EPA-600/1-78-030
May, 1978
Environmental Health Effects Research Series
USE OF EMERGENCY ROOM PATIENT POPULATIONS
IN AIR POLLUTION EPIDEMIOLOGY
Health Effects Research Laboratory
Office of Research and Development
U.S. Environmental Protection Agency
Research Triangle Park, North Carolina 27711
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RESEARCH REPORTING SERIES
Research reports of the Office of Research and Development, U.S. Environmental
Protection Agency, have been grouped into nine series. These nine broad cate-
gories were established to facilitate further development and application of en-
vironmental technology. Elimination of traditional grouping was consciously
planned to foster technology transfer and a maximum interface in related fields.
The nine series are:
1. Environmental Health Effects Research
2. Environmental Protection Technology
3. Ecological Research
4. Environmental Monitoring
5. Socioeconomic Environmental Studies
6. Scientific and Technical Assessment Reports (STAR)
7. Interagency Energy-Environment Research and Development
8. "Special" Reports
9. Miscellaneous Reports
This report has been assigned to the ENVIRONMENTAL HEALTH EFFECTS RE-
SEARCH series. This series describes projects and studies relating to the toler-
ances of man for unhealthful substances or conditions. This work is generally
assessed from a medical viewpoint, including physiological or psychological
studies. In addition to toxicology and other medical specialities, study areas in-
clude biomedical instrumentation and health research techniques utilizing ani-
mals — but always with intended application to human health measures.
This document is available to the public through the National Technical Informa-
tion Service, Springfield, Virginia 22161.
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EPA-600/1-78-030
May 1978
USE OF EMERGENCY ROOM PATIENT POPULATIONS
IN AIR POLLUTION EPIDEMIOLOGY
By
John R. Ward and Demetrios J. Moschandreas
GEOMET, Incorporated
15 Firstfield Road
Gaithersburg, MD 20760
Contract No. 68-02-2205
Project Officer
Carl G. Hayes
Population Studies Division
Health Effects Research Laboratory
Research Triangle Park, N.C. 27711
U.S. ENVIRONMENTAL PROTECTION AGENCY
OFFICE OF RESEARCH AND DEVELOPMENT
HEALTH EFFECTS RESEARCH LABORATORY
RESEARCH TRIANGLE PARK, N.C. 27711
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DISCLAIMER
This report has been reviewed by the Health Effects Research
Laboratory, U.S. Environmental Protection Agency, and approved
for publication. Approval does not signify that the contents
necessarily reflect the views and policies of the U.S. Environmental
Protection Agency, nor does mention of trade names or commercial
products constitute endorsement or recommendation for use.
ii
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FOREWORD
The many benefits of our modern, developing, industrial society are
accompanied by certain hazards. Careful assessment of the relative
risk of existing and new man-made environmental hazards is necessary
for the establishment of sound regulatory policy. These regulations
serve to enhance the quality of our environment in order to promote the
public health and welfare and the productive capacity of our Nation's
population.
The Health Effects Research Laboratory, Research Triangle Park,
conducts a coordinated environmental health research program in toxicology,
epidemiology, and clinical studies using human volunteer subjects.
These studies address problems in air pollution, non-ionizing
radiation, environmental carcinogenesis and the toxicology of pesticides
as well as other chemical pollutants. The Laboratory participates in
the development and revision of air quality criteria documents on
pollutants for which national ambient air quality standards exist or
are proposed, provides the data for registration of new pesticides or
proposed suspension of those already in use, conducts research on
hazardous and toxic materials, and is primarily responsible for providing
the health basis for non-ionizing radiation standards. Direct support
to the regulatory function of the Agency is provided in the form of
expert testimony and preparation of affidavits as well as expert advice
to the Administrator to assure the adequacy of health care and surveillance
of persons having suffered imminent and substantial endangerment of
their health.
The project described herein was a study of the feasibility of
utilizing the frequency of hospital emergency room visits as a health
end point in epidemiologic studies of air pollutants. Preliminary
field testing of the methodology raised serious questions concerning
the utility of this approach.
F. G. Hueter, Ph. D.
Acting Director,
Health Effects Research Laboratory
iii
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TABLE OF CONTENTS
Page
INTRODUCTION AND SUMMARY 1
PART I - METHODOLOGY FOR INVESTIGATION OF HEALTH EFFECTS 6
1.0 PURPOSE AND OBJECTIVES 6
2.0 BACKGROUND AND RATIONALE 8
3.0 PILOT STUDY DESIGN AND CONDUCT 16
3.1 Summary of Design Concepts 16
3.2 Conduct of the Field Test 18
4.0 RESULTS FROM THE FIELD TEST 23
4.1 Emergency Room Utilization Patterns 23
4.2 Evaluation of Medical Record Data 37
4.3 Evaluation of Followup Procedures 44
5.0 SUMMARY AND CONCLUSIONS 57
6.0 REFERENCES 61
PART II - METHODOLOGY FOR MAPPING OF AMBIENT OZONE CONCENTRATIONS 62
1.0 INTRODUCTION 62
2.0 THE PROBLEM 63
3.0 DISCUSSION OF OPTIONS, CHOICE, AND REASONS 67
3.1 Time Periods 68
3.2 Ozone Concentrations 68
3.3 Geographic Zones 70
4.0 MONTH-BY-MONTH ANALYSIS 76
4.1 The Riverside-Corona Monitoring Stations 76
4.2 Inclusion of Data from the Magnolia Monitoring Station 101
5.0 DISCUSSION AND CONCLUSIONS 105
6.0 REFERENCES 112
APPENDIX A - Protocol for Pilot Study Data Collection and Coding
APPENDIX B - Computer Model and Output for Ozone Concentration Mapping
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INDEX OF FIGURES
Figure
PART I
1 General Perspective of the Service Area and Community 20
PART II
1 The Riverside Metropolitan Area 64
2 The Metropolitan Riverside Area, the Two Geographic
Zones and the Wind Flow Pattern from the Santa Ana
Canyon 75
3 Distribution of Ozone Concentration for the "Night"
Hours During the Month of April 1975 77
4 Diurnal Variation of 03 Concentrations in Corona and
Riverside for April 20, 1975 81
5 Diurnal Variation of 03 Concentrations in Corona and
Riverside for April 29, 1975 82
6 Diurnal Variation of 03 Concentrations in Corona and
Riverside for April 30, 1975 83
7 Distribution of Ozone Concentration for the "Night"
Hours During the Month of May 1975 85
8a Computerized Wind Roses for May for Three Stations in
or Nearby the Northern Geographic Zone 90
8b Persistent Wind Direction for the Same Stations 90
9a Wind Rose for Corona During May 1975 91
9b Persistent Wind Direction for Corona During May 1975 91
10 Typical Diurnal 03 Concentration Variations for the
Three Stations in the Northern Geographic Zone 93
11 Distribution of 03 Concentration Hourly Readings for
the "Night" Hours of June 1975 97
12 Distribution of Ozone Concentrations for the "Night"
Hours During the Month of July 1975 100
(Continued)
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INDEX OF FIGURES (Concluded)
Fi gure Page
13 The Riverside Metropolitan Area, the Three Geographic
Zones Indicated from the Applications of the Ozone
Concentration Gradient Procedure on Data from the
Three Local Monitoring Stations 103
14 Criteria Used in the Definition of the Ozone Levels
with Respect to Time, Concentration, and Space 106
15 Sample Output of the Hourly Ozone Concentrations During
the Month of May 1975 107
16 Literature Illustrations from Indoor/Outdoor Air
Pollution Relations 110
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I'NDEX OF TABLES
Table Page
PART I
1 Diagnoses and Complaints for Sample Selection 22
2 Total E.R. Arrivals by Day of the Week and Month of
E.R, Visit: Metropolitan Area Patients, Selected
Weeks, October 1974 Through August 1975 25
3 Total E.R. Arrivals by Age and Month: Riverside
and Other Metro Area Patients, Selected Weeks,
October 1974 Through August 1975 26
4 Selected Conditions, Number and Rate Per 100 Patients:
Riverside and Other Metro Area Residents, Selected
Weeks, October 1974 Through August 1975 29
5 Definitions of Diagnosis Groups Used in Analysis 30
6 Respiratory and Related Conditions by Age and Month,
Number and Rate Per 100 Patients: Metro Area Residents,
Selected Weeks, October 1974 Through August 1975 32
7 Respiratory and Related Conditions, Number and Rate Per
100 Patients: Riverside Residents, Selected Weeks,
October 1974 Through August 1975 34
8 Respiratory and Related Conditions, Percentage Distri-
butions by Month: Riverside Residents, Selected Weeks,
October 1974 Through August 1975 34
9 Summary Evaluation of Medical Record Data 39
10 Number of Times Certain Clinical Parameters Were
Recorded for Selected Diagnoses 43
11 Completion of Interviews by Month of Emergency Room
Visit 45
12 Interview Completion by Ethnic Group 46
13 Interview Completion by Age of Patient 46
(Continued)
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INDEX OF TABLES (Continued)
Table Page
14 Interview Completion by Number of Telephone Calls
Made 47
15 Time for Interview 48
16 Respondent for Completed Interviews 48
17 Comparison of Complaints and Duration of Symptoms
from Patient Interview with Those from E.R. Record:
Respiratory Conditions 49
18 Usual Activity by Presence of Activity Limitation 52
19 Degree of Activity Limitation Associated With Reported
Respiratory Conditions 52
20 Outdoor Exposure Prior to Symptom Onset, for Patients
Reporting Respiratory Symptoms 53
21 Outside Exposure Prior to Symptom Onset, Patients With/
Without Chronic Limitation 53
22 Place of Work for Employed Patients 54
23 Time of Day for Work, Employed Patients 54
24 Usual Work Site, Employed Patients 54
25 Round Trip Commuting Time, Employed Patients 56
26 Extreme Exposure Conditions In Occupational Environ-
ment, Employed Patients 56
PART II
1 Total Days and Hours > 0,20 ppm of Ov, 1975-1970, for
Riverside * 69
2 Ozone Concentration Difference Between Corona and
Riverside for Days with Difference >_ 5 pphm; April 1975 ''
3 The Advection Number for Corona and Riverside for the
Month of April 1975 79
(Continued)
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INDEX OF TABLES (Concluded)
Table Page
4 Hourly Difference of Ozone Concentration from the
Monitoring Stations of Corona and Riverside for
Type II Days During the "Day" Hours of April 1975 80
5 Distribution of the Difference Between the Average
Representative 03 Concentration Value and Hourly
Values from the Corona and Riverside Monitoring Stations
for Type I Days During the "Day" Hours of April 1975 84
6 Ozone Concentration Difference Between Corona and
Riverside for Days with Difference Greater or Equal to
5 pphm; May 1975 86
7 The Advectlon Numbers for Corona and Riverside for the
Month of May 1975 88
8 Hourly Difference of Ozone Concentrations from the
Monitoring Stations of Corona and Riverside for Type II
Days During the "Day" Hours of May 1975 89
9 Distribution of the Difference Between the Average
Representative 03 Concentration and Hourly Values from
Chlno, Riverside and Redlands Monitoring Stations for
Type III Days for the Month of May 1975 95
10 Distribution of the Difference Between the Average
Representative 03 Concentration Value and Hourly
Values from the Corona and Riverside Monitoring
Stations for Type I Days During the "Day" Hours of
May 1975 96
11 Days and Hours During Which the Difference Between the
Respective Hourly 03 Concentration Readings from
Corona and Riverside Exceed + 5 pphm for the "Day"
Hours of June 1975 98
12 The Advectlon Numbers for Corona and Riverside for
the Month of June 1975 99
13 Monthly Distribution of Types of Days In the RMA 104
1x
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ACKNOWLEDGEMENTS
The authors are appreciative of the advice and assistance
received from the following individuals and organizations:
• Riverside General Hospital
t Los Angeles Basin Air Pollution Control District
• Riverside Air Pollution Research Center
• Robert Zweig, M.D., Riverside County Medical Society
• Donald A. Cavallo, Riverside County Health Department.
We are also grateful to the original Project Officer, Mrs. Edythalena A.
Tompkins and her successor, Dr. James H. Stebbings for the opportunity to
examine some problems of interest.
Any errors in concept or presentation are the responsibility
of the authors.
J.R. Ward
D.J. Moschandreas
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INTRODUCTION AND SUMMARY
This is the final report on work accomplished under EPA Contract
Number 68-02-2205, entitled "Effect of Short-Term Exposure to Indicated
Emergency Levels of Ozone on Human Morbidity." The long-term objective of
this project was the design and implementation of a particular epidemi1-
ological approach to investigation of ambient pollutant effects: the
correlation of pollutant exposure with patterns of hospital emergency room
utilization. Results from a preliminary field test of the methodology
raised serious questions concerning the hypothesized cost and effectiveness
of the proposed approach - subsequently, work was terminated.
The report covers the initial phase of development and pilot
studies. Separate discussions are provided on the two major components of
the methodology: investigation of health effects and estimation of ambient
ozone concentrations. A summary of the research is presented in the para-
graphs that follow.
Investigation of Health Effects
The approach to study of adverse health effects was premised on
the assumption that an increase in community morbidity due to environmental
air pollution would be reflected in emergency room patient populations.
Proposed measures of this "effect" were changes in the number, proportion
or severity of selected health conditions seen that corresponded with the
prior occurrence of high ambient ozone concentrations. The conditions
chosen for study were those which might result from either direct (Irri-
tative, biochemical) or indirect (stress) actions of ozone. The degree
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of change would be measured from a baseline determined after controlling
for seasonal, day-of-the-week and other typical sources of variation.
Lag time between exposure and response, and the measure of average or peak
exposure, were to be treated as experimental variables in the analysis.
Patterns of emergency room utilization are influenced by many
forces that are associated with facility characteristics, competing health
services, and the responses of different patient groups to specific ill-
ness. In addition to fluctuations in community morbidity, these patterns
may vary independently from facility to facility and from time to time.
These factors combine to obscure the potentially small perturbation due
to ozone effects that might be present, thus substantially elevating the
relative risk of Type II error over a more controlled epidemiological
approach. This risk indicated that.-the design must emphasize precision
and cost-efficiency if it was to be advantageous.
For the preliminary field test, data were collected on patients
seen at a county hospital which served as an areawide source of both
emergency care and routine primary care. Matching seven-day periods were
selected from every other month for October, 1974 through August, 1975.
The emergency room log provided basic data for analysis of utilization
patterns. In addition, small patient samples were drawn from the log to
evaluate medical record abstracting and telephone followup procedures.
In reviewing results from the pilot study a number of problem
areas were highlighted:
1. Differences in utilization patterns among the groups
seeking care at the study facility that complicate their
relationship with community incidence of illness.
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2. Difficulty in categorization of presenting health
problems in a manner which would achieve both pertinent
representation of incidence and adequate sample size.
3. Insufficient clinical data to support resolution of
diagnostic category and grading of severity.
4. Number of potentially important subclassifications of
patients that may require separate attention in the
analysis.
5. Difficulty in establishing the timing of symptoms
relative to variation in ozone exposure levels.
On the positive side, the telephone interview was considered a useful tool
for defining the patient's basic health status and exposure conditions.
Many of the technical problems explored are not unique to this
approach, but could be better controlled through direct, continuous sur-
veillance of a selected study population. It was judged that expansion
to cover a number of emergency rooms and that prospective, detailed clinical
data collection were necessary to optimize the opportunity for detecting
pollutant effects by the proposed design. The increased complications and
cost resulting from these changes would tend to negate the possible advan-
tages of the original approach. Further, no factors were identified which
would reduce the considerable risk of the Type II error that is associated
with this design. Therefore it was concluded that further development of
the approach would be unprofitable and that it did not offer a useful
method for investigation of exposure-response associations.
Mapping of Ambient Ozone Concentrations
The mapping of ambient ozone concentrations in time and space
over the Riverside metropolitan area has been investigated using data
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from two monitoring stations located within the subject area. A pro-
cedure was developed for a month-by-month comparative study of the data.
The approach was based on the gradient of the hourly ozone concentrations
and defined three characteristic units:
1. Two time periods - the "day" or structured hours,
and the "night" or background hours;
2. Three types of "day" hours - Type I, II or III
depending upon the ozone concentration gradient
structures; and
3. Two geographic zones - the N-zone and the S-zone
identified for days with large differences in
hourly average ozone concentration at the two
monitoring stations.
Analysis showed that the Riverside area may be divided in time
and space zones for the study of pollutant concentrations. It should be
pointed out that previous research on the subject considers the Riverside
metropolitan area as one zone and utilizes average concentrations. Such
premises would not fulfil the requirements of the present study.
Even though the ozone concentration gradient approach was
designed to meet the specific needs of this study, the scheme developed
is general. Furthermore, the gradient approach is straight forward, inex-
pensive and as reliable as the widely used, more complex photochemical
models. It provides a time and space concentration grid without any
simulation, and relies on only the ozone concentration gradients from
the available monitoring data.
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The ozone concentration gradient approach has been tested with
data from a third monitoring station located within the subject area. Two
conclusions have been reached from this "validation" effort:
1. The time and space grid developed from the two-
station data favorably agrees with the respective
divisions suggested by the inclusion of the third
monitoring station; and
2. The mechanism can be applied to more than two
stations, and naturally a given grid may be
expected from the inclusion of more monitoring
stations.
Details of this study appear in Part II of the report,
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PART I - METHODOLOGY FOR INVESTIGATION OF HEALTH EFFECTS*
Section 1.0
PURPOSE AND OBJECTIVES
This is the final report under Contract Number 68-02-2205,
"Effect of Short-Term Exposure to Indicated Emergency Levels of Ozone
on Human Morbidity." Part I presents the study rationale and the results
from a pilot test of procedures to measure health effects.
The general purpose of this project was to develop and test
a methodology which would evaluate possible associations between ambient
pollutant levels and utilization of medical care. More specifically,
the objective was to design a survey approach which would provide first-
order evidence of ozone-related morbidity and employ relatively low-cost
data collection.
The first phase was concerned with construction and limited
testing procedures. The field test was carried out to provide a pre-
liminary appraisal of overall technical utility, before proceeding on to
expanded phases of development and application. Appraisal of utility
primarily involved questions of sensitivity and specificity in correlating
adverse health effects with ambient ozone levels, given acceptable cost
and operational characteristics, when compared to methods that provide
for more direct surveillance of the exposed populations and for better
control of interfering variables.
Part I describes the first phase of methodology design and field
testing, excluding the approach to estimation of ambient pollutant levels
(covered in Part II). Based on observations from the field tests an
* Written by John R. Ward, M.S.P.H.
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appraisal was made of study procedures, of requirements for further
application, and of the potential for use in analysis of pollutant
effects.
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Section 2.0
BACKGROUND AND RATIONALE
Ozone (03) is the major component in a group of oxidants formed
through a complex photochemical process from the action of sunlight on
precursor agents, particularly those emitted in auto exhaust. This
process is dependent on sunlight intensity, duration of sunlight, and
air temperature. The amount of ozone is also dependent on the volume
and balance of coexisting components which act as generating or reducing
agents, as well as the usual meteorological and terrain factors which
affect atmospheric concentrations of gases.
Concentrations of photochemical oxidants that are currently
experienced during the summer months in many U.S. metropolitan areas
are thought to present a hazard to human health. Ozone has been impli-
cated primarily for its effect on structure and function of the respira-
tory system. Animal studies have shown fibrosis of lung tissue,
hemorrhaging, edema, and reduction in lung capacity. Other effects have
included histamine production, radiomimetic blood changes, and general
indications of stress.
Human studies have presented equivocal findings. Some respiratory
impairment has been observed at exposures approximating high ambient air
concentrations.2 Correlations with reduced performance of athletes and with
frequency of asthma attacks have been observed.3 In terms of morbidity sug-
gestive, but not definitive, correlations between ozone levels and frequency
of hospital admissions for "relevant" illnesses (respiratory, cardiovascular)
have been seen.4 03 exposure at ambient levels has also been associated with
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severity of symptoms.5 Other studies have not found an association with
increased admissions among patients with chronic illness, or with increased
absences from school due to respiratory illness.
In considering dose-response relationships, the available evi-
dence suggests that environmental ozone concentrations reach those required
to produce an observable acute reaction in the general population of the
area. However, there are a number of factors which complicate study of
dose-response through an epidemiological approach. Several of the most
significant factors concern type and degree of response.
Ozone acts directly on the human organism as a respiratory
irritant and secondarily through the stress of reduced pulmonary func-
tion. Individual sensitivity to these insults is considered to vary
measurably with age and health status. Thus the very young, the elderly,
and persons with asthma or infTarnation of the respiratory tract are thought
to be more vulnerable to irritant properties than healthy older children
and young adults. The stress of reduced pulmonary function is a definite
hazard to those persons with chronic obstructive lung disease, coronary
problems or other illnesses where this additional physiological burden
may exacerbate their condition. On the other hand, healthy persons may
suffer no more than discomfort at the exposure levels experienced. This
presents a wide spectrum of potential responses - from minor throat and
eye irritation to heart attack and severe respiratory distress. Measure-
ment of each type of response in turn has implications as to choice of the
appropriate study population, the means of response measurement, the lag
time for the response to occur, and control of confounding variables.
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A second set of complicating factors is related to the extent
and type of pollutant exposure. Outside the laboratory ozone will be
encountered in combination with many other agents producing similar human
responses to a greater or lesser degree. Those of main concern are Og
precursors and other byproducts of auto emissions such as nitrogen dioxide,
aldehydes and other photochemical oxidants, as these will occur simultane-
ously with ozone production. Additional common atmospheric pollutants
such as sulphur dioxide and respirable particulates might be minimized by
chosing study sites where these are not present in appreciable quantities
or by choosing seasons when these agents are close to background levels.
While carbon monoxide is not a respiratory irritant, this agent must also
be taken into account, along with smoking and the mix of home and work
exposures, in terms of the variation in continuous environmental insults.
Finally, unusual occupational extremes must be identified when attempting
to separate an association with ozone.
Three other aspects of dose are of particular concern. First,
the ambient concentration which produces any statistical significant
incidence of observable morbidity may be near the upper limits of environ-
mental levels found, based on the results from laboratory studies. Even
in such areas as the Los Angeles basin the number of days on which such
peaks are experienced is limited. This combination may hinder detecting
any increase in morbidity above normal incidence.
Second, little is known about the cumulative effects of persis-
tent daily peaks. One might hypothesize that the repeated stress of moder-
ate ozone maximum daily levels over a period of days might be as hazardous,
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or more so, than an extreme peak concentration on one day. In effect,
repeated exposure may shift the distribution of responses to increase
the frequency of the more severe reactions. Thus in relating illness
to pollutant levels, it appears advisable to account for exposure history
beyond the prior 24-hour period.
Third, there are serious questions regarding estimation of
effective exposure from air measurement network readings. This includes
the usual problems of determining the concentrations over areas between
measurement points of an unstable gas under varying wind speeds and
directions. Just as important is the degree of protection given by stay-
ing indoors. Thompson et al. have shown that ozone levels in an air
conditioned building may only reach half the outdoor concentration. Since
most persons spend much of their time indoors, and the presumably most
sensitive are routinely advised to stay inside during smog alerts, the
group of most susceptible individuals actually exposed to high concentra-
tions may be very small.
The factors discussed above suggest that a very large and/or
highly selective study sample is necessary for an epidemiological investi-
gation of ozone dose-response characteristics. They also dictate that
care must be taken in determining exposure history, symptoms and their
onset, baseline health status, and a number of concomitant variables that
may influence either exposure or response. This in turn implies a require-
ment for relatively high-cost studies, with a considerable degree of risk
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in achieving definitive results. However, since field studies under
natural conditions seem needed to better define the actual hazard posed,
alternative study approaches which might minimize cost relative to the
risk of achieving definite results should be examined.
One possibly useful methodology focuses on emergency room
patients. This has several potential advantages:
• The study population is readily identified
and a certain amount of pertinent data is
available.
0 Physician evaluation of the study subject's
condition is available.
0 A large proportion, perhaps the majority of
persons in the community with severe changes
in health status will be seen in emergency
rooms.
• Most emergency rooms now serve as a routine
source of 24-hour medical care for substan-
tial segemnts of a community, providing for
observation of a range of morbidity.
The key assumption here is that some representative proportion of at
least the more severe responses to pollution exposure will be seen in
emergency rooms. The cost of collecting basic data on response is low
and could be done retrospectively.
The risk is that any changes in the emergency room patient
population due to variations in ambient ozone concentrations may be too
small to discriminate from other forces that control emergency room
utilization, since only a small portion of the total community population
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affected will be seen. Further, even if a required sample size could be
calculated, the study sample is limited to the actual number of emergency
room arrivals and facilities in any particular geographic area. However,
in research previously cited, suggestive correlations were found between
hospital admissions and ozone levels. The emergency room population,
while excluding most elective admissions, should on the other hand provide
a broader study population base since patients in crisis who are either
admitted, or treated and discharged, will be included.
One or both of two changes in emergency room patients due to
ozone effects may be hypothesized:
• An increase in the number or proportion of
arrivals with possibly exposure-related
conditions (respiratory, coronary, etc.)
t A shift in severity of the cases seen, as
indicated by either diagnostic parameters
or the scope of care required.
Tests of either hypothesis are dependent on the quality of diagnosis and
the extent of the diagnostic data. If the medical record is used as the
data source, the completeness of documentation is also a factor.
It cannot be expected that medical charts will contain suffi-
cient information for assessing exposure to ambient or occupational pol-
lutants. While a quantitative estimate of the dose cannot be derived
with accuracy, nominal differences in the degree and type of exposure
should be identified for each patient. Remaining within a closed, air
conditioned building during the day may provide substantial protection
against effects of heat and ambient ozone levels. Continued significant
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occupational exposure may either potentiate or mask the effects of
ambient pollutants. Such patient subgroups should be treated separately.
To provide the required information it will be necessary to interview
the patient or a family member familiar with the situation around the
time of symptom onset.
An interview can also be a useful mechanism to collect details
on exposure, on socioeconomic characteristics missing from the medical
records, on symptom onset, and on the patient's condition prior to the
emergency room visit. The last two items are considered important for
several purposes. First, more complete and uniform information on timing
of symptoms and course of illness relative to exposure can be obtained.
Second, the degree of changes from baseline (usual) health status may
provide further measures of severity of the illness episode. Finally,
this information will provide some basis for identifying differences in
utilization patterns among health facilities and among socioeconomic
groups in the study community.
The interview could be conducted in the emergency room, on a
visit to the patient's home, or by telephone. Emergency room interviews
present logistical problems in that they may interfere with the care
process and an interviewer must be available around-the-clock to identify
and question selected patients. Household interviews are usually advan-
tageous in terms of volume of data and completion rate, but can be very
costly. Interviewing by telephone is dependent on the rate of success
in contacting a suitable respondent but is probably the most rapid and
least-cost approach for surveying a large group.
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In summary it was judged that attempts to design improved
methodology for population studies of pollutant effects should emphasize
three goals:
1. Minimization of data collection costs, in light
of the risk in achieving definitive results and
the large sample required.
2. Achievement of more precise and complete deline-
ation of variables defining patient characteristics,
exposure history, and health status.
3. Focus on dimensions of health effects in addition
to incidence of illness, such as variations in
course and impact of morbidity.
The design and preliminary testing of an approach to these goals is
presented in the following sections.
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Section 3.0
PILOT STUDY DESIGN AND CONDUCT
3.1 SUMMARY OF DESIGN CONCEPTS
The general concepts discussed in Section 2.0 were implemented
in a specific survey protocol. The designated target population was com-
posed of selected patients seen in a hospital emergency room and residing
within a defined service area. Initial selection was made retrospectively
by presenting complaint and/or diagnosis, and by place of residence. The
health problems used in selection were those which have been hypothesized to
be potential clinical manifestations from exposures to photochemical oxidants,
including both direct toxic reactions and secondary stress effects. Addi-
tional data on age, sex, and race were obtained from the log. The log
data then provided basic utilization statistics on emergency room use.
Distributions for the selected diagnoses and remaining arrivals were
examined to determine the stability of patterns and trends by season.
The total number of selected arrivals also served as the universe from
which to draw samples for record abstracts and patient interviews.
In the second stage of the protocol, data on patient charac-
teristics, clinical parameters, and disposition were abstracted from the
patient's chart for a sample of selected problems. This data was intended
for several purposes:
• To obtain more complete and accurate data on
demographic characteristics, complaints, and
diagnoses than appeared in the log
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• To provide indications of onset of symptoms
and severity of the illness at the time the
patient was seen
• To obtain information needed to contact the
patient for an interview.
A number, of parameters were included in the abstract which
might indicate severity of the patient's condition: nature of symptoms,
vital signs, physician's observations, values of particular diagnostic
tests, level of treatment provided, type of disposition from the emer-
gency room. If the data proved to be adequate, an objective classifica-
tion scheme could be worked out for each selected problem; otherwise
either physician judgment in each case or simple categories based on dis-
position would be necessary. Interpretation of patient status based on
procedures must be done with caution as these reflect individual hospital
policies and practices.
The third stage of the protocol called for interview of the
patient or a knowledgable respondent by telephone. Basic information
for tracing the patient was obtained from registration forms and other
records in the patient's chart and repeated attempts to contact a respon-
dent at home or work were made, following standard procedures. Much of
the interview focused on variables related to exposure: usual activity
patterns; conditions at home, work, or school; activities prior to onset
of symptoms; and length of residence. The second major topic concerned
questions about health status, including chronic illness and changes in
functional capacity after onset of symptoms. Still other items were
related to use of the emergency room.
-17-
-------
The data instruments and the detailed data collection procedures
used are provided in the appendix.
3.2 CONDUCT OF THE FIELD TEST
A field test was carried out during September-October 1975 with
the primary aim of evaluating the procedures presented in the appendix.
The specific purposes of the field test were to determine estimates of:
• Time, cost, and difficulty of data collection
• Availability of medical record data
• Success in obtaining interview data
• Utility of study concepts employed.
A key issue was the probable success of this approach in producing defini-
tive statements concerning human effects from short-term exposure, con-
sidering the relative cost of alternative approaches and the inherent
problems of detecting ozone-related effects in this target population.
3.2.1 Description of Study Site
The Riverside, California area, in the eastern portion of the
Los Angeles Basin, was selected for study. This area experiences some
of the highest seasonal ozone levels in the U.S., has a large population,
and is covered by a fairly comprehensive air quality monitoring network.
Riverside residents are also subjected to unusual exposure phenomena which
frequently sustain high ozone concentrations over the majority of daylight
hours. (The reader will find a detailed description of pollutant behavior
in Part II.) This area appeared to present suitable conditions for
-18-
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pursuing the project through pilot and feasibility studies to a fullr
scale investigation.
For the preliminary test of procedures, the cooperation of
Riverside General Hospital was sought. This facility is a 400-bed county
hospital with organized emergency and outpatient services. As the hospital
serves a large portion of the area's low-income population, which is usually
the most highly mobile, it was thought to provide the most difficult follow-
up conditions.
Copies of the emergency room log were secured for the seven-day
period beginning June 9, 1975 and used to analyze patient load, composition
and variations by time and day of the week. From this analysis a "Metropol-
itan Riverside" service area was defined which was expected to include about
80 percent of emergency room arrivals. A general perspective of the ser-
vice area and the community is presented in Figure 1.
3.2.2 Data Collection
A final version of the protocol was finished and field activities
were organized by the end of August. Two field staff were hired. One was
an experienced record analyst who was familiar with procedures at the study
hospital. The second was an interviewer who had supervised interviewing
staff in prior followup surveys.
Using photocopies of the emergency room log (with names deleted),
all patients with specific diagnoses (or specific complaints, if no diag-
nosis was listed) were marked for matching seven-day periods in every other
month, starting with October 1974 and ending with August 1975. Diagnoses and
-19-
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H: Riverside General-Hospital
: RGH Metro Service Area
: Riverside City Limits
IS Miles: Distance from Center of Riverside
Figure 1. General Perspective of the Service Area and Community
-20-
-------
complaints included are listed in Table 1. These specific times were
picked to represent each season of the past year and to standardize
emergency room utilization by day of the week. Log records were coded
for each case identified.
A systematic sample was chosen from the identified cases to pro-
vide 50 patients from each weekly period for medical record abstracting.
The quota of common diagnoses, such as upper respiratory infections, was
limited to allow the less frequent problems to enter the sample.
For a test of interview procedures, every other case in the
abstract sample was selected for the months of February, April, June,
and August of 1975. A reduced sample was used because of the time
requirements expects for this task. The time spread was picked to
investigate problems in recall and followup with elapsed time.
Further information on the procedures used is presented in
the appendix. The next section discusses results of the pilot study.
-21-
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Table 1. Diagnoses and Complaints for Sample Selection
Selected E.R. Diagnoses
Nervous System and Sense Organs
Respiratory System
Circulatory System
Gastrointestinal System
Other Selected Diagnoses
Eye Irritations, Conjunctivitis
Otitis Media*
Convulsive Disorders, Idiopathic Seizures
URI, Colds, Tonsillitis, Sinus, Allergy
Flu, Viral Syndrome*
Acute Bronchitis, Pneumonia, Pleurisy*
Asthma*
COPD, Chronic Bronchitis, Emphysema*
Cardiovascular Disorders
Cerebrovascular Disorders
Hypertension
Gastroenteritis, Gastritis
Ulcers (Upper GI)
Diabetes
Hepatitis, Hepatic Disorders
Psychiatric Disorders (Excluding O. D.)
Selected Symptoms Not Included with Above Diagnoses
Chills, Fever
Fatigue, Weakness, Fainting, Dizziness
Dehydration, Fluid Imbalance
Coma, Stupor, Unconciousness
Headache
Convulsions, Seizures
SOB, Breathing Difficulty, Hyperventilation
Chest Pain, Congestion, Cough
Sore Throat
Abdominal Pain, Cramps
Diarrhea, Nausea, Vomiting
Jaundice
Depression, Nerves, Abnormal Behavior
Epistaxis w/o Injury
* With or without URI.
-22-
-------
Section 4.0
RESULTS FROM THE FIELD TEST
4.1 EMERGENCY ROOM UTILIZATION PATTERNS
The emergency room log maintained by the study hospital was used
as the source of data for description of utilization patterns. For six
selected seven-day periods, all patients with certain diagnoses (or com-
plaints) and residing within the designated hospital service area, were
identified. The following log entries were then coded for each patient
identified:
• Month and day of the visit
• Whether discharged from the E,R. or admitted
to hospital
• Age, sex, and ethnic group
• Recorded complaints or problems and diagnoses
• City of residence.
Age and residence were coded also for the remaining patients. The log
data were tabulated to estimate the volume of patients available in each
diagnostic category and to identify significant daily and monthly varia-
tions in composition of the population seen.
One aim of the methodology is evaluating statistical associa-
tions between ambient 03 concentrations and the number and proportion
of patients seen with specific medical conditions. Variation in the
number of patients seen may reflect either fluctuations 1n incidence of
that condition among the service population or changes in size and/or
-23-
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composition of the population in the service area. The latter factors
may affect the number of susceptibles, the number using emergency rooms as
the source of care, or the number of cases with other medical conditions.
These are exogenous influences which may obscure patterns due to any
single specific cause. The degree of these changes and of their impact
on emergency room utilization cannot be conclusively determined from data
on patients seen. One is limited to assumptions that may be supported
by the analysis, and by general knowledge of the service area, as to the
importance of exogenous factors.
Tables 2 and 3 present distributions of total emergency room
arrivals (i.e., selected patients plus other patients). The last week in
each month has been chosen to control for any consistent variations within
months. In Table 2 the maximum difference in weekly totals is between
February (551) and August (622), representing a difference in average per
day of only 10 patients. The number of arrivals for each day of the week
is fairly consistent month-by-month, with the exception of those values
noted by an asterisk. If the exceptions are excluded, differences in the
adjusted averages among months are smaller. Also daily totals by day of
the week cluster more closely around the average. Usually Monday is the
busiest day of the week and Sunday the slowest. Based on the adjusted
averages, differences among months are not substantial.
In Table 3 total arrivals are distributed by age group and resi-
dence for each month. "Riverside" refers to that city while "Other Metro"
refers to other communities within the designated service area. The
-24-
-------
I
ro
en
Table 2. Total E.R. Arrivals by Day of the Week and Month of E.R. Visit: Metropolitan Area Patients,
Selected Weeks, October 1974 Through August 1975
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total
Average
Per Day
Adjusted
Average*
October
97
103*
75
83
80
87
65
t
590
84
81
December
110
89
46
96
83
80
73
577
82
82
February
106
71
99
83
90
79
23*
551
79
88
April
103
83
90
75
81
70
72
574
82
82
June
99
79
75
78
68*
101*
76
576
82
79
August
108
73
92
108*
89
75
77
622
89
86
Total
623
498
477
523
491
492
386
Average
Per Day
104
83
80
87
82
82
64
Adjusted
Average*
104
79
80
83
85
78
73
* Days marked with asterisk excluded in adjusted average.
-------
Table 3. Total E.R. Arrivals by Age and Month: Riverside and Other Metro Area Patients, Selected Weeks, October 1974 Through August 1975*
Riverside
Month
October
Decembei
February
April
June
August
Total
Average
by Age
Range
Under 2
Number
25
26
31
13
20
21
136
23
13-31
Percent
5.3
5.4
6.5
2.7
4.2
4.1
4.7
2-5
Number
18
20
33
14
18
23
126
21
14-33
Percent
3.8
4.2
6.9
2.9
3.8
4.5
4.3
6-17
Number
76
70
77
82
65
68
438
73
65-82
Percent
16.0
14.6
16.0
17.1
13.7
13.2
15.1
18-44
Number
251
271
235
258
280
290
1585
264
235-290
Percent
52.7
56.3
49.0
53.7
59.1
56.4
54.6
45-64
Number
76
64
70
81
58
84
433
72
58-84
Percent
16.0
13.3
14.6
16.9
12.2
16.3
14.9
65+
Number
30
30
34
32
33
28
187
31
28-34
Percent
6.3
6.2
7.1
6.7
7.0
5.4
6.4
Total
Number
476
481
480
480
474
514
2905
484
476-514
Percent
100.0
100.0
100.0
100.0
100.0
100.0
100.0
Other Metro Area
October
December
February
April
June
August
Total
Average
by Age
Range
4
12
9
6
5
5
41
7
4-12
3.5
12.9
12.7
6.5
5.3
4.8
7.2
8
5
4
4
7
8
36
6
4-8
7.0
5.4
5.6
4.3
7.4
7.7
6.3
20
8
9
15
14
19
85
14
8-20
17.5
8.6
12.7
16.3
14.7
18.3
14.9
66
54
39
47
53
58
317
53
39-66
57.9
58.1
54.9
51.1
55.8
55.8
55.7
14
12
8
14
10
8
66
11
8-14
12.3
12.9
11.3
15.2
10.5
7.7
11.6
2
2
2
6
6
6
24
4
2-6
1.8
2.2
2.8
6.5
6.3
5.8
4.2
.
114
93
71
92
95
104
569
95
71-114
100.0
100.0
100.0
100.0
100.0
100.0
100.0
I
ro
o\
i
* Excludes 16 unknown ages.
-------
classification is based on the postal address. For Riverside residents
only the month of August is exceptional in overall utilization. The
variation among months seen in Table 2 is accounted for largely by fluc-
tuations in numbers of "Other Metro" residents. Within age groups there
are notable differences in the number of patients by month but differences
in percent of total arrivals are remarkable only for "Other Metro" patients.
This cursory review suggests that there is a fairly stable ser-
vice population of Riverside residents. This is consistent with the
observations that this public hospital serves as a major source of care
for area low-incomd residents and that access to outpatient clinics is
through the emergency room. There are competing sources of care for
patients residing on the fringes of the service area so that there may be
more selectivity in use of care facilities.
If these interpretations are correct, they have three important
implications. First, fluctuations in use by Riverside residents may reflect
incidence of medical conditions - which benefits the study approach. Second,
use by "Other Metro" residents indicates that competing sources of care -
emergency rooms and perhaps other primary care facilities - would have to
be included in the study in order to detect the effects of ambient oxidant
levels on these groups. Finally, the small differences in utilization by
Riverside residents from month to month and season to season, implies that
measure of oxidant effects may likely depend on the occurrence of sufficient
proportional changes among diagnoses and/or in severity or other perhaps
subtle characteristics of the patient's condition, as opposed to a substantial
-27-
-------
increase in relevant conditions following high 03 levels. To explore
the last point, the tables following present data on diagnostic distri-
butions.
Table 4 shows the number of cases seen by month of the conditions
selected as possibly relevant for detection of 63 effects. (H-ICDA codes
included in each condition group are given in Table 5). The rate per
100 total arrivals for each condition is also provided in Table 4.
The conditions listed were from the diagnoses entered in the
E.R. log or, if no diagnosis was given, the patient complaints entered were
used. All conditions of interest were included, and there may be several
conditions tabulated for a patient. The reader will note from Table 5 that
a number of artibrary classifications were made. For example, chest pain
and abdominal pain without diagnosis were included in respiratory disorder
and gastrointestinal disorder, respectively. In contrast chills or fever
and headache or dizziness are shown separately, as is eye irritation. These
complaints, and chest or abdominal symptoms, were of course frequently
present for diagnoses of respiratory infection, flu, or viral syndrome.
Similarly multiple, related diseases were often entered: URI and otitis,
URI and flu, URI and gastroenteritis, etc. Some cases with respiratory
symptoms were diagnosed as URI, others as flu or viral syndrome. This
situation prohibits unequivocal classification of these patients into
discrete categories related to etiology. With these qualifications, data
in Table 4 are an attempt to determine volume of conditions available and
any trends in time.
-28-
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Table 4. Selected Conditions, Number and Rate* Per 100 Patients: Riverside and Other Metro Area Residents,
Selected Weeks, October 1974 Through August 1975
Diagnosis Group**
Respiratory Disorders (1-6) R
0
Otitis (7) R
O
Eye Irritation (8) R
O
Chills, Fever (10) R
O
Headache, Dizzyness (11) R
O
Vascular Disorders (12-14) R
O
Mental Disorders (15-16) R
O
Seizure Disorders (17) R
O
Diabetes Mellitui ( 18) R
O
Gastrointestinal Disorders R
(19-21) 0
Flu, Virus (9) R
O
Total Patients R
O
October
Number
78
11
9
3
2
-
3
-
9
6
16
3
23
6
5
1
8
-
22
8
14
-
476
114
Rate
16.4
9.6
1.9
2.6
1
-
1
-
1.9
5.3
3.4
2.6
4.8
5.3
1.1
1
1.7
-
4.6
7.0
2.9
-
December
Number
98
26
9
7
2'
-
2
-
6
2
17
1
28
2
3
1
1
-
26
6
7
-
481
93
Rate
20.4
30.0
1.9
7.5
1
-
1
-
1.2
2.2
3.5
1.1
5.8
2.2
1
1.1
1
1.1
5.4
6.5
1.5
-
February
Number
. 104
18
18
2
1
-
-
-
10
-
12
2
32
5
1
1
6
-
20
-
12
-
480
71
Rate
21.7
25.4
3.8
2.8
1
-
-
-
2.1
-
2.5
2.8
6.7
7.0
1
1.4
1.2
-
4.2
-
2.5
-
April
Number
66
8
8
1
3
-
-
-
13
3
12
2
30
5
8
-
3
-
12
5
6
2
480
92
Rate
13.8
8.7
1.7
1.1
1
-
-
-
2.7
3.3
2.5
2.2
6.2
5.4
1.7
-
1
-
2.5
5.4
1.2
2.2
June
Number
69
17
7
1
2
-
1
-
4
-
10
1
31
3
7
2
4
1
21
9
4
2
474
95
Rate
14.6
17.9
1.5
1.1
1
-
1
-
1
-
2.1
1.1
6.5
3.2
1.5
2.1
1
1.1
4.4
9.5
1
2.1
August
Number
72
15
12
4
4
-
-
-
13
1
15
3
41
5
6
-
4
-
31
7
8
1
514
104
Rate
14.0
14.4
2.3
3.8
1
-
-
-
2.5
1
2.9
2.9
8.0
4.8
1.2
-
1
-
6.0
6.7
1.6
1
no
10
i
* 1 is 1.0/100 arrivals.
** Numbers in parentheses refer to categories in Figure 3.
R - Riverside City
O - Other Metro Area
-------
Table 5. Definitions of Diagnosis Groups Used in Analysis
Diagnostic Group
CO
o
I
1. Asthma
2. Chronic Respiratory Disease: Chronic Bronchitis, Emphysems, Chronic
Obstructive Lung Disease
3. Acute Lower Respiratory Disease; Pneumonia, Bronchitis, Pleurisy, Acute
Pulmonary Edema
4. Lower Respiratory Symptoms; Pulmonary Congestion, Chest Pain, Respiratory
Difficulty, Lower Respiratory Symptoms
5. Acute Upper Respiratory Disease: Septic Sore Throat, Acute Upper Respiratory
Infections, Peritonsillitis
6. Upper Respiratory Symptoms; Chronic Pharyngitis, Allergy, Earache, Nasal
Congestion, Sore Throat
7. Otitis Media, Otitis Externa
8. Eye Irritation; Conjunctivitis, Blephoritis, Inflammation and Soreness
9. Flu; Influenza, Viral Syndrome
10. Chills, Fever
11. Vertigo, Dizziness, Headache; (Migraine, Tension, Other)
12. Cardiovascular Disorders and Symptoms
13. Cerebrovascular Disorders
14. Hypertension and Elevated Blood Pressure
15. Nonphysical Psychoses and Personality Disorders
16. Anxiety. Depression. Nerves, Neuroses
17. Epilepsy, Convulsions, Seizures
18. Diabetes Mellitus
19. Upper G.I. Ulcers, G.I. Bleeding
20. Gastroenteritis. Gastritis. Diarrheal Disease
21. Abdominal Symptoms; Pain, Nausea, Vomiting, Flatulence
H-ICDA Codes
4930-4939
4910-4929, 4960
4800-4869, 4890-4909, 5110, 5119, 5191
5140, 5149, 5197, 7740, 7780-7789,
7790-7791, 7793, 7794, 7963, 7968
0340, 4600-4659, 501
5020-5039, 5070, 7720-7722, 7760-7769,
7776-7777
380, 381
0789, 3600-3619, 7711
0799, 4700
7922, 7929
7704-7705, 7920, 3168, 346
4100-4299, 7741-7746, 7750, 7755
4300-4389
4000-4059, 7747
3060-3099, 3110-3119, 3169
3100, 3105, 3109, 317, 7926
3450-3459, 7703
2500-2509
5310-5349, 7820
0080-0099, 5350-5351, 7821
5369, 7800-7801, 7816, 7823, 7824
-------
Several observations from Table 4 appear relevant to study
objectives. Grouped in this manner, respiratory disorders is the pre-
dominate category and the only category with a discernable seasonal
trend. The winter increase in respiratory illness is consistent with
a study of hospital admissions by the local health department and repre-
sents the "flu" season in this area. Ambiguity in classification, in
combination with the small numbers, obscures possible patterns for other
disorders. If typically high- and low-oxidant periods are compared
(August and April, respectively), there are a few categories which sug-
gest any contrast in frequency. If one considers that these data are
totals for a seven-day period, the low frequency in many diagnostic cate-
gories combined with the lack of marked differences among months do not
encourage use of these diagnoses in the study.
Since they comprise the largest category, Tables 6 through 8
examine distributions of respiratory and related disorders. Otitis and
flu/viral diseases have been included as they were frequently present in
combination with conditions classified as respiratory disorders. For
convenience, the general label of "respiratory" conditions is used.
Table 6 shows the number seen and rate by age group. Age is
known to be associated with incidence of the various disorders and with
utilization of health services. Age is also thought to reflect differences
in sensitivity to oxidants. Comparing the number of conditions among age
groups is not helpful since the numbers are affected by variation in the
number of patients seen. Rates are computed using total patients in each
cell as the base.
-31-
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Table 6. Respiratory and Related Conditions by Age and Month, Number and Rate* Per 100 Patients:
Metro Area Residents, Selected Weeks, October 1974 Through August 1975
Under 2 Years
Rate
2 - 5 Years
Rate
6-17 Years
Rate
18-44 Years
Rate
45-64 Years
Rate
65 + Years
Rate
All Ages**
Rate
Riverside**
Rate
Other Metro**
Rate
October
16
55.2
11
42.3
22
22.9
43
13.6
12
13.3
2
6.2
106
18.0
95
19.9
11
9.7
December
32
84.2
19
76.0
16
20.5
63
19.4
11
14.5
2
6.2
144
25.0
111
22.8
33
36.3
February
27
67.5
22
59.5
25
29.1
51
18.6
16
20.5
7
19.4
148
26.9
128
26.7
20
28.2
April
11
57.9
8
44.4
12
12.4
37
12.1
12
12.6
7
18.4
88
15.3
77
15.9
11
12.2
June
16
64.0
7
28.0
17
21.5
49
14.7
5
7.4
3
7.7
97
16.8
78
16.2
19
19.8
August
12
46.2
15
48.4
12
13.8
45
12.9
19
20.7
4
11.8
107
17.2
87
16.8
20
19.4
* Rate = Total Cases/Total Patients in Cell x 100
** Excludes unknown age.
-32-
-------
The highest rates of respiratory conditions in all age groups
occurred in one or both of the winter months. There was a general
decrease in the rate of these conditions with increasing age, which was
most prominent for the winter months - reflecting the higher incidence
of acute respiratory infections in winter months, particularly among the
younger ages. The rates also show the relative importance of respiratory
conditions among all conditions by age. For example, in those under
two years these conditions were diagnosed in 46-84 percent of the patients
seen, while in those patients age 65 or older they accounted for 6-19 per-
cent of the diagnoses. The two bottom rows of this table further illustrate
differences in distributions between Riverside and Other Metro residents
seen earlier.
Table 7 presents data on categories of respiratory and related
conditions for Riverside residents only. Rates are computed using a base
of all patients with these conditions, rather than total arrivals as before.
The bottom rows of the table compare the number of conditions and actual
number of patients, and indicate the percentage of total arrivals with diag-
noses of respiratory and related conditions.
One percent of all arrivals averaged about five patients for the
periods studied. Considering percent of total patients, respiratory con-
ditions accounted for the majority of the variation in total arrivals during
each period. Increased utilization in the winter months is due to a higher
incidence of acute conditions - there were also more patients with a com-
bination of diagnoses. For April, June, and August the number of patients
and the proportion of total arrivals was about equal. This provided an
-33-
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Table 7. Respiratory and Related Conditions, Number and Rate* Per 100 Patients: Riverside Residents,
Selected Weeks, October 1974 Through August 1975
Diagnosis
Asthma
Chronic Respiratory
Disease
Acute Lower Respira-
tory Disease and
Symptoms
Acute Upper Respira-
tory Disease and
Symptoms
Otitis
Flu, Virus
Total Conditions
Patients: Number
Percent of
Total**
Number and Rate/100 Patients
October
Number
7
-
16
55
9
14
101
97
20.4
Rate
7.2
-
16.5
56.7
9.3
14.4
December
Number
7
2
17
72
9
7
114
107
22.2
Rate
6.5
1.9
15.9
67.3
8.4
6.5
February
Number
5
4
19
76
18
12
134
122
25.4
Rate
4.1
3.3
15.6
62.3
14.8
9.8
April
Number
6
1
18
41
8
6
80
78
16.3
Rate
7.7
1.3
23.1
52.6
10.3
7.7
June
Number
6
3
10
50
7
4
80
77
16.2
Rate
7.8
3.4
13.0
64.9
9.1
5.2
August
Number
5
4
14
49
12
8
92
81
Rate
6.2
4.9
17.3
60.5
14.8
9.9
15.8
* Patients seen with respiratory and related diagnoses.
** All arrivals.
Table 8. Respiratory and Related Conditions, Percentage Distribution by Month:
Riverside Residents, Selected Weeks, October 1974 Through August 1975
Asthma
Chronic Respiratory Disease
Acute Lower Respiratory Disease
and Symptoms
Acute Upper Respiratory Disease
and Symptoms
Otitis Media
Flu, Virus
October
19.4
0.0
17.5
16.0
9.6
27.5
December
19.4
14.3
17.5
21.0
17.3
13.7
February
13.9
28.6
22.5
22.2
25.0
23.5
April
16.7
7.1
18.7
12.0
15.4
11.8
June
16.7
21.4
10.0
14.6
13.5
7.8
August
13.9
28.6
13.8
14.3
19.2
15.7
Total
Number
36
14
80
343
52
51
Percent
100.0
100.0
100.0
100.0
100.0
100.0
-34-
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opportunity to view changes in the relative rates among categories. It
is seen that rates vary both as a function of the number of patients in
each category and of the proportion represented by acute upper respiratory
conditions per patient. Multiple conditions are more prominent in August.
In Table 8 comparisons among diagnosis categories are shown from
another perspective. Generally, the largest percentage of conditions in
all categories occurred during the winter months. The exceptions were
cases of flu or viral diseases seen in October. With the small numbers of
observations it cannot be judged whether the higher frequency was an arti-
fact or represented a real increase in incidence.
The review presented in Section 4.1 represents one component in
preliminary evaluation of the proposed approach. The purpose was to
identify characteristics of emergency room utilization that may have impli-
cations for further development and application of the technical approach.
By intention, this pilot study was limited, which in turn restricted the
reliability and scope of interpretations drawn from the data. The inter-
pretations made were largely subjective and they were meant to suggest
factors that, if correctly perceived, would be significant in judging the
utility of the approach. Points that appear important in this preliminary
evaluation are summarized below.
When certain exceptional days were excluded, overall utilization
by day of the week was remarkably consistent across months. Much of the
variation in total arrivals were due to differences in volume of "Other
Metro" residents. Comparisons of these patients with Riverside residents
showed differences by age and by groups of selected conditions. Variations
-35-
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from period to period among Riverside residents was relatively small and
the largest proportion of differences was accounted for by fluctuations
in acute respiratory and related illness. The usual increase in respira-
tory illness during the local "flu" season was seen, although individual
patterns of occurrence among the various respiratory diagnoses seemed to
be present. The number of respiratory conditions did not always vary
proportionately to the number of patients; i.e., in some periods there
were more patients with a combination of diagnoses than in other periods.
Seasonal patterns for other diagnosis groups were not apparent.
The seasonal influence in respiratory illness among "Other
Metro" residents was observed, similar to Riverside residents, and patterns
of rates which varied from those of Riverside patients could have been
affected by the small number of cases. However, more selectivity in use
of competing care resources should be considered for "Other Metro" residents -
that is, the assumption of proportional community representation was sup-
ported to a degree for Riverside residents but was not judged so for
residents of other parts of the designiated service area for this emergency
room. This indicates that the study population for explaining environmental
effects must either by limited to Riverside patients or be expanded to include
other competing service facilities outside of the city.
Distributions of patients and conditions by diagnosis suggested
several implications for further study. First, aggregated groups of condi-
tions may obscure contrasting patterns for the individual diagnoses. Second,
although daily variations by diagnosis were not explored, the fairly uniform
weekly totals across months in combination with the small number of cases
-36-
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available seemed to limit the opportunity to establish either an asso-
ciation or lack of association with environmental factors for many con-
ditions. Limiting the study to this one facility may restrict the
investigation to only acute respiratory conditions. Otherwise an increased
sample obtained from other facilities would be necessary.
4.2 EVALUATION OF MEDICAL RECORD DATA
In a full-scale application of the methodology an abstract of
the medical record would serve as the basic source for analysis of patient
characteristics and clinical parameters. The emergency room log would be
used only for preliminary identification of the patient sample and to
develop statistics on overall utilization. However, for the pilot study
a small number of medical records (about 50 per weekly period) was chosen
for abstracting, with the limited purposes of evaluating the procedures
and the availability of various data items contained in the abstract.
The proposed methodology relied on medical record entries to
provide the data for classifying individuals into analytical groups, for
establishing the timing and duration of symptoms, and for facilitating
patient followup. Three general types of patient classification were
intended:
Health effects - classification of presenting health
problems into discrete categories which permits test-
ing of associations relevant to mechanisms of induction
by ozone and other environmental factors. Pertinent
data items were complaints, symptoms, diagnosis, medi-
cal history.
-37-
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Susceptibility - classification of patients into
categories which may relate to differentials in
disease incidence, in proclivity to seek emer-
gency room care, or in sensitivity to environ-
mental factors. Pertinent data items were age,
sex, race, family income, residence, disease
history, functional status, utilization history.
Severity - classification of patients into categories
which defines gradations in response to pathophysio-
logical mechanisms, within the overall^health problem
category. Such "severity" levels might be defined
by diagnostic tests, reported functional status, or
variations in the intensity of care required. Per-
tinent data items were test results, entries describ-
ing condition of the patient, type of therapy, and
disposition.
For the first two classifications the degree of resolution permitted by
the data is clearly critical in this approach as well as other epidemio-
logical techniques of studying pollutant effects. Even in the general
category of respiratory illness ambiguity in classifying the response and/
or the patient can easily obscure small increments in incidence due to
the cause of interest.
The third classification - severity - was to be used for two
purposes if feasible: detection of shifts in average severity among
patients following ozone alerts, and possibly, to identify differentials
in tendency to seek care among diagnostic groups and among patient popu-
lations using the various emergency facilities in the area. The concept
of severity measurement was considered experimental and of potential util-
ity, although not highly critical to the success of the approach.
The availability of medical record data is summarized in Table 9.
Basic items for health effects and susceptability classification were
-38-
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Table 9. Summary Evaluation of Medical Record Data
Data Item
Observations on Availability
Demographic Data
Residence
Symptoms, Complaints
Medical History
Severity of Condition
Vital Signs
Diagnostic Test Data
(Selected Tests)
Treatment (Selected)
Diagnosis
Disposition
Age, sex, race, present for 95 percent of patients.
Address, telephone of patient or alternative contact usually
available.
Major complaints usually listed, plus symptoms noted by the
physician. Onset by complaint not always clear, and duration
of complaint missing in 35 percent of respiratory conditions
sampled.
Usually limited on E. R. record to symptom onset. More
general history available for large proportion of patients seen
inOPD.
Specific mention in record for some critical cases.
All four usually recorded, except blood pressure for children.
X-rays usually for chest complaints. Selected lab tests infre-
quently done.
Except for injections, selected therapeutic measures rarely
employed.
Tentative diagnosis usually entered.
Low rate of admissions. Entry for disposition rarely missing.
Referral to OPD for followup was noted.
-39-
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usually available. However, the tentative nature of emergency room
diagnoses in combination with the limited amount of diagnostic data, often
prohibited very precise classification of the patient's illness within a
diagnosis coding scheme. This led to arbitrary assignment of conditions
to one category or another primarily based on achieving consistency, rather
than a sound clinical rationale. Treating each symptom-diagnosis combin-
ation separately would have resulted in too many categories of illness to
handle effectively in an analysis. The alternative - a greater degree of
aggregation - appeared to obscure different patterns of incidence across
time periods.
The classification of respiratory and related conditions illu-
strates the problem. The seasonal increase for all respiratory disorders
was seen in Table 4. Two related categories - flu, otitis - did not show
the same pattern. In Table 7 it is apparent that acute upper respiratory
disease dominates the aggregate pattern of respiratory disorders, while
other categories of respiratory illness again, do not have the same pat-
tern. It must be assumed that the small frequency in several categories,
and the classification scheme, have affected these distributions to some
(unknown) extent..
"Flu" or "viral syndrome" is one example of the classification
problem. For patients with a similar group of (recorded) symptoms the
diagnosis was entered as one of these labels at times, and at other times
as a respiratory disorder, and for yet other patients as a combination
with respiratory diagnoses. If the complaint was G.I. upset, the diag-
noses may have been flu or gastroenteritis, with the latter most often
recorded for young children.
-40-
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Another example of the problem is, when no specific diagnosis
was entered, the question of including certain complaints or symptoms
with acute upper or lower respiratory diseases. With no other indication
to the contrary, symptoms such as nasal congestion and sore throat were
classified with acute respiratory diseases, and pulmonary congestion and
chest pain with acute lower respiratory disease. Obviously, these symp-
toms could have been unrelated to viral or bacterial effects on the respir-
atory system. On the other hand these complaints probably were more often
related to respiratory infection than not, so that exclusion would have
artificially lowered the rate of acute respiratory illness. It may be'.of
interest that, in the data for Table 7, about 39 percent of the acute
lower respiratory disease group consisted of symptoms without diagnosis
while symptoms comprised only about 10 percent of the acute upper respiratory
disease category.
For the "susceptability" classification the usual demographic
parameters were recorded for almost all patients. Indicators of family or
patient economic status were not available except for payment source. One
of the most important parameters was considered to be categorization as to
preexisting chronic disease. When the complaints were related to a chronic
condition there was likely to be some indication. However, history of
chronic disease was not always noted if an acute illness was diagnosed, even
though the chronic condition had been recorded on prior clinic visits. This
indicated that the records might not be adequate for analysis of responses
in individuals with or without chronic illness.
-41-
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As indicated earlier a variety of approaches to classification
by "severity" were under consideration. Direct mention of severity was
rarely found. Other approaches depended upon results of selected diag-
nostic tests, use of selected therapeutic measures that would reflect
treatment intensity, or admission rate. It was found that laboratory
tests were infrequently ordered for the patients of interest and the
particular treatment services used in only a few cases.
Table 10 presents the frequency with which a number of data
times were recorded for certain diagnostic categories. From this data
two conclusions are suggested. First, diagnosis and treatment services
are kept to a minimum indicated by the patient's condition and presenting
complaints. These parameters would be of methodological use only if
they were a consistent indicator of the more severe conditions. Use of
the available data for finer degrees of severity was highly questionable.
Second, if the first conclusion is correct few "severe" conditions are seen
and detection of a shift in "average" severity due to oxidant effects does
not appear likely.
The two other important types of data from the medical record
concerned onset of symptoms and followup of the patient. Symptom onset
was critical for relating the timing of high ozone levels and the develop-
ment of illness. Those patients whose onset of symptom "y" was subsequent
to the emergency visit must be considered as a response group separate
from those who were already experiencing symptom "y." The potential suc-
cess and efficiency of followup were also dependent on the accuracy, time-
liness and completeness of medical record information, particularly the
-42-
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Table 10. Number of Times Certain Clinical Parameters were Recorded for Selected
Diagnoses (Record Abstract Sample)
Record Abstract Data Item
Total in Sample
Presenting Complaints:
Shortness of Breath
Disorders of Respiratory Rhythm or Sound
Congestion in Chest or Chest Pain
Vital Signs:
Respiration Rate
History:
Asthma
Chronic Obstructive Pulmonary Disease
Heart Disease
Diagnostic Procedures:
Hemoglobin
Chest Film
ECG
Blood Gases
Electrolytes
Treatment Procedures:
Injection
I.V. Fluids
IPPB
Disposition:
Discharged
Admitted
Emergency Room Diagnosis
Asthma
8
3
2
2
7
7
1
-
-
-
1
1
-
3
-
2
8
-
Chronic
Respiratory
Disease
7
1
-
-
3
2
3
-
-
1
1
1
-
-
-
-
7
-
Acute Lower
Respiratory
Disorder
18
2
-
7
7
_
-
1
1
7
.
-
-
2
-
-
17
1
-43-
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availability of an alternate contact when there was no home telephone or
the patient could not be contacted at the given home address.
Some indication of illness onset was recorded for most patients.
However, this information was missing in a substantial number of cases,
and in many it was not clear if the onset given pertained to all complaints
or only those considered important to the primary diagnosis. Onset and
followup data will be discussed further in the next section.
4.3 EVALUATION OF FOLLOWUP PROCEDURES
The followup component of the methodology was seen as essential
to proper interpretation of emergency room utilization patterns. Informa-
tion collected through the interview was deemed important for more precise
classification of health effects and susceptability to environmental factors,
and for clarification of extent and timing of pollutant exposure relative
to symptom development and the emergency room visit. Certain questions
were intended as supplements to the medical record abstract while others
sought data that would not be provided by the medical record.
Contact with the patient by telephone was selected as the most
cost-effective approach when weighed against the effort and expense asso-
ciated with either emergency room or home interviews. This method had
previously been used by the author for followup of emergency room patients,
with mixed success. In this prior study response rate and data quality
were satisfactory when contact was achieved, but the high proportion of
cases for which no means of contact was readily available severely limited
the value of the data collected. However, full use of information in the
medical record and other potential resources (e.g., city directories) was
-44-
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not made, and a more extended effort may have Increased success in patient
contact.
For the pilot study a subset of the record abstract sample was
selected from the periods February, April, June, and August 1975. This
was considered sufficient to evaluate the procedures plus provide infor-
mation about any change of response rate or recall with time. A common
set of items to be used in tracing the patient was abstracted for the
interviewer. She then reviewed the record for any additional information
if the initial set proved insufficient.
A total of 88 interviews by telephone were attempted. Inter-
view completion by month of visit is shown in Table 11. For patients who
had been seen within the past month or so prior to the attempt the com-
pletion rate was considered excellent for a telephone survey (77.3 percent).
This rate dropped off sharply for the earlier months, generally because
patient mobility prevented contact. Given that a respondent was reached,
the rate of interview refusal was low.
Table 11. Completion of Interviews by Month of Emergency Room Visit
Interview Completion
Completed #
%
• ' •- *-•
Refused #
%
Not Contacted #
%
Total #
%
Month of E.R. Visit
Feb
12
48.0
3
12.0
10
40.0
25
100.0
Apr
10
50.0
1
5.0
9
45.0
20
100.0
Jun
11
52.4
1
4.8
9
42.9
21
100.0
Aug
17
77.3
0
0.0
5
22.7
22
100.0
Total
50
56.8
5
5.7
33
37.5
88
100.0
-45-
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Completion rate associated with patient ethnic group and age
is seen in Table 12 and 13. Ethnic bias did not seem an important factor.
The response rate was lower than average in the group 18-44 years which
made up the largest number of patients and which probably were the most
mobile.
Table 12. Interview Completion by Ethnic Group
Interview Completion
Completed #
%
Refused #
%
Not Contacted #
%
Total #
%
Ethnic Group
Unknown
0
0.0
0
0.0
1
100.0
1
100.0
White
32
54.2
1
1.7
26
44.1
59
100.0
Black
8
72.7
2
18.2
1
9.1
11
100.0
Mexican
9
56.3
2
12.5
5
31.3
16
100.0
Indian
1
IQQiO'
0
0.0
0
0.0
1
100.0
Total
50
56.8
5
5.7
33
37.5
88
100.0
Table 13. Interview Completion by Age of Patient
Interview Completion
Completed #
%
Refused #
%
Not Contacted #
%
Total #
%
Age of Patient (Completed Years)
Under 5
4
66.7
1
16.7
1
16.7
6
100.0
6-17
7
87.5
0
0.0
1
12.5
8
100.0
18-44
22
48.9
1
2.2
22
48.9
45
100.0
45-64
10
66.7
1
6.7
4
26.7
15
100.0
65 Plus
7
50.0
2
14.3
5
35.7
14
100.0
Total
50
56.8
5
5.7
33
37.5
88
100.0
-46-
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Table 14 reflects the effort of the interviewer in reaching
a respondent. The number of calls include all those made to locate the
patient, as well as to contact the patient's residence. Besides clues
from the medical record, a "criss-cross" directory was used to identify
neighbors through whom the patient might be contacted, if no telephone
was found. Few calls were needed to obtain completed interviews.
Table 14. Interview Completion by Number of Telephone Calls Made
Interview Completion
Completed #
%
Refused #
%
Not Contacted #
%
Total #
%
Number of Calls
1
20
40.0
2
40.0
6
18.2
28
31.8
2
13
26.0
1
20.0
9
27.3
23
26.1
3
10
20.0
1
20.0
5
15.2
16
18.2
4
3
6.0
0
0.0
6
18.2
9
10.2
5
1
2.0
1
20.0
2
6.1
4
4.5
6
2
4.0
0
0.0
2
6.1
4
4.5
7
1
2.0
0
0.0
0
0.0
1
1.1
8+
0
0.0
0
0.0
3
9.1
3
3.4
Total
50
100.0
5
100.0
33
100.0
88
100.0
Other aspects of the interviewing are presented in Tables 15
and 16. Ninety-six percent of the interviews were completed on calls of
20 minutes or less. For the bulk of the completed interviews either the
patient or a close relative was available.
-47-
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Table 15. Time for Interview (Completed Interviews)
Completed Interviews
#
%
Interview Time (Minutes)
1-5
2
4.0
6-10
24
48.0
11-15
18
36.0
16-20
4
8.0
Over 20
2
4.0
Total
SO
100.0
Table 16. Respondent for Completed Interviews
Completed Interviews
#
96
Respondent
Patient
29
58.0
Mother or
Spouse
13
26.0
Other
8
16.0
Total
50
100.0
If attempted within 30 days or less of the patient visit it
appeared that the completion rate for the interviews would be satisfactory,
even among the most mobile group of patients. This indicated that inter-
viewing must be continuous over the period of study. There was also the
question of accurate recall if the lag time was extensive.
Comparison of complaints and onset entered in the medical record
with those reported on interview provided an opportunity both to evaluate
this data and to gain some insight into recall. In Table 17 a comparison
is made between reported and recorded symptoms for patients with respira-
tory conditions. Included are all those with these diagnoses, plus others
who reported respiratory complaints but no respiratory system diagnosis
was made. In the interview the patient (or other respondent) was asked to
recall the complaints and the onset of the earliest symptom in terms of
time prior to the E.R. visit.
-48-
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Table 17. Comparison of Complaint* and Duration of Symptoms from
Patient Interview with Those from E. R. Record:
Respirator/ Conditions
CaMNonbar
1
2
3
4
S
6
7
S
9
10
11
12
13
14
IS
16
17
IS
19
20
Alt
23y
29y
30y
Cm
My
60y
«y
S3y
lly
«y
30y
2Sy
47y
29y
ISy
"y
Tly
19y
3y
«y
taMivUw
Son Toiaat ( >7d)
Cold
Paia la lowv Extremity ( >7d)
Pala la Uppat Exawlty
Piia la Back (an)
DlBia«i
Natal CoacMtioa (2-3d)
Sham** of Bnath (an)
Shactaaai of Bnath ( »7d)
Couch
Fmr
SnonuM of Bnath ( >7d)
CoacMtioB la ChM
Sbarcaaa of Bnath (3-7d)
Uriaa Abmaal
Abaonntl RatBirattoa (an)
Favai (an)
Son Thioat
Pala la Chut (2-Jd)
Pain la Chut (3-7d)
Painting (2-3d)
Pala la Chut
Sbomuai of Bnath (Id)
i-Mii.
Cold (Id)
Htidaeht
Earacha (Id)
Dtechaic* (ram Ear
Cold (l-7d)
HlCh Blood Pi aanui
Abnormal Raaplntloa ( Id)
F«T«r(2-3d)
Cold
Racial Symptomi (2-3d)
Raco»Ab«»c,
SonThmat(?)
Conch (?)
Dlacharc* from Ey« (?)
Cold(?)
Wtakaw of ExtnmHUt (?)
Paia la Cant (?)
Couch (fid)
Ewacb«(6d)
Naial CoocMdOD (3d)
H««dacb»(3h)
Naotaa (la)
Shoctaw of Bntth (3h)
ShoRDM of Bnatfa (7d)
Conch (7d)
Abdominal Pate (12h)
SbORaaa of Bnath (lib)
ShoMBMi of Bnath (3d)
Fluid Imbalaae* (3d)
PhUgm (3d)
Paia la Chan (3d)
Shonuw of Bnath (?)
Abaoimal Ruptrxtloa (?)
F«vat(2d)
Son Throat (2d)
Conch (2d)
Cold (14d)
Couch (l*d)
Pala la Choc (2d)
Pala la Back (3d)
Abdominal Pain (3d)
Pain la daft (3d)
Shorauai of Bnath (3d)
Coach (3d)
ShoraiM of Snath (?)
MiacU Aeha (7)
Bahartottl Otoonbaaea (3d)
SonThnat(?)
Eaneaa(2d)
F«vtt(2d)
Cold (7d)
Coach (14d)
Natal Coafwtioa (?)
Son Thnat (?)
Natal Conc«tton(T)
Natal Coacaadea (7d)
Eatacaa(ld)
ChUk(?)
Son Thraat (?)
Conch (?)
AncaK
AncoB
AUr"
AufOB
Aar*
Aufoat
low
Jnaa
Jan.
I~
April
April
April
F.bmaty
Fabnuty
Fabnurf
Fabnuiy
Fabmny
Ftbnaiy
Fabnuiy
T'PTIVY'
Som« An««ni«at
MeA«n«a«at
Unknown
DunttPB Total Pattana
Ancoat
JOB*
April
Pabraaty
Total
S
4
2
_4
IS
6
4
3
_7
20
-49-
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All patients listed in Table 17 who were 18 years of age or
older were interviewed directly, while a proxy respondent (usually the
mother) furnished the information for those under 18 years of age. Only
slight editorial changes were made in the reported or recorded symptoms
shown. The numbers in parentheses are durations in hours (h) or days (d).
A question mark indicates that duration was not recorded for that partic-
ular complaint and it is not clear if the time for other symptoms is
applicable.
Correspondence between reported and recorded data is summarized
at the bottom of Table 17. There was some agreement for symptoms in
75 percent of these cases, the percentage seemingly decreasing with time
elapsed since the patient was seen. Substantially less correspondence
was shown for duration but this was affected by the lack of recorded dura-
tion for 35 percent of the cases. It may be noted that Case 14 would not:
have been identified as "respiratory" from the record or Cases 2,3, .and
20 from the interview.
The importance of eliciting all symptoms and their onset has
been stressed. From this brief analysis it appears that the interview
can provide useful information on these items if the patient is contacted
soon after the visit. A better strategy perhaps would be promotion of
more complete recording by the attending providers during the period of
study.
The discussion thus far has concerned the overall utility of a
followup interview. In the tables that follow, distributions of patients
-50-
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according to responses on interview are presented. Because of the small
sample these data are intended as illustrative only.
Tables 18 and 19 provide examples of the use of functional status
scales. Table 18 indicates the frequency of chronic limitations among
activity categories. The latter categories are associated with behavior
patterns relevant to exposure and use of health facilities. For example
56 percent (11 + 17) are exposed mostly to ambient levels in the area of
their residence and of these more than half (15) have chronic limitation
from disease or injury. Such data may be used for comparisons of patient
populations among different emergency rooms. In Table 19, the change in
functional status due to the illness is indicated, adjusted for usual
limitation but not for activity category. Shifts in these proportions
over time for the same population of users may indicate degree of impact
of etiological agents. Comparisons among populations could show differen-
tial response to the same insult. A fairly high percentage did not recall
if their illness caused any change in functional level.
The remaining tables concern various factors that may be asso-
ciated with the extent of exposure to pollutants. Tables 20 and 21 show
proportions that remained indoors most of the time prior to the first
symptom and that spent at least two continuous hours outside shelter.
Tables 22 through 26 consider exposure of employed persons and illustrate
the following points:
Table 22 - Persons who leave the area for which ambient
concentrations are measured ("Metro" area)
-51-
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Table 18. Usual Activity by Presense of Activity Limitation
(Completed Interviews)
Usual Activity
Employed #
%
Housewife #
%
Student #
%
Remain at #
Home %
Total #
%
Limitation in Amount or Kind
of Activity
Unknown
1
7.1
0
0.0
1
12.5
0
0.0
2
4.0
No
Limitation
11
78.6
5
45.5
6
75.0
8
47.1
30
60.0
Chronic
Limitation
2
14.3
6
54.5
1
12.5
9
52.9
18
36.0
Total
14
100.0
11
100.0
8
100.0
17
100.0
50
100.0
Table 19. Degree of Activity Limitation Associated With Reported
Respiratory Conditions (Completed Interviews)
Degree of
Limitation
Unknown //
%
Normal //
Activity %
Reduced #
Activity %
In Bed #
%
Total #
%
Reported Respiratory Conditions
Upper
Respiratory
2
15.4
4
30.8
1
7.7
6
46.2
13
100.0
Lower
Respiratory
3
37.5
0
0.0
2
25.0
3
37.5
8
100.0
Both
1
50.0
0
0.0
0
0.0
1
50.0
2
100.0
Total
6
26.1
4
17.4
3
13.0
10
43.5
23
100.0
-52-
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Table 20. Outdoor Exposure Prior to Symptom Onset, for Patients
Reporting Respiratory Symptoms (Completed Interviews)
Outdoor Exposure
Unknown #
%
Remained #
Inside %
Outdoors #
> 2 Hours %
Total #
%
Reported Respiratory Symptoms
Upper
Respiratory
1
7.7
11
84.6
1
7.7
13
100.0
Lower
Respiratory •
0
0.0
6
75.0
2
25.0
8
100.0
Both.
0
0.0
2
100.0
0
0.0
2'
100.0
Total
1
4.3
19
82.6
3
13.0
23
100.0
Table 21. Outside Exposure Prior to Symptom Onset, Patients With/Without
Chronic Limitation (Completed Interviews)
Unknown #
%
Remained #
Inside %
Outdoors #
>2 Hours %
Total #
%
Limitation in Amount or Kind
of Physical Activities
Unknown
1
50.0
1
50.0
0
0.0
2
100.0
No
Limitation
1
3.3
23
76.7
6
20.0
30
100.0
Chronic
Limitation
2
11.1
12
66.7
4
22.2
18
100.0
Total
4
8.0
36
72.0
10
20.0
50
100.0
-53-
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Table 22. Place of Work for Employed Patients (Completed Interviews)
Completed Interviews
#
%
Place of Work
Unknown
1
7.1
Metro Area
10
71.4
Other Area
3
21.4
Total
14
100.0
Table 23. Time of Day for Work, Employed Patients (Completed Interviews)
Completed Interviews
#
%
Time of Day
Unknown
1
7.1
Day
12
85.7
Night
1
7.1
Total
14
100.0
Table 24. Usual Work Site, Employed Patients (Completed Interviews)
Completed #
Interviews %
Usual Work Site
Unknown
1
7.1
Inside
7
50.0
Outdoors
2
14.3
Combination
4
28.6
Total
14
100.0
-54-
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Table 23 - Persons who are subject to peak residential
area concentrations rather than those in the
area of their workplace
Table 24 - Persons exposed to ambient levels to a greater
extent
Table 25 - Persons exposed to pollutant levels along
commuting routes for varying lengths of time
Table 26 - Persons exposed to additional stress or pol-
lutants.
Some of these items were also obtained for school children. Respondents
were also asked if school, office, and home were air conditioned.
The tables derived from interview data show some of the infor-
mation that might be obtained and how it might be used in specifying sub-
groups for analysis.
-55-
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Table 25. Round Trip Commuting
Employed Patients (Completed Interviews)
Completed #
Interviews %
Commuting Time
Unknown
1
7.1
Under 30 min.
6
42.9
30-60 min.
5
35.7
1-2 hours
2
14.3
Total
14
100.0
Table 26. Extreme Exposure Conditions in Occupational Environment,
Employed Patients (Completed Interviews)
Completed #
Interviews %
Occupational Environment
Unknown
1
7.1
None
9
64.3
Temperature
Extreme
1
7.1
Pollution
Exposure
3
21.4
Total
14
100.0
-56-
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section 5.0
SUMMARY AND CONCLUSIONS
Ozone, a powerful oxidant, is the major component of the so-
called photochemical oxidant pollutant complex. Extensive animal experi-
ments have explored both pulmonary and extrapulmonary pathology from
ozone inhalation. Chamber studies with human volunteers, such as those
of Hackney et al., have documented marked acute respiratory responses to
ozone concentrations comparable to ambient levels experienced in some
U.S. metropolitan areas. The latter studies also found substantial differ-
ences in human sensitivity to ozone exposure.
A review of the literature has identified few epidemiological
investigations of ozone effects. These studies have reported statistical
associations of ambient levels with respiratory symptoms among nursing
students, with impaired performance of student athletes, with increased
attacks in a small proportion of asthma patients, and with hospital
admissions. In contrast, no significant relationship between oxidant
levels and school absenteesim due to respiratory illness was found.
Epidemiological research on the effects of long-term exposure in humans
was not identified.
lexicological evidence indicates that ozone acts through a
variety of pathological mechanisms, and thus sufficient exposure may be
hypothesized to result in a variety of responses. These might range
from minor throat inflammation, to increased susceptability to respiratory
infections, to exerbation of chronic conditions (respiratory and nonrespir-
atory) depending on individual dose, duration, and sensitivity. The avail-
able epidemiological studies lend some support to this hypothesis.
-57-
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This report has described an approach to study of the variety
of potential responses to high ambient ozone concentrations: correlation
of changes in emergency room utilization patterns with estimated levels
of exposure. The initial version of methodology for collection and class-
ification of pertinent epidemic!ogical data has been developed. Emphasis
in design has been placed on achieving a high degree of specificity in cate-
gorizing health status, pollutant exposure and facility utilization patterns.
A brief pilot trial has been conducted to test the procedures and to examine
the general utility of the technical plan.
In reviewing results from the pilot study a number of problem
areas were highlighted:
1. Differences in utilization patterns among the groups
seeking care at the facility that complicate their
relationship with community incidence of illness.
2. Difficulty in categorization of presenting health
problems in a manner which would achieve both per-
tinent representation of incidence and adequate
sample size.
3. Insufficient clinical data to support resolution of
diagnostic category and grading severity.
4. Number of potentially important subclassifications
of patients that may require separate attention
in the analysis.
5. Difficulty in establishing the timing of symptoms
relative to ozone exposure levels.
On the positive side, the methods of data collection met the expected
efficiency. At least in the target community a good followup rate was
achieved if initiated soon after the emergency room visit. Most of the
-58-
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interview questions appeared to meet their objective in establishing the
individual patient's situation.
Many of the technical problems discussed are not unique to this
approach. Appropriate specification of symptoms and timing, the inter-
ferrence of exogenous factors, and the large number of variables are
inherent difficulties in any epidemiological study of ambient pollutant
impact. However, adequate application of the proposed approach would
seem to require specialized data collection on a prospective basis. Also,
to obtain the patient population needed to detect ozone effects (or to
establish the hypothesis of "no effect") a number of area facilities must
be included in the study.
The modifications suggested would substantially increase the
costs of study, reducing this advantage over other approaches. They would
also require a great deal of cooperation from the facilities included.
Most important, though, each facility included would increase the problems
in interpretating utilization patterns. That is, one cannot assume that
the populations from each facility can be combined in a simple, additive
manner until it is established that the basic utilization patterns are
indeed comparable. Variation in the characteristics of the facilities
and area residents would make this unlikely. Thus each facility and area
would require separate study before any aggregation was attempted.
The pilot study does not pretend to be a full and comprehensive
test of this general approach to research on pollutant effects, or of the
particular methodology developed. That is, we cannot justify either the
acceptance or rejection of using emergency room patient populations.
-59-
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Further, the methodology is not complete in terms of effects measures and
analytical models. And, we have not yet attempted any linkage of ambient
ozone concentrations and illness patterns.
The evaluation to this point has provided guidance as to:
*
1
• Revisions which may improve specificity, i.e.,
prospective studjr with specialized data collection
by the emergency room
• Need for expansion of the scope of facilities in
the Riverside apea to provide sufficient sample
size •
• Certain problems relating to the interpretation
of emergency room utilization patterns.
From a conservative view these findings do not support the assumptions of
adequate effectiveness and low cost that were important components of the
proposed approach. It appears that no aspect has emerged which would
reduce the expected high risk in producing valid and reliable exposure-
effect determinations within a relatively uncontrolled design. Indeed,
the pilot study results have reinforced that risk. We must conclude then
that the utility of the proposed approach for definitive study of ambient
oxidant effects on human health is highly questionable.
-60-
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Section 6.0
REFERENCES
1. Stokinger, H.E. and D.L. Coffin, 1968. "Biologic Effects of Air
Pollutants." Air Pollution, Volume I. A.C. Stern, Editor. Academic
Press, New York.
2. Hackney, J.D., et al., 1975. "Experimental Studies on Human Health
Effects of Air Pollutants III: Two-Hour Exposure to Ozone Alone and
in Combination with Other Pollutant Gases." Arch. Environ. Health
30:385-40.
3. Discussed in National Air Pollution Control Administration, 1970.
Photochemical Oxidants, Air Quality Criteria. AP-63. U.S. Govern-
ment Printing Office, Washington, D.C.
4. Sterling, T.D., S.V. Pollack and S. Weinham, 1969. "Measuring the
Effect of Air Pollution on Urban Morbidity." Arch. Environ. Health
18:485-94.
5. Hammer, D.I., et al., 1974. "Los Angeles Student Nurse Study."
Arch. Environ. Health, pp. 255-260.
6. Wayne, W.S. and P.P. Wehole, 1969. "Oxidant Air Pollution and School
Absenteeism." Arch. Environ. Health 19:315.
7. Thompson, C.R., E.G. Hensel and G. Kats, 1973. "Outdoor-Indoor Levels
of Six Air Pollutants." J. Air Poll. Cont. Assoc. 23:881.
-61-
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PART II - METHODOLOGY FOR MAPPING OF AMBIENT OZONE CONCENTRATIONS*
Section 1.0
INTRODUCTION
The purpose of this study was to investigate and map the temporal
and geographical distributions of ozone concentrations in the metropolitan
Riverside area so that daily exposures might be calculated for estimating
the effect of short-term exposure to indicated emergency levels of ozone
on human morbidity. In the course of this study the possibility for a
similar but more extensive investigation was examined; such a future study
would involve a larger geographical area (i.e., the total eastern section
of the Los Angeles basin) and would necessitate the formulation of a dense
grid of ozone estimation-points from a larger number of monitoring stations
than the number involved in the initial development.
* Written by Demetrlos J. Moschandreas, Ph. D.
-62-
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Section 2.0
THE PROBLEM
Many communities have conducted air pollution monitoring studies
to determine the nature and degree of their exposure to pollutant concen-
trations. Few have utilized a systematic approach. Although the aim of
the studies was to define average pollution levels, the small number of
monitoring stations included were situated on public buildings rather
than in scientifically chosen locations and were operated on unscientific
schedules.
The subject area of this study (see Figure 1) is both an illus-
tration of the usual situation and an exception. It exemplifies the rule
because the local authorities operate only two stations to estimate the
pollution levels of an area covering approximately 300 square miles. It
constitutes an exception to the rule because the instruments used are the
most advanced, the monitoring schedules are well defined, and the data
gathered are scientifically analyzed.
The problem of pollutant concentrations, specifically of oxidant
levels, in the Los Angeles basin has been studied by many researchers,
owing to the persistence of high levels of ozone densities. The approach
described in this document is,1 however, unique because it did not seek to
estimate the pollutant source strength, the rates of the various deple-
tion mechanisms or the chemical kinetic schemes; it utilizes only ozone
concentration pollution readings and meteorological data from the two
monitoring stations in the Riverside zone of the Southern California Air
Pollution Control District (APCD).
-63-
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* * •
*•- Cucimonja
i **!•*
HD
»*»* \ «. tit •"'. fi,, ' i,n,i •••ai.r' r •^rt*o>T I _'>~*~~~i - T—•• D •«•«
| IIMHI ^ Jil "* ^SAN ^ ^S?*"! 1 L~!\^'f "'^'6Ht*^ I
n^-ol r~"i"'-v-::--'"-7 * BER'NARDJMP'T'| |»^'^!|p' fr""*1"1""*^,
i_.... .T®'..'"~" ;'" »-j. 1- . r ^n^>A-'iMr'wt^T1^^
>^»^1 -
.. fMONTCUAIR »
^ ». / ' ! g_;-j!^.
J^__i^^_l_^^^^LS- MIM^^
,-i ,' _ t 'ONTARIO "7
POMONA U..1 1 ,2
•V A * \5
)\ *'"«
/ \ «*•<•«« ^ ll
/ *^£»"» I
~**""*fc'- mort«« n
-i * t n yiw o** i..
Figure 1. The Riverside Metropolitan Area
-64-
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Almost all the relevant studies on ozone levels have focused
on the average behavior or on the daily variation of 63 for a short period
of time. The present study took a different approach; it examined the
pollutant behavior on a daily basis for the duration of the five-month
high ozone period of the year. The necessity for a day-by-day study will
become apparent later in this document. For the present, it suffices to
point out that the investigation of the average ozone level concentrations
neglects the variations within the ozone cycle and the in-depth study of
a short time interval (e.g., two weeks) is not representative of the total
ozone summer period.
Constraints imposed by the funding and time limitations of the
overall study made a phenomenological approach to the problem the only
viable alternative. That is, while we did not formulate or utilize existing
complex photochemical simulation models we also did not simply use arbitrary
methods of extrapolation between stations. The approach here used pertinent
data, incorporated available theories, validated (to the extent possible)
methods and ideas presented, enumerated the available options and explained
the choice made.
It must be pointed out that in spite of the continuous, serious,
and complex research on the subject of photochemical smog generation and
transport, there does not exist a universally accepted theory and none
seems to be forthcoming in the near future. EPA has recently recognized
the difficulties involved in the formulation of an overall theory explaining
the complex situation and has acknowledged the necessity for an empirical
study.*
Request for Proposal WA 75-R310, on "Simple Algorithms for Determining the Effect of VTM
Reduction on Oxidant Concentrations."
-65-
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It appears that our approach follows the EPA guidelines. The Agency,
while not ignoring the importance of formulating a comprehensive photo-
chemical simulation model, is also searching for a practical procedure
for estimating ozone concentrations from the data of the existing moni-
toring networks. The problem, therefore, was to formulate an empirical
model which estimates the ambient ozone concentrations in the Riverside
metropolitan area by mapping in time and space the hourly pollutant con-
centration data obtained from the two monitoring stations located within
the subject area.
-66-
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Section 3.0
DISCUSSION OF OPTIONS, CHOICE, AND REASONS
In studies of photochemical smog generation, diffusion, and
advection, it is often assumed that concentrations of ozone are uniform
over square areas with sides of 40 km or larger centered over a given
monitoring station ' or, for oxidant trend investigations, one average
concentration representing the total area of a large city is often obtained.1
The metropolitan Riverside area is smaller than the equivalent area side
of 40 km and obviously smaller than the area of large cities in Altshuller's
work. Two monitoring stations, the Riverside station and the Corona sta-
tion are operated by the Southern California Air Pollution Control District -
Riverside Zone; the distance between the two stations is 20 km. Even though
the area is small, the distance between the monitoring stations is appro-
priate for averaging and the difference in 03 concentrations is within the
limits of other studies, we could not assume one representative concentration
over the diurnal cycle. The California State Air Resources Board operates
a third station, the Magnolia monitoring station, within the subject area.
Data from this station were obtained late in the development of this pro-
ject; thus, the Magnolia data were used to "validate" the approach and
"extend" the initial procedure.
The study of the air pollution data, the requirements of the
health study, and the indications of the meteorological data analysis
have led to divisions with respect to geography, ozone concentrations,
and time intervals.
-67-
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3.1 TIME PERIODS
The present study investigated four months and includes plans
to incorporate two more months which would encompass the summer ozone
cycle. Table 1 shows the days and hours with large 0, concentrations
and their monthly variations. The illustrated range necessitates a month-
by-month study. The desire to estimate the daily exposure of an individual
to ozone concentration necessitated a more refined time interval: the
daily cycle. Further studies of the ozone concentrations indicated another
time subdivision: the "day" hours, 0900-2000 inclusive, during which all
the structure of ozone variation appears, and the "night" hours, 2100-2300
and 0000 to 0800 inclusive, which possess only a background ozone concen-
tration. During the "day" hours the hourly variations were examined,
while during the "night" hours only one representative monthly background
ozone concentration was calculated.
3.2 OZONE CONCENTRATIONS
It was assumed that a variation of at least 0.1 ppm of 03 was
necessary in order to define the effect, if any, of short-term exposure
of ozone on human morbidity. A 0.1 ppm 03 concentration (one-hour average)
is the lower limit for an ozone event to be called by the local authorities
in the Southern California APCD and, therefore, multiples of this concen-
tration seemed appropriate for use in epidemiological studies.
Type I Days
If during the "day" hours there was no hourly concentration
reading higher than 10 pphm for both stations, we estimated one repre-
sentative value for the subject area and for the total time period
-68-
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Table 1. Total Days and Hours >.20* ppm of QX» 1975-1970, for Riverside
en
Month
Jan.
Feb.
Mar.
Ape.
May
June
July
Aug.
Sept.
Oct.
Nov.
Dec.
Total
1975
Days
0
0
1
0
8
10
18
Hours
0
0
1
0
21
21
48
1974
Days
0
0
2
0
3
15
12
17
15
2
0
0
66
Hours
0
0
4
0
6
56
30
42
30
3
0
0
171
1973
Days
0
0
0
3
5
13
11
8
2
4
1
0
47
Hours
0
0
0
5
9
33
32
20
5
7
1
0
117
1972
Days
0
0
2
0
0
8
19
7
9
0
0
0
45
Hours
0
0
3
0
0
31
64
14
21
0
0
0
133
1971
Days
0
0
3
0
1
7
10
11
11
4
0
0
47
Hours
0
0
8
0
1
13
27
22
29
9
0
0
101
1970
Days
0
0
0
1
4
10
20
19
10
5
1
0
70
Hours
0
0
0
2
9
31
78
61
35
9
2
0
227
^Absolute Value (Corrected using . 8 Factor)
Note: fpsl >• 20 ppm is chosen because this is the level at which the local authorities call the first stage of an 030 alarm.
Source: Air Pollution Control District (APCD) - Riverside Zone
-------
covered by "day" hours. These days were designated Type I days and the
representative value was the mean of all the hourly concentrations from
both stations during each such day.
Type II Days
If at least one hourly 63 concentration was larger than or equal
to 10 pphm and if the difference of the hourly ozone concentrations between
the two stations was less than +_ 5 pphm, then we estimated 12 hourly ozone
concentrations for the subject area. These days were Type II days and
each of the hourly values was the mean of the respective hourly readings
from Corona and Riverside.
Type III Days
If at least one hourly [03] is greater than or equal to 10 pphm
and the difference between the two stations for at least one hour was equal
to or larger than 5 pphm, then two geographic zones were defined and one
representative hourly concentration per zone was estimated. These days
were called Type III days. The value for each zone is explained in detail
in Section 4.0.
3.3 GEOGRAPHIC ZONES
A division with respect to geographic areas was a more difficult
undertaking than the generation of the previous two classifications. The
options are easily defined: one geographic area combining the data from
both stations, two geographic zones including the areas surrounding the
monitoring stations, and finally a larger number of grid points generated
-70-
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by extrapolation or interpolation of the existing points or by the formu-
lation of a complex model. The first option was easily rejected because
during the period investigated there were readings that did not conform
to one number. It was often observed that one of the stations is continu-
ously represented by the lower limit and the other then, the upper limit.
Thus either individual reading would misrepresent the other area. Another
reason for rejecting the first choice was that ozone concentration readings
at one of the stations were often due to local production while readings
at the other encompassed ozone levels due to advection. Most importantly,
there were days when two advection mechanisms were operating. The third
option was rejected because there were only two monitoring stations; more
are required to validate the model that would be essential for the gener-
ation of a denser network. Also, the small distances involved would neces-
sitate an extremely complex model clearly beyond the scope of this work.
The definition of concentrations for each of the two geographic zones,
the second option, is not easy and involves three signature parameters:
(1) the definition of the advection mechanisms involved in the transport
of 03 from the Los Angeles and Orange County areas; (2) the boundaries
of the investigated area and its topographic features; and (3) the exis-
tence of validating data from neighboring stations, literature articles
and some routine statistical indications to confirm the final choice.
In a study on oxidant distribution and analysis in the San
Bernardino basin, Zeldin (1973) defined the "advection number" A = H - F.
This concept helps 1n ascertaining areas which appear to be more suscep-
tible to advection than to local area pollution. In the definition of
-71-
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the advection index, H is the total number of hours in a given day between
the first and the last occurrence of at least a 0.10 ppm ozone concentra-
tion value. The value of this parameter goes beyond the definition of the
advective index because it denotes the total number of hours per day with
a high ozone concentration, a factor that may directly affect the relation-
ship between ozone levels and human morbidity. Returning to the explana-
tion of the symbols in the advective index equation, F denotes the hour of
the day, based on a 24-hour clock, in which a reading of 0.10 ppm or more
was first recorded. The importance of the advective index, or advection
number, and its implications were clearly stated by Zeldin:
"A location, influenced by already existing or locally
emitted pollutants, tends to start reacting photochemically
(in the summertime) shortly after sunrise. Thus, a value
of 0.10 ppm might be reached early in the day (approximately
9:00 a.m.), gradually increase to a peak in the afternoon,
and then gradually subside to a value below 0.10 ppm (approxi-
mately 6:00 p.m.). Using this example, the advection number A,
equals 10 (hours above 0.10 ppm) minus 9 (o'clock) or a +1.
"A site more influenced by advection generally exhibits
a later rise to the 0.10 ppm value (approximately 12 noon) but
a more pronounced afternoon peak as the advected mass is car-
ried over the site. By the same token, the decrease is more
pronounced with the oxidant value falling below the 0.10 ppm
level late in the afternoon (approximately 5:00 p.m.). Under
this condition, the advection number would equal 6 (hours above
0.10 ppm) minus 12 (o'clock) or a -6. Therefore, the more
negative the advection number, the more likely advective pro-
cesses were at work. Conversely, the more positive the advec-
tion number, the greater the influence from either local or
pre-existing precursors. The advection number thus represents
a numerical means of expressing a characteristic oxidant trace."
The advection index was utilized in this document to indicate
the days of advective influence, as opposed to local generation. Studies by
-72-
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62 23
Hanna , Zeldin , E.E. Anderson , and Arnold indicated two sets of wind
flows which might influence the advective mechanism that carries the ozone
cloud from the Los Angeles area to the eastern segment of the L.A. basin.
The first one is the wind flow pattern through the Carbon Canyon which
mostly influences the San Bernardino County. The second one is the wind
flow pattern through the Santa Ana Canyon which may be divided in two
branches - the northern one induces an advection mechanism over the northern
segment of Riverside County, including the Riverside monitoring station
and the Redlands station of the San Bernardino County monitoring network.
This flow pattern may interact with the Carbon Canyon southern branch
pattern and thus generate streamlines that would relate the ozone diurnal
distribution along an axis connecting Chi no-Riverside and Redlands; such
a connection has been observed. The other branch related to the Santa Ana
Canyon wind flow pattern follows the topography to the southern segment of
the Riverside County and relates ozone concentrations of the Santa Ana,
Orange County, and Corona monitoring stations. These patterns, when present,
divide the subject area in two zones, the southern and northern zones, see
Figure 2, and were verified, to the extent possible, in the month-by-month
analysis of the available data.
It is evident that the approach taken does not consider specific
sources or sinks of ozone generation or depletion, and it does not involve
simulation procedures; it generates a geographical grid based upon the
needs of the present study, not the ozone concentration gradients calcu-
lated from readings obtained from the existing local monitoring network.
-73-
-------
Throughout this document a basic assumption was made: the horizontal dif-
fusion was considered negligible. This has been shown to be true in urban
regions5'8; thus the assumption made was that the advected ozone cloud is
transported strictly through urban regions.
-74-
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'OKTANA ! R | AUTO
fM» *r*4 f I. J
MINIMI '.
Figure 2. The Metropolitan Riverside Area, the Two Geographic Zones and the Wind Flow Pattern
from the Santa Ana Canyon. It must be emphasized that the wind streamline pattern and the
two segment division indicated is only an estimation of the persistent wind patterns.
-75-
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Section 4.0
MONTH-BY-MONTH ANALYSIS
4.1 THE RIVERSIDE-CORONA MONITORING STATIONS
This was a step-by-step process. The diurnal ozone concentration
analysis was always analyzed in two time intervals, that is each day was
divided in "day" hours (0900-2000), and "night" hours (2100-2300 and 0000-
0800). The first step was to define the representative number which
expresses the background, "night" hours, concentration.
April 1975
For the month of April 1975, the Corona "night" hour ozone con-
centration readings have an arithmetic average of 1.06 pphm, for the
Riverside monitoring station the average is 1.59 pphm and the combined
concentration average is 1.32. It was arbitrarily assumed that the com-
bined average plus one-half of the standard deviation, in this case
1.21/2 = 0.60 pphm of 03, would denote the background ozone concentration
for every day during the month under consideration. Thus the background
03 concentration is 1.92 pphm = 2.00 pphm. The correction introduced to
the average value along with the explicit statement of the concentration
distribution during the night hours (see Figure 3) denotes what was believed
to be the "best" representative 03 concentration during this time Interval.
It should be noted that the great majority of the background readings are
very close to the instrument sensitivity, 0.01 ppm , and should be
viewed under this constraint. The addition to the arithmetic mean of
the correction term defines a background concentration which is not on
the noise level of the instruments utilized.
-76-
-------
300- -
u
«W
o
| 200-
'
100 _
203 208
164
82
20
112
1
01 23 4 >5
Figure 3. Distribution of Ozone Concentration for the "Night" Hours During the Month of April 1975
Since the demarcation line for the two stations 1n the subject
area was set at 10 pphm, we next attempted to find out the number of days
and the number of hours for Type III days during the month of April. Table
2 Indicates only three such days.
Table 2. Ozone Concentration Difference Between Corona and Riverside for Days with
Difference > 5 pphm; April 1975
DAY =
DAY =
HAY =
DAY =
DAY =
HAY =
HAY =
DAY =
20
20
20
20
29
2Q
29
30
HniiR =
HniiR =
HDI)R =
HOHR =
HOIIRs
MOUR=
HOIIR =
MDHR =
12
13
19
20
10
11
1 3
10
CORONA
CHROMA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CONC =
CONC =
CONC=
CONC =
CONC=
CONC =
CONC=
CONC =
15
19
14
9
10
11
17
7
R'IVEKSIDF
RIVFKSIDF
RIVERSTOF
RIVEKSTDF
RIVFKSIOF
RIVFRSIHF
RTVFRSinF
RIVERSinF
CONC =
CONC =
CONC =
CONC =
CONC =
CONC =
CONC=
CONC =
8
9
7
4
A
5
12
13
niFF=
niFF=
DIFF=
DIFF =
DIFF =
OTFF =
niFF =
OIFF =
7
10
7
5
ft
6
5
-ft
-77-
-------
The advective index table, Table 3, Indicates not only the
various parameters entering into its definition but it also denotes all
the days that had at least one hourly ozone concentration of 10 pphm
or more; these days also necessitate further investigation because they
show structure in the diurnal variation of the ozone concentration. It
is observed that four days in Corona and five days in Riverside have a
maximum concentration of at least 10 pphm; since two of these days do
not coincide a total of six days need further investigation. These days
fall within the limit of ozone concentration difference less than 5 pphm;
therefore they are Type II days and require hourly structure. Before
this option is taken, a final check is necessary to avoid the possibility
of one of the stations continuously being the lower limit and the other
the upper limit; Table 4 illustrates this procedure. Note that the ozone
concentration difference is taken respectively for each hour during the
day hours of the diurnal ozone variation for the two pertinent stations.
The table shows quite a symmetric distribution for the different readings,
it is, therefore, concluded that for the Type II days, one hourly ozone
concentration is a representative number for the metropolitan Riverside
area.
For the three Type III days shown 1n Table 2 we need to define
two geographic zones. To do so we check the advective index, the hourly
variations for the days, the wind roses of the stations under investiga-
tion as well as other relevant stations and we call for support of our
conclusions from the literature. We shall explicitly show the details
when we investigate the month of May which has more than three days in
-78-
-------
Table 3. The Advection Number for Corona and Riverside for the Month of April 1975
STAT
Cn
cn
CO
CO
cn
CO
CO
cn
cn
cn
cn -•
cn "
CO
cn
cn
.cn
cn
cn
.cn
cn "
cn
cn
cn
cn' "'
cn
Cn '
cn
cn
cn
CO
R'I " "•"•
R I "
RI
RI
RI "
RI ' "
RI
RI '
RI
RI
RT •— '
RI
R I
RI '
RI
RI
R r~
RI
RI
R I
RI
RI
RI
RI
• HI
RI
RI
R.I
RI
RI
DATP
750401
750402
750403
750404
750405
750406
750407
750409
750410
750411
750412
750413
750414
750415
750416
"750417
75041ft
•7504V9
750420
750421
750422
750423
750424
750425
•75042"6
750427
75042R
75042.9
750430
'T50"40I
750402
750403
750404
750405
750406"
750407
"75040ft
750409
750410
750411
750412
750413
750414
750415
750416
750417
75041ft
7504T9
750420
750421
750422
750423
750424
750425
750426
750427
75042*
750429
750430
F
0
- • 0
0
0
0
0
0
• •• o
0
0
... .... 0 ... -
o
.... 0 ... -
0
0
— o
' ~ 0
12
o.
0
o" •--"
o
o " •
G
0
12
"' "~ to
0
0-
12
0
0 -•
"" '"~" 0
_. Q-
0 '
0
0"
— "o .
• o
0
0
0
- ." o " "
-Q — —
11
0
0
-0_
b
"o
0
14
12
10
MAX CIKMC TIMf:
7
q -•• ' :
7
4
" "3
4
5
5
5
f) • "-•
— a
5
3
A -
* • • 5
7
12 —
19"
ft
5
" 8
ft~
"A" '
7
7
12
17 :
— n •
y
9 ;••
10
5
' 4"
5
6
5
7.
A
- g
R '
5 " "
4
A
4
6
9
" " "Iff"
11
5
7 " '
"'«"""
5
5"
7
_ 11
13
MAX
14
17
10
12
g -
12
12
q -•• --•
15
10
1? "
13
12 " "
"0
8
13
15 •"• "
13
16 ' .
13 " -
10
ft
11 " ""
9
11 " " '
12
13
13
13
12 " ~
15
'16
12
11
""'9' "" " "
13 -
11 "
15
12
14"
14
14
'8 "" "
10
14
15
11
1A
L5. *" .
12
11 .
10
11
10
12' ." "'
14
14
"15"" '
10
M
1
I
1
1
1 ' "'
1
1
" i
I
1
"1 ~
I "
1 "
1 "
1
1
' 1 " "
1
A
10 ~
1
1
" 1 "'
1
1
1
1
6
9
3
1
1
1
1
1
1
1
1
1 ..
" 1
1
1
1
1
1
1
1
8
2
1
1
1
I
• 1 — '
1 •
2
" A"
A
A
1
1
1
1
1
1
I
1
1
1
I
1
1
1
1
1
1
1
-6
0
1
1
" I
1
1
1
1
-A
-1"
-9
i
1
-11
1.
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
-9
1
1
~'"1"
1
1
-12
""-A"
-4
-79-
-------
this category. Figures 4, 5, and 6 Illustrate the diurnal ozone concen-
tration/time variation for Riverside, the representative ozone concentra-
tion for the N-zone (N for north), and the Corona ozone concentration
variation for the S-zone (S for south) for April 20, 29, and 30,
respectively.
Table 4. Hourly Difference of Ozone Concentration from the Monitoring Stations of Corona and
Riverside for Type II Days During the "Day" Hours of April 1975
A (Riverside -Corona)
-4
-3
-2
-1
0
1
2
3
4
Number of Events
1
3
4
7
8
13
5
4
1
Partial Percent
0.02
0.07
0.08
0.15
0.17
0.28
0.11
0.09
0.02
Cumulative Percent
0.02
0.09
0.17
0.33
0.50
0.78
0.89
0.98
1.00
Thus far we have Investigated the days with at least one hourly
ozone concentration of 10 pphm or more; Type I days with readings of lower
than the designated demarcation value have to be studied. Following the
procedure set in the discussion of the ozone concentration classification
(see Section 3.0), we will estimate one ozone concentration value for each
day for the "day" hours. An Implicit assumption 1n this approach is the
conjecture that due to lack of structure or, what is the same, due to lack
of ozone concentration variability, there will be no hourly concentration
which is different from the representative ozone concentration by more
-80-
-------
OZONIi CONCENTRATION
DATE - 75
00
0
I
0
N
c
0'
N
C
25.0000 +
22.5000
20.0000
~ 17. -5000
15.0000
.P 12.*000
H
U
N
M
I
I
10.0000
7.5000
5.0000
i- R RIVERS 10
C CORONA
• *-OVERLAP -
C C
K-.-C
c •
C
H
I
R R
—. --c
•' R • * R
2.5000 + '
r • -
IR • R ' 'R ' • R R "•R"
I
1C C C
0.0 + C C C"~C C - "' ——.-... +j
*0 \ -2 3 * 5 *_7 8 9 .10 11 12 13_ 1_*_J5 16 17 18 19 20 21 22 23*j
LOCAL STANDARD TIME
Figure 4. Diurnal Variation of O Concentrations in Corona and Riverside for April 20, 1975
-------
OZONE CONCENTRATION
DATE = 75 429
oo
25.oooo ;*-"~1**w"*"--*"*"r*"*"'*. * + „ R1veRSiO
C CGkljNA
« OVERLAP
• — 22.5000
I— — '- ••--.--
0 20.0000 •
0
N
E-— —
.1 -17.5000-
n -
,N
c
-I 15.0000
V__ 12.5000 . . , C
-^ .... ._.— .. ...,R . _R R
N -~
10.0000
C
.1 "
~7;5000' ; —•"•J-' - — - - .— •• •• ••• —
C _ _
- - —'" » c
C R R _ R C C
"7*5000" R""- R " " R" R C+
""R—H '- C" " """- - - -• R
* * C
*—•'_ e~-c-—c--c—•- •-• -— - ' -~_- " • *"•
~0"~1~~2~~3 ";_<—"5" "6 7 B_ 9 10 11 12 13 _1V '"15_1*" I.7 }* "19 _20 21 22 23 j
LOCAL STANDARD TIME
Figure 5. Diurnal Variation of O Concentrations in Corona and Riverside for April 29, 197S
-------
OZONE CONCENTRATION
CO
n
z
0
N
E
c
0
N
c
M
u
.N
H
r
L
25.0000
22.SOOO
20.0000
17.5000
15.0000
DATE " 75
*• R RIVERSID
C CORONA
* OVERLAP'
P 12.5000
•10.0000
•7.5000
5.0000
"2.5000
0.0
R - R
R C-"C"'*
- R
C '
R C
R C -'
R C C
R -
R R * * *
.R "R R
C C C C
"°l""""'3 * .5 * 7 8 9 10 H IZ l3 *.* * X* 17 18 19 20 ' 21 22
LOCAL STANDARD TIME
Figure 6. Diurnal Variation of O Concentration in Coroaa and Riverdde for April 30, 1975
-------
than + 5 pphm. This premise is explicitly checked in Table 5 which illus-
trates the difference distribution from the calculated average ozone con-
centration. The difference between the daily average ozone concentration
estimate minus each hourly reading from the Corona and Riverside stations
are computed and their distribution is indicated as a partial and cumu-
lative percentage. The table shows a nearly normal distribution for the
above difference, thus verifying that the computed average representa-
tive ozone concentration for the month of April during "day" hours and
days with no substantial ozone concentration structure. It should be
mentioned that a computer program has been formulated (see Section 5.0)
which provides all the tables and figures illustrated so far, allows for
a judgement by the analyst, and outputs the required daily and/or hourly
ozone concentration(s).
Table 5. Distribution of the Difference Between the Average Representative O, Concentration
Value and Hourly Values from the Corona and Riverside Monitoring Stations for Type I Days During
the "Day" Hours of April 1975
A (Riverside, Corona
- Average)
-4
-3
-2
-1
0
1
2
3
4
Number of Eve nts
4
23
46
115
151
139
58
12
1
Partial Percent
0.01
0.04
0.08
0.21
0.27
0.25
0.11
0.02
0.00
Cumulative Percent
0.01
0.05
0.13
0.34
0.62
0.87
0.98
1.00
1.00
-84-
-------
May 1975
Following the order outlined for the month of April, we begin
by computing the background ozone which 1s the sum of the arithmetic mean
of the "night" hours for the two monitoring stations plus a correction
term of half the standard deviation; the representative ozone concentra-
tion for the month of May is 1.93 + 0.91 = 2.84 a 3.00 pphm. Comments
made for the month of April hold true for May and the subsequent months.
Figure 7 indicates the distribution of ozone concentration during these
hours for the duration of May 1975.
400 - .
soo - -
u
•8
200- -
100
187
178
136
87
72
70
0 1 2 3 4 >5
[Ogjpphm
Figure 7. Distribution of Ozone Concentration for the "Night" Hours During the Month of May 1975
-85-
-------
There are 14 Type III days during the month of May as 1s Indi-
cated 1n Table 6.
Table 6. Ozone Concentration Difference Between Corona and Riverside for Days with Difference
Greater or Equal to 5 pphm; May 1975
HAY =
P, A Y =
HAY =
DAY =
OAY =
HAY =
DAY =
DAY =
DAY =
DAY =
nAY =
DAY =
OAY =
OAY =
I)AY =
I)AY =
()AY =
I)AY =
OAY =
DAY =
I1AY =
DAY =
DAY =
OAY =
DAY =
DAY =
OAY =
DAY =
OAY =
HAY =
DAY =
DAY =
DAY =
DAY =
DAY =
OAY =
n AY =
DAY =
DAY =
D A Y =
DAY =
DAY =
2
2
3
7
q
q
q
q
q
10
10
10
10
10
] 1
11
12
12
12
12
13
13
13
13
13
13
14
14
15
23
23
23
2^
23
23
?y
24
2q
30
30
30
31
MO MR I
1 i f '\ I I M v „
Lj r"\ i 1 f\ _ _
MOIIP =
MniiR =
M Ol IP ™
t-i f i i IP ~
HOMR =
HOIIR =
HODR =
HOI'R =
HOMR =
H(ltlR =
MflHR =
MnilR =
nniiR =
HOIIP =
wniiR =
HOUR =
HOIJR =
MOIIR =
HOHR =
HniiR =
Hnnp =
HOHR =
HOUR =
HOIIR =
HOIIR =
HOUR =
HOIIR =
HOUR =
HOMR =
i i pi I I l_p _
II r~\ I I D ^
LJ f^\ i 1 15 ••
HI1HP =
MOMR =
HOI|R =
HOIIR =
HOI IK =
Hnup =
12
13
1 0
13
1 1
12
13
14
15
q
10
1 I
14
15
12
13
10
11
1.3
14
11
12
13
14
IS
1ft
12
14
14
q
10
11
17
1 R
iq
1 1
1 2
13
12
14
1 5
1 1
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CORONA
CONC =
CONC =
CDNC =
CONC =
CONC =
CONC =
C()NC =
C(1NC=
CONC =
CONC =
COMC =
CONC=
CONC =
CONC=
CONC =
CONC=
CONC =
CONC=
CONC =
CONC=
CONC =
CONC =
CONC =
CONC=
cowc=
CONC =
CONC =
CONC =
CONC =
CONC =
CONC =
CfJNC =
CONC =
CONC=
COMC =
CONC =
CI)NC =
CONC =
C'INC =
CONC=
CONC =
"20
23
q
14
15
1ft
23
23
24
1ft
iq
20
2ft
23
1ft
17
iq
20
23
17
13
15
1ft
14
10
ft
12
15
q
5
q
11
1ft
14
10
11
14
14
2ft
27
27
11
RIVERSIDE
RIVFRSIDF
RIVERSIDE
RIVERSIDE
RIVERSIDE
RIVERSIDE
RIVERSIDE
RIVERSIDE
RIVERSIDE
RIVFRSIDF
RIVERSIDE
RIVERSIDF
RIVERSIDE
RIVERSIDF
RIVERSIDF
RIVERSIDF
RIVERSIDE
RIVERSIDE
RIVERSIDF
RIVFRSIDF
RIVERSIDF
RIVERSIDE
RIVERSIDE
RIVERSIDF
RIVERSIDE
RIVERSIDE
RIVERSIDF
RIVERSIDF
RIVFRSIDF
RIVERSIDF
RIVERSIDF
RIVERSIDF
RIVERSIDE
RIVERSIDF
RIVERSIDF
RIVERSIDF
RIVFRSIDF
R TVER SI OF
RIVERSIDE
RIVERSIDF
RTVFRSIDF
R TVFRSIOH
CONC =
CONC =
CONC =
CONC=
CONC =
CONC =
CONC =
CONC =
COMC =
COMC =
COMC =
CONC =
CONC=
CONC =
CONC =
CONC =
CONC =
CONC=
CONC =
CONC =
CONC =
CONC =
COMC =
CONC =
CONC =
CONC=
CONC=
CONC =
CONC =
CONC =
CONC =
CONC =
CONC =
CONC=
CONC =
CONC=
COMC =
CONC =
CONC =
CONC =
CONC =
CONC =
14
1ft
14
9
10
11
11
14
19
11
13
14
18
17
10
12
24
25
33
2ft
20
24
24
23
17
12
17
20
14
10
14
16
11
9
5
5
5
5
1ft
2?
22
1ft
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
D I F F =
DIFF =
DIFF =
DIFF=-
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
DIFF =
D I F F =
DIFF =
DIFF =
DIFF =
ft
7
-5
b
5
5
12
9
5
5
ft
ft
8
ft
ft
5
-5
-5
10
-q
-7
-9
-a
-9
-7
*M»O
-5
-5
-5
-5
-5
-5
5
5
5
6
q
9
10
5
5
-5
-86-
-------
The advective Index table, Table 7, for the month of May shows
for Corona nine Type II days. The number of similar Type II days for
Riverside Is eight; since some of the above days do not coincide, there
1s a total of 10 days, for May, falling In this category. During these
days, representative hourly values will be chosen for the "day" hours.
Each hourly value denotes the [03] for the total subject area. Table 8
further verifies that one hourly average value is indicative of the ozone
concentration for this category. The computer program will select these
days and will output the representative value which is the hourly arith-
metic average of the two available monitoring stations. The apparent dif-
ference between the number of events expected for 10 days, 120 hours,
and the indicated number of events, 78 hours, is due to missing data.
During May there are 14 Type III days. One value cannot repre-
sent the ozone distribution over the Riverside metropolitan area. Two
values are necessary, each representing one geographic zone. The two zones
have already been defined. The steps that follow are used to strengthen
12 2 3
the validity of this choice. Studies by Zeldin , Anderson , and Arnold
strongly suggest this geographic separation. Figure 8b shows the wind
roses for the stations that are relevant in the geographic zone. The dia-
grams below the computer write-up for the wind roses illustrate the per-
sistent wind directions and further strengthen the two zone advective
mechanisms. (Persistent wind direction for purposes of the present study
is the wind direction that occurs for at least 10 percent of the month.)
In contrast to the above directions the wind rose for Corona and the per-
sistent wind direction (see Figure 9) for the month of May suggest a
-87-
-------
Table 7. The Advection Numbers for Corona and Riverside for the Month of May 1975
STAT
r.n
r.n
, r.n
I'cn
iCn
; Cn- -
,;§n-
i r rv —
! v'.r
; cn
. en
: cn
i rn .
1 V* 1 1
' cn
i CO
en
Ten
i'cn
1 en
en
, cn —
' en
en
en
r.n
en
• en
i'cn
CM
r n
I,'1
cn
en
a I
NT
RI
R I
1 PI '
' P I
! p j
' RI
; RI
• RI
i R I
L. HI
1 ' R T - - • -
i RI
RI
-
R !
D I
i'|»I
i R I - --
' Q T
• RT
p i
• RI -- -
j *T --;•;• -
' R I
VHI
PT
RI
•RI --••
OATF
750501.
75050?
750503
750504
75O505
75050ft
750507
750509
750510
750511
•7 CA c* i i
750513
750514
750515
75051ft
750517
75051 «
750519
•750570
7505?!
7*0522
750523
750574
750575
750S?ft
750527
75052R
"7 cr\ c 9o
* T * ' ^ £. "
750530
750*31
7*0501
750502
750503
T C f\ C. f\ t
7 *S f i T O **
750505
75050ft
-750507
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750523
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750525
7505?ft
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750530
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1 i
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2ft
•-•- 17 - •-•
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9
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— 15 --••
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24
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MAX
13
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1" -10
1
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ft —
1
-3
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I
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^^ ^^1 o
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3...
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10 -
1—
1
1
— - -5-
0
-11
. — -1 —
1
1
Q ^ ^^
-10
0
. 0
-------
Table 8. Hourly Difference of Ozone Concentrations from the Monitoring Station* of Corona
and Riverside for Type II Days During the "Day" Hours of May 1975
A (Riverside -Corona)
-4
-3
-2
-1
0
1
2
3
4
Number of Events
0
5
10
18
24
9
6
4
0
Partial Percent
0.00
0.07
0.13
0.24
0.32
0.12
0.08
0.05
0.00
Cumulative Percent
0.00
0.07
0.20
0.43
0.43
0.87
0.95
1.00
1.00
-89-
-------
CH| »>1 ft
N
tut
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f
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CM.*
s.tnt
10T*L
kT MlNU Ml
0
n
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n
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1)
n.o
0
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n
n.o
n
o.n
n
o.o
0
o.n
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o.o
n
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0
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0.0
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0.0
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14.«
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A n -*' Sl ' 10 "*
O.O -q.7 7-0 ,>4 ,7iT
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"•0 *•» 0.3 0.0 A.A
111 A 0 0 111
15.3 0.0 0.0 O.O 15.3
1" W 1»2 103 72^
l«.l 4S.4 2».i |4.2 ino.o
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»»r uiNn int*
N
HHf
Ht
IM
t
IM
SF
Sill!
S
MK
SW
MV
M
MM
NW
NNtf
C
-------
different wind flow channel for the southern segment of the Riverside
metropolitan area. The wind direction from Santa Ana Canyon station,
provided by the Orange County zone of the APCD, is such that it allows
for the possibility of two distinct flow patterns immediately after the
end of the Santa Ana Canyon.
Further indication of an advection mechanism involving the axis
of Chino-Riverside-Redlands and covering the northern sector of the sub-
ject area is illustrated in Figure 10. It is observed that during this
representative day the three stations peak in order with Chino leading
the way and Redlands at the end. Furthermore, the second less pronounced
peak, typical of high ozone concentration days, also suggests an advection
mechanism. It must be emphasized that all the monitoring instruments in
the various counties in southern California are calibrated by State
authorities and no correction factors are needed. Since there are no
neighboring stations to the Corona station, data from this station are
utilized for the southern zone on the basis of the wind flow patterns and
studies by Arnold3. The diurnal wind direction and speed variations
is also checked on all pertinent days to verify that the flow patterns
assumed are not contradicted by the data from the various stations.
Even though the wind data from the various stations are subject
to local topographic influences13'7'3, and thus suspect, it is encouraging
to point out that the daily data utilized strengthen the hypotheses made
in this study with respect to meteorology. The daily data from the southern
California APCD are assumed to be a secondary source used to verify the wind
flow patterns suggested by scientific works specifically designed to study
-92-
-------
O«.Tt: = . S 514
.+-
n
z
n
H
f
c
n
N
C
to
Oil
I
H
II
N
M
I
I.
25.0000
2 2. "5000
2o.cmoo
17.5000
15.0000
12.5000
10.0000
0.0
13
IS 1* 17 1« 19 20 ?1 22 ?3
ni ?345*7«<»101112
LOCAL STANDARD TIME
Figure 10. Typical Diurnal Og Concentration Variations for the Three Stations in the Northern Geographic Zone.
The orders of maximum concentration and the presence of double peak suggest an advective mechanism.
5 « i v
C r M i
U
*
i n
-------
the patterns, only because they are very strongly influenced by the local
topography. A more extensive study in the future should incorporate wind
data from a number of airports which, along with data from the APCD sta-
tions, should provide a sound scientific basis for the generation of per-
sistent wind direction patterns. The existing evidence, it must be
emphasized, strongly support the flow patterns presented here.
On the basis of the'above analysis, two 03 concentrations will
be calculated. The one for the N-geographical zone is the hourly average
of the three stations involved in the advective mechanisms, Chi no, Riverside,
and Redlands. The S-geographic zone assumes the hourly values from the
Corona monitoring station. The distribution of the hourly readings from
the average hourly reading for the N-geographic sector (see Table 9) pro-
vides a final check on how representative the N-ozone concentration is.
The last classification of the 03 concentration diurnal vari-
ation includes Type I days which show no readings of 10 pphm or higher
during the "day" hours for both the Riverside and Corona monitoring sta-
tions. Since there is no 0? structure during these days, one value will
be chosen to denote the 0? concentration throughout the "day" hours;
this value is the arithmetic average of all the readings during the per-
tinent hours from the two stations. Table 10 shows the distribution of
the difference between the average value and all the hourly readings of
the no "structure" days. The symmetry observed in the table indicates
that the chosen average is representative of the 0^ concentration for
the specific days and hours investigated.
-94-
-------
Table 9. Distribution qf theJDifferenqB Between the Average Representative 03 Conaentrati
and Hourly Values from Chino, Riverside and Redlands Monitoring Stations for Type7 HI
Days for the Month of May 1975
A (Riverside, Chino,
Redlands - Average)
-10
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
1
2
3
4
5
6
7
8
9
10
11
Number of Events
1
0
2
8
8
13
21
29
53
80
73
82
42
42
16
11
8
5
2
0
1
1
Partial Percent
0.00
0.00
0.00
0.02
0.02
0.03
0.04
0.06
0.11
0.16
0.15
0.17
0.07
0.07
0.03
0.02
0.02
0.01
0.00
0.00
0.00
0.00
Cumulative Percei&J&j
0?00 ^1
0.00
0.00
0.04 -\«
C-J
0.06 '
0.09
0.13
O.J9 *g
0.«.0 "*H
0.46
0.61
0.78
0.85 «:
0.92
0.95
0.97
0.99
1.00
1.00
1.00
1.00
1.00
-95-
-------
Table 10. Distribution of the Difference Between the Average Representative 03 Concentration
Value and Hourly Values from the Corona and Riverside Monitoring Stations
for Type I days during the "Day" Hours of May 1975
A (Riverside, Corona
- Average)
-5
-4
-3
-2
-1
0
1
2
3
Number of Events
1
1
5
13
19
46
37
16
4
Partial Percent
0.01
0.01
0.04
0.09
0.13
0.32
0.26
0.11
0.03
Cumulative Percent
0.01
0.01
0.05
0.14
0.27
0.60
0.86
0.97
1.00
While we shall not explicitly state all the steps taken in the
analysis of the subsequent months, we must emphasize that the process was
repeated for every month, all options were investigated and the choices
were verified within the limits stated in this section.
In the balance of this section, the facts and necessary support-
ing material will be summarized without a detailed analysis which, of
course, follows the steps outlined in the investigation of April and May.
June 1975
For the month of June the background 03 concentration is 1.29 +
0.68 = 1.97 = 2.00 pphm; Figure 11 shows the distribution of ozone concen-
tration for the "night" hour after June 1975.
-96-
-------
400 --
300--
o
•g
J 200-
55
100_
220 .
227
161
1 I'8 ," _
>5
[ojpphm
Figure 11. Distribution of O3 Concentration Hourly Readings for the "Night" Hours of June 1975
Table 11 provides the number of days and hours for Type III
days. During June, there are 21 such days which require two hourly
readings for the subject area, one for the N-geographic zone and the
other for the S-geographic zone. Data from the advective index table,
Table 12, suggest the possibility of advective mechanisms that cause
the high 03 concentrations, and point out the dally maximum ozone con-
centrations and the number of hours during a given day with 03 concen-
trations of 10 pphm or higher. There are seven Type II days during
June 1975, one hourly ozone concentration will denote the ozone levels
for the total area. There are no days during June when both stations
record hourly readings of less than 10 pphm throughout the "day" hours.
-97-
-------
Table 11. Days and Hours During Which the Difference Between the Respective Hourly O Concentration
Readings from Corona and Riverside Exceed + 5 pphxn for the "Day" Hours of June 1975
PAYs
OAYs
DAYS
OAY"
OAY =
OAY =
r>AVs
PAY =
OAYs
PAYs
OAY =
OAY =
OAY =
OAY=
OAY"
OAYs
OAY =
OAY"
OAY"
OAY=
DAY"
OAY =
PAYs
HAY"
PAY =
OAV =
OAY"
OAYs
OAY =
OAY =
PAY"
MAYs
OAYs
OAYs
PAY"
OAYs
riAYa
RAY"
OAY"
HAY"
PAVs
PAYs
OAY =
OAY"
OAY"
OAYs
OAYs
OAY«
OAYs
PAYs
PAVs
PAY"
CIAY"
PAY"
PAY"
OAYs
PAY =
PAYs
fiAYs
PAYs
OAV =
OAY"
PAYs
PAYs
PAY"
PAY"
OAYs
OAY"
OAY"
PAY"
OAYs
OAY"
OAY"
OAY"
PAY"
PAY"
1
1
1
7
3
5
s
5
ft
ft
7
7
7
10
10
10
10
10
11
11
11
11
17
17
17
12
17
12
17
13
13
13
13
14
14
14
14
\«i
IS
IS
15
IS
?|
77
27
22
73
25
75
75
7ft
7ft
7ft
?ft
7ft
7ft
7ft
7ft
77
77
77
77
77
77
77
77
7R
7R
7"
7"
7"
79
30
30
3O-
30
MOllBa
HOURs
HOIIRs
HOUR"
HOI i<4 =
HOI IPs
HOriBa
upnlls
HOIIU"
MOIIPs
HOIIRs
HOURs
nniiPs
uniiRs
Mm 10 =
HOIIRs
HC1IIO =
HOUR a
HOI IP s
HOI IP "
HOIIW"
HI II IBs
HOUR"
HOUR"
MOI IPs
HOUR"
HOIIRs
HOUR"
HOIIRs
HOIIRs
HOIIRs
HOUR s
HOIIRs
HOUR"
HOI (Pa
•HOIIRs
HOIIRs
HOI IPs
HOIIRs
HOUR"
HOI IP"
HOI IPs
HllllKa
HOI IP"
HOIIU"
MOIIPs
HOUR"
HOIIU"
HOIIRs
HOI IP a
HOI IP c
Ml II IP"
HOI IP a
Mfll IPs
Hill IPs
UOIIRs
HPIIP s
HflllR =
MIIIIRs
MOI IP "
Up) IPs
HOI IP s
HI II IP. a
HOI IP »
MOI IPs
HPIIP"
HOUR"
HOI IP a
HOUR"
MOI IP"
HOI IPs
HOUR"
HOUR"
HOI IB"
HOUR"
HOUR"
14
IS
1ft
is
14
1?
15
1ft
17
14
10
11
12
13
!'•
1ft
17
1R
14
1ft
17
IB
11
17
13
14
15
]ft
17
13
14
15
1ft
11
1*
17
19
17
| 3
14
IS
1ft
13
11
15
1ft
1^
14
1ft
17
17
13
14
15
|ft
17
1"
1"
Q
11
11
17
14
IS
1ft
10
g
10
11
17
14
1?
13
17
1"
19
CHROMA
CO° ON A
CORONA
CORONA
CORONA
CORONA
C' IRON A
COPONA
CORONA
CORONA
COB OMA
CORONA
CORONA
CORONA
COPONA
CORONA
CORONA
COPONA
CORONA
CORONA
CORONA
COUOUA
CORONA
COPONA
CORONA
COPONA
CIIUONA
CORONA
CORONA
CORONA
CORONA
COBilNA
COPilNA
CORONA
CORONA
CORONA
CORONA
COPONA
CORONA
COB ON A
CORONA
COP ON A
CORONA
COPONA
CORONA
CORONA
CORONA
COX OMA
CORONA
r.flBOMA
CORONA
COPONA
COD ONA
CIlPflNA
CO»I)NA
CORONA
CFI3ONA
CORONA
COR OMA
COD ONA
COT1NA
COPONA
C'lHIlNA
CORONA
COP ONA
CHROMA
COP ONA
COBIINA
CORONA
CORONA
CORONA
CORONA
COB OMA
CORONA
CORONA
CORONA
CONC"
CO|>'C =
CONC"
CONC =
CONCs
CONC"
CC1NC"
CONCs
criNCs
CONC =
CONC =
CONC"
CONC =
criNC=
CONCs
CONC =
CONC =
CONC"
CONC"
CONC"
CONC=
CONC"
CONC"
CONC"
criNC=
CONC"
CONCs
CONC =
CONCs
CONC"
CONCs
CONC"
CONC"
CONC"
CONC=
CflNC"
CONCs
CONC =
CONCs
CONG"
CflNC=
CONCs
CONC"
CONC =
CONC"
CONC"
CONC"
CONC"
CONCs
CONf."
CONC=
CriNC-
CONC"
CONCs
criNc=
Cl INC =
CONC"
C'INC"
C'lNC-
CONf.s
cnni>
COMC=
CONC"
CflNC"
CflNC"
CONf,"
CMNC »
CMMC«
CONC"
CONC"
CONC"
CONC"
CONC-
CONC"
CONC=
CONC-
10
10
10
ft
4
10
10
12
15
1R
fl
9
10
1R
1R
16
13
ft
77
72
1R
10
I)
10
11
11
11
9
ft
13
11
9
7
13-
12
10
2
11
9
R
7
5
14
11
10
fl
R
17
9
ft
11
H
R
fl
R
9
fl
5
3
R
R
10
9
fl
7
7
ft
7
7
10
11
10
9
R
9
5
HtVFHSlMF
RIVFRSIOF
KIVFRSIDF
RIVFRSIDF
RIVFRSIOF
RIVFRSIOF
MIVERSIHF
RIVFRSIOF
R IVFRSIOF
RIVFRSIOF
RIVhRSIDF
RIVFRSIOF
HIVFRSIDF
«IVFRMOF
RIVF.RSIOF
RIVERSIOF
RIVERSIOF
RIVF.RSIOF
RIVF.RSIOF
RIVFRSIOF
RIVERSII1F
R I VF.RSIDF
RIVERSIOF
R 1 VERSI DF
HI VERSI OF
HIVFRS10F
RIVERSIOF
RIVFRSIOF
RIVFRSIOF
RIVERSIOF
RIVERSIOF
RIVFRSIOE
RIVFRSIOF
RIVFRSIOF
RIVFRSIDF
RIVERSIOF
RIVFRSIDF
RIVFRSIDF
RIVF.RSIDF
RIVFRSIDF
RIVERSIDF
RIVERSIDF
RIVERSIDF
HIVFRSIOF
RIVF.RSIDF
RIVERSIDE
RIVERSIDE
RIVFRSIDF
RIVFRSIDF
RIVFRSIDF
RIVFRSIDF
HIVFKSIliF
KIVFRSIDF
RIVFHSIDF
RIVFRSIDF
R1VFRSIHF
RIVFRSIDF
R 1 VFRSIOF
RIVFKSIOF
PIVFRSIOF
RIVFRSIOF
HIVFRSIOF
RIVFRSIIlF
RIVFRSIDF
RIVFRSIOF
PIVFRSIOF
RIVFRSIOF
RIVFRSIIlF
RIVFRSIOF
RIVFRSIOF
» IVFRSIOF
RIVERSIDF
RIVFRSIDF
RIVFRSIDF
KIVFRSIDF
RIVFRSIDF
CONC"
CONC =
CONC"
CONC"
CONCs
CONCs
CONC=
CONC"
CONCs
CONC "
CHMC=
CONC"
CONC"
CONC=
CONCa
CONCa
CUNC"
ClINC"
CONC=
CIINC =
CONC"
CONC =
CONC"
f.ONC =
CONCs
CONC"
CONC"
CONC"
CONCs
CONC"
CONC=
CONC"
CONCs
CONC=
CDNCs
CONC"
CONC =
CONC"
CONC"
CONC"
CONC =
CONC"
CUNCa
CONCa
CIINC"
CONC"
CONC=
CI1NC"
CONC"
CONC"
CONC"
C'INC"
cow."
I.I INC"
CONC=
CMMC"
CONC"
(.(INC"
C.ONC"
r.'iNC"
CHNC"
CIINC"
CIINC"
CflNC"
CONC=
CONC"
CONC"
r.oMC"
CMNC"
CIINC »
CflNC"
COMC"
COMC"
CIINC"
CONC"
CONC"
17
17
16
9
1ft
21
1R
20
75
14
15
15
23
26
21
1H
14
71
31
75'
1H
1H
19
20
19
Ifl
16
12
20
17
16
13
19
17
15
7
17
16
15
13
10
20
17
17
14
14
22
15
13
1H
OtFFs
OlFFs
DIFF"
OlFFs
DIFFs
OlFFs
DIFFs-
OIFFa
DIFFs
OlFFs
OIFFa
OIFFs
OIFF =
OIFFa
DIFFs
OIFF"
OIFF =
OIFF"
OIFFa
OIFF"
OIFF =
DIFFs
OIFF"
OlFFs
OlFFs
OIFF"
OIFF"
OIFFs
DIFFn
OIFF"
IIIFFs
lllFFs
OIFF"
OIFF"
OIFF"
OlFFs
OIFF"
OIFF"
0|FF"
OIFF"
IHFFs
DIFF"
OIFFs
01FF-
DIFF"
OIFF"
OIFFs
DIFF"
OIFF"
DIFF"
OIFFs
-7
-7
-6
-7
-5
-6
11
-6
-5
-7
-6
-6
-S
-5
-H
-5
-5
-6
ft
-9
-7
-fl
-9
-9
-9
-fl
-7
-7
-6
-7
-ft
-7
-ft
-6
-5
-5
-5
-6
-7
-7
-6
-5
-6
-6
-7
-ft
-6
-S
-6
-7
-7
14 OIFFn-11
14
13
14
16
13
10
13
16
15
15
IS
13
12
7
1 7
] 4
16
15
16
15
14
13
15
11
DIFF"
IIIFFs
DIFF"
DIFF"
DIFF"
DIFF"
|)| Fpa-
OIFF"
OIFFs
OIFF"
MIFF"
MIFF"
DIFF"
OIFF"
DIFF<
DIFF"
OIFF"
MIFF"
OIFF"
f»IFF«
OIFF"
OIFF"
OIFF"
OIFFs
-ft
-b
-ft
-7
-5
-5
10
-R
-7
-5
-ft
-5
-5
-5
-ft
-7
-9
-">
-S
-5
-5
-«j
-6
-ft
-98-
-------
Table 12. The Advection Numbers for Corona and Riverside for the Month of June 1975
STAT
cn
cn
cn
cn
cn
cn
cn
cn
cn
cn
cn
cn
cn
cn
cn
cn
CO
cn
cn
cn
cn
cn
cn
CO
cn
cn
cn
cn
CO
cn
RT
RI
PI
RI
R I
RT
RT
RI
RI
R I
RI
RI
RI
RT
RI
PI
P.I
PI.
RI
RI
PI
RI
PT
RT
H I
RI
RI
RI
PI
RI
OATF
75OA01
7SOA02
7SOA03
7«50A04.
7SflAOfi
750AOA
7«iO*>o7
750A08
7t»OA09
750A10
750A11
75QA12
750A13
750A14
750A15
7«50A1A
750A17
750A18
750A19
750A20
750A21
750A?2
750A?3
750A24
750A?"?
7«50A?ft
750A27
750ft2«
750A?9
750A30
7SOAOV
750A02
7SOA03
750A04
750A05
750AOA
750A07
750AO«
75('AO°
750A10
750A1)
75PA1 ?
750A13
7SOA1A
7-50A15
750A IA
750A17
7SOA] H
750A19
7<50ft?0
7SOA?l
710A2?
7«%f)A?3
750A?/f
7c,OA?'i
7«?OA?A
7Sf'A?7
750A?8
7S(IA?CJ
7SOA^O
F
11
12
0
0
12
11
12
0
11
10
10
12
10
10
11
0
0
0
0
0
10
"10
0
0
10
10
12
12
9
9
10
12
0
0
11
10
10
14
11
10
10
10
10
10
11
0
0
0
0
0
10
10
12
1?
11
10
9
9
9
9
MAX COMC TIMP MAX
14
13
H
8
13
?0
10
7
17
18
27
11
H
18
11
A
5
4
3
A
15
15
9
9
17
11
11
'./T, 12 - -
"'•'•" 13
11
17
15
9
-1
21
25
15
10 ,
21 V
2ft
31
20
20
20
17
9
A
4
4
9
20
17
14
11
22
19
1ft
1ft
)ft
15
12
13
1?
14
14
13
12
14
13
13
14
13
12
12
11
13
13
13
11
12
12
13
11
14
14
11
13
13
10
12
14
14
1^
14
15
14
11
14
15
1A
1ft
13
13
14
12
15
12
10
14
14
1?
11
13
14
14
13
10
11
n
18
H •
A
3
1
1
A
A
2
1
7
a
9
4
5
8
2
1
1
1
1
1
8
8
1
1
A
3
2
4
A
R
H
5
1
1
7
8
7
2
7'
9
9
8
9
9
ft
1
1
1
1
1
g
9
3
4
7
10
9
9
9
11
A
-5
-9
1
1
-A
-5
-10
1
-4
-2
-1
-8
_5
-2
-9
1
1
1
1
1
-2
-2
1
1
-4
-7
-10
-a
-3
-1
-2
-7
1
1
-4
-2
-3
-12
-4
-1
-I
-2
-1
-1
-5
1
1
1
1
1
-1
-1
-Cl
-n
-A
0
0
0
0
2
-99-
-------
July 1975
Similar steps for the month of July indicate a background
average reading for the "night" hours of 1.07 + 0.86 = 1.93 = 2.00 pphm,
the distribution for these hours is indicated in Figure 12. During the
month of July there are 29 Type III days which require two representative
hourly 0, concentrations in order to define the ozone levels in the
Riverside metropolitan area. The remaining two days show at least one
Og concentration of 10 pphm or higher for at least one of the two sta-
tions* however their respective hourly differences remain within the
prescribed limit. These two days are Type II days and one hourly reading
will represent the total subject area.
The necessary distributions and further supporting material,
similar to,that provided for April and May, are given in Appendix B.
400 - •
300 - -
3
a
u
100- -
354
225
160
.33 .
I I" I
36
0 1 2 3 • 4 >5
[Ojpphm
Figure 12. Distribution of Ozone Concentrations for the "Night" Hours During the Month of July 1975
-100-
-------
4.2 INCLUSION OF DATA FROM THE MAGNOLIA MONITORING STATION
It is evident, by now, that the developed approach is a month-
by-month study based on the ozone concentration gradient between two
existing monitoring stations. We have alluded that within the Riverside
metropolitan area there exists a third monitoring station operated by
the California State Air Resource Board. Data from this station will be
utilized to test the approach, increase the geographical zones, when
necessary, and verify the procedure on more than two stations. This is
done by applying the technique on two additional station sets, the
Magnolia-Corona and Magnolia-Riverside, and investigating the results in
conjunction with the output from the Corona-Riverside set.
Magnolia is geographically located in the N-zone. During-April
inclusion of data from Magnolia indicates that the station belongs in the
N-zone. For the month of May, from a total of 156 hourly readings of
Type III days, only 3 readings would put Magnolia to the S-zone. Contin-
uing with June we find that only 40 hourly readings from a possible 228
would relocate Magnolia to the S-zone; the numbers for July are 18 and
312, respectively. The extent to which these numbers "validate" the approach
is judgmental. However, the author feels that the strength of the procedure
is its ability to include more data as they become available. Following
is a more inclusive approach offering exactly the same procedure on all
three sets of data.
If all three relative studies indicate Type I days, one ozone
concentration value is calculated for the subject area: the mean of the
three stations. If a Type II day is indicated in at least one of the three
-101-
-------
studied sets, then hourly structure is computed for the Riverside
metropolitan area, with the mean of the three hourly readings as the
representative value. The persistent windflow patterns, reviewed in
previous sections, suggest two basic geographic-pollution zones: the N-
and S-zones indicated in Figure 13. The study of the Magnolia ozone con-
centrations, the local ozone production from downtown Riverside City and
the interaction of the two advective wind flow patterns often (not always)
necessitates a third zone: the C-zone indicated in Figure 13 by the broken
line. The third zone is generated by the three stations' concentration
gradient mechanisms, only wnere the Riverside-Magnolia ozone concentra-
tions indicate a Type III day; any other combination of Type III days
will generate two zones. Even though the indicated geographical-pollution
zones must be considered as assumptions, it is emphasized that the topog-
raphy of the area, the persistent wind directions, and the study of the
advective index strongly suggest that these are appropriate demarcation
lines. Finally, the inclusion of the Magnolia ozone data does not change
the monthly background values. Table 13 summarizes the time and space
structure for the four month study for the three stations in the Riverside
Metropolitan Area.
-102-
-------
Figure 13. The Riverside Metropolitan Area, the Three Geographic Zones Indicated from the
Applications of the Ozone Concentration Gradient Procedure on Data from the Three Local Monitoring Stations
-T03-
-------
Table 13. Monthly Distribution of Types of Days in the RMA. The numbers in
parentheses indicate days with three space zones, the remaining Type III days require two zones.
Month
April
May
June
July
Type of Day
I
23
6
7
0
11
2
7
1
1
III
5(0)
18(7)
22 (19)
30 (26)
The bulk of this work refers to first the two stations studied.
The inclusion of the third station verifies the study to the extent that
only few readings put the Magnolia data in a different zone, or the extent
that, depending on our needs we may formulate a denser grid. The approach
remains essentially the same and only minor changes are necessary. The
discussion appearing in Section 5.0 refers to the two station approach.
-104-
-------
Section 5.0
DISCUSSION AND CONCLUSIONS
The temporal and geographical distribution of ozone concentra-
tions in the Riverside metropolitan area has been investigated. The approach
taken is unique because it does not seek to estimate the pollution source
strength or to define various complex chemical and meteorological kinetic
schemes utilized in the past for similar studies. The present work is also
unusual because it does not investigate trends over long time-periods or
details over short time-intervals, but it puts the foundations for a study
of the diurnal ozone level variations in the subject area for the duration
of the six-month summer ozone cycle. The resultant mapping over the area
uses three sets of criteria: time period, 03 concentration range, and
geographical zones. The step-by-step process begins by defining a time
interval of investigation, then (depending on the [03] range) defines
three classes of "day"-hours days, and finally a choice is made with
respect to the area represented by the two monitoring station readings
on the basis of the structure of the ozone concentration hourly variation.
Figure 12 illustrates the criteria.
A computer program (see Appendix B) has been written which takes
under consideration the above criteria and provides the pertinent hourly
ozone concentrations for the Riverside metropolitan area; a sample of the
monthly output is shown in Figure 13. Appendix B shows the hourly [03]
variations for the four months investigated as well as a series of distri-
butions which support the approach taken.
-105-
-------
I
M
E
P
E
R
1
O
•* 3
A
N
G
Month
1
(p^J Diurnal Variation
"Night"
^
/
Hours
\
"Day" Hours
f
One Monthly
Background
Value
/
, /
/
/
/
\
i
r
All Hours with Type I Days:
[O3]<10pphm
One Average fOal Value
L. OJ
4
At Least One Hour with Type II Days:
rO,]>10pphm
X
A^L
ar|r|
D^ I ^ 1 ^3*5 1 11 "^ v QO1U&
12 Hourly Average [OgJ Values
1
At Least One Hour with Type III Days:
/-
\L
To 1 > 10 hm
LU3J — A PP"111
and
^•Riv. L ^J Cor./ I ~
m
Two Sets of 12 Hourly [p J Values
One
Geographic
The
Riverside
Metropolitan
Area
(RMA)
Two
Geographic
Zones
1. The N - RMA
and
2. The S - RMA
£
G
R
P
H
I
c
z
0
N
S
Figure 14. Criteria Used in the Definition of the Ozone Levels with Respect to Time, Concentration, and Space
-106-
-------
HOURLY VALUFS USED
DAY
1
2
3
4
5
6
7
A
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
2A
25
26
27
2R
29
30
31
TYPF
II
III
III
I
I
I
III
II
III
III
III
III
III
III
III
II
II
II
I
I
I
II
III
II
II
II
I
II
III
III
III
NT
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
N
ft
A
7
4
5
ft
7
A
6
10
9
14
6
3
5
6
9
5
4
4
5
fl
7
6
3
3
3
7
5
7
7
9
S
6
10
9
4
5
ft
ft
A
7
16
13
17
4
3
5
6
9
5
4
4
5
n
5
A
3
3
3
7
7
6
7
10
N
7
10
10
4
5
6
A
9
7
12
10
1A
9
5
6
7
11
7
4
4
5
9
11
9
7
5
3
9
7
12
12
S
7
15
9
4
5
ft
10
9
ft
19
15
19
ft
6
6
7
11
7
4
4
5
9
9
9
7
5
3
9
9
12
11
11
N
ft
13
12
4
5
ft
A
11
11
13
12
1ft
13
R
9
7
14
A
4
4
5
9
13
13
9
A
3
11
9
13
16
*
e
1ft
10
4
5
ft
10
11
15
20
14
20
13
10
H
7
14
ft
4
4
5
9
11
13
9
8
3
11
11
17
11
1? 1
M
9
14
11
4
5
ft
9
1 '/
12
14
13
?2
ift
U
9
H
17
10
4
4
5
11
12
12
10
13
3
13
10
17
17
S
9
20
10
4
•>
ft
11.
1?
Ift
?4
1ft
2?
15
12
10
K
17
10
4
4
5
11
15
12
10
13
3
13
14
26
15
N
11
15
10
4
•j
ft
11
13
13
15
9
22
IN
IS
11
8
19
10
4
4
5
11
19
14
11
13
3
14
7
20
18
.3
S
11
23
10
4
b
ft
14
I'-i
?3
23
17
23
1ft
15
9
H
19
10
4
4
S
11
1R
14
11
13
3
14
14
23
17
HOUR
14
N
1-
17
9
4
5
ft
12
10
16
16
1 1
19
17
1ft
11
7
21
8
4
4
5
10
1ft
14
10
16
3
15
9
23
16
S
11
18
9
4
5
6
16
10
23
26
17
17
14
lb
9
7
21
fl
4
4
5
10
19
14
10
16
3
15
13
27
17
15
M
9
17
7
4
•>
ft
12
ft
1ft
16
16
13
14
13
11
ft
19
ft
4
4
5
ft
16
13
9
14
3
13
10
23
14
S
9
IS
ft
4
5
6
14
ft
24
23
15
14
10
12
10
6
19
6
4
4
5
ft
14
13
9
14
3
13
11
27
15
16
N
H
15
6
4
5
ft
10
H
If)
14
14
10
3
11
11
5
13
5
4
4
5
6
12
12
7
12
3
10
10
23
13
s
M
14
6
4
5
6
10
H
15
17
15
11
ft
11
11
5
13
5
4
4
5
6
15
12
7
1?
3
10
11
27
11
17
M
7
12
5
4
S
6
7
6
12
11
12
7
7
9
9
5
10
4
4
4
5
5
11
9
7
9
3
A
11
15
11
S
7
13
5
4
5
6
H
6
11
11
14
fl
5
10
ft
5
10
4
4
4
5
5
16
9
7
9
3
ft
10
22
14
18
M
5
9
4
4
5
6
ft
3
ft
9
10
4
5
7
6
3
7
3
4
4
5
3
ft
9
5
A
3
8
fl
14
11
S
.,
ft
5
4
5
ft
7
3
ft
ft
11
5
3
K
ft
3
7
3
4
4
5
3
14
9
5
A
3
A
9
15
13
N
4
4
3
•+
•')
n
4
•p
ft
4
7
2
3
5
4
3
5
2
4
4
5
2
5
ft
4
5
3
6
ft
10
B
19
S
4
4
6
4
5
ft
5
2
5
4
7
2
3
6
5
3
5
2
4
4
5
?
10
fl
4
5
3
6
8
9
8
20
N
4
2
3
4
b
6
2
1
2
?
4
1
1
2
3
2
4
1
4
4
5
1
1
7
2
3
3
5
4
7
5
S
4
2
6
4
5
ft
2
1
3
2
5
2
3
4
4
?
4
1
4
4
5
1
5
7
2
3
3
5
5
4
5
NT
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Figure 15. Sample Output of the Hourly Crone Concentrations During the Month of May 1975
-------
Two assumptions were made In the phenomenological approach
developed here:
(1) A demarcation line of 10 pphm of ozone concentration was
chosen as indicative of a variation that would be useful in a study of
ozone concentration dose-response correlation. While the choice is arbi-
trary it is also highly appropriate because it is the air quality stan-
dard for the State of California and very close to the Federal standard
(8 pphm). Related to this assumption is a finer subdivision for the
hourly difference between the two available stations. Different steps
are taken when at least one such hourly difference is larger than 4 pphm.
This approach guarantees that the space mapping of the ozone concentration
is always within the limit of 10 pphm of ozone.
(2) When necessary we have divided the subject area into two
zones. This division was done on the basis of scientific studies for pre-
vious years investigating the persistent wind data, and strong indications
of the meteorological data obtained from the relevant air pollution moni-
toring stations. We choose, however, to include the two geographic-zone
separation among our assumptions because the wind data are suspect. It is
believed that a more detailed study including data from a number of
neighboring airports will verify the wind flow patterns.
The following conclusions have been made on the basis of our
phenomenological approach:
• It is possible to estimate ambient ozone concen-
trations levels for the Riverside metropolitan area
without assuming a uniform ozone level over the
total subject area.
0 The practical procedure developed is equally reliable,
faster, less expensive, and less complex, than the
more detailed and quite involved models.
• The approach outlined in this document can be utilized
to cover a larger area and include the total eastern
segment of the Los Angeles basin. While the number
of monitoring stations will increase, the two basic
wind flow patterns utilized in this study will
determine the various advection mechanisms substan-
tially controlling the local ozone diurnal behavior.
-108-
-------
This procedure of time and space mapping of [03]
in urban centers can be applied outside the Southern
California area. A day-by-day study of the wind
patterns is possible anywhere if the appropriate
data set is available.
This study is meant to investigate the six-month ozone cycle,
however, data for the months of August and September were not available
at the time of completion of this phase of the project. The approach
undertaken strictly refers to the hourly ambient ozone concentration vari-
ability. Further work is needed to investigate the concentration levels
of other pollutants, and the relationship between the indoor and outdoor
concentrations. With respect to the other primary pollutants, during
the ozone cycle months of 1975 only the Riverside monitoring station
obtained relevant readings on suspended particulates, CO, NO?, NOx, and
S02 concentrations.
In terms of further steps, it is suggested that a series of
correlation studies be undertaken and pertinent hourly concentrations of
all the primary pollutants be estimated for the Riverside metropolitan
area. The relationship between indoor and outdoor pollution levels might
be projected on the basis of an in-depth literature study. Representative
results of a preliminary look are summarized in Figure 14 which illustrates
some of the findings of relevant scientific work.
In summary, this study has established a procedure which maps
ozone concentration readings in time and space from two monitoring stations
over the Riverside metropolitan area. The constructed empirical model
divided the data in two daily time intervals depending on the ozone con-
centrations levels, in three types of ozone concentration days depending
-109-
-------
(a)
ICO
140
IN
Y.
fl OMI ftlOM*
- N.I. »i*n ) mvlti Horn VOW
• inp*n« toom
-OulbM 01 WvctWf
« O ft »
* S 3 3
Tunt. M
S S 8 S
* s 8 n
Diurnal indoor/outdoor pattern for NO: House #1,
2,
spring-summer 1973 (composite day based on
6 days of data)
Diurnal indoor/outdoor pattern for NO : House # 1,
fall 1973 (first half) (composite based on
7 days of data)
(b)
"3, I* »
•n VmbUUon lumctf on
3
cm
TDM
Relative NO levels as recorded outdoors (1), indoors (2), and as reported by
the Pasadena APCD station (3) on a typical day
POO 1300 1400 IWO !WO 1700 1800 1*
T«r«.rt>T
(c)
Total oxidant levels inside and outside university
laboratory building with 100% air makeup
IJOO 1400 1500 1600 1700 IMO 1*00 20HO
Total oxidant levels outside and inside air
conditioned military hospital
(a) -W.A. Wade, IH, W.A. Cote, andJ.E. Yocom
11
(b) - R. L. Derham, G. Peterson, R. H. Sabersky, and F. H. Shair
10
(c) - C. R. Thompson, E. G. Hensel, and G. Kats
Figure 16. Literature Illustrations from Indoor/Outdoor Air Pollution Relations
-no-
-------
on the maximum hourly ozone average and the structure of the [03] variation,
and in two geographic areas depending on the advection mechanisms present.
Four summer months have been investigated with respect to ozone concen-
trations. Directions have been set for the estimation of the other primary
pollutant diurnal variations and for the study of the indoor-outdoor pol-
lutant relation.
-Ill-
-------
Section 6.0
REFERENCES
1. Altshuller, A.P. 1975. "Evaluation of Oxidant Results at CAMP Sites in
the United States." Journal of the Air Pollution Control Association,
25, 19-24.
2. Anderson, E.E. 1973. Mesoscale Windfield Analysis of the Los Angeles
Basin. Contract Number 68-02-0223 by the Center for the Environment
and Man, Inc. for the U.S. EPA, 113 pp.
3. Arnold, J. 1975. Chief Meteorologist, Air Pollution Control District,
Riverside County Zone (private communication).
4. Derham, R.L., G. Peterson, R.H. Sabersky, and F.H. Shalr. 1974. "On the
Relation Between the Indoor and Outdoor Concentrations of Nitrogen
Oxides." Journal of the Air Pollution Control Association. 24, 158-161.
5. Gifford, F.A. and S.R. Hanna. 1970. Air Pollution Monitoring. Meeting
of the International Union of Air Pollution Prev. Association. Washington.
6. Hanna, S.R. 1975. Modeling Smog Along the Los Angeles-Palm Springs
Trajectory. Technical Report. Air Resources Atmospheric Turbulence
and Diffusion Laboratory, National Oceanic and Atmospheric Administration,
Oak Ridge, Tennessee.
7. Kay, M.L. 1975. Air Pollution Control Engr. I - Orange County Zone, Air
Pollution Control District (private communication).
8. Koch, R.C. and S.D. Thayer. 1971. "Validation and Sensitivity Analysis
of the Gaussian Plume Multiple Source Urban Diffusion Model," Report
Number EF-60, GEOMET, Incorporated, Rockvllle, Maryland.
9. Longley-Cook, B. 1970. Air Pollution Particulate Mapping. Ph.D. Dis-
sertation. The University of Arizona.
10. Thompson, C.R., E.G. Hensel, and G. Kats. 1973. "Outdoor-Indoor Levels
of Six Air Pollutants." Journal of the Air Pollution Control Associ-
ation, 23, 881-886.
II. Wade, W.A., III, W.A. Cote, and J.E. Yocom. 19 . "A Study of Indoor
Air Quality." TRC - The Research Corporation of New England. Journal
of the Air Pollution Control Association. 25, 933-939.
-112-
-------
12. Zeldin, M.D. 1973. Oxidant Distribution and Analysis In the San Bernardino
Basin. Technical Report 73-1.San Bernardino County Air Pollution Control
UTstrict.
13. . 1975. Chief Meteorologist. San Bernardino County Zone, Air Pol-
TuTion Control District (private communication).
-113-
-------
Appendix A
PROTOCOL FOR PILOT STUDY DATA COLLECTION AND CODING
The following section presents the data instruments.
-114-
-------
OZON£ EFFECTS STUDY
GEOMET, INCORPORATED
PATIENT RECORD ABSTRACT
1. Case No.
5. Sex 24
M (1)
F (2)
1-4
2. Log No. S-T
6. Ethnic Group 25
W (I) M (3)
B __J2) 0 _J4)
11. Complaints 33-47
Symptoms
3. Hospital No.
7. Age 2«-28
V(3)
8-U
4
8. Married a
Y (1)
N (2)
NCHS Onset: (1) (2)
( ) h d
(
(
)
)
h d
h d
( ) h d
(
)
h d
14. Medical History
Asthma
COPD
74-79
( 1 ) Hypertension
(2) Stroke
Heart Disease
15. Diagnostic Data
Hgb. _
WBC
Lymphs
EOS
SCOT
( )
( )
( )
( )
J )
(3) Diabetes
5-20
T. Protein (
Albumin {
Globulin (
orU (
16. Treatment 21-25
Injections
I.V. Fluids
IPPB
02 (M or N
CPR
-T)
( )
( )
( )
( )
( )
!9- Admission Data 47-«
Discharge Dx:
LOS d
17. E.D.
(4)
(5>
(6)
. E.D. Arrival M-ZJ
Day: By: Amb. (1)
Date: Time: Other (2)
9. Residence 30.31 10. Payment 32
I (1) M (3)
( ) W (2) 0 (4)
12. Condition M 13. Vital Signs 69-73
Alert
Agita
Disori
Uncoi
(1) Temperature: ( )
ted (2) Pulse: J )
ented (3) Respiration: ( )
iscious (4) Blood /( )
Pressure:
Chr. G-I Disease (7)
Liver Disease (8)
Renal Disease (9)
Chest Film;
) Positive
) Negative
) ECG:
) Positive
) Negative
Blood Gases: Electrolytes:
Jl) pH Na ( )
J2) PC02 K ( )
co2 ci ( )
(1) P00 HCO, < )
.(2)
Diagnosis w-ts
(
(
(
H-
ICDA
)
)
)
)
j
H-ICDA
< >
<
[
)
)
j
1
(Code )
18. E.D. Disposition 45
Discharge: Home (1)
ECF (2)
Hospital (3)
Admit: ICU (4)
OR (5)
Other (6)
Transfer (Acute) (7)
Died in E. D. : (8)
20. Supplementary Codes ta-n
( >
( >
( >
-115-
AUGUST 1975
-------
Ozone Effects Study
GEOMET, Incorporated
Sept. 1975
Study # 9-
E.R. Log #
INTERVIEW RECORDING FORM
Interviewer
Hosp. #
Date E.R. Visit
Call Record:
Date of Try
Time of Try
8
Notes - First Call
- Call Back #1
- Call Back #2
Final Status:
Complete _
Partial
Refused
Respondent:
Other (Specify)
Patient
Mother/Spouse
Other
Time for
Interview:
min.
(Cut Along This Line)
Study # 9-
Patient Name
Street
City/Zip
Phone
Additional Information (Relatives, Place of Work, Neighbors, Etc.) Age
Sex
(REMOVE NAME SECTION WHEN FINISHED)
-116-
-------
FIRST CALL
"Hello, this is
calling from
(Name)
Riverside General Hospital. Is this the residence of
(Patient)
[IF NOT THE CORRECT NUMBER, APOLOGIZE AND HANG UP. IF
CORRECT, PROCEED.]
"The Hospital is cooperating in a research study
of patients seen in emergency rooms. I'd like to speak
wi th •"
(Patient) (Patient's Mother)
[IF PATIENT OR PRIMARY RESPONDENT IS ABLE TO SPEAK WITH
YOU, PROCEED.]
[IF PATIENT HAS DIED, APOLOGIZE AND HANG UP.]
[IF PATIENT OR PRIMARY RESPONDENT IS UNABLE TO SPEAK
WITH YOU, SAY:]
"When would be a good time soon for me to call and
talk with him(her)? I'll note down a time that would
be convenient."
[NOTE THE TIME AND CALL BACK.]
CALL BACK
[FOLLOW PROCEDURES FOR FIRST CALL. IF PATIENT OR
PRIMARY RESPONDENT IS STILL UNABLE TO SPEAK WITH YOU,
ASK:]
"Well then, may I speak with some other adult who
knows about health and background?"
(Patient's)
[WHEN KNOWLEDGEABLE PERSON COMES TO PHONE, EXPLAIN AND
PROCEED. IF THERE IS NO KNOWLEDGEABLE ADULT TO SPEAK
WITH YOU, ASK:]
"When would be a good time soon for me to call
and talk with someone about ? I'll
(Patient)
note down a time that would be convenient."
[NOTE THE TIME AND CALL BACK.]
CALL BACK #2
[FOLLOW ABOVE PROCEDURES TO TRY TO TALK TO PATIENT,
PRIMARY OR SECONDARY RESPONDENT. IF NONE AVAILABLE,
TERMINATE ATTEMPTS.]
-------
"First, I'd like to get some background information."
1. "Thinking back to
00
1 3.
, before you (he/she)
came to the emergency room, what were you (was
he/she) doing most of the time: working, keeping
house, going to school, or something else?"
2. "Which best describes your (his/her) situation at
that time: retired, on vacation, looking for work,
not looking for work, or none of these?"
"On the job were you (was he/she) regularly exposed
(at least weekly) to very cold or very hot tempera-
tures, or such things as dust, smoke, chemical fumes
or sprays?"
4. "Did you (he/she) work during the daytime or during
the evening or night?"
5. "Did you (he/she) work in
some other town?"
or
(Town of Residence)
[IF NOT, ASK:] "Where did you (he/she) work?"
(Town)
1.
2.
3.
4.
5.
(0)
(i)
(2)
(3)
(4)
(0)
(1)
(2)
(3)
(4)
(5)
(0)
(1)
(2)
(3)
(0)
(1)
(2)
(0)
(1)
(2)
Don't know Qj)
Working or combination
Keeping house (jj)
Going to school
Something else
Don't know
Reti red
Vacation
Looking for work
Not looking for work
None of these
Don't know
No, none regularly
Yes; cold or heat
Yes; dust, smoke, chemicals
Don't know
Daytime
Evening, night
Don't know
In Metro area
Outside Metro area
-------
6. "About how much time did you (he/she) spend alto-
gether getting to and from work?
• Less than 30 minutes?
• 30 minutes to an hour?
• 1 to 2 hours?
• More than 2 hours?"
7. "Did you (he/she) spend most of your (his/her) work
hours inside, riding in a car or truck, or working
outdoors?"
vo
8. "Did you (he/she) work mostly in an air conditioned
building?"
9. "Was the school in
some other town?"
[IF NOT, ASK:] "What town?"
or
10. "Were the classrooms air conditioned?"
6.
7.
8.
10.
(0)
(i)
(2)
(3)
(4)
(0)
(1)
(2)
(3)
(0)
(1)
(2)
(3)
(0)
(1)
(2)
(0)
(1)
(2)
(3)
Don't know
Less than 30 minutes
30 minutes to an hour
1 to 2 hours
More than 2 hours
Don't know Qj
Inside (5)
Riding in vehicle
Outdoors ©
Combination inside/outside
Don't know
Yes
No
Sometimes in air conditioning -I
Don't know
Metro area
Outside Metro area
Don't know
Yes
No
Some classrooms
-------
11.
12.
L 13.
ro
"Did you (he/she) go to school during the daytime
or during the evening?"
"During the time before you (he/she) came to the
emergency room, that is during ,„ and
3 ^ (Months)
before, were you (was he/she) limited in the kind
or amount of physical activity you (he/she) could
do because of a health problem?"
[IF YES, ASK:] "Had this health condition lasted
less than 3 months or more than 3 months?"
"Which of these best described your (his/her)
limitations at this time from this health problem?"
• Could move around inside and outdoors with
no help, crutches, canes, or wheelchair?
• Needed help, crutches, cane, or wheelchair
to get around but frequently went outdoors?
• Confined to the house all or most of the
time because of health?
• Confined to bed all or most of the day
because of health?
11.
12.
13.
(0)
(i)
(2)
(0)
(1)
(2)
(3)
(0)
(1)
(2)
(3)
(4)
Don't know
Daytime
Evening
Don't know
No, not limited
Yes, less than 3 months
Yes, nore than 3 months
Don't know
No assistance
Outdoors, with assistance
Confined to house
Confined to bed
-------
74. "Old your (his/her) health problems include any of
the following conditions? (Please answer Yes or No)
a. Asthma?
b. Bronchitis, emphysema or lung disease?
c. Heart trouble, stroke or high blood pressure?
d. Diabetes?
e. Ulcers or stomach trouble?
f. Liver trouble?
g. Epilepsy or some kind of seizures?
h. Kidney trouble?
i. Arthritis or problems with muscles, limbs or
joints?
15. [IF ALL NO, ASK:] "Could you tell me what the health
problem was?" _
16.
17.
"Now could you tell me what kind of symptoms or ill
ness caused you (him/her) to come to the emergency
room?"
"Abofct how long before the visit had you (he/she)
been sick or had these symptoms?
a. A few hours or less?
b. A day?
c. 2 or 3 days?
d. 3 days to a week?
e. More than a week?
14.
15.
16.
17.
(0)
(i)
(2)
(3)
(5)
Don't know
a.
b.
c.
d.
e.
f.
g.
h.
Yes
No
i.
Don't know
Few hours
A day @
2 to 3 days
3 to 7 days
More than 7 days
-------
ro
18. "Before you (he/she) came to the emergency room did
these symptoms prevent you (him/her) from doing the
things you normally do (he/she normally does) during
the day, or were you (was he/she) about as active as
usual?"
[IF YES, ASK:] "Did the symptoms cause you (him/her)
to stay in bed during any of the days before you
(he/she) came to the emergency room?"
19. "On the day of the emergency room visit, was your
(his/her) condition getting worse, getting better,
or about the same as the day before?"
.Ji
20. "Were you (was he/she) admitted to the hospital that
day?"
[IF NO, ASK:] "Were you (was he/she) admitted to a
hospital later that week?"
21. "Was this the first time you (he/she) had seen a
doctor this year for this condition?"
[IF NO, ASK:] "About how many times in the
12 months before this had you (he/she) seen a doctor
for this problem?"
18.
19.
20.
21.
(0)
(i)
(2)
(3)
(0)
(1)
(2)
(3)
(0)
(1)
(2)
(3)
(0)
(1)
(2)
(3)
Don't know
Normal activity
Reduced activity
Stayed in bed
Don't know
Worse
Better
Same
Don't know
Not admitted at any time
Admitted same day
Admitted later
Don't know
Yes, first time
No, 2 or 3 times
No, more than 3 times
-------
ro
CO
22. "Thinking back again to the day you (he/she)
started to get sick or started to have the symptoms
you mentioned, were you in _
or somewhere else?"
(Town of Residence)
[IF NOT, ASK:] "Where was this?"
23. "On that day or the day before did you (he/she)
spend more than 2 to 3 hours at one time outdoors or
in a car or truck?"
24. [IF OUTDOORS] "While you were (he/she was) outdoors,
were you (was he/she) doing anything more active than
sitting or walking? That is were you (was he/she)
doing anything that caused you (he/she) to perspire
a lot or breath harder than usual?"
"Now, I'd like to finish with a few general questions."
25. "About how long have you (has he/she) lived in
and in towns around
(Town of Residence)
Riverside?"
26. "Is your (his/her) present residence air condi-
tioned?"
22.
23.
24.
25.
26.
(0)
(2)
(0)
(1)
(2)
(3)
(0)
(1)
(2)
(1).
(2).
(3)
Don't know
In Metro area
Outside Metro area
Don't know
Not outside
Outdoors
In car or truck
Don't know
No, normal activity
Yes, heavy activity
Don't know
Yes
No
Partially
-------
27. "Would you please tell me which category best
describes your (his/her) annual family income?"
o Under $5,000?
o $5,000 to $10,000?
o $10,000 to $15,000?
o Over $15,000?
28. "Finally, could you explain why you (he/she) came
to the Riverside General emergency room instead of
some other doctor or clinic?"
"Thank you very much for your help."
27,
Don't know
Under $5,000
$5,000 to $10,000
$10,000 to $15,000
Over $15,000
28.
-------
Ozone Effects Study
PILOT STUDY - GENERAL DATA COLLECTION INSTRUCTIONS
1.0 INTRODUCTION
The purpose of GEOMET's research 1n Riverside 1s to develop
Improved methods for determining the relationship of human Illness to
ozone and other air pollutants. These methods involve data obtained on
patients who visit hospital emergency rooms. The data will be collected
from medical records and through a telephone interview.
Development of these methods will be done in several stages.
Initial versions of the data collection forms and procedures will first
be used 1n a short pilot test; then, later 1n 1975, a more extensive field
trial is anticipated. Our aim 1s to construct fairly precise and efficient
measures of the patient's course of Illness, his sensitivity to major harm-
ful chemicals in the air, and his exposure to pollutants.
Instructions and forms for the first, pilot test are contained
in this package. In particular, the package includes:
0 How the sample of patients is to be chosen
0 Use of information in the emergency room log
0 Instructions for medical record abstracts
0 Instructions for the interview
0 Guidelines for good telephone Interviewing
0 Abstracts and Interview forms.
Because this is a test, there may be changes made by the Project Director
from time to time 1n an attempt to Identify better procedures. Also, it
is Important that the field staff pay close attention to the process so that
we may learn what works, what is deficient, and why. Discussions should
September 1975 -125-
-------
be held by telephone with the Project Director every few days on the ab-
stracting and interviewing process.
2.0 GENERAL PROCEDURES
The general sequence of steps that should be followed, and the
responsible person, are listed below. (Responsible person is either
medical record abstractor (M) or interviewer (I).
1) Make xerox copies of the emergency room log for designated
time periods. (M)
2) Identify patients in the log with certain diagnoses or
complaints. (M)
3) Select patient abstract sample and assign study number. (M)
4) Complete record abstract on total sample and interview cover
sheets on interview sub-sample. (M)
5) Code record abstract. (M)
6) Conduct patient interview. (I)
7) Code identified diagnoses and complaints on log sheets. (M)
8) Forward completed material to GEOMET weekly.
While we can provide general instructions, the abstractor and interviewer
will have to work out efficient day-to-day procedures together.
3.0 SAMPLE SELECTION
3.1 Emergency Room Log Sample
The emergency room log will provide the basic source of patients
and serve as a master list. The first step is to make copies of the log sheets
for the following periods:
-126-
-------
August 25-31, 1975 February 22-28, 1975
June 24-30, 1975 December 25-31, 1974
April 24-30, 1975 October 25-31, 1974
Treat the 7 days for each month as a group.
In step two, starting with August 1975 identify all patients having
a diagnosis or a complaint on the list shown. Do this in the following
manner:
1) If a patient has one of the diagnoses on the list, make
a checkmark by the log number.
2) If no definite diagnosis has been recorded, but only the
complaint, check those patients with any of the symptoms
shown on the list.
Examples:
Fever, chills URI (/)
Fever, chills UTI (exclude)
Fever, chills - (/)
Depression - j t/j
O.D. on alcohol - (exclude)
Gastritis Hx alcoholism (exclude)
Stomach pain Anxiety (i/)
In other words, the diagnosis takes priority and patient complaints of the
type listed are included only if there is no diagnosis which shows the
patient has a condition which is not on our list of diagnoses. When in doubt,
include that patient.
-127-
-------
3.2 Selecting the Abstract Sample
For step three, after the screening, start with the first day
and the first patient checked and assign a study number to every fifth
patient until you have selected 50 patients from that week. There are
two restrictions:
1) After you have assigned numbers to the first 10 URI patients
skip the rest with this diagnosis.
2) After you have assigned numbers to the first 5 gastroenteritis
patients, skip the rest with this diagnosis.
When finished you should have 10 URI's, 5 gastroenteritis and the rest with
other diagnoses or complaints.
For step four, complete the record abstracting for that period
before you go onto the other weeks.
3.3 Selecting the Interview Sample
As you abstract records, fill out an interview cover sheet on
every second case. That is, every other patient in the abstract sample
will also be in the interview sample. (Completion of the interview cover
sheet is described in the Patient Interview Instructions.)
3.4 Further Steps
After completing the abstracts for the first week, make copies
for the next period and repeat the process above. HOWEVER, select interviews
for August, June, April and February only, not the last two weeks.
-128-
-------
4.0 LOG SHEET CODING
For each patient checked on the log (not just those with study
numbers), code the complaint and diagnosis separately. Use the symptom
code (NCHS) for complaints and the H-ICDA (2nd edition) for diagnoses
(just as on the record abstract).
Fit this task in as you can. Priority should be given to pre-
paring the abstracts and interview cover sheets so that the interviewer
won't have to wait on cases.
When coding is complete remove the patient's name from the log
sheets and forward them to GEOMET. You can either mark over the name with
a black, opaque brush pen or cut the names out and paste the two halves of
the sheet back together.
Since these log sheets will also serve as a master patient list,
check off each patient as the abstract and Interview are completed. Don't
send any sheets in until you have completed the forms for all the patients
on that sheet 1n the samples.
5.0 STUDY NUMBERS
All patients in the pilot test will be assigned to a study number
beginning with 9001. Start with the first patients selected for the abstract
sample and assign study numbers in sequence.
-129-
-------
Boundaries of Metro Area (Riverside County only)*
Highgrove
Sunnymead
March AF Base
Corona
Norco
Mira Loma
Glen Avon
Sunnysiope
* Only patients that reside within Riverside metropolitan toll-free
telephone area will be included, plus patients from Corona.
-130-
-------
i.iLjs^c&iY
. \ r(
-.. — \ .. .. •' ' ^ .;
\ / ^^ tf ,
IAN '''•" At 'll 1
-------
Diagnoses and Complaints for Sample Selection
Selected E.R. Diagnoses
Nervous System and Sense Organs
Eye Irritation, Conjunctivitis
Otitis Media*
Convulsive Disorders, Idiopathic Seizures
Respiratory System
URI, Colds, Tonsillitis, Sinus, Allergy
Flu, Viral Syndrome*
Acute Bronchitis, Pneumonia, Pleurisy*
Asthma*
COPD, Chronic Bronchitis, Emphysema*
Circulatory System
Cardiovascular Disorders
Cerebrovascular Disorders
Hypertension
Gastrointestinal System
Gastroenteritis, Gastritis
Ulcers (Upper G-I)
Other Selected Diagnoses
Diabetes
Hepatitis, Hepatic Disorders
Psychiatric Disorders (Excluding O. D.)
Total Selected Diagnoses
Selected Symptoms Not Included in
Above Diagnoses
Chills, Fever
Fatigue, Weakness, Fainting, Dizzy
Dehydration, Fluid Inbalance
Coma, Stuper, Unconciousncss
Headache
Convulsions, Seizures
SOB, Breathing Difficulty, Hyperventilation
Chest Pain, Congestion, Cough
Sore Throat
Abdominal Pain, Cramps
Diarrhea, Nausea, Vomiting
Jaundice
Depression, Nerves, Abnormal Behavior
Epistaxis w/o Injury
Total Selected Symptoms
* With or Without URI.
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OZONE EFFECTS STUDY
PATIENT RECORD ABSTRACT AND
CODING MANUAT
General Instructions
This manual contains the form, instructions and procedures for com-
pleting an abstract of the patient's medical record. The information to be
obtained is for specific patients, and is restricted to medical condition
and medical care received during specific emergency room visits. (See
Sample Selection Instructions for procedures to choose patients and visits.)
The patient Record Abstract will be completed in four steps:
1) Enter Case No., Log No., and Hospital No., from Master Patient
List.
2) Obtain medical record and enter the information called for
in this manual. Leave the section or item blank if the
information is not available in the patient's record.
3) Complete coding of each item using the supplementary coding
schedules in this manual.
4) Review form for completeness and accuracy. Then enter
initials and date in lower left corner of the form.
A notation should be made on the master list as the abstracts are completed.
Completed abstracts should be kept in a separate folder, filed in case number
order, and forwarded routinely in batches to GEOMET.
Exceptions. Situations will occur which are not covered by the
instructions. Do not make arbitrary decisions. If there are frequent ex-
ceptions, call the GEOMET Project Officer for instructions. If there are
only occasional exceptions, review these cases on the next site visit.
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OZONE EFFECTS STUDY
Section
GEOMET, Incorporated
August 1975
PATIENT RECORD ABSTRACT
CODING
Item
Case No.
Enter case number assigned for this study.
Log No.
Enter emergency department log number.
Hospital No.
Enter hospital patient record number.
E.D. Arrival
Date: Enter month and day patient was
seen in emergency department
(e.g. 06/19 is June 19)
Day: Enter code for day of the week
(1) Mon. (3) Wed. (5) Fri. (7) Sun.
(2) Tues. (4) Thurs. (6) Sat.
Time: Enter time that patient arrival
was logged, using 24-hour clock.
(e.g., 1315 is 1:15 P.M.)
By: Check (\/} whether patient arrived
by ambulance or by other means.
Sex
Check Male (M) or Female (F)
Ethnic Group
Check appropriate ethnic group
W- White
B- Black
M- Mexican
0- Other groups
Card Field
(Card 1)
1-4 XXXX
5-7
XXX
8-13 XXXXXX
14-17 XXXX
18
19-22 XXXX
23
24
25
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OZONE EFFECTS STUDY
PATIENT RECORD ABSTRACT
CODING
Section
Item
8
10
11
Age.
Enter ages as completed days, months or
years according to following groups. Circle
d, m or y to indicate meaning of value.
1-28 days as # days (29-31 days = 1 m)
1-11 months as # months (12-23 months = 1 y)
1-99 years as # years (100+ years = 99 y)
Married.
Check yes (Y) if record indicates patient is
currently married. Otherwise check no (N)
Residence.
Enter name of city patient gave as current
permanent residence. Select appropriate
location code from Schedule A and enter in
parentheses.
Payment
Check expected method of payment shown in
record.
Card Field
26-28 XXX
I- Insurance
W- MediCal
Welfare
M- Medicare
0- Cash payment and
all other third
party.
Complaints.
Symptom:
Enter name of each symptom or
problem patient gives as
presenting complaint (even if
more than five). Enter NCHS code
(Schedule B) in parentheses for
first five symptoms listed.
Onset: Enter approximate duration corres-
ponding to each symptom from time
patient first noticed onset,
according to following groups.
Circle h or d.
1-23 hours (h) as # hours
1+ days (d) as # days
29
30-31
XX
32
33-36 XXXX
40-43 XXXX
47-50 XXXX
54-57 XXXX
61-64 XXXX
37-39
44-46
51-53
58-60
65-67
XXX
XXX
XXX
XXX
XXX
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OZONE EFFECTS STUDY PATIENT RECORD ABSTRACT
CODING
Section Item Card Field
12 Condition.
Check indication of patient's condition when 68 X
seen (if noted in record), according to following.
Alert: Alert, conscious, normal behavior
Agitated: Agitated, hysterical, violent,
required restraints, behavior
problem.
Disoriented: Disoriented, confused, semi-
conscious, faint.
Unconscious: Unconscious, comatose, passed
out in E.R.
13 Vital Signs.
Enter value for each vital sign recorded when
first seen. Enter 0 if not recorded. Then
enter code (Schedule C) for appropriate group
in parentheses.
Temperature
Pulse
Respiration
Blood Pressure
14 Medical History
e.g. 99.6 (Farenheit) 69 X
Rate per minute 70 X
Rate per minute 71 X
Enter systolic on first line 72 X
and diastolic on line below. 73 X
Check any of the following conditions that #1 74 X
are mentioned on this visit as part of the #2 75 X
patient's medical history. (KP: enter code #3 76 X
for first 6) #4 77 X
Asthma (any type) £? J§ J
COPD (Chronic obstructive pulmonary ff ' A
disease, chronic bronchitis
emphysema)
Heart Disease (any type)
Hypertension (Including abnormal high
blood pressure)
Stroke (cerebrovascular accident, CVA)
Diabetes (any type)
Chronic Gastro-Intestional Disease (ulcers,
chronic gastritis only)
Liver Disease (cirrhosis, hepatitis)
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OZONE EFFECTS STUDY PATIENT RECORD ABSTRACT
CODING
Section Item Card Field
14 Renal Disease (chronic nephritis* chronic
nephrosis, renal failure)
(Enter 1 in cc 80) 80 X
(Card 2)
(Repeat Case No. in cc 1-4, card 2) 1-4 XXXX
15 Diagnostic Data
Enter values for any of the lab tests shown
that were ordered by the E.R. physician.
For total protein, albumin and globulin check
whether specimen was blood (B) or urine (U).
For chest film and EC6, check positive if any
abnormality mentioned in notes.
Then enter code (Schedule D) for individual
lab tests and for summary of blood gas findings
in appropriate parentheses.
Hgb. (Hemoglobin) 5 X
WBC (White blood cell count in thousands,
e.g. 10,500 as 10.5) 6 X
Lymphs (% of total to nearest decimal, e.g.
45.4«) 7 X
Eos (% of total to nearest decimal, e.g.
4.5%) 8 X
SCOT 9 X
Total Protein 10 X
Albumin 11 X
Globulin 12 X
Blood or Urine 13 X
Chest film 14 X
ECG 15 X
Blood Gases (summary code) 16 X
Na (Sodium) 17 X
K (Potassium) 18 X
Cl (Chloride) 19 X
HC03 (Bicarbonate) 20 X
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-------
OZONE EFFECTS STUDY PATIENT RECORD ABSTRACT
CODING
Section Item Card Field
16 Treatment.
Check any of the following procedures
that were done on this visit. Enter 1
in parentheses for each checked, 0 for
others.
•
Injections (any) 21 X
I.V. Fluids (any, including blood 22 X
products)
IPPB 23 X
02 (Oxygen, by mask or N-T tube) 24 X
CPR (resuscitation after cardiac
or pulmonary arrest) " X
17 E.D. Diagnoses
Enter name of each final E.R. diagnosis #1 26-29 XXXX
recordeTTeven if more than five). #2 30-33 XXXX
Enter code (H-ICDA, 2nd edition) for the #3 34-37 XXXX
the first five diagnoses in parentheses. #4 38-41 XXXX
#5 42-45 XXXX
18 E.D. Disposition
Check category describing disposition 46
from the emergency department.
Home (Patient's or other residence)
ECF (extended care facility, ICF,SNF,
nursing home)
Hosp. (VA, mental, tuberculosis or
other long-term care hospital)
ICU (ICU, CCU or any intensive care
unit of this hospital)
O.R. (admit direct to operating room
or recovery room for treatment)
Other (any hospital bed unit other than
ICU or O.R.)
Transfer (Acute) (transfer to another
hospital for acute, short-term
pa v*p j
Died in E.D. (died after E.R. arrival,
DOA's should not be abstracted)
19 Admission Data.
For patients admitted to this hospital from
the emergency room, enter length of stay in
days and name of final hospital discharge
diagnoses (even if more than five). Enter
code (H-ICDA, 2nd edition) for the first five
diagnoses in parentheses.
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OZONE EFFECTS STUDY
PATIENT RECORD ABSTRACT
CODING
Section
Item
Card Field
19
LOS (Length of stay): Enter total of
complete and partial days from
admission to discharge
Disch Dx (Discharge Diagnoses)
#1
#2
#3
#4
#5
47-48
49-52
53-56
57-60
61-64
65-68
20
Supplemental Codes.
Reserved for additional items or
summary codes.
#1
#2
#3
#4
#5
(Enter 2 in cc 80)
69-70
71-72
73-74
75-76
77-78
80
XX
XXXX
xxxx
XXXX
xxxx
xxxx
XX
XX
XX
XX
XX
END
-139-
-------
SPECIAL CODE SCHEDULES
The following code schedules are to be used for those sections
and items that are not preceded. The codes selected are to be entered 1n
the parentheses provided. They are not to be used in place of a data item
called for. The schedules are:
Schedule A:
B:
C:
D:
Location Codes (Section 9)
Symptom Codes (Section 11)
Vital Signs Codes (Section 13)
Diagnostic Data Codes (Section 15)
In addition, manuals for the Hospital Adaptation of ICDA (H-ICDA,
2nd edition) will be used to code diagnoses in Sections 17 and 19.
-140-
-------
OZONE EFFECTS STUDY PATIENT RECORD ABSTRACT
Schedule A
Location Codes
(to be developed when geographic grid defined)
-141-
-------
OZONE EFFECTS STUDY PATIENT RECORD ABSTRACT
Schedule B
Symptom Codes (NCHS)
The four-digit codes listed in the following pages will be used
to code each symptom listed in Section 11. They are taken from DHEW
Publication No. (HRA) 74-1337, "The National Ambulatory Medical Care Survey:
Symptom Classification." A decimal code has been added for certain specific
terms under the general heading.
For most symptoms the proper code will be readily found. Use the
index to verify coding decisions and to determine the proper code when it
is not obvious.
-142-
-------
SYMPTOM CODES
ALPHABETIC INDEX OF TERMS
Abdominal
distension 542.0
fullness 542.0
pain 540.0
rigidity 542.0
swelling 542.0
Abnormal Abnormality
breathing sounds 307.0
drug usage 822.0
ear size 739.0
eye appearance 717.0
gait. 421.0
hair 124.0
heart sounds 200.0
high blood pressure 205.0
lip color 505.0
low blood pressure 206.0
periods G53.0
protrusion (eye) 717.0
retraction (eye) 708.0
secretion (postpartum, breast) 684.0
sounds (respiratory) 307.0
stools 556.0
tongue color 525.0
Abnormal involuntary movements 050.0
eyes 708.0
muscles (sec also Twitching) 050.0
Abortion
counseling 930.0
performed 932.0
request 930.0
Absence (sec also Lack of)
appetite 545.0
feeling 059.0
hair 124.0
milk (postpartum) 684.0
Ache
all over 013.0
ankle 400.0
Ache—Con.
arm 405.0
back-415.0
back of head 410.0
cervical spine 410.0
elbow 405.0
face 410.0
fingers 405.0
foot 400.0
forearm 405.0
generalized 013.0
hand 405.0
hip 400.0
jaw 410.0
joints, not specified 425.0
knee 400.0
leg 400.0
limbs, not specified tico.u
lower back 415.0
lower extremity, part unspecified 400.0
lumbar 415.0
lumbosacral 415.0
neck 410.0
sacroiliac 415.0
shoulder 405.0
site unspecified 013.0
spine 415.0
thigh 400.0
thoracic spine 415.0
thumb 405.0
toe 400.0
upper back 415.0
upper extremity, part unspecified 405.0
upper spine 415.0
wrist 405.0
Acne 100.0
Activity
over 805.0
21
-143-
-------
Activity—Con.
over (infants) 020.0
under (infants) 020.0
Acute hearing 731.0
Alcohol-related disturbances 821.0
Allergic skin reactions 112.0
Allergy shots 910.0
Amnesia 058.0
Anesthesia 059.0
Ankle
ache 400.0
broken 400.0
cold 400.0
contracture 400.0
cramp 400.0
hot 400.0
hurt 400.0
injury 400.0
limited motion 400.0
pain 400.0
pulled muscle 400.0
soreness 400.0
spasm 400.0
stiffness 400.0
strain 400.0
swelling 400.0
Annual checkup 900.0
Antisocial behavior 815.0
Anus, symptoms referable to 560.0
Anxiety 800.0
Appetite
abnormal 545.0
decreased 545.0
excessive 545.0
loss of 545.0
Apprehension 800.0
Arm
ache 405.0
broken 405.0
cold 405.0
contracture 405.0
cramp 405.0
hot 405.0
hurt 405.0
injury 405.0
limited motion 405.0
pain 405.0
pulled muscle 405.0
soreness 405.0
spasm 405.0
stiffness 405.0
Arm—Con.
strain 405.0
swelling 405.0
Ashen color 212.0
Athlete's foot 106.0
Atrophy of extremities 420.0
Back, lower upper
ache 415.0
contracture 415.0
cramp 415.0
hurt 415.0
injury 415.0
limited motion 415.0
pain 415.0
pulled muscle 415.0
soreness 415.0
spasm 415.0
stiffness 415.0
strain 415.0
swelling 415.0
Bad
breath 502.0
complexion 100.0
habits 826.0
heart 216.0
taste 510.0
Balance, loss of sense of 069.0
Baldness 124.0
Bedwetting 601.0
Behavioral disturbances 815.0
Belching 570.0
Biliary
colic 580.0
symptoms of 580.0
Bites 116.0
Bitterness 807.0
Black-
eye 716.0
heads 100.0
out 214.0
Bladder problems (see 600.0-606.0)
Bleed, Bleeding
ear 734.0
eye 704.0
gastrointestinal 550.0
gingival 501.0
gums 501.0
lips 505.0
nose 300.0
from rectum 550.0
22
-144-
-------
Bleed, Bleeding-Con.
of rectum 560.0
tongue 525.0
tonsils 527.0
Blemishes 100.0
Blindness, partial or complete 700.0
Blind spots 701.0
Blisters
nonallergic 116.0
tongue 525.0
Bloating, gas 543.0
Blocked feeling in ears 737.0
Blood
in stools 550.0
poor 210.0
tired 210.0
vomiting 550.0
weak 210.0
Blood pressure
abnormal 205.0
decreased 206.0
elevated 205.0
high 205.0
low 206.0
Bloodshot eyes 717.0
Blueness
fingers 212.0
toes 212.0
Blurred vision 701.0
Blushing
abnormal 104.0
excessive 104.0
Boils 106.0
Bowel, Bowels
change in 556.0
dysfunction 556.0
Breaking nails 122.0
Breaking out 100.0
Breast
bump 680.0
deformity 690.0
hard spot 680.0
knot 680.0
lump 680.0
mass 680.0
nodule 680.0
pain 681.0
redness 681.0
sagging 690.0
soreness 681.0
swelling 680.0
Breast, swelling—Con.
generalized 681.0
local 680.0
tender 681.0
too large 690.0
too small 690.0
Breath, breathing
bad 502.0
problem 307.0
shortness of 306.0
sounds, abnormal 307.0
Breathlessness 306.0
Brittle
hair 124.0
nails 122.0
Bruises 116.0
Bulge (see Swelling and particular site)
Bump (see Swelling and particular site)
Bunion 429.0
Burning
eye 705.0
sensation (in chest) 322.0
skin 113.0
tongue 525.0
urination 604.0
Burns
.chemical 116.0
mouth 050.0
steam 116.0
sun 116.0
wind 116.0
Butterflies 810.0
Buzzing in ear 731.0
Calluses 108.0
Change in
bowels 556.0
voice 325.0
Charleyhorse 400.0
Chest
congestion in 321.0
pain in 322.0
pressure in 322.0
tightness 322.0
Chewing
difficulties 500.0
on hair 826.0
Chills 001.0
Choking 528.0
Clammy skin 120.0
Cloudy
eye appearance 717.0
vision 701.0
23
-145-
-------
Clumsiness 421.0
Coated tongue 525.0
Coitus, painful 661.0
Cold 312.0
Cold
ankle 400.0
arm 405.0
elbow 405.0
fingers 405.0
foot 400.0
forearm 405.0
hand 405.0
hip 400.0
knee 400.0
leg 400.0
lower extremity, part unspecified 400.0
shoulder 405.0
skin 120.0
thigh 400.0
thumb 405.0
toe 400.0
upper arm 405.0
upper extremity, part unspecified 405.0
wrist 405.0
Colic
biliary 580.0
infantile 541.0
intestinal 540.0
NOS 540.0
Collapse 214.0
Color
ashen 212.0
change in nail 122.0
change in nipple 683.0
change in skin 104.0
Coma 052.0
Compulsion 827.0
Conflict
job 941.0
marital 941.0
Confusion 053.0
Congestion
chest 321.0
nasal 301.0
sinus 304.0
Conjunctivitis 712.0
Constipation 554.0
Contraceptive counseling 930.0
Contracture (see Ache and particular site)
Convulsions 054.0
Corns 108.0
Cough, coughing 311.0
phlegm 320.0
sputum 320.0
Cracked
lips 505.0
nails 122.0
skin 120.0
Cramps (see also Ache and particular site)
menstrual 652.0
stomach 540.0
Cross-eyed 708.0
Croup 314.0
Crying 807.0
infants 020.0
Cuts 116.0
Cyst
site unspecified 015.0
skin 115.0
Dark urine 600.0
Deafness 730.0
Decreased
appetite 545.0
blood pressure 206.0
pulse 200.0
Deformity
breast 690.0
ears 757.0
Dehydration 007.0
Dejected 807.0
Delusion 824.0
Depression 807.0
Diaper rash 112.0
Diarrhea, functional 555.0
Diet control
change 940.0
counseling 940.0
Difficulty
breathing 306.0
chewing 500.0
nursing 684.0
swallowing 528.0
walking 421.0
Diminished
hearing 731.0
vision 701.0
Discharge
ear 734.0
eye 704.0T
nipple 683.0
tonsils 527.0
24
-146-
-------
Discharge—Con.
umbilicus 126.0
vaginal 662.0
Discoloration
nails 122.0
skin, 104.0
Discontented 807.0
Disorders (see also Disturbance)
respiratory rhythm 307.0
respiratory sound 307.0
urinary 610.0
voice 325.0
Dissatisfaction, job 941.0
Distention
abdominal 542.0
bladder 603.0
gas 543.0
Disturbance (see also Disorder)
hearing 731.0
memory 058.0
sensation 059.0
sleep 062.0
smell 059.0
taste 059.0
touch 059.0
vision 701.0
Divorce proceedings 941.0
Dizziness 069.0
Draining, umbilicus 126.0
Dribbling 602.0
Drinking problem 821.0
Drip, postnasal 301.0
Drippy nose 301.0
Drooling, excessive 511.0
Drooping eyelid 710.0
Drop, dropping
foot 422.0
sensation of pelvic floor 660.0
wrist 422.0
Dropsy 231.0
Dry ness
eye 705.0
hair 124.0
lips 505.0
mouth 510.0
nose 330.0
skin 120.0
Dull
eye appearance 717.0
vision 701.0
Dysfunction (see Disorders, Disturbance)
Ear
abnormal size 739.0
blocked feeling 737.0
buzzing in 731.0
discharge 734.0
extraneous noises 731.0
pain 735.0
pierced 960.0
plugged feeling 737.0
pressure 737.0
ringing 731.0
unusual sounds 731.0
wax, excessive 738.0
Earache 735.0
Edema 231.0
EKG 920.0
Elbow (see Arm and particular condition)
Elevated blood pressure 205.0
Empty
bladder, inability to 603.0
Engorged nipple 683.0
Enlarged
heart 220.0
liver 580.0
lymph nodes' 232.0
spleen 240.0
Epigastrium pain 540.0
Epitaxis 300.0
Equilibrium, loss of sense of 069.0
Erection, painful 621.0
Excessive
appetite 545.0
crying 807.0
crying (infantile) 020.0
drinking (alcohol) 821.0
drooling 511.0
hair 124.0
menstrual flow 653.0
milk secretion 684.0
phlegm 320.0
smoking 820.0
sputum 320.0
sweating 007.0
thirst 007.0
use of stimulants or depressants 822.0
wax in ear 738.0
Exhausted 004.0
Extremities
atrophy 420.0
numbness 420.0
paralysis 420.0
26
-147-
-------
Extremities—Con.
wasting, 420.0
weakness, 420.0
Eye
discharge 704.0
dryness 705.0
examination 909.0
inflamed 705.0
injuries 716.0
itching 705.0
pain 705.0
protrusion 717.0
red 717.0
swelling 705.0
tearing 704.0
watering 704.0
Eyelid
closed 710.0
drooping 710.0
dropping 710.0
itching 710.0
red 710.0
swollen 710.0
symptoms of 710.0
Face
ache 410.0
contracture 410.0
cramp 410.0
hurt 410.0
injury 410.0
limited motion 410.0
pain 410.0
pulled muscle 410.0
soreness 410.0
spasm 410.0
stiffness 410.0
strain 410.0
swelling 410.0
Fainting 214.0
Falling
(out) of hair 124.0
(out) of nails 122.0
sensation 069.0
sensation of pelvic region 660.0
Family
planning 930.0
problems 941.0
Fast
breathing 307.0
heartbeat 200.0
pulse 200.0
Fatigue 004.0
26
Fears 801.0
Feeding problem 546.0
Feeling
bad 005.0
blue 807.0
lost 807.0
low 807.0
numb 059.0
rejected 807.0
Fever 002.0
blister 505.0
Fidgety 805.0
infants 020.0
Fingers (see also Arm and particular condition)
blueness 212.0
Fit 054.0
Flashes
hot 650.0
light 701.0
Flatulence 543.0
Floaters 701.0
Flu 313.0
Fluid
imbalance 007.0
retention 007.0
Flushing 104.0
Fluttering heart 200.0
Followup visit
specified condition 980.0
unspecified condition 985.0
Foot (see also Ankle and particular condition)
drop 422.0
Forearm (see Arm and particular condition)
Foreign body (see also Injury)
ear 740.0
eye 715.0
Freckles 104.0
Frequent
menstruation 653.0
urination 601.0
Frigidity 828.0
Fullness 542.0
bladder 603.0
Functioning, Functional
bowels 556.0
diarrhea 555.0
Fussy, infants 020.0
Gain, gaining weight 010.0
Gait, abnormal 421.0
Gallbladder, symptoms of 580.0
gallstones 580.0
-148-
-------
Gas
bloating 543.0
distention 543.0
excessive 543.0
Gastrointestinal bleeding 550.0
General, generalized
ill-feeling 005.0
pain 013.0
symptoms of infants 020.0
weakness 004.0
Giddiness 069.0
Gingival bleeding 501.0
Glands, swollen 232.0
Grip 313.0
Groin, pain 540.0
Growth, lack of 009.0
Gums, bleeding 501.0
Gynecologic examination 904.0
Hair
abnormal 124.0
dryness 124.0
excessive 124.0
loss of 124.0
symptoms of 124.0
Half-vision 701.0
Halitosis 502.0
Hallucinations 824.0
Hand (see Arm and particular condition)
Hard spot (see Swelling and particular site)
Hazy
eye appearance 717.0
vision 701.0
Head, (back of) (see Face and particular
condition)
Headaches 056.0
Hearing
disturbance of 701.0
noises (nonpsychiatric) 701.0
Heart
beats, irregular 200.0
bum 570.0
flutter 200.0
murmur 201.0
pain over 322.0
rapid 200.0
sounds, abnormal, increased 200.0
weak 216.0
Hemorrhage
gastrointestinal 550.0
nose 300.0
vaginal 662.0
Hesitancy of urination 610.0
Hiccough 575.0
High
blood pressure 205.0
temperature 002.0
Hip (see Ankle and particular condition)
Hives 112.0
Hoarseness 325.0
Homosexuality 828.0
Hopelessness 807.0
Hot (see Cold and particular site)
Hurt (see Ache and particular site)
Hyperactivity 805.0
infants 020.0
Hyperesthesia 059.0
Hypersomnia 062.0
Hypertension 205.0
Hyperventilation 307.0
Hypotension 206.0
Iliac pain 540.0
Illegible item 999.0
Imbalance, fluid 007.0
Impacted sinuses. 304.0
Impending litigation 941.0
Impotence 828.0
Improper lactation 684.0
Inability
to nurse 684.0
to stand 421.0
to urinate 603.0
to walk 421.0
Incontinence of urine 602.0
Increased
blood pressure 205.0
pulse 200.0
Indigestion 570.0
Infantile colic 541.0
Infected sinuses 304.0
Infectious disorders 106.0
Infertility
counseling 930.0
female 665.0
male 620.0
Inflamed, Inflammation
eye 705.0
eyelid 710.0
mouth 510.0
nipple 683.0
skin 113.0
throat 520.0
tonsils 527.0
27
-149-
-------
Influenza 313.0
Ingrown nail 122.0
Inguinal pain 540.0
Injections of vitamins or hormones 910.0
Injury (see also Foreign body and particular site)
eye 716.0
nose 116.0
skin 116.0
Inoculations 910.0
Insertion of IUD 932.0
Insomnia 062.0
Instruction for
diet change or control 940.0
exercise 940.0
regarding imminent surgery 950.0
use of contraception 931.0
use of crutches or cane 940.0
Intestinal colic 540.0
Inversion of nipple 683.0
Involuntary
movements 050.0
movements of eyes 708.0
urination 602.0
Irregular
heartbeats 200.0
menstruation 653.0
pulsations 200.0
Irritability 815.0
infants 020.0
Irritation
ear 735.0
eye 705.0
skin 113.0
Itching
ear 740.0
eye 705.0
eyelid 710.0
rectum, anus 560.0
skin 113.0
vulva 663.0
Jaundice 579.0
Jaw (see Face and particular condition)
Job dissatisfaction 941.0
Joint manipulation 960.0
Joints (see particular site)
Joints, not specified
ache 425.0
contracture 425.0
cramp 425.0
hurt 425.0
pain 425.0
28
Joints, not specified—Con.
pulled muscle 425.0
soreness 425.0
spasm 425.0
stiffness 425.0
strain 425.0
swelling 425.0
Knee (see Ankle and particular condition)
Knot (see Swelling and particular site)
Labor, possible 667.0
Laboratory test 920.0
Lack of (see also Absence)
growth 009.0
memory 058.0
physiological development 009.0
Large menstrual flow 653.0
Leaking amniotic fluid 667.0
Left quadrant pain 540.0
Leg (see Ankle and particular condition)
Legal problems 941.0
Light, flashes 701.0
Ldghtheadedness 069.0
Lightness, sinus 304.0
Limbs, not specified (see Joints, not specified
and particular condition)
Limited motion (see Ache and particular site)
Limping 421.0
Lips
abnormal color 505.0
bleeding 505.0
cracked 505.0
dry 505.0
splitting 505.0
symptoms of 505.0
Litigation, impending 941.0
Liver, symptoms of 580.0
Loneliness 806.0
Loose stools 555.0
Loss of
appetite 545.0
family member 941.0
hair 124.0
memory 058.0
sense of equilibrium (balance) 069.0
sense of smell 059.0
sense of taste 059.0
sense of touch 059.0
weight 011.0
Lost feeling 807.0
-150-
-------
Low
blood pressure 206.0
sperm count 620.0
Lower extremity, part unspecified (see Ankle
and particular condition)
Lower quadrant pain 540.0
Lumbar (see Back and particular condition)
Lumbosacral (see Back and particular condition)
Lump (see Swelling and particular site)
Lymph nodes, swollen 232.0
Maladjustment, social 815.0
Marital conflict 941.0
Marital examination 904.0
Mass (see Swelling and particular site)
Medical examination 900.0
Medication visit 910.0
Member of family, recent loss 941.0
Memory, disturbance of 058.0
Menopause symptoms 650.0
Menstrual
cramps 652.0
disorders 653.0
tension 651.0
Migraine, headache 056.0
Milk
absence of 684.0
excessive 684.0
Misuse of medication or prescription drugs
822.0
Mole 109.0
Movements, abnormal (involuntary) 050.0
bladder 602.0
bowel 556.0
eye 708.0
Murmur, heart 201.0
Muscles (see particular site)
Muscles, unspecified (see Joints, not specified
and particular condition)
Nails
biting 826.0
brittle 122.0
discoloration 122.0
falling out 122.0
splitting 122.0
spots 122.0
stained 122.0
Nasal
bleeding 300.0
congestion 301.0
Nausea 572.0
Neck (see Face and particular condition)
Nerves, Nervous, Nervousness 810.0
headache 056.0
Night discharge 601.0
Nightmares 062.0
Nipple
discharge 683.0
inflammation 683.0
inversion 683.0
other symptoms 683.0
Nodule (see Swelling and particular site)
Noises, heard (nonpsychiatric) 731.0
Noncodable entry 998.0
Nonspecific p ain 013.0
Nose
bleed 300.0
drippy 301.0
hemorrhage 300.0
injury 410.0
red 301.0
runny 301.0
stuffy 301.0
Not feeling well 005.0
Numbness of extremities 420.0
Obesity 010.0
Obsession 827.0
Oily
hair 124.0
skin 120.0
Old age 065.0
Overactivity
adult 805.0
infant 020.0
Oversize
breast 690.0
ears 757.0
Ovulation pain 654.0
Pain (see also Ache and particular site)
abdominal 540.0
breast 681.0
chest 322.0
ear 735.0
epigastrium 540.0
eye 705.0
face 402.0
generalized 013.0
groin 540.0
head 056.0
iliac 540.0
inguinal 540.0
knee 400.0
29
-151-
-------
Pain—Con.
left quadrant 540.0
lips 505.0
lower quadrant 540.0
mouth 510.0
nonspecific 013.0
over heart 322.0
pelvic 660.0
penis 631.0
rectal 560.0
respiratory 322.0
retrosternal 322.0
rib 322.0
right quadrant 540.0
scrotum 621.0
side of chest 322.0
sinus 304.0
sternal 322.0
testicle 621.0
throat 520.0
upper quadrant 540.0
urinary 604.0
vaginal 661.0
vulva 663.0
Painful
coitus 661.0
erection 621.0
tongue 525.0
umbilicus 126.0
urination 604.0
Paleness 212.0
Pallor 212.0
Palpitation 200.0
Panic 800.0
Pap smear 904.0
Paralysis of extremities, partial or complete
420.0
Passed out 214.0
Passed stones 620.0
Peeling skin 120.0
Pelvis pelvic
relaxed 660.0
sensation of dropping 660.0
symptoms of 660.0
Penis
pain 631.0
swelling 631.0
Phlegm
bloody 320.0
coughing up 320.0
Phlegm—Con.
excessive 320.0
purulent 320.0
Phobias 801.0
Photo-
phobia 701.0
sensitivity 112.0
Physiological development, lack of 009.0
Physical therapy 911.0
Pigmentation
nails 122.0
skin 104.0
Pimples 100.0
Pink-eye 712.0
Plugged feeling in ear 937.0
Poison ivy, oak, sumac 112.0
Pooped 004.0
Poor
blood 210.0
heart 216.0
Popping in ear 737.0
Possible labor 667.0
Postnasal drip 30L.O
Postnatal examination 905.0
Postoperative visit
specified condition 980.0
unspecified condition 985.0
Postpartum breast problems 690.0
Posture problems 422.0
Pregnancy examination 905.0
Prenatal examination 905.0
Preoperative visit 950.0
Pressure
chest 322.0
ear 737.0
pelvis 660.0
sinus 304.0
Prickly feeling 059.0
Problem (see also Trouble)
breathing 306.0
drinking (alcohol) 821.0
economic 941.0
family 941.0
female 670.0
legal 941.0
male 640.0
NOS 942.0
personal 942.0
posture 422.0
pregnancy 667.0
30
-152-
-------
Problem—Con.
school 941.0
sexual 828.0
Proceedings, divorce 941.0
Products of conception passed 667.0
Progress visit (see also Visit, followup)
specified condition 980.0
unspecified condition 985.0
Psychiatric examination 902.0
Psychosexual disorders 828.0
Pulled muscle (see Ache and particular site)
unspecified site 425.0
Pulsations, Pulse
decreased 200.0
increased 200.0
irregular 200.0
skipped beat 200.0
too fast 200.0
too slow 200.0
unequal 200.0
Pupils unequal 708.0
Purulent sputum 320.0
Pus
eye 704.0
stools 556.0
Quarrelsome 815.0
Radiological examination 903.0
Rales 307.0
Rapid
breathing 307.0
heart 200.0
Rash 112.0
diaper 112.0
Receding hairline 124.0
Rectal Rcctuip
bleeding 560.0
itching 560.0
mass 560.0
pain 560.0
swelling 560.0
symptoms of 560.0
Red, Redness
eye 717.0
breast 681.0
nose 301.0
skin 104.0
umbilicus 126.0
Referral from another physician or agency
970.0
Regurgitation 574.0
Relaxed pelvic floor 660.0
Removal of
IUD 932.0
sutures 985.0
Renewal of prescription 910.0
Respiratory
insufficiency 306.0
pain 322.0
rhythm disorders 307.0
sighing 307.0
sound disorders 307.0
Restlessness 805.0
Retching 572.0
Retention of
fluid 007.0
urine 603.0
Retrostemal pain 322.0
Rib pain 322.0
Ridges, tongue 525.0
Right quadrant pain 322.0
Rigidity, abdominal 540.0
Ringing in ear 731.0
Rings on skin 104.0
Ringworm 106.0
Rough skin 120.0
Routine inoculations 910.0
Rundown 004.0
Runny nose 301.0
Sacroiliac (see Back and particular condition)
Saliva, excessive 511.0
Scales 120.0
School problems 941.0
Scratches
eye 716.0
skin 116.0
Scratchy throat 520.0
Scrotum, pain 631.0
Seizure 054.0
Senility 065.0
Sensation
burning 059.0
burning (in chest) 322.0
falling 069.0
of suffocation 306.0
pelvis floor, dropping 660.0
smell (unusual) 059.0
taste (unusual) 059.0
31
-153-
-------
Sexual problem 828.0
Shaking 050.0
Shortness of breath 306.0
Shots
allergy 910.0
injections 910.0
Shoulder (see Arm and particular condition)
Sick
feeling 005.0
head 056.0
stomach 572.0
Side of chest, pain 322.0
Sighing respiration 307.0
Sinus
infection 304.0
pain 304.0
problem 304.0
Skin
bulge 115.0
burning 059.0
change in color 104.0
clammy 120.0
cold 120.0
inflammation 113.0
irritation 113.0
mass 115.0
moles 109.0
rash 112.0
red 104.0
rings 104.0
rough 120.0
sores 113.0
thickened 120.0
warts 111.0
waxy 120.0
wrinkles 110.0
Skipped beat 200.0
Sleep
disturbances of 062.0
inability to 062.0
sleep walking 062.0
Slow pulse 200.0
Slowing of stream 610.0
Smell
disturbance of 059.0
loss of sense of 059.0
unusual sensations of 059.0
Smoking, excessive 820.0
Smooth tongue 525.0
Sneezing 310.0
Sniffles 301.0
Social maladjustments 815.0
Sore
glands 232.0
skin 113.0
throat 520.0
Soreness (see Ache and particular site)
Sounds
breathing 307.0
respiratory, abnormal 307.0
unusual, in ear 731.0
Spasm (see Ache and particular site)
eye 708.0
eyelid 710.0
Spells 054.0
Spine, thoracic spine (see Back and particular
condition)
Spine, cervical, upper spine (see Face and partic-
ular condition)
Spitting up 574.0
Splitting
lips 505.0
nails 124.0
Spots
nails 124:0
skin 104.0
vision 701.0
Sprain (see Ache and particular site)
Sputum
coughing up 320.0
excessive 320.0
purulent 320.0
Squinting 708.0
Staggering 421.0
Stammering 067.0
Stand, inability to 421.0
Sterility
female 665.0
male 630.0
Sternal pain 322.0
Stiffness (see Ache and particular site)
Stomach
cramps 540.0
pain 540.0
upset 570.0
Stones, passed 620.0
Stools
abnormal 556.0
bloody 550.0
bulky 556.0
dark 556.0
fatty 556.0
32
-154-
-------
Stools-Con.
loose 555.0
pus in 556.0
unusual color 556.0
unusual odor 556.0
Stopped up
cars 737.0
nose 301.0
sinuses 304.0
Strain (see Ache and particular site)
Stream, slowing of 610.0
Stuffy nose 301.0
Stupor 052.0
Stuttering 067.0
Sty 711.0
Suffocation, sensation 306.0
Surgery, (minor) visit 950.0
Surgical aftercare
specified condition 680.0
unspecified condition 685.0
Swallowing difficulties 528.0
Sweating Sweats
excessive 007.0
night 007.0
Swelling
abdominal 542.0
ankle 400.0
arm 405.0
back 415.0
back of head 410.0
breast, generalized 681.0
breast, local 680.0
cervical spine 410.0
ear 740.0
elbow 405.0
eye 705.0
eyelid 710.0
face 410.0
fingers 405.0
foot 400.0
forearm 405.0
generalized 015.0
hand 405.0
hip 400.0
jaw 410.0
joints, not specified 425.0
joints specified (see site)
knee 400.0
leg 400.0
limbs, not specified 425.0
lower back 415.0
Swelling—Con.
lower extremity, part unspecified 400.0
lumbar 415.0
lumbosacral 415.0
neck 410.0
pelvis 660.0
penis 631.0
sacroiliac 415.0
scrotum 631.0
shoulder 405.0
site unspecified 015.0
skin 115.0
testicle 631.0
tongue 525.0
tonsils 527.0
upper extremity, part unspecified 405.0
vagina 661.0
vulva 663.0
Swollen
ankles 400.0
glands 232.0
Syncope 214.0
Taste
disturbance of 059.0
loss of sense of 059.0
unusual sensation 059.0
Tearing of eye 704.0
Teeth, symptoms of 515.0
Temperature, high 002.0
Temper tantrums 815.0
Temporary loss of memory 058.0
Tender
breast 681.0
skin 113.0
Tension
headache 056.0
nervous 810.0
premenstrual 651.0
Test, laboratory 920.0
Testicle
pain 631.0
swelling 631.0
Texture, change in skin 120.0
Thickened skin 120.0
Thigh (see Ankle and particular condition)
Thin blood 210.0
Thirst, excessive 007.0
Throat
culture 920.0
pain 520.0
33
-155-
-------
Throat-Con.
scratchy 520.0
soreness 520.0
Thro wing up 572.0
Thumb (see Arm and particular condition)
sucking 826.0
Tic 050.0
Tightness of chest 322.0
Time-zone syndrome 062.0
Tingling 059.0
Tired 004.0
blood 210.0
Toe (see Ankle and particular condition)
blueness 212.0
Tongue
bleeding 525.0
coated 525.0
mass 525.0
painful 525.0
smooth 525.0
swelling 525.0
symptoms of 525.0
Tonsils, symptoms of 527.0
Toothache 512.0
Touch, loss of sense of 059.0
Tremor 050.0
Trouble (see also Problem)
breathing 306.0
eating 546.0
female 670.0
hearing 731.C
job 941.0
marital 941.0
school 941.0
seeing 701.0
sleeping 062.0
walking 421.0
Twitching 050.0
eyes 708.0
Ulcer
mouth 510.0
skin 113.0
tongue 525.0
vulva 663.0
Umbilical region, pain 540.0
Umbilicus
discharge 126.0
draining 126.0
painful 126.0
red 126.0
Umbilicus—Con.
symptoms of 126.0
unhealed 126.0
Under
activity (infants) 020.0
weight 011.0
Unequal
pulse 200.0
pupils 708.0
Unusual
color of stools 556.0
Upper arm (see Arm and particular condition)
Upper extremity, part unspecified (see Arm and
particular condition)
Upper quadrant, pain 540.0
Upset
emotional 810.0
stomach 570.0
Urinary
dysfunction 610.0
pain 604.0
symptoms NEC 610.0
Urination urinate
frequent 601.0
hesitancy 610.0
inability to 603.0
painful 604.0
Urine
blood 600.0
incontinence of 602.0
pus 600.0
retention of 603.0
unusual color 600.0
unusual odor 600.0
Use of orthopedic aids (instruction) 940.0
Vaccinations 910.0
Vaginal vagina
atypical discharge 662.0
bleeding 662.0
brown discharge 662.0
discharge 662.0
disorders 661.0
mass 661.0
pain 661.0
swelling 661.0
Vasectomy
advice regarding 930.0
request 932.0
Vertigo 069.0
34
-156-
-------
Vision
blurred 701.0
diminished 701.0
disturbance of 701.0
Visit, advice and instruction (see 940.0-942.0)
Visit, examination
eye 909.0
general medical 900.0
general psychiatric 902.0
gynecological 904.0
other 909.0
physical 901.0
pregnancy 905.0
radiological 903.0
well baby 906.0
Visit, family planning services
counseling 930.0
medication 931.0
other 935.0
services 932.0
Visit followup (see Progress visit)
Visit, minor surgery 950.0
Visit, preoperative 950.0
Visit, progress
specified condition 980.0
unspecified condition 985.0
Visit, referral 970.0
Visit, testing
laboratory 920.0
other 921.0
Visit, therapy
medication 910.0
other therapy 911.0
Vitamins or hormones, injections 910.0
Voice, change in 325.0
Vomiting 572.0
blood 550.0
Vulvar disorders
itching 663.0
mass 663.0
Vulvar disorders-Con.
pain 663.0
swelling 663.0
ulcer 663.0
Walk, Walking
difficulty in 421.0
inability to 421.0
Warts 111.0
Wasting of extremities 420.0
Watering of eye 704.0
Waxy skin 120.0
Weak
blood 210.0
heart 216.0
Weakness .
generalized 004.0
of extremities 420.0
Weight
gain 010.0
loss 011.0
under 011.0
Well-baby examination 906.0
Welts 115.0
Wheezing 307.0
Whiteheads 100.0
Worn out 004.0
Worrying 807.0
Wounds (skin)
bites 116.0
blisters, nonallergic 116.0
bruises 116.0
burns 116.0
cuts 116.0
scratches 116.0
Wrinkles 110.0
Wrist (see also Arm and particular condition)
drop 422.0
X-rays 903.0
35
-157-
-------
OZONE EFFECTS STUDY
PATIENT RECORD ABSTRACT
Schedule C
Vital Signs Codes
Temperature (°F):
0 Unknown, no entry
1 103 or above
2 101-102
3 99-100
4 98
5 97 or below
Pulse:
0 Unknown, no entry
1 120 or more
2 .100-119
3 86-99
4 65-85
5 64 or less
Respiration
0 Unknown, no entry
1 30 or above
2 20-29
3
4
10-19
9 or less
Blood Pressure :
(S) 0 Unknown, no entry
1 200 or more
2 150-199
3 110-149
4 90-109
5 89 or less
(D) 0 Unknown, no entry
1 100 or more
2 85-99
3 75-84
4 60-74
5 59 or less
-158-
-------
OZONE EFFECTS STUDY
PATIENT RECORD ABSTRACT
CODING
SCHEDULE D
DIAGNOSTIC DATA CODES
Test
Hgb.
WBC
Lymphs
EOS
SCOT
T. Protein
Albumin
Globulin
Blood Gas
Summary
pH*
PCO2*
C02
Codes
1 (Normal)
Male: 14-18 gm/100 ml.
Female: 12-16 gm/100 ml.
5-10,000
20-40%
1-396
5-40 units
Serum: 6-8 gm/100 ml.
Urine: "Negative"
Serum: 3. 5-5. 5 gm/100 ml.
Urine: "Negative"
Serum: 1. 5-3 gm/100 ml.
Urine: "Negative"
7.35-7.45
35-45mmHg.
24-29 mEq/1.
2
t
t
t
t
t
t
i
t
*
t
t
* Code by these values if CO2 is normal or not given.
Na
K
Cl
HC03
136-145 mEq/1.
2. 5 -5 mEq/1.
100-106 mEq/1.
26-30 mEq/1.
t
t
-r
t
3
+
4-
i
t
4-
^
1
1
1
4-
4
4-
4-
4-
5
t
t
t
6
-»•
t
t
7
i
-»•
4-
4-
Legend:
t above normal
4- below normal
•*• normal range
-159-
-------
Ozone Effects Study
PATIENT INTERVIEW INSTRUCTIONS
1.0 INTRODUCTION
Attached is an interview which will be conducted by telephone
with patients who have visited the emergency room over the past months.
The interview provides information beyond that usually found in the
medical record and it is intended to better define sensitivity to air
pollution effects, extent of exposure to pollutants, and patterns of
illness. Through the combined sources of data a more precise approach to
measurement of excess illness associated with various pollution levels
may be constructed for use in large-scale community studies.
Although some items have been used in past studies, at this
point the data collection forms and procedures are untested. The purpose
of data collection in the next few weeks is to provide an evaluation of
the interview as to the amount, quality and utility of information it pro-
duces. For this reason it is very important that:
1) The interviewer closely adhere to the procedures and
interview questions
2) The interviewer pays close attention to factors related
to reaching the respondent and conducting the interview.
Only by careful observation of a standardized process can we determine what
works well, what is deficient, and what type of modifications might be
appropriate.
2.0 GENERAL INSTRUCTIONS
Follow the sequence of steps listed below. Since this is a pilot
test specific changes may be made by the Project Director from time to time,
based on interviewer observations, in an attempt to improve the interviewing,
September 1975 -160-
-------
1) Select sample of patients for Interviewing (see separate
instructions on sampling).
2) Complete top and bottom section (identifying information) of
interview cover page from medical record — at time record
abstract is prepared.
3) If necessary, try other sources such as Directory Assistance
and city street indexes to locate useful telephone numbers
for reaching respondent.
4) Fill in blanks in interview questions (month of visit, first
name of respondent, town of residence, etc.) to prepare for
interview.
5) Attempt telephone call. Up to eight calls should be made
to reach the patient's residence or to some other appropriate
telephone number for a suitable respondent. Record date and
time of attempt.
6) If the patient's residence or some other appropriate number
is reached, but a suitable respondent is not available at
that time, two callbacks to that number should be made to
reach a suitable respondent before abandoning the interview
attempt. Make note on best time to reach a suitable respondent
and other pertinent information.
7) When interview is completed or attempts terminated, complete
remainder of interview record on cover page.
8) Edit interview to determine that entries are complete and
interviewer comments are clear.
9) Remove bottom section of interview cover sheet and file this
section in order of study number.
10) File interview in order of study number in a separate file.
11) Forward completed interviews to GEOMET at the end of each
week.
These steps are described in more detail below.
-161-
-------
2.1 Interview Preparation
At the time the record is abstracted the medical record abstractor
will complete the following items on the interview cover sheet for those
cases selected to be interviewed:
• Top section - study number, log number, hospital number,
date of ER visit
• Bottom section - patient name, address, residence telephone,
age, sex, parent's name (if patient is under 18 years and
living at home).
Location of the patient and further preparation for the interview
is the responsibility of the interviewer. Even if a residence telephone is
not listed on the current clinic form there may be additional information
in the chart which would be useful in locating the patient. However, we
neither wish to slow down the abstracting process nor keep the records out
of file too long. To review the record for the additional clues, we suggest
trying combinations of the following:
0 Pulling the records a second time for interviewer review
0 Review by the interviewer of those records without telephone
numbers at the time they are identified by the abstractor
0 Designation of specific but limited additional items by the
interviewer that would be entered by the abstractor.
To illustrate, if there is no residence telephone the abstractor might enter
any other telephone numbers or names that appear on the current clinic form
(parents, employer, responsible party). The interviewer would then utilize
this data in location. If this information is not available, the record
would be re-pulled for further interviewer review. Every few days the
-162-
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Interviewer would review these special records and any others that were
currently pulled for abstracting. Some practical arrangement should be
worked out which will not put an excess burden on the abstractor and
minimize the need to pull records a second time.
The second step in interview preparation involves filling in
the reference blanks in the body of the interview: first or last name of
patient, town of residence, month of ER visit. While this information
will be on the cover sheet, it is often more efficient to insert the
reference in the appropriate question prior to starting the interview.
NOTE: To maintain confidentiality of the data full names, street
address, telephone numbers, employer and relative names, and other identifi-
cation should only be written in the bottom section of the cover sheet.
This section will then be removed before the completed interview is sent to
GEOMET.
2.2 Interview Respondent and Attempts
Preference of respondent for the interview is in the following
order:
t First - patient (if 18 years or older)
mother (if under 18 years)
• Second - mother or spouse
• Third - any adult who claims to be knowledgeable of the
patient's health and medical care.
Up to eight (8) calls to locate the patient or a suitable respondent
should be made. Once someone is reached at the patient's residence or other
location where a suitable respondent may be contacted, but the respondent is
-163-
-------
not available at the time, two (2) callbacks to this telephone should be
made in an attempt to talk to the person you want. Information should be
obtained as to the best time to try to reach the respondent. After 8
location calls and/or 2 callbackSj attempts to obtain the interview should
be terminated.
NOTE: The interviewer should not give out her full name, address
or home telephone number on any calls. Always insist on calling the party
back.
2.3 Interview Conduct and Editing
Since this is a pilot test it is important both to get the informa-
tion and to understand why the information was not obtained. It is also
important to observe whether the question produced a valid response, or
whether the respondent was confused or misunderstood the question. Conse-
quently, the interviewer should attempt to note down any observations that
may help interpret a response or lack of response. Also, some probing should
be used when there is an indication that the nature of the question is not
clear to the respondent.
A brief guide on General Interviewing Procedures has been included
with the instruction package. This may be useful in conducting and editing
the interviews. In particular, note the editing entries to account for each
question: INAP when the question is skipped, REF when the respondent refuses
to answer, and
-------
3.0 INSTRUCTIONS FOR SPECIFIC ITEMS
3.1 Interview Recording Form
Interviewer - Enter Interviewer Initials.
Study number, etc. - This row 1s completed by abstractor -
Call Record - Enter date and time for each attempt to reach
a suitable respondent or any Information/location calls. In
the "Notes" section record any information and time you need
for the next callbacks, and why you did not reach respondent
on that call.
Final Status - When interviewing 1s terminated check box
indicating status. If "Other", explain why the interview
was not completed.
Respondent - Check which type of respondent was interviewed.
Time for Interview - The Time of Try should be entered when
you pick up the phone to call. When an interview is finished,
note the time at the bottom of the last page. The difference
(1n minutes) is entered on the cover page as the time for the
interview. No entry need be made for refused interviews or
unsuccessful attempts.
3.2 Introduction Page
Use the statements given to Introduce the interview. DO NOT
mention that this study concerns ozone or air pollution, just Indicate
that we are trying to learn more about persons who use emergency rooms
(which is true!)- Consult the interview guide for help on this.
3.3 Interview Questions
The exact wording of the question you are to ask is on the left;
boxes for check-off of the response are on the right. Numbers 1n circles
Indicate that when that response 1s given, you are to skip to the question
shown. If there 1s no circled number for the response, you are to continue
with the next question in sequence. In some cases the response should be
-165-
-------
written on the lines provided by the question, with the proper code for the
response entered later.
Most of the questions are obvious; special situations are described
below.
Ques. 1 - "Working or combination" means working, working and
keeping house, working and attending school, or any
situation where the patient is employed part-time or
full-time.
Ques. 5 - If the patient does not work in the town where he
lives, enter the proper place. Later, check Metro Area
if patient works in a town on our patient selection list;
otherwise, check Outside Metro Area.
Ques. 7 - "Inside" means inside a building.
Ques. 9 - Same situation as Ques. 5.
Ques. 13 - The categories may be confusing; you may have to
repeat them.
Ques. 14 - Read each condition and have the respondent answer;
then go on to the next condition.
Ques. 15 - Write down the health problem in the respondent's
own words. We will assign a code later.
Ques. 16 - Same situation as Ques. 15.
Ques. 17 - Read slowly and repeat if necessary. It may help to
ask which symptom was the most severe and when it started.
If so, note which symptom you used.
Ques. 18 - This may require some explanation. We are referring
to the usual, normal major daily activities of the patient
and whether he had to cut back on the things he typically
does: work, school, play, housework, working around the
house, or whatever.
Ques. 19 - Allow time to remember. Use the day before the visit
as a reference point.
Ques. 21 - Emphasize that we are interested in the 12 months prior
to the visit, not 12 months before the interview.
-166-
-------
Ques. 22 - This may be confusing. We are1 Interested where
the patient was during the daytime on that day the
symptom(s) started. Refer to the 11st to determine if
that place 1s 1n the metro area.
Ques. 25 - Refer to metro 11st 1f respondent asks whether any
particular town is considered "around Riverside." Include
only time spent 1n metro area. We will code response
later.
Ques. 27 - This refers to gross estimated total annual income
of all family members living at that residence. If the
patient is an elderly relative, just obtain the patient's
income.
Ques. 28 - Write down respondent's answer, although you don't
need to enter a verbatim response — just summary phrases.
We will code later.
NOTE:
If age, sex was not 1n the medical record get this on the
Interview. If the patient doesn't live 1n the town given
in the record, note the proper town on the Interview.
Enter any comments on the answer side of the page. Make
sure they are clear and separate from the answer boxes.
Check the response you feel fits the best.
-167-
-------
Ozone Effects Study
GEOMET, Inc.
October 1975
Interview Coding
Item
Study #
E.R. Log #
Date E.R. Visit (mo., day)
# Calls (1-8)
Format
CC
Final Status:
1 - Complete 5
2 - Partial 6
3 - Referred 7
4 - No phone 8
Moved from area
Out-of-area resident
Can't locate
Other
Respondent: 1 - Patient 3 - Other
2 - Mother/spouse
Interview time: (# minutes)
Ql
Q2
Q3
Q4
Q5
Q6
Q7
Q8
Q9
5 - Invalid 7 - Other - home
6 - Preschooler 8 - Undetermined
If code 1 then add city code.
If code 0, 2 then add 00.
If code 1 then add city code.
If code 0, 2 then add 00.
xxxx
XXX
xxxx
X
X
X
XX
X
X
X
X
XXX
X
X
X
XXX
1-4
5-7
8-11
12
13
14
15-16
17
18
19
20
21-23
24
25
26
27-29
(cont.)
-168-
-------
Item Format CC
Q10
Q11
Q12
Q13
Q14 Punch a - i separately.
0 - Don't know
1 - Yes
2 - No
Q15 H-ICDA Code
Q16 Symptom codes
Q17
Q18
Q19
Q20
Q21
Q22
Q23
Q24
Q25 # years
Q26
Q27
Q28 Code for reason (to be developed)
Card "3"
#1
#2
#3
X
X
X
X
(9)
xxxx
xxxx
xxxx
xxxx
X
X
X
X
X
X
X
X
XX
X
X
XX
X
30
31
32
33
34-42
43-46
47-50
51-54
55-58
59
60
61
62
63
64
65
66
67-68
69
70
71-72
80
-169-
-------
Interview: Question #28
01 Referred by RGH social service staff
02 Clinic card
03 Closest source after hours
04 Only source patient can get care
05 Low income
06 Brought by authorities
07 Brought by ambulance
08 Second source after seeking care elsewhere
09 Regular source of care
10 Emergency facilities of RGH
11 No regular doctor
-170-
-------
Definitions of Diagnosis Groups Used in Analysis
Diagnostic Group
H-ICOA Codes
1. Asthma
2. Chronic Respiratory Disease; Chronic Bronchitis, Emphysems, Chronic
Obstructive Lung Disease
3. Acute Lower Respiratory Disease; Pneumonia, Bronchitis, Pleurisy, Acute
Pulmonary Edema
4. Lower Respiratory Symptoms; Pulmonary Congestion, Chest Pain, Respiratory
Difficulty, Lower Respiratory Symptoms
5. Acute Upper Respiratory Disease; Septic Sore Throat, Acute Upper Respiratory
Infections, Peritonsillitis
6. Upper Respiratory Symptoms; Chronic Pharyngitis, Allergy, Earache, Nasal
Congestion, Sore Throat
7. Otitis Media, Otitis Externa
8. Eye Irritation: Conjunctivitis, Belphoritis, Inflammation and Soreness
9. Flu: Influenza, Viral Syndrome
10. Chills, Fever
11. Vertigo. Dizziness. Headache; (Migraine, Tension, Other)
12. Cardiovascular Disorders and Symptoms
13. Cerebrovascular Disorders
14. Hypertension and Elevated Blood Pressure
IS. Nonphysical Psychoses and Personality Disorders
16. Anxiety. Depression. Nerves. Neuroses
17. Epilepsy, Convulsions, Seizures
18. Diabetes Mellitus
19. Upper C.I. Ulcers, G.I. Bleeding
20. Gastroenteritis. Gastritis. Diarrneal Disease
21. Abdominal Symptoms; Pain, Nausea, Vomiting, Flatulence
4930-4939
4910-4929, 4960
4800-4869, 4890-4909, 5110, 5119, 5191
5140, 5149, 5197, 7740, 7780-7789,
7790-7791, 7793, 7794, 7963, 7968
» *
0340, 4600-4659, 501
5020-5039, 5070, 7720-7722, 7760-7769,
7776-7777
380, 381
0789, 3600-3619, 7711
0799, 4700
7922, 7929
7704-7705, 7920, 3168, 346
4100-4299, 7741-7746, 7750, 7755
4300-4389
4000-4059, 7747
3060-3099, 3110-3119, 3169
3100, 3105, 3109, 317, 7926
3450-3459, 7703
2500-2509
5310-5349, 7820
0080-0099, 5350-5351, 7821
5369, 7800-7801, 7816, 7823, 7824
-------
Definition of Symptom (Complaint) Groups Used in Analysis
Symptom Group
NCHS Code
Table Name
1. Chills, Fever
2. Fatigue, 111 Feeling
3. Coma, Stupor
4. Convulsions
5. Headache
6. Vertigo, Dizziness
7. Cardiovascular System
8. High Blood Pressure
9. Respiratory System
10. Musculoskeletal
11. Digestive System
12. Eyes
13. Ears
14. Mental Health
15. Referral Visit
16. Followup, Progress Visit
17. Not Elsewhere Classified
18. Diabetic
002
005
001
004
052
054
056
069
200
205
300-399
400-499
500-599
700-720
730-740
800-899
970
980, 985
990.0
990.1
201, 216, 220
FEVR
ILL
COMA
CONV
HACHE
DIZY
HEART
BP
RESP
MUSC
DIG
EYES
EARS
MENT
REFR
PROG
NEC
DIAB
-172-
-------
Appendix B
— COMPUTER MODEL-AMD. OUTPUT FOR mnuc £QNCEMIfiAIIQN MAPPING.
//TOTAL JOB (R170, 5212-1), LEBOWI T7. ,CLASS=H.T I MF = 1 JUH
// FXEC FnRTRCLG,PARM.FORT=IO,PARM.LKEn=NOXRFF
XXFORTGCLG PPnc COOE=S.OISP='(SMR,PASS)•.SYSLMOD='fiCSYSLMliO(GO)'. 00000010
XX LMOOIS"=' (NEW,PASS) ' .LINr)ISP=' (MOD,PASS) • ,LIN'ES = AO 00000020
*** COMPILE PROCEOURE FORTRAN Gl LEVEL COMPILER **OB/04/75** OOOOOO'-JO
XXFORT FXFC PGM=IGI FORT, PARM=«LINECNT = f,LINFS' 00000040
IFF*53I SUBSTITUTION JCL - PGM=IGIFORT .PARM= • L INFCNT=*0 '
XXSYSLIN nn nSN=Kf.SYSLI.N,OISP=6LINOISP,tlNIT=SYSDA, 00000050
IFFft53I SUBSTITUTION JCL - OSN=C6SYSLIN.niSP=(MOO,PASS),1IMIT=SYSOA ,
XX SPACF=(CYL. (2,1) ), OCB= ( RECFM=FB, LRECL=BO . BLKS I 7.F=3120 ) 000000*0
XXSYSPRINT 00 SYSf)UT=A 00000070
//FORT.SYSIN 00 *
IEF23M ALLOC. FOR TOTAL FORT
IFF237I 2*1 ALLOCATED TO SYSI.IM
IFF237I *«F ALLOCATED TO SYSPRINT
IFF237I *0'* ALLOCATFO TO SYSTN
IFF 1421 - STFP WAS FXECUTEO - CUNO COOE 0000
IFF2R5I SYS752R?.T20(S405.RVOOO.TOTAL.SYSLIN PASSF.n SIO«0000004
IFF2P5T VOL SFR NHS= 21VS99.
TFF37M STEP /FORT / START 75283.101*
TFF374I STFP /FORT / STOP 752R3.1017 CPU OMIN 01.02SFC STUR VIRT 11*K
*#*I.RCC STFP /FORT / START 1-0 COUNT nASDn0000004, TAPFaQOOOOOO
***LRCC STFP /FORT / PAGING STATS IN=0000000, OUTrOOOUOOO
XXI.KFO FXFC PGMsIEWL.PARMa«LIST,XKFF.LF.T', 00000080
XX CONO=(f.COnE,LT,FORT),REGION»12RK 00000090
IFF*53I SUBSTITUTION JCL - CONn=(5,LT,FORT).RFGIONslZBK
XXSYSLTB nn nSN=SYSl.FORTLIB,01SP=SHR 00000100
XXSYSLIN nn nSM=S6SYSLIN,niSP=F.niSP 00000110
IFF*53I SUBSTITUTION JCL - DSN=£F,SYSL IN ,01 SP= ( SHR , PASS )
xx on nnN/>MF=SYSiN 00000120
XXSYSLMOO nn nSN=6SYSLMOn,OISP=&LMOOISP,UNIT=SYSOA, 00000130
IFF*53I SUBSTITUTION JCL - OSN=C6SYSLMOO(GO).niSP=(NEW,PASS),UNIT=SY$nA,
XX SPACE=(CYL,(l,fD) 000001^0
XXSYSPRINT nn SYSOUT=A 00000150
XXSYSUT1 00 UNIT=SYSOA,SPACE=(CYL,<3,1)) 000001*0
IEF23*I ALLOC. FOR TOTAL • LKED
IFF237I 150 ALLOCATED TO SYSLIR
IFF237I 2A1 ALLOCATFO TO SYSLIN
IFF237I 2*1 ALLOCATEO TO SYSLMUD
IEF237I *RF ALLPCATFn TO SYSPRINT
IFF237I 2*1 ALLOCATED TO SYSUTI
IEF142T - STFP WAS FXECUTFO - CUND CODF 0000
IFF2RSI SYS1.FOPTLTH KEPT
IFF2SSI VOL SFB NOS= 21VS23.
T^ppnSI SYS7*>2R2 ,T20*405 .KVOOO.TOTAL .SYSLIN PASSED
VOL SFR NOS= 21VS9".
SYS752H2.T20A405.RVOOO.TOTAL.SYSLMOD PASSED SUl=OOOO021
IFF2R5I VOI. SFP. NHSs PIVS'J".
IFP2R5I SYS752R2.1 20*405.RVOOO.TOTAL.«0fil34«0 DFLFTF-H SIO=0000040
IFF2R5I VOL SFR NOS= 21VS
-------
//GO.FT14F001 DD *
IFF23M ALLOC. FOR TOTAL GO
TFE237I 261 ALLOCATED TO PGM=*.OD
IEE237I 2M ALLOCATED TO DELETE?
1FF237I '(SHE ALLOCATED TO FT06F001
IEE237I ftSO ALLOCATED TO FT07E001
IEF237I *04 ALLOCATED TO FTllFOOl
IFF237T *07 ALLOCATED TO ET12E001
IEE237I q.
1FF373I STEP /fiO / START 7S.2fl3.101V
IEF374I STEP /fiO / STOP 752«3.1017 CPU OMlN 01.H6SF-C STMR V1KT 4HK
***LRCC STFP /fiO / START I-ll COUNT DASO=0000001 . TAP(-=0000000
***LRCC STEP /fin / PARING STATS IN=0000000, ("111=0000000
IEF2H5I SYS752R2.T20ft405.RVOOO.TOTAL.SYSLMOO DELFTtD
IEF2fl'5I VOL SFR NOS= 21VS99.
IEF375I JOB /TOTAL / START 752P3.101A
I(=F37ftI JOB /TOTAL / STOP 752fl3.1017 CPU OMN 03.16SEC
-174"
-------
TV PI PFI.F.ASF. 2.0
PAGE 0001
0001
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0002
0003
0004
0005
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0007
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0009
0010
0011
0012
0013
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0015
001*
0017
001«
0019
0020
0021
0022
0023
0024
0025
002*
0027
002«
0029
0030
0031
0032
0033
0034
0035
003*
0037
003«
0039
0040
0041
0042
0043
0044
r»ATA "L CM/ 3 1.?8.^1 .30.31 ,30,31 ,31 . "40.31 .30. "•»:• y
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DATS aOMAM/'I ' . ' II ' .Ml I '/
1000 NPAY=0
1 MnAY=MOfiYJ-l
READ( 11. 100. FNO=3000) 101 , (Ml 1 , I .MDAY) , I=l.?4)
Rr4n(12,100.ENP=?000)in2. 1^(2.1 .NOAY) .1=1.24)
«EAn( 13. 100.F"'P = ?000) 11^. (M( 3, I . \-r)AV | , ! = l,24)
RFAO( 14. 1 00. fc'N 0=5*000 ) 104. (M(4. 1 ,NOAV l , 1 = 1 .24)
100 FORMAT! I*.. 14X, 2412)
IF( ini ,MF. 102 ,0k. in2.NF.in3 .0". T03.NE.!04)r,pT
HV=ini/l(>0
TYR = >'Y/100
M(l=f«y_I vi^aioo
IF( HLEM c-io ) .GT .wnAY JGOTD i
Q
C COMPUTE NIGHT RACKGROUNn
C
NOPS=0
SUM=0
SDM2=0
nO 10 MO=l,NnAY
no 10 1=1,12
TT = I
IF( II.GT. 9)11 = 11+12
no 10 j=i,2
lF(M(j.n.Nn).F0.99)r,nTn 10
NORS=N(IHS-»-l
Sl)''" = S|iM+»' (J.IT .NH)
SUM2 = SUM2+M J. I 1 . Ml) **?
10 CHNTINlliF
AVEMGT=FLOAT( SUM) /FLOAT (NOBS)
SONGT=SORT ( FLOAT i siiM2 ) /FL(IAT ( won s i -AVFNGT*AVFNGT j
NGT.p.GR = IFIX( A VFNGT + SINGT /?.-<-. S )
C
C ACC'"»*I)LATE NK;wT niSTkl«i'TIu>i
C
NEV=0
nn 11 1=1.31
niSTid)=o
niST3 ( T ) =0
11 OIST(I)=0
00 12 N'f'=l .NOAY
nn 12 1=1.12
IT=I
IPIIT.GT. 9)H = II + 1?
no 12 j=i,2
IP(M( J, I t .NO) .F0.99)GI|T() I?
^F.V=MFV+1
-------
FHPTRAN IV c-l
? .0
1-4 IN
llATr =
PAGE 0003
OOP4
OOR-5
OOR7
00"R
OOR°
00°0
0091
0092
0093
0094
0095
009A
0097
009R
0099
0100
0101
, 0102
— 0103
% 0104
I 0105
010*
0107
010R
0109
0110
0111
0112
0113
O 1 1 &
0115
0116
0117
011R
0119
0120
0121
0122
0123
0124
s -, i
»/N'1BS
QAVM( ] ) zAVF*-"/
DAYS! I )=AVFH«
2R CONTINUF
^HTO RO
C
C TYPE 3 DAY
C
30 ITYP=3
nn 31 1*1.12
DAYS (I )=M(l,I+9.wn)
I F I PAYS ( I ) . EO .99 ) PA YS ( I ) =-1
NOBS=0
SUM=0
00 32 J=2,4
IF(M(.J,I+9.ND).F0.99)r,nTP 32
NOBS=NOBS-t-l
SUf»=SUM+M ( J , I +9 . Mn )
32 COMTI\"JF
AVEHR=-1
I FCMOBS.^E.O) AVFMR=IFIX { FLOAT (SUlvl)/FU)AT(NfiBS)+.t>)
nAYN(I)=AVEHR
no 33 J=2.4
T C f M f I T 4-Q (Vfll FD yQ^PnTO 1 "•!
NFV3=NEV3+1
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IF(DEL.GT.:JI)»CL=31
IF{ncL.LT.l J'iFLsl
nisT3(nFL)=nisT:)(iiFL}-«-i
33 CPNTIMIIF
31 CrWTIMIF
C
C OUTPUT A HAY
C
RO WRITc(6.203)-'Mn.RriMAN( ITYP ) ,NGTH(;" . ( f)AYN- ( I ) . ri/\YS( I ) . I =1 . 12).*PTRGR
203 FfiRKAK IX. !4,3X.A/+.I3.1? ( [5. 13) . TH)
15 CnwTINUF
C
C OUTPUT DISTRIBUTION SUMMARIES
C*
•
-------
IV r.
2.0
10/1 7/OCj
PAGE 0003
OOR5
C
c
2 OAY
00 2R 1 = 1.12
OOR7
OOfl"
nnflo
0090
0091
0092
0093
009*
0095
009A
0097
009R
0099
0100
0101
0102
0103
010^
0105
010ft
0107
010R
0109
0110
0111
0112
0113
OLL&
U JL !• ™
0115
011A
0117
OUR
0119
0120
0121
0122
0173
012^
Si'M=C
nn 27 j=i,2
I F f v ( ) T **) NT) ) FO QQl^OT^ ? 7
wr)RS=NnaS+)
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27 CONTINUE
AVrH^e-l
TF(NnBS.^F.O) AVFH^sSUM/M'lHS
OAVVJ i ) =.AVFH^
DAYS( I )=AVFH«
2R CONTIWIIF
RnTfi RO
C
C TYPE 3 OAY
C
30 ITYP=3
no 31 1=1.12
OAVS(I)=M(1.I+9.NO)
IF ( "AYS (I). EC. 99) PAYS H )=-!
*JOBS=0
S"M=0
OP 32 J=2.^
IF{M(.J,I+9.ND).F0.09)ROTP 32
MCBS=NOBS+1
S:)V=SIIM+M ( j , i -t-9 ,MD )
32 CONTINUE
AX'EHR=-1
!F(NOBS.NE.O)AVEHR = IFIX( FLOAT ( S.!* ) /Fl»AT ( NtHS ) +. 5 )
OAYN(T)=AVFHR
DO 33 J=2,^
I F ( M ( I T+Q MD) FO QQ)mTn ^^
MFV3=NEV3+1
PFI.=M
-------
IV f,l QFLFiSF 2.0
in/i
PAI~,F-
01? S
012ft
01?7
0130
0131
0132
0133
0134
0135
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0137
013P
i-1 S I '•- I'"' C1 '»•'•' '
300
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FORTRAN IV Gl RFLF.ASF 2.0
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TECHNICAL REPORT DATA
(Please read Instructions on the reverse before completing)
1. REPORT NO.
EPA-600/1 -78-030
2.
4. TITLE AND SUBTITLE
Use of Emergency Room Patient Populations
in Air Pollution Epidemiology
7. AUTHOR(S)
J.R. Ward and D.J. Moschandreas
9. PERFORMING ORGANIZATION NAME Af
Geomet, Inc.
15 Firstfield Road
Gaithersburg, MD 20760
JO ADDRESS
12. SPONSORING AGENCY NAME AND ADDRESS
Health Effects Research Laboratory RTP, NC
Office of Research and Development
U.S. Environmental Protection Agency
Research Trianil0 Park N ** 97711
15. SUPPLEMENTARY NOTES
3. RECIPIENT'S ACCESSION NO.
5. REPORT DATE
May 1978
6. PERFORMING ORGANIZATION CODE
8. PERFORMING ORGANIZATION REPORT NO.
10. PROGRAM ELEMENT NO.
11. CONTRACT/GRANT NO.
68-02-2205
13. TYPE OF REPORT AND PERIOD COVERED
14. SPONSORING AGENCY CODE
EPA-600/1 1
16. ABSTRACT
The long-term objective of this project was the design and implementation of
a particular epidemiological approach to investigation of ambient pollutant
effects: the correlation of pollutant exposure with patterns of hospital
emergency room utilization. The report covers the initial phase of development
and pilot studies. Separate discussions are provided on the two major components
of the methodology: investigation of health effects and estimation of ambient
ozone concentrations.
The approach to study adverse health effects was premised on the assumption
that an increase in community morbidity due to environmental air pollution would
be reflected in emergency room patient populations. It was concluded, however,
that this was not a useful method for investigation of exposure- response associations.
The mapping of ambient ozone concentrations in time and space over the
Riverside metropolitan area was investigated using data from two monitoring stations
located within the subject area. A procedure was developed for a month-by-month
comparative study of the data.
17.
a. DESCRIPTORS
KEY WORDS AND DOCUMENT ANALYSIS
b. IDENTIFIERS/OPEN ENDED TERMS
epidemiology
air pollution
hospitals
18. DISTRIBUTION STATEMENT
RELEASE TO PUBLIC
19. SECURITY CLASS (This Report)
UNCLASSIFIED
20. SECURITY CLASS (This page)
UNCLASSIFIED
c. COSATI Field/Group
06 T
05 B
21. NO. OF PAGES
^06
22. PRICE
EPA Form 2220-1 (9-73)
198
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