer expenditures. Information on and their families living overseas.
out-of-pocket spending from the U.S. Bureau of the Census
State estimates in this edition of Health, United States, 2002
Services Annual Survey; U.S. Bureau of Labor Statistics
present data based on the location of the beneficiary’s
Consumer Expenditure Survey; the 1987 National Medical
residence. This differs from State estimates published in
Expenditure Survey and the 1996 Medical Expenditure Panel
Health, United States, 2001, which presented spending based
Survey conducted by the Agency for Healthcare Research
on the health care provider’s location. State estimates were
and Quality; and from private surveys conducted by the
first constructed based on the provider’s location because
American Hospital Association, American Medical Association,
data available to estimate spending by State primarily comes
American Dental Association, and IMS Health, an organization
from providers and represents the State-of-provider location.
that collects data from the pharmaceutical industry, is used to
However, the most useful unit for analyzing spending trends
develop estimates of direct spending by customers.
and differences are per capita units, which are based on
For more specific information on definitions, sources, and spending estimates for the State in which people reside.
methods used in the National Health Accounts contact: Office Therefore, we adjusted State-of-provider-based expenditures
of the Actuary, Centers for Medicare & Medicaid Services, to a State-of-residence basis using interstate border-crossing
7500 Security Blvd., Baltimore, MD 21244-1850; or visit the flow patterns that represent travel patterns across State
Centers for Medicare & Medicaid Services home page at borders for health care.
www.hcfa.gov.
Data for the interstate border-crossing flow patterns are based
on Medicare claims. Medicare is the only comprehensive
Estimates of State Health Expenditures
source upon which to base interstate flows of spending
Estimates of personal health care spending by State are between State-of-provider and State-of-beneficiary residence.
created using the same definitions of health care sectors Data for non-Medicare payers (excluding Medicaid) are also
used in producing the National Health Expenditures (NHE). based on Medicare flow patterns, but are further adjusted for
The same data sources used in creating NHE are also used age specific service mix variation in hospital and physician
to create State estimates whenever possible. Additional services. Medicaid services are not adjusted because we
sources are employed when surveys used to create valid assume that care provided to eligible State residents is most
national estimates lack sufficient sample size to create valid often provided by in-State providers; therefore, we assume
State-level estimates. State-level data are used to estimate that spending by Medicaid is identical on a residence and on
the State-by-State distribution of health spending, and the a provider basis.
NHE national totals for the specific type of service or source In addition to differences noted earlier, national totals for
of funds are used to control the level of State-by-State residence-based State health expenditures may differ slightly
distributions. This procedure implicitly assumes that national from national totals for provider-based expenditures due to
spending estimates can be created more accurately than inflows and outflows of health care spending to the U.S.
State-specific expenditures. territories. Because flow patterns are based on Medicare
The NHE data that were used as national totals for these data, we are able to adjust for services that Medicare
State estimates were published in Health, United States, beneficiaries receive outside of the U.S., and for services
2001, and differ from the sum of State estimates. This NHE received by Medicare beneficiaries in the U.S. who either live
data included expenditures for persons living in U.S. territories in the U.S. territories or in other countries. Similar
and for military and Federal civilian employees and their adjustments for the non-Medicare, non-Medicaid population
families stationed overseas. The sum of the State-level are not possible.
expenditures exclude health spending for those groups. NHE For more information contact: Office of the Actuary, Centers
published in this edition of Health, United States not only for Medicare & Medicaid Services, 7500 Security Blvd.,
reflect new data and benchmark revisions incorporated after Baltimore, MD 21244-1850; or visit the Centers for Medicare
completion of the State estimates, but incorporate a & Medicaid Services home page at www.hcfa.gov.
conceptual revision to exclude spending for persons living in

National Health and Nutrition Examination addition, data were obtained for a subsample of adults on
Survey (NHANES) overall health care needs and behavior, and more detailed
examination data were collected on cardiovascular,
Centers for Disease Control and Prevention respiratory, arthritic, and hearing conditions.
The NHANES I target population was the civilian
For the first program or cycle of the National Health noninstitutionalized population 1–74 years of age residing in
Examination Survey (NHES I), 1960–62, data were collected the coterminous United States, except for people residing on
on the total prevalence of certain chronic diseases as well as any of the reservation lands set aside for the use of American
the distributions of various physical and physiological Indians. The sample design was a multistage, stratified
measures, including blood pressure and serum cholesterol probability sample of clusters of persons in land-based
levels. For that program, a highly stratified, multistage segments. The sample areas consisted of 65 PSUs selected
probability sample of 7,710 adults, of whom 86.5 percent were from the 1,900 PSUs in the coterminous United States. A
examined, was selected to represent the 111 million civilian subsample of persons 25–74 years of age was selected to
noninstitutionalized adults 18–79 years of age in the United receive the more detailed health examination. Groups at high
States at that time. The sample areas consisted of 42 primary risk of malnutrition were oversampled at known rates
sampling units (PSUs) from the 1,900 geographic units. throughout the process. Household interviews were completed
for more than 96 percent of the 28,043 persons selected for
NHES II (1963–65) and NHES III (1966–70) examined
the NHANES I sample, and about 75 percent (20,749) were
probability samples of the Nation’s noninstitutionalized
examined.
children ages 6–11 years (NHES II) and 12–17 years (NHES
III) focusing on factors related to growth and development. For NHANES II, conducted from 1976 to 1980, the nutrition
Both cycles were multistage, stratified probability samples of component was expanded from the one fielded for NHANES
clusters of households in land-based segments and used the I. In the medical area primary emphasis was placed on
same 40 PSUs. NHES II sampled 7,417 children with a diabetes, kidney and liver functions, allergy, and speech
response rate of 96 percent. NHES III sampled 7,514 youth pathology. The NHANES II target population was the civilian
with a response rate of 90 percent. noninstitutionalized population 6 months–74 years of age
residing in the United States, including Alaska and Hawaii.
For more information on NHES I, see: Gordon T, Miller HW.
Cycle I of the Health Examination Survey: Sample and NHANES II used a multistage probability design that involved
response, United States, 1960–62. National Center for Health selection of PSUs, segments (clusters of households) within
Statistics. Vital Health Stat 11(1). 1974. For more information PSUs, households, eligible persons, and finally, sample
on NHES II, see: Plan, operation, and response results of a persons. The sample design provided for oversampling
program of children’s examinations. National Center for Health among persons 6 months–5 years of age, 60–74 years of
Statistics. Vital Health Stat 1(5). 1967. For more information age, and those living in poverty areas. A sample of 27,801
on NHES III, see: Schaible WL. Quality control in a National persons was selected for NHANES II. Of this sample 20,322
Health Examination Survey. National Center for Health (73.1 percent) were examined. Race information for NHANES
Statistics. Vital Health Stat 2(44). 1972. I and NHANES II was determined primarily by interviewer
observation.
In 1971 a nutrition surveillance component was added and
the survey name was changed to the National Health and The estimation procedure used to produce national statistics
Nutrition Examination Survey (NHANES). In NHANES I, for NHANES I and NHANES II involved inflation by the
conducted from 1971 to 1974, a major purpose was to reciprocal of the probability of selection, adjustment for
measure and monitor indicators of the nutrition and health nonresponse, and poststratified ratio adjustment to population
status of the American people through dietary intake data, totals. Sampling errors also were estimated to measure the
biochemical tests, physical measurements, and clinical reliability of the statistics.
assessments for evidence of nutritional deficiency. Detailed For more information on NHANES I, see: Miller HW. Plan and
examinations were given by dentists, ophthalmologists, and operation of the Health and Nutrition Examination Survey,
dermatologists with an assessment of need for treatment. In United States, 1971–73. National Center for Health Statistics.

Vital Health Stat 1(10a) and 1(10b). 1977 and 1978; and is the civilian noninstitutionalized population 2 months of age
Engel A, Murphy RS, Maurer K, Collins E. Plan and operation and over. The sample design provides for oversampling
of the NHANES I Augmentation Survey of Adults 25–74 among children 2–35 months of age, persons 70 years of age
years, United States, 1974–75. National Center for Health and over, black Americans, and Mexican Americans. Race is
Statistics. Vital Health Stat 1(14). 1978. reported for the household by the respondent.
For more information on NHANES II, see: McDowell A, Engel Although some of the specific health areas have changed
A, Massey JT, Maurer K. Plan and operation of the second from earlier NHANES surveys, the following goals of the
National Health and Nutrition Examination Survey, 1976–80. NHANES III are similar to those of earlier NHANES surveys:
National Center for Health Statistics. Vital Health Stat 1(15).
+ estimate the national prevalence of selected diseases and
1981. For information on nutritional applications of these
risk factors
surveys, see: Yetley E, Johnson C. Nutritional applications of
the Health and Nutrition Examination Surveys (HANES). Ann + estimate national population reference distributions of
Rev Nutr 7:441–63. 1987. selected health parameters
The Hispanic Health and Nutrition Examination Survey + document and investigate reasons for secular trends in
selected diseases and risk factors
(HHANES), conducted during 1982–84, was similar in content
and design to the previous National Health and Nutrition Two new additional goals for the NHANES III survey are:
Examination Surveys. The major difference between HHANES
and the previous national surveys is that HHANES used a + contribute to an understanding of disease etiology
probability sample of three special subgroups of the + investigate the natural history of selected diseases
population living in selected areas of the United States rather
than a national probability sample. The three HHANES For more information on NHANES III, see: Ezzati TM, Massey
universes included approximately 84, 57, and 59 percent of JT, Waksberg J, et al. Sample design: Third National Health
the respective 1980 Mexican-, Cuban-, and Puerto and Nutrition Examination Survey. National Center for Health
Rican-origin populations in the continental United States. Statistics. Vital Health Stat 2(113). 1992; Plan and operation
Hispanic ethnicity of these populations was determined by of the Third National Health and Nutrition Examination Survey,
self-report. 1988–94. National Center for Health Statistics. Vital Health
Stat 1(32). 1994; or visit the NCHS home page at
In the HHANES three geographically and ethnically distinct www.cdc.gov/nchs.
populations were studied: Mexican Americans living in Texas,
New Mexico, Arizona, Colorado, and California; Cuban
Americans living in Dade County, Florida; and Puerto Ricans
National Health Interview Survey (NHIS)
living in parts of New York, New Jersey, and Connecticut. In Centers for Disease Control and Prevention
the Southwest 9,894 persons were selected (75 percent or National Center for Health Statistics
7,462 were examined), in Dade County 2,244 persons were
selected (60 percent or 1,357 were examined), and in the The National Health Interview Survey (NHIS) is a continuing
Northeast 3,786 persons were selected (75 percent or 2,834 nationwide sample survey in which data are collected through
were examined). personal household interviews. Information is obtained on
personal and demographic characteristics including race and
For more information on HHANES, see: Maurer KR. Plan and
ethnicity by self-reporting or as reported by an informant.
operation of the Hispanic Health and Nutrition Examination
Information is also obtained on illnesses, injuries,
Survey, 1982–84. National Center for Health Statistics. Vital
impairments, chronic conditions, utilization of health
Health Stat 1(19). 1985.
resources, and other health topics.
The third National Health and Nutrition Examination Survey
The sample design plan of NHIS follows a multistage
(NHANES III) is a 6-year survey covering the years 1988–94.
probability design that permits a continuous sampling of the
Over the 6-year period, 39,695 persons were selected for the
civilian noninstitutionalized population residing in the United
survey of which 30,818 (77.6 percent) were examined in the
States. The survey is designed in such a way that the sample
mobile examination center. The NHANES III target population

scheduled for each week is representative of the target was collected from responsible family members residing in the
population, and the weekly samples are additive over time. household. Proxy responses were acceptable for Core and
The household response rate for the ongoing portion of the Supplement questionnaires when family members were not
survey (core) has been between 94 and 98 percent over the present at the time of interview. Data for children were
years. In recent years the total household response rate was collected from proxy respondents.
92 percent in 1997, 90 percent in 1998, 88 percent in 1999,
In 1997 the NHIS questionnaire was redesigned and consists
and 89 percent in 2000. Response rates for special health
of three parts: a basic module, a periodic module, and a
topics (supplements) have generally been lower. For example,
topical module. The basic module functions as the new Core
the response rate was 80 percent for the 1994 Year 2000
questionnaire and comprises three components (Family Core,
Supplement, which included questions about cigarette
Sample Adult Core, Sample Child Core). For the Family Core,
smoking and use of such preventive services as
information is obtained about all members of the family by
mammography. In 1997 the final response rate for the sample
interviewing any adult members of the household who are
adult supplement was 80 percent, 74 percent in 1998,
present and who may respond for themselves and as proxies
70 percent in 1999, and 72 percent in 2000. In 1997 the final
for other members of the family. Information in the Family
response rate for the sample child supplement was
Core component is obtained by asking respondents or proxy
84 percent, 82 percent in 1998, 78 percent in 1999, and
respondents a series of questions in an unfolding family style.
79 percent in 2000.
For example, questions on activity limitation were asked as
In 1985 NHIS adopted several new sample design features follows: ‘‘Are you/any family members limited in activities?’’ If
although, conceptually, the sampling plan remained the same so, ‘‘Who is this?’’ For the Sample Adult Core, one adult in
as the previous design. Two major changes included reducing the household is randomly selected to participate; proxy
the number of primary sampling locations from 376 to 198 for respondents are not used in this component. For families with
sampling efficiency and oversampling the black population to children under 18 years of age, one child in the household is
improve the precision of the statistics. The sample was randomly selected for participation in the Sample Child Core.
designed so that a typical NHIS sample for the data collection Data for this component are collected from a knowledgeable
years 1985–94 consisted of approximately 7,500 segments adult in the household. Starting with 1998 periodic and topical
containing about 59,000 assigned households. Of these modules are incorporated into selected years of the NHIS.
households, an expected 10,000 were vacant, demolished, or
In 1997 the collection methodology changed from paper and
occupied by persons not in the target population of the
pencil questionnaires to computer-assisted personal
survey. The expected sample of 49,000 occupied households
interviewing (CAPI). The NHIS questionnaire was also revised
yielded a probability sample of about 127,000 persons. In
extensively in 1997. In some instances, basic concepts
1994 the sample numbered 116,179 persons.
measured in NHIS changed and in other instances the same
In 1995 the NHIS sample was redesigned again. Major concepts were measured in different ways. While some
design changes included increasing the number of primary questions remain the same over time, they may be preceded
sampling units from 198 to 358 and oversampling the black by different questions or topics. For some questions, there
and Hispanic populations to improve the precision of the was a change in the reference period for reporting an event
statistics. The sample was designed so that a typical NHIS or condition. Because of the extensive redesign of the
sample for the data collection years 1995–2004 will consist of questionnaire in 1997 and introduction of the CAPI method of
approximately 7,000 segments. The expected sample of data collection, data from 1997 and later years may not be
44,000 occupied respondent households will yield a comparable with data from earlier years.
probability sample of about 106,000 persons. In 1997 the
For more information about the survey design, methods used
sample numbered 103,477 persons; 98,785 persons in 1998,
in estimation, and general qualifications of the data obtained
97,059 persons in 1999, and 100,618 persons in 2000.
from the survey, see: Botman SL, Moore TF, Moriarity CL,
The NHIS questionnaire fielded from 1982 to 1996 consisted Parsons VL. Design and estimation for the National Health
of two parts: a set of basic health and demographic items Interview Survey, 1995–2004. National Center for Health
known as the Core questionnaire and one or more sets of Statistics. Vital Health Stat 2(130). 2000; Massey JT, Moore
questions on current health topics (supplements). Information TF, Parsons VL, Tadros W. Design and estimation for the

National Health Interview Survey, 1985–94. National Center National Health Provider Inventory (NHPI). The 1992 sample
for Health Statistics. Vital Health Stat 2(110). 1989; Kovar contained 1,500 agencies. These agencies were revisited
MG, Poe GS. The National Health Interview Survey design, during the 1993 survey (excluding agencies that had been
1973–84, and procedures, 1975–83. National Center for found to be out of scope for the survey). In 1994 in-scope
Health Statistics. Vital Health Stat 1(18). 1985; Bloom B, agencies identified in the 1993 survey were revisited, along
Tonthat L. Summary Health Statistics for U.S. Children: with 100 newly identified agencies added to the sample. For
National Health Interview Survey, 1997. National Center for 1996 the universe was again updated, and a new sample of
Health Statistics. Vital Health Stat 10(203). 2002; Blackwell 1,200 agencies was drawn. In 1998 the updated sampling
DL, Tonthat L. Summary Health Statistics for the U.S. frame consisted of 16,500 home health and hospice agencies.
Population: National Health Interview Survey, 1997. National A sample of 1,350 agencies was selected. In 2000, of 15,451
Center for Health Statistics. Vital Health Stat 10(204). 2002; agencies in the sampling frame, 1,800 were sampled and the
Blackwell DL, Collins JG, Coles R. Summary Health Statistics response rate was 96.4 percent.
for U.S. Adults: National Health Interview Survey, 1997.
The sample design for the 1992–94 NHHCS was a stratified
National Center for Health Statistics. Vital Health Stat
three-stage probability design. Primary sampling units were
10(205). 2002; or visit the NHIS section of the NCHS home
selected at the first stage, agencies were selected at the
page at www.cdc.gov/nchs.
second stage, and current patients and discharges were
selected at the third stage. The sample design for the 1996,
National Health Provider Inventory (NHPI) 1998, and 2000 NHHCS has a two-stage probability design,
in which agencies were selected at the first stage and current
patients and discharges were selected at the second stage.
Current patients were those on the rolls of the agency as of
The National Master Facility Inventories (NMFIs), forerunners midnight the day before the survey. Discharges were selected
of the National Health Provider Inventory (NHPI), were a to estimate the number of discharges from the agency during
series of inventories of inpatient health facilities in the United the year before the survey. After the samples were selected,
States conducted by NCHS. The inventories included a patient questionnaire was completed for each current
hospitals, nursing and related-care homes, and other custodial patient and discharge by interviewing the staff member most
care facilities. The last NMFI was conducted in 1982. In 1986 familiar with the care provided to the patients. The respondent
a different inventory was conducted, the Inventory of was requested to refer to the medical records for each
Long-Term Care Places (ILTCP). This was an inventory of patient.
nursing and related-care homes and facilities for the mentally For additional information see: Haupt BJ. Development of the
retarded. NHPI was conducted in 1991. This was an inventory National Home and Hospice Care Survey. National Center for
of nursing homes, board and care homes, home health Health Statistics. Vital Health Stat 1(33). 1994; or visit the
agencies, and hospices. NMFI, ILTCP, and NHPI served as NHCS home page at www.cdc.gov/nchs.
sampling frames for the NCHS National Nursing Home
Survey and National Home and Hospice Care Survey.
National Hospital Ambulatory Medical Care
Survey (NHAMCS)
National Home and Hospice Care Survey
(NHHCS) Centers for Disease Control and Prevention
National Center for Health Statistics The National Hospital Ambulatory Medical Care Survey
(NHAMCS), initiated in 1992, is a continuing annual national
The National Home and Hospice Care Survey (NHHCS) is a probability sample of visits by patients to emergency
sample survey of health agencies and hospices. Initiated in departments (EDs) and outpatient departments (OPDs) of
1992, it was also conducted in 1993, 1994, 1996, 1998, and non-Federal, short-stay or general hospitals. Telephone
2000. The original sampling frame consisted of all home contacts are excluded.
health care agencies and hospices identified in the 1991

A four-stage probability sample design is used in NHAMCS, Inventory. A two-stage stratified sample design was used, with
involving samples of primary sampling units (PSUs), hospitals hospitals stratified according to bed size and geographic
with EDs and/or OPDs within PSUs, EDs within hospitals region. Sample hospitals were selected with probabilities
and/or clinics within OPDs, and patient visits within EDs ranging from certainty for the largest hospitals to 1 in 40 for
and/or clinics. In 1999 the hospital response rate for the smallest hospitals. Within each sample hospital, a
NHAMCS was 93 percent for EDs and 86 percent for OPDs. systematic random sample of discharges was selected from
In 2000 the hospital response rate was 94 percent for EDs the daily listing sheet. Initially, the within-hospital sampling
and 88 percent for OPDs. Hospital staff were asked to rates for selecting discharges varied inversely with the
complete Patient Record Forms (PRF) for a systematic probability of hospital selection, so that the overall probability
random sample of patient visits occurring during a randomly of selecting a discharge was approximately the same across
assigned 4-week reporting period. On the PRF, up to three the sample. Those rates were adjusted for individual hospitals
physicians’ diagnoses were collected and coded by NCHS to in subsequent years to control the reporting burden of those
the International Classification of Diseases, Clinical hospitals.
Modification (ICD–9–CM). Additionally, if the cause-of-injury
In 1985, for the first time, two data-collection procedures were
check box was marked on the PRF, up to three external
used for the survey. The first was the traditional manual
causes of injury were coded by NCHS to the ICD–9–CM
system of sample selection and data abstraction. In the
Supplementary Classification of External Causes of Injury and
manual system, sample selection and transcription of
Poisoning. In 1999 the number of PRFs completed for EDs
information from the hospital records to abstract forms were
was 21,103 and for OPDs 29,487. In 2000 the number of
performed by either the hospital staff or representatives of
PRFs completed for EDs was 25,622 and for OPDs 27,510.
NCHS or both. The second was an automated method, used
For more detailed information on NHAMCS, see: McCaig LF, in approximately 17 percent of the sample hospitals in 1985,
McLemore T. Plan and operation of the National Hospital involving the purchase of data tapes from commercial
Ambulatory Medical Care Survey. National Center for Health abstracting services. These tapes were then subjected to the
Statistics. Vital Health Stat 1(34). 1994; or visit the NHCS NCHS sampling, editing, and weighting procedures.
section of the NCHS home page at www.cdc.gov/nchs.
In 1988 NHDS was redesigned. The hospitals with the most
beds and/or discharges annually were selected with certainty,
National Hospital Discharge Survey (NHDS) but the remaining sample was selected using a three-stage
Centers for Disease Control and Prevention stratified design. The first stage is a sample of PSUs used by
National Center for Health Statistics the National Health Interview Survey. Within PSUs, hospitals
were stratified or arrayed by abstracting status (whether
The National Hospital Discharge Survey (NHDS) is a subscribing to a commercial abstracting service) and within
continuing nationwide sample survey of short-stay hospitals in abstracting status arrayed by type of service and bed size.
the United States. The scope of NHDS encompasses patients Within these strata and arrays, a systematic sampling scheme
discharged from noninstitutional hospitals, exclusive of military with probability proportional to the annual number of
and Department of Veterans Affairs hospitals, located in the discharges was used to select hospitals. The rates for
50 States and the District of Columbia. Only hospitals having systematic sampling of discharges within hospitals varied
six or more beds for patient use are included in the survey inversely with probability of hospital selection within the PSU.
and, before 1988, those in which the average length of stay Discharge records from hospitals submitting data via
for all patients was less than 30 days. In 1988 the scope was commercial abstracting services and selected State data
altered slightly to include all general and children’s general systems (approximately 40 percent of sample hospitals) were
hospitals regardless of length of stay. Although all discharges arrayed by primary diagnoses, patient sex and age group,
of patients from these hospitals are within the scope of the and date of discharge before sampling. Otherwise, the
survey, discharges of newborn infants from all hospitals are procedures for sampling discharges within hospitals were the
excluded from Health, United States. same as those used in the prior design.
The original sample was selected in 1964 from a frame of In 2000 the hospital sample was updated by continuing the
short-stay hospitals listed in the National Master Facility sampling process among hospitals that were NHDS-eligible

for the sampling frame in 2000 but not in 1997. The The NHSDA survey has been conducted since 1971. In 1999
additional hospitals were added at the end of the list for the NHSDA underwent a major redesign affecting the method of
strata where they belonged, and the systematic sampling was data collection, sample design, sample size, and
continued as if the additional hospitals had been present oversampling. Because of the differences in methodology and
during the initial sample selection. Hospitals that were no impact of the new design on data collection, comparisons
longer NHDS-eligible were deleted. A similar updating process should not be made between data from the redesigned
occurred in 1991, 1994, and 1997. surveys (1999 onward) and data obtained from surveys prior
to 1999. Beginning in 1999 the survey used a combination of
The basic unit of estimation for NHDS is the sample patient
computer-assisted personal interview (CAPI) conducted by the
abstract. The estimation procedure involves inflation by the
interviewer and a computer-assisted self-interview (ACASI).
reciprocal of the probability of selection, adjustment for
Use of ACASI is designed to provide the respondent with a
nonresponding hospitals and missing abstracts, and ratio
highly private and confidential means of responding to
adjustments to fixed totals. In 1999, 513 hospitals were
questions and to increase the level of honest reporting of
selected, 487 were within scope, 458 participated
illicit drug use and other sensitive behaviors.
(94 percent), and 300,460 medical records were abstracted. In
2000, 509 hospitals were selected, 481 were within scope, The 1999–2000 NHSDA sample design used a State-based
434 participated (90 percent), and 313,259 medical records sampling plan. This sample employed a 50-State design with
were abstracted. an independent, multistage area probability sample for each
of the 50 States and the District of Columbia. The eight
For more detailed information on the design of NHDS and the
States with the largest population (which together account for
magnitude of sampling errors associated with NHDS
48 percent of the total U.S. population age 12 years and
estimates, see: Popovic JR. 1999 National Hospital Discharge
over) were designated as large sample States (California,
Summary: Annual summary with detailed diagnosis and
Florida, Illinois, Michigan, New York, Ohio, Pennsylvania, and
procedure data. National Center for Health Statistics. Vital
Texas). For these States, the design provided a sample large
Health Stat 13(151). 2001; Dennison C, Pokras R. Design
enough to support direct State estimates. For the remaining
and operation of the National Hospital Discharge Survey:
42 States and the District of Columbia, smaller, but adequate,
1988 redesign. National Center for Health Statistics. Vital
samples were selected to support State estimates using
Health Stat 1(39). 2000; or visit the NHCS section of the
small-area estimation (SAE) techniques. The 1999–2000
NCHS home page at www.cdc.gov/nchs.
NHSDA design also oversampled youths and young adults, so
that each State’s sample was approximately equally
National Household Survey on Drug Abuse distributed among three major age groups: 12–17 years,
(NHSDA) 18–25 years, and 26 years and older. To enhance the
precision of trend measurement, half of the first-stage
sampling units (area segments) in the 1999 sample were also
Data on trends in use of tobacco, alcohol, and illicit drugs in the 2000 sample. However, all of the households included
among persons 12 years of age and over are from the in the 2000 sample were new.
National Household Survey on Drug Abuse (NHSDA), Each State was stratified into regions (48 regions in each of
sponsored by the Substance Abuse and Mental Health eight large States, 12 regions in each of 42 small States and
Services Administration (SAMHSA). The survey covers the the District of Columbia). At the first stage of sampling, eight
civilian noninstitutionalized population 12 years of age and area segments were selected in each region, for a total of
over in the United States. This includes civilians living on 7,200 sample units nationally. In these segments, 169,769
military bases and persons living in noninstitutionalized group addresses were screened and 71,764 persons were
quarters, such as college dormitories, rooming houses, and interviewed within the screened addresses in 2000. The
shelters. Persons excluded from the survey include homeless survey was conducted from January through December 2000.
people who do not use shelters, active military personnel, and Weighted response rates for household screening and for
residents of institutional group quarters, such as jails and interviewing were 92.8 percent and 73.9 percent, respectively.
hospitals. A description of the methodology can be found in Summary

of Findings from the 2000 National Household Survey on National Immunization Survey (NIS)
Drug Abuse, available from SAMHSA.
Direct survey estimates considered to be unreliable due to National Center for Health Statistics and
unacceptably large sampling errors are not shown in table 64 National Immunization Program
in this report, and are noted by asterisks (*). The criterion
used for suppressing all direct survey estimates was based The National Immunization Survey (NIS) is a continuing
on the relative standard error (rse), which is defined as the nationwide telephone sample survey to gather data on
ratio of the standard error (se) over the estimate. Proportion children 19–35 months of age. Estimates of vaccine-specific
estimates (p) within the range [0<p < 1], rates, and coverage are available for national, State, and 28 urban
corresponding estimated number of users were suppressed if: areas considered to be high risk for undervaccination.
[se (p) / p] / [–ln (p)] > 0.175 when p <0.5

NIS uses a two-phase sample design. First, a random-digit-
dialing (RDD) sample of telephone numbers is drawn. When
or
households with age-eligible children are contacted, the

[se(p) / (1–p)] / [–ln (1–p)] >0.175 when p≥ 0.5
interviewer collects information on the vaccinations received
by all age-eligible children. In 2000 the overall response rate
The separate formulae for p < 0.5 and p≥ 0.5 produce a
was 67 percent, yielding data for 34,087 children aged 19–35
symmetric suppression rule; that is, if p is suppressed, then
months. The interviewer also collects information on the
so will 1–p. This is an ad hoc rule that requires an effective
vaccination providers. In the second phase, all vaccination
sample size in excess of 50. When 0.05<p < 0.95, the
providers are contacted by mail. The vaccination information
symmetric properties of the rule produce a local maximum
from providers was obtained for 69 percent of all children who
effective sample size of 68 at p = 0.5. Thus, estimates with
were eligible for provider followup in 2000. Providers’
these values of p along with effective sample sizes falling
responses are combined with information obtained from the
below 68 are suppressed. A local minimum effective sample
households to provide a more accurate estimate of
size of 50 occurs at p = 0.2 and again at p = 0.8 within this
vaccination coverage levels. Final estimates are adjusted for
same interval; so, estimates are suppressed for values of p
noncoverage of nontelephone households.
with effective sample sizes below 50. A minimum effective
sample size of 68 was added to the suppression criteria in The statistical methodology for estimating vaccination
the 2000 NHSDA. As p approaches 0.00 or 1.00 outside the coverage rates for NIS data was changed in 1998. The new
interval (0.05, 0.95), the suppression criteria will still require methodology facilitates valid statistical analyses and accounts
increasingly larger effective sample sizes. Also new to the for the survey’s complex sampling design. In Health, U.S.,
2000 survey is a minimum nominal sample size suppression 2002 estimates for years before 1998 were revised to reflect
criteria (n = 100) that protects against unreliable estimates this change. Small differences exist between the revised
caused by small design effects and small nominal sample vaccination coverage estimates and those in previous editions
sizes. Prevalence estimates are also suppressed if they are of Health, United States and in MMWRs published before
close to zero or 100 percent (i.e., if p <.00005 or if p >.99995). 1998.
For more information on the National Household Survey on For more information about the survey design and methods
Drug Abuse (NHSDA), see: NHSDA Series: H-13 Summary of used in estimation, see: Zell ER, Ezzati-Rice TM, Battaglia
Findings from the 2000 National Household Survey on Drug PM, Wright RA. National Immunization Survey: The
Abuse, DHHS Pub No (SMA) 01–3549; or write: Office of Methodology of a Vaccination Surveillance System. Public
Applied Studies, Substance Abuse and Mental Health Health Reports 115:65–77. 2000; or visit the NCHS home
Services Administration, Room 16C-06, 5600 Fishers Lane, page at www.cdc.gov/nchs.
Rockville, MD 20857; or visit the SAMHSA Web site at
www.drugabusestatistics.samhsa.gov.

National Medical Expenditure Survey (NMES) is conducted by public health practitioners at local, State, and
national levels to support disease prevention and control
Agency for Healthcare Research and Quality activities.
The Household Survey (HS) and the Medical Provider Survey Notifiable disease reports are received from health
(MPS) components of the 1987 National Medical Expenditure departments in the 50 States, five territories, New York City,
Survey (NMES) were designed to provide nationally and the District of Columbia. Policies for reporting notifiable
representative estimates of the health status, health insurance disease cases can vary by disease or reporting jurisdiction,
coverage, and health care use and expenditures for the U.S. depending on case status classification (i.e., confirmed,
civilian noninstitutionalized population for the calendar year probable, or suspect). CSTE and CDC annually review the
1987. HS consisted of four rounds of household interviews. status of national infectious disease surveillance and
Income was collected in a special supplement administered recommend additions or deletions to the list of nationally
early in 1988. Events under the scope of MPS included notifiable diseases based on the need to respond to emerging
medical services provided by or under the direction of a priorities. For example, Q fever and tularemia became
physician, all hospital events, and home health care. The nationally notifiable in 2000. However, reporting nationally
sample of events included in MPS was all events for persons notifiable diseases to CDC is voluntary. Reporting is currently
covered by Medicaid and for a 25 percent sample of HS mandated by law or regulation only at the local and State
respondents. For the first core household interview, 17,500 level. Therefore, the list of diseases that are considered
households were selected. The 12-month joint core notifiable varies slightly by State. For example, reporting of
questionnaire/health questionnaire/access supplement cyclosporiasis to CDC is not done by some States in which
response rate for the household component of NMES was this disease is not notifiable to local or State authorities. More
72 percent. Missing expenditure data were imputed. information regarding notifiable diseases, including case
definitions for these conditions, is available on the Internet at
For further information see: Hahn B and Lefkowitz D. Annual
www.cdc.gov/epo/dphsi/phs.htm.
expenses and sources of payment for health care services
(AHRQ Pub. No. 93–0007). National Medical Expenditure Notifiable disease data are useful for analyzing disease trends
Survey Research Findings 14, Agency for Healthcare and determining relative disease burdens. However, these
Research and Quality. Rockville, MD. Public Health Service. data must be interpreted in light of reporting practices. Some
Nov. 1992. diseases that cause severe clinical illness (for example,
plague and rabies) are most likely reported accurately if
National Notifiable Diseases Surveillance diagnosed by a clinician. However, persons who have
diseases that are clinically mild and infrequently associated
System (NNDSS)
with serious consequences (for example, salmonellosis) might
Centers for Disease Control and Prevention not seek medical care from a health care provider. Even if
Epidemiology Program Office these less severe diseases are diagnosed, they are less likely
to be reported.
The Epidemiology Program Office (EPO) of CDC, in
partnership with the Council of State and Territorial The degree of completeness of data reporting also is
Epidemiologists (CSTE), operates the National Notifiable influenced by the diagnostic facilities available; the control
Diseases Surveillance System. The purpose of this system is measures in effect; public awareness of a specific disease;
primarily to provide weekly provisional information on the and the interests, resources, and priorities of State and local
occurrence of diseases defined as notifiable by CSTE. The officials responsible for disease control and public health
system also provides summary data on an annual basis. surveillance. Finally, factors such as changes in case
State epidemiologists report cases of notifiable diseases to definitions for public health surveillance, introduction of new
EPO, and EPO tabulates and publishes these data in the diagnostic tests, or discovery of new disease entities can
Morbidity and Mortality Weekly Report (MMWR) and the cause changes in disease reporting that are independent of
Summary of Notifiable Diseases, United States (entitled the true incidence of disease.
Annual Summary before 1985). Notifiable disease surveillance

For more information, see: Centers for Disease Control and homes in the 1982 NMFI; homes identified in the 1982
Prevention, Summary of Notifiable Diseases, United States, Complement Survey of NMFI ‘‘missing’’ from the 1982 NMFI;
1999 Morbidity and Mortality Weekly Report 48(53) Public facilities that opened for business between 1982 and June
Health Service, DHHS, Atlanta, GA, 2000; or write: Chief, 1984; and hospital-based nursing homes obtained from the
Surveillance Systems Branch, Division of Public Health Centers for Medicare and Medicaid Services. Information on
Surveillance and Informatics. Epidemiology Program Office, the facility was collected through a personal interview with the
Centers for Disease Control and Prevention, 4770 Buford administrator. Accountants were asked to complete a
Highway, MS K74, Atlanta, GA 30341–3717; or visit the EPO questionnaire on expenses or provide a financial statement.
home page at www.cdc.gov/epo. Resident data were provided by a nurse familiar with the care
provided to the resident. The nurse relied on the medical
National Nursing Home Survey (NNHS) record and personal knowledge of the resident. In addition to
employee data that were collected during the interview with
Centers for Disease Control and Prevention the administrator, a sample of registered nurses completed a
National Center for Health Statistics self-administered questionnaire. Discharge data were based
on information recorded in the medical record. Additional data
NCHS conducted six National Nursing Home Surveys, the
about the current and discharged residents were obtained in
first survey from August 1973–April 1974; the second from
telephone interviews with next of kin. Data were obtained
May–December 1977; the third from August 1985–January
from 1,079 facilities, 2,763 registered nurses, 5,243 current
1986; the fourth from July–December 1995; the fifth from
residents, and 6,023 discharges. Response rates were
July–December 1997; and the sixth from July–December
93 percent for facilities, 68 percent for expenses, 80 percent
1999.
for registered nurses, 97 percent for residents, 95 percent for
For the initial National Nursing Home Survey (NNHS) discharges, and 90 percent for next of kin.
conducted in 1973–74, the universe included only those
The 1995, 1997, and 1999 NNHS were similar to the 1985
nursing homes that provided some level of nursing care.
and 1973–74 NNHS in that they included only nursing homes
Homes providing only personal or domiciliary care were
that provided some level of nursing care. Homes providing
excluded. The sample of 2,118 homes was selected from the
only personal or domiciliary care were excluded. The 1995
17,685 homes that provided some level of nursing care and
sample of 1,500 homes was selected from a sampling frame
were listed in the 1971 National Master Facility Inventory
of 17,500 nursing homes. The frame consisted of an updated
(NMFI) or those that opened for business in 1972. Data were
version of the 1991 National Health Provider Inventory
obtained from about 20,600 staff and 19,000 residents.
(NHPI). Data were obtained from about 1,400 nursing homes
Response rates were 97 percent for facilities, 88 percent for
and 8,000 current residents. Data on current residents were
expenses, 82 percent for staff, and 98 percent for residents.
provided by a staff member familiar with the care received by
The 1977 NNHS encompassed all types of nursing homes, residents and from information contained in residents’ medical
including personal care and domiciliary care homes. The records.
sample of about 1,700 facilities was selected from 23,105
The 1997 sample of 1,488 nursing homes was the same
nursing homes in the sampling frame, which consisted of all
basic sample used in 1995. Excluded were out-of-scope and
homes listed in the 1973 NMFI and those opening for
out-of-business places identified in the 1995 survey. Included
business between 1973 and December 1976. Data were
were a small number of additions to the sample from a
obtained from about 13,600 staff, 7,000 residents, and 5,100
supplemental frame of places not in the 1995 frame. The
discharged residents. Response rates were 95 percent for
1997 NNHS included the discharge component not available
facilities, 85 percent for expenses, 81 percent for staff,
in the 1995 survey.
99 percent for residents, and 97 percent for discharges.
The 1999 sample of 1,423 nursing homes was the same
The 1985 NNHS was similar to the 1973–74 survey in that it
basic sample used in 1995 and 1997. The 1999 sample of
excluded personal or domiciliary care homes. The sample of
1,423 nursing homes was selected from a sampling frame of
1,220 homes was selected from a sampling frame of 20,479
18,419. The frame consisted of the most current National
nursing and related-care homes. The frame consisted of all
Health Provider Inventory. A supplemental frame was used to

add facilities not in the 1997 frame. Like the 1995 and 1997 information. Data from the three patient files are collected
surveys, the 1999 survey excluded out-of-scope and locally at each VA medical center and are transmitted to the
out-of-business nursing homes identified in 1997. The 1999 national databank at the VA Austin Automated Center, where
NNHS included a discharge resident component. they are stored and used to provide nationwide statistics,
reports, and comparisons.
Statistics for the National Nursing Home Surveys are derived
by a multistage estimation procedure that provides essentially The patient treatment file (PTF) collects data at the time of
unbiased national estimates and has three major components: the patient’s discharge on each episode of inpatient care
(a) inflation by the reciprocals of the probabilities of sample provided to patients at VA hospitals, VA nursing homes, VA
selection, (b) adjustment for nonresponse, and (c) ratio domiciliaries, community nursing homes, and other non-VA
adjustment to fixed totals. The surveys are adjusted for three facilities. The PTF record contains the scrambled social
types of nonresponse: (1) when an eligible nursing facility did security number, dates of inpatient treatment, date of birth,
not respond; (2) when the facility failed to complete the State and county of residence, type of disposition, place of
sampling lists; and (3) when the facility did not complete the disposition after discharge, as well as the ICD–9–CM
facility questionnaire but did complete the questionnaire for diagnostic and procedure or operative codes for each episode
residents in the facility. of care.
For more information on the 1973–74 NNHS, see: Meiners The patient census file collects data on each patient
MR. Selected operating and financial characteristics of remaining in a VA medical facility at midnight on a selected
nursing homes, United States, 1973–74 National Nursing date of each year, normally September 30. This file includes
Home Survey. National Center for Health Statistics. Vital patients admitted to VA hospitals, VA nursing homes, and VA
Health Stat 13(22). 1975. For more information on the 1977 domiciliaries. The census record includes information similar
NNHS, see: Van Nostrand JF, Zappolo A, Hing E, et al. The to that reported in the patient treatment file record.
National Nursing Home Survey, 1977 summary for the United
The outpatient clinic file (OPC) collects data on each instance
States. National Center for Health Statistics. Vital Health Stat
of medical treatment provided to a veteran in an outpatient
13(43). 1979. For more information on the 1985 NNHS, see:
setting. The OPC record includes the age, scrambled social
Hing E, Sekscenski E, Strahan G. The National Nursing
security number, State and county of residence, VA eligibility
Home Survey: 1985 summary for the United States. National
code, clinic(s) visited, purpose of visit, and the date of visit
Center for Health Statistics. Vital Health Stat 13(97). 1989.
for each episode of care.
For more information on the 1995 NNHS, see: Strahan G. An
overview of nursing homes and their current residents: Data For more information, write: Department of Veterans Affairs,
from the 1995 National Nursing Home Survey. Advance data Office of Policy and Planning, Policy Analysis Service, 810
from vital and health statistics; no 280. Hyattsville, MD: Vermont Ave., NW, Washington, DC 20420; or visit the VA
National Center for Health Statistics. 1997. For more home page at www.va.gov.
information on the 1997 NNHS, see: The National Nursing
Home Survey: 1997 summary. National Center for Health National Survey of Ambulatory Surgery (NSAS)
Statistics. Vital Health Stat 13(147). 2000. For more
information on the 1999 NNHS, see: Advance data report Centers for Disease Control and Prevention
available in the summer of 2002. Information about the 1995, National Center for Health Statistics
1997, 1999, and 2001 NNHS is also available at the NHCS
The National Survey of Ambulatory Surgery (NSAS) is a
nationwide sample survey of ambulatory surgery patient
discharges from short-stay non-Federal hospitals and
National Patient Care Database freestanding surgery centers. NSAS was conducted annually
Department of Veterans Affairs between 1994 and 1996. The sample consisted of eligible
hospitals listed in the 1993 SMG Hospital Market Database
The Department of Veterans Affairs (VA) maintains the and the 1993 SMG Freestanding Outpatient Surgery Center
National Patient Care Database that includes data files on Database or Medicare Provider-of-Service files. Facilities
patient treatment, patient census, outpatient clinic, and budget

specializing in dentistry, podiatry, abortion, family planning, or Interviews are conducted in person by professional female
birthing were excluded. interviewers using a standardized questionnaire. In 1973–88
the average interview length was about 1 hour. In 1995 the
A three-State stratified cluster design was used, and facilities
average interview lasted about 1 hour and 45 minutes. In all
were stratified according to primary sampling unit (PSU). The
cycles black women were sampled at higher rates than white
second stage consisted of the selection of facilities from
women, so that detailed statistics for black women could be
sample PSUs, and the third stage consisted of a systematic
produced.
random sample of cases from all locations within a facility
where ambulatory surgery was performed. Locations within Interviewing for Cycle 1 of NSFG was conducted from June
hospitals dedicated exclusively to dentistry, podiatry, pain 1973 to February 1974. Counties and independent cities of
block, abortion, or small procedures (sometimes referred to as the United States were sampled to form a frame of primary
‘‘lump and bump’’ rooms) were not included. In 1996, of the sampling units (PSUs), and 101 PSUs were selected. From
751 hospitals and freestanding ambulatory surgery centers these 101 PSUs, 10,879 women 15–44 years of age were
selected for the survey, 601 were in-scope and 488 selected, 9,797 of these were interviewed. Most never-married
responded for an overall response rate of 81 percent. These women were excluded from the 1973 NSFG.
facilities provided information for approximately 125,000
Interviewing for Cycle 2 of NSFG was conducted from
ambulatory surgery discharges. Up to six procedures were
January to September 1976. From 79 PSUs, 10,202 eligible
coded to the International Classification of Diseases, 9th
women were identified; of these, 8,611 were interviewed.
Revision, Clinical Modification. Estimates were derived using
Again, most never-married women were excluded from the
a multistage estimation procedure: inflation by reciprocals of
sample for the 1976 NSFG.
the probabilities of selection; adjustment for nonresponse; and
population weighting ratio adjustments. Interviewing for Cycle 3 of NSFG was conducted from August
1982 to February 1983. The sample design was similar to
For more detailed information on the design of NSAS, see:
that in Cycle 2: 31,027 households were selected in 79
McLemore T, Lawrence L. Plan and operation of the National
PSUs. Household screener interviews were completed in
Survey of Ambulatory Surgery. National Center for Health
29,511 households (95.1 percent). Of the 9,964 eligible
Statistics. Vital Health Stat 1(37). 1997; or visit the NHCS
women identified, 7,969 were interviewed. For the first time in
NSFG, Cycle 3 included women of all marital statuses.
National Survey of Family Growth (NSFG) Interviewing for Cycle 4 was conducted between January and
August 1988. The sample was obtained from households that
Centers for Disease Control and Prevention had been interviewed in the National Health Interview Survey
National Center for Health Statistics in the 18 months between October 1, 1985 and March 31,
1987. For the first time, women living in Alaska and Hawaii
Data from the National Survey of Family Growth (NSFG) are were included so that the survey covered women from the
based on samples of women ages 15–44 years in the civilian noninstitutionalized population of the entire United States. The
noninstitutionalized population of the United States. The first sample was drawn from 156 PSUs; 10,566 eligible women
and second cycles, conducted in 1973 and 1976, excluded ages 15–44 years were sampled. Interviews were completed
most women who had never been married. The third, fourth, with 8,450 women.
and fifth cycles, conducted in 1982, 1988, and 1995, included
all women ages 15–44 years. Between July and November 1990, 5,686 women were
interviewed by telephone in the first NSFG telephone
The purpose of the survey is to provide national data on reinterview. The average length of interview in 1990 was 20
factors affecting birth and pregnancy rates, adoption, and minutes. The response rate for the 1990 telephone
maternal and infant health. These factors include sexual reinterview was 68 percent of those responding to the 1988
activity, marriage, divorce and remarriage, unmarried survey and still eligible for the 1990 survey.
cohabitation, contraception and sterilization, infertility,
breastfeeding, pregnancy loss, low birthweight, and use of Interviewing for Cycle 5 of NSFG was conducted between
medical care for family planning and infertility. January and October 1995. The sample was obtained from

households that had been interviewed in 198 PSUs in the National Survey of Substance Abuse Treatment
National Health Interview Survey in 1993. Of the 13,795 Services (N-SSATS)
eligible women in the sample, 10,847 were interviewed. For
the first time, Hispanic as well as black women were sampled Substance Abuse and Mental Health Services
at a higher rate than other women. Administration
In order to make national estimates from the sample for the The National Survey of Substance Abuse Treatment Services
millions of women ages 15–44 years in the United States, (N-SSATS), formerly the Uniform Facility Data Set (UFDS), is
data for the interviewed sample women were (a) inflated by part of the Drug and Alcohol Services Information System
the reciprocal of the probability of selection at each stage of (DASIS) maintained by the Substance Abuse and Mental
sampling (for example, if there was a 1 in 5,000 chance that Health Services Administration (SAMHSA). N-SSATS is a
a woman would be selected for the sample, her sampling census of all known substance abuse treatment facilities. It
weight was 5,000), (b) adjusted for nonresponse, and seeks information from all specialized facilities that treat
(c) forced to agree with benchmark population values based substance abuse. These include facilities that treat only
on data from the Current Population Survey of the U.S. substance abuse, as well as specialty substance abuse units
Bureau of the Census (this last step is called operating within larger mental health (for example, community
‘‘poststratification’’). mental health centers), general health (for example,
Quality control procedures for selecting and training hospitals), social service (for example, family assistance
interviewers, and coding, editing, and processing data were centers), and criminal justice (for example, probation
built into NSFG to minimize nonsampling error. departments) agencies. N-SSATS solicits data concerning
facility and client characteristics for a specific reference day
More information on the methodology of NSFG is available in (on or about October 1) including number of individuals in
the following reports: French DK. National Survey of Family treatment, substance of abuse (alcohol, drugs, or both), and
Growth, Cycle I: Sample design, estimation procedures, and types of services. Public and private facilities are included.
variance estimation. National Center for Health Statistics. Vital
Health Stat 2(76). 1978; Grady WR. National Survey of Treatment facilities contacted through N-SSATS are identified
Family Growth, Cycle II: Sample design, estimation from the Inventory of Substance Abuse Treatment Services
procedures, and variance estimation. National Center for (I-SATS), formerly the National Master Facility Inventory,
Health Statistics. Vital Health Stat 2(87). 1981; Bachrach CA, which lists all known substance abuse treatment facilities.
Horn MC, Mosher WD, Shimizu I. National Survey of Family Response rates to the surveys were 88, 91, and 94 percent
Growth, Cycle III: Sample design, weighting, and variance in 1997, 1998, and 2000, respectively. The full survey was
estimation. National Center for Health Statistics. Vital Health not conducted in 1999.
Stat 2(98). 1985; Judkins DR, Mosher WD, Botman SL. For further information on N-SSATS, contact: Office
National Survey of Family Growth: Design, estimation, and of Applied Studies, Substance Abuse and Mental Health
inference. National Center for Health Statistics. Vital Health Services Administration, Room 16–105, 5600 Fishers
Stat 2(109). 1991; Goksel H, Judkins DR, Mosher WD. Lane, Rockville, MD 20857; or visit the OAS statistical
Nonresponse adjustments for a telephone followup to a information section of the SAMHSA home page:
National In-Person Survey. Journal of Official Statistics www.drugabusestatistics.samhsa.gov.
8(4):417–32. 1992; Kelly JE, Mosher WD, Duffer AP, Kinsey
SH. Plan and operation of the 1995 National Survey of
National Vital Statistics System
Family Growth. Vital Health Stat 1(36). 1997; Potter FJ,
Iannacchione VG, Mosher WD, Mason RE, Kavee JD. Centers for Disease Control and Prevention
Sampling weights, imputation, and variance estimation National Center for Health Statistics
in the 1995 National Survey of Family Growth. Vital Health
Stat 2(124). 1998; or visit the NCHS home page at Through the National Vital Statistics System, the National
www.cdc.gov/nchs. Center for Health Statistics (NCHS) collects and publishes
data on births, deaths, marriages, and divorces in the United
States. Fetal deaths are classified and tabulated separately

from other deaths. The Division of Vital Statistics obtains this report. For items on the birth certificate, the number of
information on births and deaths from the registration offices reporting States increased for mother’s education, prenatal
of all States, New York City, the District of Columbia, Puerto care, marital status, Hispanic parentage, and tobacco use;
Rico, the U.S. Virgin Islands, and Guam. Geographic and on the death certificate, for educational attainment and
coverage for births and deaths has been complete since Hispanic origin of the decedent.
1933. Trend tables in this book show data for the aggregate
of 50 States, New York City, and the District of Columbia, as Birth File
well as for each individual State and the District of Columbia.
The birth file is comprised of demographic and medical
Until 1972 microfilm copies of all death certificates and a information from birth certificates. Demographic information,
50-percent sample of birth certificates were received from all such as race and ethnicity, is provided by the mother at the
registration areas and processed by NCHS. In 1972 some time of birth. Medical and health information is based on
States began sending their data to NCHS through the hospital records. Additional information follows for selected
Cooperative Health Statistics System (CHSS). States that items on the birth certificate.
participated in the CHSS program processed 100 percent of
their death and birth records and sent the entire data file to Race—Data on birth rates, birth characteristics, and fetal
NCHS on computer tapes. Currently, the data are sent to death rates for 1980 and more recent years for liveborn
NCHS through the Vital Statistics Cooperative Program infants and fetal deaths are presented in this report according
(VSCP), following the same procedures as CHSS. The to race of mother, unless specified otherwise. Before 1980
number of participating States grew from 6 in 1972 to 46 in data were tabulated by race of newborn and fetus, taking into
1984. Starting in 1985 all 50 States and the District of account the race of both parents. If the parents were of
Columbia participated in VSCP. different races and one parent was white, the child was
classified according to the race of the other parent. When
In most areas practically all births and deaths are registered. neither parent was white, the child was classified according to
The most recent test of the completeness of birth registration, father’s race, with one exception: if either parent was
conducted on a sample of births from 1964 to 1968, showed Hawaiian, the child was classified Hawaiian. Before 1964, if
that 99.3 percent of all births in the United States during that race was unknown, the birth was classified as white.
period were registered. No comparable information is Beginning in 1964 unknown race was classified according to
available for deaths, but it is generally believed that death information on the previous record.
registration in the United States is at least as complete as
birth registration. Maternal age—Mother’s age was reported on the birth
certificate by all States. Data are presented for mother’s age
U.S. Standard Certificates—U.S. Standard Live Birth and 10–49 years through 1996 and 10–54 years starting in 1997,
Death Certificates and Fetal Death Reports are revised based on mother’s date of birth or age as reported on the
periodically, allowing careful evaluation of each item and birth certificate. The age of mother is edited for upper and
addition, modification, and deletion of items. Beginning with lower limits. When the age of the mother is computed to be
1989 revised standard certificates replaced the 1978 versions. under 10 years or 55 years or over (50 years or over in
The 1989 revision of the birth certificate includes items to 1964–96), it is considered not stated and imputed according
identify the Hispanic parentage of newborns and to expand to the age of the mother from the previous birth record of the
information about maternal and infant health characteristics. same race and total birth order (total of fetal deaths and live
The 1989 revision of the death certificate includes items on births). Before 1963 not stated ages were distributed in
educational attainment and Hispanic origin of decedents, as proportion to the known ages for each racial group. Beginning
well as changes to improve the medical certification of cause in 1997 the birth rate for the maternal age group 45–49 years
of death. Standard certificates recommended by NCHS are includes data for mother’s age 50–54 years in the numerator
modified in each registration area to serve the area’s needs. and is based on the population of women 45–49 years in the
However, most certificates conform closely in content and denominator.
arrangement to the standard certificate, and all certificates
contain a minimum data set specified by NCHS. For selected Maternal education—Mother’s education was reported on the
items, reporting areas expanded during the years spanned by birth certificate by 38 States in 1970. Data were not available

from Alabama, Arkansas, California, Connecticut, Delaware, Columbia began reporting this information. Between 1983 and
District of Columbia, Georgia, Idaho, Maryland, New Mexico, 1987 information on births of Hispanic parentage was
Pennsylvania, Texas, and Washington. In 1975 these data available for 23 States and the District of Columbia. In 1988
were available from four additional States, Connecticut, this information became available for Alabama, Connecticut,
Delaware, Georgia, Maryland, and the District of Columbia, Kentucky, Massachusetts, Montana, North Carolina, and
increasing the number of States reporting mother’s education Washington, increasing the number of States reporting
to 42 and the District of Columbia. Between 1980 and 1988 information on births of Hispanic parentage to 30 States and
only three States, California, Texas, and Washington, did not the District of Columbia. In 1989 this information became
report mother’s education. In 1988 mother’s education was available from an additional 17 States, increasing the number
also missing from New York State outside New York City. In of Hispanic-reporting States to 47 and the District of
1989–91 mother’s education was missing only from Columbia. In 1989 only Louisiana, New Hampshire, and
Washington and New York State outside New York City. Oklahoma did not report Hispanic parentage on the birth
Starting in 1992 mother’s education was reported by all 50 certificate. In 1990 Louisiana began reporting Hispanic
States and the District of Columbia. parentage. Hispanic origin of the mother was reported on the
birth certificates of 49 States and the District of Columbia in
Prenatal care—Prenatal care was reported on the birth
1991 and 1992; only New Hampshire did not provide this
certificate by 39 States and the District of Columbia in 1970.
information. Starting in 1993 Hispanic origin of mother was
Data were not available from Alabama, Alaska, Arkansas,
reported by all 50 States and the District of Columbia. In
Connecticut, Delaware, Georgia, Idaho, Massachusetts, New
1990, 99 percent of birth records included information on
Mexico, Pennsylvania, and Virginia. In 1975 these data were
mother’s origin.
available from three additional States, Connecticut, Delaware,
and Georgia, increasing the number of States reporting Tobacco use—Information on tobacco use during pregnancy
prenatal care to 42 and the District of Columbia. Starting in became available for the first time in 1989 with revision of the
1980 prenatal care information was available for the entire U.S. Standard Birth Certificate. In 1989 data on tobacco use
United States. were collected by 43 States and the District of Columbia. The
following States did not require the reporting of tobacco use
Marital status—Mother’s marital status was reported on the
in the standard format on the birth certificate: California,
birth certificate by 39 States and the District of Columbia in
Indiana, Louisiana, Nebraska, New York, Oklahoma, and
1970, and by 38 States and the District of Columbia in 1975.
South Dakota. In 1990 information on tobacco use became
The incidence of births to unmarried women in States with no
available from Louisiana and Nebraska, increasing the
direct question on marital status was assumed to be the
number of reporting States to 45 and the District of Columbia.
same as the incidence in reporting States in the same
In 1991–93, with the addition of Oklahoma to the reporting
geographic division. Starting in 1980 for States without a
area, information on tobacco use was available for 46 States
direct question, marital status was inferred by comparing the
and the District of Columbia; in 1994–98, 46 States, the
parents’ and child’s surnames and other information
District of Columbia, and New York City reported tobacco use;
concerning the father. In 1980–96 marital status was reported
in 1999 information on tobacco use became available from
on the birth certificates of 41–45 States. In 1997, all but four
Indiana and New York, increasing the number of reporting
States (Connecticut, Michigan, Nevada, and New York) and,
States to 48, the District of Columbia, and New York City;
in 1998, all but two States (Michigan and New York) included
and in 2000, with the addition of South Dakota, the reporting
a direct question about mother’s marital status on their birth
area included 49 States, the District of Columbia, and New
certificates.
York City. During 1989–2000 California did not require the
Hispanic origin—In 1980 and 1981 information on births of reporting of tobacco use in the standard format on the birth
Hispanic parentage was reported on the birth certificate by certificate.
the following 22 States: Arizona, Arkansas, California,
Colorado, Florida, Georgia, Hawaii, Illinois, Indiana, Kansas, Mortality File
Maine, Mississippi, Nebraska, Nevada, New Jersey, New
Mexico, New York, North Dakota, Ohio, Texas, Utah, and The mortality data file is comprised of demographic and
Wyoming. In 1982 Tennessee, and in 1983 the District of medical information from death certificates. Demographic

information is provided by the funeral director based on collected in the first National Health and Nutrition Examination
information supplied by an informant. Medical certification of Survey (NHANES I) with education on the death certificate for
cause of death is provided by a physician, medical examiner, decedents in the NHANES I Epidemiologic Followup Study.
or coroner. The mortality data file is a fundamental source of (Makuc DM, Feldman JJ, Mussolino ME: Validity of education
cause-of-death information by demographic characteristics and and age as reported on death certificates, American Statistical
for geographic areas, such as States. The mortality file is one Association 1996 Proceedings of the Social Statistics Section,
of the few sources of comparable health-related data for 102–6, 1997.) Results of both studies indicated that there is a
smaller geographic areas in the United States and over a tendency for some people who did not graduate from high
long time period. Mortality data can be used not only to school to be reported as high school graduates on the death
present the characteristics of those dying in the United certificate. This tendency results in overstating the death rate
States, but also to determine life expectancy and to compare for high school graduates and understating the death rate for
mortality trends with other countries. Additional information the group with less than 12 years of education. The bias was
follows for selected items on the death certificate. greater among older than younger decedents and somewhat
greater among black than white decedents.
Education of decedent—Information on educational attainment
of decedents became available for the first time in 1989 due In addition, educational gradients in death rates based on the
to revision of the U.S. Standard Certificate of Death. Mortality National Vital Statistics System were compared with those
data by educational attainment for 1989 were based on data based on the NLMS, a prospective study of persons in the
from 20 States and by 1994–96 increased to 45 States and Current Population Survey. Results of these comparisons
the District of Columbia. In 1994–96 the following States indicate that educational gradients in death rates based on
either did not report educational attainment on the death the National Vital Statistics System were reasonably similar to
certificate or the information was more than 20 percent those based on NLMS for white persons 25–64 years of age
incomplete: Georgia, Kentucky, Oklahoma, Rhode Island, and and black persons 25–44 years of age. The number of
South Dakota. In 1997–2000 information on decedent’s deaths for persons of Hispanic origin in NLMS was too small
education was available from Oklahoma, increasing the to permit comparison for this ethnic group.
reporting area to 46 States and the District of Columbia.
Hispanic origin—In 1985 mortality data by Hispanic origin of
Information on the death certificate about the decedent’s
decedent were based on deaths to residents of the following
educational attainment is reported by the funeral director
17 States and the District of Columbia whose data on the
based on information provided by an informant such as next
death certificate were at least 90 percent complete on a
of kin.
place-of-occurrence basis and of comparable format: Arizona,
Calculation of unbiased death rates by educational attainment Arkansas, California, Colorado, Georgia, Hawaii, Illinois,
based on the National Vital Statistics System requires that the Indiana, Kansas, Mississippi, Nebraska, New York, North
reporting of education on the death certificate be complete Dakota, Ohio, Texas, Utah, and Wyoming. In 1986 New
and consistent with the reporting of education on the Current Jersey began reporting Hispanic origin of decedent,
Population Survey, the source of population estimates that increasing the number of reporting States to 18 and the
form the denominators for death rates. Death records with District of Columbia in 1986 and 1987. In 1988 Alabama,
education not stated have not been included in the calculation Kentucky, Maine, Montana, North Carolina, Oregon, Rhode
of rates. Therefore the levels of the rates shown in this report Island, and Washington were added to the reporting area,
are underestimated by approximately the percent not stated, increasing the number of States to 26 and the District of
which ranged from 3 to 5 percent. Columbia. In 1989 an additional 18 States were added,
increasing the Hispanic reporting area to 44 States and the
The validity of information about the decedent’s education
District of Columbia. In 1989 only Connecticut, Louisiana,
was evaluated by comparing self-reported education obtained
Maryland, New Hampshire, Oklahoma, and Virginia were not
in the Current Population Survey with education on the death
included in the reporting area. Starting with 1990 data in this
certificate for decedents in the National Longitudinal Mortality
book, the criterion was changed to include States whose data
Survey (NLMS). (Sorlie PD, Johnson NJ: Validity of education
were at least 80 percent complete. In 1990 Maryland, Virginia,
information on the death certificate, Epidemiology 7(4):437–9,
and Connecticut, in 1991 Louisiana, and in 1993 New
1996.) Another analysis compared self-reported education

Hampshire were added, increasing the reporting area for maternal mortality trends were based on child’s race in the
Hispanic origin of decedent to 47 States and the District of denominator, which took into account the race of both
Columbia in 1990, 48 States and the District of Columbia in parents. Infant and maternal mortality trends for Hispanics
1991 and 1992, and 49 States and the District of Columbia in began with 1985 and are based on Hispanic origin of mother.
1993–96. Only Oklahoma did not provide this information in
Vital event rates for the American Indian or Alaska Native
1993–96. Starting in 1997 Hispanic origin of decedent was
population shown in this book are based on the total U.S.
reported by all 50 States and the District of Columbia. Based
resident population of American Indians and Alaska Natives
on data from the U.S. Bureau of the Census, the 1990
as enumerated by the U.S. Bureau of Census. In contrast the
reporting area encompassed 99.6 percent of the U.S.
Indian Health Service calculates vital event rates for this
Hispanic population. In 1990 more than 96 percent of death
population based on U.S. Bureau of Census county data for
records included information on origin of decedent.
American Indians and Alaska Natives who reside on or near
Race and Hispanic origin—Death rates by race and Hispanic reservations.
origin are based on information from death certificates
Mortality data in Health, United States are presented for four
(numerators of the rates) and on population estimates from
major race groups, white, black, American Indian or Alaska
the Census Bureau (denominators). Race and ethnicity
Native, and Asian or Pacific Islander, in accordance with 1977
information on the death certificate are reported by the
U.S. Office of Management and Budget (OMB) standards for
funeral director as provided by an informant, often the
presenting Federal statistics on race. Over the next several
surviving next of kin, or, in the absence of an informant, on
years, major changes will occur in the way Federal agencies
the basis of observation. Race and ethnicity information from
collect and tabulate data on race and Hispanic origin, in
the census is by self-report. To the extent that race and
accordance with the 1997 guidelines from OMB (see
Hispanic origin are inconsistent between these two data
Appendix II, Race). The major difference between the 1977
sources, death rates will be biased. Studies have shown that
and 1997 guidelines is adoption of data-collection procedures
persons self-reported as American Indian, Asian, or Hispanic
in which respondents can identify with more than one race
on census and survey records may sometimes be reported as
group.
white or non-Hispanic on the death certificate, resulting in an
underestimation of deaths and death rates for the American For more information, see: National Center for Health
Indian, Asian, and Hispanic groups. Bias also results from Statistics, Technical Appendix, Vital Statistics of the United
undercounts of some population groups in the census, States, 2000, Vol. I, Natality, and Vol. II, Mortality, Part A
particularly young black and white males and elderly persons, available on the NCHS home page at www.cdc.gov/nchs.
resulting in an overestimation of death rates. The net effects Click on Vital Statistics, Birth Data and Mortality Data.
of misclassification and undercoverage result in overstated
death rates for the white population and black population Multiple Cause of Death File
estimated to be 1 percent and 5 percent, respectively; and
understated death rates for other population groups estimated The National Center for Health Statistics (NCHS) is
as follows: American Indians, 21 percent; Asian or Pacific responsible for compiling and publishing annual national
Islanders, 11 percent; and Hispanics, 2 percent. For more statistics on causes of death. In carrying out this
information, see Rosenberg HM, Maurer JD, Sorlie PD, responsibility, NCHS adheres to the World Health
Johnson NJ, et al. Quality of death rates by race and Organization Nomenclature Regulations. These Regulations
Hispanic origin: A summary of current research, 1999. require that (1) cause of death be coded in accordance with
National Center for Health Statistics. Vital Health Stat 2(128). the current revision of the International Classification of
1999. Diseases (ICD) (see Appendix II, table VI and ICD); and
(2) underlying cause of death be selected in accordance with
Infant and maternal mortality rates are calculated with international rules. Traditionally, national mortality statistics
denominators comprising the number of live births rather than have been based on a count of deaths with one underlying
population estimates. Starting with 1980 infant and maternal cause assigned for each death. National single-cause
mortality trends are based on maternal race and ethnicity of mortality statistics go back to the year 1900.
the live birth in the denominator. Before 1980 infant and

Starting with data year 1968, electronic files exist with to correct for the 2.2–2.5 percent of records that could not be
multiple cause of death information. These files contain codes linked and addition of an imputation for not stated birthweight.
for all diagnostic terms and related codable information The 1995–99 weighted mortality rates are less than 1 percent
recorded on the death certificate. These codes comprise the to 4.1 percent higher than unweighted rates for the same
entity axis, and are the input for a software program called period. The 1995–99 weighted mortality rates with imputed
TRANSAX. The TRANSAX program eliminates redundant birthweight are less than 1 percent to 6.3 percent higher than
entity axis codes and combines other entity axis codes to unweighted rates with imputed birthweight for the same
create the best set of ICD codes for a record. The output of period.
the TRANSAX program is the record axis. Record axis data
For more information, see: Mathews TJ, MacDorman MF,
are generally used for research and analysis of multiple or
Menacker F. Infant mortality statistics from the 1999 period
nonunderlying cause of death. Because the function of the
linked birth/infant death data set. National vital statistics
TRANSAX program is not to select a single underlying cause
reports; vol 50 no 4. Hyattsville, MD: National Center for
of death, record axis data may or may not include the
Health Statistics. 2002; or visit the NCHS home page at
underlying cause. Tabulations of underlying and nonunderlying
www.cdc.gov/nchs.
cause of death in table 49 (selected occupational diseases)
are compiled by searching underlying cause of death and
Compressed Mortality File (CMF)
record axis data.
The Compressed Mortality File (CMF) used to compute death
National Linked File of Live Births and Infant Deaths rates by urbanization level is a county-level national mortality
and population database. The mortality database of CMF is
National linked files of live births and infant deaths are data
derived from the detailed mortality files of the National Vital
sets for research on infant mortality. To create these data
Statistics System starting with 1968. The population database
sets, death certificates are linked with corresponding birth
of CMF is derived from intercensal and postcensal population
certificates for infants who die in the United States before
estimates and census counts of the resident population of
their first birthday. Linked data files include all variables on
each U.S. county by age, race, and sex. Counties are
the national natality file, including the more accurate racial
categorized according to level of urbanization based on an
and ethnic information, as well as variables on the national
NCHS-modified version of the 1993 rural-urban continuum
mortality file, including cause of death and age at death. The
codes for metropolitan and nonmetropolitan counties
linkage makes available for the analysis of infant mortality
developed by the Economic Research Service, U.S.
extensive information from the birth certificate about the
Department of Agriculture. See Appendix II, Urbanization. For
pregnancy, maternal risk factors, and infant characteristics
more information about CMF, contact: D. Ingram, Division of
and health items at birth. Each year 97–98 percent of infant
Health and Utilization Analysis, National Center for Health
death records are linked to their corresponding birth records.
Statistics, 6525 Belcrest Road, Hyattsville, MD 20782.
National linked files of live births and infant deaths were first
produced for the 1983 birth cohort. Birth cohort linked file Nurse Supply Estimates
data are available for 1983–91 and period linked file data for
1995–99. Data for 1995 and after are not strictly comparable Health Resources and Services Administration
with birth cohort data for earlier years. While birth cohort
Nursing estimates in this report are based on a model
linked files have methodological advantages, their production
developed by the Bureau of Health Professions to meet the
incurs substantial delays in data availability, since it is
requirements of Section 951, P.L. 94–63. The model
necessary to wait until the close of a second data year to
estimates the following for each State: (a) population of
include all infant deaths to the birth cohort.
nurses currently licensed to practice; (b) supply of full- and
Starting with data year 1995, more timely linked file data are part-time practicing nurses (or available to practice); and
produced in a period data format preceding the release of the (c) full-time equivalent supply of nurses practicing full time
corresponding birth cohort format. Other changes to the data plus one-half of those practicing part time (or available on
set starting with 1995 data include addition of record weights that basis). The three estimates are divided into three levels

of highest educational preparation: associate degree or facility’s own administrative record system in addition to
diploma, baccalaureate, and master’s and doctorate. Among interviews with key administrative staff members.
the factors considered are new graduates, changes in

All certified nursing homes are inspected by representatives
educational status, nursing employment rates, age, migration

of the State survey agency (generally the department of
patterns, death rates, and licensure phenomena. The base

health) at least once every 15 months. Therefore a complete
data for the model are derived from the National Sample
census must be based on a 15-month reporting cycle rather
Surveys of Registered Nurses, conducted by the Division of

than a 12-month cycle. Some nursing homes are inspected
Nursing, Bureau of Health Professions, HRSA. Other data

twice or more often during any given reporting cycle. In order
sources include National League for Nursing for data on

to avoid overcounting, the data must be edited and duplicates
nursing education and National Council of State Boards of

removed. Data editing and compilation were performed by
Nursing for data on licensure. For further information,

Cowles Research Group and published in the group’s Nursing
visit HRSA’s Division of Nursing home page at:

Home Statistical Yearbook series.
www.bhpr.hrsa.gov/nursing.
For more information, see: Cowles CM, 1995 Nursing Home
Online Survey Certification and Reporting Statistical Yearbook. 1996 Nursing Home Statistical Yearbook.
1997 Nursing Home Statistical Yearbook. Anacortes, WA:
Database (OSCAR)
Cowles Research Group (CRG), 1995; 1997; 1998; Cowles
Centers for Medicare and Medicaid Services CM, 1998 Nursing Home Statistical Yearbook. 1999 Nursing
Home Statistical Yearbook. 2000 Nursing Home Statistical
The Online Survey Certification and Reporting (OSCAR) Yearbook. Washington, DC: American Association of Homes
database has been maintained by the Centers for Medicare and Services for the Aging (AAHSA), 1999; 2000, 2001;
and Medicaid Services (CMS), formerly the Health Care HCFA: OSCAR Data Users Reference Guide, 1995,
Financing Administration (HCFA), since 1992. OSCAR is an available from CMS, Health Standards and Quality Bureau,
updated version of the Medicare and Medicaid Automated HCFA/HSQB S2 11-07, 7500 Security Boulevard,
Certification System that has been in existence since 1972. Baltimore, MD 21244; or visit the CMS home page at
OSCAR is an administrative database containing detailed www.hcfa.gov or www.cms.gov or the CRG Web page at
information on all Medicare and Medicaid health care www.longtermcareinfo.com/crg. The e-mail contact for CRG is
providers in addition to all currently certified Medicare and [email protected] and for AAHSA is [email protected].
Medicaid nursing home facilities in the United States and

Territories. (Data for the Territories are not shown in this
Population Census
report.) The purpose of the nursing home facility survey
certification process is to ensure that nursing facilities meet Bureau of the Census
the current CMS long-term care requirements and thus can
participate in serving Medicare and Medicaid beneficiaries. The census of population has been taken in the United
Included in the OSCAR database are all certified nursing States every 10 years since 1790. In the 1990 and 2000
facilities, certified hospital-based nursing homes, and certified censuses, data were collected on sex, race, age, and marital
units for other types of nursing home facilities (for example, status from 100 percent of the enumerated population. More
life-care communities or board and care homes). Facilities not detailed information such as income, education, housing,
included in OSCAR are all noncertified facilities (that is, occupation, and industry were collected from a representative
facilities that are only licensed by the State and are limited to sample of the population. For most of the country, one out of
private payment sources) and nursing homes that are part of six households (about 17 percent) received the more detailed
the Department of Veterans Affairs. Also excluded are nursing questionnaire. In places of residence estimated to have less
homes that are intermediate care facilities for the mentally than 2,500 population, 50 percent of households received the
retarded. long form. The question on race for Census 2000 was
different from the one for the 1990 census in several ways.
Information on the number of beds, residents, and resident Most significantly, respondents were given the option of
characteristics is collected during an inspection of all certified selecting one or more race categories to indicate their racial
facilities. The information in OSCAR is based on each identities (see Appendix II, Race).

For more information, see: U.S. Bureau of the Census, 1990 population-based registries throughout the United States to
Census of Population, General Population Characteristics, provide data on all residents diagnosed with cancer during
Series 1990, CP–1; or visit the Census Bureau home page at the year and to provide current followup information on all
www.census.gov. previously diagnosed patients.
This report covers residents of one of the following
Population Estimates geographic areas at the time of the initial diagnosis of cancer:
Atlanta, Georgia; Detroit, Michigan; Seattle-Puget Sound,
Bureau of the Census
Washington; San Francisco-Oakland, Los Angeles, and San
National population estimates are derived by using decennial Jose-Monterey, California; Connecticut; Iowa; New Mexico;
census data as benchmarks and data available from various Utah; and Hawaii.
agencies as follows: births and deaths (National Center for Population estimates used to calculate incidence rates are
Health Statistics); immigrants (Immigration and Naturalization obtained from the U.S. Bureau of the Census. NCI uses
Service); Armed Forces (Department of Defense); net estimation procedures as needed to obtain estimates for
movement between Puerto Rico and the U.S. mainland years and races not included in data provided by the U.S.
(Puerto Rico Planning Board); and Federal employees abroad Bureau of the Census. Rates presented in this report may
(Office of Personnel Management and Department of differ somewhat from previous reports due to revised
Defense). State estimates are based on similar data and a population estimates and the addition and deletion of small
variety of other data series, including school statistics from numbers of incidence cases.
State departments of education and parochial school systems.
Current estimates are consistent with official decennial census Life tables used to determine normal life expectancy when
figures and do not reflect estimated decennial census calculating relative survival rates were obtained from NCHS
underenumeration. and in-house calculations. Separate life tables are used for
each race-sex-specific group included in the SEER Program.
After decennial population censuses, intercensal population
estimates for the preceding decade are prepared to replace For further information, see: Ries LAG, Eisner MP, Kosary
postcensal estimates. Intercensal population estimates are CL, et al. (eds). SEER Cancer Statistics Review 1973–98.
more accurate than postcensal estimates because they take National Cancer Institute. Bethesda, MD. 2001; or visit the
into account the census of population at the beginning and SEER home page at www.seer.cancer.gov.
end of the decade. Intercensal estimates have been prepared
for the 1960s, 1970s, and 1980s to correct the ‘‘error of Survey of Occupational Injuries and
closure’’ or difference between the estimated population at the Illnesses (SOII)
end of the decade and the census count for that date. The
‘‘error of closure’’ at the national level was quite small during Bureau of Labor Statistics
the 1960s (379,000). However, for the 1970s it amounted to
Since 1971 the Bureau of Labor Statistics (BLS) has
almost 5 million and for the 1980s, 1.5 million.
conducted an annual survey of establishments in the private
For more information, see: U.S. Bureau of the Census, U.S. sector to collect statistics on occupational injuries and
population estimated by age, sex, race, and Hispanic origin: illnesses. The Survey of Occupational Injuries and Illnesses is
1990–96, release PPL–57, March 1997; or visit the Census a Federal/State program in which employer reports are
Bureau home page at www.census.gov. collected from about 169,000 private industry establishments
and processed by State agencies cooperating with BLS. Data
Surveillance, Epidemiology, and End Results for the mining industry and for railroad activities are provided
Program (SEER) by Department of Labor’s Mine Safety and Health
Administration and Department of Transportation’s Federal
National Cancer Institute Railroad Administration. Excluded from the survey are
self-employed individuals; farmers with fewer than 11
In the Surveillance, Epidemiology, and End Results (SEER) employees; private households; Federal Government
Program, the National Cancer Institute (NCI) contracts with 11

agencies; and employees in State and local government Youth Risk Behavior Survey (YRBS)
agencies. Establishments are classified in industry categories
based on the 1987 Standard Industrial Classification (SIC) Centers for Disease Control and Prevention
Manual, as defined by the Office of Management and Budget. National Center for Chronic Disease Prevention and
Health Promotion
Survey estimates of occupational injuries and illnesses are
based on a scientifically selected probability sample, rather The national Youth Risk Behavior Survey (YRBS) is
than a census of the entire population. An independent conducted by the Centers for Disease Control and
sample is selected for each State and the District of Prevention’s National Center for Chronic Disease Prevention
Columbia that represents industries in that jurisdiction. BLS and Health Promotion to monitor the prevalence of priority
includes all the State samples in the national sample. health risk behaviors among high school students in grades
9–12 that contribute to morbidity and mortality in both
Establishments included in the survey are instructed in a
adolescence and adulthood.
mailed questionnaire to provide summary totals of all entries
for the previous calendar year to its Log and Summary of The national YRBS of high school students was conducted in
Occupational Injuries and Illnesses (OSHA No. 200 form). 1990, 1991, 1993, 1995, 1997, 1999, and 2001. The national
Additionally, from the selected establishments, approximately YRBS school-based surveys employ a three-stage cluster
550,000 injuries and illnesses with days away from work are sample design to produce a nationally representative sample
sampled to obtain demographic and detailed case of students in grades 9–12 attending public and private high
characteristic information. An occupational injury is any injury schools. The first-stage sampling frame contains primary
such as a cut, fracture, sprain, or amputation, that results sampling units (PSUs) consisting of large counties or groups
from a work-related event or from a single instantaneous of smaller, adjacent counties. The PSUs are then stratified
exposure in the work environment. An occupational illness is based on degree of urbanization and relative percent of black
any abnormal condition or disorder other than one resulting and Hispanic students in the PSU. The PSUs are selected
from an occupational injury, caused by exposure to factors from these strata with probability proportional to school
associated with employment. It includes acute and chronic enrollment size. At the second sampling stage, schools are
illnesses or diseases that may be caused by inhalation, selected with probability proportional to school enrollment
absorption, ingestion, or direct contact. Lost workday cases size. To enable separate analysis of data for black and
involve days away from work, days of restricted work activity, Hispanic students, schools with substantial numbers of black
or both. The response rate is about 92 percent. and Hispanic students are sampled at higher rates than all
other schools. The third stage of sampling consists of
The number of injuries and illnesses reported in any given
randomly selecting one or two intact classes of a required
year can be influenced by the level of economic activity,
subject from grades 9–12 at each chosen school. All students
working conditions and work practices, worker experience and
in the selected classes are eligible to participate in the
training, and the number of hours worked. Long-term latent
survey. A weighting factor is applied to each student record to
illnesses caused by exposure to carcinogens are believed to
adjust for nonresponse and for the varying probabilities of
be understated in the survey’s illness measures. In contrast,
selection, including those resulting from the oversampling of
new illnesses such as contact dermatitis and carpal tunnel
black and Hispanic students. SUDAAN was used to compute
syndrome are easier to relate directly to workplace activity.
standard errors. The sample size for the 2001 YRBS was
For more information, see: Bureau of Labor Statistics, 13,601. The school response rate was 75 percent, and the
Workplace Injuries and Illnesses in 2000, Washington, DC. student response rate was 83 percent, for an overall response
U.S. Department of Labor, December 2001; or visit the BLS rate of 63 percent.
occupational safety and health Internet site at
National YRBS data are subject to at least two limitations.
www.stats.bls.gov/oshhome.htm.
First, these data apply only to adolescents who attend regular
high school. These students may not be representative of all
persons in this age group because those who have dropped
out of high school or attend an alternative high school for
behavioral or other reasons are not surveyed. Second, the

extent of underreporting or overreporting cannot be profession, the government, and the public. Questionnaires
determined, although the survey questions demonstrate good are sent annually to all schools of osteopathic medicine
test-retest reliability. requesting information on characteristics of applicants and
students, curricula, faculty, grants, contracts, revenues, and
For further information on the YRBS, see: CDC. Youth risk
expenditures. The response rate is 100 percent.
behavior surveillance—United States, 1999. CDC surveillance
summaries, June 9, 2000. MMWR 2000:49(SS-05); CDC. For more information, see: Annual Statistical Report, 2000,
Youth risk behavior surveillance—United States, 2001. CDC American Association of Colleges of Osteopathic Medicine:
surveillance summaries, MMWR, available summer of 2002; Rockville, MD, 2001; or visit the AACOM home page at
or write: Director, Division of Adolescent and School Health, www.aacom.org.
National Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and Prevention, 4770 American Association of Colleges of Pharmacy
Buford Highway NE, Mail Stop K-32, Atlanta, GA 30341-3717;
or visit the Division of Adolescent and School Health home The American Association of Colleges of Pharmacy (AACP)
page at www.cdc.gov/nccdphp/dash. compiles data on the Colleges of Pharmacy, including
information on student enrollment and types of degrees
conferred. Data are collected through an annual survey; the
Private and Global Sources
response rate is 100 percent.
Alan Guttmacher Institute Abortion Survey For further information, see: Profile of Pharmacy Students.
The American Association of Colleges of Pharmacy, 1426
The Alan Guttmacher Institute (AGI) conducts periodic Prince Street, Alexandria, VA; or visit the AACP home page at
surveys of abortion providers. Data are collected from www.aacp.org.
hospitals, nonhospital clinics, and physicians identified as
providers of abortion services. A universal survey of 3,092 American Association of Colleges of Podiatric
hospitals, nonhospital clinics, and individual physicians was Medicine
compiled. To assess the completeness of the provider and
abortion counts, supplemental surveys were conducted of a The American Association of Colleges of Podiatric Medicine
sample of obstetrician-gynecologists and a sample of (AACPM) compiles data on the Colleges of Podiatric
hospitals (not in original universe) that were identified as Medicine, including information on the schools and enrollment.
providing abortion services through the American Hospital Data are collected annually through written questionnaires.
Association Survey. The response rate is 100 percent.
The number of abortions estimated by AGI through the mid- For further information, write: The American Association of
to late-1980s was about 20 percent higher than the number Colleges of Podiatric Medicine, 1350 Piccard Drive, Suite 322,
reported to the Centers for Disease Control and Prevention Rockville, MD 20850-4307; or visit the AACPM home page at
(CDC). Since 1989 the AGI estimates have been about www.aacpm.org.
12 percent higher than those reported by CDC.
For more information, write: The Alan Guttmacher Institute, American Dental Association
120 Wall Street, New York, NY 10005; or visit AGI’s home
page at www.agi-usa.org. The Division of Educational Measurement of the American
Dental Association (ADA) conducts annual surveys of
predoctoral dental educational institutions. The questionnaire,
American Association of Colleges of mailed to all dental schools, collects information on student
Osteopathic Medicine characteristics, financial management, and curricula.
The American Association of Colleges of Osteopathic For more information, see: American Dental Association,
Medicine (AACOM) compiles data on various aspects of 1999–2000 Survey of Predoctoral Dental Educational
osteopathic medical education for distribution to the

Institutions. Chicago, IL. 2001; or visit the ADA home page at only reporting hospitals and, therefore, do not include
www.ada.org. estimates.
Estimates of other types of missing data were based on data
Annual Census of Hospitals reported the previous year, if available. When unavailable,
estimates were based on data furnished by reporting hospitals
American Medical Association
similar in size, control, major service provided, length of stay,
From 1920 to 1953 the Council on Medical Education and and geographic and demographic characteristics.
Hospitals of the AMA conducted annual censuses of all For more information on the AHA Annual Survey of Hospitals,
hospitals registered by the AMA. see: Health Forum, LLC, an affiliate of the American Hospital
In each annual census, questionnaires were sent to hospitals Association, Hospital Statistics, 2002. Chicago, IL. 2002; or
asking for the number of beds, bassinets, births, and patients visit the AHA home page at www.aha.org.
admitted; average census of patients; lists of staff doctors and
interns; and other information of importance at the particular Association of American Medical Colleges
time. Response rates were always nearly 100 percent.
The Association of American Medical Colleges (AAMC)
The community hospital data from 1940 and 1950 presented
collects information on student enrollment in medical schools
in this report were calculated using published figures from the
through the annual Liaison Committee on Medical Education
AMA Annual Census of Hospitals. Although the hospital
questionnaire, the fall enrollment questionnaire, and the
classification scheme used by the AMA in published reports is
American Medical College Application Service (AMCAS) data
not strictly comparable with the definition of community
system. Other data sources are the institutional profile
hospitals, methods were employed to achieve the greatest
system, the premedical students questionnaire, the minority
comparability possible.
student opportunities in medicine questionnaire, the faculty
For more information on the AMA Annual Census of roster system, data from the Medical College Admission Test,
Hospitals, see: American Medical Association, Hospital and one-time surveys developed for special projects.
Service in the United States, Journal of the American Medical
For more information, see: Association of American Medical
Association 116(11):1055–1144. 1941; 146(2):109–184. 1951;
Colleges, Statistical Information Related to Medical Education,
or visit the AMA home page at www.ama-assn.org.
Washington, DC. 2000, or visit the AAMC home page at
www.aamc.org.
Annual Survey of Hospitals
American Hospital Association Association of Schools and Colleges of
Optometry
Data from the American Hospital Association (AHA) annual
survey are based on questionnaires sent to all hospitals, The Association of Schools and Colleges of Optometry
AHA-registered and nonregistered, in the United States and (ASCO) compiles data on various aspects of optometric
its associated areas. U.S. Government hospitals located education including data on schools and enrollment.
outside the United States were excluded. Overall, the average Questionnaires are sent annually to all the schools and
response rate over the past 5 years has been approximately colleges of optometry. The response rate is 100 percent.
83 percent. For nonreporting hospitals and for the survey
For further information, write: Annual Survey of Optometric
questionnaires of reporting hospitals on which some
Educational Institutions, Association of Schools and Colleges
information was missing, estimates were made for all data
of Optometry, 6110 Executive Blvd., Suite 690, Rockville, MD
except those on beds, bassinets, and facilities. Data for beds
20852; or visit the ASCO home page at www.opted.org.
and bassinets of nonreporting hospitals were based on the
most recent information available from those hospitals.
Facilities and services and inpatient-service area data include

Association of Schools of Public Health Yearbook—Historical Supplement 1948–97. CD-ROM Special

Issue. United Nations publication sales number E/F.99.XIII.12.
The Association of Schools of Public Health (ASPH) compiles
For more information, see: United Nations, Demographic
data on schools of public health in the United States and
Yearbook 1999, United Nations, New York, 2001; or visit the
Puerto Rico. Questionnaires are sent annually to all member
United Nations home page at www.un.org or their Web site
schools, and the response rate is 100 percent.
locator at www.unsystem.org.
Unlike health professional schools that emphasize specific
clinical occupations, schools of public health offer study in National Health Maintenance Organization
specialty areas such as biostatistics, epidemiology,
Census
environmental and occupational health, health administration,
health planning, nutrition, maternal and child health, social InterStudy
and behavioral sciences, and other population-based
sciences. From 1976 to 1980 the Office of Health Maintenance
Organizations conducted a census of health maintenance
For further information, write: Association of Schools of Public organizations (HMOs). Since 1981 InterStudy has conducted
Health, 1101 15th Street, NW, Suite 910, Washington, DC the census. A questionnaire is sent to all HMOs in the United
20005; or visit the ASPH home page at www.asph.org. States asking for updated enrollment, profit status, and
Federal qualification status. New HMOs are also asked to
Demographic Yearbook provide information on model type. When necessary,
information is obtained, supplemented, or clarified by
United Nations
telephone. For nonresponding HMOs State-supplied
The Statistical Office of the United Nations prepares the information or the most current available data are used.
Demographic Yearbook, a comprehensive collection of In 1985 a large increase in the number of HMOs and
international demographic statistics. enrollment was partly attributable to a change in the
Questionnaires are sent annually and monthly to more than categories of HMOs included in the census: Medicaid-only
220 national statistical services and other appropriate and Medicare-only HMOs have been added. Also component
government offices. Data forwarded on these questionnaires HMOs, which have their own discrete management, can be
are supplemented, to the extent possible, by data taken from listed separately, whereas, previously the oldest HMO
official national publications and by correspondence with the reported for all of its component or expansion sites, even
national statistical services. To ensure comparability, rates, when the components had different operational dates or were
ratios, and percents have been calculated in the statistical different model types.
office of the United Nations. For further information, see: The InterStudy Competitive Edge.
Lack of international comparability among estimates arises InterStudy Publications, St. Paul, MN. 2001; or visit the
from differences in concepts, definitions, and time of data InterStudy home page at www.hmodata.com.
collection. The comparability of population data is affected by
several factors, including (a) definitions of the total population, National League for Nursing
(b) definitions used to classify the population into its urban
and rural components, (c) difficulties relating to age reporting, The division of research of the National League for Nursing
(d) extent of over- or underenumeration, and (e) quality of (NLN) conducts The Annual Survey of Schools of Nursing in
population estimates. The completeness and accuracy of vital October of each year. Questionnaires are sent to all graduate
statistics data also vary from one country to another. nursing programs (master’s and doctoral), baccalaureate
Differences in statistical definitions of vital events may also programs designed exclusively for registered nurses, basic
influence comparability. registered nursing programs (baccalaureate, associate degree,
and diploma), and licensed practical nursing programs. Data
International demographic trend data are available on a on enrollments, first-time admissions, and graduates are
CD-ROM entitled United Nations, 2000. Demographic completed for all nursing education programs. Response rates

of approximately 80 percent are achieved for other areas of For more information on the AMA Physician Masterfile, see:
inquiry. Division of Survey and Data Resources, American Medical
Association, Physician Characteristics and Distribution in the
For more information, see: National League for Nursing,
U.S., 2002–2003 ed. Chicago, IL. 2002; or visit the AMA
Nursing Data Review 1997, New York, NY. 1997; or visit the
home page at www.ama-assn.org.
NLN home page at www.nln.org.
World Health Statistics Annual

Organization for Economic Cooperation and
Development Health Data World Health Organization
Organization for Economic Cooperation and The World Health Organization (WHO) prepares the World
Development (OECD) Health Statistics Annual, an annual volume of information on
vital statistics and causes of death designed for use by the
OECD provides annual data on statistical indicators on health medical and public health professions. Each volume is the
and economic policies collected from 30 member countries result of a joint effort by the national health and statistical
beginning in the 1960s. The international comparability of administrations of many countries, the United Nations, and
health expenditure estimates depends on the quality of WHO. United Nations estimates of vital rates and population
national health accounts in OECD member countries. In size and composition, where available, are reprinted directly
recent years the OECD health accounts have become an in the Statistics Annual. For those countries for which the
informal standard for reporting on health care systems. United Nations does not prepare demographic estimates,
Additional limitations in international comparisons include primarily smaller populations, the latest available data
differing boundaries between health care and other social reported to the United Nations and based on reasonably
care particularly for the disabled and elderly, and complete coverage of events are used.
underestimation of private expenditures on health. For further
information see www.oecd.org. Information published on infant mortality is based entirely on
official national data either reported directly or made available
to WHO.
Physician Masterfile
Selected life table functions are calculated from the
American Medical Association
application of a uniform methodology to national mortality data
A masterfile of physicians has been maintained by the provided to WHO, in order to enhance their value for
American Medical Association (AMA) since 1906. The international comparisons. The life table procedure used by
Physician Masterfile contains data on almost every physician WHO may often lead to discrepancies with national figures
in the United States, members and nonmembers of the AMA, published by countries, due to differences in methodology or
and on those graduates of American medical schools degree of age detail maintained in calculations.
temporarily practicing overseas. The file also includes The international comparability of estimates published in the
graduates of international medical schools who are in the World Health Statistics Annual is affected by the same
United States and meet education standards for primary problems as is the United Nations Demographic Yearbook.
recognition as physicians. Cross-national differences in statistical definitions of vital
A file is initiated on each individual upon entry into medical events, in the completeness and accuracy of vital statistics
school or, in the case of international graduates, upon entry data, and in the comparability of population data are the
into the United States. Between 1969–85 a mail questionnaire primary factors affecting comparability.
survey was conducted every 4 years to update the file For more information, see: World Health Organization, World
information on professional activities, self-designated area of Health Statistics Annual 1999, World Health Organization,
specialization, and present employment status. Since 1985 Geneva, 2001; World Health Statistics 1997–99 at
approximately one-third of all physicians are surveyed each www.who.int/whosis; or visit the WHO home page at
year. www.who.int.

Appendix II — Definitions and Methods
Appendix II premature death among many HIV-infected persons. AIDS

surveillance data are published semiannually by CDC in the
HIV/AIDS Surveillance Report. See related Human
Definitions and Methods immunodeficiency virus (HIV) infection.
Appendix II is an alphabetical listing of terms used in Health, Active physician—See Physician.

United States. It includes cross-references to related terms
Activities of daily living (ADL)—Activities of daily living are
and synonyms. It also describes the methods used for
activities related to personal care and include bathing or
calculating age-adjusted rates, average annual rate of
showering, dressing, getting in or out of bed or a chair, using
change, relative standard error, birth rates, death rates, and
the toilet, and eating. In the National Health Interview Survey
years of potential life lost. Appendix II includes standard
respondents were asked about needing the help of another
populations used for age adjustment (tables I, II, and III);
person with personal care needs because of a physical,
International Classification of Diseases (ICD) codes for cause
mental, or emotional problem. Persons are considered to
of death from the Sixth through Tenth Revisions and the
have an ADL limitation if any causal condition is chronic.
years when the Revisions were in effect (tables IV and V);
comparability ratios between ICD–9 and ICD–10 for selected In the Medicare Current Beneficiary Survey a sample person
causes (table VI); ICD–9–CM codes for external cause-of- who had any difficulty performing an activity by him or herself
injury, diagnostic, and procedure categories (tables VII, IX, and without special equipment, or did not perform the activity
and X); and industry codes from the Standard Industrial at all because of health problems, was categorized as having
Classification Manual (table VIII). New standards for a limitation in that activity. The limitation may have been
presenting Federal data on race and ethnicity are described temporary or chronic at the time of the interview. Sample
under Race and sample tabulations of NHIS data comparing persons who were administered a community interview
the 1977 and 1997 Standards for Federal data on race and answered health status and functioning questions themselves
Hispanic origin are presented in tables XI and XII. if able to do so. A proxy, such as a nurse, answered
questions about the sample person’s health status and
Abortion—The Centers for Disease Control and Prevention’s
functioning for those in a long-term care facility. See related
(CDC) surveillance system counts legal induced abortions
Instrumental activities of daily living (IADL); Limitation of
only. For surveillance purposes, legal abortion is defined as a
activity.
procedure performed by a licensed physician or someone
acting under the supervision of a licensed physician to induce Addition—An addition to a psychiatric organization is defined
the termination of a pregnancy. by the Center for Mental Health Services as a new
admission, a readmission, a return from long-term leave, or a
Acquired immunodeficiency syndrome (AIDS)—All 50
transfer from another service of the same organization or
States and the District of Columbia report AIDS cases to
another organization. See related Mental health organization;
CDC using a uniform surveillance case definition and case
Mental health service type.
report form. The case reporting definitions were expanded in
1985 (MMWR 1985; 34:373–5); 1987 (MMWR 1987; 36 Admission—The American Hospital Association defines
(supp. no. 1S): 1S–15S); 1993 for adults and adolescents admissions as patients, excluding newborns, accepted for
(MMWR 1992; 41 (no. RR-17): 1–19); and 1994 for pediatric inpatient services during the survey reporting period. See
cases (MMWR 1994; 43 (no. RR-12): 1–19). The revisions related Days of care; Discharge; Patient.
incorporated a broader range of AIDS-indicator diseases and
conditions and used HIV diagnostic tests to improve the Age—Age is reported as age at last birthday, that is, age in
sensitivity and specificity of the definition. The 1993 completed years, often calculated by subtracting date of birth
expansion of the case definition caused a temporary distortion from the reference date, with the reference date being the
of AIDS incidence trends. In 1995 new treatments for HIV date of the examination, interview, or other contact with an
and AIDS (protease inhibitors) were approved. These individual.
therapies have prevented or delayed the onset of AIDS and

Age adjustment—Age adjustment, using the direct method, Table I. Projected year 2000 U.S. population and proportion
is the application of age-specific rates in a population of distribution by age for age adjusting death rates
interest to a standardized age distribution in order to eliminate Proportion
differences in observed rates that result from age differences distribution Standard
Age Population (weights) million
in population composition. This adjustment is usually done
when comparing two or more populations at one point in time Total . . . . . . . . . . . . . 274,634,000 1.000000 1,000,000
or one population at two or more points in time. Under 1 year . . . . . . . . 3,795,000 0.013818 13,818
1–4 years . . . . . . . . . . 15,192,000 0.055317 55,317
5–14 years . . . . . . . . . 39,977,000 0.145565 145,565
Age-adjusted rates are calculated by the direct method as 15–24 years . . . . . . . . 38,077,000 0.138646 138,646
follows: 25–34 years . . . . . . . . 37,233,000 0.135573 135,573
35–44 years . . . . . . . . 44,659,000 0.162613 162,613
n 45–54 years . . . . . . . . 37,030,000 0.134834 134,834
�
i=1
r i � (pi /P) 55–64 years . . .
65–74 years . . .
.
.
.
.
.
.
.
.
.
.
23,961,000
18,136,000
0.087247
0.066037
87,247
66,037
75–84 years . . . . . . . . 12,315,000 *0.044842 44,842
85 years and over . . . . . 4,259,000 0.015508 15,508
where ri = rate in age group i in the population of interest
pi = standard population in age group i *Figure is rounded up instead of down to force total to 1.0.
SOURCE: Anderson RN, Rosenberg HM. Age Standardization of Death
n Rates: Implementation of the Year 2000 Standard. National vital statistics
P= �
i=1
pi
reports; vol 47 no 3. Hyattsville, Maryland: National Center for Health
Statistics. 1998.
n = total number of age groups over the age range of Table II. Numbers of live births and mother’s age groups
used to adjust maternal mortality rates to live births in the
the age-adjusted rate United States in 1970
Mother’s age Number

Age adjustment by the direct method requires use of a
standard age distribution. The standard for age adjusting All ages . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,731,386
death rates and estimates from most surveys in Health, Under 20 years . . . . . . . . . . . . . . . . . . . . . . . 656,460
United States is the year 2000 projected U.S. resident 20–24 years . . . . . . . . . . . . . . . . . . . . . . . . . 1,418,874
25–29 years . . . . . . . . . . . . . . . . . . . . . . . . . 994,904
population. Starting with Health, United States, 2001, the year 30–34 years . . . . . . . . . . . . . . . . . . . . . . . . . 427,806
2000 population replaces the 1940 U.S. population for age 35 years and over . . . . . . . . . . . . . . . . . . . . . . 233,342
adjusting mortality statistics. The 2000 standard population
also replaces the 1970 civilian noninstitutionalized population SOURCE: U.S. Bureau of the Census: Population estimates and
projections. Current Population Reports. Series P-25, No. 499.
and 1980 U.S. resident population, which previously had been Washington, D.C.: U.S. Government Printing Office, May 1973.
used as standard age distributions for age adjusting estimates
from NCHS surveys. the derivation of age adjustment weights for use with NCHS
survey data, see Klein RJ, Schoenborn CA. Age Adjustment
The year 2000 standard has implications for race and ethnic
Using the 2000 Projected U.S. Population. Healthy People
differentials in mortality. For example, the mortality ratio for
Statistical Notes no 20. Hyattsville, Maryland: National Center
the black and white populations is reduced from 1.6 using the
for Health Statistics. 2001. Both reports are available through
1940 standard to 1.4 using the year 2000 standard, reflecting
the NCHS home page at www.cdc.gov/nchs. The year 2000
the greater weight that the year 2000 standard gives to the
projected U.S. resident population is available through the
older population where race differentials in mortality are
Bureau of the Census home page at www.census.gov/prod/1/
smaller.
pop/p25–1130/table2.
For more information on implementing the new population
standard for age adjusting death rates, see Anderson RN, Mortality data—Death rates are age adjusted to the year
Rosenberg HM. Age Standardization of Death Rates: 2000 standard population (table I). Age-adjusted rates are
Implementation of the Year 2000 Standard. National vital calculated using age-specific death rates per 100,000
statistics reports; vol 47 no 3. Hyattsville, Maryland: National population rounded to 1 decimal place. Adjustment is
Center for Health Statistics. 1998. For more information on based on 11 age groups with two exceptions. First,

age-adjusted death rates for black males and black Table III. Projected year 2000 U.S. resident population and
females in 1950 are based on nine age groups, with age groups used to age adjust survey data
under 1 year and 1–4 years of age combined as one Number in
group and 75–84 years and 85 years of age combined Survey and age thousands
as one group. Second, age-adjusted death rates by NHIS, NAMCS, NHAMCS, NHHCS,
NNHS, NHDS, and NSAS
educational attainment for the age group 25–64 years
are based on four 10-year age groups (25–34 years, All ages . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274,634
35–44 years, 45–54 years, and 55–64 years). 18 years and over . . . . . . . . . . . . . . . . . . . . . . 203,851
25 years and over . . . . . . . . . . . . . . . . . . . . . . 117,593
Age-adjusted rates for years of potential life lost (YPLL) 40 years and over . . . . . . . . . . . . . . . . . . . . . . 118,180
65 years and over . . . . . . . . . . . . . . . . . . . . . . 34,710
before age 75 years also use the year 2000 standard
Under 18 years . . . . . . . . . . . . . . . . . . . . . . . 70,783
population and are based on eight age groups (under 1 2–17 years . . . . . . . . . . . . . . . . . . . . . . . . . 63,229
year, 1–14 years, 15–24 years, and 10-year age groups 18–44 years . . . . . . . . . . . . . . . . . . . . . . . . . 108,150
18–24 years . . . . . . . . . . . . . . . . . . . . . . . . 26,258
through 65–74 years).
25–34 years . . . . . . . . . . . . . . . . . . . . . . . . 37,233
35–44 years . . . . . . . . . . . . . . . . . . . . . . . . 44,659
Maternal mortality rates for pregnancy, childbirth, and the 45–64 years . . . . . . . . . . . . . . . . . . . . . . . . . 60,991
puerperium are calculated as the number of deaths per 45–54 years . . . . . . . . . . . . . . . . . . . . . . . . 37,030
55–64 years . . . . . . . . . . . . . . . . . . . . . . . . 23,961
100,000 live births. These rates are age adjusted to the
65–74 years . . . . . . . . . . . . . . . . . . . . . . . . . 18,136
1970 distribution of live births by mother’s age in the 75 years and over . . . . . . . . . . . . . . . . . . . . . . 16,574
United States as shown in table II. See related Rate: 40–64 years:
40–49 years . . . . . . . . . . . . . . . . . . . . . . . . 42,285
Death and related rates; Years of potential life lost.
50–64 years . . . . . . . . . . . . . . . . . . . . . . . . 41,185
National Health Interview Survey—Estimates based on NHES and NHANES
the National Health Interview Survey (NHIS) are age 20–74 years . . . . . . . . . . . . . . . . . . . . . . . . . 179,276
20–34 years . . . . . . . . . . . . . . . . . . . . . . . . 55,490
adjusted to the year 2000 projected resident population
35–44 years . . . . . . . . . . . . . . . . . . . . . . . . 44,659
(table III). Information on the age groups used in the age 45–54 years . . . . . . . . . . . . . . . . . . . . . . . . 37,030
adjustment procedure is contained in the footnotes on 55–64 years . . . . . . . . . . . . . . . . . . . . . . . . 23,961
65–74 years . . . . . . . . . . . . . . . . . . . . . . . . 18,136
the relevant tables. Prior to the 2000 edition of Health,
SAMHSA’s DAWN
United States these estimates were age adjusted to the
6 years and over . . . . . . . . . . . . . . . . . . . . . . 251,751
1970 civilian noninstitutionalized population. 6–11 years . . . . . . . . . . . . . . . . . . . . . . . . . 24,282
12–17 years . . . . . . . . . . . . . . . . . . . . . . . . 23,618
Health Care Surveys—Estimates based on the National 18–25 years . . . . . . . . . . . . . . . . . . . . . . . . 29,679
Hospital Discharge Survey (NHDS), the National Survey 26–34 years . . . . . . . . . . . . . . . . . . . . . . . . 33,812
35 years and over . . . . . . . . . . . . . . . . . . . . 140,360
of Ambulatory Surgery (NSAS), the National Ambulatory
Medical Care Survey (NAMCS), the National Hospital SOURCE: U.S. Bureau of Census: Current Population Reports. P25–
Ambulatory Medical Care Survey (NHAMCS), the 1130. Population Projections of the United States by Age, Sex, Race, and
Hispanic Origin, table 2. U.S. Government Printing Office, Washington,
National Nursing Home Survey (NNHS) (resident rates DC, 1996.
table), and the National Home and Hospice Care Survey
(NHHCS) are age adjusted to the year 2000 standard Health, United States these estimates were age adjusted
population (table III). Information on the age groups used to the 1980 U.S. resident population.
in the age adjustment procedure is contained in the
footnotes to the relevant tables. AIDS—See Acquired immunodeficiency syndrome.
National Health and Nutrition Examination Survey— Air quality standards—See National ambient air quality
Estimates based on the National Health Examination standards.
Survey (NHES) and the National Health and Nutrition
Examination Survey (NHANES) are age adjusted to the Air pollution—See Pollutant.
year 2000 standard population using five age groups:
20–34 years, 35–44 years, 45–54 years, 55–64 years, Alcohol abuse treatment clients—See Substance abuse
and 65–74 years (table III). Prior to the 2000 edition of treatment clients.

Alcohol consumption—Starting with the 1997 National Ambulatory care—Health care provided to persons without
Health Interview Survey, information on alcohol consumption their admission to a health facility.
is collected in the sample adult questionnaire. Adult
respondents are asked two screening questions about lifetime Ambulatory surgery—According to the National Survey of
alcohol consumption: ‘‘In any one year, have you had at least Ambulatory Surgery (NSAS), ambulatory surgery refers to
12 drinks of any type of alcoholic beverage? In your entire previously scheduled surgical and nonsurgical procedures
life, have you had at least 12 drinks of any type of alcoholic performed on an outpatient basis in a hospital or freestanding
beverage?’’ Persons who report at least 12 drinks in a lifetime ambulatory surgery center’s general or main operating rooms,
are then asked a series of questions about alcohol satellite operating rooms, cystoscopy rooms, endoscopy
consumption in the past year: ‘‘In the past year, how often did rooms, cardiac catheterization labs, and laser procedure
you drink any type of alcoholic beverage? In the past year, rooms. Procedures performed in locations dedicated
on those days that you drank alcoholic beverages, on the exclusively to dentistry, podiatry, abortion, pain block, or small
average, how many drinks did you have? In the past year, on procedures were not included. In NSAS, data on up to six
how many days did you have 5 or more drinks of any surgical and nonsurgical procedures are collected and coded.
alcoholic beverage?’’ See related Outpatient surgery; Procedure.
In the 1999–2000 National Household Survey on Drug Abuse Average annual rate of change (percent change)—In
information about how recent and the frequency of the Health, United States average annual rates of change or
consumption of alcoholic beverages was obtained for all growth rates are calculated as follows:
persons 12 years of age and over. An extensive list of
examples of the kinds of beverages covered was given to [(Pn / Po)1/N–1] × 100
respondents prior to the question administration. A ‘‘drink’’ is
defined as a can or bottle of beer, a glass of wine or a wine where Pn = later time period
cooler, a shot of liquor, or a mixed drink with liquor in it. Po = earlier time period
Those times when the respondent had only a sip or two from
N = number of years in interval.
a drink are not considered consumption. Alcohol use is based
on the following questions: ‘‘During the past 30 days, on how This geometric rate of change assumes that a variable
many days did you drink one or more drinks of an alcoholic increases or decreases at the same rate during each year
beverage?’’, ‘‘On the days that you drank during the past 30 between the two time periods.
days, how many drinks did you usually have?’’, and ‘‘During
the past 30 days, on how many days did you have 5 or more Average length of stay—In the National Health Interview
drinks on the same occasion?’’ Survey, average length of stay per discharged patient is
computed by dividing the total number of hospital days for a
The Monitoring the Future Study, a school-based survey of specified group by the total number of discharges for that
secondary school students, collects information on alcohol group. Similarly, in the National Hospital Discharge Survey,
use using self-completed questionnaires. Information on average length of stay is computed by dividing the total
consumption of alcoholic beverages, defined as beer, wine, number of days of care, counting the date of admission but
wine coolers, and liquor, is based on the following question: not the date of discharge, by the number of patients
‘‘On how many occasions (if any) have you had alcohol to discharged. The American Hospital Association computes
drink—more than just a few sips—in the last 30 days?’’ average length of stay by dividing the number of inpatient
Students responding affirmatively are then asked ‘‘How many days by the number of admissions. See related Days of care;
times have you had five or more drinks in a row in the last Discharge; Patient.
two weeks?’’ For this question, a ‘‘drink’’ means a 12-ounce
can (or bottle) of beer, a 4-ounce glass of wine, a 12-ounce Bed—Any bed that is set up and staffed for use by inpatients
bottle (or can) of wine cooler, or a mixed drink or shot of is counted as a bed in a facility. For the American Hospital
liquor. Association the count is the average number of beds, cribs,
and pediatric bassinets during the entire reporting period. In
the Health Care Financing Administration’s Online Survey

Certification and Reporting database, all beds in certified 19.1, 19.2, and 19.3, or access on the Internet at
facilities are counted on the day of certification inspection. www.health.gov/healthypeople/document/html/volume2/
The World Health Organization defines a hospital bed as one 19nutrition.htm.
regularly maintained and staffed for the accommodation and
full-time care of a succession of inpatients and situated in a Cause of death—For the purpose of national mortality
part of the hospital where continuous medical care for statistics, every death is attributed to one underlying
inpatients is provided. The Center for Mental Health Services condition, based on information reported on the death
counts the number of beds set up and staffed for use in certificate and using the international rules for selecting the
inpatient and residential treatment services on the last day of underlying cause of death from the conditions stated on the
the survey reporting period. See related Hospital; Mental death certificate. The underlying cause is defined by the
health organization; Mental health service type; Occupancy World Health Organization (WHO) as the disease or injury
rate. that initiated the train of events leading directly to death, or
the circumstances of the accident or violence, which produced
Birth cohort—A birth cohort consists of all persons born the fatal injury. Generally more medical information is reported
within a given period of time, such as a calendar year. on death certificates than is directly reflected in the underlying
cause of death. The conditions that are not selected as
Birth rate—See Rate: Birth and related rates. underlying cause of death constitute the nonunderlying cause
of death, also known as multiple cause of death.
Birthweight—The first weight of the newborn obtained after
birth. Low birthweight is defined as less than 2,500 grams or Cause of death is coded according to the appropriate revision
5 pounds 8 ounces. Very low birthweight is defined as less of the International Classification of Diseases (ICD) (see
than 1,500 grams or 3 pounds 4 ounces. Before 1979 low table IV). Effective with deaths occurring in 1999, the United
birthweight was defined as 2,500 grams or less and very low States began using the Tenth Revision of the ICD (ICD–10);
birthweight as 1,500 grams or less. during the period 1979–98, causes of death were coded and
classified according to the Ninth Revision (ICD–9). Table V
Body mass index (BMI)—BMI is a measure that adjusts lists ICD codes for the Sixth through Tenth Revisions for
bodyweight for height. It is calculated as weight in kilograms causes of death shown in Health, United States.
divided by height in meters squared. Overweight for children
and adolescents is defined as BMI at or above the sex- and Each of these revisions has produced discontinuities in
age-specific 95th percentile BMI cut points from the 2000 cause-of-death trends. These discontinuities are measured
CDC Growth Charts (www.cdc.gov/growthcharts/). Healthy using comparability ratios. These measures of discontinuity
weight for adults is defined as a BMI of 18.5 to less than 25; are essential to the interpretation of mortality trends. For
overweight, as greater than or equal to a BMI of 25; and further discussion, see the Mortality Technical Appendix
obesity, as greater than or equal to a BMI of 30. BMI cut
points are defined in the Report of the Dietary Guidelines
Advisory Committee on the Dietary Guidelines for Americans, Table IV. Revision of the International Classification of
Diseases (ICD) according to year of conference by which
2000. U.S. Department of Agriculture, Agricultural Research adopted and years in use in the United States
Service, Dietary Guidelines Advisory Committee, p. 23, or
Revision of the Year of Years in
access on the Internet at www.health.gov/dietaryguidelines/ International Classification conference by use in
of Diseases which adopted United States
dgac/; NHLBI Obesity Education Initiative Expert Panel on the
Identification, Evaluation, and Treatment of Overweight and First . . . . . . . . . . . . . . . 1900 1900–1909
Second . . . . . . . . . . . . . 1909 1910–1920
Obesity in Adults. Clinical Guidelines on the Identification,
Third . . . . . . . . . . . . . . . 1920 1921–1929
Evaluation, and Treatment of Overweight and Obesity in Fourth . . . . . . . . . . . . . . 1929 1930–1938
Adults—The Evidence Report. Obes Res 1998;6:51S-209S or Fifth . . . . . . . . . . . . . . . 1938 1939–1948
Sixth . . . . . . . . . . . . . . . 1948 1949–1957
access on the Internet at www.nhlbi.nih.gov/guidelines/obesity/ Seventh . . . . . . . . . . . . . 1955 1958–1967
ob_gdlns.htm; and in U.S. Department of Health and Human Eighth . . . . . . . . . . . . . . 1965 1968–1978
Ninth . . . . . . . . . . . . . . . 1975 1979–1998
Services. Tracking Healthy People 2010. Washington, DC: Tenth . . . . . . . . . . . . . . . 1992 1999–
U.S. Government Printing Office, November 2000. Objectives

Table V. Cause-of-death codes, according to applicable revision of International Classification of Diseases (ICD)
Sixth and
Seventh Eighth Ninth Tenth
Cause of death (Tenth Revision titles) Revisions Revision Revision Revision
Communicable diseases . . . . . . . . . . . . . . . . . . ... ... 001–139, 460–466, A00–B99, J00–J22

480–487, 771.3
Chronic and noncommunicable diseases . . . . . . . . ... ... 140–459, 470–478, C00–I99, J30–R99
490–799
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ... E800–E869, E880–E929, V01–Y34, Y85–Y87,
E950–E999 Y89
Meningococcal Infection . . . . . . . . . . . . . . . . . . ... ... 036 A39
Septicemia . . . . . . . . . . . . . . . . . . . . . . . . . . ... ... 038 A40–A41
Human immunodeficiency virus (HIV) disease1 . . . . ... ... *042–*044 B20–B24
Malignant neoplasms . . . . . . . . . . . . . . . . . . . . 140–205 140–209 140–208 C00–C97
Colon, rectum, and anus . . . . . . . . . . . . . . . . 153–154 153–154 153, 154 C18–C21
Trachea, bronchus, and lung . . . . . . . . . . . . . . 162–163 162 162 C33–C34
Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 174 174–175 C50
Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . 177 185 185 C61
In situ neoplasms and benign neoplasms . . . . . . . ... ... 210–239 D00–D48
Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . 260 250 250 E10–E14
Anemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ... 280–285 D50–D64
Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ... 320–322 G00, G03
Alzheimer’s disease . . . . . . . . . . . . . . . . . . . . . ... ... 331.0 G30
Diseases of heart . . . . . . . . . . . . . . . . . . . . . . 6th: 410–443 390–398, 390–398, 402, I00–I09, I11,
7th: 400–402, 402, 404, 404–429 I13, I20–I51
410–443 410–429
Ischemic heart disease . . . . . . . . . . . . . . . . . ... ... 410–414, 429.2 I20–I25
Cerebrovascular diseases . . . . . . . . . . . . . . . . . 330–334 430–438 430–434, 436–438 I60–I69
Atherosclerosis . . . . . . . . . . . . . . . . . . . . . . . ... ... 440 I70
Influenza and pneumonia . . . . . . . . . . . . . . . . . 480–483, 470–474, 480–487 J10–J18
490–493 480–486
Chronic lower respiratory diseases . . . . . . . . . . . 241, 501, 502, 490–493, 490–496 J40–J47
527.1 519.3
Chronic liver disease and cirrhosis . . . . . . . . . . . 581 571 571 K70, K73–K74
Nephritis, nephrotic syndrome, and nephrosis . . . . . ... ... 580–589 N00–N07, N17–N19,
N25–N27
Pregnancy, childbirth, and the puerperium . . . . . . . 640–689 630–678 630–676 A34, O00–O95,
O98–O99
Congenital malformations, deformations, and
chromosomal abnormalities . . . . . . . . . . . . . . . ... ... 740–759 Q00–Q99
Certain conditions originating in the perinatal
period . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ... 760–779 P00–P96
Newborn affected by maternal complications
of pregnancy . . . . . . . . . . . . . . . . . . . . . . . ... ... 761 P01
Newborn affected by complications of placenta,
cord, and membranes . . . . . . . . . . . . . . . . . ... ... 762 P02
Disorders related to short gestation and
low birthweight, not elsewhere classified . . . . . . ... ... 765 P07
Birth trauma . . . . . . . . . . . . . . . . . . . . . . . . ... ... 767 P10–P15
Intrauterine hypoxia and birth asphyxia . . . . . . . ... ... 768 P20–P21
Respiratory distress of newborn . . . . . . . . . . . . ... ... 769 P22
Sudden infant death syndrome . . . . . . . . . . . . . . ... ... 798.0 R95
Unintentional injuries2 . . . . . . . . . . . . . . . . . . . E800–E936, E800–E929, E800–E869, V01–Y34, Y85–Y87, Y89
E960–E965 E940–E946 E880–E929
Motor vehicle-related injuries2 . . . . . . . . . . . . . E810–E835 E810–E823 E810–E825 V02–V04, V09.0, V09.2,
V12–V14, V19.0–V19.2,
V19.4–V19.6, V20–V79,
V80.3–V80.5, V81.0–V81.1,
V82.0–V82.1, V83–V86,
V87.0–V87.8, V88.0–V88.8,
V89.0, V89.2
Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . E963, E970–E979 E950–E959 E950–E959 X60–X84, Y87.0
Homicide . . . . . . . . . . . . . . . . . . . . . . . . . . . E964, E980–E983 E960–E969 E960–E969 X85–Y09, Y87.1
Injury by firearms . . . . . . . . . . . . . . . . . . . . . . ... E922, E955, E922, E955.0–E955.4, W32–W34, X72–X74,
E965, E970, E965.0–E965.4, E970, X93–X95, Y22–Y24, Y35.0
E985 E985.0–E985.4
. . . Cause-of-death code numbers are not provided for causes not shown in Health, United States.
1
Categories for coding human immunodeficiency virus infection were introduced in 1987. The * indicates codes are not part of the Ninth Revision.
2
In the public health community, the term ‘‘unintentional injuries’’ is preferred to ‘‘accidents’’ and ‘‘motor vehicle-related injuries’’ to ‘‘motor vehicle accidents.’’

available on the NCHS web site at www.cdc.gov/nchs/about/ 1992 traditional smoking measure revealed that the crude
major/dvs/mortdata.htm. See related Comparability ratio; percent of current smokers 18 years of age and over
International Classification of Diseases. remained the same as 1991. The statistics for 1992 combine
data collected using the traditional and the revised questions.
Cause-of-death ranking—Selected causes of death of public
health and medical importance comprise tabulation lists and In 1993–95 estimates of cigarette smoking prevalence were
are ranked according to the number of deaths assigned to based on a half-sample. Smoking data were not collected in
these causes. The top-ranking causes determine the leading 1996. Starting in 1997 smoking data have been collected in
causes of death. Certain causes on the tabulation lists are the sample adult questionnaire. For further information on
not ranked if, for example, the category title represents a survey methodology and sample sizes pertaining to the NHIS
group title (such as Major cardiovascular diseases and cigarette smoking data for data years 1965–92 and other
Symptoms, signs, and abnormal clinical and laboratory sources of cigarette smoking data available from the National
findings, not elsewhere classified); or the category title begins Center for Health Statistics, see: National Center for Health
with the words ‘‘Other’’ and ‘‘All other.’’ In addition when one Statistics, Bibliographies and Data Sources, Smoking Data
of the titles that represents a subtotal (such as Malignant Guide, no. 1, DHHS pub. no. (PHS) 91-1308-1, Public Health
neoplasms) is ranked, its component parts are not ranked. Service. Washington, DC: U.S. Government Printing Office.
The tabulation lists used for ranking in the Tenth Revision of 1991.
the International Classification of Diseases (ICD) include the In the National Household Survey on Drug Abuse information
List of 113 Selected Causes of Death, which replaces the on current cigarette smoking is obtained for all persons 12
ICD–9 List of 72 Selected Causes, HIV infection and years of age and over based on the following question:
Alzheimer’s disease; and the ICD–10 List of 130 Selected ‘‘During the past 30 days, have you smoked part or all of a
Causes of Infant Death, which replaces the ICD–9 List of 60 cigarette?’’
Selected Causes of Infant Death and HIV infection. Causes
that are tied receive the same rank; the next cause is In the Youth Risk Behavior Survey information on current
assigned the rank it would have received had the cigarette smoking is obtained from high school students
lower-ranked causes not been tied, i.e., skip a rank. See (starting in 1991) based on the following question: ‘‘During the
related International Classification of Diseases. past 30 days, on how many days did you smoke cigarettes?’’
In the Monitoring the Future Survey information on current
Cigarette smoking—In the National Health Interview Survey cigarette smoking is obtained for high school seniors (starting
(NHIS) information about cigarette smoking is obtained for in 1975) and eighth graders (starting in 1991) based on the
adults 18 years of age and over. Starting in 1993 current following question: ‘‘How frequently have you smoked
smokers are identified based on the following two questions: cigarettes during the past 30 days?’’
‘‘Have you ever smoked 100 cigarettes in your lifetime?’’ and
‘‘Do you now smoke cigarettes every day, some days, or not In natality data, information on cigarette smoking of the
at all?’’ Persons who have ever smoked 100 cigarettes and mother during pregnancy is based on Yes No responses to
who now smoke every day or some days are defined as the birth certificate item ‘‘Other risk factors for this pregnancy:
current smokers. Before 1992 current smokers were identified Tobacco use during pregnancy.’’
based on a positive response to the following two questions:
Civilian noninstitutionalized population; Civilian
‘‘Have you ever smoked 100 cigarettes in your lifetime?’’ and
population—See Population.
‘‘Do you smoke now?’’ (traditional definition). In 1992 the
definition of current smoker in the NHIS was modified to Cocaine-related emergency department episodes—The
specifically include persons who smoked on ‘‘some days.’’ Drug Abuse Warning Network monitors selected adverse
(revised definition). In 1992 cigarette smoking data were medical consequences of cocaine and other drug abuse
collected for a half-sample with half the respondents episodes by measuring contacts with hospital emergency
(one-quarter sample) using the traditional smoking questions departments. Contacts may be for drug overdose, unexpected
and the other half of respondents (one-quarter sample) using drug reactions, chronic abuse, detoxification, or other reasons
the revised smoking question (‘‘Do you smoke every day, in which drug use is known to have occurred.
some days, or not at all?’’). An unpublished analysis of the

Cohort fertility—Cohort fertility refers to the fertility of the ICD–9 codes used to calculate death rates for 1980 through
same women at successive ages. Women born during a 1998 differ from the ICD–9 codes most nearly comparable
12-month period constitute a birth cohort. Cohort fertility for with the corresponding ICD–10 cause-of-death category.
birth cohorts of women is measured by central birth rates, Examples of these causes are ischemic heart disease,
which represent the number of births occurring to women of cerebrovascular diseases, trachea, bronchus and lung cancer,
an exact age divided by the number of women of that exact unintentional injuries, and homicide. To address this source of
age. Cumulative birth rates by a given exact age represent discontinuity, mortality trends for 1980–98 were recalculated
the total childbearing experience of women in a cohort up to using ICD–9 codes that are more comparable with codes for
that age. Cumulative birth rates are sums of central birth corresponding ICD–10 categories. Table V shows the ICD–9
rates for specified cohorts and show the number of children codes used for these causes. While this modification may
ever born up to the indicated age. For example, the lessen the discontinuity between the Ninth and Tenth
cumulative birth rate for women exactly 30 years of age as of Revisions, the effect on the discontinuity between the Eighth
January 1, 1960, is the sum of the central birth rates for the and Ninth Revisions is not measured.
1930 birth cohort for the years 1944 (when its members were
Preliminary comparability ratios shown in table VI are based
age 14) through 1959 (when they were age 29). Cumulative
on a comparability study in which the same deaths were
birth rates are also calculated for specific birth orders at each
coded by both the Ninth and Tenth Revisions. The
exact age of woman. The percent of women who have not
comparability ratio was calculated by dividing the number of
had at least one live birth by a certain age is found by
subtracting the cumulative first birth rate for women of that
Table VI. Comparability of selected causes of death between
age from 1,000 and dividing by 10. For method of calculation, the Ninth and Tenth Revisions of the International
see Heuser RL. Fertility tables for birth cohorts by color: Classification of Diseases (ICD)
United States, 1917–73. Rockville, Maryland: NCHS. 1976. Preliminary
See related Rate: Birth and related rates. comparability
Cause of death1 ratio2
Community hospitals—See Hospital. Human immunodeficiency virus (HIV) disease . . . . 1.1448

Malignant neoplasms . . . . . . . . . . . . . . . . . . . . 1.0068
Colon, rectum, and anus . . . . . . . . . . . . . . . . 0.9993
Comparability ratio—About every 10–20 years the
Trachea, bronchus, and lung . . . . . . . . . . . . . . 0.9837
International Classification of Diseases (ICD) is revised to Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.0056
stay abreast of advances in medical science and changes in Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . 1.0134
Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . 1.0082
medical terminology. Each of these revisions produces breaks Diseases of heart . . . . . . . . . . . . . . . . . . . . . . 0.9858
in the continuity of cause-of-death statistics. Discontinuities Ischemic heart diseases . . . . . . . . . . . . . . . . 0.9990
Cerebrovascular diseases . . . . . . . . . . . . . . . . . 1.0588
across revisions are due to changes in classification and Influenza and pneumonia . . . . . . . . . . . . . . . . . 0.6982
rules for selecting underlying cause of death. Classification Chronic lower respiratory diseases . . . . . . . . . . . 1.0478
Chronic liver disease and cirrhosis . . . . . . . . . . . 1.0367
and rule changes impact cause-of-death trend data by shifting Pregnancy, childbirth, and the puerperium . . . . . . . *
deaths away from some cause-of-death categories and into Unintentional injuries . . . . . . . . . . . . . . . . . . . . 1.0305
Motor vehicle-related injuries . . . . . . . . . . . . . . 0.9754
others. Comparability ratios measure the effect of changes in
Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.9962
classification and coding rules. For causes shown in table VI, Homicide . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.9983
comparability ratios range between 0.9754 and 1.0588, except Injury by firearms . . . . . . . . . . . . . . . . . . . . . . 0.9973
for influenza and pneumonia, with a comparability ratio of Chronic and noncommunicable diseases . . . . . . . . 1.0100
Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.0117
0.6982, indicating that influenza and pneumonia is about
Communicable diseases . . . . . . . . . . . . . . . . . . 0.8536
30 percent less likely to be selected as the underlying cause HIV disease . . . . . . . . . . . . . . . . . . . . . . . . 1.1448
of death in ICD–10 than in ICD–9; and HIV disease with a Other communicable diseases . . . . . . . . . . . . . 0.8023
comparability ratio of 1.1448, indicating that HIV disease is

*Figure does not meet standards of reliability or precision.
more than 14 percent more likely to be selected as the 1

See table V for ICD–9 and ICD–10 cause-of-death codes.
2
underlying cause. Ratio of number of deaths classified by ICD–10 to number of deaths
classified by ICD–9.
Another factor also contributes to discontinuities in death SOURCE: Anderson RN, Miniño AM, Hoyert DL, Rosenberg HM.
Comparability of cause-of-death classification between ICD–9 and
rates across revisions. For selected causes of death, the ICD–10: Preliminary estimates. National Vital Statistics Reports. Vol 49
No 2. Hyattsville, Maryland: National Center for Health Statistics. 2001.

deaths classified by ICD–10 by the number of deaths based on specific indicators of hospital, medical, dental, and
classified by ICD–9. The resulting ratios represent the net drug prices. A revision of the definition of CPI has been in
effect of the Tenth Revision on cause-of-death statistics and use since January 1988. See related Gross domestic product;
can be used to adjust mortality statistics for causes of death Health expenditures, national; Appendix I, Consumer Price
classified by the Ninth Revision to be comparable with Index.
cause-specific mortality statistics classified by the Tenth
Revision. Crude birth rate; Crude death rate—See Rate: Birth and
related rates; Rate: Death and related rates.
The application of comparability ratios to mortality statistics
helps to make the analysis of change between 1998 and Days of care—According to the American Hospital
1999 more accurate and complete. The 1998 comparability- Association, days, hospital days, or inpatient days are the
modified death rate is calculated by multiplying the number of adult and pediatric days of care rendered during
comparability ratio by the 1998 death rate. Comparability- the entire reporting period. Days of care for newborns are
modified rates should be used to estimate mortality change excluded.
between 1998 and 1999.
In the National Health Interview Survey, hospital days during
Caution should be taken when applying the comparability the year refer to the total number of hospital days occurring
ratios presented in table VI to age-, race-, and sex-specific in the 12-month period before the interview week. A hospital
mortality data. Demographic subgroups may sometimes differ day is a night spent in the hospital for persons admitted as
with regard to their cause-of-death distribution, and this would inpatients.
result in demographic variation in cause-specific comparability
In the National Hospital Discharge Survey, days of care refers
ratios.
to the total number of patient days accumulated by patients
For more information, see Anderson RN, Miniño AM, Hoyert at the time of discharge from non-Federal short-stay hospitals
DL, Rosenberg HM. Comparability of cause of death between during a reporting period. All days from and including the date
ICD–9 and ICD–10: Preliminary estimates; and Kochanek KD, of admission but not including the date of discharge are
Smith BL, Anderson RN. Deaths: Preliminary data for 1999. counted. See related Admission; Average length of stay;
National vital statistics reports. vol 49 no 2 and vol 49 no 3. Discharge; Hospital; Patient.
Hyattsville, MD: National Center for Health Statistics. 2001.
See related Cause of death; International Classification of Death rate—See Rate: Death and related rates.
Diseases; tables IV and V.
Dental visit—In the National Health Interview Survey
Compensation—See Employer costs for employee respondents are asked ‘‘About how long has it been since
compensation. you last saw or talked to a dentist? Include all types of
dentists, such as orthodontists, oral surgeons, and all other
Condition—A health condition is a departure from a state of dental specialists as well as hygienists.’’ This question was
physical or mental well-being. In the National Health Interview not asked for children under 2 years of age for years
Survey, a chronic condition refers to any condition lasting 3 1997–99 and under 1 year of age for 2000 and beyond.
months or more or is a condition classified as chronic
regardless of its time of onset (for example, diabetes, heart Diagnosis—See First-listed diagnosis.
conditions, emphysema, and arthritis). The National Nursing
Home Survey uses a specific list of chronic conditions, also Diagnostic and other nonsurgical procedures—See
disregarding time of onset. Procedure.
Consumer Price Index (CPI)—The CPI is prepared by the Discharge—The National Health Interview Survey defines a
U.S. Bureau of Labor Statistics. It is a monthly measure of hospital discharge as the completion of any continuous period
the average change in the prices paid by urban consumers of stay of one night or more in a hospital as an inpatient.
for a fixed market basket of goods and services. The medical According to the National Hospital Discharge Survey and the
care component of CPI shows trends in medical care prices American Hospital Association, discharge is the formal release
of an inpatient by a hospital (excluding newborn infants), that

is, the termination of a period of hospitalization (including education, 37 percent 12 years of education, 20 percent
stays of 0 nights) by death or by disposition to a place of 13–15 years, and 25 percent 16 or more years of education.
residence, nursing home, or another hospital. See related
See related Appendix I, National Vital Statistics System. For
Admission; Average length of stay; Days of care; Patient.
further information on measurement of education, see:
Domiciliary care homes—See Nursing home. Kominski R and Siegel PM. Measuring education in the
Current Population Survey. Monthly Labor Review, September
Drug abuse treatment clients—See Substance abuse 1993: 34–38.
treatment clients.
Emergency department—According to the National Hospital
Education—Two approaches to defining educational Ambulatory Medical Care Survey (NHAMCS), an emergency
categories are used in this report. The more recent approach department is a hospital facility that provides unscheduled
used to collect and present survey data defines educational outpatient services to patients whose conditions require
categories based on information about educational immediate care and is staffed 24 hours a day. Off-site
credentials, such as diplomas and degrees. The older emergency departments open less than 24 hours are included
approach defines educational categories based on years of if staffed by the hospital’s emergency department. See related
education completed. Emergency department visit; Outpatient department.
Beginning in 1997 the National Health Interview Survey Emergency department visit—Starting with the 1997
(NHIS) questionnaire was changed to ask ‘‘What is the National Health Interview Survey, respondents to the sample
highest level of school ___ has completed or the highest adult and sample child questionnaires are asked about the
degree received?’’ Responses were used to categorize number of visits to hospital emergency rooms during the past
individuals according to educational credentials (for example, 12 months. In the National Hospital Ambulatory Medical Care
no high school diploma or general educational development Survey an emergency department visit is a direct personal
(GED) high school equivalency diploma; high school diploma exchange between a patient and a physician or other health
or GED; some college, no bachelor’s degree; bachelor’s care providers working under the physician’s supervision, for
degree or higher). the purpose of seeking care and receiving personal health
Prior to 1997 the education variable in NHIS was measured services. See related Emergency department; Injury-related
by asking, ‘‘What is the highest grade or year of regular visit.
school ___ has ever attended?’’ and ‘‘Did ___ finish the
Employer costs for employee compensation—This is a
grade/year?’’ Responses were used to categorize individuals
measure of the average cost per employee hour worked to
according to years of education completed (for example, less
employers for wages and salaries and benefits. Wages and
than 12 years, 12 years, 13–15 years, 16 or more years).
salaries are defined as the hourly straight-time wage rate, or
Years of educational attainment are currently used to present
for workers not paid on an hourly basis, straight-time earnings
vital statistics data.
divided by the corresponding hours. Straight-time wage and
Data from the 1996 and 1997 NHIS were used to compare salary rates are total earnings before payroll deductions,
distributions of educational attainment for adults 25 years of excluding premium pay for overtime and for work on
age and over using categories based on educational weekends and holidays, shift differentials, nonproduction
credentials (1997) with categories based on years of bonuses, and lump-sum payments provided in lieu of wage
education completed (1996). A larger percent of persons increases. Production bonuses, incentive earnings,
reported ‘‘some college’’ than ‘‘13–15 years’’ of education and commission payments, and cost-of-living adjustments are
a correspondingly smaller percent reported ‘‘high school included in straight-time wage and salary rates. Benefits
diploma or GED’’ than ‘‘12 years of education.’’ In 1997, covered are paid leave—paid vacations, holidays, sick leave,
19 percent of adults reported no high school diploma, and other leave; supplemental pay—premium pay for overtime
31 percent a high school diploma or GED, 26 percent some and work on weekends and holidays, shift differentials,
college, and 24 percent a bachelor’s degree or higher. In nonproduction bonuses, and lump-sum payments provided in
1996, 18 percent of adults reported less than 12 years of lieu of wage increases; insurance benefits—life, health, and

sickness and accident insurance; retirement and savings provided to the insured person. Also known as indemnity
benefits—pension and other retirement plans and savings and health insurance. See related Health insurance coverage.
thrift plans; legally required benefits—social security, railroad
retirement and supplemental retirement, railroad Fertility rate—See Rate: Birth and related rates.
unemployment insurance, Federal and State unemployment
Fetal death—In the World Health Organization’s definition,
insurance, workers’ compensation, and other benefits required
also adopted by the United Nations and the National Center
by law, such as State temporary disability insurance; and
for Health Statistics, a fetal death is death before the
other benefits—severance pay and supplemental
complete expulsion or extraction from its mother of a product
unemployment plans.
of conception, irrespective of the duration of pregnancy; the
Expenditures—See Health expenditures, national. death is indicated by the fact that after such separation, the
fetus does not breathe or show any other evidence of life,
Family income—For purposes of the National Health such as beating of the heart, pulsation of the umbilical cord,
Interview Survey and National Health and Nutrition or definite movement of voluntary muscles. For statistical
Examination Survey, all people within a household related to purposes, fetal deaths are classified according to gestational
each other by blood, marriage, or adoption constitute a family. age. In this report tabulations are shown for fetal deaths with
Each member of a family is classified according to the total stated or presumed gestation of 20 weeks or more and of 28
income of the family. Unrelated individuals are classified weeks or more, the latter gestational age group also known
according to their own income. In the National Health and as late fetal deaths. See related Gestation; Live birth; Rate:
Nutrition Examination Survey and the National Health Death and related rates.
Interview Survey (in years prior to 1997) family income was
the total income received by members of a family (or by an First-listed diagnosis—In the National Hospital Discharge
unrelated individual) in the 12 months before the interview. Survey, this is the first recorded final diagnosis on the
Starting in 1997 the National Health Interview Survey has medical record face sheet (summary sheet).
been collecting family income data for the calendar year prior
First-listed external cause of injury—In the National
to the interview. (For example, 1997 family income data are
Hospital Ambulatory Medical Care Survey, this is the
based on 1996 calendar year information.) Family income
first-listed external cause of injury coded from the Patient
includes wages, salaries, rents from property, interest,
Record Form (PRF). Up to three causes of injury can be
dividends, profits and fees from their own businesses,
reported on the PRF. Injuries are coded by NCHS to the
pensions, and help from relatives. In the National Health
International Classification of Diseases, Ninth Revision,
Interview Survey, family income data are used in the
Clinical Modification Supplementary Classification of External
computation of poverty level. For data years 1990–96, about
Causes of Injury and Poisoning. See table VII for a listing of
16–18 percent of persons had missing data on poverty level.
injury categories and codes. See related Injury-related visit.
Missing values were imputed for family income using a
sequential hot deck within matrix cells imputation approach. A General hospitals—See Hospital.
detailed description of the imputation procedure as well as
data files with imputed annual family income for 1990–96 are
available from NCHS on CD-ROM NHIS Imputed Annual
Table VII. Codes for first-listed external causes of injury
Family Income 1990–96, series 10, no 9A. See related from the International Classification of Diseases, Ninth
Poverty level. Revision, Clinical Modification
External cause of injury category E-Code numbers

Federal hospitals—See Hospital.
Unintentional . . . . . . . . . . . . . . . . E800–E869, E880–E929
Motor vehicle traffic . . . . . . . . . . E810–E819
Federal physicians—See Physician. Falls . . . . . . . . . . . . . . . . . . . . E880–E886, E888
Struck by or against objects or
Fee-for-service health insurance—This is private persons . . . . . . . . . . . . . . . . . E916–E917
Caused by cutting and piercing
(commercial) health insurance that reimburses health care instruments or objects . . . . . . . . E920
providers on the basis of a fee for each health service Intentional (suicide and homicide) . . . E950–E969

General hospitals providing separate psychiatric located in the United States. As long as the labor and
services—See Mental health organization. property are located in the United States, the suppliers (that
is, the workers and, for property, the owners) may be either
Geographic region and division—The 50 States and the U.S. residents or residents of the rest of the world. See
District of Columbia are grouped for statistical purposes by related Consumer Price Index; Health expenditures, national.
the U.S. Bureau of the Census into 4 geographic regions and
9 divisions. The groupings are as follows: Health care contact—Starting in 1997 the National Health
Interview Survey has been collecting information on health
Northeast care contacts with doctors and other health care
New England professionals. This information is collected in a detailed
Maine, New Hampshire, Vermont, section pertaining to all types of health care contacts.
Massachusetts, Rhode Island, Connecticut Analyses of the percent of children without a health care visit
Middle Atlantic are based upon the following question: ‘‘During the past 12
New York, New Jersey, Pennsylvania months, how many times has ___ seen a doctor or other
health care professional about (his/her) health at a doctor’s
Midwest
office, a clinic, or some other place? Do not include times
East North Central
____was hospitalized overnight, visits to hospital emergency
Ohio, Indiana, Illinois, Michigan, Wisconsin
rooms, home visits, or telephone calls.’’ Beginning in 2000
West North Central
dental visits were also excluded. Analyses of the distribution
Minnesota, Iowa, Missouri, North Dakota,
of health care visits are based on a summary measure
South Dakota, Nebraska, Kansas
combining information about visits to doctors’ offices or
South clinics, emergency departments, and home visits. See related
South Atlantic Emergency department visit; Home visit.
Delaware, Maryland, District of Columbia,
Virginia, West Virginia, North Carolina, Health expenditures, national—See related Consumer Price
South Carolina, Georgia, Florida Index; Gross domestic product.
East South Central
Health services and supplies expenditures—These are
Kentucky, Tennessee, Alabama,
outlays for goods and services relating directly to patient
Mississippi
care plus expenses for administering health insurance
West South Central
programs and government public health activities. This
Arkansas, Louisiana, Oklahoma, Texas
category is equivalent to total national health
West expenditures minus expenditures for research and
Mountain construction.
Montana, Idaho, Wyoming, Colorado,
National health expenditures—This measure estimates
New Mexico, Arizona, Utah, Nevada
the amount spent for all health services and supplies
Pacific
and health-related research and construction activities
Washington, Oregon, California, Alaska, Hawaii
consumed in the United States during the calendar year.
Gestation—For the National Vital Statistics System and the Detailed estimates are available by source of
Centers for Disease Control and Prevention’s Abortion expenditures (for example, out-of-pocket payments,
Surveillance, the period of gestation is defined as beginning private health insurance, and government programs), and
with the first day of the last normal menstrual period and by type of expenditures (for example, hospital care,
ending with the day of birth or day of termination of physician services, and drugs), and are in current dollars
pregnancy. See related Abortion; Fetal death; Live birth. for the year of report. Data are compiled from a variety
of sources.
Gross domestic product (GDP)—GDP is the market value
of the goods and services produced by labor and property

Nursing home expenditures—These cover care rendered late 1996, Medicaid was delinked from AFDC and SSI.
in establishments primarily engaged in providing inpatient Starting in 1997 persons have been considered covered by
nursing and rehabilitative services and continuous Medicaid if they report Medicaid or a State-sponsored health
personal care services to persons requiring nursing care program. Starting in 1998 persons are considered covered by
(skilled nursing and intermediate care facilities, including Medicaid if they report being covered by the Child Health
those for the mentally retarded) and continuing care Insurance Program (CHIP) or the State Child Health
retirement communities with on-site nursing care Insurance Program (SCHIP).
facilities. The costs of long-term care provided by
Medicare or military health plan coverage is also determined
hospitals are excluded.
in the interview and, starting in 1997, other government-
Personal health care expenditures—These are outlays for sponsored program coverage is determined as well.
goods and services relating directly to patient care. The If respondents do not report coverage under one of the above
expenditures in this category are total national health types of plans and they have unknown coverage under either
expenditures minus expenditures for research and private health insurance or Medicaid, they are considered to
construction, expenses for administering health insurance have unknown coverage.
programs, and government public health activities.
The remaining respondents are considered uninsured. The
Private expenditures—These are outlays for services uninsured are persons who do not have coverage under
provided or paid for by nongovernmental sources— private health insurance, Medicare, Medicaid, public
consumers, insurance companies, private industry, assistance, a State-sponsored health plan, other government-
philanthropic, and other nonpatient care sources. sponsored programs, or a military health plan. Persons with
only Indian Health Service coverage are considered
Public expenditures—These are outlays for services uninsured. Estimates of the percent of persons who are
provided or paid for by Federal, State, and local uninsured based on the NHIS (table 129) may differ slightly
government agencies or expenditures required by from those based on the March Current Population Survey
governmental mandate (such as workmen’s (CPS) (table 147) due to differences in survey questions,
compensation insurance payments). recall period, and other aspects of survey methodology. See
related Fee-for-service health insurance; Health maintenance
Health insurance coverage—National Health Interview organization; Managed care; Medicaid; Medicare.
Survey (NHIS) respondents were asked about their health
insurance coverage in the previous month in 1993–96 and at Health maintenance organization (HMO)—An HMO is a
the time of the interview in other years. Questions on health prepaid health plan delivering comprehensive care to
insurance coverage were expanded starting in 1993 members through designated providers, having a fixed
compared with previous years. In 1997 the entire monthly payment for health care services, and requiring
questionnaire was redesigned and data were collected using members to be in a plan for a specified period of time
a computer-assisted personal interview (CAPI). (usually 1 year). Pure HMO enrollees use only the prepaid
Respondents are covered by private health insurance if they capitated health services of the HMOs panel of medical care
indicate private health insurance or if they are covered by a providers. Open-ended HMO enrollees use the prepaid HMO
single service hospital plan, except in 1997 and 1998 when health services but in addition may receive medical care from
no information on single service plans was obtained. Private providers who are not part of the HMOs panel. There is
health insurance includes managed care such as health usually a substantial deductible, copayment, or coinsurance
maintenance organizations (HMOs). associated with use of nonpanel providers. These open-ended
products are governed by State HMO regulations. HMO
Until 1996 persons were defined as having Medicaid or other model types are:
public assistance coverage if they indicated that they had
either Medicaid or other public assistance, or if they reported Group—An HMO that delivers health services through a
receiving Aid to Families with Dependent Children (AFDC) or physician group that is controlled by the HMO unit or an
Supplemental Security Income (SSI). After welfare reform in

HMO that contracts with one or more independent group promoting, maintaining, or restoring health; or for minimizing
practices to provide health services. the effects of disability and illness including terminal illness.
Individual practice association (IPA)—An HMO that Home visit—Starting in 1997 the National Health Interview
contracts directly with physicians in independent practice, Survey has been collecting information on home visits
and/or contracts with one or more associations of received during the past 12 months. Respondents are asked
physicians in independent practice, and/or contracts with ‘‘During the past 12 months, did you receive care at home
one or more multispecialty group practices. The plan is from a nurse or other health care professional? What was the
predominantly organized around solo-single-specialty total number of home visits received?’’ These data are
practices. combined with data on visits to doctors’ offices, clinics, and
emergency departments to provide a summary measure of
Mixed—An HMO that combines features of group and health care visits. See related Emergency department visit;
IPA. This category was introduced in mid-1990 because Health care contact.
HMOs are continually changing and many now combine
features of group and IPA plans in a single plan. Hospice care—Hospice care as defined by the National
Home and Hospice Care Survey is a program of palliative
See related Managed care. and supportive care services providing physical,
psychological, social, and spiritual care for dying persons,
Health services and supplies expenditures—See Health
their families, and other loved ones. Hospice services are
expenditures, national.
available in home and inpatient settings.
Health status, respondent-assessed—Health status was
Hospital—According to the American Hospital Association,

measured in the National Health Interview Survey by asking
hospitals are licensed institutions with at least six beds whose

the respondent ‘‘Would you say _____’s health is excellent,
primary function is to provide diagnostic and therapeutic

very good, good, fair, or poor?’’
patient services for medical conditions by an organized

Healthy People 2010—Healthy People 2010 is the prevention
physician staff, and have continuous nursing services under
agenda for the Nation. It is a statement of national health
the supervision of registered nurses. The World Health
objectives designed to identify the most significant
Organization considers an establishment to be a hospital if it
preventable threats to health and to establish national goals
is permanently staffed by at least one physician, can offer
to reduce these threats. Healthy People 2010 is a set of
inpatient accommodation, and can provide active medical and
health objectives for the Nation to achieve over the first
nursing care. Hospitals may be classified by type of service,
decade of the new century. More information on Healthy
ownership, size in terms of number of beds, and length of
People 2010 is available on the Web at www.health.gov/
stay. In the National Hospital Ambulatory Medical Care Survey
healthypeople. See related Leading Health Indicators.
(NHAMCS) hospitals include all those with an average length
of stay for all patients of less than 30 days (short-stay) or
Hispanic origin—Hispanic origin includes persons of
hospitals whose specialty is general (medical or surgical) or
Mexican, Puerto Rican, Cuban, Central and South American,
children’s general. Federal hospitals and hospital units of
and other or unknown Latin American or Spanish origins.
institutions and hospitals with fewer than six beds staffed for
Persons of Hispanic origin may be of any race. In the
patient use are excluded. See related Average length of stay;
National Health Interview Survey questionnaire, questions on
Bed; Days of care; Emergency department; Outpatient
Hispanic origin precede questions on race. See related Race.
department; Patient.
HIV—See Human immunodeficiency virus (HIV) disease. Community hospitals traditionally included all non-Federal
short-stay hospitals except facilities for the mentally
Home health care—Home health care as defined by the retarded. In the revised definition the following additional
National Home and Hospice Care Survey is care provided to sites are excluded: hospital units of institutions, and
individuals and families in their place of residence for alcoholism and chemical dependency facilities.

Federal hospitals are operated by the Federal codes changed to B20-B24. Beginning with data for 1987,
Government. NCHS introduced category numbers *042-*044 for classifying
and coding HIV infection as a cause of death in ICD–9. HIV
For profit hospitals are operated for profit by individuals, infection was formerly referred to as human T-cell
partnerships, or corporations. lymphotropic virus-III/lymphadenopathy-associated virus
(HTLV-III/LAV) infection. The asterisk before the category
General hospitals provide diagnostic, treatment, and
numbers indicates that these codes were not part of the
surgical services for patients with a variety of medical
original ICD–9. Before 1987 deaths involving HIV infection
conditions. According to the World Health Organization,
were classified to Deficiency of cell-mediated immunity (ICD–9
these hospitals provide medical and nursing care for
279.1) contained in the title All other diseases; to
more than one category of medical discipline (for
Pneumocystosis (ICD–9 136.3) contained in the title All other
example, general medicine, specialized medicine, general
infectious and parasitic diseases; to Malignant neoplasms,
surgery, specialized surgery, and obstetrics). Excluded
including neoplasms of lymphatic and hematopoietic tissues;
are hospitals, usually in rural areas, that provide a more
and to a number of other causes. Therefore, before 1987,
limited range of care.
death statistics for HIV infection are not strictly comparable
Nonprofit hospitals are operated by a church or other with data for 1987 and later years, and are not shown in this
nonprofit organization. report.
Morbidity coding: The National Hospital Discharge Survey
Psychiatric hospitals are ones whose major type of
codes diagnosis data using the International Classification of
service is psychiatric care. See related Mental health
Diseases, Ninth Revision, Clinical Modification (ICD–9–CM).
organization.
Discharges with diagnosis of HIV as shown in Health, United
Registered hospitals are hospitals registered with the States have at least one HIV diagnosis listed on the face
American Hospital Association. About 98 percent of sheet of the medical record and are not limited to the
hospitals are registered. first-listed diagnosis. During 1984 and 1985 only data for
AIDS (ICD–9–CM 279.19) were included. In 1986–94
Short-stay hospitals in the National Hospital Discharge discharges with the following diagnoses were included:
Survey are those in which the average length of stay is acquired immunodeficiency syndrome (AIDS), human
less than 30 days. The National Health Interview Survey immunodeficiency virus (HIV) infection and associated
defines short-stay hospitals as any hospital or hospital conditions, and positive serological or viral culture findings for
department in which the type of service provided is HIV (ICD–9–CM 042–044, 279.19, and 795.8). Beginning in
general; maternity; eye, ear, nose, and throat; children’s; 1995 discharges with the following diagnoses were included:
or osteopathic. human immunodeficiency virus (HIV) disease and
asymptomatic human immunodeficiency virus (HIV) infection
Specialty hospitals, such as psychiatric, tuberculosis, status (ICD–9–CM 042 and V08). See related Acquired
chronic disease, rehabilitation, maternity, and alcoholic or immunodeficiency syndrome; Cause of death; International
narcotic, provide a particular type of service to the Classification of Diseases; International Classification of
majority of their patients. Diseases, Ninth Revision, Clinical Modification.
Hospital-based physician—See Physician. ICD; ICD codes—See Cause of death; International

Classification of Diseases.
Hospital days—See Days of care.
Illicit drug use—In the 1999–2000 National Household
Human immunodeficiency virus (HIV) disease—Mortality Survey on Drug Abuse (NHSDA), information on illicit drug
coding: Starting with data year 1999 and the introduction of use was collected for all persons 12 years of age and over.
the Tenth Revision of the International Classification of Information on any illicit drug use, including marijuana or
Diseases (ICD–10), the title for this cause of death was hashish, cocaine, heroin, hallucinogens, and nonmedical use
changed to HIV disease from HIV infection and the ICD of prescription drugs is based on the following questions:

‘‘During the past 30 days, on how many days did you use Table VIII. Codes for industries, according to the Standard
(specific illicit drug)?’’ Industrial Classification (SIC) Manual
Industry Code numbers

The Monitoring the Future Study, a school-based survey of
secondary school students, collects information on marijuana Agriculture, forestry, and fishing . . . . . . . . . . . . . 01–09
Mining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10–14
use using self-completed questionnaires. The information is
Construction . . . . . . . . . . . . . . . . . . . . . . . . . 15–17
based on the following questions: ‘‘On how many occasions Manufacturing . . . . . . . . . . . . . . . . . . . . . . . . 20–39
(if any) have you used marijuana in the last 30 days?’’ and Transportation and public utilities . . . . . . . . . . . . 40–49
Wholesale trade . . . . . . . . . . . . . . . . . . . . . . . 50–51
‘‘On how many occasions (if any) have you used hashish in Retail trade . . . . . . . . . . . . . . . . . . . . . . . . . . 52–59
the last 30 days?’’ Questions on cocaine use include the Finance, insurance, and real estate . . . . . . . . . . . 60–67
Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70–89
following: ‘‘On how many occasions (if any) have you taken Public administration . . . . . . . . . . . . . . . . . . . . 91–97
‘‘crack’’ (cocaine in chunk or rock form) during the last 30
days?’’ and ‘‘On how many occasions (if any) have you taken
cocaine in any other form during the last 30 days?’’
Questions on inhalant use (sniffed glue, or breathed the The category ‘‘Private sector’’ includes all industry divisions
contents of aerosol spray cans, or inhaled other gases or except public administration and military. The category ‘‘Not
sprays in order to get high) and MDMA (‘‘ecstasy’’) follow a classified’’ is used for fatalities for which there was insufficient
similar format. information to determine a specific industry classification.
Incidence—Incidence is the number of cases of disease Infant death—An infant death is the death of a live-born child
having their onset during a prescribed period of time. It is before his or her first birthday. Deaths in the first year of life
often expressed as a rate (for example, the incidence of may be further classified according to age as neonatal and
measles per 1,000 children 5–15 years of age during a postneonatal. Neonatal deaths are those that occur before the
specified year). Incidence is a measure of morbidity or other 28th day of life; postneonatal deaths are those that occur
events that occur within a specified period of time. See between 28 and 365 days of age. See related Live birth;
related Prevalence. Rate: Death and related rates.
Individual practice association (IPA)—See Health Injury—See First-listed external cause of injury.
maintenance organization (HMO).
Injury-related visit—In the National Hospital Ambulatory
Industry of employment—Industries are classified according Medical Care Survey an emergency department visit was
to the Standard Industrial Classification (SIC) Manual of the considered injury related if, on the Patient Record Form
Office of Management and Budget. Two editions of the SIC (PRF), the checkbox for injury was indicated. In addition,
are used for coding industry data in Health, United States: injury visits were identified if the physician’s diagnosis or the
the 1977 supplement to the 1972 edition and the 1987 patient’s reason for visit code was injury related . See related
edition. The changes between versions include a few detailed Emergency department visit; First-listed external cause of
titles created to correct or clarify industries or to recognize injury.
changes within the industry. Codes for major industry
divisions (table VIII) were not changed between versions. Inpatient care—See Mental health service type.
Establishments engaged in the same kind of economic activity Inpatient days—See Days of care.
are classified by the same industry code, regardless of type
of ownership—corporations, sole proprietorships, and Instrumental activities of daily living (IADL)—Instrumental
government agencies. Data from the Census of Fatal activities of daily living are activities related to independent
Occupational Injuries are therefore further broken out by living and include preparing meals, managing money,
private sector and government. Data from the Survey of shopping for groceries or personal items, performing light or
Occupational Injuries and Illnesses are provided for the heavy housework and using a telephone. If a sample person
private sector only and exclude the self-employed. from the Medicare Current Beneficiary Survey had any
difficulty performing an activity by him or herself and without

special equipment, or did not perform the activity at all ICD–9–CM is arranged in 17 main chapters. Most of the
because of health problems, the person was categorized as diseases are arranged according to their principal anatomical
having a limitation in that activity. The limitation may have site, with special chapters for infective and parasitic diseases;
been temporary or chronic at the time of the interview. neoplasms; endocrine, metabolic, and nutritional diseases;
Sample persons who were administered a community mental diseases; complications of pregnancy and childbirth;
interview answered health status and functioning questions certain diseases peculiar to the perinatal period; and
themselves if able to do so. A proxy, such as a nurse, ill-defined conditions. In addition, two supplemental
answered questions about the sample person’s health status classifications are provided: classification of factors influencing
and functioning for long-term care facility interview. In the health status and contact with health services and
National Health Interview Survey respondents are asked classification of external causes of injury and poisoning. For
about needing the help of another person for handling routine more information, see www.cdc.gov/nchs/icd9.htm. See related
IADL needs due to a physical, mental, or emotional problem. International Classification of Diseases.
Persons are considered to have an IADL limitation if any
causal condition is chronic. See related Activities of daily Late fetal death rate—See Rate: Death and related rates.
living (ADL); Limitation of activity.
Leading causes of death—See Cause-of-death ranking.
Insured—See Health insurance coverage.
Leading Health Indicators—The Leading Health Indicators
Intermediate care facilities—See Nursing home. (LHIs) highlight major risk factors Americans face and draw
attention to the most significant areas where individual and
International Classification of Diseases (ICD)—The ICD community action regarding health improvements need to be
provides the ground rules for coding and classifying made. Five of the indicators relate primarily to individual
cause-of-death data. The ICD is developed collaboratively behaviors including physical activity, overweight and obesity,
between the World Health Organization (WHO) and 10 tobacco use, substance abuse, and responsible sexual
international centers, one of which is housed at NCHS. The behavior. The other five address mental health, injury and
purpose of the ICD is to promote international comparability violence, environmental quality, immunization, and access to
in the collection, classification, processing, and presentation of health care. The LHIs will be used to measure important
health statistics. Since the beginning of the century, the ICD determinants of the Nation’s health during the first decade of
has been modified about once every 10 years, except for the the twenty-first century. More information on the LHIs is
20-year interval between ICD–9 and ICD–10 (see table IV). available on the World Wide Web at www.health.gov/
The purpose of the revisions is to stay abreast with advances healthypeople/LHI/. See related Healthy People 2010.
in medical science. New revisions usually introduce major
disruptions in time series of mortality statistics (see tables V Length of stay—See Average length of stay.
and VI). For more information, see www.cdc.gov/nchs/about/
Life expectancy—Life expectancy is the average number of
major/dvs/icd10des.htm. See related Cause of death;
years of life remaining to a person at a particular age and is
Comparability ratio; International Classification of Diseases,
based on a given set of age-specific death rates, generally
Ninth Revision, Clinical Modification.
the mortality conditions existing in the period mentioned. Life
International Classification of Diseases, Ninth Revision, expectancy may be determined by race, sex, or other
Clinical Modification (ICD–9–CM)—The ICD–9–CM is based characteristics using age-specific death rates for the
on and is completely compatible with the International population with that characteristic. See related Rate: Death
Classification of Diseases, Ninth Revision. In Health, United and related rates.
States the ICD–9–CM is used to code morbidity data and
Limitation of activity—In the National Health Interview
starting with data year 1999 ICD–10 is used to code mortality
Survey limitation of activity refers to a long-term reduction in
data. Diagnostic categories and code number inclusions for
a person’s capacity to perform the usual kind or amount of
ICD–9–CM are shown in table IX; procedures and code
activities associated with his or her age group due to a
number inclusions are shown in table X.
chronic condition. Limitation of activity is assessed by asking

Table IX. Codes for diagnostic categories from the International Classification of Diseases, Ninth Revision, Clinical Modification
Diagnostic category Code numbers
Females with delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V27
Human immunodeficiency virus (HIV) (1984–85) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279.19
(1986–94) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 042–044, 279.19, 795.8
(Beginning in 1995) . . . . . . . . . . . . . . . . . . . . . . 042, V08
Malignant neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140–208
Large intestine and rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153–154, 197.5
Trachea, bronchus, and lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162, 197.0, 197.3
Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174–175, 198.81
Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Alcohol and drug . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291–292, 303–305
Serious mental illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295–298
Diseases of the nervous system and sense organs . . . . . . . . . . . . . . . . . . . . . . . . . . 320–389
Diseases of the circulatory system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390–459
Diseases of heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391–392.0, 393–398, 402, 404, 410–416, 420–429
Ischemic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410–414
Acute myocardial infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
Congestive heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428.0
Cerebrovascular diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430–438
Diseases of the respiratory system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460–519
Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466.1, 480–487.0
Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
Hyperplasia of prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
Decubitus ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707.0
Diseases of the musculoskeletal system and connective tissue . . . . . . . . . . . . . . . . . . . 710–739
Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 715
Intervertebral disc disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 722
Injuries and poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800–999
Fracture, all sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800–829
Fracture of neck of femur (hip) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
respondents a series of questions about limitations in their Live birth—In the World Health Organization’s definition, also
ability to perform activities usual for their age group because adopted by the United Nations and the National Center for
of a physical, mental, or emotional problem. Respondents are Health Statistics, a live birth is the complete expulsion or
asked about limitations in activities of daily living, instrumental extraction from its mother of a product of conception,
activities of daily living, play, school, work, difficulty walking or irrespective of the duration of the pregnancy, which, after
remembering, and any other activity limitations. For reported such separation, breathes or shows any other evidence of life
limitations, the causal health conditions are determined and such as heartbeat, umbilical cord pulsation, or definite
respondents are considered limited if one or more of these movement of voluntary muscles, whether the umbilical cord
conditions is chronic. has been cut or the placenta is attached. Each product of
such a birth is considered live born. See related Gestation;
Sample persons from the Medicare Current Beneficiary
Rate: Birth and related rates.
Survey who report no limitations in the activities of daily living
(ADL) or instrumental activities of daily living (IADL) due to Live-birth order—In the National Vital Statistics System this
health problems are included in the category ‘‘none.’’ Sample item from the birth certificate refers to the total number of live
persons with limitations in at least one IADL, but no ADL, are births the mother has had, including the present birth as
included in the category ‘‘IADL’’ only. Sample persons with recorded on the birth certificate. Fetal deaths are excluded.
ADL limitations are categorized by the number of limitations See related Live birth.
(1 to 2, 3 to 5) regardless of the number of IADL limitations.
See related Activities of daily living; Condition; Instrumental Low birthweight—See Birthweight.
activities of daily living.

Table X. Codes for procedure categories from the International Classification of Diseases, Ninth Revision, Clinical Modification
Procedure category Code numbers
Extraction of lens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.1–13.6
Insertion of prosthetic lens (pseudophakos) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.7
Myringotomy with insertion of tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.01
Tonsillectomy, with or without adenoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28.2–28.3
Coronary angioplasty (Prior to 1997) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.0
(Beginning in 1997) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.01–36.05, 36.09
Coronary artery bypass graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36.1
Cardiac catheterization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37.21–37.23
Pacemaker insertion or replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37.7–37.8
Carotid endarterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38.12
Endoscopy of large or small intestine with or without biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . 45.11–45.14, 45.16, 45.21–45.25
Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.2
Prostatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60.2–60.6
Bilateral destruction or occlusion of fallopian tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66.2–66.3
Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68.3–68.7, 68.9
Cesarean section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74.0–74.2, 74.4, 74.99
Repair of current obstetrical laceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.5–75.6
Reduction of fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76.7, 79.0–79.3
Arthroscopy of knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.26
Excision or destruction of intervertebral disc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.5
Total hip replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.51
Lumpectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85.21
Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85.4
Angiocardiography with contrast material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.5
Managed care—Managed care is a health care plan that Medicaid—Medicaid was authorized by Title XIX of the Social
integrates the financing and delivery of health care services Security Act in 1965 as a jointly funded cooperative venture
by using arrangements with selected health care providers to between the Federal and State governments to assist States
provide services for covered individuals. Plans are generally in the provision of adequate medical care to eligible needy
financed using capitation fees. There are significant financial persons. Medicaid is the largest program providing medical
incentives for members of the plan to use the health care and health-related services to America’s poorest people.
providers associated with the plan. The plan includes formal Within broad Federal guidelines, each of the States
programs for quality assurance and utilization review. Health establishes its own eligibility standards; determines the type,
maintenance organizations (HMOs), preferred provider amount, duration, and scope of services; sets the rate of
organizations (PPOs), and point of service (POS) plans are payment for services; and administers its own program. Thus,
examples of managed care. See related Health maintenance the Medicaid program varies considerably from State to State,
organization; Preferred provider organization. as well as within each State over time. See related Health
expenditures, national; Health maintenance organization;
Marital status—Marital status is classified through Medicare.
self-reporting into the categories married and unmarried. The
term married encompasses all married people including those Medical specialties—See Physician specialty.
separated from their spouses. Unmarried includes those who
are single (never married), divorced, or widowed. The Medical vendor payments—Under the Medicaid program,
Abortion Surveillance Reports of the Centers for Disease medical vendor payments are payments (expenditures) to
Control and Prevention classified separated people as medical vendors from the State through a fiscal agent or to a
unmarried before 1978. health insurance plan. Adjustments are made for Indian
Health Service payments to Medicaid, cost settlements, third
Maternal mortality rate—See Rate: Death and related rates. party recoupments, refunds, voided checks, and other
financial settlements that cannot be related to specific
provided claims. Excluded are payments made for medical

care under the emergency assistance provisions, payments Multiservice mental health organizations directly provide
made from State medical assistance funds that are not two or more of the program elements defined under
federally matchable, disproportionate share hospital payments, mental health service type and are not classifiable as a
cost sharing or enrollment fees collected from recipients or a psychiatric hospital, general hospital, or residential
third party, and administration and training costs. treatment center for emotionally disturbed children. (The
classification of a psychiatric or general hospital or
Medicare—This is a nationwide health insurance program residential treatment center for emotionally disturbed
providing health insurance protection to people 65 years of children takes precedence over a multiservice
age and over, people entitled to social security disability classification, even if two or more services are offered.)
payments for 2 years or more, and people with end-stage

renal disease, regardless of income. The program was Partial care organizations provide a program of
enacted July 30, 1965, as Title XVIII, Health Insurance for the ambulatory mental health services.
Aged of the Social Security Act, and became effective on July

1, 1966. It consists of two separate but coordinated Private mental hospitals are operated by a sole
programs, hospital insurance (Part A) and supplementary proprietor, partnership, limited partnership, corporation, or
medical insurance (Part B). See related Health expenditures, nonprofit organization, primarily for the care of persons
national; Health maintenance organization; Medicaid. with mental disorders.
Mental health organization—The Center for Mental Health Psychiatric hospitals are hospitals concerned primarily
Services defines a mental health organization as an with providing inpatient care and treatment for the
administratively distinct public or private agency or institution mentally ill. Psychiatric inpatient units of Department of
whose primary concern is provision of direct mental health Veterans Affairs general hospitals and Department of
services to the mentally ill or emotionally disturbed. Excluded Veterans Affairs neuropsychiatric hospitals are combined
are private office-based practices of psychiatrists, into the category Department of Veterans Affairs
psychologists, and other mental health providers; psychiatric psychiatric hospitals because of their similarity in size,
services of all types of hospitals or outpatient clinics operated operation, and length of stay.
by Federal agencies other than the Department of Veterans

Residential treatment centers for emotionally disturbed
Affairs (for example, Public Health Service, Indian Health

children must meet all of the following criteria: (a) Is not
Service, Department of Defense, and Bureau of Prisons);

licensed as a psychiatric hospital and has the primary
general hospitals that have no separate psychiatric services

purpose of providing individually planned mental health
but admit psychiatric patients to nonpsychiatric units; and

treatment services in conjunction with residential care; (b)
psychiatric services of schools, colleges, halfway houses,

Includes a clinical program directed by a psychiatrist,
community residential organizations, local and county jails,

psychologist, social worker, or psychiatric nurse with a
State prisons, and other human service providers. The major

graduate degree; (c) Serves children and youth primarily
types of mental health organizations are described below.

under the age of 18; and (d) Has the primary diagnosis
Freestanding psychiatric outpatient clinics provide only for the majority of admissions as mental illness,
outpatient services on either a regular or emergency classified as other than mental retardation,
basis. A psychiatrist generally assumes the medical developmental disability, or substance-related disorders,
responsibility for services. according to DSM-II/ICDA-8 or DSM-IIIR/ICD–9–CM
codes.
General hospitals providing separate psychiatric services

are non-Federal general hospitals that provide psychiatric State and county mental hospitals are under the
services in either a separate psychiatric inpatient, auspices of a State or county government or operated
outpatient, or partial hospitalization service with assigned jointly by a State and county government.
staff and space.

See related Addition; Mental health service type.

Mental health service type—This term refers to the following Multiservice mental health organizations—See Mental
kinds of mental health services: health organization.
24-hour mental health care, formerly called inpatient National ambient air quality standards—The Federal Clean
care, provides care in a mental health hospital setting. Air Act of 1970, amended in 1977 and 1990, requires the
Environmental Protection Agency (EPA) to establish National
Less than 24-hour care, formerly called outpatient or Ambient Air Quality Standards. EPA has set specific
partial care treatment, provides mental health services on standards for each of six major pollutants: carbon monoxide,
an ambulatory basis. lead, nitrogen dioxide, ozone, sulfur dioxide, and particulate
matter whose aerodynamic size is equal to or less than 10
Residential treatment care provides overnight mental
microns (PM-10). Each pollutant standard represents a
health care in conjunction with an intensive treatment
maximum concentration level (micrograms per cubic meter)
program in a setting other than a hospital. Facilities may
that cannot be exceeded during a specified time interval. A
offer care to emotionally disturbed children or mentally ill
county meets the national ambient air quality standards if
adults.
none of the six pollutants exceed the standard during a
See related Addition; Mental health organization. 12-month period. See related Particulate matter; Pollutant.
Metropolitan statistical area (MSA)—The Office of Neonatal mortality rate—See Rate: Death and related rates.
Management and Budget (OMB) defines metropolitan areas
Non-Federal physicians—See Physician.
according to published standards that are applied to Census
Bureau data. The collective term ‘‘metropolitan area’’ includes Nonpatient revenues—Nonpatient revenues are those
metropolitan statistical areas (MSAs), consolidated revenues received for which no direct patient care services
metropolitan statistical areas (CMSAs), and primary are rendered. The most widely recognized source of
metropolitan statistical areas (PMSAs). An MSA is a county or nonpatient revenues is philanthropy. Philanthropic support
group of contiguous counties that contains at least one city may be direct from individuals or may be obtained through
with a population of 50,000 or more or a Census philanthropic fund raising organizations such as the United
Bureau-defined urbanized area of at least 50,000 with a Way. Support may also be obtained from foundations or
metropolitan population of at least 100,000. In addition to the corporations. Philanthropic revenues may be designated for
county or counties that contain all or part of the main city or direct patient care use or may be contained in an endowment
urbanized area, an MSA may contain other counties that are fund where only the current income may be tapped.
metropolitan in character and are economically and socially
integrated with the main city. If an MSA has a population of 1 Nonprofit hospitals—See Hospital.
million or more and meets requirements specified in the
standards, it is termed a CMSA, consisting of two or more Notifiable disease—A notifiable disease is one that, when
major components, each of which is recognized as a PMSA. diagnosed, health providers are required, usually by law, to
In New England, cities and towns, rather than counties, are report to State or local public health officials. Notifiable
used to define MSAs. Counties that are not within an MSA diseases are those of public interest by reason of their
are considered to be nonmetropolitan. contagiousness, severity, or frequency.
For National Health Interview Survey (NHIS) data before Nursing care—The following definition of nursing care applies
1995, metropolitan population is based on MSAs as defined to data collected in National Nursing Home Surveys through
by OMB in 1983 using the 1980 Census. Starting with the 1977. Nursing care is provision of any of the following
1995 NHIS, metropolitan population is based on MSAs as services: application of dressings or bandages; bowel and
defined by OMB in 1993 using the 1990 Census. For further bladder retraining; catheterization; enema; full bed bath;
information on metropolitan areas, see U.S. Department of hypodermic, intramuscular, or intravenous injection; irrigation;
Commerce, Bureau of the Census, State and Metropolitan nasal feeding; oxygen therapy; and temperature-pulse-
Area Data Book. See related Urbanization. respiration or blood pressure measurement. See related
Nursing home.

Nursing care homes—See Nursing home. skilled nursing facilities provide skilled nursing services
on a daily basis to individuals eligible for Medicaid
Nursing home—In the Online Survey Certification and benefits.
Reporting database, a nursing home is a facility that is
certified and meets the Health Care Financing Administration’s Intermediate care facilities are certified by the Medicaid
long-term care requirements for Medicare and Medicaid program to provide health-related services on a regular
eligibility. In the National Master Facility Inventory (NMFI), basis to Medicaid eligibles who do not require hospital or
which provided the sampling frame for 1973–74, 1977, and skilled nursing facility care but do require institutional
1985 National Nursing Home Surveys, a nursing home was care above the level of room and board.
an establishment with three or more beds that provided
nursing or personal care services to the aged, infirm, or Not certified facilities are not certified as providers of
chronically ill. The following definitions of nursing home types care by Medicare or Medicaid.
applied to facilities listed in the NFMI. The 1977 National
Beginning with the 1995 through the 1999 National Nursing
Nursing Home Survey included personal care homes and
Home Surveys, nursing homes have been defined as facilities
domiciliary care homes while the National Nursing Home
that routinely provide nursing care services and have three or
Surveys of 1973–74, 1985, 1995, 1997, and 1999 excluded
more beds set up for residents. Facilities may be certified by
them.
Medicare or Medicaid or not certified but licensed by the state
Nursing care homes must employ one or more full-time as a nursing home. The facilities may be freestanding or a
registered or licensed practical nurses and must provide distinct unit of a larger facility.
nursing care to at least one-half the residents.
See related Nursing care; Resident.
Personal care homes with nursing have some but fewer
Nursing home expenditures—See Health expenditures,
than one-half the residents receiving nursing care. In
national.
addition, such homes must employ one or more
registered or licensed practical nurses or must provide Obesity—See Body Mass Index (BMI).
administration of medications and treatments in
accordance with physicians’ orders, supervision of Occupancy rate—The American Hospital Association defines
self-administered medications, or three or more personal hospital occupancy rate as the average daily census divided
services. by the average number of hospital beds during a reporting
period. Average daily census is defined by the American
Personal care homes without nursing have no residents Hospital Association as the average number of inpatients,
who are receiving nursing care. These homes provide excluding newborns, receiving care each day during a
administration of medications and treatments in reporting period. The occupancy rate for facilities other than
accordance with physicians’ orders, supervision of hospitals is calculated as the number of residents reported at
self-administered medications, or three or more personal the time of the interview divided by the number of beds
services. reported. In the Online Survey Certification and Reporting
database, occupancy is the total number of residents on the
Domiciliary care homes primarily provide supervisory
day of certification inspection divided by the total number of
care but also provide one or two personal services.
beds on the day of certification.
The following definitions of certification levels apply to data
Office—In the National Ambulatory Medical Care Survey, an
collected in National Nursing Home Surveys of 1973–74,
office is any location for a physician’s ambulatory practice
1977, and 1985:
other than hospitals, nursing homes, other extended care
Skilled nursing facilities provide the most intensive facilities, patients’ homes, industrial clinics, college clinics, and
nursing care available outside a hospital. Facilities family planning clinics. Offices in health maintenance
certified by Medicare provide posthospital care to eligible organizations and private offices in hospitals are included.
Medicare enrollees. Facilities certified by Medicaid as See related Office visit; Outpatient visit; Physician.

Office-based physician—See Physician. (soot, dust, and dirt) and toxic materials (for example, lead,
asbestos, suspended sulfates, and nitrates). See related
Office visit—In the National Ambulatory Medical Care Survey, National ambient air quality standards; Pollutant.
an office visit is any direct personal exchange between an
ambulatory patient and a physician or members of his or her Patient—A patient is a person who is formally admitted to the
staff for the purposes of seeking care and rendering health inpatient service of a hospital for observation, care, diagnosis,
services. See related Outpatient visit. or treatment. See related Admission; Average length of stay;
Days of care; Discharge; Hospital.
Operations—See Procedure.
Percent change—See Average annual rate of change.
Outpatient department—According to the National Hospital
Ambulatory Medical Care Survey (NHAMCS), an outpatient Perinatal mortality rate; ratio—See Rate: Death and related
department (OPD) is a hospital facility where nonurgent rates.
ambulatory medical care is provided. The following are
examples of the types of OPDs excluded from the NHAMCS: Personal care homes with or without nursing—See
ambulatory surgical centers, chemotherapy, employee health Nursing home.
services, renal dialysis, methadone maintenance, and
Personal health care expenditures—See Health
radiology. See related Emergency department; Outpatient visit.
expenditures, national.
Outpatient surgery—According to the American Hospital
Physician—Physicians, through self-reporting, are classified
Association, outpatient surgery is performed on patients who
by the American Medical Association and others as licensed
do not remain in the hospital overnight and occurs in inpatient
doctors of medicine or osteopathy, as follows:
operating suites, outpatient surgery suites, or procedure
rooms within an outpatient care facility. Outpatient surgery is Active (or professionally active) physicians are currently
a surgical operation, whether major or minor, performed in practicing medicine for a minimum of 20 hours per week.
operating or procedure rooms. A surgical operation involving Excluded are physicians who are not practicing,
more than one surgical procedure is considered one surgical practicing medicine less than 20 hours per week, have
operation. See related Ambulatory surgery; Procedure. unknown addresses, or specialties not classified (when
specialty information is presented).
Outpatient visit—The American Hospital Association defines
outpatient visits as visits for receipt of medical, dental, or Federal physicians are employed by the Federal
other services by patients who are not lodged in the hospital. Government; non-Federal or civilian physicians are not.
Each appearance by an outpatient to each unit of the hospital
is counted individually as an outpatient visit. In the National Hospital-based physicians spend the plurality of their
Hospital Ambulatory Medical Care Survey an outpatient time as salaried physicians in hospitals.
department visit is a direct personal exchange between a
patient and a physician or other health care provider working Office-based physicians spend the plurality of their time
under the physician’s supervision for the purpose of seeking working in practices based in private offices.
care and receiving personal health services. See related
Emergency department visit; Outpatient department. Data for physicians are presented by type of education
(doctors of medicine and doctors of osteopathy); place of
Overweight—See Body mass index (BMI). education (U.S. medical graduates and international medical
graduates); activity status (professionally active and inactive);
Partial care organization—See Mental health organization. employment setting (Federal and non-Federal); area of
specialty; and geographic area. See related Office; Physician
Partial care treatment—See Mental health service type. specialty.
Particulate matter—Particulate matter is defined as particles Physician specialty—A physician specialty is any specific
of solid or liquid matter in the air, including nontoxic materials branch of medicine in which a physician may concentrate.

Data are based on physician self-reports of their primary area Pollutant—A pollutant is any substance that renders the
of specialty. Physician data are broadly categorized into two atmosphere or water foul or noxious to health. See related
general areas of practice: generalists and specialists. National ambient air quality standards; Particulate matter.
Generalist physicians are synonymous with primary care Population—The U.S. Bureau of the Census collects and
generalists and only include physicians practicing in the publishes data on populations in the United States according
general fields of family and general practice, general to several different definitions. Various statistical systems then
internal medicine, and general pediatrics. They use the appropriate population for calculating rates.
specifically exclude primary care specialists.
Total population is the population of the United States,
Primary care specialists practice in the subspecialties of including all members of the Armed Forces living in
general and family practice, internal medicine, and foreign countries, Puerto Rico, Guam, and the U.S.
pediatrics. The primary care subspecialties for family Virgin Islands. Other Americans abroad (for example,
practice include geriatric medicine and sports medicine. civilian Federal employees and dependents of members
Primary care subspecialties for internal medicine include of the Armed Forces or other Federal employees) are
diabetes, endocrinology and metabolism, hematology, not included.
hepatology, cardiac electrophysiology, infectious diseases,
diagnostic laboratory immunology, geriatric medicine, Resident population includes persons whose usual place
sports medicine, nephrology, nutrition, medical oncology, of residence (that is, the place where one usually lives
and rheumatology. Primary care subspecialties for and sleeps) is in one of the 50 States or the District of
pediatrics include adolescent medicine, critical care Columbia. It includes members of the Armed Forces
pediatrics, neonatal-perinatal medicine, pediatric allergy, stationed in the United States and their families. It
pediatric cardiology, pediatric endocrinology, pediatric excludes international military, naval, and diplomatic
pulmonology, pediatric emergency medicine, pediatric personnel and their families located in this county and
gastroenterology, pediatric hematology/oncology, residing in embassies or similar quarters. Also excluded
diagnostic laboratory immunology, pediatric nephrology, are international workers and international students in
pediatric rheumatology, and sports medicine. this country and Americans living abroad. The resident
population is usually the denominator when calculating
Specialist physicians practice in the primary care birth and death rates and incidence of disease. The
specialties, in addition to all other specialist fields not resident population is also the denominator for selected
included in the generalist definition. Specialist fields population-based rates that use numerator data from the
include allergy and immunology, aerospace medicine, National Nursing Home Survey.
anesthesiology, cardiovascular diseases, child and
adolescent psychiatry, colon and rectal surgery, Civilian population is the resident population excluding
dermatology, diagnostic radiology, forensic pathology, members of the Armed Forces. However, families of
gastroenterology, general surgery, medical genetics, members of the Armed Forces are included. This
neurology, nuclear medicine, neurological surgery, population is the denominator in rates calculated for the
obstetrics and gynecology, occupational medicine, NCHS National Hospital Discharge Survey, the National
ophthalmology, orthopedic surgery, otolaryngology, Home and Hospice Care Survey, and the National
psychiatry, public health and general preventive Survey of Ambulatory Surgery.
medicine, physical medicine and rehabilitation, plastic
Civilian noninstitutionalized population is the civilian
surgery, anatomic and clinical pathology, pulmonary
population not residing in institutions. Institutions include
diseases, radiation oncology, thoracic surgery, urology,
correctional institutions, detention homes, and training
addiction medicine, critical care medicine, legal medicine,
schools for juvenile delinquents; homes for aged and
and clinical pharmacology.
dependent persons (for example, nursing homes and
See related Physician. convalescent homes); homes for dependent and
neglected children; homes and schools for mentally or

physically handicapped persons; homes for unwed record as provided by the agency staff member most familiar
mothers; psychiatric, tuberculosis, and chronic disease with the care provided to the patient.
hospitals; and residential treatment centers. Census
Bureau estimates of the civilian noninstitutionalized Primary care specialties—See Physician specialty.
population are used to calculate sample weights for the
Private expenditures—See Health expenditures, national.
NCHS National Health Interview Survey, National Health
and Nutrition Examination Survey, and National Survey of Procedure—The National Hospital Discharge Survey (NHDS)
Family Growth, and as denominators in rates calculated and the National Survey of Ambulatory Surgery (NSAS) define
for the National Ambulatory Medical Care Survey and the a procedure as a surgical or nonsurgical operation, diagnostic
National Hospital Ambulatory Medical Care Survey. procedure, or therapeutic procedure (such as respiratory
therapy) recorded on the medical record of discharged
Postneonatal mortality rate—See Rate: Death and related
patients. A maximum of four procedures per discharge in
rates.
NHDS and up to six procedures per discharge in NSAS were
Poverty level—Poverty statistics are based on definitions recorded and coded to the International Classification of
originally developed by the Social Security Administration. Diseases, Ninth Revision, Clinical Modification. Previous
These include a set of money income thresholds that vary by editions of Health, United States classified procedures into
family size and composition. Families or individuals with surgical and diagnostic and other nonsurgical procedures. The
income below their appropriate thresholds are classified as distinction between surgical and diagnostic and nonsurgical
below the poverty level. These thresholds are updated procedures has become less meaningful due to development
annually by the U.S. Bureau of the Census to reflect changes of minimally invasive and noninvasive surgery. Thus the
in the Consumer Price Index for all urban consumers (CPI-U). practice of classifying procedures as surgical or diagnostic
For example, the average poverty threshold for a family of has been discontinued. See related Ambulatory surgery;
four was $17,029 in 1999 and $13,359 in 1990. For more Outpatient surgery.
information, see U.S. Bureau of the Census: Consumer
Proprietary hospitals—See Hospital.
Income and Poverty 1999. Series P-60. Washington, DC: U.S.
Government Printing Office. Also see www.census.gov/hhes/ Psychiatric hospitals—See Hospital; Mental health
poverty.html. See related Consumer Price Index; Family organization.
income.
Public expenditures—See Health expenditures, national.
Preferred provider organization (PPO)—This is a health
plan generally consisting of hospital and physician providers. Public health activities—Public health activities may include
The PPO provides health care services to plan members any of the following essential services of public health—
usually at discounted rates in return for expedited claims surveillance, investigations, education, community mobilization,
payment. Plan members can use PPO or non-PPO health workforce training, research, and personal care services
care providers; however, financial incentives are built into the delivered or funded by governmental agencies.
benefit structure to encourage utilization of PPO providers.
See related Managed care. Race—In 1977 the Office of Management and Budget (OMB)
issued Race and Ethnic Standards for Federal Statistics and
Prevalence—Prevalence is the number of cases of a Administrative Reporting in order to promote comparability of
disease, infected persons, or persons with some other data among Federal data systems. The 1977 Standards
attribute present during a particular interval of time. It is often called for the Federal Government’s data systems to classify
expressed as a rate (for example, the prevalence of diabetes individuals into the following four racial groups: American
per 1,000 persons during a year). See related Incidence. Indian or Alaska Native, Asian or Pacific Islander, black, and
white. Depending on the data source, the classification by
Primary admission diagnosis—In the National Home and race was based on self-classification or on observation by an
Hospice Care Survey the primary admission diagnosis is the interviewer or other person filling out the questionnaire.
first-listed diagnosis at admission on the patient’s medical

In 1997 new standards were announced for classification of total category. Where applicable, comparison tabulations by
individuals by race within the Federal Government’s data race and Hispanic origin are shown based on the 1977
systems (Federal Register, 62FR58781–58790). The 1997 Standards. Because there are more race groups with the
Standards have five racial groups: American Indian or Alaska 1997 Standards, the sample size of each race group under
Native, Asian, Black or African American, Native Hawaiian or the 1997 Standards is slightly smaller than the sample size
Other Pacific Islander, and White. These five categories are under the 1977 Standards. Only those few multiple race
the minimum set for data on race in Federal statistics. The groups with sufficient numbers of observations to meet
1997 Standards also offer an opportunity for respondents to standards of statistical reliability are shown. Tables XI and XII
select more than one of the five groups, leading to many also illustrate changes in labels and group categories in the
possible multiple race categories. As with the single race 1997 Standards. The race designation of Black was changed
groups, data for the multiple race groups are to be reported to Black or African American and the ethnicity designation of
when estimates meet agency requirements for reliability and Hispanic was changed to Hispanic or Latino.
confidentiality. The 1997 Standards allow for observer or
Additional information is provided in Appendix I under National
proxy identification of race but clearly state a preference for
Vital Statistics System. See related Hispanic origin.
self-classification. The Federal government considers race and
Hispanic origin to be two separate and distinct concepts. Rate—A rate is a measure of some event, disease, or
Thus Hispanics may be of any race. Federal data systems condition in relation to a unit of population, along with some
are required to comply with the 1997 Standards by 2003. specification of time. See related Age adjustment; Population.
Data systems included in Health, United States, other than Birth and related rates
the National Health Interview Survey (NHIS), generally do not
permit tabulation of estimates for the detailed race and Birth rate is calculated by dividing the number of live
ethnicity categories shown in tables XI and XII, either because births in a population in a year by the midyear resident
race data based on the 1997 standard categories are not yet population. For census years, rates are based on
available, or because there are insufficient numbers of unrounded census counts of the resident population, as
observations to meet statistical reliability or confidentiality of April 1. For the noncensus years of 1981–89 and
requirements. Starting with Health, United States, 2002 1991, rates are based on national estimates of the
race-specific estimates based on the NHIS are tabulated resident population, as of July 1, rounded to 1,000s.
using the 1997 Standards for data years 1999 and beyond. Population estimates for 5-year age groups are
Prior to data year 1999, the 1977 Standards were used. generated by summing unrounded population estimates
Because of the differences between the two Standards, the before rounding to 1,000s. Starting in 1992 rates are
race-specific estimates shown in trend tables based on the based on unrounded national population estimates. Birth
NHIS for 1999 and later years are not strictly comparable rates are expressed as the number of live births per
with estimates for earlier years. Each trend table based on 1,000 population. The rate may be restricted to births to
the NHIS includes a footnote that discusses differences women of specific age, race, marital status, or
between estimates tabulated using the two Standards for data geographic location (specific rate), or it may be related to
year 1999. the entire population (crude rate). See related Cohort
fertility; Live birth.
Tables XI and XII illustrate NHIS data tabulated by race and
Hispanic origin according to the 1997 and 1977 Standards for Fertility rate is the total number of live births, regardless
two health statistics (cigarette smoking and private health of age of mother, per 1,000 women of reproductive age,
insurance coverage). In these illustrations, three separate 15–44 years.
tabulations using the 1997 Standards are shown: 1) Race:
mutually exclusive race groups, including several multiple race Death and related rates
combinations; 2) Race, any mention: race groups that are not
Death rate is calculated by dividing the number of deaths
mutually exclusive because each race category includes all
in a population in a year by the midyear resident
persons who mention that race; and 3) Hispanic origin and
population. For census years, rates are based on
race: detailed race and Hispanic origin with a multiple race
unrounded census counts of the resident population, as

Table XI. Current cigarette smoking by persons 18 years of age and over, according to race and Hispanic origin under the 1977
and 1997 Standards for Federal data on race and ethnicity: United States, average annual 1993–95
Sample Standard Sample Standard

1997 Standards size Percent error 1977 Standards size Percent error
Race
White only . . . . . . . . . . . . . . . . . . . . . 46,228 25.2 0.26 White . . . . . . . . . . . . . . . . . . . . . . . . 46,664 25.3 0.26
Black or African American only . . . . . . . . . 7,208 26.6 0.64 Black . . . . . . . . . . . . . . . . . . . . . . . . . 7,334 26.5 0.63
American Indian and Alaska Native only . . . 416 32.9 2.53 American Indian and Alaska Native . . . . . . 480 33.9 2.38
Asian only . . . . . . . . . . . . . . . . . . . . . . 1,370 15.0 1.19 Asian and Pacific Islander . . . . . . . . . . . . 1,411 15.5 1.22
2 or more races total . . . . . . . . . . . . . . . 786 34.5 2.00
Black or African American; White . . . . . . 83 *21.7 6.05
American Indian and Alaska Native;
White . . . . . . . . . . . . . . . . . . . . . . 461 40.0 2.58
Race, any mention
White, any mention . . . . . . . . . . . . . . . . 46,882 25.3 0.26
Black or African American, any mention . . . 7,382 26.6 0.63
American Indian and Alaska Native, any
mention . . . . . . . . . . . . . . . . . . . . . . 965 36.3 1.71
Asian, any mention . . . . . . . . . . . . . . . . 1,458 15.7 1.20
Native Hawaiian and Other Pacific Islander,
any mention . . . . . . . . . . . . . . . . . . . . 53 *17.5 5.10
Hispanic origin and race

Not Hispanic or Latino: Non-Hispanic:
White only . . . . . . . . . . . . . . . . . . . . 42,421 25.8 0.27 White . . . . . . . . . . . . . . . . . . . . . . . 42,976 25.9 0.27
Black or African American only . . . . . . . 7,053 26.7 0.65 Black . . . . . . . . . . . . . . . . . . . . . . . 7,203 26.7 0.64
American Indian and Alaska Native only . . 358 33.5 2.69 American Indian and Alaska Native . . . . . 407 35.4 2.53
Asian only . . . . . . . . . . . . . . . . . . . . 1,320 14.8 1.21 Asian and Pacific Islander . . . . . . . . . . 1,397 15.3 1.24
2 or more races total . . . . . . . . . . . . . 687 35.6 2.15
Hispanic or Latino . . . . . . . . . . . . . . . . . 5,175 17.8 0.65 Hispanic . . . . . . . . . . . . . . . . . . . . . . . 5,175 17.8 0.65
*Relative standard error 20–30 percent.

NOTES: The 1997 Standards for Federal data on race and ethnicity set five single race groups (White, Black, American Indian or Alaska Native, Asian, and
Native Hawaiian or Other Pacific Islander) and allow respondents to report one or more race groups. Estimates for single race and multiple race groups not
shown above do not meet standards for statistical reliability or confidentiality (relative standard error greater than 30 percent). Race groups under the 1997
Standards were based on the question, ‘‘What is the group or groups which represents _____ race?’’ For persons who selected multiple groups, race groups
under the 1977 Standards were based on the additional question, ‘‘Which of those groups would you say best represents ____ race?’’ Race-specific estimates
in this table were calculated after excluding respondents of other and unknown race. Other published race-specific estimates are based on files in which such
responses have been edited. Percents are age adjusted to the year 2000 standard using three age groups: Under 18 years, 18–44 years, and 45–64 years of
age. See Appendix II, Age adjustment.
SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics. National Health Interview Survey.
of April 1. For the noncensus years of 1981–89 and (specific rate) or it may be related to the entire
1991, rates are based on national estimates of the population (crude rate).
resident population, as of July 1, rounded to 1,000s.
Population estimates for 10-year age groups are Fetal death rate is the number of fetal deaths with stated
generated by summing unrounded population estimates or presumed gestation of 20 weeks or more divided by
before rounding to 1,000s. Starting in 1992 rates have the sum of live births plus fetal deaths, stated per 1,000
been based on unrounded national population estimates. live births plus fetal deaths. Late fetal death rate is the
Rates for the Hispanic and non-Hispanic white number of fetal deaths with stated or presumed gestation
populations in each year are based on unrounded State of 28 weeks or more divided by the sum of live births
population estimates for States in the Hispanic reporting plus late fetal deaths, stated per 1,000 live births plus
area. Death rates are expressed as the number of late fetal deaths. See related Fetal death; Gestation.
deaths per 100,000 population. The rate may be
Infant mortality rate based on period files is calculated by
restricted to deaths in specific age, race, sex, or
dividing the number of infant deaths during a calendar
geographic groups or from specific causes of death
year by the number of live births reported in the same

Table XII. Private health care coverage for persons under 65 years of age, according to race and Hispanic origin under the 1977
and 1997 Standards for Federal data on race and ethnicity: United States, average annual 1993–95
Sample Standard Sample Standard

1997 Standards size Percent error 1977 Standards size Percent error
Race
White only . . . . . . . . . . . . . . . . . . . . . . . 168,256 76.1 0.28 White . . . . . . . . . . . . . . . . . . . . . . 170,472 75.9 0.28
Black or African American only . . . . . . . . . . . 30,048 53.5 0.63 Black . . . . . . . . . . . . . . . . . . . . . . . 30,690 53.6 0.63
American Indian and Alaska Native only . . . . . 2,003 44.2 1.97 American Indian and Alaska Native . . . . 2,316 43.5 1.85
Asian only . . . . . . . . . . . . . . . . . . . . . . . . 6,896 68.0 1.39 Asian and Pacific Islander . . . . . . . . . . 7,146 68.2 1.34
Native Hawaiian and Other Pacific Islander
only . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 75.0 7.43
2 or more races total . . . . . . . . . . . . . . . . . 4,203 60.9 1.17
Black or African American; White . . . . . . . . 686 59.5 3.21
American Indian and Alaska Native; White . . 2,022 60.0 1.71
Asian; White . . . . . . . . . . . . . . . . . . . . . 590 71.9 3.39
Native Hawaiian and Other Pacific Islander;
White . . . . . . . . . . . . . . . . . . . . . . . . 56 59.2 10.65
Race, any mention

White, any mention . . . . . . . . . . . . . . . . . . 171,817 75.8 0.28
Black or African American, any mention . . . . . 31,147 53.6 0.62
American Indian and Alaska Native, any
mention . . . . . . . . . . . . . . . . . . . . . . . . 4,365 52.4 1.40
Asian, any mention . . . . . . . . . . . . . . . . . . 7,639 68.4 1.27
Native Hawaiian and Other Pacific Islander, any
mention . . . . . . . . . . . . . . . . . . . . . . . . 283 68.7 6.23
Hispanic origin and race

Not Hispanic or Latino: Non-Hispanic:
White only . . . . . . . . . . . . . . . . . . . . . . 146,109 78.9 0.27 White . . . . . . . . . . . . . . . . . . . . . 149,057 78.6 0.27
Black or African American only . . . . . . . . . 29,250 53.9 0.64 Black . . . . . . . . . . . . . . . . . . . . . 29,877 54.0 0.63
American Indian and Alaska Native only . . . . 1,620 45.2 2.15 American Indian and Alaska Native . . . 1,859 44.6 2.05
Asian only . . . . . . . . . . . . . . . . . . . . . . 6,623 68.2 1.43 Asian and Pacific Islander . . . . . . . . 6,999 68.4 1.40
Native Hawaiian and Other Pacific Islander
only . . . . . . . . . . . . . . . . . . . . . . . . . 145 76.4 7.79
2 or more races total . . . . . . . . . . . . . . . 3,365 62.6 1.18
Hispanic or Latino . . . . . . . . . . . . . . . . . . . 31,040 48.8 0.74 Hispanic . . . . . . . . . . . . . . . . . . . . . 31,040 48.8 0.74
NOTES: The 1997 Standards for Federal data on race and ethnicity set five single race groups (White, Black, American Indian or Alaska Native, Asian, and
Native Hawaiian or Other Pacific Islander) and allow respondents to report one or more race groups. Estimates for single race and multiple race groups not
shown above do not meet standards for statistical reliability or confidentiality (relative standard error greater than 30 percent). Race groups under the 1997
Standards were based on the question, ‘‘What is the group or groups which represents _____ race?’’ For persons who selected multiple groups, race groups
under the 1977 Standards were based on the additional question, ‘‘Which of those groups would you say best represents ____ race?’’ Race-specific estimates
in this table were calculated after excluding respondents of other and unknown race. Other published race-specific estimates are based on files in which such
responses have been edited. Percents are age adjusted to the year 2000 standard using three age groups: Under 18 years, 18–44 years, and 45–64 years of
age. See Appendix II, Age adjustment.
SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics. National Health Interview Survey.
year. It is expressed as the number of infant deaths per numerator of a birth cohort rate may have occurred in
1,000 live births. Neonatal mortality rate is the number of the same year as, or in the year following, the year of
deaths of children under 28 days of age, per 1,000 live birth. The birth cohort infant mortality rate is expressed
births. Postneonatal mortality rate is the number of as the number of infant deaths per 1,000 live births. See
deaths of children that occur between 28 days and 365 related Birth cohort.
days after birth, per 1,000 live births. See related Infant
death. Perinatal relates to the period surrounding the birth
event. Rates and ratios are based on events reported in
Birth cohort infant mortality rates are based on linked a calendar year. Perinatal mortality rate is the sum of
birth and infant death files. In contrast to period rates in late fetal deaths plus infant deaths within 7 days of birth
which the births and infant deaths occur in the same divided by the sum of live births plus late fetal deaths,
period or calendar year, infant deaths constituting the stated per 1,000 live births plus late fetal deaths.

Perinatal mortality ratio is the sum of late fetal deaths Registered hospitals—See Hospital.
plus infant deaths within 7 days of birth divided by the
number of live births, stated per 1,000 live births. Registered nursing education—Registered nursing data are
shown by level of educational preparation. Baccalaureate
Maternal death is defined by the World Health education requires at least 4 years of college or university;
Organization as the death of a woman while pregnant or associate degree programs are based in community colleges
within 42 days of termination of pregnancy, irrespective and are usually 2 years in length; and diploma programs are
of the duration and site of the pregnancy from any cause based in hospitals and are usually 3 years in length.
related to or aggravated by the pregnancy or its
management, but not from accidental or incidental Registration area—The United States has separate
causes. Maternal death is one for which the certifying registration areas for birth, death, marriage, and divorce
physician has designated a maternal condition as the statistics. In general, registration areas correspond to States
underlying cause of death. Maternal conditions are those and include two separate registration areas for the District of
assigned to Pregnancy, childbirth, and the puerperium, Columbia and New York City. All States have adopted laws
ICD–10 codes A34, O00-O95, O98-O99 (see table V). that require registration of births and deaths and reporting of
Maternal mortality rate is defined as the number of fetal deaths. It is believed that more than 99 percent of births
maternal deaths per 100,000 live births. The maternal and deaths occurring in this country are registered.
mortality rate is a measure of the likelihood that a The death registration area was established in 1900 with 10
pregnant woman will die from maternal causes. The States and the District of Columbia, and the birth registration
number of live births used in the denominator is a proxy area was established in 1915, also with 10 States and the
for the population of pregnant women who are at risk of District of Columbia. Both areas have covered the entire
a maternal death. Changes have been made in the United States since 1933. Currently, Puerto Rico, U.S. Virgin
classification and coding of maternal deaths between Islands, and Guam each constitutes a separate registration
ICD–9 and ICD–10, effective with mortality data for 1999. area, although their data are not included in statistical
ICD–10 changes pertain to indirect maternal causes and tabulations of U.S. resident data. See related Reporting area.
timing of death relative to pregnancy. If only indirect
maternal causes of death (i.e., a previously existing Relative standard error—The relative standard error (RSE)
disease or a disease that developed during pregnancy is a measure of an estimate’s reliability. The RSE of an
which was not due to direct obstetric causes but was estimate is obtained by dividing the standard error of the
aggravated by physiologic effects of pregnancy) are estimate (SE(r )) by the estimate itself (r ). This quantity is
reported in Part I and pregnancy is reported in either expressed as a percent of the estimate and is calculated as
Part I or Part II, ICD–10 classifies this as a maternal follows: RSE = 100 × (SE(r )/r ).
death. ICD–9 only classified the death as maternal if
pregnancy was reported in Part I. Some State death Relative survival rate—The relative survival rate is the ratio
certificates include a separate question regarding of the observed survival rate for the patient group to the
pregnancy status. A positive response to the question is expected survival rate for persons in the general population
interpreted as ‘‘pregnant’’ being reported in Part II of the similar to the patient group with respect to age, sex, race,
cause-of-death section of the death certificate. If the and calendar year of observation. The 5-year relative survival
medical certifier did not specify when death occurred rate is used to estimate the proportion of cancer patients
relative to the pregnancy, it is assumed that the potentially curable. Because over one-half of all cancers occur
pregnancy terminated 42 days or less prior to death. in persons 65 years of age and over, many of these
Under ICD–10 a new category has been added for individuals die of other causes with no evidence of recurrence
deaths from maternal causes that occurred more than 42 of their cancer. Thus, because it is obtained by adjusting
days after delivery or termination of pregnancy observed survival for the normal life expectancy of the
(O96-O97). In 1999 there were 15 such deaths. general population of the same age, the relative survival rate
is an estimate of the chance of surviving the effects of
Region—See Geographic region and division. cancer.

Reporting area—In the National Vital Statistics System, the assuring access to health care for underserved State
reporting area for such basic items on the birth and death residents.
certificates as age, race, and sex, is based on data from
residents of all 50 States in the United States and the District Substance abuse treatment clients—In the Substance
of Columbia (DC). The reporting area for selected items such Abuse and Mental Health Services Administration’s National
as Hispanic origin, educational attainment, and marital status, Survey of Substance Abuse Treatment Services, substance
is based on data from those States that require the item to abuse treatment clients have been admitted to treatment and
be reported, whose data meet a minimum level of have been seen on a scheduled appointment basis at least
completeness (such as 80 or 90 percent), and are considered once in the month before the survey reference date or were
to be sufficiently comparable to be used for analysis. In inpatients on the survey reference date. Types of treatment
1993–96 the reporting area for Hispanic origin of decedent on include 24-hour detoxification, 24-hour rehabilitation or
the death certificate included 49 States and DC. Starting in residential care, and outpatient care.
1997 the Hispanic reporting area includes all 50 States and
Suicidal ideation—Suicidal ideation is having thoughts of
DC. See related Registration area; National Vital Statistics
suicide or of taking action to end one’s own life. Suicidal
System, Appendix I.
ideation includes all thoughts of suicide, both when the
Resident—In the Online Survey Certification and Reporting thoughts include a plan to commit suicide and when they do
database, all residents in certified facilities are counted on the not include a plan. Suicidal ideation is measured in the Youth
day of certification inspection. In the National Nursing Home Risk Behavior Survey by the question ‘‘During the past 12
Survey, a resident is a person on the roster of the nursing months, did you ever seriously consider attempting suicide?’’
home as of the night before the survey. Included are all
Surgical operations—See Procedure.
residents for whom beds are maintained even though they
may be on overnight leave or in a hospital. See related Surgical specialties—See Physician specialty.
Nursing home.
Uninsured—See Health insurance coverage.
Resident population—See Population.
Urbanization—In this report, death rates are presented
Residential treatment care—See Mental health service type. according to the urbanization level of the decedent’s county
of residence. Counties and county equivalents were assigned
Residential treatment centers for emotionally disturbed
to one of five urbanization levels based on their classification
children—See Mental health organization.
in the Urban Influence code system (December 1996
Rural—See Urbanization. Revision) developed by the Economic Research Service, U.S.
Department of Agriculture. There are three levels for
Self-assessment of health—See Health status, respondent- metropolitan counties and two levels for nonmetropolitan
assessed. counties. The categorization of counties as metropolitan or
nonmetropolitan in the Urban Influence code system is based
Short-stay hospitals—See Hospital. on the June 1993 OMB definition of metropolitan areas (the
application of the 1990 metropolitan area standards to the
Skilled nursing facilities—See Nursing home.
1990 decennial census data). Metropolitan areas include
Smoker—See Cigarette smoking. metropolitan statistical areas (MSAs), consolidated
metropolitan statistical areas (CMSAs), and primary
Specialty hospitals—See Hospital. metropolitan statistical areas (PMSAs). See Metropolitan
statistical area, Appendix II for definitions of metropolitan and
State health agency—The agency or department within State nonmetropolitan counties.
government headed by the State or territorial health official.
Generally, the State health agency is responsible for setting The Urban Influence code system classifies metropolitan
statewide public health priorities, carrying out national and counties as either large metro (counties in MSA/PMSAs of 1
State mandates, responding to public health hazards, and million or more population) or small metro (counties in

MSA/PMSAs of less than 1 million population). For this 1–14 years, 15–24 years, 25–34 years, 35–44 years, 45–54
report, the large metro category of the Urban Influence code years, 55–64 years, 65–74 years. The number of deaths for
system was divided into two urbanization levels: large central each age group is multiplied by years of life lost, calculated
metro and large fringe metro. Thus, metropolitan counties as the difference between age 75 years and the midpoint of
were assigned to one of three metropolitan urbanization the age group. For the eight age groups, the midpoints are
levels: (a) large central—counties in large (1 million or more 0.5, 7.5, 19.5, 29.5, 39.5, 49.5, 59.5, and 69.5. For example,
population) MSA/PMSAs that contain all or part of the largest the death of a person 15–24 years of age counts as 55.5
central city of the MSA/PMSA; (b) large fringe—counties in years of life lost. Years of potential life lost is derived by
large (1 million or more population) MSA/PMSAs that do not summing years of life lost over all age groups. In Health,
contain any part of the largest central city of the MSA/PMSA United States, 1995 and earlier editions, YPLL was presented
(counties in a few PMSAs with less than 1 million population for persons under 65 years of age. For more information, see
were assigned to the large fringe urbanization level because Centers for Disease Control. MMWR. Vol 35 no 25S, suppl.
the PMSA in which they are located is adjacent to a large 1986.
central county of the CMSA); and (c) small—counties in small
(less than 1 million population) MSA/PMSAs.
The Urban Influence code system divides nonmetropolitan
counties into seven categories based on adjacency to a
metropolitan area and size of the largest city. A county is
considered to have a city with a specified size if it includes
all or part of the city. The seven categories were collapsed
into two categories: (d) nonmetro counties with a city of
10,000 or more population and (e) nonmetro counties without
a city of 10,000 or more population.
Usual source of care—Usual source of care was measured

in the National Health Interview Survey (NHIS) in 1993 and
1994 by asking the respondent ‘‘Is there a particular person
or place that ____usually goes to when ____is sick or needs
advice about ___health?’’ In the 1995 and 1996 NHIS, the
respondent was asked ‘‘Is there one doctor, person, or place
that ____usually goes to when ____is sick or needs advice
about ____health?’’ Starting in 1997 the respondent has been
asked ‘‘Is there a place that ____usually goes when he/she is
sick or you need advice about (his/her) health?’’ Persons who
report the emergency department as their usual source of
care are defined as having no usual source of care in this
report.
Wages and salaries—See Employer costs for employee

compensation.
Years of potential life lost—Years of potential life lost

(YPLL) is a measure of premature mortality. Starting with
Health, United States, 1996–97, YPLL is presented for
persons under 75 years of age because the average life
expectancy in the United States is over 75 years. YPLL-75 is
calculated using the following eight age groups: under 1 year,

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Pastor PN, Makuc DM, Reuben C, Xia H.

Chartbook on Trends in the Health of Americans.

Health, United States, 2002. Hyattsville, Maryland:

National Center for Health Statistics. 2002.

Library of Congress Catalog Number 76–641496

For sale by Superintendent of Documents

U.S. Government Printing Office

Department of Health and Human Services

Centers for Disease Control and Prevention

National Center for Health Statistics

Racial and Ethnic Data

Appendix II is an alphabetical listing of terms used in the report.

(table VIII); and sample tabulations of NHIS data comparing the

the Health, United States home page and CD-ROM,

described below under Electronic Access.

iv Chartbook on Trends in the Health of Americans Health, United States, 2002

Chartbook on Trends in the Health of Americans Health, United States, 2002 v

Gibson, Leslie Greenwald, Helen C. Lazenby, Katharine R.

vi Chartbook on Trends in the Health of Americans Health, United States, 2002

II. Definitions and Methods . . . . . . . . . . . . . . . . . . . . 110

List of Chartbook Figures. . . . . . . . . . . . . . . . . . . . . . . . viii

Geographic Regions and Divisions of

Health Care Utilization and Resources . . . . . . . . . . . . . . 7

Health Care Expenditures . . . . . . . . . . . . . . . . . . . . . . . 9

Chartbook on Trends in the Health of

Race and Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Health Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . 28

Preventive Health Care . . . . . . . . . . . . . . . . . . . . . . . . . 32

Child Limitation of Activity . . . . . . . . . . . . . . . . . . . . . 36

Adult Limitation of Activity . . . . . . . . . . . . . . . . . . . . . 38

Chronic Health Conditions . . . . . . . . . . . . . . . . . . . . . 40

Child and Young Adult Mortality . . . . . . . . . . . . . . . . . 47

Adult Mortality: 25–44 Years of Age . . . . . . . . . . . . . . 49

Adult Mortality: 45–64 Years of Age . . . . . . . . . . . . . . 51

Adult Mortality: Elderly . . . . . . . . . . . . . . . . . . . . . . . . 53

Data Tables for Figures 1–28 . . . . . . . . . . . . . . . . . . . . . 54

List of Chartbook Figures

List of Chartbook Figures Limitation of Activity

Health, United States, 2002 3

Morbidity Syphilis facilitates transmission of HIV disease. The

4 Health, United States, 2002

Health, United States, 2002 5

Suicide rates rose through 1980 and have since declined

slightly. HIV disease was the leading cause of death in this

age group in the mid-1990s; with decreasing HIV disease

death rates, it dropped to the fifth leading cause of death in

1999 (figures 23 and 24).

decreased by nearly 50 percent overall. During this period

decreased while cancer mortality rose slowly through the

1980s and then declined. Cancer is the leading cause of

of deaths in this age group in 1999 (figures 25 and 26).

until 1995 and has since decreased slightly (figure 27).

groups. In 1990 life expectancy at birth was 7 years longer

difference had narrowed to 5.9 years and by 2000, to 5.6

Despite overall declines in mortality, racial and ethnic