CHAPTER X
Statistical Reports and Projects, 1932-57
In order for the data on Army health and Army Medical Service operations, or for any data, to achieve their full intended usefulness, they must reach those for whose use they are intended. This requires a logical and well-planned system of publication and distribution.
Medical statistical information in the Army has traditionally been made available to potential users in three principal ways. The first and perhaps most important of these methods is that of inclusion of yearly data tables derived from tabulation of the individual medical records and their corresponding analyses and interpretation in the annual reports of The Surgeon General. The second means is the regular weekly and monthly transmission of current data derived from the summary statistical reports to The Surgeon General, key officials in his office, and other major headquarters. The third technique of dissemination of this information is compliance with day-to-day inquiries and requests for special data and analyses which may entail the use of either summary report statistics or individual record data or both. Such special requests stem from a wide variety of sources including the other operating divisions of the Office of the Surgeon General; Army, Navy, and Air Force offices; members and committees of the Congress and other U. S. Government agencies; medical research workers; and commercial enterprises, such as equipment and drug manufacturers, insurance companies, and news agencies.
REPORT OF THE SURGEON GENERAL
The past 25 years have seen many modifications in the details of the implementation of these methods of getting the data to the users, but the basic pattern has not changed in any
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important respect. Some reference has already been made to the difficulties encountered during World War II and in the postwar years in obtaining the support necessary for the production of the statistical data necessary for the annual reports. A principal difficulty was the loss of direct control over the essential tabulating resources which occurred when, toward the end of 1943, the machine records unit of the Medical Statistics Division was combined with the recently established machine activity of the Supply Division. This placed the Medical Statistics Division in the position of having to compete for tabulating priority with current and frequently urgent supply information requirements. As a result, the full-scale comprehensive and detailed individual medical records tabulations of the type needed for annual reports preparation and for long-range planning were never accomplished during World War II.
It might be said that the necessity of competing for tabulating priority was extremely unfortunate for the medical statistics program and for the Army Medical Service. It seems inconceivable at this time that a situation should ever arise in which such competition with supply or with fiscal accounting must be a consideration. It would be only by a most rare and fortuitous combination of circumstances that all of the individuals involved in resolving such a problem of priority would have the vision, the judgment, and the perspective required to arrive at the right, in contradistinction to the expedient, solution. This stems from the elements of intangibility and often deferred benefits which are an inherent part of the medical statistics process. At the moment when a priority decision is required, medical statistics may well seem much less urgent and much less important than 10 carloads of medical supplies, or the payment of 50 vouchers, or the detailing of a $1 million segment of a budget request. This can be a narrow and dangerously fallacious view, and the action to which it leads amounts to dipping into the capital fund for operating expenses. While the occasions for dramatic single instances of use of medical statistics may be fewer, the whole general level of quality of medical service policy and operating decisions is affected by the continuous flow and availability of adequate quantitative facts about medical service experience. When this flow is impeded or stopped, there is an insidious, but nonetheless real, deterioration of such evalutions, judgments, and decisions because they
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come to be more and more based on information which is no longer valid, on intuition, and on guesswork. The solution of choice is, of course, to take the necessary actions to insure that there is adequate support for both kinds of tabulating programs.
As has been stated, it was not until the end of World War II that the Machine Records Branch was restored to the Medical Statistics Division. The division was then faced with the task of tabulating some 20 million punchcards relating to World War II experience, to be followed by the analysis, interpretation, and preparation of this wealth of material for publication, in addition to the mission of continuing to provide adequate statistical support for current operations.
Before even an adequate beginning could be made on the task of liquidating this huge backlog, the economy coincident with the end of a war was instituted. Reductions in personnel and in funds for tabulating equipment rental were ordered which were presumed to be consistent with the then current size of the Army. However, the backlog to be dealt with in the Medical Statistics Division was one derived from a 7-million man force and could not be supported by a staff of a size appropriate for a force of 1.5 million. The division staff continued to be of a size generally sufficient to maintain an essentially current status in processing the weekly and monthly summary statistical reports on health and hospitalization; to code, on an appropriately adjusted sampling basis, the individual records more or less currently; and to comply, to the extent that data were available, with the daily inquiries and correspondence. The staff was not adequate, however, to complete the planned World War II and postwar tabulations nor to analyze, interpret, and prepare this virtually unique body of data for publication. The Medical Statistics Division, with its sharply limited resources, followed a mainly chronological pattern in its tabulation and analysis program.
After the outbreak of war in Korea, demands for statistical information increased manyfold. Many of the requests were of the kind which could be answered only from tabulations of the individual medical record punchcards. Although some increases in personnel for the division were authorized, they were occupied with increases which had already occurred in the current workload. Little was able to be done, therefore, to improve the backlog situation. It was decided that abandonment
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of the straight chronological pattern of individual medical record tabulation was now essential, regardless of the effect this might have on the ultimate completion of tabulation and analysis of the World War II data. Appropriate steps were taken to attain and maintain a current status, and the calendar year 1950 was chosen as the start of the 'current era' for tabulations. The current year's tabulations were done currently, with the backlog considered as a separate workload entity to be reduced bit by bit as available time and personnel permitted.
In the immediate post-Korea period, The Surgeon General, aware of the usual retrenchment coincident with the end of a war and cognizant of the effects such action had had on the medical statistics program after World War II, appointed a committee to make a thorough review and evaluation of the medical statistics program and its requirements for personnel. This committee was composed of the comptroller of the Office of the Surgeon General, the chief of the Medical Plans and Operations Division, the assistant program coordinator, and the chief of the Medical Statistics Division. Its purpose was to make a thorough analysis of the mission and the functions of the division and each of its component parts; to determine whether or not each report monitored by the division was essential; to establish whether or not the processes and procedures employed by the division were efficient and economical; and finally to set firm and justified personnel requirements for performing the current work on a current basis and in this way to identify automatically that portion of the staff which could be considered as presently available to work on reduction of the backlog. A careful estimate was to be made of the number of man-months required to complete each portion of the backlog. A fulltime staff of officers was assigned to the committee to assist in the fact-finding phase of its task. About 15 months were spent by the committee in carrying out its mission, and its final report was approved by The Surgeon General, becoming the official policy guidance document in this field. Reductions in civilian personnel did become necessary to meet limitations imposed by the Department of the Army. The basic staff for current operations was unaffected, but the time required for the liquidation of the backlog was, in effect, extended by a fairly accurately predictable amount of time.
In June 1955, work was completed on a volume entitled
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'Medical Statistics of the United States Army-Calendar Year 1953-Annual Report of The Surgeon General.' This represented the long-planned and anticipated resumption of the series of annual reports which was suspended after publication of the report for fiscal year 1941 containing the statistics for calendar year 1940. In 1956, the second in the newly resumed series of annual reports of The Surgeon General on medical statistics of the Army, that for the calendar year 1954, was published, and the report for 1955 is now (1957) nearing completion. It is to be hoped that the series can be continued without interruption and that the plan which has been devised for dosing the earlier gap can be successfully carried through. This plan contemplates coverage of 1943-45 in two volumes of the Medical Department History of World War II, a one-volume summary of 1946-49, and a two-volume presentation of the statistics of the period of the Korean War, 1950-53. As of this writing (1957), limitations on personnel and funds have again slowed progress on the completion of these volumes.
CURRENT SUMMARY REPORTS
In the area of prompt and timely distribution of summary report data, the experience has been considerably more favorable. From 1932 through 1940, the summary statistical information was distributed as a monthly mimeographed report which included strengths, number of admissions, admission rates per 1,000 strength per year, and comparisons of the current rates with the corresponding rates for the previous month and for the same month in the preceding year. This information was shown by station, for the United States and for overseas. Data were also provided on days lost and the noneffective rate for the current month. Certain information on deaths by cause was also included. For some periods during this time, a limited number of items of dental statistics and veterinary statistics were also shown.
By the beginning of 1941, it was recognized that the operating needs incident to rapid expansion and change in the Army could not be adequately met by only monthly dissemination of health and hospitalization statistics. Starting in January 1941, the monthly report was replaced by the summary of the weekly
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statistical report. In addition to the change in the period covered, from month to week, several substantive changes were introduced. This report was confined in geographic coverage, to the United States, with a breakdown by corps area and station. The rates were expressed in terms of "per 1,000 per week" in lieu of 'per 1,000 per annum.' Information was added on the acute respiratory diseases and on the venereal diseases, and shortly afterwards scarlet fever, measles, mumps, and pneumonia were also added. Data on the numbers of vacant beds were shown, and from time to time graphs were appended to this report, indicating trends of incidence for specific diseases or disease groups. From 1941 until the present (1958), some form of weekly report has continued to be provided. Since the middle of 1943, the health data have been published separately from the hospitalization data, with each of these weekly reports being more definitively tailored to the interests and the requirements of their slightly different lists of users.
In 1943, the Army Service Forces, War Department, began publication of the Monthly Progress Report, consisting of several separately bound sections. Section 7 was titled 'Health' and was intended to provide background information and guidance, on the most current basis possible, to the war planners, commanders, and surgeons. Special analyses were presented on battle casualties, replacements, and rotation; the cold injury experience was described, and preventive measures were discussed; and recurring tables were shown on admissions for disease and injury and on hospitalization in the Zone of Interior and overseas, with particular emphasis on the utilization of beds. The official distribution of this report, which was published until May 1946, included the Secretary, the General and Special Staffs, the Administrative and Technical Services, the Army Air Forces, the Army Ground Forces, each of the overseas commands, and some six other U. S. Government agencies. When the Monthly Progress Report series was abolished in 1946, The Surgeon General retitled what had been Section 7 as 'Health of the Army' and, with certain relatively slight changes in format and design, continued it as a publication of the Office of the Surgeon General.
After the beginning of the Korean War, the Department of
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the Army reinstituted an Army Progress Report series and, in April 1951, Health of the Army became section 11-B of that series. After the truce in Korea, a decision was made that the progress report components would be published only on a quarterly basis. Therefore, beginning in November 1953, Health of the Army was published as a monthly report of the Office of the Surgeon General, and a separate modified and somewhat curtailed quarterly format was provided for publication as the continuation of section 11-B of the Army Progress Report series.
Since 1947, Health of the Army has included in its May issue, each year, a statistical review of the admission and disease incidence experience for the preceding calendar year, based on summary report data.
At the present time (1958), a typical issue of Health of the Army contains a lead article presenting data, analysis, and interpretation on a topic of particular current interest or concern; a brief description and analysis of current experience and trends in admissions, noneffectiveness, hospitalization, and mortality; and recurring tables on morbidity by diagnostic class and installation in the United States, patient flow by command and installation, morbidity among Army personnel, worldwide by command for the preceding month, and admission and death rate for disease and nonbattle injury by overseas command.
SPECIAL PROJECTS
In addition to the operations just described, several activities were undertaken by the Medical Statistics Division as the need arose. During World War II, the chief and other Division representatives traveled to all the theaters of operations and to most of the Zone of Interior installations. In the spring of 1953, the chief of the Medical Statistics Division was requested by the Surgeon of the Eighth U. S. Army in Korea to make an official visit to that area to review and render advice on medical records and reports. In the course of this review, which covered recording and reporting in Korea, Japan, and Hawaii, at all levels from battalion aid station to general hospitals, in both combat- and garrison-type situations, the need for improved training of registrars and enlisted medical records personnel was again made evident. A series of long-range plans
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were subsequently undertaken in an attempt to effect improvement. In 1956, the Medical Statistics Division planned and conducted an Institute for Registrars which was held at the Walter Reed Army Institute of Research and was attended by registrars from hospitals and headquarters all over the world. This was a part of the general plan to improve the quality of performance of the registrar's essential part of the functioning of the medical statistics program. Work was also continued on the development of a program of instruction for a course specifically intended for the training of registrars, which, it was hoped, could be instituted at the Army Medical Service School at Brooke Army Medical Center. At the time of this writing (1957), this is much closer to being a reality, the program of instruction has been completed and is being forwarded for approval to the Continental Army Command.
Another procedure which had important workload implications for the Medical Statistics Division resulted from the Dependents Medical Care Act (Public Law 569, 84th Congress) which went into effect in December 1956. For many months before this effective date, several members of the Division staff had been closely involved in the intensive program of developing and planning the detailed procedures by which the act might be efficiently implemented. Special attention was given the design of the voucher form which would serve both as a statistical record and as a basis for payment to the civilian physicians and hospitals from which care of authorized dependents had been procured; in the selection, design, or adaptation of codes and classifications for types of personnel, categories of care, diagnoses, and surgical operations; and in the development of the tabulating and accounting plans, since it had been decided that the Machine Records Branch would provide the electrical accounting machine and tabulating support for the newly established Office for Dependents Medical Care in the Office of the Surgeon General.
In 1956, a project was culminated, which, for 9 or 10 years, had been requiring time and effort of personnel of the Division. The Army Regulations were published, under which there would be instituted in the Army, on 1 January 1957, a system of individual continuous health records for active-duty military personnel. The system, which had been long and carefully
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planned, may perhaps best be understood by consideration of the manner in which it works for a man newly entering the Army. At entrance into the Army, a health record folder is initiated for the man, which contains the record of his entrance medical examination. From this point on, a record of every event which is relevant to his medical and dental history and status is included; every immunization, outpatient visit, episode of hospitalization, or examination is made a part of the record and is thus available to the medical or dental officer called on to treat the individual and to those concerned with the evaluation of his physical status, with decisions as to retention or separation, and with the adjudication of claims.
The health record system went into full operation with the beginning of 1957; and now, alter going through the period of its greatest workload impact and more than half a year of normal operation, it has been gratifying to observe that the forecasts of its opponents, regarding confusion, disruption, and excessive workloads, were in error. It is probable that, after the system has been in operation for a time, these records will provide an important basis for medical and related research.
