United States OHice of Policy Octobci 1988
Enviror.tr.onr.il Protection Planning and Evaluation EPA 230 10-88 042
Agency Washington DC. 20460
vvEPA Heart Disease Patients
Averting Behavior, Costs
of Illness, and Willingness
to Pay to Avoid Angina
Episodes
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30273-101
REPORT DOCUMENTATION »• Report no. *.
PAGE EPA-230-10-88-042 '¦}
R«clpJ*nf* Acc««tlon No
4. Title end Subtitle
Heart Disease Patients' Averting Behavior, Costs of Illness,
and Willingness to Pay to Avoid Angina Episodes
& Report Date
October 1988
e.
7. Author**)
L.G. Chestnut, S.D. Colome. L.R. Keller, W.E. Lambert, et al.
L Performing Organization Rapt. No.
9. Performing Organization Name and Address
University of California, Irvine
Graduate School of Management
Irvine, CA 92717
10. Pre]sct/Tash/Worfc Unit No.
11. ConlratKC) or Orant(Q) No. *'
(C)
«> CR-812826
12. Sponsoring Organization Name and Address
Office of Policy Analysis, PM-221
U.S. Environmental Protection Igency
Washington, D.C. 20460
13. Tjrpa of Report * Period Covered
Final Report
14.
15. Supplementary NotM
16. Abstract (Umlt: 200 words)
Insufficient blood flow to the heart muscle will cause low-oxygen stress, which
may be manifest as anginal pain. Oxygen delivery may be impaired by exposure to the
air pollutant, carbon monoxide, causing expisodes of angina. This report presents an
economic irodel of behavior for an individual's health and response to environmental
pollution. In a pilot" test^ data was collected from a sample of 50 .men with heart
disease. Cost of illness measures were computed to include lost/work time-and
expenditures to avoid angina. Contingent valuation methods were' used:to elicit
willingness to pay for avoiding additional angina. Results from the alternative
approaches are compared, and recommendations are provided for a more representative
study. . -
17. Document Analysis a. Descriptor*
morbidity valuation
angina
ischemia
b. Identlfiert/OpervCnded Terms
morbidity values
cost of illness measures
c. COSAT] Field/Group
cost-of-illness
willingness to pay
carbon monoxide
contingent valuation
averting behavior
willingness to pay
defensive expenditure
11 Availability Statamenl
No restriction on distribution
Available from National Technical
Information Service, Springfield, VA
11 Becuittj CUts (This
unclassified
XI. No. of Pa«ee
22161
SO. Security Class (This
unclassified
—.-3.*?
J 22. Price / ^
(See ANS»-Z39.in
OPTIONAL FORM m (4-r
(Formerly NTIS-35)
Department of Commerce
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HEART DISEASE PATIENTS' AVERTING BEHAVIOR,
COSTS OF ILLNESS, AND WILLINGNESS TO PAY
TO AVOID ANGINA EPISODES
FINAL REPORT TO
OFFICE OF POLICY ANALYSIS
U.S. ENVIRONMENTAL PROTECTION AGENCY
OCTOBER, 1988
by
Lauraine G. Chestnut^"
Steven D. Colome
L. Robin Keller^
2
William E. Lambert
Bart Ostro
Robert D. Rowe^
2
Sandra L. Wojciechowski
1. RCG/Hagler, Bailly, Inc.,
(formerly Energy and Resource Consultants), Boulder, CO
2. University of California, Irvine, CA
3. U.S. Environmental Protection Agency
The information in this document has been funded wholly or in part by the
United States Environmental Protection Agency under Cooperative Agreement No.
CR-812826 to University of California, Irvine. It has been subjected to the
Agency's peer and administrative review and has been approved for publication
as an EPA document. Mention of trade names or commercial products does not
constitute endorsement or recommendation for use. The authors thank Dr. Ann
Fisher of the Office of Policy Analysis and three anonymous reviewers for
helpful comments on a previous draft of this report.
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EXECUTIVE SUMMARY
Background and History: Cardiac Health Symptoms and Carbon Monoxide Exposure
The University of California, Irvine has been examining the relationship
between community exposure to carbon monoxide and the occurrence of cardiac
health symptoms, including angina pectoris, in male research subjects with
demonstrable ischemic heart disease (atherosclerotic disease of the coronary
arteries which impairs blood flow to the heart muscle). During January to May
1985, ischemic heart disease subjects carried electronic monitors to measure
personal exposure to carbon monoxide during their normal course of daily
activity. Carbon monoxide exposure profiles and biological monitoring
demonstrated that heart disease subjects frequently encountered carbon
monoxide in the urban environment and at times developed blood levels of
carboxyheraoglobin which have been observed in clinical studies to aggravate
angina symptoms.
In July 1985 it was recognized that the study's large data base and
intact subject pool offered the opportunity for research on defensive
behaviors and expenditures made by heart disease subjects in an effort to
avoid angina. This led to a cooperative agreement between the U.S.
Environmental Protection Agency Office of Policy Analysis, University of
California, Irvine, and RCG/Hagler Bailly, Inc. (formerly Energy and Resource
Consultants) to demonstrate the feasibility of placing a value on the cost of
angina and related cardiac symptoms. Using the established pool of heart
disease subjects, willingness to pay to avoid angina episodes was to be
elicited, using contingent valuation methods. Information on the cost of
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2
illness related to ischemic heart disease and associated symptoms was
collected and compared to what subjects were willing to pay to avoid those
episodes. In addition, information was obtained regarding defensive
expenditures and behaviors undertaken to avoid or reduce angina symptoms.
This report presents the results of this cooperative pilot study. Due to the
small, nonrandom sample and exploratory nature of the study design, the
results should be interpreted as suggestive only and are intended to guide the
design of future research efforts.
Theoretical Framework for Evaluating the Impacts of Carbon Monoxide Exposure
on Ischemic Heart Disease Patients
We have developed a framework for assembling many of the components
required for the evaluation of the impacts of carbon monoxide exposure on
ischemic heart disease patients who experience angina pain.
Chapter 2 contains a review of previous work on the adverse health
effects of carbon monoxide on ischemic heart disease patients and the methods
used in the University of California, Irvine community exposure study.
A theoretical structure which can be used to evaluate different carbon
monoxide standards is also presented in Chapter 2. The basis of this approach
is an economic model of individual behavior, in which a person's utility is
assumed to be a function of health and the goods or services he consumes. The
level of a person's health is modeled as a function of defensive expenditures,
pollution exposure, and the biological, social and economic characteristics of
the person. It is assumed that a person maximizes utility, which is
constrained by available income. Income may be deflated by previous medical
expenses and by wages lost through loss of work. This economic model of
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3
individual behavior, when aggregated over a number of individuals, can be used
to determine levels of utility for the population resulting from certain
carbon monoxide emission standards.
Studv Design
Chapter 3 describes the survey methods used to elicit economic
information from the 50 subjects in the study. Information on demographics
and the adverse effects of angina were obtained by telephone interviews. The
adverse effects included time spent sick, lost days of work, partial or full
loss of employment, medical expenditures made in response to illness, rankings
of the relative bothersomeness of the effects of angina/heart disease,
willingness to pay to avoid additional angina, and defensive expenditures and
activities.
Results
Chapter U contains the survey results and the analysis of the personal
carbon monoxide exposure data. Using multiple measures, the results converge
on a picture of ischemic heart disease and associated angina as a burdensome
state of health, with substantial medical costs, loss of opportunities to earn
wages, psychological burdens, and expenditures to avoid further adverse health
effects. The results for each type of impact are summarized below.
Cost of Illness
Annual out-of-pocket medical expenditures due to ischemic heart disease
for the study subjects averaged $256 per person. This included out-of-pocket
cost of treatment and medication, and travel to the physician's office. Other
annual medical expenditures incurred by any source (including the Veterans
Administration hospital, private insurers, but not the individual) averaged
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4
$4,523 per person. Annual loss of wages due to sick days or partial or full
loss of employment due to the illness and associated symptoms averaged $9,581
per person. The total annual cost of expenses and lost earnings thus averaged
$14,359 per person. Costs for the "latest angina incident" were reported to
be zero or a few cents. Regression analysis suggested no relationship between
total reported costs and the rate of angina incidents, reflecting the probable
unsuitability of using a COI measure to value changes in angina frequency and
intens ity.
Lifestyle and Emotional and Physical Effects
In general, the subjects said that the most bothersome effects if a
worsening of their condition caused an increase in angina would be decreased
ability to do desired activities (recreation, chores, or work), and pain or
discomfort. Patients' concern about the worry or inconvenience caused for
family and friends, and the possibility of a heart attack or need for bypass
surgery were also stressful. Less important, but none the less stressful,
were decreased ability to work at a job (for reasons other than income), more
non-medical expenses (such as paying for services), more medical treatment
expenses, and lost ability to earn income.
Willingness to Pay
The mean willingness to pay to avoid additional angina was $40 per
episode among the 42 subjects who responded with a dollar amount. When
respondents who gave the answer "I'd pay anything I have to avoid added
angina" were coded to be equal to the highest dollar amount they had agreed to
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5
when asked a close-ended question of the form "Would you pay $y per month to
avoid 4 (or 8) additional angina episodes per month?", the lower bound on the
willingness to pay for all 49 responding subjects was $42 per month. (The
frequency of angina episodes in the sample averaged 1 per week or 4-5 episodes
per month.) When those who would pay "anything" had their answers recoded to
a feasible maximum amount equal to their total monthly income, the average
willingness to pay was $103 per episode.
Expenses Due to Defensive Expenditures
Subjects were asked to itemize expenditures for goods or services
purchased to avoid additional angina. Twenty-one of the 50 subjects hired
services (e.g., yard work, plumbing, car maintenance) or purchased goods
(e.g., lawn mowers, household appliances, and new automobiles) yielding an
average annual expense of $2,151 for these 21 subjects. Sixteen of the 21
subjects estimated the number of added angina episodes they avoided by hiring
the service they purchase most often or the largest purchase of a good. The
average expenditure for these services or goods was $603 for these sixteen
subjects. The mean expenditure per episode for these 16 subjects was $38 and
ranged from $3.50 to $140. This mean may be compared to the average
willingness to pay of $28 per angina episode given by the same 16 subjects.
Note that willingness to pay measures the amount a person would pay to avoid
additional episodes, given that expenditures for services or equipment have
already been incurred.
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6
Activity Patterns and CO Exposure
Data on activity patterns and carbon monoxide exposure in urban locations
were collected in an earlier University of California, Irvine research
effort. An analysis of these data suggests that ischemic heart disease
patients frequently encounter carbon monoxide in the course of their daily
activities, and may develop carboxyhemoglobin levels greater than 2.5 percent,
a point where aggravation of angina has been observed in clinical studies.
Conclus ions
The results of this pilot study suggest that useful information for
valuing changes in angina frequency can be obtained from patients with
ischemic heart disease. An especially promising result was the consistency
between the estimate of defensive expenditures and stated willingness to pay
per angina episode avoided. As expected, evaluating changes in angina
symptoms is confounded by the complexity and significance of the overall
effect on the patient's life of having ischemic heart disease.
This was highlighted by the difficulty found in putting any meaningful
cost of illness value on small changes in angina frequency. Specific
recommendations for future research efforts are given in Chapter U.
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Angina pectoris is a specific type of chest pain associated with
atherosclerotic disease of the coronary arteries. This pain is a sensation of
tightness or pressure in the chest, and is induced by factors which increase
the oxygen requirements of the heart tissue. These factors include physical
exertion, emotional stress, and cold weather. Insufficient blood flow to the
heart muscle will cause low-oxygen stress, or ischemia, which may be manifest
as anginal pain. Oxygen delivery may be further impaired by exposure to the
air pollutant carbon monoxide (CO), which binds strongly to hemoglobin and
decreases the oxygen-carrying capacity of the blood, thereby causing episodes
of angina. Regardless of the cause, recurrent anginal symptoms can reduce the
quality of life, restrict activities, and cause psychological stress. But the
limited quantitative information on the economic consequences of these effects
has constrained the evaluation of public policies to reduce urban CO
exposures. This paper presents an economic model of behavior which describes
an individual's health and response to environmental pollution. In addition,
a survey instrument was developed to measure the economic impacts associated
with angina, and was pilot tested with a sample of 50 men with ischemic heart
disease. The cost of illness was computed from information elicited on
insurance premiums, medication and treatment costs and lost work time;
information on expenditures for services or purchases of goods to avoid angina
was also elicited. Additionally, the dollar amount that a subject was willing
to pay to prevent additional angina was elicited using contingent valuation
methods. The performance of the survey instrument suggests that it is
feasible to elicit many of the components required in the theoretical model
describing the economic behavior of people with angina pectoris who are
exposed to CO.
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8
TABLE OF CONTENTS
ABSTRACT
TABLE OF CONTENTS
LIST OF TABLES
LIST OF FIGURES
LIST OF ABBREVIATIONS
1. INTRODUCTION AND SUMMARY
1.1 Background and History
1.2 Summary
2. MEASURING AND VALUING HEALTH EFFECTS OF CARBON MONOXIDE
2.1 Biological and Health Effects of CO
2.2 Background on Economic Health Valuation
2.3 Theoretical Framework for the Study Design
3. METHODS
3.1 Questionnaire Development
3.2 Panel Selection
3.3 Sampling Procedures
3.4 Data Analysis
4. RESULTS AND DISCUSSION
4.1 Cost of Illness
4.2 Willingness to Pay
4.3 Averting Behaviors
4.4 Community CO Exposure of IHD Subjects
4.5 Conclusions and Recommendations
REFERENCES
TABLES
FIGURES
APPENDIX
1. Subject Screening Interview Questions
2. Questionnaires
Subject Version
Interviewer Version with Descriptive Statistics
3. Data Codebook
4. Aggregate Results
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1
1
1
2
3
1
2
3
U
5
6
7
8
9
10
10
10
11
12
9
LIST OF TABLES
Characceristics of Research Subjects Used to Evaluate the Survey
Instrument
Schedule of Dollar Amounts (Treatments) Used in Close-Ended
Willingness-to-Pay Question (Question 32)
Workloss Due to Angina
Definitions of Variables Used to Compute Wages Lost From Current
Employment Due to Angina
Regression Analysis Relating Cost of Illness and Individual
Characteristics
Rating and Share Means of Potential Effects of an Increase in Angina
Pearson Correlations of "Bothersomeness Shares" and Personal
Characteristics
Comparisons of Shares to Subject Characteristics
Summary of Responses to the Open-Ended Willingness-to-Pay Questions
(Questions 30a, 30b, and 33)
Summary of Responses to the Close-Ended Willingness-to-Pay Question
(Question 32)
Logit Analysis of Responses to the Close-Ended Willingness-to-Pay
Question (Question 32)
Evaluation of High WTP Responses Relative to History of Heart
Disease and Income
Mean Responses to the Open-Ended OTP Question 33
Number of Years since Myocardial Infarction and Willingness-to-Pay
to Avoid Four or Eight Angina Episodes
Regression Analysis Predicting Willingness to Pay Dollar Amounts
from the Open-Ended WTP Question 33
Regression Analysis Predicting Willingness to Pay Dollar Amounts
from the Open-Ended WTP Question 33
Regression Analysis Predicting Willingness to Pay Expressed as a
Percentage of Monthly Income (PAYINC)
Definitions of Variables used in Regression Analyses
Summary of Means and Variances of Variables used in the Regression
Analyses
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4.2-13
4.3-1
4.3-2
4.3-3
4.4-1
4.4-2
4.5-1
10
Derivatives of WTP with Respect to MONFREQC and SURG
Regression Analysis Predicting the Probability of Defensive Action
Regression Analysis Predicting the Probability of Defensive
Expenditures
Regression Analysis Predicting Average Carbon Monoxide Exposure
Ranking of Time-Weighted Exposures by Activity Class
Ranking of Time-Weighed Exposures by Microenvironment Class.
Occupancy Time Refers to Time Spent in Location Class
Summary of Dollar Welfare Estimates for IHD Patients
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11
LIST OF FIGURES
3.1-1 Linkages between Expenditures and Health for IHD Patients
3.2-1 Angina Subject Selection and Disposition
4.2-1 Willingness-to - Pay in Dollars to Prevent an Additional Four or Eight
Episodes of Angina
4.3-1 Average Averting Expenditures
4.4-1 Proportion of Time Spent in Major Microenvironmental Classes for
Nonsmoking IHD Subjects While Wearing the CO Personal Exposure
Monitors
4.4-2 Distribution of Minute-by-Minute Personal CO Exposure Measurements
for Nonsmoking Subjects (N = 36; 142 Person Days)
4.4-3 Distribution of Minute-by-Minute COHb Estimates as Predicted for
Nonsmoking IHD Subjects by PEM Measurements using the Linear Model
of Ott and Mage (1978) (N = 36; 142 Person Days)
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LIST OF ABBREVIATIONS
CABG
CO
COHb
COI
CV
ECG
EPA
ERC
Hb
IHD
MET
MI
02Hb
PTCA
PEM
ppm
UC Irvine
VA
WTA
WTP
Coronary artery bypass graft
Carbon monoxide
Carboxyhemoglobin (compound formed by the combination of
carbon monoxide with hemoglobin)
Cost of illness
Contingent valuation
Electrocardiogram
U.S. Environmental Protection Agency
Energy and Resource Consultants, Inc.
Hemoglobin (iron-containing protein respiratory pigments
occurring in the red blood cells of vertebrates and
transporting oxygen to the tissues and carbon dioxide from
the tissues)
Ischemic heart disease
Metabolic activity unit
Myocardial infarction (heart attack)
Oxyhemoglobin
Percutaneous transluminal coronary angioplasty, also called
angioplasty
Personal exposure monitor
Parts per million
University of California, Irvine
Veterans Administration
Willingness to accept
Willingness to pay
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12
CHAPTER 1. INTRODUCTION AND SUMMARY
1.1 Background and History
Since January 1985, research has been conducted at the University of
California, Irvine (UC Irvine), examining the relationship between community
exposure to carbon monoxide (CO) and the occurrence of cardiac health
symptoms, including angina pectoris. A sample of male subjects with
demonstrable ischemic heart disease, atherosclerotic disease of the coronary
arteries that impairs blood flow to the heart muscle, was assembled from the
patient populations of two regional medical centers in the Los Angeles and
Orange County areas. During January to May 1985, ischemic heart disease (IHD)
subjects carried electronic monitors to measure personal exposure to CO during
their normal course of daily activity. CO exposure profiles and biological
monitoring demonstrated that IHD subjects frequently encountered CO in the
urban environment, and at times developed blood levels of carboxyhemoglobin
(COHb) which have been observed in clinical studies to aggravate angina
symptoms.
In July 1985 it was recognized that the study's large data base and
intact subject pool offered the opportunity for research on defensive
behaviors and expenditures made by IHD subjects in an effort to avoid
angina. This led to a cooperative agreement between the U.S. Environmental
Protection Agency Office of Policy Analysis, UC Irvine, and Energy and
Resource Consultants (ERC) to demonstrate the feasibility of placing a value
on the cost of angina and related cardiac symptoms. Using the established
pool of IHD subjects, alternative measures of the value of avoiding angina
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14
episodes were elicited, using survey research methods. Information was
obtained on medical expenses, work loss, defensive expenditures, and
willingness to pay to avoid angina episodes. In addition, defensive
expenditures and behaviors were related to CO exposure as actually measured in
an earlier community monitoring study. This report presents the results of
this cooperative study.
1.2 Summary
We have developed a framework for assembling many of the components
required for the evaluation of the welfare impacts of carbon monoxide exposure
on ischemic heart disease patients who experience angina pain.
Chapter 2 contains a review of previous work on the adverse health
effects of CO on ischemic heart disease patients and the methods used in the
UC Irvine community exposure study.
A theoretical structure that can be used to evaluate different carbon
monoxide standards is also presented in Chapter 2. The basis of this approach
is an economic model of individual behavior, in which a person's utility is
assumed to be a function of health and the goods or services he consumes. The
level of a person's health is modeled as a function of defensive expenditures,
pollution exposure, and the biological, social and economic characteristics of
the person. It is assumed that a person maximizes utility, which is
constrained by available income. Income may be deflated by previous medical
expenses and by wages lost through loss of work. This economic model of
individual behavior, when aggregated over a number of individuals, can be used
to determine levels of utility for the population resulting from alternative
carbon monoxide emission standards.
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15
Chapter 3 describes the survey methods used to elicit economic
information from the 50 subjects in the study. Information on demographics
and the adverse effects of angina were obtained by telephone interviews. The
adverse effects included time spent sick, lost days of work, or partial or
full loss of employment, medical expenditures made in response to illness,
rankings of the relative bothersomeness of the effects of angina/heart
disease, willingness to pay to avoid additional angina, and defensive
expenditures and activities.
Chapter b contains the survey results and the analysis of the personal CO
exposure data. Using multiple measures, the results converge on a picture of
IHD as a burdensome state of health, with substantial medical costs, loss of
opportunities to earn wages, psychological burdens, and expenditures to avoid
further adverse health effects. Angina is a bothersome symptom of IHD for
these patients, but it was, in some cases, difficult for subjects to isolate
angina symptoms from their disease as a whole. The results for each type of
economic welfare measure are described separately. The results must be used
with caution because the sample used for this pilot test was small and not
necessarily representative of all IHD patients.
Cost of Illness
Annual out-of-pocket medical expenditures due to IHD for the study
subjects averaged $256 per subject. This included out-of-pocket cost of
treatment and medication, and travel to the physician's office. Total annual
medical expenditures incurred by society (including the Veterans
Administration (VA) hospital and private insurers, but not the individual)
averaged $
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16
or full loss of employment due to angina averaged $9,581 per subject. The
total annual cost of expenses and lost earnings to the subject and to society,
thus averaged $14,359 per subject across all 50 subjects. Because CO is
believed to aggravate angina symptoms in patients who already have IHD,
analysis was undertaken to estimate the marginal cost of small changes in
angina frequency and the cost of the "latest incident." The results suggest
that although the total costs associated with IHD are substantial, the
marginal cost of small changes in angina is minimal.
Lifestyle and Emotional and Physical Effects
In general, the subjects reported that the most bothersome effects of an
increase in angina would be decreased ability to do desired activities
(recreation, chores, or work), and pain or discomfort. Subjects' concern
about the worry or inconvenience caused to family and friends, and the
possibility of a heart attack or need for bypass surgery were also
important. Less important, but still bothersome, were decreased ability to
work at a job (for reasons other than income), more non-medical expenses (such
as paying for services), more medical treatment expenses and loss of ability
to earn income.
Willingness to Pay
The mean willingness to pay to avoid angina was $40 per episode among the
42 subjects who responded with a dollar amount. When respondents who gave the
answer "I'd pay anything I have to avoid added angina" were coded to be equal
to the highest dollar amount they had agreed to when asked a close-ended
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17
question of the form "Would you pay $y per month to avoid 4 (or 8) additional
angina episodes per month?", the lower bound on the willingness to pay for all
49 responding subjects was $42 per month. (The frequency of angina episodes
in the sample averaged 1 per week or 4-5 episodes per month.) When those who
would pay "anything" had their answers recoded to a feasible maximum amount
equal to their total monthly income, the average willingness to pay was $103
per episode.
Expenses Due to Defensive Expenditures
Subjects were asked to itemize expenditures for goods or services
purchased to avoid additional angina. Twenty-one of the 50 subjects hired
services (e.g., yard work, plumbing, car maintenance) or purchased goods
(e.g., lawn mowers, household appliances, and new automobiles) yielding an
average annual expense of $2,151 for these 21 subjects. Sixteen of the 21
subjects estimated the number of added angina episodes they avoided by hiring
the service they purchase most often or the largest purchase of a good. The
average expenditure for these services or goods was $603 for these sixteen
subjects. The mean expenditure per episode for these 16 subjects was $38 and
ranged from $3.50 to $140. This mean may be compared to the average
willingness to pay of $28 per angina episode given by the same 16 subjects.
Note that willingness to pay measures the amount a person would pay to avoid
additional episodes, given that expenditures for services or equipment have
already been incurred.
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18
Activity Patterns and CO Exposure
Data on activity patterns and CO exposure in urban locations were
collected in an earlier UC Irvine research effort. An analysis of these data
suggests that ischemic heart disease patients frequently encounter CO in the
course of their daily activities, and may develop carboxyhemoglobin levels
greater than 2.5 percent, a point where aggravation of angina has been
observed in clinical studies.
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19
CHAPTER 2. MEASURING AND VALUING HEALTH EFFECTS OF CARBON MONOXIDE
The first two sections of this chapter give a brief review of the health
and economics literature relevant to measuring and valuing health effects of
CO for IHD patients. The third section presents the theoretical framework for
the instrument design and data analysis conducted in this study.
2.1 Biological and Health Effects of CO
People with IHD are considered to be particularly sensitive to the toxic
action of CO because of their impaired coronary blood flow (Ayres, et al.,
1970) . Narrowing of the coronary arteries by atherosclerotic plaque limits
blood flow, and hence oxygen delivery to the heart muscle (myocardium). When
increases in the demand for both coronary blood flow and oxygen delivery
exceed the available supply, myocardial ischemia ensues. Ischemia, or low
oxygen stress, is manifest in several physiologic endpoints, including
decreased force of contraction and changes in electrophysiology of the
myocardium, and chest pain.
Chest pain, and the complex of symptoms associated with ischemic cardiac
pain, are medically termed angina pectoris, or more simply angina. Chest
discomfort or tightness may be accompanied by pain in the throat or lower jaw,
or pain radiating across the chest to the arms. The frequency and severity of
angina episodes are related to the extent of coronary disease and the work
load placed upon the heart muscle. The most common form of cardiac pain is
that provoked by exertion.
Myocardial ischemia is quantitatively related to changes in heart rate
and blood pressure, and angina sufferers often learn to identify the level of
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20
physical activity that will precipitate the pain. Angina may be brought on by
walking uphill or upstairs, hurried walking on level ground, or lifting heavy
objects. Pain may also be precipitated by emotional stress; excitement,
anger, or tension may increase autonomic nervous system activity and increase
heart rate and blood pressure. Exposure to cold temperature may cause
constriction of peripheral blood vessels, thereby increasing blood pressure,
and in turn raising the cardiac work load. Angina pain comes on quickly, and
it is steady and constant, usually lasting for several minutes. Longer
periods of ischemic pain are associated with more serious outcomes of
myocardial infarction (heart attack). Under most circumstances, angina is
relieved by rest, however nitrate medications may also be taken to increase
coronary blood flow and dilate peripheral blood vessels, thereby decreasing
the resistance against which the heart muscle pumps.
Exposure to carbon monoxide can decrease the exercise tolerance of IHD
subjects who suffer angina. Inhaled CO displaces the oxygen in blood
hemoglobin and alters the binding characteristics of oxyhemoglobin, further
decreasing oxygen supply to the myocardium (Roughton and Darling, 1944). In
standardized exercise tests, Andersen et al. (1973) observed statistically
significant decreases in exercise duration to the onset of angina after four
hours exposure to 50 or 100 ppm CO. The carboxyhemoglobin (COHb)
concentrations resulting from these relatively low-level exposures were 2.9
and 4.5 percent, respectively. These COHb concentrations may be attained by
nonsmoking residents of metropolitan areas (Wallace et al., 1987; Akland et
al., 1985; Radford and Drizd, 1982), and therefore represent an important
public health concern. Currently, the Health Effects Institute and the
California Air Resources Board are funding research to replicate and extend
the Andersen et al. (1973) study. Other clinical studies by Aronow (1981) and
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21
Aronow and Isbell (1973) have suggested aggravation of angina at COHb levels
near 3 percent. However, the methodology employed in these studies has not
withstood rigorous scientific review (U.S. EPA, 1984 a and b).
Although provocation of angina is the endpoint of interest in our study,
decrements in cardiac function have been measured in other clinical studies,
which support the hypothesis of increased health risk from CO exposure.
Significant decreases in left ventricular ejection fraction, indicating a
decrease in the forcefulness of contraction of the myocardium, were observed
in IHD patients whose COHb levels were elevated to 5.9 percent. In healthy,
nonsmoking individuals, free of cardiac disease, COHb levels greater than 5
percent exceed the compensatory response of the cardiovascular system to
hypoxic challenge; oxygen demands exceed the supply provided by increased
coronary blood flow (Ayres and Grace, 1970), and exercise performance is
generally impaired (Ekblom and Hout, 1972; Horvath et al., 1975; Weiser et
al., 1978; Klein et al., 1980). The consistent demonstration of decreased
aerobic work capacity in healthy individuals at the 5 percent COHb level lends
indirect support to the Andersen et al. (1973) observations of angina
aggravation in IHD subjects at 3 percent COHb. At the present time, CO
exposure has not been unequivocally associated with changes in the
electrophysiology of the heart muscle. Human and animal studies are limited
in number and provide inconsistent data on disturbances in conduction velocity
and heart rhythm (DeBias et al., 1973; Davies and Smith, 1980; Foster, 1981).
Epidemiologic evidence on the relationship between CO exposure and
increased incidence of myocardial ischemia also is limited. In Los Angeles,
total deaths and deaths from atherosclerotic heart disease (myocardial
infarction) were significantly associated with daily mean outdoor CO
concentration (Cohen et al., 1969; Hexter and Goldsmith, 1971). Kurt et al.
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22
(1978, 1979) considered the specific relationship between community CO levels
and the incidence of angina in Denver, Colorado. The incidence of
cardiorespiratory complaints, including angina, were significantly associated
with 24-hour mean CO levels exceeding 5 ppm. These epidemiologic studies have
assumed that outdoor levels of CO are generally representative of personal
exposures. The validity of conclusions based on this asumption is questioned
by later research demonstrating that time-weighted personal exposures are not
strongly correlated with CO measurements at nearby outdoor fixed-site
locations (Akland et al., 1985; Hartwell et al., 1984; Johnson, 1984).
Previous Assessments of Community CO Exposure
The most comprehensive population-based study of community CO exposures
was performed in the winter of 1982-83 by the U.S. EPA in the cities of
Denver, Colorado, and Washington, D.C. (Akland et al., 1985). In each
metropolitan area, five-hundred nonsmoking residents, age 18-70, were randomly
selected to carry a personal exposure monitor for one or two 24-hour
periods. Each subject kept a written diary of activities and locations during
their monitoring day, and samples of end-expired breath were collected at the
end of the monitoring period for analysis of CO content and estimation of COHb
level. Microenvironments associated with automobile activity displayed the
highest mean personal exposures to CO (7-14 ppm) and included exposure indoors
in public garage, service station, or auto repair facility, and in transit in
a motor vehicle (Hartwell et al., 1984; Johnson et al., 1984). Moderate
exposures (2-5 ppm) were measured in indoor public places such as restaurants,
stores, and health care facilities. Schools, residences, and outdoor
recreational areas generally demonstrated lower mean exposures (0.5-2 ppm).
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In Denver, 3 percent of Che daily maximum personal exposures exceeded Che 35
ppm 1-hour average federal sCandard, and 11 percenC exceeded Che daily maximum
9 ppm 8-hour average federal sCandard. In Washington, while no subjecC's
personal exposure exceeded the 1-hour standard, 3.5 percent of personal
exposures exceeded the 9 ppm standard (Akland et al., 1985; Ott et al., 1987).
Fixed monitoring sites in Denver and Washington tended to overestimate
mean exposures for the population, predicting that the daily 9 ppm 8-hour
standard in Denver and Washington would be exceeded 25 and 7 percent of the
time, respectively. When personal exposure monitoring data and breath
estimates of blood COHb were entered into the Coburn equation to estimate
recent CO exposures, 10 percent of the nonsmoking population of Washington,
D.C. was estimated to have exceeded the 9 ppm 8-hour ambient standard (Wallace
et al., 1987). The authors based this upward revision primarily on the
negative measurement bias observed in the electronic instrumentation used to
measure personal CO exposure. The Denver and Washington studies do identify
portions of the population at risk to CO exposure by characteristics of
working outside the home, commuting time greater than 6 hours per week, high
exposure source at work, and unvented gas stove present at the residence
(Akland et al., 1985).
As part of the 1976-1980 National Health and Nutrition Examination Survey
(NHANES II), over 8,000 blood samples were analyzed for COHb content and
classified according to demographic and personal characteristics (Radford and
Drizd, 1982). Wintertime mean COHb concentrations in never-smokers living in
urban areas, aged 12-74 years, was 1.25 percent. Over U percent of nonsmoking
adults displayed COHb levels greater than 2.5 percent; however, the exact
source of elevated exposure could not be identified. The subgroup comprised
of children aged 3-11, if used as a proxy for urban residents free of
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confounding exposures from occupational and personal tobacco use, had mean
COHb levels of 1.01 percent during winter months when COHb levels were
substantially higher. In the winter, 3.3 percent of the children had COHb
levels in excess of 2.5 percent. These results, when extrapolated to the
nonsmoking adult population, indicate that 3-4 percent of the population may
be exposed during the winter to CO levels exceeding the 9 ppra 8-hour and 35
ppra 1-hour standards chosen to keep COHb levels from rising above 1.5 percent.
In summary, population-based sampling of CO exposure and COHb levels
indicates that a portion of the population living in metropolitan areas is
exposed to higher CO levels because of personal activities. The results of
the Denver and Washington surveys suggest that these higher exposures are more
strongly associated with mobile sources, gas stove use, and passive smoking,
than with occupational settings characterized by high exposure. While the
sensitive population of interest, IHD subjects, may not necessarily be found
in high-exposure occupations, their normal urban activities may place them in
situations which include exposure to the emissions of gas stoves, furnaces and
space heaters, and gasoline-powered appliances, and also to environmental
tobacco smoke. The Program in Social Ecology at UC Irvine conducted a field
study during January to May 1985 to characterize the activity patterns and CO
exposures of men diagnosed with severe IHD.
Community Exposure to CO Experienced by IHD Subjects
In the UC Irvine study, a sample of individuals was selected from medical
records at UC Irvine Medical Center and Long Beach VA Medical Center. As
identified from coronary angiogram data, each individual invited to
participate in the study had at least 50 percent occlusion of one of the three
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major coronary arteries. A further criterion for selection was "objective"
electrocardiographic evidence of ischemia during exercise stress testing.
Since angina is a "subjective" indicator of ischemia, and may or may not occur
reproducibly during exercise tests, the presence of angina during clinical
stress testing was not a prerequisite for participation in the research
program.
Subjects with IHD were continuously monitored as they went about their
normal day-to-day activities. The subjects wore a personal CO monitor
recording minute average exposures in an electronic memory and, at times, a
Holter ambulatory ECG monitor. Only the results of the exposure monitoring
were used and presented in the current study of economic risks, and therefore
electrocardiographic measurements will not be presented. Subjects maintained
a diary of activities, locations, and symptoms during 24-hour sampling
periods. The subjects also provided end-expired breath samples into
collection bags during the monitoring days to assess COHb levels which, when
analyzed, were compared with levels predicted from CO exposure profiles.
While wearing the CO monitors, subjects were asked to maintain a diary of
their daily activities. The time-activity diaries were designed to provide
detailed information on the subject's surroundings and promixity to potential
pollution sources. Diaries for this study also requested detailed information
on the physical state of the individual: activity level, health symptoms, and
medication taken. These data were used to estimate myocardial oxygenation
demands, identify periods of perceived ischemia as manifested in angina
pectoris or palpitation, and corrective actions. Subjects completed
questionnaires on potential exposures to CO in the workplace and residence as
well as background on health and lifestyle. Subjects were asked to wear CO
personal exposure monitors (PEM) for five 24-hour periods: four weekdays and,
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if possible, 1 weekend day. While wearing the monitor, subjects were asked to
provide end-expired breath samples at six specified intervals. These samples
were used to estimate COHb.
This monitoring served several purposes, including characterization of
the time-activity schedules of IHD subjects for comparison against data for
the normal population, characterization of the CO exposure pattern encountered
in normal urban activities, and estimation of the resulting COHb experienced
by an IHD subgroup. Forty-three (43) subjects participated in CO monitoring,
contributing 159 person-days of personal exposure data. Thirty of these
subjects participated in the present study on economic impacts of angina.
Twenty additional subjects were specifically enlisted to participate in the
economic impact research.
The results of this field study are presented in Section 4.4. The CO
exposure information from the personal exposure monitors characterized the
types of exposure-activity environments encountered by IHD patients. This
information is useful in evaluating the risk of IHD patients developing
particular levels of COHb in their urban movements. The 1440 individual one-
minute CO averages, making up the 24-hour monitoring period, were entered into
uptake-elimination model algorithms to predict the individual's COHb response
to exposure. Exposure profiles from individuals who had participated in the
original 1985 field survey were used as input in the analysis of non-medicai
defensive behaviors, presented in Section 4.3.
2.2 Background on Economic Health Valuation
There are two different ways commonly used
valuation of changes in health. One is cost of
to approach the economic
illness (COI), which is
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historically more common. The COI approach is described by Rice (1966) and
Hartunian et al. (1981), and involves estimating the medical expenditures and
productivity losses associated with the health condition of interest. It has
long been recognized that COI measures do not reflect the full welfare impact
of a health problem because the financial impact of an illness is only part of
the story. Health problems also typically involve discomfort, inconvenience,
and activity restrictions that go beyond what is reflected in direct
expenditures and lost income.
The second approach to the economic valuation of changes in health is
willingness to pay (WTP). The WTP measure is defined as the change in income
that would cause the same change in utility (well-being) for the individual as
that caused by the health condition of interest. WTP measures are more
appropriate than COI measures for comparison to the costs of public policies
to protect human health, such as pollution control regulations, because they
are a dollar measure of the full impact of the potential change in health. In
general, WTP measures are expected to exceed COI measures for the same change
in health, although there may be some exceptions. It is also important to
note that there may be a difference in who incurs the impact of cost. For
example, an individual who gets paid sick leave may not consider his lost
productivity as a cost to himself, but it is a cost to society.
WTP measures, although theoretically more desirable for benefit-cost
analysis, are more difficult to obtain than COI estimates. There are
basically two types of approach for estimating WTP for changes in health. The
first is called the "averting behavior" method, and involves inferring WTP
from real-life situations where individuals are choosing a tradeoff between
some benefit or cost that has a dollar value and some perceived or derived
change in health. The second method, termed "contingent valuation," involves
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asking subjects to respond to a hypothetical situation in which such a
tradeoff is required.
For this study, a survey instrument was designed to obtain both COI and
WTP information for evaluating changes in angina symptoms. WTP estimation
involved both direct WTP questions and actual trade-off situations presented
to subjects. The emphasis of the study is on the WTP estimates, but the COI
information serves as an important standard for comparison.
2.2.1 Previous Studies Estimating WTP for Changes in Health
To date, few studies have been conducted estimating WTP for changes in
non-fatal health effects that may be associated with air pollution exposure.
Methods for estimating WTP for changes in morbidity are in developmental
stages and our study contributes to this method development effort. Four
studies have been conducted that have important similarities to our research
effort: Loehman et al. (1979), Rowe and Chestnut (1985, 1986), Tolley et al.
(1985), and Dickie et al. (1986, 1987). This discussion is not intended as a
detailed review of these studies, but as an explanation of how this study
builds upon previous research efforts.
Loehman et al. (1979) conducted a mail survey concerning common
respiratory symptoms such as coughing and sneezing, shortness of breath, and
head congestion. The sample was drawn from the general population in the
Tampa, Florida area. The questionnaire was quite brief, explaining simply
that policymakers could use information about how the public values the
avoidance of specific health problems. Respondents were asked to select among
a list of possible dollar values for avoiding one or seven days of minor or
severe symptoms, for each of three types of symptoms. It was observed that
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subjects offered higher dollar amounts for preventing the severe symptoms.
This would be expected and suggests some logical consistency. The results
also indicated that values per symptom day avoided were lower when respondents
were asked about seven days than when they were asked about one day. This
finding is consistent with economic theory concerning diminishing marginal
utility of additional amounts of a good, although health is not a typical
economic good, such as apples and automobiles, and might not necessarily show
all the same properties.
The research of Loehman et al. (1979) has important implications for
policy analysis. Evaluation of policy actions that will result in changes in
the amount of illness is more complicated than simply applying a fixed value
per ur.it of illness to the amount of illness expected to be avoided. The
value per unit of illness is expected to be a function of the amount of
illness reduced or avoided, i.e., values estimated for a one-day-per-year
reduction in head congestion per person should not be simply multiplied by 20
to evaluate a program that will prevent 20 days per year of head congestion
per person.
Another finding in the Loehman et al. (1979) results is that mean values
were significantly larger than median values for each symptom. This indicates
a skewed distribution, and the authors of this study suggest that the median
values were actually more representative of the central tendency of the
responses than the mean values. The mean values were influenced by a few
responses that were very large compared to most of the responses. One
question that has subsequently been raised is whether some of these large bids
may be protest responses by individuals who object to putting dollar values on
health. This is being explored further in subsequent research, including the
study reported here.
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Tolley et al. (1985) conducted personal interviews in a general
population sample to assess WTP to prevent seven common symptoms, including
cough, head congestion, headache, and nausea. Another set of questions also
elicited dollar values for preventing angina symptoms. Each symptom was
described, and the respondents were asked to estimate the most they would be
willing to pay to prevent having the symptom on a given number of days in a
year. Mean values were generally of the same order of magnitude as the mean
values obtained by Loehman et al. (1979). The WTP estimates per day of
symptoms avoided were significantly lower when the question was for 30 days
rather than one day, a result also consistent with the Loehman study. The
findings of Tolley et al. (1985) indicated that values for preventing symptoms
were higher for respondents who more often experience those symptoms, and for
respondents who reported being in poor general health. The results from
questions addressing angina symptoms are inconclusive because respondents were
asked to consider angina symptoms whether or not they had the kind of heart
condition that is associated with angina. This type of approach is
problematic for two reasons: 1) people who have never had angina probably
have a more difficult time estimating a value for preventing angina symptoms
than symptoms they have experienced, and 2) the CO policy issue is not whether
people without IHD will develop IHD and experience angina, but whether people
with IHD will experience angina more frequently than they would otherwise. It
may be appropriate to ask healthy subjects about values for preventing risks
of developing chronic illnesses if such a risk is at issue for a particular
air pollutant, but actual development is not the primary concern with regard
to CO and angina.
Dickie et al. (1986, 1987) have pioneered an application of the averting
behavior method for estimating WTP for reduction of symptoms potentially
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related to ozone exposure, such as coughing, throat irritation, sinus pain,
and headache. The averting behavior method considers behaviors the individual
may undertake to reduce symptoms and infers a value for the reduction in
symptoms from the cost of the averting behavior. The averting activities
considered in this study were automobile air conditioning, home air
conditioning, home air purification, and switching from gas to electric
cooking.
By analysis of a model of utility-maximizing behavior with respect to
health, Dickie et al. (1986, 1987) derived the following expression for
marginal WTP for symptom reduction.
WTP - Qi/Si (2-1)
where: Qi - full price (including time) of the ith averting
activity
Si = marginal product of the ith averting activity in
reducing the symptom.
The common sense interpretation of this expression is that the individual
will put resources into the averting activity to the point where the value of
the marginal benefit (the utility gained by reducing the symptom) just equals
the marginal cost of obtaining the symptom reduction. The averting activity
can therefore be interpreted as a market activity in which the individual can
be observed "purchasing" a symptom reduction, and the "price" paid can be
interpreted as an estimate of the WTP for the symptom reduction.
Dickie et al. (1986, 1987) estimated Equation (2-1) for several different
symptoms by first estimating separate symptom production functions that show
the relationship between the probability of experiencing the symptom and
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whether the averting activity was undertaken. Equation 2-1 was then evaluated
for a single day of each of the symptoms avoided. The estimated values tended
to be lower than the Loehraan et al. (1979) and Tolley et al. (1985) mean WTP
responses for similar symptoms on a single day, but were closer to the per-day
values obtained when respondents were asked about avoiding 7, 30, or 90 days
of each symptom in a year. For comparison, Dickie et al. (1986, 1987) also
asked direct WTP questions concerning avoiding one day of each symptom. The
mean responses were similar to those obtained by earlier studies.
The application of the averting behavior method is an important
innovation for using actual behavior to infer WTP values for changes in
symptoms, but significant limitations remain. For example, most of the
behaviors involve benefits beyond the reduction of symptoms, and may in fact
be primarily motivated by some other purpose, such as obtaining a more
comfortable living environment.
An averting behavior approach is also used in the analysis of angina
symptoms presented in this report. An expression like Equation 2-1 is
evaluated using data obtained from the respondents. This is discussed more
fully in subsequent sections of this report (e.g., in Section 4.3).
Rowe and Chestnut (1985, 1986) conducted a study with a panel of
asthmatics to obtain information on the benefits of reducing or preventing
asthma symptoms. Information was obtained from about 90 asthmatics living in
Glendora, California, concerning behavior adjustments they made to avoid or
reduce asthma symptoms and the medical costs related to the asthma, and what
they would be willing to pay to have their symptoms reduced. Information was
obtained on the effect of the asthma symptoms on their lives, and included
financial and nonfinancial impacts. The study also involved an analysis of
averting behaviors undertaken on days when subjects were concerned that their
asthma symptoms might occur.
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The study augmented the conventional contingent valuation approach by
obtaining information on the subjects' beliefs concerning the primary benefits
of reduction in asthma symptoms. On average, the subjects ranked reductions
in discomfort and activity restrictions as more important than reductions in
medical expenses and income loss (the primary components of a COI measure).
This supports the hypothesis that COI measures underestimate the total value
of reducing or avoiding asthma symptoms. Additional information obtained
about each subject also allowed consistency checks to evaluate the credibility
and validity of the responses to the direct WTP questions. Since a few very
high responses can unduly influence mean values, and contingent valuation
questions are hypothetical and do not require that an actual payment be made,
personal characteristic information is essential for valid interpretation of
results of contingent valuation questions. Hopefully, future WTP efforts will
be better structured to understand and evaluate the validity of the responses
given to these contingent valuation questions.
2.3 Theoretical Framework for the Study Design
An economic model of individual behavior and utility maximization with
respect to health is based on a theory of consumer behavior developed by
Becker (1971). The model was first used by Grossman (1972) and later applied
to the health effects of environmental pollution. The basic concept is that
the individual combines purchased goods and services with his own time and
skills to produce desired outputs that contribute to his utility (or well-
being) . What this means for health is that the individual uses medical care
and health-enhancing activities, such as exercise and sleep, to maintain his
health at an optimal level, given his preferences, time and dollar budget
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constraints, biological endowment, and effectiveness at producing health.
Thus, given certain constraints, the individual chooses his level of health.
The relationship between the individual's health and health-enhancing
expenditures and activities is referred to as the health production
function. Technology, biological endowment, and pollution levels will
influence this relationship. The model provides an analytical tool for
examining the effect of changes in health on the individual's utility and for
identifying factors that will be helpful in evaluating changes in health.
The basic health production function model of consumer behavior presented
below is a synthesis of the models presented by Gerking et al. (1983, 1986)
and Harrington and Portney (1987), developed specifically to analyze WTP for
changes in pollution that may affect health. This model is useful because it
can be used to define specific components of an individual's WTP for changes
in his own health by analyzing the ways that health can be expected to affect
an individual's utility. The results of the analysis suggest ways to approach
the estimation of WTP and give criteria by which to evaluate the completeness
of WTP estimates.
The individual's utility is a function of the goods and services consumed
and his or her state of health, which directly influences the enjoyment of
life's activities and how good the individual feels. The direct effects of
the individual's state of health on utility would include pain and discomfort
experienced during an illness.
U - u(X,H)
(2-2)
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Where:
U =
the individual's utility in a given time period
X ¦
goods, services, and leisure activities the individual
consumes that are unrelated to his or her health
H
the individual's state of health
The individual's state of health (H) is a function of defensive
expenditures and health-enhancing activities undertaken. These include
preventive medical care, exercise, and diet; exogenously determined levels of
pollution; and biological, social and economic characteristics of the
individual (e.g., congenital conditions, age, and education) that influence
the effectiveness with which he can maintain a given state of health.
Two simplifying assumptions are used in this presentation of the model:
pollution levels are exogenous, and defensive expenditures and activities
affect utility only through their effect on health. The model could treat
pollution exposure as an endogenously determined variable influenced by the
actions of the individual, but that is not the focus of this analysis.
Relaxing the second assumption would result in a more complex model, but in
reality many defensive activities may produce utility in more than one manner
for example, playing tennis produces enjoyment of the game jointly with the
health benefit of the exercise. This problem is addressed in the study desig
and analysis but is not included in this presentation of the model.
The level of defensive expenditures and activities is chosen by the
individual as a function of the individual's health, environmental pollution,
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and other factors. The health production function and the defensive
expenditures function are therefore simultaneous equations.
H = h(D,P,Zl) (2-3)
D = d(H,P,Z2) (2-4)
Where:
D = defensive expenditures and activities
P = pollution
Zl = biological, social and economic characteristics of the
individual
Z2 - biological, social and economic characteristics of the
individual that influence defensive expenditures and
activities
Duration of illness and medical expenditures made in response to illness
enter into the individual's budget constraint because they affect the amount
of time and money the individual has for other things, but they do not
directly enter the individual's utility function. These medical expenditures
do not prevent additional illness but may mitigate the discomfort and loss of
activity that accompany illness.
Ts - t(H) (2-5)
M -
m(Ts)
(2-6)
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Where:
Ts = time spent sick
M - medical expenditures in response to illness
The individual faces the following time and budget constraints.
X*Px + D*Pd + M*Pm = v-Tw + I (2-7)
X*Tx + D*Td + M*Tm + Ts + Tw = T (2-8)
Where:
Pi = price per unit of i, for i = x, d, and m
Ti - time per unit of i, for i - x, d, and m
Tw - time spent working
w = the individual's wage rate
I = nonwage income
T - total time available
Equations 2-7 and 2-8 can be combined into a "full income" constraint by
assuming all time is valued at the wage rate, and defining a combined dollar
and time cost: Qi = Pi + w*Ti. Using w as the value for all time assumes that
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individuals choose Co work to the point where the marginal benefits of working
(the wage earned) just equal the marginal costs in terms of the value of time
lost from other activities. In this simple model, it is also assumed that all
costs of defensive and medical care are borne by the individual and that
prices in the medical care market reflect marginal social costs of producing
medical care.
X*Qx + D*Qd + M*Qm + w*Ts = v*T + I (2-9)
The individual can be expected to choose levels of X and D that maximize
utility (Equation 2-2) subject to the constraints of Equations 2-3 to 2-9.
The choice is made by allocating time and dollar expenditures such that the
marginal benefits equal the marginal costs of each good and service for the
individual. For defensive expenditures, for example, the marginal benefit is
the dollar value of the improvement in utility obtained by an additional unit
of defensive effort, plus the medical expenditures that no longer have to be
incurred, and the opportunity costs of time not spent in sickness as a result
of the unit increase in defensive efforts.^" The marginal cost is the unit
cost of defensive efforts, including both money and time (Qd). This means
that the amount of defensive efforts undertaken will depend on the
effectiveness of these efforts in maintaining health and on the costs and
discomfort associated with time spent sick, as well as on the direct costs of
the defensive efforts.
Dickie et al. (1986, 1987) have used this model to derive the following
expression for the dollar amount that would keep utility constant if a change
''"The first order condition for defensive efforts (D) is aL/aD - - a(Qd +
Mts*TS*Hd) - 0, where subscripts denote partial derivatives.
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occurs in H. This is the marginal WTP to prevent or obtain a potential change
in H. An expression for willingness to accept (WTA) compensation would be the
same, only the reference level of utility would be different. WTA for a
decrease in health is the increase in dollar income that would offset the
decrease in utility associated with the decrease in health. For an increase
in health, the WTA would be the decrease in dollar income that would offset
the increase in utility associated with the increased health.
WTP,
Hd * Qd
Where:
(2-10)
WTP^ = marginal WTP for changes in H
Hp = the partial derivative of H with respect to D
Equation (2-10) is equivalent to Equation (2-1) and suggests that when an
inexpensive defensive action is available to offset a potential decrease in H,
then the WTP to prevent that decrease in H will be small, not exceeding the
cost to the person of the defensive action. Similarly, WTP to obtain an
improvement in H will not exceed the cost to the individual of the defensive
action to obtain the improvement.
Another expression for marginal WTP for potential changes in H can be
derived from Equation (2-10), using the first order condition for D.
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WTP^ = vr*Ts^ + Qm*M^ + Qd*D^ + a*U^ (2-11)
where the subscripts denote partial derivatives.
The first term is the opportunity cost of the change in time spent sick
associated with a change in H, the second term is the change in medical
expenditures associated with the change in H, the third term is the change in
defensive expenditures associated with the change in H, and the fourth term is
the dollar equivalent of the direct change in utility (i.e., the pain and
discomfort) associated with the change in H. The dollar equivalent of a unit
change in U (i.e., the marginal utility of a one-unit change in income) is
represented by (a) in the fourth term.
The utility maximization conditions of the model suggest that when there
is a change in pollution, the individual will adjust the allocation of his
resources so as to minimize any adverse effect on utility, or maximize any
advantageous effect. For example, if pollution increases, the individual may
choose to completely offset the effects on his health by increasing defensive
expenditures only if the resulting reduction in income available for other
goods (X) reduces utility less than the decrease in utility that would have
occurred from the decrease in H. The individual will, of course, be
constrained by his ability to affect health with defensive expenditures. An
expression for marginal WTP for a change in pollution (P), similar to Equation
(2-11), can be derived from the model. This expresssion can be written as
follows where, for example, dM/dP is the total change in medical expenditures
as a result of the change in P after the individual has adjusted to maximize
utility.
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WTPp = w-*(dts/dP) + Qm*(dM/dP) + Qd*(dD/dP) + a*(-dU/dP) (2-12)
Harrington and Porcney (1987) use this derived expression for WTP for
changes in pollution to argue that under certain reasonable assumptions, cost
of illness estimates for changes in pollution that include income lost and
medical expenditures can be expected to be a lower bound on WTP. Income lost
due to time spent sick will be less than or equal to the first term, which is
all time spent sick multiplied by the wage rate. Medical expenditures are
equivalent to the second term. Cost of illness will be less than WTP as long
as the third and fourth terms are non-negative for an increase in pollution.
This requires the assumption that the relationships in the model are such that
when pollution increases, the new equilibrium level of health is the same or
lower and that defensive efforts stay the same or increase. This assumption
may not be correct in every instance. The analysis by Courant and Porter
(1981) suggests that it is at least conceivable that the health production
function and utility maximization conditions of the model are such that when
pollution increases, health increases.
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U2
CHAPTER 3. METHODS
3.1 Questionnaire Development
The primary purpose of the study was to develop the means to estimate the
value of changes in angina symptoms. Part of this work involved developing
and testing a survey instrument for collecting information from IHD patients
that would be useful in evaluating the effects of CO on angina symptoms. The
study focused on the evaluation of changes in angina symptoms, whatever the
underlying cause, and the effect of CO exposure was separately factored into
the health production function (Equation 2-3). Figure 3.1-1 shows an
expansion of the health/behavior model presented in the previous section as it
is applied to the IHD patient with angina. This model guided the choice of
measures and items in the survey instrument. Subject and interviewer versions
of the questionnaire are included in Appendix 2.
The survey instrument combined several different approaches to examine
the welfare implications of changes in angina symptoms for IHD patients.
These included cost of illness, defensive activities, and contingent valuation
estimates of WTP. The model presented in the previous section suggests that a
comprehensive approach for evaluating the effects of CO on angina symptoms
would involve the specification and estimation of Equations 2-3 and 2-4.
However, estimating this system of equations is difficult due to the
complexities of the relationships involved. A larger sample size than that
obtained for this test of the developed instrument is needed for a more
satisfactory evaluation of this approach.
Throughout the questionnaire we have attempted to keep questions about
angina symptoms in the context of the overall effects of having IHD on the
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Figure 3.1-1. Linkage between expenditures and health for IHD patients
% Occlusion
of Arteries
Preventive
Medical
Treatment
Personal Exposure
to CO
Medical Treatment
of Symptoms
Defensive
Expenditures
Behavior
Adjus tments
Heart
Attack
Angina
Shortness
of breath
SYMPTOMS
Activity Restrictions
Reduced Consumption of
Other Goods
'aTLFARE EFFECTS
Risk of Death
Workloss
Pain
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4 3
patients' lives. It was uncertain at the outset whether the subjects would be
able to isolate angina symptoms from other concerns, especially concern about
potential heart attacks. Such a perceived (whether real or not) association
may be very significant in determining how a subject reacts to questions about
angina and may mean that isolated consideration of angina symptoms is
inappropriate.
3.1.1 Cost of Illness
To develop an estimate of annual medical costs, the survey instrument
collected detailed information on medical treatment associated with IHD
obtained in the past year. Because most of our subjects were VA patients, or
had some other medical insurance, little information could be obtained about
actual costs. A different sample of patients might produce a different
result.
Even though the extensive insurance coverage for this sample meant that
few of the medical costs were borne by the individual, medical cost estimates
are still useful. Medical costs that are not borne by the individual would
not be expected to be reflected in the estimates of WTP derived from the
individual's behavior or from direct WTP questions. Medical costs are,
however, a cost to society and should be considered in a comprehensive
analysis of the effects of a policy that would result in changes in IHD
symptoms. Medical care information is also important for the health
production function estimation, and in many cases should be considered a
defensive effort.
The costs of medical treatment were estimated using each individual's
self report of treatment. Treatment scenarios were assembled under the
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44
guidance of a staff cardiologist from the UC Irvine Medical Center. The costs
of a typical emergency room visit, hospitalization for complaint of chest pain
or myocardial infarction, or surgical procedures were estimated using
accounting records furnished by UC Irvine Medical Center. Data on the costs
of each procedure could not be obtained for the VA Medical Center. Therefore,
without access to accounting records for each subject, the costs of medical
treatment derived in this study represent the best estimate based upon
reasonable scenarios and the fee-for-service data of one regional medical
center.
The survey also included questions on work loss due to angina and other
IHD symptoms. Patients currently working were asked about work loss days and
paid sick leave. Subjects younger than retirement age who were not working
were asked if they had ceased work because of IHD and what they had earned
previously. This allowed quantification of income lost due to IHD.
3.1.2 Defensive Activities and Expenditures
The subjects were next asked a series of questions regarding expenditures
undertaken to avoid or reduce angina symptoms. These questions were intended
to allow evaluation of Equation 2-10. Additionally, they extended medical
care information to nonmedical activities that may be important in the overall
status of the individual's health. Finally, these questions help those
respondents with expenditures focus upon their own revealed willingness to pay
to reduce angina prior to the direct willingness to pay questions.
One series of questions probed whether the individual hired help for
chores he would otherwise do on his own, such as lawn mowing and house
cleaning. Subjects were asked to identify the type of help hired, if any, and
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^5
whether the hiring was primarily motivated by their heart condition. This
inquiry served to identify joint benefits. Expenditures were included in this
part of the analysis only if the subject said that he would prefer to do the
work himself if his health permitted. The subject was then asked to estimate
the number of angina episodes he believed he avoided by making the
expenditure. He was asked whether other health concerns, such as heart attack
risks, might also motivate the expenditure. This provided an estimate of
from Equation 2-10, based on the perceptions of the subject.
In addition, subjects were asked to list all expenditures undertaken to
avoid angina, to develop a total defensive expenditure estimate for each
subject. Some descriptive information about changes made in activities due to
the heart problem was also obtained.
3.1.3 Direct WTP Questions
Estimation of WTP was approached by directly asking questions about the
amounts subjects would be willing to pay to avoid an increase in angina
symptoms. Prior to these questions, subjects were asked to describe recent
typical, severe, and mild angina episodes. They were also asked to rate the
significance of various aspects of the problems associated with angina,
including pain, medical costs, lost income, and worry about heart attacks.
These questions gave better characterization of the impact of angina symptoms
on the patient, and prompted the subject to think about how the symptoms
affected him.
Two types of WTP questions were asked. Close-ended questions asked
whether subjects would pay certain given dollar amounts to prevent a specific
increase in angina, these were followed by open-ended questions in which
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4 6
subjects were asked to give a dollar estimate of the maximum amount they would
be willing to pay to prevent the hypothesized increase in angina. The
decision to use both types of WTP questions was made following the preliminary
interviews, in which subjects found the open-ended WTP questions alone
difficult to answer. It was easier to give a dollar amount after being asked
to consider a few specific amounts suggested by the interviewer. It is
possible that the amounts suggested in the close-ended questions were leading
the responses to the open-ended question. This problem is addressed in the
analysis, in Section 3.4 of this chapter.
To discuss whether the WTP amount per episode would change if different
numbers of episodes were anticipated, approximately half the subjects were
asked about an angina increase of four episodes per month, and the other half
were asked about eight episodes per month. The numbers of episodes were
selected as small enough to be potentially realistic with respect to the
impacts of air pollution and large enough to be significant to the
individual. Since some subjects no longer had active angina, and therefore
had no interest in decreasing their symptoms, all subjects were asked about a
potential increase rather than decrease in angina symptoms. It was also
considered more realistic for most IHD patients to consider an increase rather
than decrease in symptoms as they had already made all the health improvement
they could through surgery, treatments, and lifestyle changes. This question
is also policy relevant because IHD tends to be a progressive disease with
symptoms increasing over time. Reductions in air pollution might prevent
angina symptoms from increasing as much as they would otherwise have for some
patients. The hypothesized payment vehicle was a medication that would
prevent an increase in angina, but that would not be covered by insurance.
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U1
Follow-up questions were used to probe refusals, zeros, and responses of
very large WTP amounts. Interviewers also recorded comments offered by the
subjects while responding to these questions.
3.1.4 Health Production Function
Given the small sample size of this study, we did not attempt to estimate
a health production function; pertinent information was obtained, however, to
contribute to such an estimation with a larger study sample. This information
included medical history, attitudes toward health risks and angina, and
information that would help assess potential exposure to CO.
3.2 Panel Selection
Medical records from the UC Irvine Medical Center and the Long Beach VA
Medical Center were reviewed to identify potential participants (Figure 3.2-
1). A subject pool of 500 men was identified for earlier community exposure
monitoring and clinical studies on the health effects of CO (California Air
Resources Board projects performed by UC Irvine). Of this group, 127 men with
a history of chest pain and physician diagnosis of angina pectoris were
targeted to confirm their angina experience and solicit participation in the
study. Seventy-six men were successfully contacted by telephone and completed
the initial screening interview (Appendix 1). A modified version of the Rose
Questionnaire (Rose et al., 1977) was administered to each subject to identify
individuals who had experienced angina symptoms within the previous 12
months. The Rose Questionnaire has demonstrated a sensitivity of 81 percent
and a specificity of 97 percent in similar field applications (Heyden et al.,
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Figure 3.2-1. Angina, subject selection and disposition
Were Lost
Fol low-Uf
7 Individuals
Declined to
Participate
127 Individuals Were
Chosen to Approach
50 Individuals Completed
the WTP Questionnaire
1 Individual
Declined to
Answer the WTP
Questionnaire
500 Individuals' Medical
Records Screened
For Likely Angina Subjects
20 Individuals
Were Lost to
Fol low-Up
2 Individuals
Did Not Meet
Angina Criteria
and Were Released
From Further
Participation
21 Individuals
Completed Mailed
Screening Questions
76 Individuals
Underwent
the Telephone
Screening Interview
25 Individuals Had
No Angina Experience &
Were Not Selected
For Further Participation
64 Individuals With
Angina Experience
Were Mailed the
WTP Questionnaire in
Anticipation of the
Telephone Interview
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48
1971). If a subject's answers to this screening interview identified him as
having experienced the complex of symptoms associated with angina pectoris
within the last year, he was asked if he would be willing to participate in a
longer interview regarding his angina and how it affected his lifestyle.
Targets who could not be reached by telephone were contacted by mail and asked
to complete an abbreviated form of the initial telephone interview to confirm
a history of angina. No compensation was offered for participation in the
study.
Of the 127 individuals with angina experience, 64 were identified as
having recent angina symptoms and were mailed the Subject Version
Questionnaire to complete and have available as a visual guide during the
telephone interview. Telephone interview contact was attempted seven to 10
days later. (See cover letter, Appendix 2). Of the 64 potential subjects, 50
completed the interview; 11 could not be contacted by telephone and were lost
to follow-up; two did not qualify and were released from further
participation; and one declined to answer the questions, judging them to be of
a highly personal nature.
Characteristics of the Sample
The 50 men participating in the study represent a wide range of angina
experience (Table 3.2-1). Forty-three subjects were currently experiencing
angina with a mean frequency of one episode per week, with a discomfort level
described as generally being mild to moderate. Information on the length of
time that the subjects had experienced angina symptoms was not collected.
However, all subjects' angina experience was at least two years, corresponding
to the age of hospital medical records from which the subjects were
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Table 3.2-1. Characteristics of research subjects used to evaluated the
survey instrument
Characteristic
Mean Value
Frequency or Range
Current Angina
Former Angina
Experienced a Heart Attack
Angina Frequency
Angina Severity
Coronary Artery Bypass Surgery
VA Health Insurance
Private Health Insurance
Medicare
HMO Program
MediCal
Employed
Household Income
Age
Married
Number in Household
Education
1/Veek
Mild to moderate
$22,021
61.5
2.4
Completed
High School
43/50
7/50
34/50
< 1/mo to > 3/day
No to very severe
discomfort
23/50
39/50
15/50
22/50
3/50
7/50
15/50
< $4,999 to > $60,000
44-83
39/50
1 to 5
3rd grade to
Postgraduate
Ancestral Origin
Current Smoker
Former Smoker
43/50 White
4/50 Latino
2/50 Black
1/50 Indian
5/50
37/50
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49
selected. Seven subjects no longer experienced angina and largely attributed
relief to bypass surgery. Thirty-four subjects had experienced at least one
heart attack. The median time since last heart attack was two to three
years. Twenty-three subjects had undergone coronary artery bypass graft
surgery.
Thirty-nine of the 50 subjects were eligible to receive health services
from the Veterans Administration. The majority of subjects supplemented their
VA coverage with private insurance or Medicare. In general, subjects had
complete coverage for physician office charges and emergency room and
hospitalization expenses.
Fifteen subjects were currently employed. The household income of
subjects ranged from less than $4,999 to greater than $60,000, with a mean of
$22,000.
The age of the subjects ranged from 44 to 83 years, with a mean of 61.5
years.
Thirty-nine of the subjects were not currently smoking tobacco and of
this group, eight had never smoked.
Thirty-four of the 50 subjects had participated in an earlier research
project conducted by UC Irvine measuring personal exposure to CO in the
community, and 14 subjects had participated in clinical studies examining the
effects of CO on the heart under exercise stress.
3.3 Sampling Procedures
All subjects lived in the greater Los Angeles area. Interviews were
conducted between February 20 and July 1, 1986. The four earliest
interviews, conducted in February, served as pilot interviews. Based upon
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50
responses, the questionnaire was edited. The survey of the main sample began
in April with the majority of the interviews being conducted in May and
June. Typically, several calls were required to schedule a convenient time to
conduct the 45-minute interview. Subjects often requested additional time to
review the questions prior to the interview.
Three interviewers were used in the study; each read dialogue and
questions from the Interviewer Version Questionnaire. Telephone headsets were
used to free the interviewer's hands and facilitate accurate recording of the
responses. Average interview length was approximately AO minutes.
Immediately after concluding the interview, an additional 20 minutes was
needed to review and edit interviewer notations, and check for completeness of
questionnaire information and tracking documentation.
The number of episodes and the dollar amounts assigned to the closed-
ended willingness-to-pay question (Question 32, see page 13, Subject Version
of Questionnaire, Appendix 1) were randomly assigned to subjects according to
the Treatment Code schedule in Table 3.3-1. Treatments 1 through 10 were
randomly assigned in the first mailing of questionnaires to 20 subjects in
early April, 1986. After completing 15 of the 20 interviews, ERC and UC
Irvine reviewed responses and saw that nearly all subjects said they would pay
the highest amount suggested. Indeed, the response to the subsequent open-
ended question was typically a higher sum than the highest amount suggested in
the close-ended question. A revised treatment schedule was formulated on May
8, 1986; treatments 21 through 28, was used for the remainder of the subject
pool (Table 3.3-1).
An additional adjustment was made at this time. Relative to Questions 32
and 33, a high rate of refusals and very high dollar responses were observed
for Questions 30a and 30b. This suggested that without the more detailed
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Table 3.3-1. Schedule of dollar amounts (treatments) used in close-ended
willingness - to-pay question (Question 32)
TREATMENTS
EPISODES
DOLLAR AMOUNTS
1
4
5
50
200
2
8
5
50
200
3
4
10
25
50
4
8
10
25
50
5
4
25
50
100
6
8
25
50
100
7
4
50
100
200
8
8
50
100
200
9
4
100
200
400
10
8
100
200
400
21
4
10
50
200
22
8
10
50
200
23
4
25
100
300
24
8
25
100
300
25
4
50
200
400
26
8
50
200
400
27
4
100
500
1000
28
8
100
400
1000
Treatments 1-10 were randomly assigned in the first mailing of
questionnaires to twenty subjects in early April 1986. After completing 15 of
the 20 interviews, ERC and UCI reviewed the success of the dollar amounts in
bracketing the range of observed responses, and a revised treatment schedule
was formulated on May 8, 1986. The revised schedule, treatments 21-28, was
used for the remainder of the subject pool.
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Table 3.3-1 cont.
An additional adjustment was made at the time of this revision. It was
decided that Questions 30a and 30b should be asked out of sequence, after
completing Question 32 and 33. A third digit was added to the Treatment Code
to indicate this change of sequence. If Questions 30a and 30b were asked in
sequence after completing the line of inquiry on the "typical recent" angina
episode, the third digit of the treatment code was assigned a "1." If
Question 30a and 30b were asked after the willingness-to-pay Questions 32 and
33, then the third digit of the treatment codes was assigned a "2." For
example, Treatment Code 242 represents Treatment 2U (eight episodes, $25,
$100, and $300) and Questions 30a and 30b were asked after completing
Questions 32 and 33. (Note that this change in sequence was instituted
immediately and several individuals in the first treatment schedule were
interviewed using the adjusted sequence of waiting to ask Questions 30a and
30b) .
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51
context given for the WTP question, subjects had more difficulty making a
decision. It was therefore decided that sequencing of Questions 30a and 30b
(asking for the maximum dollar amount one was willing to pay to avoid one or
two typical angina episodes) should follow completion of Questions 32 and 33,
which were introduced by a more careful explanation of the payment
situation. A third digit was added to the Treatment Code to indicate this
change of sequence (Table 3.3-1). If Questions 30a and 30b were asked in the
original sequence, the third digit of the Treatment Code became "1." If
Questions 30a and 30b were asked after the willingness-to-pay Questions 32 and
33, then the third digit of the Treatment Code became "2." For example,
Treatment Code 242 represents Treatment 24 (eight episodes--$25, $100, and
$300) and Questions 30a and 30b were asked after completing Questions 32 and
33.
3.4 Data Analysis
Questionnaire data were coded according to the format described in
Appendix 3. Open-ended responses and research subjects' comments were
transcribed and assembled by question number (Appendix 4). Data was entered
into an IBM personal computer using dBASE III software. Accuracy of the
coding and data entry was verified by independent observers. Data files were
converted to standard ASCII format, written to floppy diskettes, and
distributed among the co-investigators. Specific statistical analyses are
described within each section of the Results and Discussion.
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52
CHAPTER 4. RESULTS AND DISCUSSION
4.1 Cost of Illness
4.1.1 Medical Expenditures
Medical expenses associated with anginal pain, and more generally the IHD
condition, were estimated for each subject (See Appendix 4). Responses to
questions on yearly insurance premiums paid (Question 9b), mileage to
physician's office (Question 10), frequency of office visits (Questions lib
and 12a), costs of emergency room visits (Question 15b) , hospitalizations
(Question 16), medical treatment programs (Question 17), and medications
(Question 14) were tabulated.
Annual health insurance premiums ranged from $0 to $1002 with a mean of
$201 per subject. Twenty-three subjects made no expenditure for health
insurance and largely relied upon coverage from the VA. Nineteen subjects
receiving VA health care benefits chose to supplement that coverage with
Medicare. Annual Medicare premiums cost $186. Fifteen subjects were covered
by private medical insurance; ten of these subjects also received VA health
benefits. For those subjects purchasing private insurance, premiums ranged
from $0 to $822, with a mean of $365 per subject.
One-way mileage to the physician's office for a regular checkup ranged
from 1 to 45 miles, with a mean of 14 miles. Yearly expenditures for travel
to the physician's office were estimated from the number of regular office
visits (Question 11a) , additional office visits due to angina symptoms
(Question 12), round trip mileage (Question 10), and an assumption of personal
motor vehicle expense of $0,205 per mile. Annual mileage expenses ranged from
$0 to $226, with a mean of $38 per subject.
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53
In general, the expense of physician office visits, emergency room
visits, and hospitalizations was completely covered by the subjects' health
insurance benefits. Of 44 subjects reporting visits to their physician during
the previous year, nine reported out-of-pocket expenditures ranging from $12
to $192; the mean annual office visit expense paid by the subject across the
44 subjects was $22. No out-of-pocket expenses were incurred by the 13
subjects reporting emergency room visits during the previous year. Of 15
subjects experiencing overnight hospitalizations during the year, two reported
out-of-pocket expenses of $1,000 and $380, respectively.
Medication expenses were not as well covered by insurance as health
services. Fourteen subjects reported paying $12 to $1440 during the previous
year for heart related medications. The group of 36 subjects whose medication
expenses were paid in total by health insurance was largely composed of
recipients of VA benefits. Across the sample of 50 individuals, the mean
annual out-of-pocket medication cost averaged $144 per subject.
The sum of all expenses paid by the subject in the aforementioned expense
categories, omitting health insurance premiums, provided an estimate of the
yearly expenditures made by each subject for ischemic heart disease medical
care. Personal annual medical expenditures ranged from $0 to $2610, with a
mean of $256 per subject across all 50 subjects. Health insurance costs were
omitted from this sum because insurance provided care for a broad spectrum of
medical problems, not just ischemic heart disease.
The societal costs of health services for this group are substantial.
Societal costs are defined as the expenditures made by insurance companies, or
the government in the case of the VA, to provide care. It is important to
note that "societal" costs do not include the out-of-pocket expenses incurred
by the individual. Societal costs were estimated from medication dosages and
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the types of medical services used by the subjects. The cost of medications
was estimated using the mean price of generic and name brand prescription
drugs distributed by a privately-owned pharmacy and by a major chain pharmacy
(Appendix 4). The cost of health services (Appendix 4) was estimated using
fee schedules from the UC Irvine Medical Center and the Report on Medical Fees
in Southern California (1986). Dennis M. Davidson, MD., a UC Irvine
cardiologist, and the UC Irvine Medical Center accounting staff assisted in
assembling scenarios of the services likely to be rendered during typical
emergency room visits and hospital stays. The estimates derived from these
for the cost of hospitalization reflect conservative (i.e., low) estimates of
the types and numbers of procedures likely to be associated with the subject's
generalized description of the event (e.g., "'emergency room visit for chest
pain,' 'angioplasty,' '3-day hospital stay for heart tests'"). It is
important to note that professional fees for services are not reflected in
these estimates (e.g., anesthesiologist's fee for bypass surgery). It was
sometimes possible to use a subject's report of the cost to the insurance
company. However, this strategy could only be used in a few instances as the
sample was predominantly composed of VA patients who did not receive any
billing information. For reasons of patient confidentiality, VA accounting
records could not be accessed for estimating cost of services.
The societal costs of medication for the 50 subjects ranged from $0 to
$2429 per year, with a mean of $676. Likewise, the societal cost of office
visits ranged from $0 to $3780 per year, with a corresponding mean of $576 per
subject. The cost to society of the emergency room visits made by 13 subjects
ranged from $77 to $1364 per year, with a mean of $342 per subject. Fifteen
subjects had been hospitalized during the previous year. The annual cost of
hospitalization, including surgical procedures, for these 15 subjects was
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55
estimated to range from $1630 to $33,435, with a mean of $10,607 per
subject. These costs include the major medical events of three coronary
artery bypass graft surgeries (CABG) and two angioplasty (PTCA) procedures.
In summary, annual medical costs to society ranged from $0 to $34,963, with a
mean of $4523 per subject across all 50 subjects. This result suggests that
the societal burden of angina-related medical expenses is at least ten times
that of the personal expenses incurred in this sample of IHD subjects.
4.1.2 Workloss Due to Angina and the IHD Condition
Information was obtained from the subjects concerning the effects of
angina on their employment status and time lost from current jobs. This
information is summarized in Table 4.1-1. Table 4.1-2 contains definitions
for variables used in these calculations. Dollar estimates were developed for
three types of work loss: (1) days lost from current jobs due to angina, (2)
additional work days desired for those working less than they would like due
to angina, and (3) wages lost by subjects who were compelled to give up
working due to angina. Dollar values were based on the wages reported by the
subjects. For two subjects who refused to give their wages, estimates were
made based upon their reported occupations and hours worked.
Fifteen of the subjects (30 percent of the total sample) reported being
currently employed. These 15 subjects worked an average of 35 hours per week
and earned an average of $19,400 annually.
Of the 15 employed subjects in the sample, six subjects had missed some
days from their regular work schedule in the past year due to angina. The 15
employed subjects missed an average of four days from work in the past year
due to angina, incurring an average social cost of $347 in lost productivity
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Table 4.1-1. Workloss due to angina.
Average Annual Average Annual
Employed Subjects Workloss for Wage Lost for
with Some Workloss Employed Subjects Employed Subjects
Due to Angina (N = 15) (N = 15)
15 Subjects
Employed (30% 6 4 days $ 347
of Total Sample)
15 Subjects
Employed (30%
of Total Sample)
Employed Subjects
Working Less
Than Des i red
6
Average Annual
Additional Work
Days Desired
(N = 6)
108 days
Average Annual
Wage Lost for
Employed Subjects
(N = 6)
$3973
Average Annual
Wage Lost for
Subjects Not Working
(N = 13)
13 Subjects Not
Working Due to
Angina (37% of $34615
Non-Working
Subjects)
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Table 4.1-2. Definitions of variables used to compute wages lost from current
employment due to angina
SWLD Wages lost to subject due to days lost from current employment
If Q21DSKLV = 1, then SWLD - Q21CMISS * HRWAGE * 8
If Q21DSKLV = 2, then SWLD - Q21DDAYS * HRWAGE * 8
TWLD Total wages lost due to days lost from current employment
TWLD = Q21CMISS * HRWAGE * 8
WKRED Wages lost to currently employed due to being unable to work as
much as desired
If Q21FFEWER = 1, then WKRED = 0
If Q21FFEWER - 2, then WKRED - (Q21FLIKE - Q21AHRS) * HRWAGE * 52
JOBLOSS Wages lost due to having quit working due to angina
JOBLOSS - QA21CINC evaluated at the midpoint of the reported range
in dollars
SWKLOSS Workloss in all three categories incurred by subject
SWKLOSS = SWLD + WKRED + JOBLOSS
TWKLOSS Total workloss in all three categories
TWKLOSS - TULD + WKRED + JOBLOSS
HRWAGE Hourly wage for currently employed
HRWAGE = Q21GINC/(Q21AHRS * 52), where Q21GINC is evaluated at the
midpoint of the reported range in dollars
For Subject 6, an electronic technician working 62 hours/week
estimated annual income was $35,000
For Subject 16, a clerical employee working 20 hours/week
estimated annual income was $6,000
Additional notes:
1. For Subject 72, Q21DDAYS was recoded from blank to 0 because the subject
did have paid sick leave, but did not miss any days due to angina.
2. For Subject 107, Q21DC0VR was recoded from 2 to 1 due to a previous coding
error.
3. WKRED was actually calculated on responses from 5 subjects since Subject
16 said he would like to work more but did not give any estimate of how
much more.
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56
measured by the wage rate. Only one of the subjects who missed work due to
angina had any paid sick leave, therefore the average wage loss incurred by
the subjects themselves ($336) was very close to the total wage loss.
Of the 15 employed subjects, six subjects said they would have liked to
work more, but were unable to because of angina. These six subjects currently
worked an average of 20 hours per week and would have liked to work an average
of 40 hours per week. For these six subjects the average annual wage loss
caused by working less hours than desired was $3973. We assume that this work
loss is in addition to occasional sick days lost from a regular work schedule
and therefore add these two estimates to obtain total losses for employed
subjects. One subject also said he had changed jobs due to angina and had
incurred a reduction in income due to this job change. A dollar estimate of
this loss was not obtained.
Of the 35 non-employed subjects, 13 said they had ceased to work or had
taken an early retirement in the last five years due to their angina. These
subjects had earned an average of $34,615 annually before they ceased
working. Assuming that all these subjects would have been working this past
year if they could, their previous annual wage was used as an estimate of the
annual loss due to being unable to work. To allow more precision in this
estimate it would have been preferable to also ask the subjects if they would
be working now if they could. Also, disability payments might be mitigating
some of this lost income for the subjects causing our estimate of loss to the
subject to be overestimated. This does not, however, affect the total loss
incurred by society as a whole.
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57
4.1.3 Annual Cost of Illness for Ischemic Heart Disease
The medical expenditures (due to IHD) data in Section 4.1.1 was combined
with the income lost due to angina (from Section 4.1.2) to obtain a total cost
of illness estimate. The mean annual medical expense and income lost incurred
by the individual was $9,833 for this group of subjects, ranging from $0 to
$65,374. The mean cost incurred by the individual and others (insurance
companies, VA, etc.) per year due to ischemic heart disease was $14,359,
ranging from $0 to $67,176.
The focus of this study is the potential effect of changes in CO exposure
on the frequency of angina pains. To evaluate the potential welfare impact of
changes in CO exposure, we are therefore interested in the effect of a
marginal change in angina pain on costs incurred. Regression analysis was
conducted relating cost of illness measures to characteristics of the
individual illness to determine whether a marginal cost per angina episode
could be estimated. The results are shown in Table 4.1-3. Potential
explanatory variables included were whether the subject had a heart attack in
the previous year (MIYR1), whether the subject had bypass surgery in the
previous year (SURGYR1), current monthly angina frequency (MONFREQC), and
income. Regressions were estimated with four different cost of illness
variables: (1) medical expenses incurred by the subject (MEDSELF), (2) total
medical expenses (MEDTOT), (3) medical expenses and income loss incurred by
the subject (COISELF), and (4) total medical expenses and income lost
(COITOT).
The results indicate that very little of the variation in these cost of
illness estimates across this sample is explained by these variables, and
angina frequency is not statistically significant in any of the regressions.
-------
Table 4.1-3- Regression analysis relating cost of illness and individual characteristics
Analysis of Variance
Dep Variable:
MEDSELF
SOURCE
MODEL
ERROR
C TOTAL
ROOT MSE
DEP MEAN
C.V.
DF
4
'12
'16
SUM OF
SQUARES
502001 .75970
9507502.71
1000950'! .47
'175-7826
262.1064
181 .5227
MEAN
SQUARE
125500 .43992
226369.11210
R-SQIJARE
ADJ R-SQ
F VALUE
0.554
0.0502
-0.0'I03
PROB > F
0.6969
Parameter Estimates
VARIABLE
DF
PARAMETER
ESTIMATE
STANDARD
ERROR
T For HQ:
PARAMETER = 0 PROB > ITI
INTERCEP
MIYR1
SURGYR1
MONFREQC
Q43HINCM
75-76267837
25-38154878
-57-7657
2.61060003
0.68142915
154.94207071 0.489
199.90387347 0.127
290.00827743 -0.199
3-24238982 0.805
0.48939933 1-392
0.6274
0.8996
0.8431
0.4253
0.1711
-------
Table A. 1-3 cont.
SOURCE DF
Dep Variable:
MEDTOT
MODEL 1
ERROR 12
C TOTAL 46
ROOT MSE
DEP MEAN
C.V.
VARIABLE DF
INTERCEP 1
MIYR1 1
SURGYR1 1
MONFREQC 1
Q13HINCM 1
Analysis of Variance
SUM OF
SQUARES
MEAN
SQUARE
F VALUE
PROB > F
2068001158
821520312.99
2889521771
517001 1 11.57
19560007 .'15
26.13?
0.0001
1122.67
1921 .191
89.8699
R-SQUARE
ADJ R-SQ
0.7157
0.6886
Parameter Estimates
PARAMETER
ESTIMATE
STANDARD
ERROR
T For H0:
PARAMETER = 0 PROB > IT I
2827.35651
7026.69510
23100.81120
-20.131
-0.75965
1110.27153 1.963
1858.22002 3-781
2695.79161 8.681
30.13985152 -0.668
1.51921170 -0.167
0.0563
0.0005
0.0001
0.5078
0.8682
-------
Table 4.1-3 cont.
SOURCE DF
Dep Variable:
COISELF
MODEL 4
ERROR 42
C TOTAL 46
ROOT MSE
DEP MEAN
C.V.
VARIABLE DF
INTERCEP
MIYR1
SURGYR1
MONFREQC
Q43HINCM
Analysis of Variance
SUM OF
SQUARES
MEAN
SQUARE
F VALUE
PROB > F
704973692.90
15336119332
16041093025
19108.79
10415.28
182 .9'l 19
176243423.23
365145698.38
R-SQUARE
ADJ R-SQ
0.483
0.439
-0.071
0.7483
Parameter Estimates
PARAMETER
ESTIMATE
STANDARD
ERROR
T For H0:
PARAMETER = 0
PROB
6366.09593
-4407 .81
5531 .15387
155.39545313
10.1189970
6222.91496 1.023
8028.70905 -0.549
11647.55861 0.475
130.22361230 1.193
19.65567146 0.515
0.3122
0.5859
0.6373
0.2395
0.6094
-------
Table 4-1.3 con1t
SOURCE DF
Dep Variable:
COITOT
MODEL 4
ERROR 42
C TOTAL 46
ROOT MSE
DEP MEAN
C.V.
VARIABLE DF
INTERCEP 1
MIYR1 1
SURGYR1 1
MONFREQC 1
Q4 3HINCM 1
Analysis of Variance
SUM OF
SQUARES
MEAN
SQUARE
F VALUE
PROB > F
2552325*122
16552119378
1910444801
638081355.57
39^098080.'14
1 .619
0.1873
19851 .9
15104 .36
131 .4316
R-SQUARE
ADJ R-SQ
0.1336
0.0511
Parameter Estimates
PARAMETER
ESTIMATE
9117.68980
2593.50550
28989.76376
132.65382029
8.67792023
STANDARD
ERROR
6464.91668
8340.93593
12100.51822
135.28785265
20.42005699
T For Hq:
PARAMETER = 0
1 .410
0.31 1
2.396
0.981
0.425
PROB > | T|
0.1658
0.7574
0.0211
0.3324
0.6730
-------
58
There is a significant relationship between total medical expenses and heart
attack or bypass surgery in the past year. In the cost of illness regressions
the angina frequency coefficients are positive and might be statistically
significant in a larger sample.
Additional information on out-of-pocket costs associated specifically
with angina episodes was obtained in the series of questions asked about the
subject's most recent angina episode. In response to the question, "If there
was any monetary cost to you due to this episode, can you estimate how much it
was?" The vast majority of the subjects responded that there was no cost
other than the few cents for a nitro tablet. One subject said that there was
a cost due to time missed from work. A very serious angina episode might be
more likely to cause the patient to seek immediate medical attention, but only
a small percentage of episodes would be this serious. A larger sample might
find some out-of-pocket cost significantly different from zero with a question
like this, but we recommend that the regression approach previously presented
also be applied. It is possible that a higher frequency of angina is
associated with additional costs (e.g., more medical check-ups) that cannot be
easily linked to a specific episode.
These results suggest that the incremental dollar cost associated with a
marginal change in angina frequency could be expected to be relatively
insignificant. This means that a welfare measure based on cost of illness
only would reflect minimal impact on a subject's welfare due to a marginal
change in angina frequency. This result, which is not substantiated by other
evidence provided by the respondents, makes it all the more important to
consider other welfare measures such as willingness to pay and averting
expenditures estimates.
-------
59
4.2 Willingness to Pay
4.2.1 Introduction
A variety of questions were used to obtain an overall picture of the
potential effects of changes in angina severity or frequency. Subjects were
first asked to rate eight possible effects of an increase in angina on a scale
of "bothersomeness" (Question 31). The aggregate rankings of these effects
are given in Section 4.2.2. Subjects were also asked whether or not they
would be willing to pay specific dollar amounts to prevent a specific increase
in angina episodes (Question 32). The analysis of the responses to these
close-ended willingness - to-pay questions is in Section 4.2.4. Finally,
subjects were asked to specify dollar amounts that they would be willing to
pay to prevent a specific increase in angina. Willingness to pay to prevent
one and two episodes (Questions 30 and 30b) is analyzed in Section 4.2.3.
Willingness to pay to prevent four or eight episodes (Question 33) is analyzed
in Section 4.2.5. Special focus is placed on answers of $0 or very large
dollar amounts. The relationship of a person's willingness to pay amount with
his other survey responses is analyzed in Section 4.2.6.
4.2.2 Rankings of Effects of Increased Angina
For Question 31, subjects were asked to place eight potential effects of
an increase in angina on a scale of 1 to 10, with 1 being the least bothersome
and 10 being the most bothersome. Table 4.2-1 shows the mean rating for each
category. In some cases the subjects responded that a particular category was
not relevant to them. A zero rating was used in these calculations when the
-------
Table 4.2-1. Racing and share means of potential effects of an increase in angina.
Percentage shares for each effect are calculated using the total number
of points given by each subject for all eight categories, thus
providing a normalized measure of bothersomeness (Question 31)
Answers to question: Most bothersome effects you may experience if your angina
worsened:
Ratine; (1 to 10)* Share (%)
Std. Error Std. Error
Mean of Mean Mean of Mean
a. More medical treatment 3.28 .44 .066 .008
expenses.
b. Less ability to earn 3.24 .53 .061 .009
income.
c. More non-medical expenses 3.98 .43 .083 .008
(such as paying for
services)
d. More pain or discomfort. 7.84 .35 .181 .012
e. Less ability to work 5.18 .57 .106 .011
at a job (for reasons
other than income).
f. Less ability to do desired 8.06 .31 .180 .008
activities (recreation,
chores , or work).
g. More concern to you 7.12 .44 .155 .010
about potential heart
attack or bypass surgery.
h. More concern to you 7.46 .42 .167 .011
about worry or incon-
venience to family and
friends due to your health.
*1 = least bothersome; 10 - most bothersome
-------
60
subject said the category was not relevant. This occurred most often with the
income and job performance categories for the subjects who are not
employed. It is important to note that these two categories might receive a
higher rating if an improvement in angina were being considered rather than a
deterioration, especially from subjects younger than retirement age who are
not working due to their disease.
The mean ratings are all statistically significantly different except for
(f) activity restriction and (d) pain. These two effects were rated as the
most potentially bothersome, followed by (h) others' worry and (g) heart
attack concern. Job satisfaction was next, followed by the three financial
categories. Even though these subjects all had medical insurance, (a) medical
expenses received a slightly higher rating than (b) ability to earn income.
Ability to earn income may not be an important concern for many of the
subjects who are beyond retirement age.
To adjust for possible differences in the subjects' use of the 1 to 10
scale, percentage shares for each category were calculated based on the total
number of points given by each subject for all eight categories. The mean
shares are also given in Table 4.2-1. The order is the same except that (f)
activity restriction and (d) pain are reversed. The mean shares are all
statistically significantly different except for (a) medical expenses and (b)
ability to earn income.
Simple correlations among the shares were estimated to determine whether
the ratings were related to one another. The significant correlations are
shown in Table 4.2-2. There were three significant positive correlations:
(b) ability to earn income with (e) job performance, (d) pain with (f)
activity restriction, and (g) heart attack concern with (h) others' worry.
The negative correlations suggest that the subjects who were more concerned
-------
TABLE 4.2-2.
Pearson Correlations of "Bothersomeness Shares" and Personal Characteristics (Question 31)
(P in parentheses)
a. b. c. d. e. f. g. h.
Medical Earning Defensive Job Activity MI Others' Household
Expenses Ability Expenses Pain Satisfaction Restriction Concern Uorry Married Income WTP/Income
More medical treatment
expenses.
-.33
(.02)
Less abiIi ty to earn
income.
-.30
(.04)
.46
(.00)
- .34
(.02)
-.24
(.10)
-.41 -.31
(.00) (.03)
.33
(.04)
More non-medical
expenses (such as
paying for services).
-.43
(.00)
-.28
(-08)
More pain or
di scomfort.
.30
(.03)
Less ability to work at
a job (for reasons
other than income).
-.47
(.00)
-.53
(.00)
.24
(.10)
Less abiIi ty to do
des i red act i vi t i es
(recreation, chores,
or work).
-.41
(.00)
More concern to you
about potential heart
attack or bypass
surgery.
.25
(.08)
More concern to you
about uorry or
inconvenience to
family and friends
.40
(.00)
-------
61
about financial effects tended to be less concerned about pain, activity
restriction, heart attack concern and others' worry.
Some significant correlations with other characteristics of the
individuals are also shown in Table 4.2-2. Being married positively
correlated with (h) others' worry and negatively correlated with (b) concern
about ability to earn income. Annual household income is positively
correlated with (e) job satisfaction, suggesting that subjects who earn more
also obtain more general job satisfaction. Two of the shares were
significantly related to willingness to pay to prevent an increase in angina
(Question 33) as a percent of household income: (b) concern about earning
ability was positively related, and (c) concern about defensive expenses was
negatively related. Charactertistics that showed no significant relationship
to any of the shares were number of heart attacks, income lost, total
defensive expenses, current angina frequency, and willingness to pay to
prevent an increase in angina (not as a percent of income).
The effects of subject characteristics on the ratings were further
explored by examining the differences between mean shares for groups with
different characteristics. These comparisons are shown in Table 4.2-3.
Overall, these comparisons reveal differences in ratings that would be
expected for subjects in different circumstances, and they support the
conclusion that the subjects were able to distinguish among the categories of
potential effects and give meaningful ratings to each.
4.2.3 WTP Responses for One or Two Isolated Episodes
Before any of the willingness to pay questions, the subjects were asked
to describe a typical angina episode in terms of how it affected them as well
-------
Table 4.2-3. Comparisons of shares to subject characteristics*
CoinDar ison
1
: What subjects do on days when expect
more Angina (Question 19)
Ac tivity
Restriction Share
Group 1
-
Makes no changes in activities
.148
(.068) N=9
(choice 1)
Group 2
-
Avoid active recreation or
. 186
(.052) N=29
physical exertion (choice 2 or 3)
Comriar ison
2
: Cost of Illness
Medical
Expense + Income Share
Group L
-
Incur some COI (pay some medical
. 144 (
.080) N=25
expense or lost income)
Group 2
-
No COI (100% insurance coverage
.111 (
.088) N=25
and no lost income)
Conmar ison
3
: Defensive Expenses
Defensive Expense Share
Group 1
-
Incur some defensive expense
.097
(.059) N=21
Group 2
-
Incur no defensive expense
.07^
(.074) N=29
CoinDar ison
4
: Previous MI
MI (ana
Surgery)Concern Share
Group 1
-
Have had no MI
. 147
(.065)' N'= 16
Group 2
-
Have had MI
. 159
(.075) N'=34
ComDarison
5
: Previous Bypass Survery
MI (and
Surgery) Concern share
Group 1
-
Have had no bypass surgery
. 169
(.072) N=27
Group 2
—
Have had bypass surgery
. 139
(•069) N-23
ComDarison
6
: Marital Status
Others'
Worry Concern
Group L ¦
- Not married
. 1L1
(.07 5) N= 11
Group 2 ¦
Married
. 183
(.069) N=39
*Standard Error of Mean in Parentheses
-------
62
as what they did to minimize the impact (Questions 22-29). Subjects were also
asked to recall the single worst episode they had experienced, as well as a
typical mild episode. One of the goals of this set of questions was to focus
the subjects' thinking on the range of their experience with angina and how it
affected them. Additionally, the questions provided some background
information about angina from the subjects' point of view.
Subjects were asked what they would be willing to pay to avoid having a
typical angina episode tomorrow (Question 30a). If subjects were willing to
answer this question, they were also asked what they would be willing to pay
to avoid two typical angina episodes in the next week (Question 30b). After
the first set of 15 interviews were conducted, it appeared that subjects were
having a harder time answering these questions than Questions 32 and 33.
Concern was that these questions did not have sufficient introduction to make
the willingness to pay question seem realistic, thus resulting in more
refusals and potentially affecting the subsequent willingness to pay
response. Questions 32 and 33 provided a more, detailed explanation about a
hypothetical circumstance under which such a payment might occur.
In an attempt to address this concern, the questions on one and two
isolated episodes (Questions 30a and 30b) were asked after Questions 32 and 33
in all subsequent interviews. The questions were deleted from the Subject
Version questionnaires mailed to the second wave of subjects, and the
interviewer simply read the questions over the phone after Questions 32 and 33
were completed.
Eight of the subjects had particular difficulty answering the questions
concerning willingness to pay to prevent one and two episodes. Two of them
refused to answer, two said they didn't know, and four said they would pay
something but didn't know how much. In addition, two subjects gave extremely
-------
63
high dollar responses ($10,000 and $60,000 to prevent one episode), and four
said that they would pay anything to prevent one episode. The two who gave
the very high but non-infinite responses stuck to their answers when
questioned by the interviewer as to whether that was what they meant. They
said that they would be willing to pay anything they could, although they both
gave lower estimates when asked Question 33 (both were asked about one and two
episodes first). We interpret these very high bids as similar to the infinite
responses, the difference being that these two subjects figured out what their
income constraints might be. Half of these 14 "problem responses" occurred in
the first 15 interviews, suggesting that the sequence change improved
responses to this question but some problems remained.
Fourteen problematic responses were observed for Questions 30a and 30b.
Seven of these were obtained from the 15 subjects who were asked the questions
before Questions 32 and 33. The rate of problematic responses therefore
declined somewhat after the order of the questions was changed (7/34 versus
7/15), but problems still occurred.
Table 4.2-4 shows a breakdown of the types of responses obtained for the
three open-ended WTP questions. Overall, it appears that the subjects found
it easier to answer Question 33 regarding the prevention of an increase in
four or eight episodes per month for an indefinite time period. This may be
due to 1) the more detailed explanation about the circumstance under which
such a payment would be made, 2) the practice obtained with the YES/NO options
with Question 32, and/or 3) the more realistic scenario that an overall
ongoing change in the subject's condition might occur that would cause an
increase in angina each month. With Question 33 there were three more
infinite responses, but fewer problem responses of other types. These were
discussed and evaluated in a previous section.
-------
Table 4.2-4. Summary of responses to the three open-ended willingness-to-pay
questions (Questions 30a, 30b and 33)
Total Subjects
Asked Question 32
Zero Response
Non-zero, Non-infinite
Response
Infinite Response
Response of $10,000
or More
Don't Know, But
Something > 0
Don't Know
Refusal
WTP 1
Episode
49
20
17
4
4
2
2
WTP 2 WTP 4 or 8
Episodes* Episodes/Month**
35
16
4
50
7
35
7
0
0
1
*12 of the 14 not asked had given $0 to WTP for one episode, the other two
were "don't know" responses to WTP for one episode.
**Numbers in this column reflect adjustments made in 3 responses discussed in
text: two "don't know, but something > 0" responses were changed to dollar
amounts based on their responses to Question 32, and one refusal was changed
to zero based on the verbal explanation given.
-------
64
Of particular interest with respect to the WTP responses concerning one
episode is that more than half of the subjects who gave a dollar value said
zero dollars. The explanation of this response by all but one of the 20
subjects was that it would not be worth anything to them to prevent just one
episode. The one subject said he could not afford to pay anything. Several
added further comments that supported the explanation that one angina episode
more or less really didn't matter that much. What mattered they said would be
an overall change in their condition. Therefore, these 20 zeros were
interpreted as true zero bids for preventing a single angina episode.
The means of the dollar responses concerning one and two episodes are as
follows (excluding the two very high responses, but including all zero
responses):
WTP for One WTP for Two
Episode Episodes
$64 (N=35) $165 (N-22)
These means are not directly comparable because twelve subjects who said zero
to one episode were not asked about two episodes. This was a
misinterpretation of the instructions to the interviewers to skip the two-
episode question if the subject refused to answer the question concerning one
episode. A zero response should not have been interpreted as a refusal. If
these twelve zeros are removed from the first mean, as well as a $20 response
from a subject who then said he didn't know for two episodes, the two means
are more comparable:
-------
6 3
WTP for One WTP for Two
Episode Episodes
$100 (N=22) $165 (N=22)
Of these 22 subjects, two gave infinite responses to Question 33. Due to the
small sample size and the apparent lack of difference in responses for four or
eight episodes (see Section 4.2.5), we have combined these responses for this
comparison. The means for the remaining 20 subjects for all three WTP
questions are:
WTP for One WTP for Two WTP/Month for Four/Eight
Episode Episodes Episodes/Month
$61 (N-20) $82 (N=20) $200 (N=20)
Comparing just the responses for one episode to the four or eight episodes
allows 10 zero responses for one episode to be included, and the sample
increases to thirty:
WTP for One WTP/Month for Four/Eight
Episode Episodes/Month
$41 (N-30) $145 (N-30)
These means suggest declining marginal utility for avoiding an increasing
number of angina episodes and show general consistency in responses to the
three difference questions in terms of the order of magnitude of the per-
episode value. The comparison of the means, however, masks a few problems
that should be noted. One is the significant number of zeros (higher
variance) given for one and two isolated episodes, keeping the mean responses
to these questions low. Another is that several subjects gave fairly high
-------
66
responses to the question regarding one episode and then didn't increase the
response very much for two. It appears from the recorded comments that many
subjects may have been focusing on how much they could afford to pay for a
reduction in angina but not focusing on the exact amount of angina being
avoided, and therefore responded with an estimate that was more related to
their budget constraint than to the amount of angina. This tended to bring
the means for one and two episodes closer together, giving the impression of
declining marginal utility, and perhaps upwardly biasing responses for one or
two episodes.
A look at the responses for each individual across the three questions
provides some additional, and inconclusive, information about whether the
responses show a declining marginal utility for additional episodes reduced.
There were 27 non-infinite dollar responses to Questions 30a and 30b that
could be compared with the non-infinite, non-zero responses to Question 33.
Of these, 11 said zero for one episode, four showed increasing values per
episode, and 12 showed equal or decreasing values per episode for the one- and
two-episode questions. Of the 12 sets of responses that were consistent with
equal or declining marginal utility for additional episodes reduced, four gave
the same amount for preventing one or two episodes, and eight gave double the
amount for two than for one. Of these same 12 subjects, six showed equal or
declining marginal utility across all three questions.
Overall, the responses do not provide conclusive evidence of declining
marginal utility for more episodes prevented. The most that can be said is
that a good share of the responses, although by no means all of them, show
some logical consistency across the different WTP questions. This question is
also addressed in the cross-sectional analysis of the WTP responses reported
in Section 4.2.5, where there is again no conclusive evidence of declining
marginal utility.
-------
67
k.l.U Willingness to Pay to Prevent Degradation of Health Status: Analysis
of the Close-Ended WTP Responses
In Question 32, subjects were asked if they would pay a given amount per
month to prevent an increase of either four or eight angina episodes per
month. If they responded "yes," then they were asked if they would pay a
specified higher amount, and if they responded "yes" again they were asked if
they would pay a third specified higher amount. Question 32 was worded as
follows: "Suppose your heart condition were to become worse so that with your
current medical treatment and lifestyle your angina episodes would occur more
often. Suppose also that a new medical treatment were available that could
prevent the additional angina without causing undesirable side effects or
requiring lifestyle changes. If the treatment would prevent additional
angina episodes per month and you had to pay the entire cost yourself, would
you take the treatment if it cost $ each month? (Yes/No) Would you
take the treatment if it cost $ each month? (Yes/No) Would you take
the treatment if it cost $ each month?"
Payment amount combinations were randomly assigned, and these
combinations were previously described in Table 3.3-1.
Overview of Responses
Two subjects refused to answer the close-ended WTP questions. One of
these subjects refused to answer all income and financial questions. Another
subject said that he wasn't able to decide whether he would be willing to pay
the amount asked. Six subjects said they would not pay the first amount
-------
asked. All of these subjects also said they would riot pay anything to prevent
an increase in angina in response to Question 33. Three of these subjects
said that they could not afford to pay anything, one said it would not be
worth anything to avoid that amount of angina, and two said that what mattered
was their overall heart condition, not a few more angina episodes.
Question 32, the close-ended WTP question, combined three questions to
bound the amount a subject was willing to pay to prevent additional angina.
With two refusals and three questions for each subject, a total of 144
responses was obtained. When a subject said "no" to one amount, the
interviewer went on to Question 33, and the response for any subsequent higher
amounts was coded as "no." About two-thirds of the responses were "yes." The
responses are summarized in Table 4.2-5 and are separated according to the
question sequence. As expected, the percentage of "yes" responses declined as
the amount increased. For all amounts under $200, more than half of the
responses were "yes." At $200, the split was 50/50, and for all amounts above
$200, one-half or more of the responses were "no."
Analysis of the Responses
Analysis of the close-ended responses was based on the following utility
model. This section follows Hanemann (1984).
U - U(A,Y,S) (4-1)
Where:
U = an individual's utility
A = angina episodes per month
Y - income (representing all consumption)
S = socioeconomic characteristics of the individual
-------
Table 4.2-5. Summary of responses to the close-ended willingness - to-pay question
(Question 32)
Close-Ended WTP Question Responses
Dollar Total No. Total Question Sequence
Amount Subjects Response First Second Third
Asked* Yes No Yes No Yes No Yes No
$5
4
4
(100%)
0
(0%)
4
(100%)
0
(0%)
-
-
-
-
$10
7
6
(86%)
1
(14%)
6
(86%)
1
(14%)
-
-
-
-
$25
18
16
(89%)
2
(11%)
13
(93%)
1
(7%)
3
(75%)
1
(25%)
-
-
$50
24
20
(83%)
4
(17%)
7
(78%)
2
(22%)
10
(91%)
1
(9%)
3
(75%)
1
(25?
$100
29
22
(76%)
7
(24%)
12
(86%)
2
(14%)
8
(73%)
3
(27%)
2
(50%)
<-v
(501
$200
20
10
(50%)
10
(50%)
-
-
5
(42%)
7
(58%)
5
(63%)
3
(385
$300
10
2
(20%)
8
(80%)
-
-
-
-
2
(20%)
8
(305
$400
12
5
(42%)
7
(58%)
-
-
-
-
5
(42%)
7
(58s
$500
10
5
(50%)
5
(50%)
-
-
5
(50%)
5
(50%)
-
-
$1000
10
3
(30%)
7
(70%)
-
-
-
-
3
(30%)
7
(70i
Total 144 93 51 42 6 31 17 20 28
*Each subject was asked three different dollar amounts. Two subjects refused to
answer these WTP questions. Therefore, a total of 144 responses obtained from 48
subj ec ts.
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69
In Question 32, potential changes in A and in Y were hypothesized. The
subject's initial utility is
U* = U (An,Y,S) (4-2)
Where:
Aq - the initial level of angina.
Question 32 posed a choice between making a specified payment, X, or having
angina frequency increase to A^, where A^ is either Aq + 4 or Aq + 8. Thus,
the subject chose between:
U0 = U(Aq, Y-X, S) (4-3)
and
UL = U(AX, Y, S). (4-4)
Because some components of these utilities are unobservable to the
investigator, they can be treated as stochastic, so that Uq and are random
variables with means of v(Aq, Y-X, S) and v(A^, Y, S), and distributed
according to some probability distribution. Uq and can thus be written as:
Uq - v(Aq, Y-X, S) + eQ (4-5)
UL = v(Ax, Y, S) + eL
(4-6)
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70
The probability that the subject will be willing to make payment X rather than
have angina increase to A^ is given by the probability that Uq is greater than
or equal to U^:
PQ - Pr ( v(A0, Y-X, S) + eQ > v(Alt Y, S) + e^ . (4-7)
If we define E = e^ -eg and let Fj. (.) be the cumulative density function of
E, then the probability of being willing to pay amount X may be written as:
P0 - Fe (Av), (4-8)
where
Av = v(Aq, Y-X, S) - v(A1, Y, S).
In the probit model Fg- (.) is the standard normal cumulative density
function. In the logit model it is
PQ - Fe (Av) - 1/(1 + exp(-Av)). (4-9)
Hanemann concludes that the argument of Fg- must take the form of a utility
difference to be consistent with the economic hypothesis of utility
maximization. He suggests two examples: a linear utility function and a log-
linear utility function. Using a linear function, the utility difference is
given by:
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71
Av = (a + b^AQ + b2 (Y-X) + b^S) - (a' + b-^A-^ + b2Y + b^S) (4-11)
= a* + b-^AA - b2X (4-12)
where:
a* - a - a', and
AA - Ag - A^ (taking a value of -4 or -8) .
It would be expected that b-^ is less than or equal to zero because the
probability of agreeing to pay X would probably increase when AA goes from -4
to -8. It would be expected that b2 is greater than or equal to zero because
as -X decreases (X becomes larger) the probability of agreeing to pay X
probably decreases.
The estimation results of the logit form of equation 4-12 are shown in
Table 4.2-6. The coefficient b2 for the X variable, the amount the subject
was asked to pay, is statistically significant and has the expected sign. The
coefficient b-^ on the change in angina hypothesized does not have the expected
sign and is not statistically significant. This is consistent with the
finding in the analysis of the open-ended responses that there was not a
significant difference in asking about an additional four or eight more
episodes.
In order to show the implications of the estimated coefficients, X' is
defined as the amount at which Av is zero. This is the amount where the
probability of saying "yes" is 0.5, which can be interpreted as a point of
indifference between making the payment or having the change in angina.
Evaluated at the sample mean of NCHANG (-5.84 angina episodes per month), X'
-------
Table 4.2-6. Logic analysis of responses to the close-ended willingness-to -
pay question (Question 32)
A. Av = a + bx (NCHANG) + b2 (NPAY)
X1 - a/b2 + (bx/b2) (NCHANG)
Full Sample (N = 144)
Estimated Standard
Variable Coefficient Error Prob
Intercept (a)
NCHANG
NPAY
2.190
. 1430
.0033
.646
.095
.00085
.0007
.1323
.0001
¦ i _
$411 (at NCHANG =• -5.84)
B. Av - a + bx (NPAY)
X1 - a/b1
Full Sample (N = 144)
Estimated Standard
Variable Coefficient Error Prob
Intercept (a)
NPAY
1.324
.0032
$414
.259
.00084
.0001
.0001
C. Subsample with Non-Infinite Responses to Question 33 (N = 123)
Estimated Standard
Variable Coefficient Error Prob
Intercept 1.951 .703 .0055
NCHANG .1306 .101 .1952
NPAY .0037 .001 .0002
X1 - $321 (at NCHANG - -5.84)
Note: NCHANG - AQ - A:
NPAY - -X
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72
is $411. This is about twice the mean of the non-infinite responses to
Question 33. It would be expected that this value would be higher since those
who said they would pay anything are included. To test the impact of the
insignificant b-^ coefficient on this estimate of X' , the equation was
estimated assuming = 0. The X' value was essentially equivalent at $414.
To determine the extent to which these X' values may be influenced by the
subjects who said they would pay anything and by the subjects who said they
would pay nothing, the logit estimation was repeated for the subjects who gave
non-zero and non-infinite responses to Question 33. The results are reported
in Part C of Table 4.2-6. The coefficients are quite similar to those
estimated for the whole sample, but they do result in a considerably lower X'
value of $321.
4.2.5 Willingness to Pay to Prevent Degradation of Health Status:
Evaluation of Open-Ended WTP Question
In an attempt to obtain a dollar estimate of the total value (utility)
angina patients place on preventing a deterioration in health status, we asked
an open-ended question immediately after Question 32.
(Question 33): "What is the most that you would pay for this
treatment if it would prevent (four or eight) additional episodes per
month?"
Responses to this question are graphed in Figure 4.2-1. Half the subjects
were asked the amount they were willing to pay to avoid four additional
episodes this month. The other group was asked about eight episodes. Two
-------
Figure 4.2 - 1 Willingness-to-pay in dollars to prevent an additional four or eight
episodes of angina
4 EPISODES
Number
of
Subjects
5
4
3
2
1
i '
MEAN = $203
•if
0
10
25 35 50 75 100
200 250 300
500
1,000 2,000
Willingness to Pay in Dollars (logarithmic scale)
N = 27
Very
High
Number
of
Subjects
8 EPISODES
6 -
5 -
4 ••
3 -
2 -
1 ¦¦
¦ 'W'
0 10
MEAN = $218
4
25
35 50
75 100 125
200
300 500
2,000
Willingness to Pay in Dollars (logarithmic scale)
N = 22
Very
High
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73
major patterns of response were observed. First, both groups were willing to
pay similar dollar amounts to avoid angina. The average WTP for avoiding
eight additional episodes ($218) is only $15 more than the average WTP to
avoid four additional episodes ($203). These means include all non-infinite
responses. Second, a sizable number of subjects (6 of 50 = 12%) said they
would pay nothing to avoid the increased angina while another group (7 of 50 =
14%) said they'd give everything they had to avoid additional angina episodes.
In the next sections the responses of zero and of very high amounts are
evaluated to determine whether they should be accepted as true responses or
treated as protests. The responses shown in Figure 4.2-1 reflect a few
adjustments made on the basis of this evaluation.
Responses of Zero
Six of the 50 subjects gave zero as the maximum amount they would be
willing to pay to prevent the increase in angina. Subjects who gave zero were
asked a follow-up question to help determine whether their responses indicated
that they really would pay nothing to prevent such an increase or whether they
gave this answer because they objected to or did not believe the premises of
the question. After considering the explanations given by these subjects, all
six zeros were retained as valid responses. In addition, one subject's
response was changed from a refusal to a zero because his explanation was
similar to that given by other subjects who said zero. This subject had said
no to the specific dollar amounts in Question 32.
Two of these subjects said that it would not be worth anything to prevent
that much angina, three subjects said that they could not afford to pay
anything, and one subject gave both explanations. Subject 16 said that it
-------
/
didn't matter unless the heart was in good condition, that more or less angina
didn't matter that much. One of the other subjects gave a similar explanation
saying, "I would mortgage my house and pay $100,000 to be rid of all my
angina, but I would not pay to avoid eight episodes." This subject currently
had angina about twice a day. Five of these seven subjects reported having
angina once a day or more, and apparently several of them felt that an
increase of four or eight episodes a month would not be worth paying to
prevent, although a significant improvement in their overall condition would
be worth a great deal.
All but one of the subjects who gave a zero response to Question 33 had
also said no to the amounts suggested in Question 32. One subject had,
however, said yes to $100 (the first amount asked for that subject in Question
32) and no to the second higher amount. When asked Question 33 the subject
said zero and explained that he really couldn't afford even the $100 he had
previously said yes to. This suggests the possibility that in a close-ended
question some subjects will go along with a higher amount than they would
actually be willing to pay. Some similarly inconsistent responses are
discussed below. This is something that should continue to be checked in
future efforts of this type.
Refusals
Four subjects refused to give a dollar' response to Question 33. After
evaluating the comments and other answers given by each of these subjects, one
of these responses was retained as a refusal and the other three were recoded
to some dollar amount. As discussed in the previous section, one refusal was
recoded to zero because the explanation given by the subject indicated that
-------
75
the change in angina posed by the question was not significant to him relative
to his overall condition.
Two of the remaining three subjects said that they would be willing to
pay something, but refused to give a dollar amount. Their responses to the
previous Question 32 were used to estimate a maximum amount that they would be
willing to pay. One subject had said yes to $25, $100 and $300, but when
asked Question 33 this subject had said the amount he would be willing to pay
would be less than $300. His response to Question 33 was therefore recoded
from a refusal to $100. The second subject had said yes to $25 and $100, and
no to $300. This subject said he would be willing to pay something in
response to Question 33, so $100 was entered as a response for this subject.
Very High Responses
Seven subjects said that they would pay "anything" to prevent the
increase in angina. Several of these subjects recognized by their responses
that there would be a limit to the amount of money they could actually pay,
but many of them explicitly said that they would sell or mortgage their
houses. All these subjects had said yes to every dollar amount asked in
Question 32. They emphasized in their explanations that they would place a
very high value on preventing an increase in angina. In contrast to the
subjects who said zero for Question 33, only one of these seven subjects
currently had one or more angina episodes a day. Thus, an increase of four or
eight episodes represents a very significant worsening the angina condition
for most of these subjects.
All of the very high responses appeared to be sincere indications of a
willingness to pay any amount possible to prevent additional angina,
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76
reflecting that such an increase would have a very significant impact on these
individuals. None of these responses appeared to be a protest against the
question, as is sometimes observed with willingness to pay questions.
The highest dollar amount that these subjects were asked in Question 32
could be interpreted as a minimum estimate of the amount each individual would
be willing to pay. These amounts were as follows:
Highest Amount Number of Subjects
$1000 1
400 1
200 3
50 2
Consistency of Close-Ended and Open-Ended Responses
A comparison was made between responses to Question 33 and the highest
amount the subject said he would pay in response to Question 32. Five
inconsistencies were observed in which subjects gave a lower amount for
Question 33 than the highest amount they had said "yes" to in Question 32.
The amounts involved in each case were as follows:
Amount Agreed Amount Given
Subject to in Question 32 in Question 33
7 $500 $100
22 $1000 $200
24 $1000 $500
109 $100 $0
106 $300 $100
Four of these subjects offered the explanation that they really could not
afford the higher amount. The other said something to the effect that he
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77
would pay the higher amount if he really had to and the treatment worked. It
appeared there might be a tendency for some subjects to go along with a higher
amount when the question was asked in the form of a yes/no format. In the
subsequent analysis of the open-ended responses, the lower amount given in
Question 33 was used. This appears to be a more accurate estimate of the
maximum WTP for these subjects.
High Responses Relative to Income
The responses to Question 33 were evaluated relative to the reported
household income to determine whether any individuals had given
unrealistically high responses relative to their apparent ability to pay. It
should be noted that current income is only one indication of the ability to
pay as it does not take into account accumulated wealth (such as homes) that
individuals may have.
The willingness to pay as a percent of monthly household income was
calculated yielding an average of 16 percent. This percentage figure was
distributed as follows across the 40 subjects who provided a finite dollar
response to the WTP question and answered the income questions.
WTP as Percent of
Monthly Income
Number of
Subj ects
0- 9%
10-19
20-29
30-39
40-49
50-59
60-69
70-79
80-89
90-99
23
9
3
1
1
0
0
0
1
0
2
100 or more
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78
Three responses stand out as being at the high end of the distribution.
The information available about each of these subjects was evaluated to
determine whether these high responses might be reasonable for these
individuals. This information is reported in Table 4.2-7. In light of the
apparent sincerity of the very high responses discussed in the previous
subsection, it is possible that these high values relative to income are of a
similar nature. The information about the three subjects does not contradict
this interpretation and the responses were kept as probably valid.
Average WTP After Adjustments
Three different WTP estimates were defined based on responses to
Questions 33 and 32. Q33PAYM was defined as the response given to Question
33, with Subject 16 recoded from refusal to $0 and Subject 2 and Subject 106
recoded from refusals to $100. The remaining refusal and the very high
responses were treated as missing values. Q33ADJ1 was defined as equivalent
to Q33PAYM, except the highest value the subject accepted in Question 32 was
used if the subject gave a very high response to Question 33. Q33ADJ2 was
equivalent to Q33PAYM, except the monthly income was included for subjects who
gave very high responses. Q33ADJ1 therefore incorporates the very high
responses in a conservative way, and Q33ADJ2 gives an upper bound to the
extent that payments are limited by current income.
The means and standard errors of the means for each of the measures are
reported in Table 4.2-8. The means for Q33PAYM and Q33ADJ1 are quite
similar. The mean for Q33ADJ2 is about twice as large as the other two. When
separated for four or eight angina episodes, the means are not statistically
-------
TABLE 4.2-7. Evaluation of High UTP Responses Relative to History of Heart Disease and Income
Subject
Monthly Annual
Question Household Current Current Response Annual Defensive
33 Income Bypass Heart Angina Angina to Uorkloss Expenditures
Resr>onse (range) Surgery Attacks Frequency Severity Question 32 (SUKLOSS) (DEFCOST )
Addi t i onal
Comments
#24
$ 500
recoded
to $1000
$ 625
(417-833)
yes
2/month
$ 100 yes
500 yes
1000 yes
S
$ 750
"Uould pay $1000 if
had to and if it
really worked"
#89
$ 250
$ 208
(0-417)
3+/day
$ 50 yes
100 yes
200 yes
$65000
#94
$2000
$1875
(1667-2083)
yes
4/month
$ 100 yes
200 yes
400 yes
$ 9087
$12780
"You pay as much as
you can afford"
Saniple
Average
.46 1.5 15/month 3.7
$ 9577 $ 904
-------
Table A.2-8. Mean responses to the open-ended WTP Question 33. Responses
are adjusted for consistency with WTP dollar amounts elicited
from the close-ended Question 32. Q33ADJ1 is equivalent to
Q33PAYM except that the highest value accepted in Question 32
was used for subjects who gave very high responses to Question
33. Q33ADJ2 is equivalent to Q33PAYM except that monthly
income was used for subjects who gave very high responses
Q33PAYH Q33ADJ1 Q33ADJ2
All subjects $210 $223 $499
(SE_ = 54) (SE_ = 49) (SE_ = 121)
XXX
(N = 42) (N = 49) (N = 49)
4 episodes $203 $204 $590
(SE_ = 54) SE_ - 45) (SE_ = 177)
XXX
(N = 22) (N = 27) (N - 27)
8 episodes $218 $246 $387
(SE_ - 99) SE_ - 97) (SE_ = 163)
XXX
(N - 20) (N => 22) (N = 22)
WTP/episode $40 $42 $103
(SE_ - 9) (SE_ = 8) (SE_ - 27)
XXX
(N - 42) (N = 49) (N =¦ 49)
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79
different. This suggests that four and eight episodes per month were not
viewed as significantly different by the subjects, or at least that no
difference shows up cross-sectionally for a small sample of subjects with
current angina frequency varying from zero episodes per month to 90 or more
episodes per month. This is discussed below and explored further in the
analysis of the willingness to pay responses.
The average WTP per episode was $40 for Q33PAYM, $42 for Q33ADJ1, and
$103 for Q33ADJ2. Although the latter is about two and one-half times the
other two values, it suggests that if the subjects who gave infinite responses
are taken into account, a value per episode is likely to be between $50 and
$100.
Another summary statistic of interest is that the median and the mode for
each of these measures is $100. This is true for four episodes and eight
episodes. The median and the mode of the anchoring values asked in Question
32 are also $100, indicating that these values may have influenced the
responses to Question 33. This observation is explored further in the
analysis of the WTP responses (Section 4.2.5, subheading "Survey Instrument
Influences").
Lack of Differences Between Responses Concerning Four and Eight Episodes of
Angina
The similar aggregate patterns of responses to the four and eight episode
WTP questions might be interpreted in at least four ways, assuming the
subjects in the two groups are similar on other characteristics. It must be
emphasized that these are hypotheses for future research, not conclusions of
the study.
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80
First, relative to the wide range of angina severity/frequency
experienced by the subjects, four and eight episodes per month may not be
perceived as a very different health level. For example, for subjects
currently having angina twice a day, four or eight episodes a month may not
seem like very much, while subjects having angina once a month may see both
four and eight added episodes as a significant increase. With the small
sample size, it may be difficult to detect small real differences in WTP.
Second, the responses may show rapidly decreasing marginal value
(utility) for avoiding additional episodes. This possibility was explored in
Section 4.2.3, in which responses for willingness to pay for one or two
isolated angina episodes are reported. The data are inconclusive regarding
the presence of declining marginal utility for additional episodes reduced.
Third, the responses for willingness to pay for preventing additional
episodes may have been at the maximum possible level regardless of the amount
of angina reduced. Responses and comments suggest that some subjects were
focusing more on what they could afford to pay than on the amount of angina
being hypothesized. In Questions 30a and 30b, each subject was asked his
willingness to pay for avoiding both one and two episodes. From a few
subjects' comments, it was seen that income constrained some answers. For
example, when asked about paying to avoid one typical angina episode, Subject
18 answered $100 and added "I just don't have the money. If I made a salary
then I'd pay more. I'd have to consider what would happen to my family if I
paid more." For two episodes the subject also answered $100, stating, "Just
couldn't pay any more." Subject 22 answered $500 for both one and two
episodes and stated "$500 is the most I can give for 1, 2, 5 or whatever."
Similarly, some subjects would have paid everything they had to avoid 1, 2 or
more additional episodes.
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81
These subjects may have given a response indicating how bad additional
angina would be, but the response was not specific to a certain number of
episodes. This is likely to happen if people have difficulty separating angina
symptoms from IHD as a whole. If this was the case, using a variable such as
"willingness to pay to avoid x additional angina episodes" in a model for
2
evaluating CO may be inappropriate.
Further, it may be the case that decision-based valuation questions are
inappropriate for exploring the impacts of angina on subjects because they
oversimplify the issue. When asked to give a dollar amount to avoid a
specific number of episodes, a subject may respond to the "demand" for an
answer even though the question is not consistent with how he views his
symptoms. Much of the subject's behavior results from many small decisions or
changes that become habits. Long-term angina sufferers may be able to
describe their habits (such as resting whenever short of breath), but not be
able to describe the tradeoffs they made in acquiring those habits.
Hypothetical decision questions, such as asking for a decision on an amount to
pay to avoid excess angina, are framed with a context and a response mode
which may not match the patient's perspective. For example, some subjects who
no longer work indicated that this wasn't bothersome at all anymore, though it
did bother them in the past. See Keller and Lambert (1986) for a discussion
of the problem of measuring habitual behaviors via decision questions. In
2
In fact, clinical laboratory research has shown that CO aggravates angina,
but it is still unclear whether it increases the risk of myocardial
infarction. If it is found that CO doesn't increase risk of death, then it
would be important to explain to subjects the health effects of increased
angina and to separate risk of death from other effects. We probed the
subjects' opinions on the relationship between angina and heart health in
Question 37; 60 percent (N = 50) of the subjects said their heart is probably
not harmed when they have an angina episode (indicating the angina is simply
their bodies' warning to slow down). Thirty-six percent said their heart may
be harmed a small amount; half of these people believe it probably does not
heal and half believe it probably does heal.
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82
this questionnaire, it was suspected that subjects could make more sense of
hypothetical tradeoffs when the more realistic context was used (in Questions
32 and 33) of an ongoing change in health status rather than one episode (as
in Question 30). In general, the responses to the defensive expenditures
questions indicate that subjects did make direct tradeoffs that they were
aware of.
There are other potential problems with using WTP measures to value
angina reduction. It is important to mention these problems, and great care
was taken in designing the questionnaire to prompt subjects after certain WTP
responses to give their reasons behind the response. First, patients may
discount their willingness to pay to avoid angina if they see angina as an
early warning to slow down before precipitating a myocardial infarction.
Second, patients "pay" to avoid attacks by avoiding exertion, rather than
spending money. Finally, reducing the number of angina attacks (without a
complete cure) may not reduce the psychological and behavioral effects on the
patient, his family and friends (Keller and Lambert, 1986).
Bimodal Distribution of WTP Responses
It may seem paradoxical that some angina patients indicated they would
pay zero to avoid added angina attacks while others said they would pay
everything they had to avoid the next episode(s). One exploratory analysis
using cross tabulations of the WTP responses versus responses to the health,
attitude, and demographic questions did not reveal any systematic differences
between those responding zero and those responding "everything they own". (An
alternative analysis based upon disease and surgery history in Section 4.2.6
is more promising.) The Classification and Regression Tree (CART) software
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83
package by Breiman et al. (1984) for classifying items (i.e., angina patients)
into homogeneous categories, based upon multiple characteristics (i.e.,
responses to survey questions), did not work on this data set due to small
sample size and relatively homogeneous responses. As reported in Section
4.2.6, the dollar amount all subjects (not just those giving zero or very high
responses) were willing to pay to prevent four or eight episodes was
significant and positively related to annual household income, to having had
coronary artery bypass surgery, etc.
McClelland et al. (1986) have found a similar pattern of responses for
WTP bids for insurance to protect against a $4 or $40 loss in an experimental
laboratory setting. They found a bimodal distribution of bids, with one mode
at or near $0 and the other mode a high amount, above the expected value of
the monetary risk being faced. This pattern occurred when the probability of
loss was low (10 percent or 1 percent). Since the probability of death
following one angina episode is low, it may be useful in further research to
explore whether the behavior observed in these "low probability of loss"
laboratory experiments can give us clues to the angina patients' response
pattern. McClelland et al. (1986) hypothesized that the bimodal answers
resulted from the influence of two cognitive processes: editing, and
anchoring and adjustment.
In the angina context, these processes can be used to interpret the zero
and everything answers given by some subjects. First, editing refers to a
stage prior to decision making when a person simplifies a problem by
selectively focusing on only some of the possible outcomes and the perceived
chances of those outcomes. The simplified problem is then used as the model
for decision making. When facing one or a few additional angina episodes,
some subjects may have considered the probability of death from the episode(s)
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84
as being very small and edited the problem by considering this probability
virtually zero. Then, paying zero to avoid an added episode makes sense when
the probability of death is seen as zero. Some subjects' comments indicated
they were focusing on the insignificance of the marginal change in symptoms
being hypothesized, especially when they were currently experiencing a great
deal of angina.
Second, some people may be anchoring on the possible loss from ischemic
heart disease as a whole (severe pain, total incapacitation or even death from
a heart attack). They then consider how much they'll pay to avoid this loss
(everything they have) and adjust downward since the loss will not occur for
sure. Some subjects' comments indicated they were focusing on the
significance of their disease in a larger sense and on how they would do
"everything" to improve it. However, although the coefficient on the
variables "concern about heart attack" was positive in the willingness - to-pay
regressions, it was not very significant. So, some subjects may have focused
on the disease as a whole and others may have narrowed the focus to just
angina. Even if death from IHD is not considered, other aspects of the
disease such as worry to family and friends and ability to hold a job may
enter into the decision process.
In the McClelland et al. (1986) laboratory experiments, the fraction of
subjects who bid $0 increased when there were repeated trials without
experiencing the loss. Similarly, the dollar amount of bids by those stating
a positive amount decreased when there were repeated trials without loss.
This suggests that angina subjects who have not experienced a myocardial
infarction recently might be more likely to bid $0 than others.
Unfortunately, due to a small sample size, it was not possible to
statistically test this hypothesis. Table 4.2-9 contains a cross - tabulation
-------
Table 4.2 - 9 Number of years since myocardial infarction and willingness-to-pay
to avoid four or eight angina episodes
This
Year
1 986
Last
Year
1 985
Column 3
Total 9.4%
4
12.5%
11
34.4%
5
15.6%
4
12.5%
14 Years Row
Ago (72) Total
0
1
2
3
4
11
12
14
No Money
0
1
1
1
1
1
1
Some Money
1
3
3
9
3
3
1
1
Infinite Money
2
1
1
1
2 1 2 32
6.3% 3.1% 6.3% 100.0%
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85
of the number of years since a myocardial infarction (for the 32 subjects who
had them) and response to the willingness to pay question about either four or
eight episodes (Question 32). Unfortunately, this does not reveal a suggested
pattern. Future surveys should ask the subject how long he has had angina,
since behavior and judgment processes may have altered over the course of the
disease.
A less plausible reason for the observed zero and infinity answers is
that subjects might have been framing the problem in two different ways. Some
subjects may have been framing the problem as the amount they were willing to
pay to avoid decrements in health status (the original intent of the
questions) and others may have framed the questions as the amount of
compensation they would demand from an agent who will cause adverse health
effects. At least one subject considered different problem frames prior to
responding to the willingness to pay question. Subject 43 asked why the study
was being done. He said he thought perhaps the government had cut back on the
research funds and that they were going to ask for funds. He also wanted to
know whether there was some medical treatment developed that would get rid of
angina, but that had not been made public. Previous research has demonstrated
that people respond differently to the two problem frames (Gregory, 1986;
Knetsch and Sinden, 1984). An interesting question for further research is
whether framing a problem as one of "compensation demanded" leads more people
to anchor on the potential loss and adjust downward to reflect lack of
certainty that it will happen. Framing a problem as willingness to pay may
lead more people to edit the risk to zero.
There is another possible explanation for the zero/everything phenomenon.
Subjects can be divided into "those who give very low values for willingness
to pay to avoid extra angina because they feel that they should bear the
-------
86
burden of the disease themselves and not bother others with it, and those who
give very high values because they feel that they deserve to devote whatever
resources are available to easing their burden" (Keller and Lambert, 1986).
Ramshaw and Stanley (1984) found a similar pattern. They divided angina
patients who had undergone CABG into two groups. People who had scored low on
a neuroticism scale and coped well with previous stressful situations
generally rated themselves as "well off" one year after their operation. In
contrast, those who scored high on neuroticism and had not coped well with
stress did not rate themselves as well off as the other group.
Future research on the zero/everything phenomenon will clarify the
understanding of the way angina patients value improvements in their symptoms
and may suggest alternative research paradigms for eliciting the information
needed for making policy decisions about health risks resulting from
environmental pollutants. The discussion here is purposefully speculative and
is meant to stimulate further research rather than to imply that this study
provides much evidence for testing the different hypotheses.
4.2.6 Analysis of Relationship of Open-Ended WTP Response with Other
Responses
Regression analysis was used to identify relationships between responses
to Question 33 and potential explanatory factors, including personal
characteristics and survey instrument factors. Regression results obtained
for Q33PAYM (dollar payment per month to prevent four or eight angina
episodes) are reported in Table 4.2-10 (a and b). The variables are defined
in Table 4.2-11 and means for the variables are given in Table 4.2-12. The
two presented regressions differ in the use of either defensive expenditures
-------
Table 2-10a. Regression analysis predicting willlngness-to-pay dollar amounts from the open-ended WTP Question
33- Defensive expenditures are represented by DEFANG, the defensive expenditure per angina episode
avoided
Regression Analysis
Equation 1
Dep Variable:
Q33PAYM
SOURCE
MODEL
ERROR
C TOTAL
ROOT MSE
DEP MEAN
C.V.
DF
9
26
35
SUM OF
SQUARES
2616023.65
2132581 .91
1718605-56
286.3955
208.8889
137 • 10'I2
MEAN
SQUARE
290669.29^50
82022-38096
R-SQUARE
ADJ R-SQ
F VALUE
3-511
0.5509
0.395*1
PROB > F
0.0055
Parameter Estimates
VARIABLE
INTERCEP
CHANG
Q13HINCM
MONFREQC
SURG
SURGANG
DEFANG
PAY1
COISELF
Q31GMI
DF
PARAMETER
ESTIMATE
STANDARD
ERROR
T For HQ:
PARAMETER = 0 PROB > IT I
-936.101
'12.19950139
1 .21951930
5.89151688
216.51566198
-12.2317
6.18185953
3.66830380
-0.000998279
31 .25966729
315.22521911
28.60039065
0.10193782
3.17960235
1 18.32953508
1.67301211
1 .58929189
1 .13707072
0.002967115
19.79188162
-2.712
1.186
3-086
1 .851
2.081
-2.618
3.892
2.553
-0.336
1.579
0.0117
0.1193
0.0018
0.0751
0.0172
0.0115
0.0006
0.0169
0.7393
0.1263
-------
Table 4.2-10b. Regression analysis predicting willingness-to-pay dollar amounts from the open-ended WTP Question
33- Defensive expenditures are represented by DEFCOST, the total annual defensive expenditure
Regression Analysis
Equation 2
Dep Variable:
Q33PAYM
SOURCE
MODEL
ERROR
C TOTAL
ROOT MSE
DEP MEAN
C.V.
DF
9
26
35
SUM OF
SQUARES
2617112.80
2131^92.76
4748605-56
286.3224
208.8889
137-0692
MEAN
SQUARE
290790.31082
81980.49070
R-SQUARE
ADJ R-SQ
F VALUE
3-547
0.5511
0.3958
PROB > F
0-0054
Parameter Estimates
VARIABLE
INTERCEP
CHANG
QH3HINCM
MONFREQC
SURG
SURGANG
DEFCOST
PAY1
COISELF
Q31GMI
PARAMETER
DF ESTIMATE
-764 .436
37-40540586
1 .07454138
4 .39890900
218.73022059
-11 .5897
0.06746431
3-62645011
-0.000802583
24.22031521
STANDARD
ERROR
334.75028533
28.55545084
0.39248825
3-12352005
118.65061709
4.67027184
0.01732397
1 .43755033
0.002970846
19-43102467
T For HQ:
PARAMETER = 0
-2-284
1 .310
2-738
1 .'108
1.843
-2.482
3-894
2.523
-0.270
1 .246
PROB > I TI
0.0308
0.2017
00.0110
0.1709
0.0767
0.0199
0.0006
0.0181
0.7892
0.2237
-------
Table 4.2-10c. Regression analysis predicting willingness-to-pay expressed as a percentage of monthly income (PAYINC)
Regression Analysis
Equation 3
Dep Variable:
PAYINC
SOURCE
MODEL
ERROR
C TOTAL
DF
9
26
35
SUM OF
SQUARES
1.22093904
1 .12178613
2.3^272516
MEAN
SQUARE
0.13565989
0.04314562
F VALUE
3-144
PR0B> F
0.0107
ROOT MSE
DEP MEAN
C.V.
0.2077152
0.1421593
146.1144
R-SQUARE
ADJ R-SQ
0.5212
0.3554
Parameter Estimates
PARAMETER
STANDARD T For HQ:
VARIABLE
DF ESTIMATE
ERROR PARAMETER = 0
PROB >
INTERCEP
1 -0.400396
0.25038291 -1.599
0.1219
CHANG
1 0.0209298
0.02074312 1.009
0.3223
Q43HINCM
1 0.0002473776
0.0002936909 0.8'I2
0.4073
MONFREQC
1 0.006316575
0.002306083 2.739
0.0110
SURG
1 0.14229324
0.08582135 1.658
0.1093
SURGANG
1 -0.00898299
0.003389236 -2.650
0.0135
DEFANG
1 * 0.003218624
0.0011526746 2.792
0.0097
PAY1
1 0.002298914
0.00104227 2.206
0.0364
COISELF
1 .00000358463
.00000215219 1.666
0.1078
Q31GMI
1 0.007541569
0.01435454 0.525
0.6038
-------
Table 4.2-11. Definitions of Regression Variables
Q33PAYM Responses to Question 33 with recodes to $0 for Subject 16 and to
$100 for Subjects 62 and 106, in dollars per month to prevent an
increase of four or eight angina episodes per month.
PAYINC Q33PAYM/(Q43HINCM/12): Willingness to pay to prevent an increase
in angina as a percent of monthly household income.
CHANG Change in angina posed to subject, either four or eight episodes
per month.
Q43HINCM Annual household income in $100s, midpoint of range selected for
Question 43.
MONFREQC Current frequency of angina in episodes per month, adjusted from
the 1-9 scale in Question 6 to number of episodes per month.
Subjects who report no angina at present were coded as ,01/month.
SURG If subject has had bypass surgery, SURG ¦= 1. Otherwise, SURG ¦=» 0.
SURGANG SURG-MONFREQC: Current angina frequency for subjects who have had
surgery, 0 for subjects who have not had surgery.
DEFANG Defensive expenditure per angina episode avoided, based on
Questions 20c, 20d, ALT-20b, and ALT-20c.
DEFCOST Total annual defensive expenditures in dollars, based on Questions
20c, 2Oh, 20i, ALT - 20b, and ALT-20g.
PAY1 The first dollar amount the subject was asked in Question 32.
COISELF Annual income lost to subject in dollars due to angina, based on
Questions 21, 21d, 21f, 21g, ALT-21, and ALT-21c, and medical
expenses incurred by the subject in the past year.
Q31GMI Rating given (on 1 to 10 scale) of the concern about increased
risk of MI that the subject would feel if angina became more
frequent.
-------
Table 4.2-12. Summary of means and variances of variables used in the regression analyses
Variable
N.
Mean
Standard
Deviation
Mi ni mum
Value
Max.i mum
Value
Std Error
of Mean
Q33PAYM
42
210.0000
351 .2087
0.0000
2000.0000
54.1927
PAYINC
40
0.1637
0.2698
0.0000
1 .2000
0.0427
CHANG
50
5.8400
2.0138
4.0000
8.0000
0.2848
Q43HINCM
47
220.2128
152.2154
25.0000
650.0000
22 .2029
MONFREQC
50
15.4414
24 .8640
0.0100
90.0000
3.5163
SURG
50
0.4600
0.5035
0.0000
1 .0000
0.0712
SURGANG
50
6 .6406
14 .2633
0.0000
60.0000
2.0171
DEFANG
45
13-5157
30.2717
0.0000
140.0000
4 .5126
DEFCOST
50
903.5800
2523.4981
0.0000
12780.0000
356.8765
PAY1
50
47 .0000
36.1967
5.0000
100.0000
5.1190
COISELF
50
9833 -0
18258.0
0.0
65374 .0
2582.5
Q31 GMT
50
7.120
3.114
1 .0
10.0
0.440
-------
87
per angina episode avoided (DEFANG), or total annual defensive expenditures
(DEFCOST) as the independent variables. The adjusted R-squared statistics
indicate that about 40 percent of the variation in Q33PAYM is explained by the
independent variables in each of these regressions. This is reasonably good
for a small sample of cross - sectional information (the best adjusted R-squared
obtained by Rowe and Chestnut (1986) in a similar analysis was .25). Some
alternative specifications that were rejected in favor of these two regression
models are discussed below.
One additional regression is reported in Table 4.2-10c. The
dependent variable is PAYINC, the willingness to pay as a percent of monthly
income. This dependent variable was defined because several of the subjects
said that they would pay as much as they could afford to prevent any
additional angina. Therefore, it seemed that their responses might be
appropriately characterized in relation to their incomes. The explanatory
power of the independent variables is, in general, very similar for the PAYINC
regression.
The regression results are discussed below in terms of the effects of the
independent variables on the willingness to pay measures.
Change in Angina Episodes (CHANG)
One important result of the regression analyses, with implications for
future instrument design, is that the CHANG coefficient is positive, as
expected, but is not statistically significant (Table 4.2-10a-c). This is
consistent with the finding that the means of Q33PAYM for four and eight
episodes are not significantly different, suggesting that subjects did not
find four and eight episodes per month sufficiently distinct.
-------
88
Two alternative measures of change in angina frequency were considered.
One possibility considered whether it was the change relative to the current
level that was important, but variables defined as 1) percentage change from
current angina frequency, and 2) as the ratio of current angina frequency to
proposed new level, were also insignificant relative to Q33PAYM. Another
possibility considered in the analyses was a constant elasticity of WTP with
respect to changes in angina frequency. This would result in a declining
value per additional episode prevented, so that a constant total WTP would be
observed and WTP would appear to be unrelated to the number of episodes. If
this were the case, Q33PAYM/CKANG could be expected to be negatively related
to CHANG. This relationship was, however, found to be insignificant.
These results suggest that asking some subjects about four episodes and
some about eight episodes per month was not sufficient to determine how WTP
could be expected to change as a function of the size of the change in
angina. This may be due to four and eight episodes being quite similar
relative to the current range in angina frequency among the subjects: 0 to 90
or more episodes per month. A recommendation for subsequent instrument design
is that each subject be asked about more than one size change, and/or that the
change in angina posed to the subject be treated as a percentage change from
current frequency or tied in some other way to the current level.
Income (Q43HINCM)
Annual household income was found to be positively related to Q33PAYM (p
- .005 in Equation 1 and p - .011 in Equation 2). This is a stronger
relationship than is found in similar WTP estimates and may reflect the
feeling expressed by many of the subjects that they would pay whatever they
-------
69
could afford to prevent additional angina episodes. The implied income
elasticity (the percent change in WTP for a one percent change in income) at
the variable means is 1.3 for Equation 1 and 1.1 for Equation 2.
The results in Table 4.2-10c indicate that income is not related to
PAYINC. This means that subjects with higher household incomes were not
giving WTP responses that reflected a higher percentage of income, as might
have been expected.
Current Angir.a Frequency and Disease History
It was expected that heart condition at the time of interview and medical
history would influence WTP. Four variables were used to describe heart
health. MONFREQC is the average number of angina episodes the subjects
reported as currently experiencing each month. Seven of the 50 subjects
reported having no angina at present, although they had previously had angina
attacks. For these subjects MONFREQC was given a value of .01. It was
expected that MONFREQC would be insufficient to fully characterize the
subject's experience with heart problems because it does not take into account
how ill the subject might have been previously. Therefore, a variable for
whether the subject had had bypass surgery (SURG), an interaction term of
angina and surgery (SURCANG - MONFREQC * SURG), and the number of heart
attacks the person had had (NUMMI) were also used. NUMMI was dropped because
the estimated coefficient was insignificant in all specifications.
The estimated coefficient for MONFREQC was positive, as expected, and was
statistically significant (p < .10) in Equations 1 and 3. It was expected
that subjects who had had surgery might be more concerned about preventing an
increase in angina. The coefficient for SURG was positive and significant (p
< .10) in most of the specifications.
-------
90
The coefficient for SURGANG was negative and significant (p < .05) in all
the specifications. The expected sign for SURGANG was negative because the
difference between subjects who had and had not had surgery was expected to be
greatest for those with the lower levels of current angina frequency. Thus, a
subject who had surgery and was now experiencing low current angina would be
expected to respond to the WTP question more like a person who was currently
experiencing more frequent angina. Moreover, they have just paid a
significant amount (if not in money then in personal energy) related to having
surgery to reduce angina. However, a person who had surgery but now had many
angina episodes would have a larger decrease in WTP relative to others,
perhaps because of an attitude that the angina could not be made better. An
alternative approach might use levels of angina experienced previous to
treatment, surgery, or lifestyle change. This information was not obtained,
but should be considered in future instrument design.
To show the combined effects of the coefficients for MONFREQC, SURG and
SURGANG, derivatives were calculated for Q33PAYM and PAYINC with respect to
MONFREQC and SURG for Equations 1 and 3. These are shown in Table 4.2-13.
For subjects who had not had bypass surgery, the derivative of Q33PAYM with
respect to MONFREQC was 5.9. This means that for subjects who had not had
bypass surgery, every additional episode per month in terms of current angina
frequency was associated with a $5.90 increase in Q33PAYM. For subjects who
had surgery, the derivative was -6.3. That this is negative means a subject
who had surgery and low angina would have been willing to pay more to prevent
an increase in angina than a subject who had surgery and high angina
frequency. This latter group might be more inclined to feel that a change of
four or eight episodes was not significant, and that the increase is
inevitable.
-------
Table 4.2-13. Derivatives of WTP with respect to MONFREQC and SURG
MONFREQC
Eauation 1
6M0NFREQC ' 5'9 ' 12'2 * SURG
F°r SURG * 0: InmATqc " 5'9
For SURG - 1: 5Q33PAYM
6M0NFREQC
Equation 3
fiHONFREQC " -0063 " -0090 * SURG
For SUEG " °: 6MONFREQC " '0063
, 5PAYINC
For SURG = 1: rw^tT_„• -.0033
5M0NFREQC
SURG
Equation 1
5SURGAYM = 246•5 _ 12•2 * MONFREQC
Shifts from positive to negative at MONFREQC = 20
Equation 3
5PAYINC
5 SURG
- .14 - .0090 * MONFREQC
Shifts from positive to negative at MONFREQC - 16
-------
91
The derivatives of the WTP measures with respect to SURG are positive
over the lower range of angina frequencies, indicating that for these subjects
WTP was higher if the individual had had bypass surgery. At high frequencies
of angina (20 per month in Equation 1 and 16 per month in Equation 3), this
derivative becomes negative, indicating that WTP was lower for subjects who
had had bypass surgery.
These findings generally confirm the expectation that subjects who have
more severe heart conditions are willing to pay more to prevent that condition
from becoming worse, but they also illustrate the complexity involved in
characterizing an individual's condition. The findings are also consistent
with the comments offered by some subjects that a change in angina of four or
eight episodes per month would not have been that important to them, and that
it was their overall condition that concerned them. It appears this kind of
response is more likely to be obtained from subjects who have had surgery and
still experience a high frequency of angina; in other words, subjects who, by
these measures have the most severe conditions.
Defensive Expenditures (DEFANG AND DEFCOST)
Estimates of defensive expenditures incurred by each subject were
positively and significantly (p < .01) related to WTP in each of the
specifications. In Equation 1, the coefficient for DEFANG was about 6,
indicating that for every dollar increase in the amount the subject was
currently spending to prevent an additional angina episode (DEFANG), WTP to
prevent four or eight additional episodes increased by $6.00. Since the
average number (across all subjects) of additional episodes hypothesized was
5.8, the DEFANG coefficient implies nearly a one-to-one relationship between
-------
92
what the subject: was currently spending to prevent an angina episode and what
he said he would be willing to spend to prevent an additional episode. This
is strong support for the hypothesis that the subjects were giving responses
to Question 33 that were consistent with their circumstances.
The coefficient for DEFCOST was also positive and significant. DEFCOST
was the total annual defensive expenditure incurred regardless of the number
of episodes reduced. This coefficient indicated that subjects who were
spending more were willing to pay more to prevent additional episodes. One
possible factor that may contribute to these findings is that subjects who
said they were incurring expenses to prevent angina may have been more willing
to consider the idea presented in Question 33 (that a payment might be related
to angina frequency) and might therefore have given higher dollar responses.
Income Lost and Out-of-Pocket Medical Expenses Due to Angina
The coefficient for COISELF was not significant in the Q33PAYM equations,
but was positive and marginally significant (p = .11) in the PAYINC
equations. This suggests that subjects with more lost income and out-of-
pocket medical expenses due to angina were willing to pay a higher percentage
of their current monthly incomes to prevent an increase in angina.
Survey Instrument Influences
It was hypothesized that the dollar amounts the subjects were asked in
the close-ended willingness-to-pay Question 32 might influence their responses
to the open-ended Question 33. This was supported by the finding of a
significant (p < .05) coefficient for the first dollar amount asked of the
-------
93
subject (PAY1) in every specification. The size of the coefficient in the
Q33PAYM equations was about 4, indicating that for every dollar increase in
the first amount asked in Question 32, the response to Question 33 increased
by about $4. This is evidence of a strong starting point anchoring bias.
Other specifications of the effects of Question 32 were also tested. The
third amount asked and the difference between the first and second amounts
were also positively related to responses to Question 33, but the statistical
significance was not quite as strong as for PAY1. These measures were all
correlated to some extent and may therefore be reflected in the PAY1
coefficient. In other words, a higher value for PAY1 means that there was
often a larger increment between the first and second amounts in addition to
the first amount being higher.
The order of the questions concerning one angina episode (Question 30,
which was moved to follow Question 33 part way through the interviews) was not
found to be significantly related to the non-infinite responses to Question
33.
The finding of a strong starting point bias from Question 32 poses a
problem for future instrument design. Preliminary interviews suggested that
the subjects would have a hard time answering an open-ended WTP question due
to difficulty with the concept of trading dollars for health and to a lack of
experience with deciding how much they would be willing to pay. Therefore,
Question 32 was added to obtain some information about WTP in case Question 33
received too many refusals and to get the subjects thinking about how much it
would be worth to prevent additional angina. This seemed to be helpful in
preparing them to answer Question 33, but it apparently also influenced their
answers. Future efforts may need to continue to use some preliminary
questions before subjects will be ready to answer an open-ended WTP question,
-------
94
but potential effects of these preliminary questions should be thoroughly
considered in the analysis. For example, yea saying to the first dollar
amount in closed-ended referendum bidding questions may occur, resulting in a
bias similar to the starting bid bias in an interactive bidding approach.
Some evidence of this behavior was found in this application, but the sample
sizes were too small to address the concern.
Concern About Heart Attacks
The rating given by the subject regarding concern about heart attacks or
bypass surgery if angina were to increase, Q31GMI, also was included in the
regression. The estimated coefficient was consistently positive, but not
statistically significant.
This issue should be further explored in future research efforts. It was
apparent from responses to several questions that for many of the subjects
concern about temporary or permanent heart damage was associated with angina
symptoms. A variable such as Q31GMI might be statistically significant in a
larger sample. In response to Question 37, 18 out of the 50 subjects said
they thought some heart damage was associated with angina pain. Vhen subjects
were asked about help hired to reduce risks of angina, 19 out of 20 subjects
responding to this question said they thought their risk of heart attack would
be higher if they did this work themselves. This all suggests that for some
subjects, concern about heart attacks may be reflected in responses to WTP for
changes in angina frequency. To the extent that perceived changes in welfare
are to be considered, this inclusion may be valid whether or not it is
medically correct.
-------
95
4.3 Averting Behaviors
In Questions 20 and ALT-20, subjects were asked about non-medical
expenditures they had made in the past year to reduce or prevent potential
angina symptoms. The most common expenditures were for hiring help with yard
work and car maintenance that would otherwise have been done by the subjects
themselves. Goods purchased to prevent additional angina included lawn
mowers, household appliances and new automobiles (to ensure reliable
transportation and reduce maintenance work).
The 21 subjects with these expenditures were asked to estimate their
annual costs for the help they most often hired. The results are summarized
in Figure 4.3-1. Including answers to Questions 20c and ALT-20b only, the
average annual expense for this item was $603 (Figure 4.3-1). Other defensive
expenditures in Questions 20h and 20i were not included. Twenty of the
subjects with these expenses said that they believed they would have
experienced more frequent angina if they had not incurred this expense, and
sixteen of them were able to give an estimate of the additional episodes they
might have had. The average estimate was 31 additional episodes in a year.
With this estimate it was possible to calculate an estimate of the expenditure
per angina episode avoided for these 16 subjects. The average expenditure per
angina episode was $38, with a minimum of $3.50 and a maximum of $140.
It is interesting to note that the average willingness to pay given in
response to Question 33 for this group was $28 per angina episode avoided
(with two of the 16 subjects giving very high values). That these subjects
were actually spending a similar amount per episode avoided supports the
credibility of the WTP estimates. This comparison is not exact, however,
because these two dollar measures do not necessarily reflect exactly the same
-------
Figure 4.3-1
Average Averting Expenditures
(Single Expense Listings)
No
Yes
Yes
No
$603/yr
More frequent angina without
defensive expenditures?
Estimate additional
number of angina
episodes without expenditures?
Average of 31
additional episodes at
$38/episode
Note: Including multiple expense listings for the group of 21, average
averting expenditures were $2,151 per year (n - 21).
-------
thing. Even chough we asked subjects to list services that they would not
purchase if they did not have angina, there may be some joint benefit to the
subject from the purchase (for example, angina is avoided and time is freed
from mowing the lawn). Also, the subject's ability to reduce risks of angina
is probably not reflected by a smooth or continuous production function. The
individual may be forced to choose between purchasing too little or too much
relative to the actual utility optimizing amount.
Fourteen of the 21 subjects with some expenses gave more than one
example. With information provided by the subjects, and estimates of typical
costs of services, an estimate of total annual defensive expenditures for each
of the fourteen subjects was developed. Answers to Questions 20c, 20h, 20i,
ALT-20b and ALT-20g were used along with the following estimates of costs:
For the 21 subjects with some defensive expenditures, the average annual
total expense was estimated to be $2,151, ranging from $84 to $12,780.
Given the existence of significant defensive activity on the part of the
angina subjects, it is of interest to explore the decision to mitigate or
avert the potential adverse health effects. Therefore, the following will
identify characteristics that determine whether an individual will undertake
defensive behavior, examine the factors that may explain the actual level of
defensive spending, and finally examine the relationship between defensive
activity and exposure to CO.
Activity Category
Cost per Event
meal preparation
indoor cleaning
outdoor cleaning
indoor repairs
outdoor repairs
appliance repair
car maintenance
$15
30
25
75
150
40
40
15
meals at restaurants
-------
97
Factors Influencing Defensive Spending
Defensive behavior was indicated by a positive response to survey
questions about hiring help for yard work, home, or auto maintenance, or for
purchasing special equipment. These purchases would reduce physical exertion
which has been linked to the aggravation of angina. It was hypothesized that
the decision to undertake a defensive expenditure would depend on several
factors, including ability to pay, attitude towards risk, previous health
habits and awareness, severity of angina, age, and household size. The latter
could involve two opposite effects. First, it might be expected that in
bigger households, there would be less need to hire outside help since
household members can share the responsibilities for yard and repair work.
Conversely, in larger households there may be more direct and implicit
pressure for the individual with a heart condition to take better care of
himself. Also, if the household includes younger children, there may be more
demands on the subject.
This hypothesis was explored using both a linear probability model in
ordinary least squares regression and a logistic model. A. binary variable was
created which indicated whether a subject identified himself as having had
defensive expenses. With the linear probability model, a forward stepwise
procedure was used to select from among a large number of candidate
explanatory variables. Variables selected at the 0.500 significance level of
entry were used to specify a logistic model. Since the logistic model
generated results similar to the linear probability model, only the linear
probability model is described in full in this text. The results of the least
squares regression are displayed in Table 4.3-1.
-------
Table 4.3-1. Regression analysis predicting the probability of defensive
action
B S.E . p value
Intercept -.25 (.027) .03
Income -.062 (.027) .03
Maximum Severity
of Angina .143 (.043) .002
Doctor Visits
for Angina .013 (.017) .47
Household Size .064 (.051) .22
Age .015 (.008) .08
Pack Years
(thousand) -.013 (.005) .01
Near Smoker
(Q S17) - .166 ( .122) .18
Belief
(Q 37) -.116 (.078) .15
R2 = .51
N - 41
Note: Income is a categorical variable (see Question 21g). Maximum severity
is the highest severity recorded in response to inquiry about seasonal
differences in severity (Question 7).
-------
93
The regression model, which explained 51 percent of the variability of
the decision to undertake defensive action, suggests that this decision is
related to factors that reflect current health status (greater angina
severity, angina-related doctor visits), health concern and awareness (belief
that angina attacks will harm the heart, rarely near smokers), past health
habits (fewer pack years of smoking), demographics (age and household size) ,
and lower household income. All of the coefficients were plausibly signed
except income.
The regression results indicated that for the sample of 41 subjects for
which the data were complete, the probability of a defensive action was
positively associated with greater severity of angina attacks during the
previous year, age of the subject, greater number of angina-related doctor
visits, and larger household size. Of the positive associations, only the
variable representing maximum severity was statistically significant (p =
.002). However, age, one of the positive terms related to severity of disease
and health concern, approached statistical significance (p = .08). The
regression indicates that for a 10-year increase in age, the probability of a
defensive action increases 15 percent.
A higher probability of defensive action was inversely associated with
pack years of cigarette smoking, frequency with which subjects were around
smokers, household income, and greater belief that the heart is harmed by
angina episodes. Of these variables with negative associations, pack years (p
= .01) and income (p = .03) were statistically significant. The inverse
association of pack years and defensive action suggests that individuals who
exhibit avertive behavior have smoked less over their lifetime and demonstrate
a greater aversion to risk.
-------
99
The inverse association of income and defensive action was an unexpected
result since it indicated that those with higher incomes were less likely to
have defensive actions. This association may be partly explained by the
slight correlation (r = .29; p - .12) between income and bypass surgery (thus
mitigating the need for further defensive actions); by the current health
status of those who had a higher income and who were therefore more likely to
be healthier and employed; or by the phrasing of the defensive expenditure
question. Subjects with higher incomes are more likely to hire help with
yardwork anyway and may therefore be less likely to attribute this expenditure
to concern about angina.
Next, the factors that determined the amount of defensive expenditures
were analyzed for the group of subjects reporting such expenditures (n =
21). Theoretically, the demand for defensive expenditures is expected to be
related to income, the price of the potential purchase, the number of angina
episodes that can be reduced by the purchase, the severity of the current
angina condition, risk perception, and demographic factors such as age and
household size. As a pilot analysis with a small sample, an ordinary least
squares stepwise regression procedure was used to determine how these
variables would affect expenditures (Table 4.3-2). Because of the small
sample size, the number of independent variables was limited to four. Both
household income and personal income were tested, while price was assumed
constant through the one-year period. Variables were included to represent
the number of episodes that were perceived to be reduced, heart attack
history, the number of angina-related doctor visits in the last year, the
perception of whether an angina episode added damage to the heart, the
perception of the additional heart attack risk if an individual did not
undertake the defensive action, age, and the number of people in the
-------
Table 4.3-2. Regression analysis predicting the amount of defensive
expenditures
3 S . E. p value
Cons tant
-22947
Household Size
3035
(812)
.003
Age
271
(125)
.05
Angave
35.8
(36.3)
.34
Episaved
0.66
(3.24)
.84
R2 = .40
N - 21
Note: Angave is the average frequency of angina based on Question 6
Episaved is the total number of angina episodes saved by defensive
expenditures.
-------
ICO
household. Unfortunately, since the sample size was so small, these results
only indicate the explanatory variables that were most associated with higher
defensive cost.
The results of the stepwise regression indicate that age and household
size were highly associated with the level of defensive expenditures. Both
were significant statistically, and together explained 40 percent of the
variation in expenditures. The significance of household size may indicate
changes in lifestyles, or that the members of the household, usually family
members, may exert a protective influence on the heart patient. Age may be
related to perceived risk or severity. Neither the "average" level of angina
frequency (average of Question 6 across seasons) nor the number of angina
episodes that would be reduced were statistically associated with
expenditures. Thus, the number of angina episodes currently experienced
demonstrates an insensitivity to the costs associated with defensive
expenditures. This result was reinforced during other regression analyses.
When attempting to explain defensive expenditures per episode reduced, or the
"price of an episode," an F-test was never significant.
Averting Behavior and CO Exposure
Since 18 of the 50 subjects had participated in earlier exposure
monitoring research, we next examined the relationship between averting
behavior and CO exposure. The level of subjects' exposure to CO was examined
using the arithmetic average of personal exposure monitor readings over a 2-5
day monitoring period (see Section 4.4). The small sample size limits the
inferences that can be made about these results.
-------
101
We expected that the actual exposure would depend on current health
status, attitude about the harmfulness of pollution, expressed desire to
reduce pollution exposure, attitudes towards risk, voluntary contact with CO
sources (e.g., amount of driving, proximity to gasoline-powered engines on the
job or at home), smoking status, socioeconomic factors, and degree to which
other defensive action was undertaken. Several variables were also included
that would represent indoor exposures to CO since current research indicates
that it is an important determinant of total CO exposure. Thus, variables
indicating the use of a kitchen exhaust fan or opening of windows for
ventilation and home insulation practices, were included among the candidate
variables for selection. Again, an ordinary least squares stepwise regression
procedure was used to observe the priority of entry into the model of the
explanatory variables. The first three variables selected into the model
(Table 4.3-3) were 1) whether the individual felt angina pain when walking at
an ordinary pace on level ground; 2) whether the individual indicated that air
pollution aggravated their angina; and 3) whether the individual was currently
smoking.
Since personal tobacco use is a significant source of CO, the inclusion
of smoking status was a reassuring result. Of particular interest, however,
was the selection into the model of two variables which indicate possible
averting behavior. If the angina subject gets an attack without too much
strain, such as level walking, it suggests that he probably would do less
walking and generally be outside less. Thus, exposure may be lessened if
subjects do not walk on city streets or perform exertional activities such as
using a gasoline-powered lawn mower. Conversely, increased reliance upon the
automobile for transportation could increase CO exposure. The implications
for exposure are therefore uncertain. The third variable, indicating that the
-------
Table 4.3-3. Regression analysis predicting average carbon monoxide exposure
S. E. p value
Intercept
CM
r-
VTLKLEV3
-2.86
0.79
.003
SMOKED6
3.75
1.60
.03
P0LL18
-1.07
.66
.13
R2 - .69
N = 18
WLKLEV3 = pain from angina when walking on level ground (Yes =1; No = 0)
SM0KE46 = current smoker (Yes =1; No = 0)
P0LL18 = 1 if yes to Question 18; otherwise - 0 - does air pollution bother
your angina
-------
102
subject feels his condition is aggravated by air pollution also may indicate
less time outside and less active behavior. However, due to the small sample
size and modest significance level, these results can only be viewed as
suggestive.
These results, taken together, appear to indicate that behavior aimed at
reducing the risks relating to exposure to CO was consistent with other
choices made about health care and status by the subjects. For example, those
with more severe angina were more likely to engage in defensive actions. They
were more likely to hire household help and purchase equipment to reduce
further risks of angina, and were likely to have reduced exposure to CO.
Those who appeared to have greater concern for health or who were more risk
averse, such as those who believed angina would increase heart attack risk and
those who had smoked less in the past, were also more likely to undertake
defensive behavior. Also of interest was the role household size appeared to
play on health. Subjects from a larger household were more likely to hire
help and purchase defensive equipment, and, among all those who had defensive
expenditures, spent more. Although the analysis is limited by small sample
size, it does suggest that defensive action may be an important aspect of
health care and an important determinant of pollution exposure.
4.4 Community CO Exposures of IHD Subjects
Activity Patterns
In the sample of IHD subjects followed in the UC Irvine study, time spent
in indoor residential microenvironments dominated the time-weighted
classification of daily activities (Figure 4.4-1, Tables 4.4-1 and 4.4-2).
-------
Figure 4.4-1 .
Proportion
nonsmoking
monitors
of time spent in major microenvironmental classes for
IHD subjects while wearing the CO personal exposure
PROPORTION OF TIME SPENT IN VARIOUS MICROENVIRONMENTS
ED Inaoors, home
@ Indoors, public
ss Outdoors
§ In Transit
-------
TABLE 4.4-1. Ranking of time-weighted exposures by activity class. Occupancy
time refers to the time engaged in specific activity.in a 24-hour period
RANK ACTIVITY OODE
1 Night sleep 4 5
2 Television viewing 91
3 Travel related to goods and services 39
4 Meals, snacks at home 43
5 Personal hygiene 40
6 Monitor attachment 38
7 Relaxing, thinking, doing nothing 98
8 Taking a walk 82
9 Resting 4 7
10 Reading books 93
11 Travel related to social activities 79
12 Preparing (ood 10
13 Travel to and from work 09
14 Meals at restaurant 44
15 Marketing 30
16 Reading newspapers 95
17 Other household duties 19
18 Civic participation 62
19 Visiting with friends 75
20 Regular work 00
21 Gardening, animal care 17
22 Waiting for goods or services 36
23 Travel related to personal care 49
24 Active sports 80
25 Travel related to organizational 69
activity
26 Parlies, receptions, picnics 76
27 Shopping for durable household goods 31
28 Social activity at cafe or bar 7 7
29 Personal care 32
30 Medical caro 33
31 Other household upkeep and ropairs 16
32 Travel related to study or school 59
33 Work (for pay) at homo 01
34 Repair services 35
35 Travel related to active leisure 89
TIME-WEIGHTED GEOMETRIC MEAN GEOMETRIC MEAN
CO EXPOSURE OCCUPANCY TIME CO CONCENTRATION
(ppm-min) (mm) (ppm)
825.6 471 0 1.8
245.4 91.5 2.7
244.1 39.7 6.1
130.4 47.5 2.7
91.7 38 4 2.4
81.5 27.8 2.9
80.7 29 5 2.7
29 0 105 2.8
26 5 8 6 3.1
21 7 7.3 3.0
21 1 34 6.2
20.1 7.3 2.8
17.4 2.9 6.0
16 0 3.9 4.1
15 3 3 3 4.7
14.3 4.7 3.0
14.2 4 4 3.2
14.0 1.2 122
13 2 4.3 3.1
13 1 4.5 2.9
13 0 36 3.7
13 0 2.0 6 4
11.2 26 4.4
11.0 3.6 3.1
108 1.8 5.8
10.2 1.5 6.8
9.8 2.7 3 6
93 1.1 88
8.5 1.1 7.5
0 4 2.5 3.3
80 24 33
7.9 1.1 7.4
7.8 1.0 4 4
7 5 1.2 6.2
7 5 1 7 4.4
-------
TABLE 4.4-1 Con't.
RANK ACTIVITY
OODE
36 Clothes care 15
37 Conversations 96
38 Travel with child 29
39 Outdoor chores 13
40 Meal cleanup, doing dishes 11
41 Obtaining other services 37
42 Religious activities 64
43 Travel related to passive leisure 99
44 Daytime sleep 46
4 5 House cleaning 12
46 Work breaks 08
4 7 Child care 21
48 Other classes or courses 51
49 Waiting, delays at work 04
50 Volunteer activities 63
51 Hobbies 83
52 Reading or writing letters 97
53 Playing records or tapes 92
54 Travel for job 03
55 Government or financial services 34
56 Parlor games 87
57 Meals at work 06
58 Household activities related to heat 18
or water
59 Radio listening 90
60 Religious practice 65
61 Personal medical care 41
62 Making music 86
63 Reading magazines 94
64 Private activity 48
65 Outdoor playing with children 25
66 Other active leisure 88
67 Laundry, ironing of clothing 14
68 Fishing, hiking 81
69 Entertainment events 71
70 Sports events 70
TIME WEIGHTED
CO EXPOSURE
(ppmmin)
GEOMETRIC MEAN
OCCUPANCY TIME
(min)
GEOMETRIC MEAN
CO CONCENTRATION
(ppm)
7.3
7.2
6.9
6.8
6.4
6.3
5 9
5.8
5.8
5.4
5.1
4.9
4.9
4.6
4.3
4.4
4.1
4.1
4.0
3.9
3.8
3.8
3.0
2.9
2 9
2 4
2.1
1.8
1.6
1.5
1.4
1.4
1.3
1.3
1.1
1.1
24
1.2
2 9
13
1.1
12
1.2
1.2
2.1
1.3
1.1
1.2
1.1
16
12
1.3
1.1
1.3
1.7
1.6
1.3
12
1.3
1.2
1.2
1.2
1.3
1.2
1.2
1.1
1.2
1.1
1.1
1.1
6.5
3.0
5.7
2 3
4.9
5.8
4 8
5.0
4.8
2.5
4.0
4.3
4.0
4.3
2.7
3 8
3 2
3.7
3 2
2.2
2.4
2.9
2.5
2.3
2.3
2 0
1.8
1.4
13
1.4
1.3
1.2
1.2
1.2
1.0
-------
TABLE 4.4-2 Ranking of time- weighed exposures by microenvironment
class. Occupancy Lime refers to time spent in location class.
RANK M1CROENVIRONMFNT COOG
1 Bedroom 115
2 Personal Auto 310
3 Living Room 114
4 Kitchen 112
5 Indoors, home, unspecified 110
6 Bathroom 116
7 Hospital (includes monitor attachment) 138
8 Outdoors, around the house1 210
9 Store, post oflice, barbershop 132
10 Dining room area 113
11 Restaurant 131
12 Family room, den 111
13 Truck 311
14 Occupational Health Center Van 317
15 Meeting hall, lodge, clubhouse 147
16 Indoor gymnasium or swimming facility 142
17 Within 10 yards of active roadway 212
18 Work area (assemblyline, shop, warehouse) 122
19 Shopping mall 133
20 Outdoors, service station or motor vehicle 214
repair facility
21 Parking lot or carport (open car building) 213
22 Indoors, service station or other motor 144
vehicle repair facility
23 Indoors at home of friend 146
24 Indoors, unspecified 100
25 Garage or enclosed carport 118
26 Motor home 318
TIME WEIGHTED GEOMETRIC MEAN GEOMETRIC MEAN
CO EXPOSURE OCCUPANCY TIME CO CONCENTRATION
(ppm min) (min) (ppm)
786 8 436 8 1.8
357 2 63 8 5.6
242.0 87 6 2.8
59 7 20.6 2.9
60.9 20.1 3.0
56 7 26 1 2.2
56 5 18.2 3.1
45.7 14.9 3.1
27.9 64 4.4
25 2 8.7 2.9
17.8 4 2 4.3
15 8 5.4 2.9
12.9 1.7 7.7
12 8 1 4 9.3
10 8 29 3.7
10 2 1.2 8.3
9 7 3 2 3.0
9.1 2 7 3.3
89 20 4.4
8.0 13 6.1
7.7 1.5 5.1
7.6 1.1 7.0
7.6 2.4 3.2
7.2 1.2 6.2
6.5 2.4 2.8
61 1.2 5.2
1Yard, patio, outside house, within building areas but not in own unit.
-------
TABLE 4.4-2 Con't.
RANK MICROENVIRON^ENT OCOE
27 Indoors, home, other room 119
28 Bus 312
29 Motorcycle 313
30 Church 135
31 Neighborhood residential streets 211
32 School 136
33 Park, golf course, outdoor recreation area, 215
beach
34 Lunchroom, breakroom 123
35 Office, public place 134
36 Bowling alley 141
37 Outdoor store, lumber yard, nursery 220
38 Walking 314
39 Olfice, work area 121
40 Indoors, public place, unspecified 130
41 Outdoors, walking 230
42 Home laundry room, workshop, utility room 117
43 Jogging or brisk walk for exercise 316
44 Bicycle 315
45 Outdoors, truck yard 231
46 Hotel/motel room 148
4 7 Diesel truck 319
48 Bicycle path 219
49 Outdoors, unspecified 200
50 Dance hall 140
51 Indoors, work, unspecified 120
52 Library 149
TIME-WEIGHTED
CO EXPOSURE
(ppm-min)
GEOMETRIC MiAN
OCCUPANCY TIME
(min)
GEOMETRIC MEAN
CO CONCENTRATION
(ppm)
6 0
5 8
5 4
5 4
5 3
5 1
5 0
5 0
4.6
4 6
4 2
4 2
4.2
3.7
3 4
3.3
2 9
2.9
2.8
2.7
26
1.9
1.4
13
12
1.1
1.0
1.1
1.1
1.6
3 6
13
16
12
1.8
1.1
1.1
1.1
1.6
1.1
1.3
1.4
1.1
1.3
1.2
1.3
12
12
1.0
1.1
1.1
1.0
5.7
5.1
4 9
3 5
2.3
4.1
3 2
4.3
2.6
4.1
4.0
3.7
2 6
3.4
2 6
2.3
2 6
22
2 3
2.0
2.2
1.5
1.3
1.2
1.1
1.0
-------
103
The subjects spent 79 percent of their monitoring day in their residence.
Night sleep and bedroom were the single largest duration activity and
microenvironment location occupied each day. Television viewing and other
passive leisure activities largely took place in the living room or family
room. Resting and relaxing activities were generally associated with the
indoor residential environment. Time in personal auto accounted for most of
the 10 percent of daily time spent in transit microenvironments. Generally,
these values are comparable to those published for the general population
(Chapin, 1974; Robinson, 1977; Ziskind et al. 1982). Daily time devoted to
walking for exercise (10.5 minutes) and active sports (3.5 minutes) is
substantially less than the 90 minutes national average for all age classes
combined (Chapin, 1974).
Time activity patterns have important implications for myocardial oxygen
demand. Several classes of activity are associated with very high myocardial
oxygen demands. These include regular work at a job site or at home; outdoor
chores at home; lifting work at home such as carrying firewood or moving
furniture; exercise and outdoor recreation; sexual activity; and travel such
as bicycling or walking, and driving in stressful situations. However, in the
IHD subpopulation sampled, the occurrence of these strenuous activities was
relatively infrequent, not only in terms of the number of occurrences but also
in terms of the number of subjects choosing to engage in such activities. As
indicated by the low geometric means, sustained intervals of heavy activity
were uncommon across the aggregate. Yet certain subjects who were inclined to
do heavy work did undertake such activity on a regular routine and, at times,
maintained high levels of exertion for periods as long as two hours.
Interviews revealed that though these subjects were prone to exertional
angina, they were able to undertake heavy activity if they paced themselves.
-------
104
These activities included heavy carpentry, auto repair, and cutting
firewood. During the intervals, very high levels of exertion were achieved.
Walking for exercise represents the upper level of daily exertion for the
majority of the IHD subjects studied in this effort (98 separate occurrences
by 25 unique subjects). For most subjects it is a walk at a pace that is just
slightly below their personal threshold of angina. It was not unusual for
angina symptoms to be reported during walking exercise. During separate
graded exercise testing on a treadmill using a modified Naughton protocol, the
majority of the subjects identified a workload of 3-4 METs (i.e., 3-4 times
the resting metabolic rate) as subjectively equivalent to their personal level
of perceived exertion during walking. Thus, a low functional capacity was
characteristic of this IHD group selected for study.
Community CO Exposure
The highest CO exposures occurred during commuting and when near internal
combustion engines. Average personal exposures were elevated during city
street and freeway driving, and while in parking lots and automobile service
stations (Tables 4.4-1 and 4.4-2). In contrast, residential exposures were
generally low, allowing CO absorbed by the body while at other locations to
wash out of the blood during the time spent at home. High short-term
exposures were found in proximity to small gas-powered garden equipment.
Transient peaks as high as 134 ppm were observed with use of a chain saw and
226 ppm with use of a lawn edger. Occupational exposures were highly variable
with elevated exposures associated with warehouses, assembly lines, and
garages. Generally, CO exposures remained below the federal standards of 35
ppm for 1-hour and 9 ppm over 8-hours (Figure 4.4-2).
-------
Figure 4.4-2,
Distribution of minute-by-minute personal CO exposure
measurements for nonsmoking subjects (N=36; 142 person days)
NONSMOKERS CO EXPOSURE <100 PPM
TOTAL MINUTES
45000 t
40000
35000
30000
25000
20000 ¦
15000
10000 ¦
5000 ¦
WtTTHmw nii
10 20
u im n inn itmuuiniuniiiH
-------
Activity data and microenvironmental CO exposures were combined to
estimate the accumulation of CO in the blood. Coburn et al. (1965) have
determined that several physiologic and environmental factors regulate CO
flux: inhaled CO concentration, endogenous CO production, barometric
pressure, diffusing capacity for CO, alveolar ventilation, blood volume, mean
capillary oxygen tension, and oxyhemoglobin concentration. Duration of
occupancy of microenvironments will determine uptake and washout, and the
degree to which blood carboxyhemoglobin attains steady state with the
setting's CO concentration. Increased levels of physical activity within a
microenvironment will speed the rate at which uptake or elimination to steady
state COHb is achieved. Strenuous activity such as exercise or yardwork is
associated with increased minute alevolar ventilation and increased diffusing
capacity for CO. An increase in either or both of these physiologic factors
increases CO flux. Strenuous levels of activity were relatively infrequent
across the IHD sample group. In general, the subjects' highest level of
exertion would still be considered moderately light for individuals free of
coronary artery disease. For these reasons, the requirements of uptake and
elimination modeling become simplified and a linear model can be applied (Ott
and Mage, 1978). This model assumes light physical activity and does not
incorporate the input of individual physiologic parameters as the Coburn
equation does. Preliminary analyses indicate that 56 percent of the IHD
subjects experienced COHb levels in excess of 2.5 percent during the 142
person days of monitoring, corresponding to 1.8 percent of the total
monitoring time (Figure 4.4-3).
Federal standards for ambient air are designed to prevent accumulation of
CO in the body to levels where health effects have been demonstrated. The
standards are sec at 9 ppm for 8 hours and 35 ppm for one hour. Individuals
-------
Figure 4.4-3.
Distribution of minute-by-minute COHb estimates as predicted
for nonsmoking IHD subjects bv PEM measurements using the linear
model of Ott and Mage (1978) "(N=36; 142 person days)
NONSMOKERS MODELED COHb
30000 t
25000
20000 ¦¦
TOTAL MINUTES 15000 ¦¦
1 0000
5000 ¦¦
8 9 10
COHb (%
ENLARGEMENT OF COHb DISTRIBUTION > 2.0%
2000 r
1800 ¦
1 600 ¦
1400 ¦
1200
TOTAL MINUTES 1000 |
800 •
600
400
200
0
k
1
mm
ttmirm111
4 5
em+
6
COHb
10
-------
106
exposed to CO at these concentrations and durations would develop
carboxyhemoglobin levels of approximately 1.5 percent, a level below the 2-4
percent carboxyhemoglobin range at which exercise performance is impaired in
people with ischemic heart disease (Anderson et al., 1983). Thus, the
standards are set at levels which are intended to provide a margin of safety.
CO concentrations in microenvironraent locations are poorly correlated
with those measured at nearby outdoor sites (Ott et al., in press; Hartwell et
al., 1984). Personal exposures experienced in settings such as commuting on
freeways or walking on a roadside path may be several-fold higher than CO
concentrations measured at the nearest ambient monitoring site. Further, it
is reasonable to speculate that depending upon the conditions of the exposure
(e.g., concentration, duration, breathing rate), the resulting
carboxyhemoglobin concentrations may be elevated to levels higher than those
estimated from outdoor fixed-site monitors. Further research is needed to
address the relationship between ambient measurements and carboxyhemoglobin
levels in the population. Alternative placements for monitors may give a more
reliable measure of the actual personal exposures and the protection afforded
to IHD subjects by the present federal standards.
4.5 Conclusions and Recommendations
4.5.1 Introduction
There are many components of an analytical evaluation of alternative
carbon monoxide standards. Section 2 presented one theoretical framework, an
economic model of individual behavior, which can, when aggregated over
individuals, be used to evaluate different carbon monoxide standards. In this
-------
107
framework, a person's utility is a function of health and goods or services
consumed. The level of a person's health is modeled as a function of
defensive expenditures D, pollution exposure P, and biological, social, and
economic characteristics of the person (Zl). It is assumed that a person
maximizes utility, which is constrained by available income through an income
constraint. Income may be deflated by previous expenses due to medical
expenditures or by foregone wages due to loss of work.
In this project, we have gathered four kinds of information on the
adverse effects of ischemic heart disease, including time spent sick
(resulting in lost days of work or partial or full loss of employment) and
medical expenditures made in response to illness (Section 4.1), rankings of
the relative bothersomeness of the effects of angina/heart disease (Section
4.2.1), willingness to pay to avoid additional angina (Section 4.2.5), and
defensive expenditures and activities (Section 4.3). We also have done a
secondary analysis of data collected on personal CO exposure in the urban
setting (Section 4.4).
We have thus developed a feasible framework for eliciting many of the
components required for the evaluation of the impacts of carbon monoxide
exposure on ischemic heart disease patients who experience angina pain.
Additional components that still must be determined through other research
efforts are
1. defining the relationship between carbon monoxide standards and
resulting personal exposures to carbon monoxide in microenvironments;
2. quantifying the number of additional angina episodes per month that
would occur due to changes in personal exposures to carbon monoxide,
(the type of information that is needed will be of the form, "if the
personal CO exposure is changed by an increment so that the average
-------
10S
level of carboxyhemoglobin (COHb) in the blood goes from 2 percent to
1 percent, and peak levels go from 3.5 percent to 2.5 percent, there
would be x fewer angina episodes per month for people with moderately
severe angina.");
3. characterizing the functional relationship between defensive
expenditures (D), pollution exposure (P), and personal characteristics
(Zl) in the health production function.
4.5.2 Summary of Results
Using multiple measures, the results converge on a picture of ischemic
heart disease as a burdensome health state, with substantial medical costs,
losses of opportunities to earn wages, psychological stress, and expenditures
to avoid further adverse health effects.
Cost of Illness
Annual out-of-pocket medical expenditures due to ischemic heart disease
for this sample averaged $256 per person. This included out-of-pocket medical
expenditures for treatment and medication and travel to the physician's
office. It is important to note that this sample was dominated by VA patients
who may have lower out-of-pocket expenses than the average IHD patient. Total
annual medical expenditures due to heart disease incurred by society
(including the VA, private insurers, but not the individual) averaged $4,523
per person. For the 15 employed subjects, the average annual income lost due
to time lost from the regular work schedule because of angina was about
$347. For the 19 subjects working less than they would like due to angina
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109
(including those unable to work at all) the average annual income lost was
about $26-,940. Thus, the total average annual loss due to medical
expenditures and lost income (by the individual or on behalf of the
individual) totalled $14,359 per person across all 50 subjects. Because CO is
believed to aggravate angina symptoms in patients who already have IHD,
analysis was undertaken to estimate the marginal costs of small changes in
angina frequency. The results suggest that although the total costs
associated with IHD are substantial, the marginal cost of small changes in
angina is minimal.
Lifestyle/Emotional/Physical Effects
In general, the subjects reported that the most bothersome effects of a
potential increase in angina would be less ability to do desired activities
(recreation, chores, or work), and pain or discomfort. The next two most
bothersome effects were the patients' concern about worry or inconvenience to
family and friends, and concern about the possibility of having a heart attack
or bypass surgery. The remaining effects, in order of decreasing
bothersomeness were less ability to work at a job (for reasons other than
income), more non-medical expenses (such as paying for services), more medical
treatment expenses, and less ability to earn income.
Willingness to Pay
The mean willingness to pay to avoid angina was $40 per episode among the
42 subjects who responded with a dollar amount. When respondents who gave the
answer "I'd pay anything I have to avoid added angina" were coded to be equal
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110
to the highest amount they had agreed to when asked a close-ended question of
the form "Would you pay $y per month to avoid four (or eight) additional
angina episodes per month?", the lower bound on the willingness to pay for all
49 responding subjects was $42 per month. When those who would pay "anything"
had their answers recoded to a feasibly maximum amount equal to their total
monthly income, the average willingness to pay was $103 per episode.
Expenses Due to Defensive Expenditures
Subjects were asked to itemize expenditures they made for goods or
services to avoid additional angina. Twenty-one of the 50 subjects hired
services (e.g., yard work, plumbing, or car maintenance), yielding an average
annual expense of $2,151, for these subjects. Sixteen of the 21 subjects
estimated the number of added angina episodes they avoided by hiring
services. The mean expenditure per episode for these 16 subjects was $38, and
ranged from $3.50 to $140. This mean may be compared to the average stated
willingness to pay of $28 per angina episode given by the same 16 subjects in
response to Question 33.
Comparison of Alternative Dollar Measures of Changes in Well Being Due to
Changes in Angina
Table 4.5-1 summarizes the dollar welfare estimates obtained from this
study. The cost of illness estimates listed in the first section of the table
are annual costs associated with all aspects of the heart disease. The
figures given are averages for our sample, which should not be interpreted as
representative of all IHD patients because the sample was not randomly
-------
Table 4.5-1. Summary of dollar welfare estimates for ischemic heart disease patients
A. Average annual expenses related to IHD*
Cost of illness expenses:
Medical expenses incurred by patient: $256
(OPSUM2 = Sum of out-of-pocket medical expenses,
less insurance premia. Cost of travel to obtain medical
care included.)
Medical expenses paid by insurance or VA: $4,523
(SOCSUM2 - OPSUM2)
Income Lost $9,581
TWKLOSS = Employer paid sick days' cost and
Lost wages due to angina (SWKLOSS)
Total cost of illness (COISOC) $14,360
Defensive expenditures " 903
Total IHD-related expenses (N = 50) S15.263
B. Alternative estimates of average willingness to pay per angina episode avoided for
small changes in angina frequency
Mean WTP
per episode
1. Finite responses to open-ended $40 (N = 42)
contingent valuation question
2. Defensive expenditure for specified $38 (N=16)
angina reduction
These estimates are averages for our sample, which is not necessarily
representative of all IHD patients. These costs varied considerably from one
individual to another.
This represents total defensive expenditures listed by each subject. For 29
subjects, this was $0. The average for the 21 subjects with some defensive
expenditures was $2,151.
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Ill
selected. In particular, medical insurance coverage may be greater than
average because many of the subjects were completely covered by the Veterans
Administration.
The second section of Table 4.5-1 shows the two alternative willingness
to pay estimates obtained for small changes in angina frequency. We do not
give any cost of illness estimate here because the analysis suggested that
such costs do not vary significantly for small changes in angina frequency.
The cost of illness (COI) approach has historically been the one most
frequently used. Analysis of the COI data obtained for this sample did not
show any significant relationship between costs and angina frequency. This
suggests that the marginal welfare impact (as measured by COI) of marginal
change in angina frequency is minimal. However, other information obtained in
this study suggests that marginal changes in angina frequency do have a
significant welfare impact. The willingness to pay and defensive expenditures
analysis, when adjusted to per angina episode avoided, are generally
comparable and in the range of $25 to $100 per episode. Even though there are
significant concerns in accurately estimating economic value measures for
changes in angina using willingness to pay and defensive expenditure
approaches, their consistency with one another, and with the rankings of
impact categories, suggest they may be more likely to accurately represent the
value of marginal changes in angina than the results of a COI analysis.
Activity Patterns and CO Exposure
Data on activity patterns and CO exposure in urban locations was
collected in an earlier UC Irvine research effort. An analysis of this data
suggested that IHD patients frequently encounter CO in the course of their
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112
daily activities and may develop COHb levels greater than 2.5 percent, a point
where aggravation of angina has been observed in clinical studies.
4.5.3 Recommendations for Further Research
Several recommendations for further research have resulted from this pilot
study. A subsequent larger study, with more funding, should include the
suggested revisions and expansions. The recommendations are divided into the
following three categories: carbon monoxide exposure, health effects
resulting from CO exposure, and valuation of health effects in ischemic heart
disease patients
Carbon Monoxide Exposure
* Conduct further studies to link microenvironmental CO exposure to
exposure at outdoor fixed-site monitors. Investigate the possibility
of selecting alternative placements of monitors for more reliable
measure of actual personal exposures.
Health Effects Resulting from CO Exposure
* Conduct further studies to link actual personal CO exposure and angina
by developing a dose - response curve which may be applied in the
natural exposure environment of the community.
Valuation of Health Effects in Ischemic Heart Disease Patients
* Conduct further contingent valuation studies with modifications
suggested by this study and with a larger and more representative
sample of IHD patients. This work would implement further tests of
-------
the valuation methodology, such as investigating yea saying on
referendum willingness to pay questions.
Conduct longitudinal studies following "healthy" people at risk of
developing IHD (e.g., overweight males aged 35-50 with high blood
pressure). Attitudes, behaviors, and willingness to pay to avoid
symptoms would be monitored over a number of years. Preferences are
expected to change with the onset of symptoms and over the
developmental course of coronary disease.
Extend the framework developed for valuing angina in this project to
consider explicitly the whole complex of health outcomes including
heart attacks and cardiac death.
The present study assumed certain expenditures or behaviors were
motivated by a desire to avoid additional angina. Further time-
activity studies should explore how averting behaviors are chosen by
angina patients, asking subjects to supply concurrent reasoning behind
the choice of activities. People may consciously make tradeoffs
between the costs of accepting more angina and the benefits of
engaging in more activity.
It is important to understand how subjects are framing the valuation
questions. For example, when a subject states his willingness to pay
to avoid one additional angina episode is $50, he may mean that $50 is
the sum total of actual costs incurred by one extra angina episode
(e.g., due to doctor's office visits and medication), plus foregone
wages due to work loss from the one episode, plus defensive
expenditures (e.g., hiring a yard worker for that day), plus extra pay
for pain and suffering. Alternatively, he may mean chat $50 is only
the amount of extra pay for pain and suffering, or that it is his
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114
maximum for any "similar" illness episode. Further, he also may mean
that this is a measure of how much it would be worth to be "cured" of
heart disease totally. The actual interpretation used by the subject
may be discernible by follow-up questions in the survey. Then
subjects could be divided into groups based on the concerns focused
on, and separate analyses could be conducted for the subsample. To
counteract the problem of shifting question framings, contingent
valuation willingness to pay questions could be asked in several
formats to focus the framing on the components which might be included
in a person's response. For example, asking: "If you get one added
angina episode out of four times you mow your own lawn, will you hire
someone to mow your lawn all four times if it costs $100?," will
frame the amount as a defensive expenditure. Different framings would
isolate the other components. In addition, the realism of the context
for payment to avoid added episodes and believable degrees of
incremental changes in number of episodes for each type of subject
should be investigated.
Consider collecting representative prototypical patients and
interviewing them in depth to determine their valuation of added
adverse health effects. A decision analysis procedure in which each
person's multiattribute utility function is assessed, and the
preferences of the group of people are then aggregated, probably would
work well in this setting.
Conduct studies to determine if the willingness to pay to avoid
multiple health endpoints is additively cumulative. For example, a
person with heart and lung disease may be adversely affected by carbon
monoxide exposure in at least two ways: additional angina episodes
-------
and obstructed breathing. A study could assess willingness to pay to
avoid changes in all health endpoints at once and the results could be
contrasted with those when subjects consider one health endpoint at a
time. Then a formal model of whether the added effects have a
diminishing effect on the cumulative willingness to pay could be
constructed.
Obtain provider-verified medical expenses to improve the accuracy of
the medical cost analysis.
A more extensive study also could obtain a larger data base on
employment status and earning. Then an alternative average measure of
workloss impacts could be obtained by using analytic statistical
techniques to examine the effects of the existence and severity of IHD
and angina on employment and earnings. However, a person's perceived
work loss still is needed to evaluate and interpret the willingness to
pay responses.
Assess values for two levels of change in angina episodes both across
subjects (as in the pilot test for U and 8 episodes per month) and for
each subject.
Assess perceived changes in cost of illness which would be associated
with the hypothesized changes in angina incidence (i.e., U or 8
episodes) in the contingent valuation willingness to pay questions.
The pilot testing suggests that analysis of averting expenditures
appears promising. This work can be pursued with more extensive
modeling and data collection on multiple averting activities and on
the resultant impacts on multiple health endpoints.
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116
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HEART DISEASE PATIENTS' AVERTING BEHAVIOR,
COSTS OF ILLNESS, AND WILLINGNESS TO PAY
TO AVOID ANGINA EPISODES
APPENDICES FOR
FINAL REPORT TO
OFFICE OF POLICY ANALYSIS
U.S. ENVIRONMENTAL PROTECTION AGENCY
OCTOBER, 1988
by
Lauraine G. Chestnut^"
Steven D. Colome
L. Robin Keller
William E. Lambert
Bart Ostro"^
Robert D. Rowe
2
Sandra L. Wojciechowski
The information in this document has been funded wholly or in part by the
United States Environmental Protection Agency under Cooperative Agreement No.
CR-812826 to University of California, Irvine. It has been subjected to the
Agency's peer and administrative review and has been approved for publication
as an EPA document. Mention of trade names or commercial products does not
constitute endorsement or recommendation for use. The authors thank Dr. Ann
Fisher of the Office of Policy Analysis and three anonymous reviewers for
helpful comments on a previous draft of this report.
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Appendix
APPENDIX (UCI)
1. Subject Screening Interview Questions
2. Questionnaires
Cover Letter
Subject Version
Interviewer Version
3. Data Codebook
4. Aggregate Results
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Appendix 1
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SUBJECT:
INTERVIEWED BY:
ADDRESS: DATE INTERVIEWED:
PHONE:
Hello, may I speak to Mr. :
My name is and I an calling from the University of Califor
Irvine. In the past, you have helped us with different research projects involving
your heart health and monitoring of air pollution.
We are again preparing for another project and were hoping to be able to interview you
again regarding your recent heart health and any experiences you have had with angina.
The questions I have are just short answer questions and will take about five (5)
minutes of your time.
Is this a convenient time to do the interview or is there another tine that would be
better? (If it is convenient, proceed to question L introduction. If not, set
up a time that you can call back.)
TIME TO CALL BACK:
To help us prepare for the new project, we would like to ask you a few questions regard!
your heart health. You may have answered these in the past for us, but we would
appreciate your answers again.
1. HAVE YOU HAD CHEST PAIN DURING THE PAST 12 MONTHS? (Do not include pain due to a
cold or to an accident or injury.)
Yes (Go to question 3)
No
2. HAVE YOU HAD ANY DISCOMFORT, HEAVINESS OR PRESSURE IN YOUR CHEST DURING THE PAST
12 MONTHS? (Not caused by a cold or by an accident or injury.)
Yes
No (Go to question 8)
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3. HOW OFTEN DO YOU GET THIS FEELING IN YOUR CHEST? (Circle)
1 Almost every day
2 A few times a week
3 About once a week
4 A few times a month
5 About once a month
6 Less than once a month
4. DO YOU GET THIS FEELING IN YOUR CHEST WHEN YOU WALK UPHILL OR HURRY?
Yes
No
5. DO YOU GET THIS FEELING IN YOUR CHEST WHEN YOU WALK AT AN ORDINARY PACE ON
LEVEL GROUND?
Yes
No
6. WHAT DO YOU USUALLY DO WHEN YOU GET THIS FEELING IN YOUR CHEST WHILE WALKING?
Stop for a while
Slow down
Continue at same pace
Take a nitroglycerine
7. WHERE DO YOU USUALLY FEEL THIS PAIN?
Left side of chest
Right side of chest
Middle of chest
Neck or jaw
Left arm
Right arm
8. HAS A DOCTOR EVER SAID THAT YOU HAD ANGINA? (An-JI-na or AN-ji-na)
Yes (Go to question 13)
No (Go to end of questionnaire, Part A)
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9. DURING THE PAST 3 MONTHS, HOW MUCH PAIN HAS YOUR CHEST PAIN OR HEART TROUBLE
CAUSED YOU?
A great deal of pain
Some pain
A little pain
No pain at all
10. DURING THE PAST 3 MONTHS, HOW MUCH HAS YOUR CHEST PAIN OR HEART TROUBLE WORRIED
OR CONCERNED YOU?
A great deal
Somewhat
A little
Not at all
11. DURING THE PAST 3 MONTHS, HOW MUCH OF THE TIME HAS YOUR CHEST PAIN OR HEART
TROUBLE KEPT YOU FROM DOING THE KINDS OF THINGS OTHER PEOPLE YOUR AGE DO?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
12. DURING THE PAST 30 DAYS, HOW MANY DAYS HAS YOUR CHEST PAIN OR HEART TROUBLE KEPT
YOU IN BED ALL DAY OR MOST OF THE DAY? (If none, write in "0".)
days in bed. (Go to end of questionnaire, Part B.)
13. WHEN DID YOU LAST SUFFER CHEST PAIN OR SYMPTOMS THAT YOUR PHYSICIAN CALLED
ANGINA?
number of months ago
14. WHY DID YOUR ANGINA STOP? WAS IT BECAUSE OF:
your prescribed medication
angioplasty
coronary artery bypass surgery
lifestyle changes (changed diet, started exercise program, etc.)
-------
15. WHEN YOU HAD THESE EPISODES OF ANGINA, HOW OFTEN DID THEY OCCUR?
about every day
a few times a week
about once a week
a few times a month
about once a month
less than once a month
16. DID YOU GET THIS FEELING WHEN YOU WALKED UPHILL OR HURRIED?
Yes
No
17. DID YOU GET THIS FEELING IN YOUR CHEST WHEN YOU WALKED AT AN ORDINARY PACE ON
LEVEL GROUND?
Yes
No
18. WHAT DID YOU USUALLY DO WHEN YOU GOT THIS FEELING IN YOUR CHEST WHILE WALKING?
Stop for a while
Slow down
Continue at same pace
Take a nitroglycerine
19. WHERE DID YOU USUALLY FEEL THIS PAIN?
Left side of chest
Right side of chest
Middle of chest
Neck or jaw
Left arm
Right arm
-------
20. WHEN YOU HAD THIS CHEST PAIN OR HEART TROUBLE, HOW MUCH PAIN DID IT CAUSE YOU?
A great deal of pain
Some pain
A little pain
No pain at all
21 WHEN YOU HAD THIS CHEST PAIN OR HEART TROUBLE, HOW MUCH WORRY OR CONCERN DID IT
CAUSE YOU?
A great deal
Somewhat
A little
Not at all
22. WHEN YOU HAD THIS CHEST PAIN OR HEART TROUBLE, HOW MUCH OF THE TIME DID IT KEEP
YOU FROM DOING THE KINDS OF THINGS OTHER PEOPLE YOUR AGE DID?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
(Go to end of questionnaire, Part B)
PART A (If the subject has NOT experienced angina:)
That concludes the questions that we have. I appreciate your time in answering
them. We also want to thank you again for your help to us in the past projects
that we have had and hope the opportunity will come when we might be able to
work with you again.
PART B (If subject has experienced angina:)
That concludes the questions we have for you today and we appreciate your time.
The project that we spoke about at the beginning of this phone call will be
coming up within the next two (2) months. We would like to call you again for
a more lengthy interview, possibly 45 minutes or so, regarding what changes you
have made in your lifestyle due to the angina pain you have had. We will be
asking questions about the types of activities you are involved in and how air
pollution effects what you do. Do you feel you would be able to be involved
in that interview?
If yes: For that interview, do you have a preference of day of the week or time
of day to be contacted?
-------
Preference
Are you currently smoking cigarettes, cigars or a pipe?
No
Yes. How many per week/day?
Cigarettes — Packs per day/week (Convert figure to ppw)
Cigars per day
Pipes, bowls per day
May I also confirm your mailing address? I have (see top of front page,
making any changes needed there - check zip code also):
Again, thank you for your time today and I look forward to talking with you
in the near future.
PARTICIPATED IN: Yes No
24. Mail-in diary
25. CO PEM diary
26. CO/ECG diary
27. Telephone interview
28. Palmes Tubes
29. Kleinman Exposure/Exercise
-------
Appendix 2
-------
UNIVERSITY OF CALIFORNIA, IRVINE
Pf-Vf ry • DAVIS • WVINE • LOS ANCELZS • RIVERS
SAN SIECO • SAN FRANCUCO
sa.vta 3arbah.». • sant\ cf.vz
PROGRAM IN SOCIAL ECOLOGY
IRVINE, CALIFORNIA 92717
August 9, 1986
NO ITEM TO INSERT
Dear
NO ITEM TO INSERT
Several months ago, at the time of your exercise test at UCI, we requested your
help in a one-time phone interview assessing how your heart condition affects your
lifestyle. We thank you for agreeing to participate. We have enclosed a copy of the
questionnaire for you to read before we call you. You may want to write down some of
your answers or make notes to yourself about things you want to tell us. We will be
writing down your answers for you during the course of the interview and therefore you
do not need to worry about returning this questionnaire to us. Your answers will be held
in strict confidence.
We expect it will take 45 minutes to complete the telephone interview. Of course
the interview will go more quickly if you have thought about your answers beforehand.
We will call you during the afternoon or early evening hours. If we should reach you at
an inconvenient time please tell us, and we will be happy to reschedule. The earliest
date at which we will trv to telephone you is
NO ITEM TO INSERT
Again, thank you for your continued interest in this research. We will look forward
to talking with you.
If you should have any questions, please feel free to call me at (714) 856-5545.
Sincerely.
William E. Lambert
Research Associate
WEL:fr
Encls.
-------
SUBJECT VERSION
CORONARY HEART DISEASE STUDY
QUESTIONNAIRE
I. CURRENT ANGINA STATUS
1. Have you ever had angina related pain, discomfort, heaviness, or pressure
in your chest (not caused by a cold or by an accident or injury)?
NO
YES
2. Do you (or did you) get this feeling when you walk uphill or hurry?
NO
YES
3. Do you (or did you) get this feeling when you walk at an ordinary pace on
level ground?
NO
YES
4. Has a doctor ever said that you have angina?
NO
YES
Coronary heart disease patients sometimes have pressure or heaviness in their
chests even if they do not report it as angina pain. In the following
questions, references to angina pain and discomfort are meant to include such
episodes of pressure or heaviness.
5. Do you still have angina pain or discomfort sometimes, or do you no longer
have it?
1 NO LONGER HAVE IT ~
2 STILL HAVE IT SOMETIMES
Interviewer will ask some
additional questions and then
skip to Question 9
-1-
-------
6. For each season, please check the box under the angina frequency level
that best describes how often you usually have angina in that season.
Season Level of Frequency
1
NEVER
OCCURS
2
LESS
THAN
ONCE A
MONTH
3
ABOUT
ONCE A
MONTH
4
ABOUT
TVICE A
MONTH
5
ABOUT
ONCE A
WEEK
6
ABOUT
2 OR 3
TIMES
A VEEK
7
ABOUT
ONCE
A DAY
8
ABOUT
TVICE
A DAY
9
3 TIMES
A DAY
OR MORE
SUMMER
(Jun-Aug)
FALL
(Sep-Nov)
VINTER
(Dec-Feb)
SPRING
(Mar-May)
7. For each season, please check the box under the angina severity
(discomfort) level that best describes hov severe your angina tends to be
in that season.
Season Level of Discomfort (Severity)
1
NONE
2
VERY
MILD
3
MILD
A
MODERATE
5
MODERATELY
SEVERE
6
SEVERE
7
VERY
SEVERE
SUMMER
(Jun-Aug)
FALL
(Sep-Nov)
VINTER
(Dec-Feb)
SPRING
(Mar-May)
8. During the past 12 months, how many days has angina pain or discomfort
kept you resting on the couch or chair or in bed for most of the day?
days
-2-
-------
II. ANGINA EPISODES: PREVENTION AND RESPONSE
Medical Care
9. Do you have medical insurance or participate in any program that pays part
or all of your medical bills?
tfhy not?
9a. Circle all that apply:
1
2
3
L
5
PRIVATE HEDICAL INSURANCE
VA BENEFITS
MEDICARE
HEALTH MAINTENANCE PROGRAH
OTHER (please specify)
9b.
What is the total monthly cost to you of this coverage
(insurance premiums, membership fees)?
9c.
What percentage (or dollar amount) of your medical
expenses for office visits, hospital services, and
prescription medication are covered under this (these)
program(s)?
doctor office
visit
emergency room and
hospital services
(including surgery),
prescription
medication..
10. How far do you drive each way to see the doctor about your heart condition?
miles
-3-
-------
11. Do you go for regular checkups?
]
NO
YES-
11a. Hov often do you go for checkups?
lib. Vhat is the average cost to you of a checkup?
(Do not include any amount paid by insurance.)
' $ ¦ ' : '
12. Hov many times in the past 12 months have you visited the doctor's office
because of angina or other heart problems (in addition to any regular
checkups)?
doctor's office visits
(If more than 0) What vas the cost to you of your last
office visit due to angina or other heart problems?
(Do not include any amount paid by insurance.)
$
13. Please list all the prescription medications you are presently taking for
your heart condition. You may simply give the prescription information
directly from the bottles.
Medication Name Dose
-U-
-------
14. Vhat is the average monthly cost to you of all the medications you take
for your heart problem? (Do not include any amount paid by insurance.)
$
15. Have you been to the emergency room in the past 12 months due to your
angina or other heart problems?
NO
YES 1
15a- Hov manv times?
15b. tfhat va_s the cost to you of your last emergency room
visit? (Do not include any amount paid by insurance.)
16. Have you stayed overnight in a hospital in the last 12 months because of
angina or other heart problems?
NO
YES
Please list (starting vith most recent stay):
Dates Length of Cause/Treatment Cost
Stay to You
_____ days ' ¦ ". " $
: : days : ' ¦¦ $
: days : $
17. In the past 12 months, have you had any other medical treatment or been in
any exercise program (including use of exercise equipment in your home)
for your heart condition?
NO
YES
Please give type of treatment and annual cost to you. (Do
not include any amount paid by insurance.) If it involves
a one-time only purchase such as exercise equipment,
please give the amount spent in the past year:
Treatment
Cost to You in the Past Year
$
$
$
-5-
-------
Lifestyle Changes and Related Expenditures
18. Which of the following things do you think sometimes bring on or
aggravate your angina? (Circle all that apply)
1 COLD TEMPERATURE
2 STRESS OR ANXIETY
3 EXCITEMENT
4 PHYSICAL EXERTION (SUCH AS WALKING FAST OR HEAVY LIFTING)
5 AIR POLLUTION
6 CIGARETTE SMOKE
7 MEALS (PAIN AFTER MEALS OR AFTER CERTAIN FOODS OR BEVERAGES)
8 OTHERS (please describe)
Vhich do you think is the most important factor?
19. what kinds of changes do you make in your activities on days when for any
reason you feel you are more likely to have an angina episode? (Circle
all that apply)
1 MAKE NO CHANGES IN ACTIVITIES
2 AVOID ACTIVE RECREATIONAL ACTIVITIES
3 AVOID PHYSICAL EXERTION SUCH AS HOUSEWORK OR YARDWORK
4 SLEEP OR REST MORE
5 TAKE TIME OFF FROM WORK
6 STAY HOME
7 DO THE SAME ACTIVITIES, BUT AT A SLOWER PACE
8 AVOID EMOTIONAL STRESS
9 AVOID EXPOSURE TO HOT OR COLD WEATHER
10 AVOID EXPOSURE TO AIR POLLUTION
11 AVOID EXPOSURE TO CIGARETTE SMOKE
12 OTHER (please specify)
20. In the past 12 months, have you hired any help for yard vork, home or auto
maintenance, or housework to reduce or prevent angina or other problems
related to your heart condition?
NO "
YES
1
Interviewer will ask some additional
questions and then skip to Question 21.
20a. Please give an example of the type of help you hire most
often. Consider only work that you would prefer to do
yourself rather than have someone else do.
20b. How often do you hire help for this purpose?
times per year
-6-
-------
20c- On average, how much does this cost you?
$ per year
20d. If you did this vork yourself for a year, do you believe
you would probably have more frequent angina?
If you did this vork yourselft how many
additional angina episodes per year do you
think you would get, over vhat you now get?
¦ : ¦. ;:v:-¦¦¦¦¦ additional episodes per year
20e. If you did this vork yourself for a year, do you think, the
severity of your angina episodes after doing this vork
would be worse or be about the same as your current angina
episodes?
1 ABOUT THE SAME
2 VORSE *
Using our 1 to 7 scale, hov severe do you
think your angina episodes after doing this
vork would be?¦;
1 NO DISCOMFORT
2 VERY HILD DISCOMFORT
3 MILD DISCOMFORT
4 MODERATE DISCOMFORT
5 MODERATELY SEVERE DISCOMFORT
6 SEVERE DISCOMFORT
7 VERY SEVERE DISCOMFORT
20f. If you did this vork yourself for a year, do you believe
this might increase your chances of having a heart attack?
If you did this vork for a year, hov much do
you think this would add to your chances of
having a heart attack during the year?
1 ADD A SMALL AMOUNT (ADD LESS THAN 5%) .
2 ADD A MODERATE AMOUNT (ADD'5-10Z)
3 ADD A MODERATELY LARGE AMOUNT (ADD
11-25%)
4 ADD A LARGE AMOUNT (ADD MORE THAN 25%)
5 OTHER (please
explain)
-7-
-------
20g. Do you hire this help for any other reasons, in addition to
possible concern about angina and heart attack risks?
Please explain
20h. Please list any other examples of help you hire due to your
heart condition. Please describe the type of help, for
example help with housework or home maintenance, and
estimate hov many times in the past year you hired this
help. Please do not include any help that you think you
would hire even if you did not have any trouble with your
¦ heart.
Type of Help
Times Hired
in past year
in past year
in past year
in past year
20i. In the past year, have you purchased any special equipment
or made structural changes in your home to reduce physical
exertion that might aggravate your heart problem? Examples
might be an electric garage door opener or the addition of
a ground-floor bedroom.
Please describe each expenditure and give the
cost to you in the past year. Do not include
any expenditures that you think you would have
made even if you did not have any trouble with
your heart.
Type of Expenditure
Cost to You
in Past Year
-8-
-------
Employment
21. Are you employed?
NO -
YES
~
Interviewer will ask. some additional
questions and then skip to Question 22
21a. What are your average total hours per week (all jobs)?
hours per week
Zlb. Vhat kind of work do you do (occupation)?
Job:'l ' ' . :
Job 2
21c. How many days have you missed from work (all jobs) in the
past year due to angina or other illness related to your
heart problem?
days
21d. Do you have paid sick leave?
NO
YES
Please estimate how many days you
aissed from work due. to all types
of illness in the past year that
were not covered by sick leave.
days
Does it cover all of the time you typically
miss frora vcrk due to all types of illness?
NO -
YES
21e. Save you changed jobs in the past 5 years because of
your heart condition?
NO
YES-
Did the job change mean a reduction in
income?
NO
YES
-9-
-------
i I
21f. Are you working fever hours than you would like because of
your heart condition?
NO
YE!
How many hoursper veek would you like to be
working?
hours per week
21g. Please indicate the category that represents how much you
earn annually at your current job(s).
1 LESS THAN $4,999
2 S 5,000 - $9,999
3 $10,000 - $14,999
4 $15,000 - $19,999
5 $20,000 - $24,999
6 $25,000 - $29,999
7 $30,000 - $34,999
8 $35,000 -$39,999
9 $40,000 - $44,999
10 $45,000 - $49,999
11 $50,000 - $59,999
12 $60,000 OR MORE
III. IMPORTANCE OF CHANGES IN ANGINA
22. Please think of your most recent angina episode that you would say was
typical. Vhen did this occur?
23. Vhere were you?
24. Vhat were you doing?
25. How long were you doing this activity?
minutes
26. How long did the pain or discomfort last?
minu tes
-10-
-------
27. Vhat did you do after this typical angina episode began? (Check all that
apply)
1 STOPPED FOR A VHILE AND RESTED. LATER RESUMED THE ACTIVITY.
Hov long did you rest before starting again? mins.
2 STOPPED THE ACTIVITY ALTOGETHER.
3 CONTINUED AT THE SAME PACE.
A SLOVED DOWN BUT DID NOT STOP.
5 TOOK NITROGLYCERIN OR OTHER MEDICATION.
6 OTHER, please describe:
Vhich of these vas the most important means of relief for this particular
episode?
28. Sometimes an angina episode nay cause you some inconvenience, expense, or
other effect on your life. Vhich of the following possible effects of
this angina episode bothered you? (Check, all that apply)
1 MEDICAL TREATMENT EXPENSES.
2 LOST INCOME.
3 NON-MEDICAL EXPENSES (SUCH AS PAYING FOR SERVICES).
4 PAIN AND DISCOMFORT.
5 LESS ABILITY TO VORX AT A JOB (FOR REASONS OTHER THAN INCOME).
5 LESS ABILITY TO DO DESIRED ACTIVITIES (RECREATION, CHORES, ETC.).
7 CONCERN TO YOU ABOUT POTENTIAL HEART ATTACK OR 3YPASS SURGERY.
8 CONCERN TO YOU ABOUT VORRY OR INCONVENIENCE TO FAMILY AND FRIENDS
DUE TO YOUR HEALTH.
9 OTHER, please explain
Vhich vas mcsc bothersome Co you?
29. If there vas any actual monetary cost Co you due to this episode, can you
estimate hov auch it vas? S
The interviewer will now ask a few questions about ocher angina episodes you
have had. Before the interviewer calls, you may wish to think about the worst
angina episode you have had and about the mildest episodes you have had.
-------
31. This question is about hov you think you vould be affected if your heart
condition were to become vorse, causing you to have angina pain or
discomfort more often than you do nov. Ve are interested in finding out
hov much the different effects of such a change in your condition vould
bother you, once you had done vhat you could to minimize the effects.
Listed belov are some effects on your life that might occur if you vere to
have angina more often. For the effect that vould be most bothersome to
you, circle the number 10. For the effect that vould be least bothersome
to you, circle the number 1. For the remaining effects on the list,
please circle the number that best describes hov bothersome it vould be
relative to these extremes. You may circle the same number for more than
one effect if they vould be equally bothersome to you.
Effects you may experience if
your angina vorsened
Relative bothersomeness
of the effect
Leas t
Bothersome
Most
Bothersome
a. More medical treatment
expenses.
123456789 10
b. Less ability to earn income. 123456789 10
c. More non-medical expenses 123456789 10
(such as paying for services).
d. More pain or discomfort. 123456789 10
e. Less ability to vork at a job 123456789 10
(for reasons other than income).
f. Less ability to do desired 123456789 10
activities (recreation, chores,
etc.).
g. More concern to you about 123456789 10
potential heart attack or
bypass surgery.
h. More concern to you about vorry 123456789 10
or inconvenience to family and
friends due to your health.
-12-
-------
32. Suppose your heart condition vere to become vorse so that with your
current medical treatment and lifestyle your angina episodes would
occur more often. Suppose also that a new medical treatment vere
available that could prevent the additional angina without causing
undesirable side effects or requiring lifestyle changes.
If the treatment would prevent additional angina episodes per
month and if you had to pay the entire cost yourself, would you take
the treatment if it cost $ each month?
NO
YES 1
Would you take the treatment if it cost $
each month? ¦
NO
Vould you take the treatment if it cost $
NO
YES
each month?
33. What is the most that you would pay for this treatment if it would
prevent additional angina episodes per month?
S per month
IV. HEART DISEASE HISTORY
34. Has a doctor ever said you had a heart attack?
NO
YES ~
Please list dates starting with most recent (month and
year is sufficient):
-13-
-------
35. Has a doctor ever recommended you have coronary artery bypass surgery?
NO
YES
Has the doctor said vhy not
Please list dates (starting
vith most recent)r
Did you have the surgery?
YES
36. Have you ever had angioplasty to improve the blood flov to your heart
tissue? (Angioplasty involves catheterization with a balloon catheter that
expands narroved coronary arteries.)
NO
YES
Please list dates (starting with most recent)
tfas blood flov improved?
NO
YES
37. Each time you have an angina episode, do you believe (Circle the best
ansver):
1 YOUR HEART MAY BE HARMED A SMALL AMOUNT AND PROBABLY DOES NOT
HEAL?
2 YOUR HEART MAY BE HARMED A SMALL AMOUNT BUT PROBABLY DOES HEAL?
3 YOUR HEART IS PROBABLY NOT HARMED, THE ANGINA IS SIMPLY YOUR
BODY'S WARNING TO SLOW DOWN?
4 OTHER (please explain)
-14-
-------
38. Circle the number on the scale that best describes how often the statement
has been true for you in the past fev years.
a. I get as much exercise as my NEVER ALWAYS
physical condition allows. 1 2 3 4 5 6 7
b. I exert myself physically NEVER ALWAYS
until I begin to feel angina 12 3 4 5 6 7
pain or discomfort.
c. I follow the diet recommend- NEVER ALWAYS
ations of my doctor. 12 3 4 5 6 7
d. I watch my pulse rate during NEVER ALWAYS
exercise or take my blood 12 3 4 5 6 7
pressure at home.
e. I am under a lot of stress. NEVER ALWAYS
1 2 3 4 5 6 7
V. PERCEPTIONS ABOUT AIR POLLUTION
39. How do you usually tell when air pollution is high? (Circle all that apply)
1 DON'T USUALLY NOTICE AIR POLLUTION
2 SEE OR HEAR REPORTS IN THE NEWSPAPER, TV OR RADIO
3 SEE IT IN THE AIR
4 FEEL IT AFFECTING MY EYES OR LUNGS
5 SMELL IT
6 OTHER (please describe)
40. How often do you think, there is enough air pollution in the areas where
you live or work to affect your health or the health of others?
1 NEVER
2 LESS THAN 7 DAYS PER YEAR
3 7 TO 14 DAYS PER YEAR
4 14 TO 30 DAYS PER YEAR
5 30 TO 60 DAYS PER YEAR
6 MORE THAN 60 DAYS PER YEAR
41. (If you think air pollution sometimes aggravates your angina) On days when
you are concerned that air pollution might affect your angina, what do you
usually do? (Circle all that apply)
1 NOTHING DIFFERENT, KEEP TO MY USUAL ROUTINE
2 SPEND LESS TIME OUTDOORS
3 EXERCISE LESS
4 GO TO A LESS POLLUTED AREA OR PART OF TOWN
5 OTHER (please specify)
-15-
-------
42. Please indicate the level of air pollution you think is usually associated
vith each of the following activities or locations.
Lov
Pollut ion
a. Driving at rush hour.
b. Driving on city streets in normal traffic.
c. Driving on freeways in normal traffic.
d. Walking on city streets.
e. Outdoors, near your home.
f. Outdoors, in parks or other public places.
g. Indoors, in restaurants, stores, or other
public places.
h. Indoors, in your home.
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
High
Pollution
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
VI. ADDITIONAL BACKGROUND QUESTIONS
43. Please indicate the category that represents your household's current
annual income, including any disability payments.
1 LESS THAN $ 4,999
2 $ 5,000 - $ 9,999
3 S10,000 - $14,999
4 $15,000 - $19,999
5 $20,000 - $24,999
6 $25,000 - $29,999
7 $30,000 - $34,999
8 $35,000 - $39,999
9 $40,000 - $44,999
10 $45,000 - $49,999
11 $50,000 - S59,999
12 $60,000 OR MORE
The interviewer will nov ask a few additional background questions.
-16-
-------
DATE
SUBJECT INTERVIEWER VERSION
INTERVIEWER
CORONARY HEART DISEASE STUDY
QUESTIONNAIRE
I. CURRENT ANGINA STATUS
SUB.
P.#
1. Have you ever had angina related pain, discomfort, heaviness, or
pressure in your chest (not caused by a cold or by an accident or
inj ury)?
1 NO
2 YES
I 2. Do you (or did you) get this feeling when you walk uphill or hurry?
1 NO
2 YES
3. Do you (or did you) get this feeling when you walk at an ordinary
pace on level ground?
1 NO
2 YES
J 4. Has a doctor ever said that you have angina?
1 NO
2 YES
Coronary heart disease patients sometimes have pressure or heaviness
in their chests even if they do not report it as angina pain. In the
following questions, references to angina pain and discomfort are
meant to include such episodes of pressure or heaviness.
5. Do you still have angina pain or discomfort sometimes, or do you no
longer have it?
1 NO LONGER HAVE IT
2 STILL HAVE IT SOMETIMES
INTERVIEWER: GO TO ALT-6
-1-
-------
(INTERVIEWER: THIS BLOCK OF QUESTIONS IS NOT ON THE SUBJECT'S VERSION, BUT
SHOULD BE ASKED INSTEAD OF QUESTIONS 6-8 FOR THOSE VHO ANSWER 1 TO QUESTION
5)
ALT-6. If you no longer have angina pain or discomfort, did you formerly
have angina pain or discomfort that has been stopped due to surgery,
treatment, or due to some other reason?
N0-
YES-
INTERVIEVER: STOP INTERVIEW AND
DISCUSS
ALT-6a.
When was the last time you experienced angina?
years or months ago (Circle years or months)
ALT-6b.
What do you think, stopped the angina? (Circle all that
apply)
1
BYPASS SURGERY
2
MEDICATION
j
LIFESTYLE ADJUSTMENTS
k
ANGIOPLASTY
5
OTHER (please explain)
ALT-6c.
How often did you have angina when you used to have it?
(Circle best answer)
1
NEVER OCCURRED
2
LESS THAN ONCE A MONTH
3
ABOUT ONCE A MONTH
k
ABOUT TWICE A MONTH
5
ABOUT ONCE A WEEK
6
ABOUT 2 OR 3 TIMES A WEEK
7
ABOUT ONCE A DAY
8
ABOUT TWICE A DAY
9
3 TIMES A DAY OR MORE
ALT-6d.
How uncomfortable or severe was your angina when you
used to have it? (Circle best answer)
1
NO DISCOMFORT
2
VERY MILD DISCOMFORT
3
MILD DISCOMFORT
4
MODERATE DISCOMFORT
5
MODERATELY SEVERE DISCOMFORT
6
SEVERE DISCOMFORT
7
VERY SEVERE DISCOMFORT
SKIP TO
QUESTION 9 (SUBJECT PAGE NO. 3)
-2-
-------
S 6. For each season, please check the box under the angina frequency level
that best describes how often you usually have angina in that season.
Season Level of Frequency
1
NEVER
OCCURS
2
LESS
THAN
ONCE A
MONTH
3
ABOUT
ONCE A
MONTH
4
ABOUT
TVICE A
MONTH
5
ABOUT
ONCE A
VEEK
6
ABOUT
2 OR 3
TIMES
A VEEK
7
ABOUT
ONCE
A DAY
8
ABOUT
TWICE
A DAY
9
3 TIMES
A DAY
OR MORE
SUMMER
(Jun-Aug)
FALL
(Sep-Nov)
VINTER
(Dec-Feb)
SPRING
(Mar-May)
3 7. For each season, please check the box under the angina severity
(discomfort) level that.best describes how severe your angina tends to
be in that season.
Season Level of Discomfort (Severity)
1
NONE
2
VERY
MILD
3
MILD
A
MODERATE
5
MODERATELY
SEVERE
6
SEVERE
7
VERY
SEVERE
SUMMER
(Jun-Aug)
FALL
(Sep-Nov)
VINTER
(Dec-Feb)
SPRING
(Mar-May)
<3 8. During the past 12 months, hov many days has angina pain or discomfort
kept you resting on the couch or chair or in bed for most of the day?
days (INTERVIEWER: IF SUBJECT INDICATES RECALL TROUBLE
ASK ABOUT PAST 3 MONTHS: DAYS)
-3-
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II. ANGINA EPISODES: PREVENTION AND RESPONSE
Medical Care
9. Do you have medical insurance or participate in any program that
pays part or all of your medical bills?
1 NO >
2 YES
9a. Circle all that apply:
1 PRIVATE MEDICAL INSURANCE
2 VA BENEFITS
3 MEDICARE
A HEALTH MAINTENANCE PROGRAM
5 OTHER (please specify)
Why not?
9b. What is the total monthly cost to you of this coverage
(insurance premiums, membership fees)?
$
9c. What percentage (or dollar amount) of your medical
expenses for office visits, hospital services, and
prescription medication are covered under this (these)
program(s)?
(INTERVIEVER-ASK. ABOUT DEDUCTIBLES AND FIXED FEES, IF
APPLICABLE, AND CLEARLY MARK RESPONSES.)
doctor office
visit
emergency room and
hospital services
(including surgery)..
prescription
medicat ion
-------
•3 10. How far do you drive each way to see the doctor about your heart
condition?
mi les
H_ 11. Do you go for regular checkups?
1 NO
2 YES
11a. How often do you go for checkups?
(INTERVIEWER MARK IN TIMES PER YEAR)
lib. What is the average cost to you of a checkup?
(Do not include any amount paid by insurance.)
$
(INTERVIEWER PROBE: DO YOU KNOW HOW MUCH YOUR INSURANCE
CO. IS CHARGED? $ )
*1 12. How many times in the past 12 months have you visited the doctor's
office because of angina or other heart problems (in addition to
any regular checkups)?
doctor's office visits
s/
(If more than 0) What was the cost to you of your last office
visit due to angina or other heart problems? (Do not include
any amount paid by insurance.)
$
(INTERVIEWER PROBE: DO YOU KNOW HOW MUCH YOUR INSURANCE CO. WAS
CHARGED? $ )
-5-
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13. Please list all the prescription medications you are presently
taking for your heart condition. You may simply give the
prescription information directly from the bottles.
Medication Name Dose
5 14. What is the average monthly cost to you of all the medications you
take for your heart problem? (Do not include any amount paid by
insurance. )
(INTERVIEWER PROBE: DO YOU KNOW HOW MUCH YOUR INSURANCE CO. IS
CHARGED? $ )
5 15. Have you been to the emergency room in the past 12 months due to
your angina or other heart problems?
1 NO
2 YES
15a. How many times?
15b. What was the cost to you of your last emergency room
visit? (Do not include any amount paid by insurance.)
$
(INTERVIEWER PROBE: DO YOU KNOW HOW MUCH YOUR INSURANCE
CO. WAS CHARGED? $ )
-6-
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5 16. Have you stayed overnight in a hospital in the last 12 months
because of angina or other heart problems?
NO
YES->
Please list (starting with most recent stay):
Dates Length of Cause/Treatment
Stay
days
days
days
Cost
to You
(INTERVIEWER PROBE: DO YOU KNOW BOW MUCB YOUR INSURANCE
CO. WAS CHARGED? MARK ANSWERS AFTER COST TO YOU.)
17. In the past 12 months, have you had any other medical treatment or
been in any exercise program (including use of exercise equipment
in your home) for your heart condition?
1 NO
2 YES—^
Please give type of treatment and annual cost to you (do
not include any amount paid by insurance). If it
involves a one-time only purchase such as exercise
equipment, please give the amount spent in the past
year:
Treatment
Cost to You in the Past Year
-7-
-------
Lifestyle Changes and Related Expenditures
C9 18. Which of the following things do you think, sometimes bring on or
aggravate your angina? (Circle all that apply)
1 COLD TEMPERATURE
2 STRESS OR ANXIETY
3 EXCITEMENT
4 PHYSICAL EXERTION (SUCH AS WALKING FAST OR HEAVY LIFTING)
5 AIR POLLUTION
6 CIGARETTE SMOKE
7 MEALS (PAIN AFTER MEALS OR AFTER CERTAIN FOODS OR BEVERAGES)
8 OTHERS (please describe)
Which do you think, is the most important factor?
(j, 19. What kinds of changes do you make in your activities on days when
for any reason you feel you are more likely to have an angina
episode? (Circle all that apply)
1 MAKE NO CHANGES IN ACTIVITIES
2 AVOID ACTIVE RECREATIONAL ACTIVITIES
3 AVOID PHYSICAL EXERTION SUCH AS HOUSEWORK OR YARDVORK
4 SLEEP OR REST MORE
5 TAKE TIME OFF FROM WORK
6 STAY HOME
7 DO THE SAME ACTIVITIES, BUT AT A SLOWER PACE
8 AVOID EMOTIONAL STRESS
9 AVOID EXPOSURE TO HOT OR COLD WEATHER
10 AVOID EXPOSURE TO AIR POLLUTION
11 AVOID EXPOSURE TO CIGARETTE SMOKE
12 OTHER (please specify)
-8-
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20. In the past 12 months, have you hired any help for yard work, home
or auto maintenance, or housework, to reduce or prevent angina or
other problems related to your heart condition?
N0-
YES-
(INTERVIEWER: SKIP TO ALT-20, INTERVIEWER
PAGE 12. SUBJECT DOES NOT HAVE ALT-20, BUT
SEQUENCE AND RESPONSE CHOICES ARE VERY SIMILAR
TO QUESTION 20)
7
7
20a. Please give an example of the type of help you hire most
often. Consider only work that you would prefer to do
yourself rather than have someone else do.
20b. How often do you hire help for this purpose?
times per year
20c. On average, how much does this cost you?
$ per year
20d. If you did this work yourself for a year, do you believe
you would probably have more frequent angina?
1 NO
2 YES—>
If you did this work yourself, how many
addi tional angina episodes per year do you
think you would get, over what you now get?
additional episodes per year
-9-
-------
20e. If you did this work yourself for a year, do you think the
severity of your angina episodes after doing this work
would be worse or be about the same as your current other
angina episodes?
1 ABOUT THE SAME
2 WORSE 1
Using our 1 to 7 scale, how severe do
you think
your angina episodes after doing this
work would
be?
1 NO DISCOMFORT
2 VERY MILD DISCOMFORT
3 MILD DISCOMFORT
4 MODERATE DISCOMFORT
5 MODERATELY SEVERE DISCOMFORT
6 SEVERE DISCOMFORT
7 VERY SEVERE DISCOMFORT
20f. If you did this work yourself for a year, do you believe
this might increase your chances of having a heart attack?
NO
YES
If you did this work for a year, how much do
you think this vould add to your chances of
having a heart attack during the year?
1 ADD A SMALL AMOUNT (ADD LESS THAN 5%)
2 ADD A MODERATE AMOUNT (ADD 5-10%)
3 ADD A MODERATELY LARGE AMOUNT (ADD 11-25*)
4 ADD A LARGE AMOUNT (ADD MORE THAN 25%)
5 OTHER (please explain)
20g. Do you hire this help for any other reasons, in addition
to possible concern about angina and heart attack risks?
1 NO
2 YES—>
Please explain:
(INTERVIEWER: CHECK HERE TO MAKE SURE THEY
WOULD PREFER TO DO THE WORK THEMSELVES)
-10-
-------
9
20h. Please list any other examples of help you hire due to
your heart condition. Please describe the type of help,
for example help with housevork or home maintenance, and
estimate how many times in the past year you hired this
help. Please do not include any help that you think you
would hire even if you did not have any trouble with your
hear t.
Type of Help
Times Hired
in past year
in past year
in past year
in past year
20i. In the past year, have you purchased any special equipment
or made structural changes in your home to reduce physical
exertion that might aggravate your heart problem?
Examples might be an electric garage door opener or the
addition of a ground-floor bedroom.
1 NO
2 YES-
Please describe each expenditure and give the
cost to you in the past year. Do not include
any expenditures that you think you would
have made even if you did not have any
trouble with your heart.
Type of Expenditure
Cost to You
in Past Year
$
$
$
-11-
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INTERVIEWER: SKIP TO QUESTION 21 (SUBJECT PAGE NO. 9) UNLESS ANSWER TO
QUESTION 20 WAS NO.
ALT-20. In the past 12 months, have you purchased any special equipment or
made structural changes in your home to reduce physical exertion
that might aggravate your heart problem. Examples might be an
electric garage door opener or the addition of a ground-floor
bedroom.
N0-
YES-
SKIP TO QUESTION 21 (SUBJECT PAGE NO. 9)
ALT-20a. Please give an example of your largest purchase or
expenditure of this type. Consider only purchases that
you would not have made if you did not have any trouble
with your heart.
ALT-20b. What was the cost to you of this purchase in the past
year?
ALT-20c. If you did the same work or activity for a year without
using this equipment (or without making this change in
your home), do you believe you would have more frequent
angina?
NO
YES-
If you did the same work or activity for a year
without using this equipment or making these changes,
how many additional angina episodes per year do you
think you would get, over what you now get?
additional episodes per year
-12-
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ALT-20d. If you did the same work or activity for a year without
using this equipment (or without making this change in
your home), do you believe the severity of any resulting
angina episodes would be worse or be about the same as
your current angina episodes?
1 ABOUT THE SAME
2 VORSE ,
Using our 1 to 7 scale, how severe do you
think the
resulting angina episodes would be?
(INTERVIEWER: ANSWER CHOICES ARE THE SAME
AS UNDER
QUESTION 20e—SUBJECT PAGE NO. 7)
1 NO DISCOMFORT
2 VERY MILD DISCOMFORT
3 MILD DISCOMFORT
k MODERATE DISCOMFORT
5 MODERATELY SEVERE DISCOMFORT
6 SEVERE DISCOMFORT
7 VERY SEVERE DISCOMFORT
ALT-20e. If you did the same work or activity for a year without
using this equipment (or without making this change in
your home), do you believe this might increase your
chances of having a heart attack?
1 NO
2 YES 1
Vithout using this equipment (or without making this
change in your home) how much would this add to your
chances of having a heart attack during the year?
(INTERVIEWER: ANSWER CHOICES ARE THE SAME AS UNDER
QUESTION 20f—SUBJECT PAGE NO. 7)
1 ADD A SMALL AMOUNT (ADD LESS THAN 5%)
2 ADD A MODERATE AMOUNT (ADD 5-102)
3 ADD A MODERATELY LARGE AMOUNT (ADD 11-252)
4 ADD A LARGE AMOUNT (ADD MORE THAN 25%)
5 OTHER (please explain)
-13-
-------
ALT-20f. Have you made this expenditure for any other reasons, in
addition to possible concern about angina and heart attack
risks?
Please explain
ALT-20g. Please list any other examples of expenditures you have
made in the past year for special equipment or structural
changes in your home to reduce physical exertion due to
your heart problem. Please describe each expenditure and
give the cost to you in the past year. Do not include any
expenditures that you would have made even if you did not
have any trouble with your heart.
Type of Expenditure Cost to You in Past Year
$
$
$
$
-14-
-------
Employment
21. Are you employed?
1 NO ^
2 YES-
INTERVIEVER: ASK ALT-21, INTERVIEVER PAGE 17.
IT IS NOT ON SUBJECT'S QUESTIONNAIRE
21a. Vhat are your average total hours per week (all jobs)?
hours per veek
21b. Vhat kind of work do you do (occupation)?
Job 1
Job 2
21c. Hov many days have you missed from work (all jobs) in the
past year due to angina or other illness related to your
heart
days
21d. Do you have paid sick leave?
NO
YES-
Does it cover all of the time you typically
miss from vork due to all types of illness?
N0-
YES
Please estimate how
many days you missed from vork
due to all types of illness in
the past year that were not
covered by sick leave.
days
21e. Have you changed jobs in the past 5 years because of your
heart condition?
1 NO
2 YES >
Did the job change mean a reduction in
income?
1 NO
2 YES
-15-
-------
21f- Are you working fever hours than you vould like because
of your heart condition?
1 NO
2 YES ^
How many hours per week would you like to be
working?
hours per week
21g. Please indicate the categ
you earn annually at your
1 LESS THAN $4,999
2 $5,000 - $9,999
3 $10,000 - $14,999
4 $15,000 - $19,999
5 $20,000 - $24,999
6 $25,000 - $29,999
iry that represents how much
current job(s).
7 $30,000 - $34,999
8 $35,000 - $39,999
9 $40,000 - $44,999
10 $45,000 - $49,999
11 $50,000 - $59,999
12 $60,000 OR MORE
-16-
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INTERVIEWER: ASK THE FOLLOWING ALTERNATIVE QUESTIONS IP SUBJECT IS NOT
CURRENTLY EMPLOYED
ALT-21. If you are currently not employed, did you have to quit working at
a paid job (or take an early retirement) in the past 5 years due
to your heart problem?
1 NO >
2 YES
SKIP TO QUESTION 22
(SUBJECT PAGE NO. 10)
ALT-21a. How long ago did you quit working?
years ago
ALT-21b. What kind of work did you used to do (occupation)?
ALT-21c. Please indicate the category that represents how much
you earned annually before you quit working.
(INTERVIEWER: ANSWER CHOICES ARE THE SAME AS UNDER
QUESTION 21g—SUBJECT PAGE NO. 10)
1
LESS THAN $4,999
7
$30,000 -
$34,999
2
$5,000 - $9,999
8
$35,000 -
$39,999
3
$10,000 - $14,999
9
$40,000 -
$44,999
4
$15,000 - $19,999
10
$45,000 -
$49,999
5
$20,000 - $24,999
11
$50,000 -
$59,999
6
$25,000 - $29,999
12
$60,000 OR MORE
ALT-21d. Since you quit working, has your condition improved
enough (due to bypass surgery or other treatment) that
you believe you could return to work, but have been
unable to return to work due to your health history?
1 NO
2 YES
-17-
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III. IMPORTANCE OF CHANGES IN ANGINA
IP 22. Please think of your most recent angina episode that you would say
was typical. When did this occur?
(INTERVIEWER: IF EPISODE WAS WHEN THEY ANSWERED THE PHONE FOR THIS
INTERVIEW, ASK THEM TO THINK OF ANOTHER RECENT EPISODE AND REPEAT
QUESTION.)
IQ 23. Where were you?
10 24. What were you doing?
10 25. How long were you doing this activity?
minutes
10 26. How long did the pain or discomfort last?
minutes
I | 27. What did you do after this typical angina episode began? (Check all
that apply)
1 STOPPED FOR A WHILE AND RESTED. LATER RESUMED THE ACTIVITY.
How long did you rest before starting again? mins.
2 STOPPED THE ACTIVITY ALTOGETHER.
3 CONTINUED AT THE SAME PACE.
4 SLOWED DOWN BUT DID NOT STOP.
5 TOOK NITROGLYCERIN OR OTHER MEDICATION.
6 OTHER, please describe:
Which of these was the most important means of relief for this
particular episode?
-18-
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I I 28. Sometimes an angina episode may cause you some inconvenience, expense,
or other effect on your life. Which of the following possible effects
of this angina episode bothered you? (Check, all that apply)
1 MEDICAL TREATMENT EXPENSES.
2 LOST INCOME.
3 NON-MEDICAL EXPENSES (SUCH AS PAYING FOR SERVICES).
4 PAIN AND DISCOMFORT.
5 LESS ABILITY TO WORK AT A JOB (FOR REASONS OTHER THAN INCOME).
6 LESS ABILITY TO DO DESIRED ACTIVITIES (RECREATION, CHORES, ETC.).
7 CONCERN TO YOU ABOUT POTENTIAL HEART ATTACK OR BYPASS SURGERY.
8 CONCERN TO YOU ABOUT UORRY OR INCONVENIENCE TO FAMILY AND
FRIENDS DUE TO YOUR HEALTH.
9 OTHER, please explain
Vhich was most bothersome to you?
I I 29. If there was any actual monetary cost to you due to this episode,
can you estimate how much it was?
$
1 1 30a. If you could expect to have a similar typical angina episode
tomorrow, but that it would be possible to avoid it by paying some
amount of money, what is the most would you be willing to pay to
avoid having this episode tomorrow?
$
(INTERVIEWER: IF SUBJECT RESPONDS $0 OR REFUSES TO ANSWER, ASK THE
FOLLOWING QUESTION, NOT ON SUBJECT'S VERSION. DO NOT PUSH FOR A
DOLLAR ANSWER.)
Which of the following reasons best explains your answer to the
previous question about how much you would pay to avoid a typical
episode?
1 I DON'T BELIEVE I SHOULD HAVE TO PAY FOR SOMETHING LIKE THIS.
2 I CAN'T IMAGINE HOW AN ANGINA EPISODE COULD BE AVOIDED BY
PAYING SOMETHING.
3 IT WOULD NOT BE WORTH ANYTHING TO ME TO AVOID ONE ANGINA
EPISODE.
4 OTHER, please explain
(INTERVIEWER: IF SUBJECT REFUSED TO ANSWER 30a, DO NOT ASK 30b)
) I 30b. If you could expect to have 2 such episodes in the next week, what is
the most you would be willing to pay to avoid having both of them?
$
-19-
-------
The interviever will ask a fev questions about other angina episodes you have
had. Before the interviever calls, you may wish to think about the vorst
angina episode you have had and about the mildest episodes you have had.
(INTERVIEWER: QUESTIONS 22b-28b CONCERN THE WORST EPISODE AND QUESTIONS
22c-28c CONCERN THE MILDEST ESPISODE. THEY PARALLEL THE QUESTIONS FOR THE
TYPICAL EPISODE. THEY ARE NOT ON SUBJECT'S VERSION.)
22b. Please think of the worst angina episode you have ever had. When
did this occur?
23b. Where were you?
24b. What vere you doing?
25b. How long vere you doing this activity?
minutes
26b. How long did the pain or discomfort last?
minutes
27b. What did you do after this worst angina episode began? (Check all
that apply)
(INTERVIEWER: RESPONSES ARE THE SAME AS FOR QUESTION 27,
SUBJECT PAGE 11)
1 STOPPED FOR A WHILE AND RESTED. LATER RESUMED THE ACTIVITY.
How long did you rest before starting again? mins.
2 STOPPED THE ACTIVITY ALTOGETHER.
3 CONTINUED AT THE SAME PACE.
4 SLOWED DOWN BUT DID NOT STOP.
5 TOOK NITROGLYCERIN OR OTHER MEDICATION.
6 OTHER, please describe:
Which of these was the most important means of relief for this
particular episode?
-20-
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28b. Sometimes an angina episode may cause you some inconvenience,
expense, or other effect on your life. Vhich of the following
possible effects of this worst angina episode bothered you? (Check
all that apply)
(INTERVIEWER: RESPONSES ARE THE SAME AS FOR QUESTION 28,
SUBJECT PAGE 11)
1 MEDICAL TREATMENT EXPENSES.
2 LOST INCOME.
3 NON-MEDICAL EXPENSES (SUCH AS PAYING FOR SERVICES).
A PAIN AND DISCOMFORT.
5 LESS ABILITY TO WORK AT A JOB (FOR REASONS OTHER THAN
INCOME).
6 LESS ABILITY TO DO DESIRED ACTIVITIES (RECREATION, CHORES,
ETC.).
7 CONCERN TO YOU ABOUT POTENTIAL HEART ATTACK OR BYPASS
SURGERY.
8 CONCERN TO YOU ABOUT VORRY OR INCONVENIENCE TO FAMILY AND
FRIENDS DUE TO YOUR HEALTH.
9 OTHER, please explain
Which was most bothersome to you?
(INTERVIEWER: THIS MAY BE TOO DIFFICULT FOR THOSE WHO HAVEN'T HAD ANGINA
FOR QUITE A WHILE. IF SO, SKIP AHEAD TO QUESTION 31, SUBJECT PAGE NO. 12.)
22c. Please think of a recent example of the mildest angina episodes
you have. When did this occur?
23c. Where were you?
24c. What were you doing?
25c. How long were you doing this activity?
minutes
26c. How long did the pain or discomfort last?
minutes
-21-
-------
27c. What did you do after this mild angina episode began? (Check all
that apply)
(INTERVIEVER: RESPONSES ARE THE SAME AS FOR QUESTION 27,
SUBJECT PAGE 11)
1 STOPPED FOR A WHILE AND RESTED. LATER RESUMED THE ACTIVITY.
Hov long did you rest before starting again? mins.
2 STOPPED THE ACTIVITY ALTOGETHER.
3 CONTINUED AT THE SAME PACE.
U SLOWED DOWN BUT DID NOT STOP.
5 TOOK NITROGLYCERIN OR OTHER MEDICATION.
6 OTHER, please describe:
Which of these vas the most important means of relief for this
particular episode?
28c. Sometimes an angina episode may cause you some inconvenience,
expense, or other effect on your life. Which of the following
possible effects of this mild angina episode bothered you? (Check
all that apply)
(INTERVIEWER: RESPONSES ARE THE SAME AS FOR QUESTION 28,
SUBJECT PAGE 11)
1 MEDICAL TREATMENT EXPENSES.
2 LOST INCOME.
3 NON-MEDICAL EXPENSES (SUCH AS PAYING FOR SERVICES).
4 PAIN AND DISCOMFORT.
5 LESS ABILITY TO WORK AT A JOB (FOR REASONS OTHER THAN
INCOME).
6 LESS ABILITY TO DO DESIRED ACTIVITIES (RECREATION, CHORES,
ETC.).
7 CONCERN TO YOU ABOUT POTENTIAL HEART ATTACK OR BYPASS
SURGERY.
8 CONCERN TO YOU ABOUT WORRY OR INCONVENIENCE TO FAMILY AND
FRIENDS DUE TO YOUR HEALTH.
9 OTHER, please explain
Which vas most bothersome to you?
-22-
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J3. 31. This question is about how you think you would be affected if your
heart condition were to become worse, causing you to have angina
pain or discomfort more often than you do now. Ve are interested
in finding out how much the different effects of such a change in
your condition would bother you, once you had done what you could
to minimize the effects.
Listed below are some effects on your life that might occur if you
were to have angina more often. For the effect that would be most
bothersome to you, circle the number 10. For the effect that would
be least bothersome to you, circle the number 1. For the remaining
effects on the list, please circle the number that best describes
how bothersome it would be relative to these extremes. You may
circle the same number for more than one effect if they would be
equally bothersome to you.
Effects you may experience if Relative bothersomeness
your angina worsened of the effect
Least Most
Bothersome Bothersome
a. More medical treatment
expenses.
1 2
3
4
5
6
7
8
9
10
b. Less ability to earn income.
1 2
3
4
5
6
7
8
9
10
c. More non-medical expenses
(such as paying for services).
1 2
3
4
5
6
7
8
9
10
d. More pain or discomfort.
1 2
3
4
5
6
7
8
9
10
e. Less ability to work at a job
(for reasons other than income).
1 2
3
4
5
6
7
8
9
10
f. Less ability to do desired
activities (recreation, chores,
or work).
1 2
3
4
5
6
7
8
9
10
g. More concern to you about
potential heart attack or
bypass surgery.
1 2
3
4
5
6
7
8
9
10
h. More concern to you about worry
or inconvenience to family and
friends due to your health.
1 2
3
4
5
6
7
8
9
10
-23-
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13 32. Suppose your heart condition were to become worse so that with your
current medical treatment and lifestyle your angina episodes would
occur more often. Suppose also that a nev medical treatment were
available that could prevent the additional angina without causing
undesirable side effects or requiring lifestyle changes.
If the treatment would prevent additional angina episodes per
month and if you had to pay the entire cost yourself, would you take
the treatment if it cost $ each month?
1 NO
2 YES-
Vould you take the treatment if it cost $
1 NO
2 YES
each month?
Vould you take the treatment if it cost $ each
month?
NO
YES
13 33. What is the most that you would pay for this treatment if it would
prevent additional angina episodes per month?
$ per month
INTERVIEWER: IF ALL THE ANSWERS TO QUESTION 32 WERE NO,
OR THE ANSWER TO QUESTION 33 WAS $0,
OR REFUSED TO ANSWER
ASK THE FOLLOWING QUESTION (NOT ON SUBJECT'S VERSION)
Which of the following reasons best explains your answer to the
previous questions about how much you would pay for such a treatment?
1 I DON'T BELIEVE I SHOULD HAVE TO PAY FOR A NEV TREATMENT.
2 I DON'T BELIEVE THERE COULD BE ANY SUCH TREATMENT.
3 IT VOULD NOT BE VORTH PAYING ANYTHING FOR PREVENTING THAT MUCH
ANGINA
h OTHER (PLEASE EXPLAIN) __
-24-
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HEART DISEASE HISTORY
34. Has a doctor ever said you had a heart attack?
1 NO
2 YES >
Please list dates starting with most recent (month
and year is sufficient):
35. Has a doctor ever recommended you have coronary artery bypass
surgery?
1 NO—>
Has the doctor said why not?
2
Why not?
Please list dates (starting vith most
recent):
Did you have the surgery?
NO
YES—>
-25-
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)H 36. Have you ever had angioplasty to improve the blood flow to your
heart tissue? (Angioplasty involves catheterization with a balloon
catheter that expands narrowed coronary arteries.)
1 NO
2 YES •
Please list dates (starting with most recent):
Was blood flow improved?
NO
YES
)H 37. Each time you have an angina episode, do you believe (Circle the
best answer):
1 YOUR HEART MAY BE HARMED A SMALL AMOUNT AND PROBABLY DOES NOT
HEAL?
2 YOUR HEART MAY BE HARMED A SMALL AMOUNT BUT PROBABLY DOES
HEAL?
3 YOUR HEART IS PROBABLY NOT HARMED, THE ANGINA IS SIMPLY YOUR
BODY'S WARNING TO SLOW DOWN?
4 OTHER (please explain)
15 38. Circle the number on the scale that best describes how often the
statement has been true for you in the past few years.
a. I get as much exercise as my NEVER ALWAYS
physical condition allows. 12 3 4 5 6 7
b. I exert myself physically NEVER ALWAYS
until I begin to feel angina 12 3 4 5 6 7
pain or discomfort.
c. I follow the diet recommend- NEVER ALWAYS
ations of my doctor. 12 3 4 5 6 7
d. I watch my pulse rate during NEVER ALWAYS
exercise or take my blood 12 3 4 5 6 7
pressure at home.
e. I am under a lot of stress. NEVER ALWAYS
1 2 3 4 5 6 7
-26-
-------
V. PERCEPTIONS ABOUT AIR POLLUTION
1*5 39. How do you usually tell when air pollution is high? (Circle all
that apply)
1 DON'T USUALLY NOTICE AIR POLLUTION
2 SEE OR HEAR REPORTS IN THE NEWSPAPER, TV OR RADIO
3 SEE IT IN THE AIR
4 FEEL IT AFFECTING MY EYES OR LUNGS
5 SMELL IT
6 OTHER (please describe)
>5 40. How often do you think there is enough air pollution in the areas
where you live or work to affect your health or the health of
others?
1 NEVER
2 LESS THAN 7 DAYS PER YEAR
3 7 TO 14 DAYS PER YEAR
4 14 TO 30 DAYS PER YEAR
5 30 TO 60 DAYS PER YEAR
6 MORE THAN 60 DAYS PER YEAR
>*5 41. (If you think air pollution sometimes aggravates your angina) On
days when you are concerned that air pollution might affect your
angina, what do you usually do? (Circle all that apply)
1 NOTHING DIFFERENT, KEEP TO MY USUAL ROUTINE
2 SPEND LESS TIME OUTDOORS
3 EXERCISE LESS
4 GO TO A LESS POLLUTED AREA OR PART OF TOWN
5 OTHER (please specify)
9 not applicable
-27-
-------
il ca'wll vJ-
Lou
Pollution
High
Pollution
r family?
oke per week?
hour.
streets in normal traffic,
ays in normal traffic,
streets,
our home.
c.s or other public places,
lurants, stores, or other
home.
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
smoke per week?
ROUND QUESTIONS
:he category that represents your household's
985) income, including any disability payments,
99
7 $30,000 - $34,999
9
8 535,000 - $39,999
999
9 $40,000 - $44,999
999
10 $45,000 - $49,999
)99
11 $50,000 - $59,999
>99
12 $60,000 OR MORE
: few additional background questions.
G QUESTIONS DO NOT APPEAR ON THE SUBJECT'S
= last year of school that you completed.
¦I SONS
in your household.
inches
10 9th GRADE
11 10th GRADE
12 11th GRADE
13 12th GRADE
14 FIRST YEAR OF COLLEGE
15 SECOND YEAR OF COLLEGE
16 THIRD YEAR OF COLLEGE
17 FOURTH YEAR OF COLLEGE
18 GRADUATE STUDIES
-28-
-------
54. What is your national or ancestral origin?
1 WHITE, CAUCASIAN
2 ASIAN
3 HISPANIC
4 BLACK, AFRO-AMERICAN
5 OTHER (specify)
ANY ADDITIONAL COMMENTS?
-30-
-------
DATE
SUBJECT
INTERVIEWER
SUPPLEMENTARY QUESTIONS ON CO EXPOSURE
CORONARY HEART DISEASE STUDY
Now that we are at the end of the questionnaire I'd like to ask you
a few questions about factors of your lifestyle thar may influence
your exposure to an air pollutant, carbon monoxide.
1. Do you usually travel by auto, bus or foot?
1 personal auto
2 car pool
3 bus
4 walking
5 motorcycle
6 other
2. Do you travel to and from work or any other place at least
three (3) times per week?
1 NO
2 YES - ,
2a. How much time do you spend
traveling one way?
minutes
How many hours do you spend in heavy traffic while traveling
each week?
hrs.
4. Are you frequently around running autos or gasoline powered
engines on the job or at home (e.g., auto repair work at
home)?
1 NO
2 YES
S-L
-------
5. Do you regularly use lawn equipment powered by gasoline engines?
1 NO
2 YES
6. Is a garage attached to your home or within the building in
which you live?
1 NO
2 YES
i
I Are autos parked in the garage?
1 NO
2 YES
7. Do you have natural gas fuel appliances in your home?
1 NO > INTERVIEWER PROBE: IS YOUR HOME
ALL ELECTRIC?
1 NO
2 YES
2 YES
8. Do you use any of the following gas fueled appliances in
your hone?
1 gas heater
2 gas cooking stove or range
3 gas cooking oven
4 gas water heater
5 gas clothes dryer
6 gas or kerosene space heater
7 other gas appliance
8 other (please specify)
9. To your knowledge is each of these appliances vented to
the outside?
1 NO
2 YES
S-2
-------
10. Does your home have a fireplace?
1 NO
2 YES
' INTERVIIWER PROBE: HOW MANY TIMES i
PER MONTH DO YOU USE YOUR FIREPLACE i
I DURING THE WINTERTIME? I
11. If you have a kitchen exhaust fan do you use it when
cooking?
1 No, or almost never
2 Yes, at times
3 Yes, always
9 Not applicable
12. If you have a kitchen window, do you open it when cooking?
1 No, or almost never
2 Yes, at times
3 Yes, always
9 Not applicable
13. Do you have energy-saving insultation or weather stripping
installed in your home?
1 NO
2 YES
14. What main type of heating system do you use in your home?
(Circle best answer.)
1 Central warm air furnace with ducts to individual rooms
2 Wall furnace
3 Floor furnace
4 Portable electric room heater (circulating or radiant)
5 Oil or kerosene space heaters
6 Fireplace or woodburning stove
7 Solar
8 No heating equipment, or other
9 Do not know
S-3
-------
15. Do you notice drafts in your home?
1 No, never
2 Yes, but rarely
3 Yes, often (each day)
16. Is your home located near (within three (3) blocks) any of
the following? (Circle all that apply.)
1 Busy roadway or intersection
2 Auto or truck maintenance area or garage
3 Site of open burning
4 Manufacturing plant or industry with heavy smoke
emission or furnaces
5 Electricity or steam plant
6 Other (please specify)
17. How often are you around other who smoke?
1 Rarely
2 Frequently
Where? 1 on the job
2 at heme
3 other (please specify)
INTERVIEWER: IF ANSWER TO QUESTION 48 WAS YES (PAGE 29 INTERVIEWER
VERSION) ASK THE FOLLOWING QUESTION.
18. If smokers are present at home, how nar.y?
Number of smokers
Approximate number of packs smoked within the home by
all smokers during a typical week's time.
-------
Appendix 3
-------
ECONOMIC ASPECTS OF RISK POSED BY CARBON
MONOXIDE
CODEBOOK
PROGRAM IN SOCIAL ECOLOGY
UNIVERSITY OF CALIFORNIA, IRVINE
EPA COOPERATIVE AGREEMENT
JULY 1986
Revised December, 1986
-------
TABLE OF CONTENTS
General Coding Guidelines
"Interviewer Version" of Questionnaire
Supplemental Questionnaire
Structure for Database Files
Coding Scheme for Interviewer Version
Question 13 -- Medication Codes
Question 16 -- Hospitalization Codes
Question 17 -- Itemized Expenditures for Health or Fitness Program Codes
Question 20i and Question 20a -- Equipment or Structural Expenditure Codes
Question 21b and Question Alt 21b -- Occupation Codes
Question 23, Question 23b and Question 23c -- Microenvironment Codes
Question 24, Question 24b and Question 24c -- Activity Codes
Question 30a, Question 30b and Question 33 -- Dollar Amount Willing to Pay Codes
Question 30a, Question 30b and Question 33 -- Additional Comments Offered by
Subject Codes
Question 32 -- Willingness to Pay Treatment Codes
Question 35 -- Reason for Doctor Not Recommending CABG. Codes
Question 35a -- Reason for No CABG Surgery After Positive Doctor's
Recommendation Codes
Comments
-------
GENERAL CODING GUIDELINES
GENERAL CODES APPLIED TO ALL QUESTIONS
-99 = Subject declined to answer.
- 9 = Missing data (e.g., interviewer omitted question).
- 5 = Subject did not know or could not remember.
If all responses within a question are blank, the question was not asked (e.g., line of
questioning branched away).
OTHER CODING GUIDELINES
1. Rounding of values -- when the response was a range of values (e.g., time,
money), the midpoint of the given range was coded. For example, if length of
activity was given as "30-45 minutes" , it was coded as 38 minutes. If the
duration of angina pain was given as "2-3', it was rounded up to the nearest
minute.
2 If the value given was less than 1, a default value of "1" was assigned.
3. Comments of the research subject and the interviewer are organized by question
number and are recorded separately.
4. The "1 = No, 2 = Yes" and other numbered responses on the Interviewer Version
of the questionnnaire were preserved in the coding.
The subsequent section of the codebook contains the "Interviewer
Version" of the questionnaire. In turn the coding scheme is presented
with column number fields indicated and, as appropriate, coding
information unique to each question. Medication, occupation, medical
treatment, expenditure, activity, and microenvironment codes follow
in later sections in the same numerical sequence as presented in the
questionnaire.
-------
z-7 4 ' / c •> /
^¦' ^6-ldr- •— £ ^^E^/cu^HLy
,7
U
DATE
SUBJECT INTERVIEWER VERSION
INTERVIEWER
CORONARY HEART DISEASE STUDY
QUESTIONNAIRE
I. CURRENT ANGINA STATUS
SUB.
P.*
1 1. Have you ever had angina related pain, discomfort, heaviness, or
pressure in your chest (not caused by a cold or by an accident or
injury)?
O 1 NO
SO 2 YES
1 2. Do you (or did you) get this feeling vhen you valk uphill or hurry?
/ 1 NO
2 YES
J 3. Do you (or did you) get this feeling vhen you valk at an ordinary
pace on level ground?
43 2 STILL HAVE IT SOMETIMES
INTERVIEWER: GO TO ALT-6
-------
(INTERVIEWER: THIS BLOCK OF QUESTIONS IS NOT ON THE SUBJECT'S VERSION, BUT
SHOULD BE ASKED INSTEAD OF QUESTIONS 6-3 FOR THOSE WHO ANSWER 1 TO QUESTION
5)
ALT-6. If you no longer nave angina pain or discomfort, aid you formerly
have angina pain or discomfort that has been stopped due to surgery,
treatment, or due to some other reason?
& 1 NO 7>
? 2 YES
INTERVIEWER: STOP INTERVIEW AND
DISCUSS
ALT-6a. When vas Che last time you experienced angina?
/O-'f years or months ago (Circle years or months)
( ~ <£--2 */¦ /7>u} )
ALT-6b. What do you think stopped the angina? (Circle all that
apply)
3 1 BYPASS SURGERY
/ 2 MEDICATION
/ 3 LIFESTYLE ADJUSTMENTS
ff 4 ANGIOPLASTY
3 5 OTHER (please explain)
ALT-6c. Hov often aid you have angina vhen you used to have it?
(Circle best ansver)
/ 1 NEVER OCCURRED
/ 2 LESS THAN ONCE A MONTH
^ 3 ABOUT ONCE A MONTH
0 4. ABOUT TWICE A MONTH
4 5 ABOUT ONCE A WEEK
JL 6 ABOUT 2 OR 3 TIMES A WEEK
/ 7 ABOUT ONCE A DAY
/ 8 ABOUT TWICE A DAY
/ 9 3 TIMES A DAY OR MORE
ALT-6d. Hov uncomfortable or severe vas your angina vhen you
used to have it? (Circle best ansver)
/ 1 NO DISCOMFORT
/ 2 VERY MILD DISCOMFORT
¥ 3 MILD DISCOMFORT
/ 4 MODERATE DISCOMFORT
JL 5 MODERATELY SEVERE DISCOMFORT
/ 6 SEVERE DISCOMFORT
0 7 VERY SEVERE DISCOMFORT
SKIP TO QUESTION 9 (SUDJECT PACE NO. 3)
-2-
-------
'J
2 6. For each season, please check the box under the angina frequency level
that best describes hov often you usually have angina in that season.
Season
Level of Frecuencv
4 ,V
£.0
S.l
S.l
4-1
1
NEVER
OCCURS
LESS
THAN
ONCE A
MONTH
3
ABOUT
ONCE A
MONTH
u
ABOUT
TWICE A
MONTH
5
ABOUT
ONCE A
WEEK
6
ABOUT
2 OR 3
TIMES
A WEEK
1
ABOUT
ONCE
A DAY
a
ABOUT
TWICE
A DAY
q
3 TIMES
i A DAY
j OR MORE
SUMMER
(Jun-Aug)
3
V
3
2
d
/
/o
r
J
FALL
(Sep-Nov)
/
r
6
4
L
9
//
f
JL
/
FALL
jz (Sep-Nov)
/
r
//
9
/
/
WINTER
J.
/
D. 8. During the past 12 months, hov many days has angina pain or discomfort
kept you resting on the couch or chair or in bed for most of the day?
/
-------
II. ANGINA EPISODES: PREVENTION AND RESPONSE
Medical Care
9. Do you have medical insurance or participate in any program that
pays part or all of your medical bills?
9a. Circle all that apply:
/r 1 PRIVATE MEDICAL INSURANCE
Jf 2 VA BENEFITS
3 MEDICARE
J 4 HEALTH MAINTENANCE PROGRAM
X 5 OTHER (please specify)
r (> MebiCRL
9b. What is the total monthly cost to you of this coverage
(insurance premiums, membership fees)?
9c. Vhat percentage (or , _ your medical
expenses for office visits, hospital services, and
prescription medication are covered under this (these)
program(s)?
(INTERVIEVER-ASK ABOUT DEDUCTIBLES AND FIXED FEES, IF
APPLICABLE, AND CLEARLY MARK RESPONSES.)
6 1 NO > Vhy not?
SO 2 YES
emergency room and
hospital services
(including surgery)..
doctor office
visi t
f j. 4$% fthnsz, $0 7e - /&> %
Tk> -f W 'O , / ,
prescrip tion
medication
3 V % SO % - /fa
<3
7 I
7 I
-------
-3 10. Hov far do you drive each vav to see the doctor about your heart
condi tion?
/3. miles
/- /O^uo&s.
¦cy
11. Do you go for regular checkups?
C 1 NO
2 YES-
11a. Hov often do you go for checkups?
rrtuj^ (INTERVTEVER MARK IN TIMES PER YEAR)
C A' / ~ / T~ sJi/AS
lib. What is the average cost to you of a checkup?
(Do not include any amount paid by insurance.)
35'&uJjUL£i. . 40.
sy*JUc*<~s = ^O-
(INTERVIEVER PROBE: DO YOU KNOV HOV MUCH YOUR INSURANCE
CO. IS CHARGED? $ *-3S ) * /
cA duJx-*
*r
12. Hov many times in the pas: 12 months have you visited the doctor's
office because of angina or other heart problems (in addition to
any regular checkups)?
/yrxj_a^y rJ. >3.4 doctor's office visits-
/id-*cdk-
yfcXO.
f'
(If more than 0) What vas the cost to you of your last office
visit due to angina or other heart problems? (Do not include
any amount paid by insurance.)
*¦ / JuMfitt = ^<205 CK
c*oJ
-------
•M 13. Please list all the prescription medications you are presently
taking £or your heart condition. You may simply give the
prescription information directly from the bottles.
-=r o-i
Medication Name Dose
S /V /tA ate S
J £-£/>!r J? S"
7
/ Gin/n idtnt*
/ /) /aox i n /')/a,7ti//s
-/ ' j
/ Pr0Ca.'nam/d& /
^ - /At /*L
£ jj_ mre,1)csMatzr#/ JZ
/ /nsuh'n /
5 14. What is the average monthly cost to you of all the medications you
take for your heart problem? (Do not include any amount paid by
insurance.) JS"
/ dujLut, = o&t-»'&
/JvUiLKs S_/J__2S_ = •&/ - &/JU>.
(INTERVIEVER PROBE: DO YOU KNOW HOW HUCH YOUR INSURANCE CO. IS
CHARGED? $ )
5 15. Have you been to the emergency room in the past 12 months due to
your angina or other heart problems?
31 I NO
/3 2 YES
/3
. L
15a. Hov many times? /•
= /-S"
15b. What vas the cost to you of your last emergency room
visit? (Do not include any amount paid by insurance.)
. /J. SuXfdij -
$ Q / "J
(INTERVIEVER PRODE: DO YOU KNOU HOW MUCH YOUR INSURANCE
CO. VAS CHARGED? $ # r* ) /yJd^ut, ' #7?
-6-
-------
16. Have you stayed overnight in a hospital in the las; 12 months
because of angina or other heart problems?
3S" 1 NO
/S 2 YES->
Please list (starting vi:h most recant stay):
(/f
( / jJ*
(J
Dates Length of
Stay
-at/ days
Jl / days
days
Cause/Treatnent
*32o-/*vdJ
A rrnjULujtgUusttj)
Cos:
to You
£yJ:
/j-
9lSj
rt7lLC«*
(INTERVIEWER PROBE: DO YOU KNOW HOW MUCH TOUR INSURANCE
CO. WAS CHARGED? MARK ANSWERS AFTER COST TO YOU.)
17. In the past 12 months, have you had any other medical treatment or
been in any exercise program (including use of exercise equipment
in your home) for your heart condition?
¥o i
/o 2
MO
YES—>
Please give type of treatment and annual cost to you (do
not include any amount paid by insurance). If it
involves a one-time only purchase such as exercise
equipment, please give the amount spent in the past
year:
Treatment
/0
-j
Cost to You in the Past Year
W
$ /&
/yraLt**cJ
<.*& ¦
*0
M)
-------
Lifestyle Changes and Related Expenditures
(e 18- Which of the following things do you think, sometimes bring on or
aggravate your angina? (Circle all that apply)
J! A. 1 COLD TEMPERATURE ¦ - -
VJ. 2 STRESS OR ANXIETY
3 EXCITEMENT
PHYSICAL EXERTION (SUCH AS WALKING FAST OR HEAVY LIFTING)
/f 5 AIR POLLUTION
/o 6 CIGARETTE SMOKE
/T 7 MEALS (PAIN AFTER MEALS OR AFTER CERTAIN FOODS OR BEVERAGES)
6 8 OTHERS (please describe)
/ =
<£. — sS / " U /
Which do you think, is the most important factor? -V -
-------
io 20. In the pas: 12 months, have you hired any help for yard vork, home
or auto maintenance, or housevork to reduce or prevent angina or
other problems related to your heart condition?
J7 1
/
33. additional episodes per yea
( AbtJtc, 3
If you did this vork yourself, hov many
aadi tional angina episodes per year do you
think you vould get, over vhat you nov get?
£ Cf-eU;
C / '
/J. 7
/J?
/£/
/A 3
jp-6
^TyuuM, ji"!
sC. '~£j-u
-------
20e. If you did this vork yourself for a year, do you think the
severity of your angina episodes after doing this vork
would be vorse or be about the same as your current other
angina episodes?
<2- 1 ABOUT THE SAME / ~
/£ 2 VORSE j b
6
c
0
oZ
e
Using our 1 to 7 scale, hov severe do
you think
your angina episodes after doing this
vork vould
be?
1 NO DISCOMFORT
2 VERY MILD DISCOMFORT
2 MILD DISCOMFORT
a MODERATE DISCOMFORT
5 MODERATELY SEVERE DISCOMFORT
6 SEVERE DISCOMFORT
7 VERY SEVERE DISCOMFORT
20 f.
/
/?
If you aid this vork yourself for a year, do you believe
this night increase your chances of having a heart attack?
/ !/f"
1 NO
//
YES-
•7
/
//
/
If you aid this vork for a year,
you think this vould add to your
having
hov much do
chances of
a heart attack during the year?
IX)
1 ADD A SMALL AMOUNT (ADD LESS THAN
2 ADD A MODERATE AMOUNT (ADD 5-102)
3 ADD A MODERATELY LARGE AMOUNT (ADD 11-252)
4 ADD A LARGE AMOUNT (ADD MORE THAN 252)
5 OTHER (please explain)
on
20g. Do you hire this help for any other reasons, in adaiti
to possible concern about angina and heart attack risks?
1 NO
4 2 YES—^ Please exdain:
(INTERVTEVER: CHECK HERE TO MAKE SURE THEY
VOULD PREFER TO DO THE VORK THEMSELVES)
-10-
-------
/*/ /Icub £Cs&
/
20h. Please list any other examples of help you hire due to
your heart condition. Please describe the type of help,
for example help vith housevork or home maintenance, and
estimate hov many times in the past year you hired this
help. Please do not include any help that you think you
voula hire even if you did not have any trouble vith your
heart.
Type of Help
Times Hired
/7 in past year
7
20i. In the past year, have you purchased any special equipment
or made structural changes in your home to reduce physical
exertion that might aggravate your heart problem?
Examples might be an electric garage door opener or the
addition of a ground-floor bedroom.
/r i
¥ 1
NO
YES'
c\
Please describe each expenditure and give the
cost to you in the past year. Do not include
any expenditures that you think you vould
have made even if you did noc have any
trouble vith your heart.
Type of ExDenditure
Cost to You
in Past Year
/O1/, /of, /to,
/J/
$ <=¦?/ <££>?¦
$ 3*t ¦
/JJL
/.0O3
s-c
=
-11.
-------
Cjc.
0
INTERVIEWER: SKIP TO QUESTION 21 (SUBJECT PAGE NO. 9) UNLESS ANSWER TO
QUESTION 20 UAS NO.
ALT-20. In the past 12 months, have you purchased any special equipment or
made structural changes in your home to reduce physical exertion
that might aggravate your heart problem. Examples might be an
electric garage door opener or the addition of a ground-floor
bedroom.
«J? 1
J. 2
N0-
YES-
> SKIP TO QUESTION 21 (SUBJECT PAGE NO. 9)
//
ALT-20a. Please give an e>*smpie of your largest purchase or
expenditure of this type. Consider only purchases that
you vould not have made if you aid not have any trouble
with your heart.
/0/> ///
C JLuwj
/Tn^w/As, /T/uULi&jUL>
¦)
ALT-20b. What vas the cost to you of this purchase in the past
year?
_ t*
s A Id.
/yy\jL4siLS ,
ALT-20c. If you did the same vork or activity for a year without
using this equipment (or vithout making this change in
your home), do you believe you vould have more frequent
angina?
/ 1
y 2
NO
YES-
If you did the same vork or activity for a year
vithout using this equipment or making these changes,
hov many additional angina episodes per year do you
think you vculd get, over what you nov get?
/4-f
additional episodes per year
"cri
-------
ALT-20d. If you did the same vork or activity for a year"vithout
using this equipment (or without making this change in
your home), do you believe the severity of any resulting
angina episodes vould be vorse or be about the same as
your current angina episodes?
/ i ABOUT THE SAME
J. 2 WORSE
£
P
4
1
/
t
/
Using our 1 to 7 scale, how severe do you
think the
resulting angina episodes vould be?
(INTERVIEWER: ANSWER CHOICES ARE THE SAME
AS UNDER
QUESTION 20e—SUBJECT PAGE NO- 7)
1 NO DISCOMFORT
2 VERY MILD DISCOMFORT
3 MILD DISCOMFORT
4 MODERATE DISCOMFORT
5 MODERATELY SEVERE DISCOMFORT
6 SEVERE DISCOMFORT
7 VERY SEVERE DISCOMFORT
ALT-20e. If you did the same vork or activity for a year without
using this equipment (or without making this change in
your home), do you believe this might increase your
chances of having a heart attack?
/ 1 NO
«£ 2 YES 1
/
/
0
/
9>
Without using this equipment (or without making this
change in your home) how much would this add to your
chances of having a heart attack during the year?
(INTERVIEWER: ANSWER CHOICES ARE THE SAME AS UNDER
QUESTION 20f—SUBJECT PAGE NO. 7)
1 ADD A SMALL AMOUNT (ADD LESS THAN 52)
2 ADD A MODERATE AMOUNT (ADD 5-102)
3 ADD A MODERATELY LARGE AMOUNT (ADD 11-252)
A ADD A LARGE AMOUNT (ADD MORE THAN 252)
5 OTHER (please explain)
-------
ALT-20f. Have you made this expenditure for any other reasons, in
addition to possible concern about angina and heart attack
risks?
A 1
2
Please explain
ALT-20g. Please list any other examples of expenditures you have
mace in the past year for special equipment or structural
changes in your home to reduce physical exertion due to
your heart problem. Please describe each expenditure and
give the cost to you in the past year. Do not include any
expenditures that you vould have made even if you did not
have any trouble with your heart.
Type of Expenditure Cost to You in Past Year
/o7: /j.e>
/ /
© $
¦*— s
- 1 A -
-------
Employment
21. Are vou emDloyed?
3f 1 N0-
/£" 2 YES-
INTERVIEVER: ASK ALT-21, INTERVTEVER PAGE 17.
IT IS NOT ON SUBJECT'S QUESTIONNAIRE
/yytl^L *fr"» X? days
21a. Vhat ars your average total hours pez/pesk. (all jobs)?
hours per week ^>yt.
Did the job change mean a reduction in
income?
/ 1 NO
/ 2 YES
* /Julfut wZZZEZ cuyj •
/ / 0
-------
/S~ Jo
21f- Ara you vorking fever hours than you would like because
of your heart condition?
7 1 NO
6 2 YES ^
Hov many hours per week would you like to be
vorking?
'r*4A*o3l. C hours per ve
ek
21g. Please indicate the category that represents hov much
you earn annually at your current job(s).
4 1 LESS THAN $4,999
¦3 2 $5,000 - $9,999
3 $10,000 - $14,999
/ 4 $15,000 - $19,999
5 $20,000 - $24,999
/ 6 $25,000 - $29,999
/ 7 $30,000
^ 8 $35,000
/ 9 $40,000
/ 10 $45,000
/ 11 $50,000
$34,999
$39,999
$44,999
$49,999
$59,999
/ 12 $60,000 OR MORE
X fa /&*c-eAj /TvlPJMJ-
0
- 1 A
-------
£.C^
-------
III. IMPORTANCE OF CHANGES IN ANGINA
IP 22. Please think of your most recent angina episode that you vouia say
vas typical. When aid this occur?
/mJUuv /02. /V 2-A4) . C /— /,cJ
(INTERVIEWER: IF EPISODE WAS THEN THEY ANSWERED THE PHONE FOR THIS
INTERVIEW, ASK THEM. TO THINK OF ANOTHER RECENT EPISODE AND REPEAT
QUESTION.)
\C 23. Vhere vera you?
lo 24. What vere you doing?
IO 25. Hov long vere you doing this activity? /i /
yy \ <=A &*<-' cU*-» 'c. A/™
/rrUJUtw 33¦7-S' minutes ( / -36>0/rrus*<^ J
10 26. Hov long did the pain or discomfort last?
-------
1
2
V
3
J3
4
/£
c
JJL
6
/I
7
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8
a
/
9
J
/D
11 28. Sometimes an angina episode may cause you some inconvenience, expense,
or other effect on your life. Which of the following possible effects
of this angina episode bothered you? (Check all that apply)
MEDICAL TREATMENT EXPENSES.
LOST INCOME.
NON-MEDICAL EXPENSES (SUCH AS PAYING FOR SERVICES).
PAIN AND DISCOMFORT.
LESS ABILITY TO WORK AT A JOB (FOR REASONS OTHER THAN INCOME).
LESS ABILITY TO DO DESIRED ACTIVITIES (RECREATION, CHORES, ETC.).
CONCERN TO YOU ABOUT POTENTIAL HEART ATTACK OR BYPASS SURGERY.
CONCERN TO YOU ABOUT WORRY OR INCONVENIENCE TO FAMILY AND
FRIENDS DUE TO YOUR HEALTH.
OTHER, please explain / J -
, I .y - /y ^
None. I S = 3
____ ^2 -
Vhich vas most bochersome to you? \ 9 - 7 " . / ,
/ ^ ^ '^uJ
I I 29. If there vas any actual monetary cost to you* dii% 'to^t'nis episode,
can you estimate hov much it vas?
yj ^ O — ¦'/f
$ JfD/. * Si = / V
/O-OKz /
1 I 30a. If you could expect to have a similar typical angina episode
tomorrow, but that it vould be possible to avoid it by paying some
amount of money, what is the most vould you be willing to pay to
avoid having this episode tomorrow?
/) j -i
-------
The interviever vill ask a fev questions about other angina episodes you have
had. Before the interviever calls, you may visn to think, about the vorst
angina episode you have had ana about the mildest episodes you have had.
(INTERVIEVER: QUESTIONS 22b-28b CONCERN THE WORST EPISODE AND QUESTIONS
22c-28c CONCERN TEE MILDEST ESPISODE. TEET PARALLEL THE QUESTIONS FOR THE
TYPICAL EPISODE. THEY ARE NOT ON SUBJECT'S VERSION.)
22b. Please think of the vorst angina episode you have ever had. When
did this occur?
/, / 7/
J-9999
23b. Where vers you?
24b. What vere you doing?
25b. Hov long vere you doing this activity?
// C- S" minutes
26b. Hov long did the pain or discomfort last?
/V*?. minutes /" 9 ^
27b. What did you do after this vorst angina episode began? (Check all
that apply)
(INTERVIEVER: RESPONSES ARE THE SAME AS FOR QUESTION 27,
SUBJECT PAGE 11)
1 STOPPED FOR A WHILE AND RESTED. LATER RESUMED THE ACTIVITY.
Hov long did you rest before starting again? mins. d/&-bD
11 2 STOPPED THE ACTIVITY ALTOGETHER.
/ 3 CONTINUED AT THE SAME PACE.
A 4 SLOWED DOWN BUT DID NOT STOP.
5 TOOK NITROGLYCERIN OR OTHER MEDICATION.
^ 6 OTHER, please describe:
Ao ? Hospital
Which of these vas the most important means of relief for this
particular episode?
/ - ^ yUcA-jti/s
j * r "0
S~ -
b => 3
f 9 '1 " "
-------
28b. Sometimes an angina episode may cause you some inconvenience,
expense, or other effect on your life. Which of the folloving
possible effects of this worst angina episode bothered you? (Check,
all that apply)
(INTERVIEWER: RESPONSES ARE THE SAME AS FOR QUESTION 28,
SUBJECT PAGE 11)
f 1 MEDICAL TREATMENT EXPENSES.
-------
27c. What did you do after this mild angina episode began? (Check all
that apply)
(INTERVIEWER: RESPONSES ARE TEE SAME AS FOR QUESTION 27,
SUBJECT PAGE 11)
/£" 1 STOPPED FOR A VEILS AND RESTED. LATER RESUMED TEE ACTIVITY. /_ £
Hov long did you rest before starting again? //f- mins. j
6 2 STOPPED THE ACTIVITY ALTOGETHER.
* 3 CONTINUED AT THE SAME PACE.
? A SLOWED DOWN BUT DID NOT STOP.
/? 5 TOOK NITROGLYCERIN OR OTHER MEDICATION.
(, 6 OTHER, please describe:
d 1 HvsP/tal
Which of these vas the most important means of relief for this
28c- Sometimes an angina episode may cause you some inconvenience,
expense, or other effect on your life. Which of the following
possible effects of this mild angina episode bocherea you? (Check
all that apply)
(INTERVIEWER: RESPONSES ARE THE SAKE AS FOR QUESTION 28,
SUBJECT PAGE 11)
/I MEDICAL TREATMENT EXPENSES.
A 2 LOST INCOME.
/ 3 NON-MEDICAL EXPENSES (SUCH AS PAYING FOR SERVICES).
A PAIN AND DISCOMFORT.
V 5 LESS ABILITY TO WORK AT A JOB (FOR REASONS OTHER THAN
INCOME).
/(, 6 LESS ABILITY TO DO DESIRED ACTIVITIES (RECREATION, CHORES,
ETC.).
7 CONCERN TO YOU ABOUT POTENTIAL HEART ATTACK OR BYPASS
SURGERY.
* 8 CONCERN TO YOU ABOUT WORRY OR INCONVENIENCE TO FAMILY AND
FRIENDS DUE TO YOUR HEALTH.
/0 9 OTHER, please explain
S" /o flotJG
S -
Which vas most bothersome to you?
L - (,
7- - j
? = f
-------
15. 31. This question is about hov you think you would be affected if your
heart condition were to become worse, causing you to have angina
pain or discomfort more often than you do nov. Ue are interested
in finding out hov much the different effects of such a change in
your condition would bother you, once you had done vhat you could
to minimize the effects.
Listed below are some effects on your life that might occur if you
were to have angina mora often. For the effect that would be most
bothersome to you, circle the number 10. For the effect that would
be least bothersome to you, circle the number 1. For the remaining
effects on the list, please circle the number that best describes
how bothersome it would be relative to these extremes. You may
circle the same number for more than one effect if they would be
equally bothersome to you.
Effects you may experience if Relative bothersomeness
your angina worsened of the effect
Leas c Mos t
Bothersome Bothersome ^ ^££z
3.3$
*/.j£
£¦<&/
a. More medical treatment
1
2
3
4
5
6
7
8
9
10
i
expenses.
A
A
/
X
3
/
3
3
b. Less ability to earn income.
1
2
3
4
5
6
1
8
9
10
/X.
/i
2
/
/
A
/
J.
/
sr
r
c. More non-medical expenses
l
2
3
L
5
6
1
8
9
10
/
(such as paying for services).
n
3
¥
3
¥
¥
¥
¥
J
JL
d. More pain or discomfort.
i
2
3
4
5
6
1
8
9
10
/
0
3
/
s~
&
¥
3
r
e. Less ability to work at a job
i
2
3
4
5
6
1
8
9
10
'/
(for reasons other than income)
. c
/
/
A
X
A
¥
/f
f. Less ability to do desired
i
2
3
4
5
6
1
8
9
10
activities (recreation, chores,
/
/
0
0
r
C,
3
9
S
/ ?
friends due to your health.
-------
32. Suppose your heart condition were to become vorse so that with your
current medical treatment and lifestyle your angina episodes would
occur more often. Suppose also that a new medical treatment were
available that could prevent the additional angina without causing
undesirable side effects or requiring lifestyle changes.
If the treatment would prevent additional angina episodes per
month and if you had to pay the entire cost yourself, would you take
the treatment if it cost S each month?
t> 1
YA 2
NO
YES-
Would you take the treatment if it cost $
^ 1 NO / 'J-
3! 2 YES
each month?
H'
Would you take
the treatment if it cost $
each
month?
H 1 NO
.io 2 YES
13 33. What is the most that you would pay for this treatment if it would
prevent additional angina episodes per month?
/] ^
$ J/S~SO per month ^
- *> /
INTERVIEWER: IF ALL THE ANSWERS TO QUESTION 32 VERE NO,
OR THE ANSWER TO QUESTION 33 WAS $0,
OR REFUSED TO ANSWER
ASK THE FOLLOWING QUESTION (NOT ON SUBJECT'S VERSION)
Which of the following reasons best explains your answer to the
previous questions about how much you would pay for such a treatment?
6 1 I DON'T BELIEVE I SHOULD HAVE TO PAY FOR A NEW TREATMENT.
P 2 I DON'T BELIEVE THERE COULD BE ANY SUCH TREATMENT.
3 3 IT WOULD NOT BE WORTH PAYING ANYTHING FOR PREVENTING THAT MUCH
ANGINA
7 4 OTHER (PLEASE EXPLAIN)
-------
HEART DISEASE HISTORY
34. Has a doctor ever said you had a heart attack.?
NO
J/2 YES >
Please list dates starting vith most recent (month
and year is sufficient):
2C ~
'fc -
gtj r- //
13
JJ-= U^UL
A " 0
rr - T
- A
JL Af j 4p/
*3 Hi " - '*>*-&
=*V Ml " " '7° ~
¦J e- ! » " Yo 9 - 2J-
35- Has a doctor ever recommended you have coronary artery bypass
surgery?
/T 1 NO—>
Has the doctor saia vhy not?
33 2 YES—>
Did you have
the surgery?
JO 1 NO >
Vhy not?
Please list dates (starting vith most
recen t):
mo-mi,
/
-------
36. Have you ever had angioplasty to improve the blood flow to your
heart tissue? (Angioplasty involves catheterization vith a balloon
catheter that expands narrowed coronary arteries.)
3°f 1
// 2
NO
YES.
Please list dates (starting vith most recent):
/97L- /MC
:Ja.s blood flow improved?
^ i no / y
YES
£ 2
37. Each time you have an angina episode, do you believe (Circle the
bes t ansver):
? 1 YOUR HEART MAY BE HARMED A SMALL AMOUNT AND PROBABLY DOES NOT
HEAL?
? 2 YOUR HEART MAY BE HARMED A SMALL AMOUNT BUT PROBABLY DOES
HEAL?
30 3 YOUR HEART IS PROBABLY NOT HARMED, THE ANGINA IS SIMPLY YOUR
BODY'S WARNING TO SLOW DOWN?
SL 4 OTHER (please explain)
38. Circle the number on the scale that best describes how often the
statement has been true for you in the past fev years.
a. I get as much exercise as my NEVER ALWAYS
physical condition allows. 1234567 y
3 3 /C /o /3 &
b. I exert myself physically NEVER ALWAYS j
until I begin to feel angina 1 2 3 A 5 6 7
pain or discomfort. /j/ •>/- 9 ? 8 &
c. I follow the diet recommend- NEVER ALWAYS
ations of my doctor. 1234567 J?
V / 7 £ // /JL ?
d. I watch my pulse rate during NEVER ALWAYS j,
exercise or take my blood 12 3 4 5 6 7
pressure at home. A $ 3 3 V /¦/
e. I am under a lot of stress. NEVER ALWAYS J.
1 2 3 4 5 6 7
7 ? /3 /X & 3
Y,-
-------
V. PERCEPTIONS ABOUT AIR POLLUTION
1*5 39- Hov do you usually tell vner. air pollution is high? (Circle all
that apply)
? 1 DON'T USUALLY NOTICE AIR POLLUTION
2 SEE OR HEAR REPORTS IN THE NEWSPAPER, TV OR RADIO
jo 3 SEE IT IN THE AIR
30 4 FEEL IT AFFECTING MY EYES OR LUNGS
A3 5 SMELL IT
(, 6 OTHER (please describe)
15 40. How often do you think there is enough air pollution in the areas
where you live or vork to affect your health or the health of
o thers?
/ 1 NEVER
S' 2 LESS THAN 7 DAYS PER YEAR
/6 3 7 TO 14 DAYS PER YEAR
4 14 TO 30 DAYS PER YEAR
/ 5 30 TO 60 DAYS PER YEAR
/r 6 MORE THAN 60 DAYS PER YEAR
/ aQ * 7 j
15 41. (If you think air pollution sometimes aggravates your angina) On
days when you are concerned that air pollution might affect your
angina, vnat do you usually do? (Circle all that apply)
/? 1 NOTHING DIFFERENT, KEEP TO MY USUAL ROUTINE
etc 1 SPEND LESS TIME OUTDOORS
A/3 EXERCISE LESS
S 4 GO TO A LESS POLLUTED AREA OR PART OF TOVN
r 5 OTHER (please specify)
not applicable
-------
ICo 42. Please indicate the level of air pollution you think, is usually
associated vith each of the following activities or locations.
Low
Pollution
High
Pollution
~i>a v 'L
XtfO-UJ
I Cc
a. Driving at rush hour.
1
2,
3
4
5
4
P
0
V
/3
3/
b. Driving on city streets in normal traffic.
1
2
3
4
5
/
/
j/
•7 J
/o
(,
c. Driving on freeways in normal traffic.
1
2
3
4
5
/
/
S
•»¥
//
£
d. Walking on city streets.
1
2
3
4
5
/
/
//
/&
£~
e. Outdoors, near your home.
1
2
3
4
5
//
W
/&
/-L
/
f. Outdoors, in parks or other public places.
1
n
L
3
4
5
.2
/0
'2
/3
£
/
g. Indoors, in restaurants, stores, or other
1
2
3
4
5
/
public places.
/s
/r
//
V
/
/
h. Indoors, in your home.
1
2
3
4
5
JtS
//
3
a
*
VI. ADDITIONAL BACKGROUND QUESTIONS
43. Please indicate the category that represents your household's
current annual (1985) income, including any disability payments.
/I LESS THAN $4,999
'o 2 $5,000-39,999
"3 $10,000 - $14,999
S 4 $15,000 - $19,999
S 5 $20,000 - $24,999
V 6 $25,000 - $29,999
A 7 $30,000 - $34,999
8 $35,000 - $39,999
A 9 $40,000 - $44,999
$49,999
J
d 10 $45,000
7 11 $50,000 - $59,999
J 12 $60,000 OR MORE $ . .
otei, 0
-------
45. Is there a history of coronary heart disease in your family?
•IS 1 NO
2 YES
46. Do you smoke cigarettes?
ys* l no
y 2 YES
/ /3cjtLL>
jL\
On average, hov mar$ packs do you smoke per ^eek?
/Mb* £ ¦ Jf pacics
Hov many years have you smoked?
3S^f years
/-i
/£-S~6
47. (If NO to Q-46) Did you ever smoke cigarettes?
$ 1 NO
JY 2 YES
On average, hov many packs did you smoke per veek?
//. ob packs /- J2
Hov many years aid you smoke?
£ •?! years 6 -S~0
A
48. Does anyone else in your household smoke?
-// 1 NO
f 2 YES
49. What is your current marital status?
J9 1 MARRIED
S 2 NEVER HARRIED
J> 3 DIVORCED, SEPARATED, VIDOVED
50. What is your relationship in your household?
£ 1 HEAD OF HOUSEHOLD LIVING ALONE
4 2 HEAD OF HOUSEHOLD LIVING VITH NON-RELATIVES
t/0 3 HEAD OF HOUSEHOLD VITH 2 OR MORE RELATED PERSONS
4 OTHER (specify)
51. Including yourself, hov many individuals live in your household?
persons
52. What is your heighc?
/ ~ ¦£*
fee c £?.SA inches
53. Vhat is your veighc? //XT/ pounds
-""i _
-------
54.
What
is your national or ancestral origin?
43 1 WHITE, CAUCASIAN
0 2 ASIAN
*r 3 HISPANIC
4 BLACK, AFRO-AMERICAN
/ 5 OTHER (specify)
ANY ADDITIONAL COMMENTS?
-30-
-------
DATE
SUBJECT
INTERVIEWER
"A't/c,
T~
SUPPLEMENTARY QUESTIONS ON CO EXPOSURE
CORONARY HEART DISEASE STUDY
Now that we are at Che end of the questionnaire I'd like to ask you
a few questions about factors of your lifestyle that uav influence
your exposure to an air pollutant, carbon monoxide.
Do you usually travel by auto, bus or foot?
4# 1 personal auto
2 car pool
0 3 bus
/ 4 walking
5 motorcycle
6 other
Do you travel to ana from work or any other place at leas;
three (3) tines per week?
/* 1 NO
3^ 2 YES-
I
2a. How much time do you spend
traveling one wav?
r /
minutes
3. How many hours do you spend in heavy traffic while traveling
each week?
/• dS" hrs. 0 - /O
cA3 s ft
4. Are you frequently around running autos or gasoline powered
engines on the job or at home (e.g., auto repair work at
home)?
J3 1 NO
/(, 2 YES
S-l
-------
5. Do you regularly use lawn equipment powered by gasoline engines?
>32 L NO
Af 2 YES
Is a garage attached to your home or within the building in
which ycu live?
A* L NO
4 r 2 YES-
Are autos parked in the garage?
i—*
si
o
/J-
2 YES i
7. Do you have natural gas fuel appliances in your home?
y 1 NO >
INTERVIEWER PROBE: IS YOITR HOME
ALL ELECTRIC?
1 NO
2 YES J.
-/J" 2 YES
8. Do you use any of the following gas fueled appliances in
your home?
<3c 3
31 4
9.
137 I gas heater
<31 2 gas cooking stove or range
gas cooking oven
gas water heater
/
-------
10. Does your hone have a fireplace?
J 3 1
2
NO
YES
INTERVIEWER PROBE: HOW MA.\T TIMES
PER MONTH DO YOU USE YOUR FIREPLACE
DURING THE WINTERTIME?
. L 4 L.
TT^
11. If you have a kitchen exhaust: fan do you use it when
cooking?
/3 1 No, or almost never
/f 2 Yes, at tices
/g 3 Yes , alvays
jl 9 Not applicable
12. If you have a kitchen window, do you open it when cooking?
Si No, or almost never
2 Yes, at times
jp ^ 3 Yes, always
3 9 Noc applicable
13. Do you have energy-saving insulation or weather stripping
installed in your home?
/S" I NO
33 2 YES
/ '/b jt^u)
14. What main type of heating system do you use in your home?
(Circle best answer.)
3o 1 Central warm air furnace with ducts to individual
rooms
9 2 Wall furnace
*f- 3 Floor furnace
/ 4 Portable electric room heater (circulating or radiant)
5 Oil or kerosene space heaters
0 6 Fireplace or woocburning stove
& 7 Solar
V 8 No heating equipment, or other
/ 9 Do not know
S-3
-------
15. Do you notice drafts in your hone?
3? 1 No, never
// 2 Yes, but raraiv
J 3 Yes, often (each day)
16.
Is your home located near any (within three blocks) of
the following? (Circle ail that apply.)
3$ 1
2
jrf 3
/ 4
/ 5
/ 6
Busy roadway or intersection
Auto or truck maintenance area or garage
Site of open burning
Manufacturing plant or industry with heavy smoke
emission or furnaces
Electricity or steam plant
Other (please specify)
17. How often are you around others who smoke?
33 1 Rarely
/ ^ 2 Frequently
1
Where? 1 on the job
2 at home
3 other (please specify)
INTERVIEWER: IF ANSWER TO QUESTION 48 (PAGE 29 INTERVIEWER VERSION)
WAS YES, PLEASE ASK THE FOLLOWING QUESTION. ^
18. If smokers are present at home, how many? %
Number of smokers
Approximate number of packs smoked within the home by
all smokers during a typical week's time, =. jD
A
d
-------
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Niiscsr of data reccrde : 50
"ate of last uciate : 03/02/36
Field
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Type
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5tru:ti:rb for sataoase : A:PIL0TGU3.dbf
Mustier of data records : 50
Date of last update : 02/02/86
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Type
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:: Total n
-------
QUESTION
Date of Interview
Subject Identification
Interviewer
Coder
Question 1
Question 2
Question 3
Question 4
Question 5
Question Alt-6
Question Alt-6 Why?
Question Alt-6a
Question Alt-6b
Question Alt-6c
Question Alt-6d
Question 6
CODING SCHEME
PILOTQU1 .DBF
VARIABLE CHARACTER TYPE OR
NAME COLUMNS ASSIGNMENT
MONTH 1-2 Numeric
3 /
DAY 4-5 Numeric
6 /
YEAR 7-8 Numeric
SUBJECT 9-13 Alphanumeric
INTVIEWR 14-16 Alphabetic
CODER 17-19 Alphabetic
QIAEVER 20-21 1=NO 2=YES
Q2WLKUP 22-23 1=NO 2=YES
Q3WLKLEV 24-25 1=NO 2=YES
Q4DRDX 26-27 1=NO 2=YES
Q5ACUR 28-29 1=NO 2=YES
QA6AFORM 30-31 1=NO 2=YES
QA6COM 32-51 Alphabetic (Comment Field)
QA6AWHEN 52-54 Numeric (No. of months ago)
QA6BCABG 55-56 2=YES
QA6BRX 57-58 2=YES
QA6BLIFE 59-60 2=YES
QA6BPTCA 61-62 2=YES
QA6BOTH 63-64 2=YES
QA6CFRQ 65-66 1-9
QA6DSEV 67-68 1-7
Q6FRQSU 69-70 1-9
Q6FRQFA 71-72 1-9
-------
Q6FRQWI 73-74
QoFRQSP 75-76
Question 7 Q7SEVSU 77-78
Q7SEVFA 79-80
Q7SEVWI 81-82
Q7SEVSP 83-84
Q8REST 85-87
Question 8
Question 9
Question 9 Why?
Question 9a
Q9INS 88-89
Q9NOREAS 90-91
Q9APVT 92-93
Q9AVA 94-95
Q9AMCARE 96-97
Q9AHMO 98-99
Q9AOTH 100-101
Q9AMCAL 102-103
Question 9b Q9BPREM 104-109
Question 9c Q9CDRPC 110-112
Q9CERPC 113-115
QSCRXPC 116-118
Q9CYRDED 119-122
Question 10 Q10MILES 123-125
Question 11 Q11REGCK 126-127
Question 11a Q11AFRQ 128-129
Question 11b Q11BCST 130-133
Question 11b Insurance Q11 BINS 134-138
Question 12 Q12AFRQ 139-140
Question12a Q12ACST 141-145
Question 12a InsuranceQ12AINS 146-151
1-9
1-9
1-7
1-7
1-7
1-7
Numeric (No. of days in 12
months)
1=NO 2=YES
2=COMMENT (See Listing)
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
Numeric (Exact amount paid
dollars and cents)
Numeric
Numeric
Numeric
Numeric (Yearly deductible
whole dollars)
Numeric
1=NO 2=YES
Numeric
Numeric (Whole dollars)
Numeric (Whole dollars)
Numeric
Numeric (Whole dollars)
Numeric (Whole dollars)
-------
Question 13
Question 14
Q13RX1
Q13RX1MG
Q13RX2
Q13RX2MG
Q13RX3
Q13RX3MG
Q13RX4
Q13RX4MG
Q13RX5
Q13RX5MG
Q13RX6
Q13RX6MG
Q13RX7
Q13RX7MG
Q13RX8
Q13RX8MG
Q14RXCST
Question 14 Insurance Q14RXINS
Question 15 Q15ER
Question 15a Q15ERFRQ
Question 15b Q15ERCST
Question 15b Insurance Q15ERINS
Question16
Question 16
Q16QVRNI
Q16H1DAY
Q16H1STY
Hospitalization 1 Q16H1DX
Q16H1CST
Q16H1 INS
152-154
155
156-159
160-162
163
164-167
168-170
171
172-175
176-178
179
180-183
184-186
187
188-191
192-194
195
1 96-199
200-202
203
204-207
208-210
211
212-215
216-218
219-222
223-224
225-227
228-231
232-236
237-238
239-242
243-245
246-248
249-253
254-255
Numeric (See Medication Codes)
/
Numeric (Dose per day in whole
mg)
Numeric
/
Numeric
Numeric
/
Numeric
Numeric
/
Numeric
Numeric
/
Numeric
Numeric
/
Numeric
Numeric
/
Numeric
Numeric
/
Numeric
Numeric (Whole dollars)
Numeric (Whole dollars)
1=NO 2=YES
Numeric
Numeric (Whole dollars)
Numeric (Whole dollars)
1=NO 2=YES
Numeric (Month and Year)
Numeric (Stay in days)
Numeric (Cause, see Q16 codes)
Numeric (Cost in whole dollars)
Numeric (Cost in 1,000 dollars)
Q16H2DAY
256-259
Numeric
-------
Q16H2STY 260-262
Hospitalization 2 Q162DX 263-265
Q16H2CST 266-270
Q16H2INS 271-272
Q16H3DAY 273-276
Q16H3STY 277-279
Hospitalization 3 Q16H3DX 280-282
Q16H3CST 283-287
Q16H3INS 288-289
Question 17
Question 17
Q17MEDTR
Q17T1
Q17T1CST
Q17T2
Q17T2CST
Q17T3
Q17T3CST
290-291
292-294
295
296-299
300-302
303
304-307
308-310
311
312-315
Question 18 Q18TEMP 316-317
Q18STR 318-319
Q18EXCIT 320-321
Q18EXR 322-323
Q18POL 324-325
Q18SMK 326-327
Q18MEALS 328-329
Q180TH 330-331
Q18RATE 332-333
Question 19
Q19NOCHG
Q19NOREC
Q19NOEXR
Q19SLEEP
Q190FFWK
Q19HOME
Q19SLOW
Q19NOSTR
Q19NOWTH
Q19NOPOL
Q19NOSMK
Q19NOOTH
334-335
336-337
338-339
340-341
342-343
344-345
346-347
348-349
350-351
352-353
354-355
356-357
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
1=NO 2=YES
Numeric (Treatment, see Q17
Codes)
/
Numeric (Cost in whole dollars)
Numeric
/
Numeric
Numeric
/
Numeric
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
1-8
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
Question 20
Q20HIRE
358-359
1 =NO 2=YES
-------
Question 20a
Q20EXAMP
360-362
Numeric (See Activity Codes)
Question 20b
Q20BFRQ
363-365
Numeric
Question 20c
Q20CCST
366-369
Numeric (Cost in whole dollar;
Question 20d
Q20DMORE
370-371
1=NO 2=YES
Question 20d
Additional Q20DADD
372-374
Numeric
Question 20e
Q20ESEV
375-376
1=NO 2=YES
Question 20e
Q20ESEV7
377-378
1-7
Question 20f
Q20FMI
379-380
1=NO 2=YES
Question 20f
Q20FMIPC
381-382
1-5
Question 20g
Q20GREAS
383-384
1=NO 2=YES
Question 20h
Q20H1
385-387
Numeric (See Activity Codes)
Q20H1FRQ
388-390
Numeric
Q20H2
391-393
Numeric
Q20H2FRQ
394-396
Numeric
Q20H3
397-399
Numeric
Q20H3FRQ
400-402
Numeric
Q20H4
403-405
Numeric
Q20H4FRQ
406-408
Numeric
Question 20i
Q20IEQP
409-410
1=NO 2=YES
Question 20i
Q20IEQP1
411-425
Numeric (Purchase, see Q20i
Codes)
Question Alt-20
Question Alt-20a
Q20I1CST 426-430 Numeric (Cost in whole dollars)
Q20IEQP2 431-445 Numeric
Q20I2CST 446-450 Numeric
Q20IEQP3 451-465 Numeric
Q20I3CST 466-470 Numeric
QA20EQP 471-472 Numeric
QA20AEX 473-487 Numeric (See Activity Codes)
-------
PIL0TQU2.DBF
QUESTION
VARIABLE
NAM^
COLUMNfS)
CHARACTER TYPE OR
ASSIGNMENT
Subject identification
SUBJECT
1-5
Alphanumeric
Question Alt-20b
QA20BCST
6-10
Numeric
Question Alt-20c
QA20CINC
11-12
1=NO 2=YES
Question Alt-20c
QA20CADD
13-15
Numeric
Question Alt-20d
QA20DSEV
1 6-17
1-2
Question AIt-20d
QA20DSV7
1 8-19
1 -7
Question Alt-20e
QA20EMI
20-21
1=NO 2=YES
Question Alt-20e
QA20EMIR
22-23
1-5
Question Alt-20f
QA20FRQA
24-25
1=NO 2=YES
Question Alt-20f
QA20FCOM
26-40
Alphabetic (Comment Field)
Question Alt-20g
QA20GEQP
QA20G1CS
QA20GE2
QA20G2CS
QA20GE3
QA20G3CS
QA20GE4
QA20G4CS
41-55
56-60
61-75
76-80
81-95
96-1 00
101-115
1 16-120
Numeric (Purchase, see Q20i
Codes)
Numeric (Cost in whole dollars)
Numeric
Numeric
Numeric
Numeric
Numeric
Numeric
Question 21
Q21EMPLY
121-122
1=NO 2=YES
Question 21a
Q21AHRS
123-124
Numeric
Question 21b
Q21BOCC1
Q21BOCC2
125-128
129-132
Numeric
Numeric
Question 21c
Q21CMISS
133-135
Numeric
Question 21 d
Q21DSKLV
Q21DCOVR
Q21DDAYS
136-137
138-139
140-142
1=NO 2=YES
1=NO 2=YES
Numeric
Question 21e
Q21ECGJB
143-144
1=NO 2=YES
-------
Q21EREDC
145-146
1 =N0 2=YES
Question 21 f
Q21FFEWR
Q21FUKE
147-148
149-150
1=NO 2=YES
Numeric
Question 21 g
Q21GINCM
151-153
1-1 2
Question Alt-21
QA21QUIT
154-155
1=NO 2=
=YES
Question Alt-21 a
QA21AAGO
156-157
Numeric
Question Alt-21 b
QA21BOCC
158-161
Numeric (See Occupation Codes)
Question Alt-21 c
QA21CINC
162-164
1-12
Question Alt-21 d
QA21DRET
165-166
1=NO 2=
=YES
Question 22
Q22WHEN
167-170
Numeric
(Days ago)
Question 23
Q23LOC
171-173
Numeric
(See Microenvironment
Codes)
Question 24
Q24ACT
174-176
Numeric
(See Activity Codes)
Question 25
Q25TIM
177-179
Numeric
Question 25
Q26DUR
180-1 82
Numeric
Question 27
Q27REST
183-184
2=YES
185
/
Q27MIN
186-188
Numeric
Q27STOP
189-190
2=YES
Q27SAME
191-192
2=YES
Q27SLOW
193-194
2=YES
Q27NTG
195-1 96
2=YES
Q270TH
197-198
2=YES
Q27HOSP
199-200
2=YES
(Sought relief at
hospital)
Q27RATE
201-202
1-7
Question 28
Q28MED
203-204
2=YES
Q28LOST
205-206
2=YES
Q28EXP
207-208
2=YES
Q28PAIN
209-210
2=YES
Q28JOB
21 1-212
2=YES
Q28ACT
213-214
2=YES
Q28MI
215-216
2=YES
Q28WOR
217-218
2=YES
Q280TH
219-220
2=YES
-------
Q28RATE
223-224
1-10
Question 29
Q29CST
225-230
Numeric
(Cost in whole dollars)
Question 30a
Q30AAVD1
231-238
Numeric
(Payment in whole
dollars)
Q30AREAS
239-240
1-4
Q30ACOM
241-242
1-4 (See Q30a Codes)
Question 30b
Q30BAVD2
243-250
Numeric
(Payment in whole
dollars)
Question 22b
Q22BWHEN
251-254
Numeric
(Days ago)
Question 23b
Q23BLOC
255-257
Numeric
(See Microenvironment
Codes)
Question 24b
Q24BACT
258-260
Numeric
(See Activity Codes)
Question 25b
Q25BTIM
261-263
Numeric
Question 26b
Q26BDUR
264-266
Numeric
Question 27b
Q27BREST
267-268
2=YES
269
/
Q27BMIN
270-272
Numeric
Q27BSTOP
273-274
2=YES
Q27BSAME
275-276
2=YES
Q27BSLOW
277-278
2=YES
Q27BNTG
279-280
2=YES
Q27BOTH
281-282
2=YES
Q27BHOSP
283-284
2=YES
(Sought relief at
Q27BRATE
hospital)
285-286
1-7
Question 28b
Q28BMED
287-
•288
2=
=YES
Q28BLOST
289-
•290
2=
=YES
Q28BEXP
291 -
•292
2=
=YES
Q28BPAIN
293-
•294
2=
=YES
Q28BJOB
295-
•296
2=
=YES
Q28BACT
297-
•298
2=
=YES
Q28BMI
299-
•300
2=
=YES
Q28BWOR
301-
•302
2=
=YES
Q28BOTH
303-
304
2=
=YES
Q28BNONE
305-
306
2=
=YES
Q28BRATE
307-
•308
1-
•10
Question 22c
Q22CWHEN
309-312
Numeric (Days ago)
-------
Question 23c
Q23CLOC
313-315
Numeric (See Microenvironment
Codes)
Question 24c
Question 25c
Question 26c
Question 27c
Question 28c
Question 31
Q24CACT
Q25CTIM
Q25CDUR
Q27CREST
Q27CMIN
Q27CSTOP
Q27CSAME
Q27CSLOW
Q27CNTG
Q27COTH
Q27CHOSP
Q27CRATE
Q28CMED
Q28CLOST
Q28CEXP
Q28CPAIN
Q28CJOB
Q28CACT
Q28CMI
Q28CWOR
Q28COTH
Q28CNONE
Q28CRATE
Q31AMED
Q31BINC
316-318
319-321
322-324
325-326
327
328-330
331-332
333-334
335-336
337-338
339-340
341-342
343-344
345-346
347-348
349-350
351-352
353-354
355-356
357-358
359-360
361-362
363-364
365-366
367-368
369-370
Q31CEXP 371-372
Q31DPAIN 373-374
Q31EJOB 375-376
Q31 FACT 377-378
Q31GMI 379-380
Q31HWOR 381-382
Question 32 Q32TREAT 383-385
Q320NE 386-388
Q32TWO 389-390
Numeric (See Activity Codes)
Numeric
Numeric
2=YES
/
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES (Sought relief at
hospital)
1-7
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
2=YES
1-10
1-10
1-11 (11 = Subject believed
not applicable; e.g.,
retired)
1-1 0
1-10
1-11 (11 = Subject believed
not applicable; e.g.,
retired)
1-10
1-10
1-10
Numeric (See Treatment Codes)
1 =NO 2=YES
1=NO 2=YES
-------
Q32THREE
391-392
"UNO 2=YES
PILOTQU3.DBF
QUESTION
Subject Identification SUBJECT
Question 33
Question 34
Question 35
Question 36
VARIABLE COLUMNS CHARACTER TYPE OR
NAME ASSIGNMENT
1-5 Alphanumeric
Numeric (Payment in dollars)
1-4
1-4 (See Q30a Codes)
1=NO 2=YES
Numeric (Year of most recent
Ml)
Numeric
Numeric
Numeric
Numeric
1=NO 2=YES
Numeric (See Q35 Codes)
1=NO 2=YES
Numeric (See Q35 Codes)
Numeric (Month of 1st CABG)
/
Numeric (Year of 1st CABG)
Numeric (Month of 2nd CABG)
/
Numeric (Year of 2nd CABG)
1=NO 2=YES
Numeric (Month of 1st PTCA)
/
Numeric (Year of 1st PTCA)
Q36A2MO 96-97 Numeric (Month of 2nd PTCA)
98 /
Q36A2YR 99-100 Numeric
Q36FLOW 101-102 1=NO 2=YES
Q33PAY
6-1
0
Q33REAS
1 1
-12
Q33COM
13
-32
Q34MIDX
33
-34
Q34MI1YR
35
-36
Q34MI2YR
37'
-38
Q34MI3YR
39-
-40
Q34MI4YR
41-
-42
Q34MI5YR
43-
-44
Q35NCABG
45-
-46
Q35DRNO
47-
•61
Q35YCABG
62-
•63
Q35NREAS
64-
•78
Q35BG1MO
79-
•80
81
Q35BG1YR
82-
•83
Q35BG2MO
84-
•85
86
Q35BG2YR
87-
•88
Q36PTCA
89-
•90
Q36A1MO
91-
•92
93
Q36A1YR
94-
•95
(Year of 2nd PTCA)
Question 37
Question 38
Q37BEUF
Q38AEXER
Q38BPAIN
Q38CDIET
Q38DPULS
103-104
105-106
107-108
109-110
111-112
1-4
1-7
1-7
1-7
1-7
-------
Q38ESTR
113-114
1-7
Question 39
Question 40
Question 41
Question 42
Question 43
Question 44
Question 45
Question 46
Question 47
Question 48
Question 49
Question 50
Question 51
Q39DONT
115-116
2=YES
Q39HEAR
117-118
2=YES
Q39SEE
119-120
2=YES
Q39FEEL
121-122
2=YES
Q39SMELL
123-124
2=YES
Q390TH
125-126
2=YES
Q40AFFCT 127-128 1-6
Q41USUAL
129-130
2=YES
Q41NOOUT
131-132
2=YES
Q41NOEXR
133-134
2=YES
Q41GOAWY
135-136
2=YES
Q410TH
137-138
2=YES
Q41NOTAP
139-140
2=YES
Q42ARUSH
141-142
1-5
Q42BCITY
143-144
1-5
Q42CFRWY
145-146
1-5
Q42DWALK
147-148
1-5
Q42EOHOM
149-150
1-5
Q42FPARK
151-152
1-5
Q42GINPP
153-154
1-5
Q42HIHOM
155-156
1-5
Q43HHINC
157-159
1-12
Q44EDUC
160-161
1-18
Q45CHDFM
162-163
1=NO 2=YES
Q46CSMK
164-165
1=NO 2=YES
Q46CPPW
166-167
Numeric
Q46CYR
168-169
Numeric
Q47FSMK
170-171
1=NO 2=YES
Q47FPPW
172-173
Numeric
Q47FYR
174-175
Numeric
Q48HHSMK
176-177
1=NO 2=YES
Q49MARRY
178-179
1-3
Q50HEAD
180-181
1-4
Q51HHNUM
182-183
Numeric
-------
Question 52
Question 53
Question 54
Comments?
Q52HT 184-185 Numeric (Height in inches)
Q53WT 1 86-188 Numeric (Weight in pounds)
Q54RACE 189-190 Numeric
COM 191-192 1=NO 2=YES (See Listing)
Supplementary Questions
Question 1
Question 2
Question 2a
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
Question 10
Question 11
Question 12
Question 13
S1 TRAVEL
S2COMUTE
S2AMIN
S3TRAFHR
S4 ENGINE
S5UWVNEQ
S6GARATT
S6GARPK
S7NATGAS
S7ALLELE
S8GASFUR
S8GASRNG
S8GASOVN
S8GASWH
S8GASDRY
S8GASSPC
S8GASOTH
S80TH
S9VENT
S10FP
S10FPFRQ
S11KFAN
S12KWIN
S13INSUL
193-194 1-6
195-196 1 =NO 2=YE3
197-199 Numeric
200-202 Numeric
203-204 1=NO 2=YE3
205-206 1=NO 2=YES
207-208 1=NO 2=YES
209-210 1=NO 2=YES
211-212 1=NO 2=YES
213-214 1=NO 2=YES
215-216 2=YES
217-218 2=YES
219-220 2=YES
221-222 2=YES
223-224 2=YES
225-226 2=YES
227-228 2=YES
229-243 Alphabetic (Comment Field)
244-245 1=NO 2=YES
246-247 1=NO 2=YES
248-250 Numeric
251-252 1-3, 9
253-254 1-3, 9
255-256 1=NO 2=YES
-------
Question 14
S14FUR
257-258
1-9
Question 15
S15DRAFT
259-260
1=NO 2=YES
Question 16
S16ROAD
261-262
2=YES
S16MAINT
263-264
2=YES
S16BURN
265-266
2=YES
S16INDST
267-268
2=YES
S16STEAM
269-270
2=YES
S160TH
271-272
2=YES
Question 17
S170SMK
273-274
1-2
S170SMKW
275-276
1-3
Question 18
S18HSMK
277-278
Numeric
S18HSMKP
279-280
Numeric
Input Date
INMO
281-282
Numeric
283
/
INDAY
284-285
Numeric
286
/
INYR
287-288
Numeric
Entry Person INPUT
289-291
Alphabetic
-------
QUESTION 13 - MEDICATION CODES
Experimental Drugs, unspecified 050
Nitrates, Oral
Nitrate capsules, unspecified 100
Nitroglycerin tablets 101
Isordil 102
Isosorbide dinitrate 103
Nitro-bid capsules 104
Cardilate 105
Peritrate 106
Persantine (Dipyidamole) 107
Sorbitrate 108
109
110
Nitrates, Transdermal
Nitrate ointment, unspecified 150
Nitropatch 151
Nitro-bid ointment 152
Nitrol 153
Nitrong 155
Nitrostat 156
157
158
Calcium Channel Blockers, oral
Calcium channel blockers, unspecified 200
Calan (Verapamil) 201
Cardizem (Diltiazem) 202
Procardia (Nifedipine) 203
Isoptin (Verapamil) 204
205
206
Beta-Blockers, oral
Beta blockers, unspecified 300
Corgard (Nadolol) 301
Corzide (Nadolol) 302
Inderol (Propranolol) 303
Inderide (Propranolol) 304
Lopressor (Metaprolol tartrate) 305
Tenormin (Atenolol) 306
Viskin (Pindolol) 307
303
309
310
-------
Quinidine, oral
Quinidine sulfate, unspecified 400
Quinadez (quinidine) 401
Cardioquin (quinidine) 402
403
404
405
Digoxin and Digitalis, oral
Digoxin, digitalis, unspecified 500
Lanoxin (Digoxin) 501
Lanoxicaps (Digoxin) 502
Crystodigin (Digitalis glycoside) 503
504
505
Procainamide, oral
Procainamide hydrochloride, unspecified 600
Pronestyl (Procainamide) 601
602
603
Anti-hypertensives, oral
Anti-hypertensives, unspecified 700
Hydrochlorothiazide, unspecified 701
Aldactizide 702
Aldactone 702
Catapres (Clonidine) 703
Hydrodiuril 705
Hygroton 706
Minipress (Prazosin) 707
Minizide (Prazosin) 708
Nitropress 709
Tenormin 710
Dyazide 711
Hydropress 712
Hydroxyzine hydrocloride 713
714
715
Capoten (Captopril) 750
Blood Thinning and Anti-coagulant Medications
Persantine (Dipyridamole) 797
Coumadin, oral (Warfarin sodium) 798
Aspirin 799
-------
Diuretics, oral
Diuretic, unspecified 800
Furosemide, unspecified 801
Lasix (Furosemide) 802
Maxzide (K sparing, with hydrochlorothiazide) 803
Spironolactone 805
Potassium replacement 806
807
808
Cholesterol Lowering Drugs
Cholesterol lowering medications, unspecified 850
Colestid 851
Permacol 852
Probucol 853
854
855
Insulin and Blood Glucose Lowering Drugs
Insulin, specified 900
Diabenase 950
Micronase 952
Orinase 953
Tolinase 954
Insulin, Regular (Lente, Ultralente) 955
Insulin, NPH 957
Chloropropamide 958
Penday 959
960
Tranquilizers, oral
Tranquilizers, unspecified
(Valium, Xanac, Meprobamate)
960
-------
QUESTION 16 - HOSPITALIZATION CODES
Heart Illness
Heart ailment, unspecified 100
Severe or recurrent angina 101
Severe or recurrent arrthymia 102
Acute myocardial infarction 103
Cardiac failure (cardiac insufficiency) 104
Pericarditis 105
106
107
108
109
Heart Tests or Treatment
Heart testing or treatment, unspecified 110
Treadmill stress test 111
Angiogram 112
Angioplasty (PTCA) 113
Coronary artery bypass graft surgery (CABG) 114
115
116
117
-------
QUESTION 17 - ITEMIZED EXPENDITURES FOR HEALTH OR FITNESS
PROGRAM CODES
Exercise or fitness program expenses
Exercise program expenses, unspecified 100
Walking/jogging shoes and clothing 101
Weights/dumbbells 102
Bicycle 103
Exercycle 104
Health club or spa membership and use fees 105
Medical rehabilitation program expenses
Medical rehabilitation program 106
107
108
109
110
-------
QUESTIONS 20i AND ALT-20a • EQUIPMENT OR STRUCTURAL
EXPENDITURE CODES
New appliances, unspecified 100
Power yardcare equipment 101
Kitchen appliances 102
Power home maintenance equipment 103
Garage door opener 104
Cart/wheelbarrow 105
Air conditioner 106
Clothes washer and/or dryer 107
Structural changes to home (e.g., railings, ramps) 108
Cart to carry items (e.g., groceries, trash cans) 109
New furniture, unspecified 110
Bed 111
Chair 112
113
114
115
New Automobile
120
-------
QUESTIONS 21b AND ALT-21 b ¦ OCCUPATION CODFS
Three-digit classification scheme obtained from Robert Friis, University of California,
Medical Center. Source information and citation is unknown.
Oz-to-'-n * y/->>»• - pr • ^ v;
(The single letter or 3-aigIt nunher in the left margin is the cede synboi for
the occupation category'; "n.e.c." neons not elsev/here classified)
PROFESSICMAL, TECHNICAL, A:D XUXRED TCPiZPS
COO
Acscur.tar.ts and auditors
010
Actors and actresses
012
Airplane pilots and navigators
013
Architects
014
Artists ar.d art teachers
015
Athletes
020
Authors
C21
Chenlsts
022
Chiropractors
023
CI erg}— en
College presidents, professors',
, and instructcrs (n.e.
030
College presidents ar.d deans
031
Professors ar.d instructors,
agricultural sciences
032
Professors and instructors,
¦biological sciences
024.
Professors and instructors,
chanistry
035
Professors ar.d instructors,
econcnics
040
Professors and instructcrs,
—3 -A—— --a
Cil
Professors ar.d instructors,
geology and geophysics
042
Professors and instructcrs,
catheaatics
04.3
Professors and instructors,
nedical sciences
045
Professors and instructors,
physics
050
Professors and instructors,
psychology
051
Professors and instructors,
statistics
052
Professors ar.d instructors,
natural sciences (n.e.
053
Professors and instructors,
social sciences (n.e.c
054.
Professors and instructors,
nonscientific subjects
060
Professors and instructors,
subject not specified
070
Dancers and dancing teachers
071
Dentists
072
Designers
073
Dietitians and nutritionists
074.
Draftsmen
075
Editors and reporters
CoO
Engineers, aeronautical
0S1
Engineers, chanical
C32
Engineers, civil
CS3
CS4
Engineers, industrial
CS5
Engineers, nechar.icol
GSO
Engineers, netallurgical, and n
letallurgists
091
Engineers, nining
092
Engineers, sales
093
Engineers (n.e.c.)
101
Entertainers (n.e.c.)
102
r am and hene nanngenent advisers
103
Foresters ar.d conservationists
104
Funeral directors and enhalners
1G5
Lasers nnd Judges
111
120
liisicians and nusic teachers
-------
PROr xuMAL, TZ'
A^iD Kjl^xDR^D' i'icR.\^*"iS—"Con,
Natural scientists (n.e.c.)
L'O Agricultural scientists
131 Biological scientists
134 Geologists and gecphysicists
135 .Vathe.T.aticians
14.0 Physicists
145 Miscellaneous natural scientists
150 Kurses, professional
151 N'urses, student professional
152 Optctatrists
153 Osteopaths
154 Personnel and labor relations 7rorker3
160 Pharmacists
161 Photographers
162 Physicians and surgeons
163 Public relations nan and publicity Tritars
164 P.adio operators
165 Recreation and group workers
170 P.2ligious TOriers
171 Social and welfare workers, except group
Social scientists
172 Economists
173 Psychologists
174 Statisticians and actuaries
175 Miscellaneous social scientists
150 Sports instructors and officials
151 Surveyors
1E2 Teachers, elementary schools
153 Teachers, secondary schools
154 Teachers (n.e.c.)
155 Technicians, radical and dental
150 Technicians, electrical and electronic
191 Technicians, other engineering and physical sciences
192 Technicians (n.e.c.)
j.93 Therapists and healers (n.e.c.)
194 Veterinarians
195 Professional, technical, and kindred workers (n.e.c.)
FAPJ.HP.S AlO FARH liUJASZRS
220 Farmers (owner3 and tenants)
222 Farm managers
XA2XCZZS, C77ICIALS, A2ID PROPRIETORS, EXCEPT FAPii
250 Buyers and departnant heads, store
251 Buyers and shippers, farm products
252 Conductors, railroad
2-53 Credit nan
254 Floor men and floor nanagars, store
260 Inspectors, public administration
262 Lianagers and superintendents, building
265 Officers, pilots, pursers, and engineers, ship
270 'Officials and administrators (n.e.c.), public administration
275 Officials, lodge, society, union, etc.
2£0 Postmasters
235 . Purchasing agents and buyers (n.e.c.)
299 LLmagers, officials, and proprietors (n.e.c.)
-------
CLERICAL AXD iCuCCRZD VQFJZHS
301 Agents (n.e.c.)
202 Attendants and assistants, library
202 Attendants, physician's and dentist's office
204. Baggagenen, transportation
205 Bank tellers
210 Bookkeepers
212 Cashiers
212 Collectors, bill and account
214. Dispatchers ana starters, vehicle
215 Express nessengers and railTray nail clerks
220 File clerks
221 lnsurar.ee adjusters, exaninars, and investigators
222 Mail carriers
224. Messengers and office beys
225 Office nachine operators (computer operator)
322 Payroll and tinekeeping clerks
340 Postal clerks
341 Receptionists
342 Secrexaries
343 Shipping and receiving clerks
34.5 Stenographers
250 Stock clerks and storekeepers
251 Telegraph nessengers
252 Telegraph operators
352 Telephone operators
354. Ticket, station, and express agents
160 'typists
3^g Clerical and kindred irorkers (n.e.c.)
SALES VCPZZP-S
3£0 Advertising agents «-n salesnan
3ol Auctioneers
353 Hucksters and peddlers
3S5 Insurance agent3, brokers, and underwriters
250 Xevsboys
392 F.eal estate agents and brokers
255 Stock and bend salesnsn
399 Salesnsn and sales clerks (n.e.c.)
CRAFTSMEN, rCRI/SI, ACT ICTTHZD
401 Eakers
402 Blacksniths
4C3 Eoilemakers
4C4. Bookbinders
405 Sris1—ioons, stonemasons, and tile setters
410 Cabinetnzkers
412 Carpenters
413 Cemnt and concrete fini3hsr3
^1-r Ccnpositers and typesetters
415 Cransnsn, derricin^in, ar~ hoistnsn
420 Decorators and window dressara
421 Electricians
423 Hectroxypers and storectypera
-------
CRAFTSMEN, F0S2.2N, AND Xi:ORID rtCPJZHS—Ccc.
424 Engravers, except photoengravers
425 Excavating, gracing, ar.d read machinery operators
430 Foremen (n.e.c.)
431 Forgenan ar.d hammermen
432 Furriers
434 Glaciers
435 Heat treaters, amealers, ar.d tamperers
444 Inspectors, scalers, ar.d graders, leg and lumber
450 Inspectors (r..e.c.)
451 Jewelers, watchmakers, goldsmiths, and silversmiths
452 Job setters, cetal
453 Linemen ar.d servicemen, telegraph, telephone, and pcrrer
454 Locomotive engineers
460 Locomotive firemen
461 Loom fixers
465 .Vj.chir.ists
470 Mechanics and repairmen, air conditioning, heating, and refrigeration
471 Mechanics and repairman, airplane
472 Mechanics and repairmen, automobile
473 Mechanics and repairmen, office machine
474 Mechanics and repairmen, radio and television
475 Mechanics and repairman, railroad and car ahep
420 Mechanics and repairmen (n.e.c.)
450 Millers, grain, flour, feed, etc.
491 M'"1'reights
492 .Voiders, metal
493 Motion picture projectionists
494 Opticians, and lens grinders and polisher3
495 Painters, construction and maintenance
501 Paperhangers
502 Pattern and model makers, except paper
503 Photoengravers ar.d lithographers
504 Piano and organ tuners and repairmen
505 Plasterers
510 Plumbers end pipe fitters
512 Pressman and plate printers, printing
513 Rollers and roll hands, metal
514 Roofers and slaters
515 Shoemakers and repairers, exoept factory
520 Stationary engineers
521 Stone cutters and stone carvers
523 Structural metal workers
524 Tailors and tailcresses
525 Tinsmiths, coppersmiths, and sheet metal workers
530 Tcolmakers, and die makers ar.d setters
535 Upholsterers
545 Craftsmen and kindred workers (n.e.c.)
555 Members of the armed forces
OPERATIVES A:." KINDRED TORI-IERS1
601 Apprentice auto mechanics
602 Apprentice bricklayers and nasons
603 Apprentice carpenters
6C4 Apprentice electricians
605 Apprentice machinists and toolnakers
610 Apprentice mechanics, except auto
-------
OPERATIVES Ai3 XrZL=ED -,TO?:-CEL-.£—Con.
Al r Apprentice plunbers ar.d pipe fitters
613 Apprentices, building trices (n.e.c.)
614- Apprentices, cetalv/crking traces (n.e.c.)
615 Apprentices, printing traces
620 Apprentices, otter specified trades
621 Apprentices, trace not specified
630 Asbestos ar.d insulation vorkars
651 Assemblers
632 Attendants, auto service and parking
634. Blasters and pcwdeitren
635 3oat=cn, canalnen, and lock keepers
640 Brakasen, railroad
641 Bus drivers
642 Chai=en, rccnen, and ai=en, surveying
643 Checkers, examiners, and inspectors, manufacturing
645 Conductors, bus and street rail-ray
650 Deliverynen and roil ten en
651 Dressmakers and se.irstresses, except factory
652 Dyers
653 Filers, grinders,and polishers, netal
654. Fruit, nut, and vegetable graders and packers, except factory
670 ' Fumace=en, sneltar=an, and pcurers
671 Graders and sorters, manufacturing
672 Heaters, netal
673 Knitters, loopers, and toppers, textile
674 . Laundry and dry cleaning operatives
675 iVjeat cutters, except slaughter and packing house
680 Llilliners
6S5 .'.line operatives and laborers (n.e.c.)
: 690 Mo-o—an, nine, factor-/, logging canp, etc.
691 liotomen, street, sub-ray, and elevated rail-ray
652 Oilers and greasers, except auto
653 Packers and -wrappers (n.e.c.)
654 Painters, except construction and maintenance
695 Photographic process Trcrkers
7C1 Pcrrer station operators
703 Sailors and deck v°—'g
7C4 Sa-/ers
705 Se~rers and stitchers, manufacturing
710 Spinners, textile
712 Stationary firemen
713 Switchmen, railroad
714 Taxioab drivers and chauffeurs
715 Truck and tractor drivers
720 leavers, textile
721 Welders and flama-cuttars
729 Operatives and kindred -scrkers (n.e.c.)
PRIVATE HOUSEHOLD TORXZHS
8G1 Baby sitters, private household
SC2 Housekeepers, private household
603 Laundresses, private household
Aqq Private household Tcrkers (n.e.c.)
-------
SZKVTCZ EXCEPT PP.I7ATE HC'uSZriGLD
810 Attendants, hospital and other institutions
812 Attendants, professional and personal service ("n.e.c.)
813 Attendants, recreation and anusesent
814. Barbers
615 Bartenders
823 Bootblacks
£21 Hoarding and lodging house keepers
823 Chaaber=aids ar.d naids, except private household
824. Charwomen and cleaners
825 Cooks, except private household
830 Counter and fountain workers
831 Elevator operators
843 Hairdressers and cosmetologists
832 Housekeepers and stewards, except private household
82-i Janitors and sextons
835 Kitchen workers (n.e.c.), except private household
84.0 IJidwives
841 Porters
842 Practical nurses
Protective service workers
850 Firemen, firs protection
851 Guards, watchnen, and doorkeepers
852 Marshals and constables
853 Policemen and detectives
854. Sheriffs and bailiffs
860 Watchmen (crossing) and bridge tenders
874. Ushers, recreation and acusenent
875 Waiters and waitresses
890 Service workers, except private household (n.e.c.)
FA3.1 LA30P.Z7S A2CD FQHZLE:!
9G1
Faro
foreman
902
FaT^,
laborers, i&ge TOriers
903
Far^
laborers, uzp^id family Trorizers
905
Fazrz.
service laborers, selT-er^lc/ed
LABCKZP3, EXCEPT FASH AJE iCXE1
960 Carpenters' helper:, except legging and n'trrlr.g
962 Fishemsn and oyste—en
963 Garage laborers, and car washers and greasers
964. Gardeners, except faro, and groundskeepers
965 Longshoremen and stevedores
970 Lunbemen, raft—zen, and Tcodchoppers
971 Teamsters
972 Truck drivers' helpers
973 TTarehousenen (n.e.c.)
97q Laborers (n.e.c.)
995 OCCUPATION NOT HEPC3TED
1 iilne laborers are included in the najor group "Operatives.and kindred workers."
-------
QUESTIONS 23. 23b. and 23c - MICROENVIRONMENT CODES
Indoors, unspecified 1C0
Indoors, home, unspecified 110
Family room, den 111
Kitchen 112
Dining room or area 113
Living room 114
Bedroom 115
Bathroom 116
Laundry room, utility room, workshop 117
Garage (or enclosed carport) 118
Other room 119
Indoors, work, unspecified 120
Office (Clerical or administrative) 121
Work area (e.g., assemblyline, shop, warehouse) 122
Lunch room or break area 123
Rest room or locker room 124
125
126
127
Indoors, public places, unspecified 130
Restaurant 131
Store, post office, barbershop 132
Shopping mall 133
Office 134
Church 135
School 136
Bar or night club 137
Health care facility (e.g., hospital, doctor's office) 138
Auditorium 139
Dance hall 140
Bowling alley 141
Indoor gymnasium or swimming facitlity 142
Public garage (enclosed parking structure) 143
Service station or auto repair facility 144
Other repair shop 145
Home of a friend 146
Meeting hall or lodge, clubhouse 147
-------
Hotel or motel room
Library
Court
152
153
154
155
148
149
150
151
Outdoors, unspecified 200
Around the house (e.g., yard, patio outside house,
within building areas but not in own unit) 210
Within ten yards of active roadway 211
Parking lot or non-enclosed carport 212
Service station or motor vehicle repair service 213
Park, golf course, or other outdoor recreation area
(e.g., beach, tennis courts) 214
Restaurant patio 216
Restaurant, drive-in area 217
Sports arena, stadium, amphitheater 218
Bike path 219
Outdoor store (e.g., lumber yard, nursery) 220
221
222
223
224
225
230
231
Outdoor work location
Truck yard
In Transit, unspecified 300
Personal Automobile 310
Truck 311
Bus 312
Motorcycle 313
Walking 314
Bicycle 315
Jogging or brisk walk for exercise 316
SOHC van (Used to transport subjects to
and from UCI) 317
Motor home 318
Diesel truck 320
321
322
323
-------
QUESTION 24. QUESTION 24b. and QUESTION 24c - ACTIVITY CODES
Three-digit classification scheme obtained from John Robinson, University of
Maryland. The coding system was developed at the University of Michigan, Survey
Research Center, and is an extension of the two-digit scheme used in the Multinational
Time-Budget Research Project (Szalai, 1972).
August 1, 1985
ACTIVITY CODES FOR HOUSEHOLD TIME DIARIES
** 2 ascerisks next Co an activity code indicates
the code is to be used in coding children'3
diaries only.
00: NO ACTIVITY
000 No Activity Reported
WORK AND OTHER INCOME PRODUCING ACTIVITIES
0J_: WORK
011 Main job: activities at the main job, travel which is part of the
job, and overtime; "working", "at work".
012 Work at home; work activities for pay done in the hone when home
is Che nain workplace. (Include travel as Oil.)
i.e.- Self-employed people running a business out of Che home.
013 Additional work home; additional job (L.e. consulting, coctage
industry)
014 Work at home for no pay, work connected with main job.
015 Other work at home - general
016 Reading (work brought home)
(EormerLy 944*)
02: UNEMPLOYMENT
022 Job search; looking for work, including visir..^ r.n employment
agencies, phone calls Co prospective employers, answering want ads.
023 Unemployment benefits; applying for or collecting unemployment
compensation.
024 Welfare; food stamps; applying for or collecting welfare food scamps.
-------
-2-
£5: S ECO NT) JC3
059 Other paid work; second job; paid work activities which are not
par; of the main job (use this code when R clearly indicates
a second job or "other" job); paid work for those not having
main job; garage sales, rental property.
(CHILD DEFINITION) Part-tine jobs when R is full-time student.
06: SATING
063 Eating while working; smoking, drinking coffee as n .secondary
activity while working (at work place)
069 Lunch uc workplace; lunch eaten at work, cafeteria lunchroom
when "where" = work (lunch at a restaurant, code 449; lunch at
home, code 439)
07: ACTIVITIES AT WORK
078 Activities before or after work; activities at the workplace before
starting or after stopping work; include - "conversations," other
work. Do not code secondary activities with this primary activity.
0/9 Other work related
08_: BREAKS
089 Coffee breaks and other breaks at the workplace; breaks during
non-work during work hours at the workplace; "took a break";
"hac coffee: (as a primary activity). Do not code secondary
activities with this primary activity.
09: TRAVEL RELATED TO WORK ACTIVITIES
097 Travel related to job search, unemployment benefits, welfare,
food stamp, waiting for related travel.
098 Interrupted travel to work; travel to and from workplace when R's
trips to and from work were both interrupted by stops; waiting
for related travel.
099 Travel to and from workplace, including time spent waiting for
transportation.
-------
-3-
HOUSEHOLD ACTIVITIES
1_0: FOOD
108 Meal preparation; cooking, fixing lunches
109 Serving food, setting table, putting groceries away, unloading
car after grocery shopping.
U_: CLEANUP
118 Doing dishes, rinsing dishes, loading dishwasher
119 Meal cleanup, clearing table, unloading dishwasher
12: CLEANING
128 Miscellaneous "work around house"; NA if indoor or outdoor
129 Routine indoor cleaning and chores, picking up, dusting, making
beds, washing windows, vacuuming, "cleaning," "fall/spring
cleaning," "housework".
13_: OUTDOOR CLEANING
139 Routine outdoor cleaning and chores; yard work, raking leaves
mowing grass, garbage removal, snow shoveling, putting on storm
windows, cleaning garage, cutting wood.
_1_4: CLOTHES CARE
148 Washing clothes
1^9 Other clothes care
J_6: REPAIRS
161 Indoor repairs, maintenance, fixing, furnace, plumbing, painting
a room.
162 Outdoor repairs; maintenance, exterior; fixing repairs outdoors,
painting the house, fixing the roof, repairing the driveway
(patching).
163 Routine car oare; necessary repairs and routine care to cars;
tune up-
-------
164
165
166
167
168
il:
171
173
Ii:
188
189
191
192
193
194
195
196
197
Home Improvements; additions to and remodleing done to the house
garage; new roof.
Repairing appliances
Repairing furniture
Car maintenance; changed oil, changed tire9, washed cars; heavier maintenance
"worked on car" except when clearly as hobby — (code 832)
Improvements to grounds around house; repaved driveway
PLANT CARE
Gardening; flower or vegetable gardening; spading, weeding,
composting, picking, "worked in garden".
Care of house plants
PET CARE
Play with animals
(formerly 844*)
Care of household pets
OTHER HOUSEHOLD
Other indoor chores; NA whether cleaning or repair
Other outdoor chores; "worked out3ide," "puttering in garage"
Household paperwork; paying bills, balancing the check-book,
making liscs, getting mail, working on the budget
** Watching another person do typically female household tasks (108,
109, 118,119, 148, 149)
** Watching another person do typically male household tasks
** Watching another person do household tasks, not listed above
Other household chores; (no travel), picking up things at home,
e.g., "picked up deposit slips" (related travel to purpose)
-------
-5-
CHILD CARE
20: BABY CARE
209 Baby care; care to children age 4 and under
2_1_: CHILD CARE
218 Child care; mixed ages or NA ages of children
219 Care Co children ages 5-17
22: HELPING/TEACHING
221 Helping/teaching children learn, fix, make things;
helping son bake cookies; helping daughter fix bike
222 Helping kids with homework or supervising homework
23: TALKING/READING
236 Giving child orders or instructions; asking them to help; telling
them to behave
237 Disciplining child; yelling at kids, spanking children
238 Reading to child
239 Conversations with household children only; listening to children
24: INDOOR PLAYING
248 ** Playing with babies aged 0-2; "playing with baby," indoors or
outdoors
249 Indoor playing with kids; other indoor activities with children
including games ("playing" unless obviously outdoor games)
_25: OUTDOOR PLAYING
253 Leading outdoor activities; coaching, non-organizational activities
259 Outdoor playing with kids; including sports, walks, biking with,
other outdoor games
-------
-6-
26: MEDICAL CARE - CHILD
269 Medical care at home or outside home; activities associated
with childran'3 health; "took son to doctor", "gave daughter
medicine"
27_: OTHER CHILD CARE
277 Co-ordinating child's social or instructional non-school activities
(travel related code 298)
278 Babysitting (unpaid) or child care outside R's home or to
children not residing in HH
279 Other child care, including phone conversations relating to
child care other than medical
29: TRAVEL RELATED TO CHILD CARE
298 Travel related to non-school activities
299 Other travel related to child care
-------
OBTAINING GOODS AND SERVICES
30: EVERYDAY SHOPPING
30L Shopping for food
302 Other shopping; including for clothing, small appliances;
at drug stores, hardware stores, department stores, "downtown"
or "uptown", shopping center, buying gas, window shopping
3J_: DURABLE/HOUSE SHOP
311 Shopping for durable goods; shopping for large appliances, cars
furniture
312 Shopping for house or apartment; activities connected by buying,
selling, renting, looking for house, apartment, including phone
calls; showing house, including traveling around looking at real
estate property (for own use)
32: PERSONAL CARE SERVICES
320 Phone calling for goods
321 Phone calling for services
329 Personal care services; beauty, barber shop; hairdressers
33: MEDICAL APPOINTMENTS
339 Medical care for self
3A_: GOVT/FINANCIAL SERVICES
341 Financial services; activities related to taking care of financial
business; going to the bank, paying utility bills (not by mail)
going to accountant, tax office, loan agency, insurance office
342 Other government services; post office, driver's license, sporting
licenses, marriage licenses, poLice station
35: REPAIR SERVICES
351 Auto services; repair and other auto services incLuding waiting
for such services
-------
-8-
352 Clothes repair and cleaning; cleaners, laundromat:, tailor
353 Appliance repair; including furnace, water heater, electric or
battery operated appliances; including watching repair person
354 Household repair services; including furniture; other repair
services NA type; including watching repair person
36_: LIBRARY
360 Tine spent at library
361 Travel to/from library
369 ** Getting gifts or money from adult, e.g. got lunch money
21: 0TH£R SERVICES
377 Other professional services; lawyer, counseling (therapy)
379 Other services; "going to the dump"
38.: ERRANDS
389 Running errands; NA whether for goods or services; borrowing goods
39_: TRAVEL RELATED TO GOODS AND SERVICES
399 Travel related to obtaining goods
-------
-9-
PERSONAL NEEDS AND CARE
40: WASHING/DRESSING
408 Bathing; washing, showering
409 Personal Hygiene; getting dressed, packing and unpacking clothes,
going to the bathroom
41: MEDICAL CARE
411 Medical care at home to self
412 Medical care to adults in HH
42: HELP AND CARE
421 Non-aedical care to adults in HH; routine non-nedical care to
adults in household; "got my wife up," "ran a bath for my husband"
422 Help to relatives not in HH; helping caring for, providing for
needs of relatives; (except travel) helping move, bringing food,
assisting in emergencies, doing housevork for relatives; visiting
when sick
423 Help to neighbors, friends
424 Help and to others, NA relationship to R; (same as 422 for others)
43_: MEALS AT HOME
439 Meals at home; including coffee, drinking, smoking, food from
a restaurant eatan at home, "breakfast," "lunch"
44_: MEALS OUT
448 Meal3 at friend's home; eaten at a friend's home (inc. coffee,
drinking, smoking)
449 Meals at restaurants
4_5: NIGHT SLEEP
458 Longest sleep of the day; including in bed but not asleep
(formerly 459* )
-------
-10-
459 Beginning of longest sleep of next night, night sleep
(formerly 460*)
46_: NAPS/SLEEP
469 Naps and resting
48; N_.A. ACTIVITIES
481 Time gap of more than 10 minutes
482 Personal/private; "none of your business"
483 Sex, making out
484 Affection between household members: giving and getting hug3
kisses, sitting on laps
485 Interview/ questionnaire; completing time diaries
(formerly 978*)
487 ** At babysitters before and after school or if child does not
attend school. (NOTE: all secondary activities should be coded
when this is a primary activity).
488 ** Receiving child care; child is passive recipient of personal
care; e.g. "Mom braided my hair"
489 Other personal care activities; watching personal care activities
49: TRAVEL RELATED TO FSRSONAL CARE
498: Travel related to helping, related to code3 421, 422, 423,
424, including travel which is the helping activity; waiting
for related travel
499 Other personal travel
-------
-11-
EDUCATION AND PROFESSIONAL TRAINING
50; STUDENTS' CLASSES
500 Television-based education
509 Studenc attending classes full-time; includes daycare, nursery
school for children not in school
51_: OTHER CLASSES
519 Other classes, courses, lectures, academic or professional;
R not a full time student or NA whether a student; being tutored
54; HOMEWORK
5^8 Reading (class related)
(formerly 945*)
549 Homework, studying, research
56: OTHER EDUCATION
568 ** At day care/nursery before or after school only (NOTE; all
secondary activities should be coded when this is a primary
activity)
569 Other education
59: TRAVEL RELATED TO EDUCATION
597 ** Travel directly from home to school
598 ** Travel directly from school to home
(NOTE: 597 and 598 are child codes only)
599 Other school-related travel; waited for related travel; travel
to school not originating from home
-------
-12-
ORGANIZATIONAL ACTIVITIES
60; PROFESSIONAL/UNION ORGANIZATIONS
601 Meetings of professional/union groups
602 Other activities, professional/union group including social
activities and meals
61: SFECIAL INTEREST IDENTITY ORGANIZATIONS
Includes groups based on sex, race, national origin; NOW, NAACP,
Polish-American Society, neighborhood, block organizations, CR
groups, senior citizens, Weight Watchers, etc
611 Meetings of identity organization
612 Other activities, identity organizations and special interest
groups, including social activities and meals
62: POLITICAL PARTY AND CIVIC PARTICIPATION
621 Meetings political/citizen organizations; including city council
622 Other activities, political/citizen organizations, including
social activities, voting, jury duty, helping with election,
and meals
63_: VOLUNTEER/HELPING ORGANIZATIONS
Hospital volunteer group, United Fund, Red Cross, Big Brother/Sister
631 Attending meetings of volunteer, helping organizations
632 Officer work; work as an officer of volunteer, helping organizations,
R must indicate he/she is an officer to be coded here
633 Fund raising activities as a member of volunteer helping
organization, collecting money, planning a collection drive
634 Direct voluntary help as a member of volunteer group; visiting
bringing food, driving
635 Other volunteer activities, including social events and meals
64: RELIGIOUS PRACTICE
-------
-13-
641 Meetings of religious helping groups; ladies aid circle, missionary
society, Knights of Columbus
642 Other activities of religious helping groups listed in 641 including
social activities and me3l3
643 Mestir.g3, other church groups; attending meetings of church groups
which are not primarily helping oriented or NA if helping oriented
644 Other activities, other church groups; other activities as a member
of church groups which are not helping oriented or NA if
helping, including social activities and meals; choir practice;
bible class
65_: RELIGIOUS PRACTICE
651 Attending services of a church or synagogue, including
participating in the service; ushering, singing in choir, leading
youth group, going to church, funerals
652 Individual practice, or religious practice carried out in a 3mall
group; praying, meditating, Bible study group (not at church),
visiting graves
6o_: FRATERNAL ORGANIZATIONS
Moose, VFV, Kiwanis, Lions, Civitan, Chamber of Commerce, Shriners
American Legion
661 Meetings fraternal organizations
662 Other activities as a member of a fraternal organization including
social activities and helping activities and meals
67: CHILD/YOUTH/FAMILY ORGANIZATIONS
671 Meetings, family/youth/child organizations
672 Other activities as a member of child/youth/family organizations
including social activities and raeal3
63: OTHER ORGANIZATIONS
688 ** Meetings practices for team 3ports
(formerly 883* and 884*)
689 Other organizations; any activities a3 a member of an organization
not fitting into above categories; (meetings and other
activities Included here)
-------
-14-
69_: TRAVEL RELATED T0_ ORGANIZATIONAL ACTIVITY
698 Travel related to organizational activities as a member of a
volunteer organization; including travel which is the helping
activity, waiting for related travel
699
Travel related to all other organizational activities; waiting
for related travel
-------
-15-
ENTERTAINMENT/SOCIAL ACTIVITIES
70: SPORT EVENTS
708 Watch other people do active leisure activities
(formerly 882*)
709 Attending sport3 event3
7l_: MISCELLANEOUS EVENTS
719 Miscellaneous spectacles, events; circu3, fairs, rock concerts,
accidents
72: MOVIES
729 Attending movies; "went to the show"
_73: THEATRE
739 Theatre, opera, concert, ballet
7MUSEUMS
749 Attending museums, zoos, arc galleries, exhibitions
7_5_: VISITING
752 Visiting with others; socializing with people other than R's
own HH members either at R's home or another home (visiting
on the phone, cade 965); talking/chatting in the context of
receiving a visit or paying a visit
7_6_: PARTIES
768 Picnicking (* new code)
769 Party, reception, wedding
77: BARS/LOUNGES
771 At bar, cocktail lounge, nightclub; socializing or hoping to
socialize at bar, lounge
772 Dancing
-------
-16-
78: OTHER EVENTS
789 Other events, of socializing that do not fit above
79_: TRAVEL RELATED TO EVENTS/SOCIAL ACTIVITIES
799 Related travel; waiting for related travel
-------
-17-
SPORTS AND ACTIVE LEISURE
80: ACTIVE SPORTS
800 Lessons in sports ; (formerly 885*)
swimming, golf, tenni3, skating, roller skating (codes 801 - 807,
811 - 817, 821 - 826)
801 Football, basketball, baseball, volleyball, hockey, soccer,
field hockey
802 Tennis, squash, racquetball, paddleball
803 Golf, miniature golf
804 Swimming, waterskiing
805 Skiing, ice skating, sledding, roller skating
806 Bowling, pool, ping pong, pinball
807 Frisbee, catch
808 Exercises, yoga, weightlifting
809 Judo, boxing, wrestling
8_1_: OUTDOORS
811 Hunting
812 Fishing
813 Boating, sailing, canoeing
814 Camping, at the beach
815 Snowmobiling, dune-buggies
816 Gliding, ballooning, flying
817 Excursions, pleasure drives (no destination), rides
with the family
82_: WALKING/3 IKING
821 Walking for pleasure
822 Hiking
-------
823
824
825
826
83:
831
832
833
834
835
836
84_:
84 1
842
843
8_5_:
851
852
86_:
860
861
862
863
-18-
Jogging, running
Bicycling
Motorcycling
Horseback riding
HOBBIES
Photography
Working on car3 — not necessary to their running; customizing,
painting
Working on leisure time equipment repair (repairing the boat,
"sorting out fishing tackle")
Collections, scrapbooks
Carpentry, woodworking
Making movies (formerly 925*)
DOMESTIC CRAFTS
Preserving foodstuffs (cleaning, pickling)
Knitting, needla-vork, weaving, crocheting (including classes),
crewel, embroidery, quilting, quilling, raacrame
Sewing
ART/ LITERATURE
Sculpture, painting, potting, drawing
Literature, poetry, writing (not Letters), writing a diary
MUSIC/DRAMA/DANCE
Other lessons; (formerly 888*)
(831-835, 841-844, 851-852, 871-888)
Playing a rau3lc3l Instrument, (include practicing), whistling
S Lnging
Acting (rehear3al for play)
-------
-19-
864 Non-social dancing; ballet, modern dance, body movement
865 Gymnastics
866 Pretend, dress-up
867 Lessons in music, dance, gym, judo, singing, body movement
(formerly 886*,and 887*)
(808-309, 864-365, 861-863)
869 Other active leisure; "hanging around"
(formerly 889*)
87: GAMES
871 Playing card games (bridge, poker)
872 Playing board games (Monopoly, Yahtzea, Bingo, Dominoes, Trivial
Pursuit)
873 Playing social games (scavenger hunts), "played games"— NA kind
874 Puzzles
875 Played with toys
876 Played outdoors
377 Played indoors
88_: COMPUTER USE
884 Using computer - general
(formerly 894*)
885 Computer use for education
(formerly 895*)
886 Computer games - child
(formerly 896*)
887 Computer games - adult
(formerly 897*)
888 Other computer use; (formerly 898*)
889 Other active leisure
89: TRAVEL RELATED TO ACTIVE LEISURE
899 Related travel
-------
-20-
PASSIVE LEISURE
90: RADIO USE
900 Radio transmitting/CS radio
(formerly 910*)
909 Radio U3e
91_: TV USE
914 VCR/Horae Movie3
(formerly 920*)
918 Cable TV
919 TV viewing
92: RECORDS/TAPES
926 Recording music (formerly 930*)
927 Records
923 Tapes
929 Records, tapes, stereo, listening to music, listening to
ochers playing a musical instrument
93_: READ BOOKS
939 Reading books for pleasure
94: READING MAGAZINES/NA
9^1 Reading magazines, reviews, pamphlets
942 Reading NA what; or other
943 ** Being read to
95: READING NEWSPAPER
959 Reading newspaper (formerly 949*)
-------
-21-
96: CONVERSATIONS
960 ** Receiving instructions
(formerly 967*)
961 ** Being disciplined; (formerly 966*)
962 Other talking/ arguing with non-HH members
(formerly 962* & 964*)
963 Conversations/arguing with HH members
(formerly 965* & 963*)
964 Local calls placed
(formerly 957*)
965 Local calls received
(formerly 958*)
966 Long distance call placed
(formerly 959*)
967 Long distance call received
(formerly 960*)
963 Telephone use for organizational activities
969 Other phone conversations (formerly 961*)
9_7_: LETTERS
977 Typing; (formerly 980*)
979 Letters, (reading or writing) reading mail
98: OTHER PASSIVE LEISURE
981 Relaxing
982 Thinking, planning, reflecting
983 Doing nothing
984 Activities of others reported
989 Other passive leisure; smoking dope, pestering, teasing,
joking around, me33ing around, laughing
99_: TRAVEL RELATED TO PASSIVE LEISURE
997 ** W,iicing in car for adu 11
-------
-22-
998 ** Travel of child with adult when not clear whether child
participated in adult's purpose of trip—e.g. went to bank
(with parent) ana waited in car; code travel portion 998
999
Related travel; waiting for related travel
-------
-23-
EXAMPLES OF ACTIVITIES IN "OTHER" CATEGORIES
079 OTHER WORK RELATED
Foster parent activities
197 OTHER HOUSEHOLD
Wrapping presents
Checked refrigerator for shopping list
Unpacked gifts from shower
Packing/Unpacking car
"Settle in" after trip
Hook up boat to car
Showed wife car (R was fixing)
Packing to move
Moved boxes
Looking/searching for things at home (inside or out)
279 OTHER CHILD CARE
Waited for son to gee hair cut
Picked up nephew at sister'3 house
"Played with kids" (R's children from previous marriage
not living with R)
Called babysitter
379 OTHER SERVICES
Left clothing at Goodwill
Unloaded furniture (jusc purchased)
Returned books (ac library)
Brought clothes in from car (after laundromat)
Delivered some stuff to a friend
Waited for father to pick up meat
Waited for stores to open
Put away things from swap meat
Sat in car waiting for rain to stop before shopping
Waiting for others while they're shopping
Showing Mom what I bought
489 OTHER PERSONAL
Waiting to hear from daughter
Stopped at home, NA what for
Getting hysterical
-------
-24-
Breaking up a fight (noc child care ralaced)
Waited for wife Co get up
Waiting for dinner at brother's home
Waiting for plane (meeting someone at airport)
Laughing
Crying
Moaning — head hurt
569 OTHER EDUCATION
Watched a film
In discussion group
639 OTHER ORGANIZATION
Attending "Club House coffee klatch"
Waited for church activities to begin
"Meeting" NA kind
Cleanup after banquet
Checked into swap meet — selling and looking
789 OTHER SOCIAL, ENTERTAINMENT
Waiting for movies, other events
Opening presents (at a party)
Looking at gift3
Decorating for party
Tour of a home (friends or otherwise)
Waiting for date
Preparing for a shower (baby shower)
Unloaded uniforms (for parade)
889 OTHER ACTIVE LEISURE
Fed bird3, bird watching
Astrology
Swinging
At park
Showing slides
Showing sketches
Hung around airport (NA reason)
Picked up fishing gear
Inspecting motorcycle
Arranging flower3
Worked on model airplane
Picked up Softball equipment
Registered to play golf
Toured a village or lodge
-------
-25-
989 OTHER PASSIVE LEISURE
Lying in the sun
Listening to birds
Looking at slides
Stopped at excavating place
Looking at pictures
Walked around outside
Waiting for a call
Watched plane leave
Girl watching/boy watching
Watching boats
Wasted time
Inside and outside of the house
-------
QUESTION 30a QUESTION 30b AND QUESTION 33b - DOLLAR AMOUNTS
WILLING TO PAY
If the subject answered that they would be willing to pay an "infinite amount" or "pay
with everything I have", then the dollar amount in Q30AAVD1, Q30BAVD2, and
Q33PAY was coded "all 9's", e.g. 99999999. If the subject answered they would pay
something but did not know how much, the dollar amount was coded "-1".
QUESTION 30a AND QUESTION 33 - ADDITIONAL COMMENTS OFFERED
BY SUBJECT CODES
1 = Subject answered $0.00 and stated "could not afford anything".
2 = Subject answered "would pay what could afford on limited income" and
usually offered a dollar amount.
3 = Subject answered large dollar amount and stated "would pay with
everything I have".
4 = Other comment.
-------
QUESTION 32 - WILLINGNESS-TO-PAY TREATMENT CODES
TREATMENTS EPISODES DOLLAR AMOUNTS
1
4
5
50
200
2
8
5
50
200
3
4
10
25
50
4
8
10
25
50
5
4
25
50
100
6
8
25
50
100
7
4
50
100
200
8
8
50
100
200
9
4
100
200
400
10
8
100
200
400
21
4
10
50
200
22
8
10
50
200
23
4
25
100
300
24
8
25
100
300
25
4
50
200
400
26
8
50
200
400
27
4
100
500
1000
28
8
100
500
1000
Treatments 1-10 were randomly assigned to the twenty subjects in the first mailing
of questionnaires in early April 1986. After completing 15 of the 20 interviews, ERC
and UCI reviewed the success of the dollar amounts in bracketing the range of observed
responses, and a revised treatment schedule was formulated on May 8, I986. The
revised schedule, Treatments 21-28, was used for the remainder of the subject pool.
An additional adjustment was made at the time of this revision. It was decided that
Questions 30a and 30b should be asked out of sequence, after completion of Questions
32 and 33. A third digit was added to the Treatment Code to indicate this change of
sequence. If Questions 30a and 30b were asked in sequence after completing the line of
inquiry on the "typical recent" angina episode, the third digit of the treatment code
was assigned a "1". If Questions 30a and 30b were asked after the willingness-to-pay
Questions 32 and 33, then the third digit of the treatment code was assigned a "2".
-------
For example, Treatment Code 242 represents Treatment 24 (8 episodes; $25, $100,
and $300) and Questions 30a and 30b were asked after completing Questions 32 and
33. (Note that this change in sequence was instituted immediately and several
individuals in the first treatment schedule were interviewed using the adjusted
sequence of waiting to ask Questions 30a and 30b.)
-------
QUESTION 35 - REASON FOR DOCTOR NOT RECOMMENDING CABG CODES
1 = In physician's opinion, the subject was not a candidate because of the low
chance of surviving the CABG surgery (e.g., "not a good candidate for
surgery").
2 = Physician recommended alternative medical treatment or angioplasty.
3 = Other (including "never talked about it")
QUESTION 35a - REASON FOR NO CABG SURGERY AFTER POSITIVE
DOCTOR'S RECOMMENDATION CODES
1 = In subject's opinion, CABG surgery was too great at risk.
2 = Subject chose alternative medical treatment or angioplasty.
3 = Subject refused CABG surgery (e.g., believed "not necessary" or "too
expensive").
4 = Other
-------
EPA CHD COMMENTS
QUESTION 1
001 HA 2 YEARS AGO*
033JS EXERCISE, LIFTING ARMS ABOVE WAIST
062JT HEAVINESS IN CHEST
022CE MAALOX, MVLANTA, GAS, ALWAYS RELIEVES D[SCOMFORT. NITRC
ALSO WORKS. PAUSES & RESTS & TAKES I1YLA.NTA.
QUESTION 2
108JA SOMETIMES
001 HA 2 YEARS AGO. UPSTAIRS. WORKING IN YARD, STOP S< CATCH
BREATH
083J S SHORTNESS OF BREATH TOO
QUESTION 3
023WF BUT MILD
107JB NOT CURRENTLY
039HK RARELY
052HR OCCASIONALLY
012JB SOMETIMES
025JF SOMETIMES
043VL USUALLY EXERTION
050EP FULSE RATE SLOWS DOWN, WEAK, BEND OVER
001HA LAST TMST AT VA. MIGHT HAVE TO HAVE BYPASS. HAD
ANGIOGRAM, SPENT 2 WEEKS IN HOSPITAL
033JS CAN ONLY REMEMBER 3 OR 4 TIMES. TOOK NITRO RIGHT AWAY,
062JT EVEN BICYCLE DOES NOT BRING ON NOW.
QUESTION 4
023WF WHEN FIRST STARTED SUBJECT BELIEVED IT WAS INDIGESTION-
1973,, ST MARY'S
043VL SOMETIMES
062JT BEFORE CABG SURGERY
QUESTION 5
0°1 IM LAST EPISODE WAS ABOUT 1 YEAR AGO
050EP HEADACHE. SHOULDER DOWN THE ARM
001 HA RECENTLY HAD LUNG TROUBLE, LUNG PROBLEM, FLUID IN LUKCi
MEDICATION,, DIGOXIN, 2 MONTHS, CONTINUE TO HAVE LUNG
PAIN
-------
QUESTION ALT-
J-i
i 0~J!
10 MONTHS
BACK TO 5
w
n
} A V AS SO UN AS
QUESTION ALF-zE
091 lii
0*.' 1 HA
062 J T
OTHER=RE~IREMENT
n u ;c - ¦=-~npp'C-r)
"I DON'T KNC'f, I'M NOT A DOCTOR"
UPON EXERCISE. AMY EXERTION
GUEST ION
-.n
0*1 IM
AF-EC7ED BREATH I f-JS
HAD T'lTRO MED
-LAY DOWN, REST SO—15 HIN
QUESTION
082J M
043VL
025 J F
01 SRC
034EB
100WC
102 J B
005CB
1 u3 J A
023WF
107 J 3
03° HI-
0 03 GB
017LC
001 HA
030RH
094 F'G
067SW
HAVE IT EACH EVENING, AFTER DINNER WHEN MOVING CARS
"THE SEASONS DON'T DO ANYTHINS FOR ME"
IN SPRING SET CUT TO THE HIGH DESERT
ANSWERS PERTAIN TO TIME SINCE SURGERY OCT '83
DIFFICULT TO JUDGE BECAUSE VISIT MINNESOTA DURING' WINTER
FOR WHILE. COLD & HEAT MAKES WORSE 8-. MORE FREQUENT
MORE FREQUENT IN SUMMER 2< SPRING
HAPPENS SIX TIME3 PER DAY
SOMETIMES 3-4 TIMES PER MONTH. SOMETIMES NOT AT ALL.
DON'T NOTICE SEASONAL DIFFERENCE BUT DOES NOTICE
EXERCISE AND EMOTIONAL TIE
INTERVIEWED NOTE: SUBJECT DOES NOT PAY ATTENTION,
CANNOT ANSWER
SIT MORE THAN WORK, HEAVINESS S CHEST PAIN OCCUR IN
MORNING AFTER HAVING BEEN UP ABOUT 1 HR. INTERVIEWER-
NOTE: SMOKER, DRINKS COFFEE BEFORE CIGARETTE.
BEFORE SURGERY, COLD TEMPERATURE CAUSED ANGINA 3-
PER DAY
DURING WINTER 6-7 TINES PER DAY
BEFORE SURGERY HAD ANGINA ABOUT TWICE A MONTH IN
SUMMER-
MORE FREQUENT ?, SEVERE IM WINTER DUE TO COLD
HAPPENS DURING WORK Oil TALKING USUALLY
ABOUT SAME ^
SOME DIFFERS
PROBLEMS LATELY, JUS
IN SUMMER. HEAT
4 TI HE
_L THROUGH \EAR
•ICE IN FREQUENCY
GOT SAC].: FROM V;
-------
QUESTION 7
080WR WHEN IM COLORADO ALTITUDE CAUSED PAIN IN CHEST WHICH
WOULD RADIATE TO THE THROAT» TOOK NITRG AND STOP
ACTIVITY TO.RELIEVE. WAS WORSE THEM
100WC ALSO I10RE SEVERE PAIN IN SUMMER AND SPRING
012-JB WORSE ANGINA BETWEEN 3-7PM
005CB ALL EPISODES BY SEASON ARE MODERATE
075T8 ANGINA LASTS FOR A FEW SECONDS (4-5 SECONDS;
0-L'ORH ALWAYS VERY MILD
O'"-5—P'3 NO DIFFERENCE IN SEVERITY
033JS SLIMMER IS CLOSER TO 6 THAN FALL AND WINTER
003JS WINTER HAS SOB, TAKE MORE NITRO
062JT MORE RELATED TO ACTIVITY, SENSITIVE TO EXERTION MORE
THAN SEASON
022CE TIREDNESS. HAVE NOT OUTRIGHT PAIN, BUT DOES GET "TIRED
FEELING" ?< "HEAVY FEELING" AND MUST SIT DOWN.
QUESTION 3
100WC ABOUT 1 DAY EACH WEEK, MY ARMS ARE NUMB, FEEL
LIGHTHEADED AND HAVE CHEST PAIN. "TAKE NITRO, LAY DOWN,
GO TO SLEEP FOR SEVERAL HOURS. I'M OUT."
103JA > 3 DAYS ALL RECENTLY
052HR 12 DAYS AT LEAST. LAST WEEK 1 DAY, WHERE DOWN MOST OF
DAY
09IIMO ZERO (0) DAYS EVEN WHEN HAD CHEST PAIN
107JB "MAY KEEP ME DOWN FOR 15-30 MINUTES, SEVERAL TIMES
DURING THE DAY, BUT DON'T LOSE AN ENTIRE DAY. I PACE
MYSELF. BEFORE SURGERY IN JUNE, 1935, WAS DOWN
EVERYDAY."
003GB 1 DAY, LAST SUMMER BEFORE SURGERY
017LC NORMALLY SPEND EVERYDAY INDOORS IN CHAIR
001HA "NOT EVEN WHEN I USED TO HAVE IT, NEVER HAD TO STAY
DOWN."
OOSJB STAND UP, LAYING DOWN UK 'J± FT1NG r'Hli ' WUFSE, RAi) 1A i !=.=•
TO LEG ?•: ARMS.
062J T BEFORE SURGERY NEVER LOST TIME FOR WORK OR ACTIVITIES.
TOOK A NITRO ?•: RESUMED. NEVER LET IT GET HIM DOWN
MENTALLY.
022CE USUALLY REST FOR 30 MINUTES i; GET UP AND RESUME
ACTIVITY
-------
QUESTION ?A
024 AF USED VA BENEFITS FOR HEART. USE FHP FOR OTHER ILLNESSES
AND FOR WIFE
034EB HAS MEDICARE BUT USES VA. WOULD PREFER MAYO CLINIC rC
DC C'TCA BUT DON'T THINK VA WOULD PAY
00-D? PRIVATE MEDICAL INSURANCE FROM AARP
100WC ANSWERED MEDICARE BUT NOT OLD ENOUGH. RE20DED AS
MEDICAL
021 RE PRIVATE MEDICAL INSURANCE FROM AARP
0:3LD HAVEN'T USED VA IN 5 MONTHS. WENT TO KAISER IN JANUARY
023WF CHECKING INTO VA TOMORROW FOR ERECTION PROBLEMS
033RH PRIVATE MEDICAL INSURANCE FROM AARP
107JB USE VA BENEFITS WHEN NECESSARY BUT THAT IS SELDOM
MAINLY USE MEDICARE AND BLUE CRCSS SUPPLEMENTARY
(PRIVATE MEDICAL INSURANCE FROM BLUE CROSS SUPP.)
00365 INTERVIEWER NOTE; INTERVIEWERS KNOW FROM PAST RESEARCH
WITH SUBJECT THAT HE MAKES USE CF VA SERVICES WHICH
PROVIDE 100% COVERAGE FOR HEART CONDITION
046EM HEALTH MAINTENANCE PROGRAM FROM HORIZON INSURANCE. HIS
DOCTOR BELONGS TO THIS GROUP, SO HE JOINED
007F3 PRIVATE MEDICAL INSURANCE IS METROPOLITAN AND MAX I CARE
033J S USES VA FOR HEART CONDITION . .
062JT HCAG MEMORIAL HOSPITAL BILL WAS *5000, $2900 ANGIO—
SURGEON; 5300 BLOOD SUGAR CONSULTATICN-ENDOCRINOLCGIST
QUESTION 9C
0S7RS FIRST $ 1500 IN EACH YEAR MUST PAY HIMSELF FOR DR. OFFICE
VISITS, OR EMERGENCY ROOM AND HOSPITAL SERVICES
024AF "COULD GET ASPIRIN AT VA HOSPITAL BUT IT IS TOO STRONG
FOR ME, SO I BUY MY OWN."
009DE MEDICARE AND PRIVATE INSURANCE PAYS ALL OF MOST THINGS.
MEDICARE 80%, AARP 20%, "OCCASIONALLY SOME ITEMS OP
PORTIONS OF ITEMS ARE NOT COVERED AND I HAVE TO PAY FRCM
POCKET. IT IS VARIABLE, A DISGUSTING PROCESS."
100WC "FOR DR. OFFICE VISIT, COVERED TO THE FIRST '£35. FOR
EMERGENCY ROOM AND HOSPITAL, I HAVE 100% COVERAGE.
PRESCRIPTIONS ARE 30% COVERAGE. IF NEEDED, HAVE 100%
COVERAGE BY VA. "
021FE DCESN"T USE VA OFTEN
108JA PRESCRIPTIONS COST S15/M0IMTH, FLAT FEE
013LD '52. 50 PER PRESCRIPTION
0O.bWB PETITIONED HMO TO USE UCIMC AND WAS GFANTED THAT
LOCATION. MUST REQUEST TREATMENT FIRST TO BE COVERED OR
FAY TOTAL COST HIMSELF. RECEIVES PRESCRIPTIONS FRG;"'I
UCIMC PHARMACY BUT HAS MOT BEEN 3CLLED FOR ANY
PRESCRIPTIONS VET. IF DUPLICATE. UNNECESSARY. LP
SUPPLEMENTARY PROCEDURES ARE PERI- ORMED, COVERAGE
CHANGES
-------
A WHILE AGO HAD TO PAY FULL COST OF PRESCRIPTIONS, NOW
J'JST STARTING AARP
$7.00 PER REFILL
PRESCRIPTION MEDS PROVIDED FREE OF CHARGE WHILE ON 20
WEEK EXPERIMENTAL PROGRAM CONDUCTED BY PFISER
ACTUALLY HAS 1007. COVERAGE AT VA BUT DOES NOT ALWAYS
SUBJECT PAYS SI FCR EACH DR. OFFICE VISIT AND EACH
PRESCRIPTION. HEALTH MAINTENANCE PROGRAM FROM HORIZON
EMPLOYER PAYS FOR ALL COVERAGE
QUESTION 11
02-iAF SUBJECT IS CURRENTLY ON EXPERIMENTAL TREATMENT. SEEMS
TO BE A LITTLE MORE ACTIVE, TAKES CODED MEDICATIONS,
TOOK OFF ALL PREVIOUS MEDS AND NOW ON PROGRAM WHERE
NEITHER HE NOR HIS PERSONAL PHYSICIAN KNOW
MED ICAT IONS (DOUBLE-BLIND >
034E3 WHEN MEDS ARE CHANGED GO AN EXTRA TIME
009DB SUPPOSED TO GO TWO TIMES PER YEAR
02IRE DR. INCLUDES ANY MEDS DISPENSED AT THAT TIME IN THE
220.00 PER VISIT
OlSLD STARTED KAISER (LOCATED IN FONTANA) IN JANUARY
051JR NO COST FOR A CHECKUP EXCEPT THAT.OF TRAVEL/MILEAGE
030RH "ONCE THEY FOUND OUT THAT I DO NOT TAKE THEIR MEDICATION
THEN I WAS OFF THEIR PROGRAM — HEART IS NOW ONLY
CHECKED AS PART OF A PHYSICAL EXAM ONCE EACH YEAR."
LAST REGULAR EXAM WAS IN AUGUST 1935, MO LONGER GOES TO
HEART CLINIC
04cEM PAYS A $2 FLAT FEE FOR EACH CHECKUP
003JB PCC EVERY SIX MONTHS
062JT NOT FOR HEART.. BUT FOR DIABETES 3 TIMES/YR
022CE ONCE PER WEEK NOW: ONCE EVERY SIX WEEKS BEFORE COUMADIN
QUESTIon 12
0S4E3 FOR A CHECK ON HOW MEDS ARE REGULATING
009DB STILL TRYING TO SETTLE, STILL GETTING BILLS, BUT WON'T
PAY UNTIL HAVE BATTLED INSURANCE CO. AND MEDICARE
100WC "THE LAST OFFICE VISIT COST #.4?7; DON'T KNOW MY PART
YET. BUT IN THE PAST INSURANCE HAS PAID ALL."
OO'fCB "NO VISITS IN PAST 12 MONTHS, BUT AM GOING TOMORROW FCR
ANGINA — MADE APPOINTMENT."
O'ZEHR ONE VISIT WAS FOR ANGIOPLASTY AND ONE WAS FOR ANGINA -
SPENT SEVERAL DAYS IN HOSPITAL
OV.isWB HAVE NOT RECEIVED BILL YET
Ol'TCK SHORT 1' IE S3 OF BREATH PROBLEMS; BELIEVED TO BE RELATED TO
HEART
001HA TURNED GUT TO 3E LUNG PAIN AND NOT THE HEART
032WH PRESCRIPTIONS RAN OUT AMD HfiD TO HAVE CHECKUP BEFORE
PRESCRIPT EON RENEWAL
-------
QUESTION 15
103RM NEXT TO LAST EMERGENCY ROOM COST WAS S121* (COMMUNITY
HOSPITAL), BUT THE LAST WAS =0 (VA)
033EP "I DO NOT KNOW THE COST OF IIY LAST EMERGENCY ROOM VISIT;
BUT KNOW IN THE FUTURE MY INSURANCE COMPANY WILL BE
CHARGED <577 PER EMERGENCY ROOM VISIT,"
QUESTION 16
033J3 IF HANDLE RIGHT DOIT T HAVE PROBLEMS AND CAN AVOID
SEVERE PAIN. "HAVE LEARNED ABOUT HOW MUCH I CAN DC
062JT HOME — CALISTHENICS •!< STRETCHING. RIDING BIKE
QUESTION 17
030WR
057RS
024AF
034EB
013LD
052HR
*.) (.) .3 W B
023WF
033RH
107 J B
079LB
039HK
051JR
032 WH
PERSONAL PROGRAM OF WALKING FOR EXERCISE. WALKS TO
IMPROVE HEART CONDITION AND REMAIN FIT
"BICYCLE IS THE ONLY THING I HAVE PURCHASED."
WALKS 2 MILES EACH DAY VERY SLOWLY
"EXERCISE BIKE PROVIDED — DO OCCASIONALLY, BUT NOT LIKE
I SHOULD."
HAD MANY TESTS BECAUSE TRANSFERRING SELF TO KAISER""
RATHER THAN USE LONG BEACH VA. WANTS TO GET RECORDS
TRANSFERRED. HAD UPPER GI, 2 ECG7S. ECHOGRAM ALL AGAIN
AT KAISER
JUST WALKING
SUBJECT ALSO INCURRED 5250 INITIATION FEE PAID 13 MOS.
AGO AT LOCAL HEALTH CLUB/SPA
SUBJECT DID HAVE THERAPY FOR LEG AND BACK INJURIES
SUSTAINED IN AUTO ACCIDENT
SUBJECT DID PURCHASE AN EXERCYCLE FOR 5 LOO 2-3 YEARS
AGO
SUBJECT ALREADY HAD EXERCISE BTKE; IT WAS PURCHASED
SEVERAL YEARS AGO, PURCHASED NO SHOES
JTTHING.
WALKS 3 MILES DAILY IN EARLY MORNING. DOES SOMETIMES
RIDE THE EXERCYCLE
BOUGHT EXERCYCLE LONGER THAN 12 MONTHS AGO
WENT TO SEE ABOUT HAVING BALLOON INSERTED IN STOMACH TO
HELP LOSE WEIGHT. NOT ABLE TO BECAUSE OF PAST STOMACH
AND INTESTINAL SURGERY. NO COST. WOULD HAVE HAD fO PAY
IF HAD BEEN ABLE FO HAVE I HE SURGERY
SUBJECT CITES COST OF CLOTH INC. SHOES, AND DRIVING '!"0
AREA WHERE CAN WALK
SUBJECT WAS TOLD TO WALK AND WAS GIVEN EXERCISES TO DO
-------
QUESTION 13
030 WR OTHER=ALTITUDE
015RC PRIMARY FACTOR 13 EXERTION, SECONDARY IS STRESS AND
ANXIETY
034EB OTHER-HIGH ALTITUDE AND HIGH HUMIDITY. LAST SUMMER
BUSSED THROUGH DENVER. HIGH ALTITUDES. HAD TC
HYPERVENTILATE. HOT HUMID WEATHER HARD, ALSC NOTICED
AIR POLLUTION TO BE MORE CP A FACTOR IN THE LAST YEAR OR
SO.
100WC PGS7-INTERVIEW COMMENTS: "AIR POLLUTION DOES BOTHER ME
AT TIMES BUT AROUND NY HOUSE IN SAN JUAN CAP ISTRING aJE
JUST DON"T HAVE IT (AIR POLLUTION). BUT IT DOES BOTHER
ME AMD IT CAN BRING ON ANGINA. I DON'" T GO TO L. A. ,
THEREFORE I DO NOT GENERALLY ASSOCIATE AIR POLLUTION
l- l i H A N G 11J A . "
012JB OCCASIONALLY STRESS OR ANXIETY AND EXCITEMENT
025HR COLD TEMPERATURE CAUSED AN6INA ON A TRIP TC OREGON A
COUPLE OF YEARS AGO
023WF AIR POLLUTION IS A FACTOR, RECALLED CLEAN AIR IN LONG
BEACH YEARS AGO, FELT BETTER. CIGARETTE SMOKE IS A
FACTOR, TO SAY NO WOULD BE STUPID. OCCASIONALLY HAVE
PAIN AFTER MEALS, USE SELTZER WATER TO RID—GAS PAIN.
USUALLY RELAX AND IT PASSES
050EP ' MEALS A FACTOR IF ATE TOO MUCH
051JR OTHER=NOT HAVING REGULAR MEALS
036GS MEALS ARE SOMETIMES A FACTOR. OTHER=INDIGESTI ON DUE TO
MEDICATIONS
017LC COLD BEVERAGES LIKE ICE WATER AND ICE TEA BRING ON
ANGIMA
106BD OTHER=ANGEi~<
067SW PHYSICAL EXERTION SUCH AS WALKING AND DANCING FAST
046EM "MEALS ARE A FACTOR BUT MOSTLY GAS; HAD TO GET
PRESCIRTION LAST TIME — THREE DAYS 7 TIL WELL."
032WH "STRESS OR ANXIETY IS A FACTOR BECAUSE I CANNOT DO THE
THING'S I Wr-ii-T 10 - "
033J3 "STRESS OR ANXIETY. IRRITATION, EVEN WHEN OTHERS
ARGUE."
QUE3iION 1V
080 WR OTHER- TRY TO TAKE MIND OFF OF TIMINGS
043VL OTHER —-JU37 TAKE IMITRO AND CONTINUE
03-E3 NO YARD-LIVE IN APARTMENT
005CD OTHER = OF:IVE INSTEAD OF WALK
-------
023WF DO THE SAME ACTIVITIES BUT AT A SLOWER PACE, "MY
ACTIVITIES HAVE CHANGED DUE TO BACK AND LEG INJURIES
INCURRED IN CAR ACCIDENT — NO GOLF OR BOWLING. AVOID
EMOTIONAL STRESS — AVOID ARGUMENTS OF ANY KIND. AVOID
EXPOSURE TO HOT WEATHER. TO DECREASE MY OWN SMOKING
BEHAVIOR I KEEP MYSELF OCCUPIED." SLEEP OR REST MORE —
LAY DOWN AMD RELAX. TAKE 10-15 MINUTES DEEP SLEEP NAP,
IF INDICATION OF CHEST PAIN, THEN RELAX, DRINK AN GLASS
OF WATER OR TAKE NAP, IF DOESN'T LEAVE IN 4-5 MINUTES,
TAKE MITRO, TRY TO SET OUT CF HOUSE AT LEAST ONCE PER
DAY
072PD MAIN ADJUSTMENT IS TO SLOW DOWN, BUT NEVER HAD TO STOP
MOST ACTIVITIES
107JB STILL MANAGE TO CARRY OUT ACTIVITIES — ALWAYS DID — IT
SIMPLY TOOK LONGER DUE TO REST BREAKS, COULD ALWAYS
CARRY OUT ALL BUSINESS (OFFICE, MAINTENANCE' WORK
030RH "WHEN I FEEL IT COMING ON I JUST SLOW DOWN — I
SOMETIMES STOP BUT ALWAYS RESUME AND FINISH THE
ACTIVITY."
0c7SW "I TAKE OFF TIME FROM WORK FOR NAP AND EXERCISE EACH
DAY. 0THER=WALK MORE SLOWLY AND DO LESS FAST DANCES (NO
DISCO)," INTERVIEWER NOTE: SUBJECT RUNS BUSINESS FROM
OWN HOME
0S3JS OTHER-RUN AIR CONDITIONER, NOT NEARLY AS ACTIVE. "DON'T
GO OUTSIDE, DON'T DRIVE FAR.
003JB AVOID NIGHT AIR ?< FIRST THING IN MORNING, WARM UP CAR,
THEN COME IN, STAND UP.
022CE "START S< GOTTA STOP. 1/4 THROUGH CAR WASH OR YARD WORK.
BUT DO FINISH. JUST SLOWER. MUST PACE AND REST."
GUESTION 20A
080WR YARDWCRK — CANNOT DO HEAVY CUTTING OR LAWN ANY LONGER,
"BACK PROBLEM TOO, BUT NEVER PREVENTED ME FROM DOING
YARDWGRK. WOULD PREFER TO DO MYSELF."
032JII ANSWERED NO TO #20. " I DO HAVE MEN WORK ING FOP ME CM
CONSTRUCTION LABOR THAT I MIGHT DO MYSELF IF I DID NOT
HAVE ANGINA — BUT I HAVE HAD THEM WORKING FOR ME FOR ;
NUMBER OF YEARS. I'VE ADJUSTED. I DO NOT WANT TO DO
PHYSICAL LABOR."
043VL ANSWERED NO TO If 20. LIVES IN AN APARTMENT — ALL
MAINTENANCE TAKEN CARE OF
024AF WIFE HAD STROKE AND CANNOT DC ANY WORK, NOW DO MOST
EVERYTHING IF AT GETS DONE AT ALL
-------
034E5 HEAVY HOUSEWORK AND HARD VACUUMING. " DAUGHTER COMES IN
AND DOES HEAVY CLEANING ONCE A MONTH, NO NOME',-' CHANGES
HANDS. TRY TO DO MICE THINGS FOR HER. DAUGHTER CLEANS
12/YEAR. NO COST BECAUSE ITS MY DAUGHTER." ESTIMATES
52 ADDITIONAL ANGINA EPISODES PER YEAR. "I WOULD CLEAN
EVERY WEEK IF I DIDN'T GET CHEST PAINS, BUT VACUUMING
REALLY IS TREACHEROUS. BECAUSE MY DAUGHTER DOES IT AND
WON'T TAKE MONEY. ONLY HAVE HEAVY CLEANING DONE ONCE PER
MONTH." ANGINA WOULD BE MORE SEVERE AND WOULD ADC A
LARGE AMOUNT OP HEARr ATTACK RISK. THERE IS NO OTHER
REASON FOR DAUGHTER TO DO THIS WORK. SUBJECT ALSC USES
CARWASH 24 TIMES PER /EAR. PURCHASED NO EQUIPMENT NCR
MADE ANY STRUCTURAL CHANGES > >J HUME
012J3 HIRE OUT HEAVY LABOR ON JOBS
023WF ANSWERED NO TC 420. SCN DOES LAWN. AUTO WORK. HOUSE
FAINTING- HE IS A CARPENTERS7 SUPERVISOR. 'FOUR-FIVE
HOURS TO MOW AND CUT LAWN — HALF THE TIME I REST*"
033RH ANSWER NO TC *20. "I LIVE IN LEISURE WORLD — IT'S
TAKEN CARE CP."
107JB ANSWER MO TO 420 — NO NEVER HIRED OUT JOBS. STILL
CONTINUED TO DC HIMSELF DESPITE ANGINA INCONVENIENCE
031 EH ANSWERED NO TO 420 — DAUGHTER DOES ALL WORK
037CK ANSWERED NO TO 420 — DOES NOT HIRE HELP. JUST TAKES
HIS TIME TO DO JOBS AROUND HOUSE, MIGHT MOW FRONT YARD
ON ONE DAY AND THE BACK THE NEXT OR A FEW DAYS LATER,
"NO HURRY, IF IT GETS DONE, IT SETS DONE."
017LC ANSWERED NO TO 420 — WIFE DOES A LOT OF WORK AROUND THE
HOUSE. VERY SMALL YARD. HE WILL USE AN ELECTRIC POWER
LAWN MOWER "ON A GOOD DAY" BUT NOT OFTEN. WIFE USUALLY
MOWS THE LAWN. SHE WILL EMPTY THE GRASS CATCHER FOR
HIM. HE WILL MOW THE LAWN A LITTLE AT A TIME OVER 2-3
DAYS. "BECAUSE OF MY INTERCCULAF IMPLANTS I HAVE BEEN
INSTRUCTED TO NEVER LOWER BY HEAD BELOW THE LEVEL OF MY
HEART. I MUST FOLD UP LIKE AN ACCORD I AN TO PICK
SOMETHING UP THAT I HAVE DROPPED."
O^JF'G HIRES OUT WORK SUCH AS PAINTING, AUTO MAINTENANCE AND
HOME REPAIRS KIDS DC HEAW YARDWORK, SUBJECT GAVE
EXAMPLE OF HIRING HELP TO 00 CARPET LAYING AND PAINTING
OF A BEDROOM. WOULD PREFER AND NGPMALL / WOULD DO
HIMSELF. "I DO A BETTER JOB — I LIKE My JOB BETTER,"
103RM SUBJECT COMPLETED QUESTIONNAIRE ANO RETURNED BY MAIL,
WHEN LATER CALLED ON PHONE WAS RELUCT ANT TO ITEMIZE
EXPENSES FOR INDIVIDUAL SERVICES HI-ED. INTERV I EWER 'S
JUDGEMENT WAS TC USE THE EXTENSIVE HOME MAINTENANCE
COSTS '-S2000) AS THE EXAMPLE FOR #20A.
067SW ANSWERED NO TO 420 — HAS MOT HIRED ANY SERVICES TO
PREVENT ANGINA. STILL WORKS IN YARD: DOES HAVE A
GARDENER AT -560/MONTH
046Ei1 ANSWERED NO TO 420 — HAS THREE SONS. OLDEST IS AUTO
MECHANIC AND HE DOES THE OAR i/iOr-.K, TWO '''OUNGEP MAINT.~I!!
THE YARD, PLUMBING, ETC
032WH ANSWERED NO TO 420 — HAVE FOUR BOYS AMD THE: ;>0
-------
03 SEP
062J T
01SLD
024 AF
005C3
10SJA
0 1SLD
052HR
006WB
051JR
094PG
083 J S
1 00 wc
052HR
006 WB
033 J 3
ANSWERED NO TO #20 — SON IS LIVING BACK AT HONE. SON
DOES ALL THE HEAVY WORK
ANSWERED MO TO #20 — STAMINA AS A YOUNGER GUY, NOW LIVE
IN TOWNHOUSE APARTMENT. EVERYTHING IS GOING ALONG FINE
NOW.
QUESTION 20B
MAJOR JOBS. "MY SONS TAKE CARE OF SMALL JOBS. OIL
CHANGE. TUNE-UPS, ETC. "
"DO IT MYSELF NOW. GNL"-" HIRED ONCE WHEN I WAS TOO ILL
TO DO IT BECAUSE OF ANGINA PROBLEMS."
QUESTION 20D
"I WOULDN'T MAKE IT THROUGH IT."
WOULD HAVE ADDITIONAL ANGINA BUT CANNOT SAY HOW MANY
EPISODES—WOULD HAVE A HEART ATTACK
WOULD HAVE ADDITIONAL ANGINA BUT CANNOT SAY HOW MANY
EPISODES
WOULD HAVE ADDITIONAL ANGINA BUT CANNOT SAY HOW MANY
EPISODES. "JUST CAN'T DO EVEN ONCE. NO WAY TO DO THE
WHOLE YEAR BECAUSE OF ANGINA."
"ONE TIME WAS PLANTING A TREE USING A POSTHQLE DIGGER
AND ENDED UP IN THE HOSPITAL."
ANSWERED NO. "ONLY HIRED ONCE WHEN TOO ILL TO DO IT
BECAUSE OF ANGINA PROBLEMS, DO IT MYSELF NOW."
2
-------
QUESTION 20F
030WR
100WC
006WB
051JR
033 J 5
WOULD ADD A
IN THE LONG
— "I DON'T
WOULD ADD A'
SUBJECT DID
SMALL AMOUNT OF RISK — ALSO COMMENTED THAT
RUN WORKING IN THE YARD WOULD HELP HIS HEART
THINK ANGINA WOULD ADD MUCH."
LARGE AMOUNT — 40%
NOT KNOW. "UNKNOWN, BECAUSE I NOW DO THIS
WORK. I"
ANSWERED
CHANCE IF
ANSWERED
WAS ONLY ONCE
"HAT I
ADD A LARGE AMOUNT
' I DC NOTHING, ''
lOO--;—"IN A HURRY.
hire:
' D R . -
IT.
EA
DY
. u
QUEST ION
'6
012JB
006WB
OB6GS
1OOWC
094PG
" PART I ~ ' C-JSE I'M LAZY."
"THAT WAS THE ONLY REASON I HIRED IT DONE BECAUSE I UiAS
TOO ILL FROM HEART PROBLEMS TO DO 1~ THEN. BUT I DO IT
ALL THE TIME NOW."
ANSWERED YES — IN ORDER FOR HIM TC BE TRANSPORTED HE
MUST HAVE A WORKING CAR — WANTS TC KEEP CAR RUNNING
WELL
ANSWERED NO — WOULD PREFER tq DO HIMSELF
ANSWERED NO — WOULD PREFER TO DO.HIMSELF
QUESTION 20H
030WR
024 AF
1 r> o w c
052HR
013LD
0 39HK
1 0°MM
05 WR
SUBJECT HAS HEAVY DUTY CLEANING DONE AROUND THE HOUSE
EVERY 6 WEEKS AT $75 PER VISIT. SUBJECT USED TO DO
VACUUMING FOR WIFE BUT CANNOT DO IT ANYMORE. ONCE PER
YEAR HIRES OUT HEAVY YARDWCRK WHICH INVOLVES
TRANSPLANTING AT S75 ABOVE NORMAL YARDCARE SERVICE
CHARGES
HOUSE PAINTING, WINDOW WASHING, RUG CLEANING, AND AUTO
REPAIR
"SNAPPED A RIFE — TRIED (TO FIX > M ."SEur SU1 CGL'LDiV- T
TWIST — HAD TO CALL A PLUMBER TO TURN ONE PIPE, HE
RIPPED ME OFF." PLUMBER C0ST=£120, ONE VISIT
AUTO REPAIR ONCE DURING THE YEAR AT -50. "TORE DOWN CAR
COULDN'T GET IT BACK TOGETHER (BECAUSE OF ANGINA) — HAD
TO HIRE HELP."
SUBJECT LISTED YARD WORK AND PLUMB:
BE i
;e SUBJECT
WAS NOT ABLE TO CAPE FOR HIS LAWN, HE HAD IT CONVERTED
70 A ROCK GARDEN. HE HIRES HIS GRANDKIDS TO PULL THE
WEEDS A COUPLE TIMES EACH YEAR AMD PAYS THEM A TOKEN
AMOUNT
TV REPAIRS. CLEANING OF CARPETS., CLEANING OF DRAKES
AUTO MAINTENANCE
SUBJECT LISTED "EATING CUT 150 TIMES IN PAST YEAR"
BECAUSE HE CANNOT STAND AND WALK 01 STANCE IN GROCERY
S FORES NCR CARRY SACKS INTO THE HOUSE. ALSO LIS TED
HOUSEWORK. YARDWCRK. AND HOUSE MAINTENANCE ' PLUMBING.
ELECTR J CAL. ETC.'
-------
I
HIRED COOK 30 TIMES IN PAST YEAR. SUBJECT CANNOT STAND
LONG
YARDCARE, AUTO MAINTENANCE, PAINTING, PLUMBING, AND
HOUSE MAINTENANCE
GARDENING, AUTO MAINTENANCE, AMD HOME MAINTENANCE
03 6 >3 5
09J-PG
i 03RM
QUESTION 201
030WF ANSWERED NO — BOUGHT GARAGE DOOR OPENER MORE FOR
CONVENIENCE, NOT BECAUSE OF HEART. NO OTHER
EXPENDITURE
024AF INSTALLED RAILING AROUND PATIO — LIVE IN MOBILE HOME
W ITH AN ELEVATED PATIO
005C3 ANSWERED NO BUT SUBJECT NOTED THAT HIS CHILDREN GAVE
HIM A TV REMOTE CONTROL FOR FATHER'S DAY SC HE WOULD NOT
HAVE TO GET UP TO CROSS ROOM
G52KR ANSWERED NO FOR THE PAST YEAR — ALREADY HAS MADE
EXPENDITURES — WITHOUT POWER EQUIPMENT COULD NOT DO
WORK
039HK SUBJECT LISTED RECLINER CHAIR, HEATING PAD FOR CHEST,
MATTRESS, AND OXYGEN EQUIPMENT AND CYLINDER REFILL
EXPENSE
# 094PG SUBJECT LISTED A NEW AUTOMOBILE AT 510,000. SUBJECT
WOULD PREFER A USED CAR BECAUSE HE LIKES TO WORK ON CARS
AND FIX THEM UP. BUT REALIZED "I NEEDED A DEPENDABLE
CAR AND CAN NO LONGER DO THE WORK ON OLDER CARS THAT
NEED MORE MAINTENANCE."
103RM ELECTRIC GARAGE DOOR OPENER AND A CART TO CARRY OUT
TRASH CANS TO CURB
QUESTION ALT—20
032JM ANSWERED NO — NOT IN PAST 12 MONTHS BUT PREVIOUS
C57R3 ANSWERED NO AND THEM NOTED THAT WHEN HE RETURNED TO WORK
FOR TWO MONTHS (JANUARY TO MARCH 1936 > HE HAD TO HIRE ?¦
"HONCHO" Tu DO THE FLOOR COVERING WORK THAT HE USED TO
DO HIMSELF BEFORE HE HAD THE HEART TROUBLE. SUBJECT is
SELF-EMFLOYED IN THE FLOOR COVERING BUSINESS. AFTER tug
MONTHS HE QUIT DUE TO JOB STRESS — "TOOK ME 6 WEEKS
BEFORE I FELT RIGHT AGAIN,"
37CK ANSWERED NO — ROWER LAWN EQUIPMENT OLDER THAN 12
MONTHS
046EM ANSWERED NO — BUT NOTED THAT CHILDREN BOUGHT HIM AN
ALUMINIUM bAF.Ai.3E DOuR !-OR i- A TI-'EK* 3 DAY
062JT ANSWERED NO — SOLD HOUSE .•* PUT MONEY INTO BUSINESS.
DID MOT HAVE TO WORRY ABOUT YARD OR HOME MAINTENANCE rM
APARTMENT.,
-------
QUESTION ALT-20A
017LC LAWN MOWER AT $140 WAS USED BY SUBJECT TO ANSWER AL7-2CA
TD E. SUBJECT ALSO IMGTED PURCHASE OF RECLINER CHAIR AT
$350 TO ENABLE Hill TO SLEEP IN A MORE UPRIGHT POSTURE
AND AVOID ANGINA AT MIGHT. ESTIMATED THAT RECLINER
PREVENTED AM ADDITIONAL 365 EPISODES OF AMSINA <¦ AT LEAST
ONE PER NIGHT). SUBJECT ALSO NOTED THE PURCHASE OF
WASHER AND DRYER AT $350 A PIECE, FORMERLY SUBJECT HAD
TG TAKE CLOTHES TO LAUNDROMAT ONCE PER WEEK i TRIP OUT
ALSO ASSOCIATED WITH ANGINA. WASHER AND DRYER, AND
RECLINER ENTERED INTO ALT-203
0 32 WH MATTRESS WAS PURCHASED TO SLEEP BETTER AND GET MORE REST
— "ANGINA AT NIGHT IS LESS,"
QUESTION AL7-2CF
017LC ANSWERED NO BUT NOTED THAT PURCHASES DO ALSO MAKE THINGS
EASIER FOR HIS WIFE
QUESTION ALT-20G
017LC WASHER AND DRYER AT $700; RECLINER CHAIR AT 5350
032WH NEW AUTOMOBILE AT 511,000, "WIFE DOES MOST OF THE
DRIVING BECAUSE DON'T DO MYSELF MUCH. CAN'T REPAIR OR
ALLOW HER TO GET STUCK."
QUESTION 21
091IM ANSWERED NO — RETIRED 2 YEARS AGO
030RH ANSWERED NO — WORKS A3 A VOLUNTEER AT THE LONG BEACH
VETERANS ADMINISTRATION MEDICAL CENTER ON 1 DAY EACH
W EEK
OS^EB ANSWERED MO -- WORKS OCCASIONALLY AT ANAHEIM STADIUM
PARKING LOT AS AN ATTENDANT WHEN SOME OF THE REGULARS
CANNOT — IS NOT EVEN REGULAR PARTTIME WORK
033RH SUBJECT IS 33 YEARS OLD — RETIRED FOR 17 YEARS
001HA SUBJECT IS RETIRED FOR 16 YEARS — WAS A CAB DRIVER
062JT 10-12 HOURS, SIX DAYS PER WEEK
-------
QUESTION 21B
032 J M CONSTRUCTION WORK
025JF LIGHT ELECTRICAL OR PLUMBING
012JB WORKING CONTRACTOR — CARPENTRY, LIGHT CONSTRUCTION
006WB ELECTRICAL -TEST TECHNICIAN AT SAN ONOFRE NUCLEAR
GENERATING STATION
072PD WORKS 50 HOURS PER WEEK AT HUGHES SATELLITE AS AN
ELECTRICAL ENGINEER. WORKS ON OWN CONSULTING BUSINESS UN
THE SIDE
107JB MANAGER OF MINI—STORAGE. WAREHOUSE; 6°'.'% OFFiCE WORK AND
40'A MAINTENANCE
016GC FREELANCES AT OFFICE WORK; WORKS FROM 1-20 HOURS PER
WEEK. IS CM FULL DISABILITY
0S6GS REAL ESTATE SALES
06-DT HOL'SECLEAN ING
094PG MANUFACTURING ENGINEER
103RN REAL ESTATE BROKER
067SW BROKER — MARKETS OWN PRODUCT (GIFT BOXES) FROM HOME TO
VARIOUS RETAIL CHAINS
007FB CARPENTER FOR ROCKWELL
QUESTI ON 21C
107JB 9 DAYS DUE TO CABG — STARTED'BACK' TO WORK IMMEDIATELY
UPON RELEASE FROM THE HOSPITAL — GRADUALLY WORKED BACK
INTO THINGS, ANSWERED PHONES, MESSAGES
QUESTION 21E
006WB ANSWERED NO — REALLY WANTED TO CHANGE POSITIONS BUT
WASN'T ALLOWED. AFTER ELECTROCUTION INJURY, WAS OFF
WORK 13 MONTHS BUT WENT BACK TO SAME POSITION
094PG ANSWERED YES — FORMERLY A DESIGN ENGINEER — WORKED
MORE HOURS AND MADE MORE MONEY PER HOUR
QUESTION 21F
094PG "I PREFER TC WORK MORE HOURS THAN THE NORMAL PERSON DOES
— IT'S MORE SATISFYING,"
-------
QUESTION 21G
094PG " MADE TWICE THAT (-$20-24.9K> AT MY OTHER JOB."
006WB REFUSED AND COMPLAINED. DOESN'T THINK IT IS ANYONE'S
BUSINESS, ESPECIALLY A GOVERNMENT AGENCY7 S LIKE EPA,
"IF I TOLD YOU MY SALARY THE GOVERNMENT MIGHT THINK THAT
OUT OF THAT AMOUNT I SHOULD SE ABLE TO SPEND A CERTAIN
AMOUNT FOR HEALTH CARE AND THAT'S NOT TRUE. EVEN IF
SCME PEOPLE MAKE MORE MONEY IT DOESN'T MEAN THEY HAVE
MORE TO SPEND JUST BECAUSE THE GOVERNMENT THINKS THEY
DC, MO ONE SHOULD "'ELL ME WHAT THEY THINK I CAN AFFORD
TO SPEND ON ANY PART OF MY LIFE."
QUESTION ALT—21
043VL ANSWERED YES — "EARLY RETIREMENT TO GET AWAY FROM
HAVING A HEART ATTACK."
024AF ANSWERED NO — QUIT 1930 — MADE VALVES FOR MUSICAL
INSTRUMENTS
013FC ANSWERED NO — QUIT 1965 — RETIRED AFTER 21 1/2 YEARS
IN THE NAVY AT AGE 33 — WORKED 7 YEARS AFTER THAT THEN
GU IT
03 4EB ANSWERED NO — WENT ON 1007. DISABILITY 7 YEARS AGO WITH
HEART PROBLEMS
005CB ANSWERED YES — QUIT 3 YEARS AGO — DROVE FORKLIFT WITH
GASOLINE ENGINE; FUMES MADE THE SUBJECT DIZZY AMD GAVE
HIM PROBLEMS
103JA ANSWERED YES — HEART ATTACK IN 1933
01ELD ANSWERED YES — IN 1931, SET-UP OWN SHEET METAL SHOP
BUSINESS, HAD TO QUIT. HIS SONS TRIED TO MAKE IT GO —
LOST BUSINESS
052HR ANSWERED YES BUT CODED NO — QUIT WORKING 7 YEARS AGO.
WAS EMPLOYED IN ELECTRICAL POWER CONSTRUCTION WITH LOS
ANGELES DEPARTMENT OF WATER AND POWER. SALARY WAS $20-
2 *. ?K. PHYSICIANS WILL NOT LET HI!'1 GO BACK TO WORK
023W!- ANSWERED MO — QUI . WORKING II I 1 7/3. WAS EMPLUYtD A'o h
COMMERCIAL TRUCK DRIVER AND CHARTER/SCHOOL BUS DRIVER.
SUBJECT WAS A LINE DRIVER ON CROSS-COUNTRY RUNS. WOULD
DRIVE FOR 6-3 HOUR STRETCHES. BY QUITTING, SUBJECT LOST
TEAMSTERS PENSION AND SCHOOL DISTRICT RETIREMENT
OPPORTUNITIES, SALARY WAS $25-23. 9i<. DOES NOT FEEL
CONDITION HAS IMPROVED ENOUGH TO RETURN TO WORK
039HK ANSWERED NO — QUIT 14 YEARS AGO. WAS EMPLOYED AS A
CORPORATE PILOT (PIPER AZTEC AND LEAR JET), SALARY WAS
0"MM ANSWERED NO — CLOSED COMPANY IN 1773 IMMEDIATELY AFTER
HAVING HEART RFOBLENS
037CK ANSWERED YES BUT CODED NO — QUIT IN !.9~2 OR ;?7~. WAS
EMPLOYED AS A UN ION CARFENTER. DECK I NED TO STATE
SALARY. DOES NO I BELIEVE CONDITION HAS IMPROVED EMU! JOH
THAT HE COULD RETURN TO WORK
-------
017LC ANSWERED NO — QUIT WORK AS AIRCRAFT INDUSTRY INSPECTOf
IN JANUARY 1977 AND HAD CABG SURGERY ON MAY 4, 1977
046EM ANSWERED NC — RETIRED 1976
03ZWH ANSWERED NO — QUIT IN 1973, BLACKED GUT AND FELL OFF
HORIZONTAL BORING MILL MACHINE. HURT BACK IN FALL
033JS "HAD TO QUIT. TOO YOUNG FOR SOCIAL SECURITY, NO
RETIREMENT, SO WAS REALLY HARD OFF FOR 1-1/2 YRS UNTIL
ABLE TO GET SOCIAL SECURITY"
QUESTION ALT-21B
057RS SELF EMPLOYED IN FLOOR-COVERING BUSINESS
043VL FACILITIES MANAGER FOR SEVERAL SAVINGS AND LOAN
BUILDINGS
100WC CONSTRUCTION — SALES, BUT DID DO HEAVY LABOR
02 IRE TEACHER
005CB FORKLIFT OPERATOR
103JA SALESMAN
01SLD SHEET METAL CRAFTSMAN — SELF EMPLOYED
091IM REAL ESTATE APPRAISER
039KC ELECTRICAL ENGINEER — SELF EMPLOYED, CONSULTANT
079LB MANAGEMENT — HOME IMPROVEMENT
003GB ADMINISTRATOR — GROUP HEALTH CARE PROGRAM FOR A MAJOR
CORPORATION , .
106BD COMPUTER PROGRAMMER/OPERATOR
QUESTION 2 ID
057RS ANSWERED NC — WITH PHYSICIAN'" S APPROVAL. RETURNED TO
WORK (OWN-FLOOR COVERING BUSINESS) IN JANUARY 19S6.
AFTER TWO MONTHS OF WORK STOPPED AGAIN. "SIX WEEKS
BEFORE I FELT GOOD AGAIN — PROBABLY COULD WORK BUT IT'S
JUST NOT WORTH IT."
091 IM ANSWERED YES — ON A PARTTI ME BASIS
089KC ANSWERED NO — JT?S I-Hv9TCIANS) PEING DEBATED IT HE
SHOULD RETURN TO WORK
079LB ANSWERED NO — IMPROVED. BUT NOT THAT MUCH — NOT SURE
106BD ANSWERED NO — IS LOOKING FOR A JOB. WAS LAID OFF AFTER
HEART AND HIGH BLOOD PRESSURE PROBLEM. DOES HAVE SCME
ANXIETY ABOUT RETURN INO TO WORK
-------
QUESTION 23
025JF PUTTING IN CEILING FAN IN ATTIC AT HOME
057RS DRIVING HQ,"IE FROM ANAHEIM STADIUM IN PERSONAL CAR
043VL SOCIAL DANCING AT A LONG BEACH DANCE CLUB
082JM MOVING CARS* INTO GARAGE AND PARKING ON DRIVEWAY
030WR INDOORS AT HOME, SITTING, THINKING ABOUT BUSINESS
PROBLEMS
024AF AFTER DINNER AT RESTAURANT, TALKING
01 SRC GETTING READV TO TAKE DAUGHTER TO THE PROM - OPENING CAR
DOOR
034E3 SITTING AT HOME THINKING; TROUBLED ABOUT RUNNING OUT OF
THAT I nNP.
009 CB NOCTURNAL ANGINA JUST BEFORE USUAL WAKING TIME FROM
NIGHT SLEEP
100WC IN LIVING AREA AT HOME; FLA'' I NO WITH DOG
012JB AT WORK AT SOMEONE ELSE'S HONE; MOVING FURNITURE
02IRE AT LOCAL LAKE3IDE RECREATION AREA; WALKING BRISKLY WITH
FRIEND
005CB AT HOME, WALKING UP STAIRS
103J A IN BED. GETTING UP THAT MORNING
013LD AT HOSPITAL AFTER UPPER GI; TALKING TO WIFE.
052HR ON FREEWAY DRIVING IN FROM RIVERSIDE IN PERSONAL CAR
091IM AT HOME DGING THINGS AROUND THE HOUSE IN THE MORNING
006WB OUTDOORS AT WORKSITE, WALKING UP MANY FLIGHTS OF STAIRS
" TO WHERE CAR WAS PARKED
023WF IN BATHROOM SHOWERING; RINSED OFF, SAT ON STOOL UNTIL
ANGINA PASSED
039KC IN LIVING ROOM, GETTING OUT OF CHAIR TO WALK ACROSS THE
ROOM
072PD OUTDOORS. GOING TO LUNCH WITH ASSOCIATES-. WALKING
UPHILL
033RH "OCCURRED ABOUT 1 MONTH AGO, CANNOT REMEMBER WHAT I WAS
DOING OR WHERE I WAS AT, DON'T USUALLY HAVE TO STOP THE
ACTIVITY AND RARELY TAKE A NITRO." (RESRONDANT IS 33
YEARS OLD,)
107JP DOING DRYWALL REPAIR AT WORKSITE (HOME BUSINESS;
031 EH INDOORS AT HOME. WATCHING TV
075TS IN HOME GARAGE, TAKING ENGINE OUT OF CAR
077LB IN SHOWER, SHAMPOOING HAIR
016GC IN EED. SEXUAL ACTIVITY
039HK OUTSIDE APARTMENT, CARRYING GROCERIES UPSTAIRS (1
FLIGHT OF STAIRS)
003GB MORNING WALK FOR EXERCISE Or-! NEIGHBORHOOD STREETS
109MM IN BED. SEXUAL ACTIVITY
050EP INDOORS. WORKING AROUND THE HOUSE: PICKED UP SOMETHING
HEAVY
051JR WALKING ON THE STREET (MAIN THOROUGHFARE)
086GS STARTING NIGHT SLEEP. IN BED AT HOME
064DT INDOORS AND OUTDOORS AROUND THE HOUSE; VACUUMING,
SWEEPING AND PICKING UP
037CK C'JTDOORS [H YARD, MOWING LAWN WITH SELF PROPELLED GAS
LAWN MOWER
-------
017LC MORNING WALK FOR EXERCISE ON NEIGHBORHOOD STREETS; COLD
WIND BLOWING
106BD JUST RETURNED FROM TAKING ROOMMATE TO WORK; IN KITCHEN,
DOING DISHES AND CLEANING UP
001 HA OUTDOORS IN YARD, DOING MOWING AND SPADING WORK
030RH DOING VOLUNTEER WORK, WALKING INDOORS AT THE VA
HOSPITAL
103RM OUTDOORS AT HOME, PUSHING TRASH CANS ON CART TO THE
p! ICO
*_> I • !_•
067SW AT WiZDD ING RECEPTION, DOING A FAST DANCE
046EM AT HOME, WATCHING TV AND RELAXING IN RECLINES
032WH OUTDOORS IN YARD, MOWING LAWN WITH GAS POWER MOWER
007F3 AT WORKSITE, IMD00R3. DOING LIFTING AND CARRYING WORK
OSSEP OUTDOORS 1"N YARD. DOING GARDENING AMD MOWING LAWN
094PG OUTDOORS IN YARD. WALKING AROUND
033J3 MOWING FRONT LAWN AT HOME
002J3 WALKING LP DRIVEWAY AT HOME, COLD, DAMP
062JT AT WORK. INDOORS SHOP AREA.
022CE INDOORS, LIVINGRCOM, WATCHING TV
QUESTION 27
057RS OTHERS"RESTED WHEN I GOT HOME — WATCHED TV, "
030WR OTHER="I THINK ABOUT SOMETHING ELSE — GET MY MIND OFF
OF THINGS. TRY NOT TO TAKE NITRO — GIVES ME
HEADACHES."
0S4E3 TOOK NITROGLYCERINE AND TRANQUILIZER
009DD OTHER=GET UP FROM BED, SLOWLY MOVE AROUND, TAKE DEEP
BREATHS AND WALK A LITTLE
02IRE TAKE ISOSORBIDE
006WB PAIN STARTED AFTER COMPLETING CLIMB OF STAIRS
(ESTIMATED 300-400 STEPS); STOPPED AND LEANED AGAINST
POST THEN WALKED TO CAR
0S9KC OTHER-LEFT FOR HOSPITAL WHERE THEY HELPED HIM "HANDLE"
THE STRESS
033PH INTERVIEWER PROBE: SO A TYPICAL EPISODE FOP VC'J IS MILD.,
AND YCU CAN SIMPLY SLOW DOWN AND THE CHEST PAIN WILL SO
AWAY? "YES."
0S6G3 OTHER-CHANGED SLEEPING POSITION OF BODY
01 ^LC OTHER15TURNED AROUND AND PUT BACK TO COLD WIND WHILE
RESTING
106 BD BOTH 1 AND 3 WERE IMPORTANT MEANS OF RELIEF — COULD! !7 T
SAY WHICH 13 MOST IMPORTANT
001HA "THIS WAS BEFORE I TOOK NITRO, SLOWED DOWN — PAIN WENT
AWAY."
00 7FB "I JUST SLAPPED ON A NITRO PAT'CH — PAIN WENT AWAY.
THOSE THINGS (NITRO PATCHES) GENERALLY' WORK FOR 24
HOURS."
OCGEP GOTH 1 AMD J3 WERE IMPORTANT MEANS OF RELIEF — COULDN'T
SAY WHICH IS MORE IMPORTANT.
-------
033JS WAITED 5 OR 6 HRS. UNTIL COOL OF EVENING TO FINISH
003JB COME INSIDE HOUSE, TAKE NI7R0, WARM UP OVER FLOOR
FURNACE
062JT WOULD TAKE NITRG ONLY IF MORE TENSE OF PRESSED FOR T
022CE OTHER=MAALQX, "EASED ME DOWN A PI-." SHUT PROGRAM 0
WENT OUTSIDE RELAXING, THINKING ABOUT OTHER THINGS.
READ PAPER. FELT BETTER.
QUESTION 23
082JM OTHER="NO PARTICULAR EFFECT. I"VE ADJUSTED TO IT* I
DOESN'T BOTHER ME."
0S4EB "IF I DIDN'T HAVE VA WOULD WORRY ABOUT MEDICAL TREAT
EXPENSES." "WOULD PREFER 70 BE ACTIVE."
021 RE OTHEF:=" I WISHED I COULD GET INTO EXPERIMENTAL RROGF.A
(LASER REMOVAL OF CORONARY ARTERY OCCLUSIONS) AT UCI
013LD "AT THE EXACT MOMENT OF THE ATTACK I THINK OF BU
AFTER YOU GET TO FEEL BETTER THEN NUMBER 6."
0^1 IM "WAS WORRIED COULD NOT FINISH JOB (APPRAISAL),"
023WF QTHER="NC WORRY — MIND GOES BLANK — LET THE WORLD
BY — THINK ABOUT NOTHING — BLOCK IT — WORK AROUND
IT. "
033RH "ANYBODY WOULD WORRY ABOUT A HEART ATTACK."
075TS LOST INCOME — STOPPED DOING FREELANCE AUTO REPAIR
109MM OTHER="DISEASE — JUST HAVING D ISEASE. "'
051JR OTHER-"IMMINENT DEATH."
017LC OTHER="NOTHING REALLY HERE THAT IS PARTICULARLY
BOTHERSOME — I GET MY SOCIAL SECURITY CHECK EACH MO
—ALREADY HAVE GONE THROUGH BYPASS. JUST A DAILY l^A
LIFE."
001HA "ALWAYS MILD PAIN WHEN I HAD IT."
007FB ANSWERED NO TO HEART ATTACK OR CABG — "ALREADY BEEN
THROUGH ALL OF THAT." BOTH 6 AND 3 WERE BOTH EQUALL
BOTHERSOME, "NO DIFFERENCE."
033JS OTHERS"PERSONAL DISAPPOINTMENT BECAUSE OF DOUBTS TKA
YOU CAN'T DC WHAT YOU SET GUT TC DO." "ALWAYS CONCE
ABOUT LOST INCOME BECAUSE YOU DON'T LIVE ON SOCIAL
SECURITY, YOU EXIST., NO POSSIBLE WAY TO LIVE ON S.S
062JT OTHER—DEATH, POTENTIAL EXPENSES FOR NON-MEDICAL COST
022CE HAD VA & WAS RETIRED., NO CONCERN FOR FIRST TWO. NO
CONCERN ABOUT MI, " I ACCEPTED IT NOW,, DOESN'T BOTHER
ME" CONCERN TO FAMILY "VERY MUCH SO, I SEE IT IN "I
FAMILY'S' FACES. "
-------
QUESTION 29
012JE $0.12 — THE COST OF 1 NITRO TABLET. CODED AS $0
018LD COST OF NITRO — 1 TABLET. CODED A3 SO
005CB $56 — ANSWERED 58 X 7 = $56, WORKING
091IM $0.00 — "DELAYED. HAD TO GO BACK NEXT DAY (TO FINISH
APPRAISAL)."
0S9KC $100,000 - INTERVIEWER EXPLAINED THAT WE WERE SEEKING AN
ANSWER -OR THIS PARTICULAR ANGINA ER ISQDESUBJECT STILL
RESPONDED WITH 5100,000 ANSWER , INTERVIEWER COMPLETED
THE REMAINING QUESTIONS AND RETURNED TO THIS QUESTION,
THE RESPONDENT GAVE THE SANE ANSWERS. THE SUBJECT ALSO
GAVE ANSWERS IN THE SANE MONETARY RANGE FOR if30A AND B.
062JT ANSWERED $0. "NOT ON A PER EPISODE BASIS, BUT THE WHOLE
SITUATION ENDED UP IN A FINANCIAL LOSS, MORE ON A
BIGGER SCALE. VQU START ADJUSTING YOURSELF—YOU START
BEING LESS PRODUCTIVE. YOU7 RE MENTALLY IN ANOTHER GEAR
ABOUT EVERYTHING YOU DO."
022CE ANSWERED $0. "NOT THIS EPISODE BUT DOES IMPACT OTHER
WORK THAT I DO—$100/M0. I DO ELECTRICAL WORK FOR
NEIGHBORS (NEW OUTLETS, REPLACE BURNED OUT BREAKER)
HELPS ME WITH MY WIFE AND MAKES ME FEEL BETTER ABOUT
CONTRIBUTING TO THE HOUSE."
QUESTION 30A Z< 3OB
043 VL ANSWERED 50 AND #3 — "WORTH VERY LITTLE TO ME — JUST
TAKE A NITRO."
032JM ANSWERED $0 AND #3 — "JUST A MATTER OF ADJUSTMENT. I'D
JUST SLOW DOWN AND REST,"
024AF INTERVIEWER FORGOT TO ASK QUESTION 30.
01SRC ANSWERED $ INFINITE — "YES, WOULD SELL HOUSE - CAR.
WHATEVER I HAVE."
0S4EB ANSWERED $0 AMD #4 — "I'VE LEARNED HOW TO GET RID OF MY
ANGINA AT NO COST - I STOP DOING THE ACTIVITY AND IT
DOESN7 T MAKE SENSE (TO PAY MONEY) UNLESS IT
-------
023WF ANSWERED NON-SO AND #2 — "CANNOT PUT A PRICE TAG ON
IT."
072PD ANSWERED SO AND #3 — "IF MYOCARDIAL DAMAGE BEING DOME,
WOULD BE WILLING TO PAY TO AVOID THAT — I'M NOT SURE IT
IS. FOR THE RAIN ONLY I AN WILLING TO PAY NOTHING. THE
PAIN AVOIDANCE IS NOT WORTH PAYING ANYTHING TO ME. IF I
WAS PAYING TO AVOID THE RISK OF AN MI, AND I AM NOT SURE
ABOUT THAT, I MIGHT 6E WILLING TO PAY SOMETHING."
INTERVIEWER DID NOT PRESS HERE: "YOU SHOULD ANSWER
ACCORDING TO YOUR KNOWLEDGE AND BELIEFS ABOUT ANGINA —
LATER WE WILL ASK YCU SOME QUESTIONS ABOUT THEM."
033RH ANSWERED $ INFINITE AMOUNT — "INDEFINITE (SIC) AMOUNT -
-WOULD PAY ANYTHING — $40-50,000." FOR TWO SUCH
EPISODES ALSO ANSWERED "INDEFINITE (SIC), WOULD PAY
ANYTHING, LIKE WHAT YOU ALREADY ASKED ME."
107E3 ANSWERED $ INFINITE AMOUNT — "E7ERYTING I HAVE, I'D PAY
IT ALL, IT'S (THE ANGINA) THAT BAD." FOR TWO SUCH
EPISODES, "PAY ANYTHING, LIKE ABOVE".
031 EH ANSWERED 510,000 FOR 30A — "IT WOULD BE WORTH ALL THAT
I HAD TO AVOID IT — I HAVE THIS 310,000 TO DO IT TOO."
ANSWERED 530,000 FOR 30B — "ALL THAT I HAVE — ALL
STOCKS, BONDS THAT I COULD OBTAIN DURING THE WEEK."
016GC ANSWERED SO AND #3 — SUBJECT COULDN'T ANSWER — DOESN'T
THINK AN EPISODE MEANS ENOUGH TO PAY MONEY — "DON'T
THINK IT IS THAT BIG A DEAL."
039HK ANSWERED 3500 FOR 30A AND $1000 FOR 30B — WOULD BE
WILLING TO PAY THESE AMOUNTS BUT ACTUALLY ONLY ABLE TO
AFFORD, AND WOULD PAY, $50 AND $50 RESPECTIVELY FOR #30A
AND B.
003GB ANSWERED $0 AND #4 — "IT WAS NOT UNCOMFORTABLE ENOUGH
NCR LASTED LONG ENOUGH TO WORRY ABOUT."
051JR ANSWERED $0 AND #4 — "JUST TAKE CARE OF SELF."
056GS ANSWERED $12,50 — SUBJECT RECALLED OTHER WTP QUESTION
(#32) AND DIVIDED $100 BY 3 EPISODES TO COME UP WITH
$12.50. SIMILARLY CALCULATED $25 FOR *t30B.
064DT ANSWERED $10 FOR 30A AND 520 FOR 30B — SUBJECT FIRST
ANSWERED ^0 AND #2, BUT i'iHEN SAID Ir I T REALL; COULD
WORK THAN $10 AND $20.
037CK ANSWERED $0 AND #3 — "I DON'T THINK NATURE IS MADE UP
IN DOLLARS — I DON'T HAVE ANY (MONEY) STORED UP."
017LC ANSWERED N0N-$0 — "I WOULD PAY SOMETHING — THAT'S HARD
TO SAY — JUST NOT SURE WHAT,"
106BD ANSWERED ^INFINITE — "WILLING TO PAY ANYTHING — BUT
YOU CANNOT AFFORD TO PAY EVERYTHING,"
001 HA ANSWERED IMON-SO AND #4 — WOULD BE WILLING TO PAY —
"DIDN'T KNOW HOW MUCH - WHATEVER IT WOULD TAKE TO BE FREE
OF IT. "
030RH ANSWERED 50 AND #3 — "NOT WORTH IT, I CAN JUS" SLOW UP
A BIT. IT'S TOO MILD TO WORRY ABOUT."
J 03RN ANSWERED MOO FOR 30A AND * 130 FOR 30 B — "MOST I'D
WILLING TO PAY, I ONLY GRING HI SoOO PER MONTH ON SOCIAL
SECURITY."
-------
REFUSED TO ANSWER 30A — "THIS 13 A SUPERFICIAL
QUESTION. IS THERE SUCH A THING?" INTERVIEWER
RESPONDED "THIS IS A HYPOTHETICAL QUESTION" AND THE
SUBJECT THEN AGAIN COMPLAINED AND ANSWERED "$200 THEN",
BUT STILL USED A REFUSAL TOME OF VOICE. CODED AS
REFUSAL.
ANSWERED =0 AMD #4 — "DON'T HAVE EXTRA MONEY RIGHT
NOW, "
ANSWERED xr AND — "I DON'T LET IT BUG ME.
ANSWERED 30 AND #3 — "IF I KNEW I WOULD HAVE IT AGAIN
THEN 330 —BUT FCR ONI_v ONE EPISODE 30."
ANSWERED -520 FOR 30A — "I WOULD BE WILLING TO PAY 320
FOR A PILL THAT WOULD TAKE AWAY ONE EPISODE." UNABLE T
ANSWER 30B — "DIF"ICULT TQ SAY — UNCERTAINTIES OF
BEING FREE FROM "ME OP 8 EPISODES (REFERRING TO #32) IS
HARD TO JUDGE," 'IF I COULD PAY SOME AMOUNT TO BE FREE
OF ALL ANGINA — I WOULD PAY ANYTHING. I WOULD SELL M
HOUSE AND CAR. BUT JUST ONE EPISODE DOESN'T MEAN A
WHOLE LOT." INTERVIEWER NOTE; SUBJECT FIRST ANSWERED
3800-1000, THEN CHANGED ANSWERS
ANSWERED 210-15 THOUSAND THEN SAID "BUT DON'T HAVE ANY
MONEY. IF I HAD MONEY. I'D PAY WHAT I HAD. BUT I DON'
MAKE ENOUGH. I CAN'T TAKE THAT FROM MY FAMILY. IF I
WAS RICH I'D GIVE 3 10-15 THOUSAND."
ANSWERED 325 FOR 30A THEN CHANGED TO 0. SUBJECT SAID I
WAS THE WORST ANGINA, HE WOULD PAY 325, BUT FOR TYPICAL
NOTHING. ANSWERED 325 FOR 30B. THEN TO 0 FOR TYPICAL
EPISODE. "IF I SURVIVED THE FIRST ONE, I "M STINGY, I'M
BROKE, WOULDN'T PAY ANY MORE."
ANSWERED 30 AND #3. "IF I COULD DO SOMETHING TO DEAL
WITH IT. IF VERY SEVERE OR APPROACHING A HEART ATTACK,
THEN I'D PAY."
ANSWERED 3500 FCR BOTH 30A & 30B. INTERVIEWER PROMPT;
"MOST YOU COULD AFFORD7" SUBJECT; "RIGHT NOW ABOUT
3500." SUBJECT; 3500 IS THE MOST I CAN GIVE FOR 1, 2,
5 OR WHATEVER. 1
QUESTIONS 23B AND 24B
"I REALLY CANNOT RECALL A WORST EPISODE — NOME WAS
PARTICULARLY MOPE PAINFUL THAN OTHERS." INTERVIEWER
PROMPT: "WORST IN TERMS OF CONSEQUENCES"" "NO, I CANNOT
PICK ONE our."
CLIMBING CN ROOF '0 DO REPAIRS
IN BED SLEEPING: HEART ATTACK
INDOORS AT HOME. SITTING. UNSTABLE ANGINA EPISODE.
WENT TO VA AND WAS HOSPITALIZED FOR 4 DAYS,, HAD NQRPHIN
AND STREPTOKINASE TREATMENTS. "THAT 13 WHEN THEY
STARTED ME ON THESE MED I CAT I QMS AMD I "-'E BEEN OK EVER
-------
109HM AT HOME, DRINKING BEER AND WHISKEY ALL DAY
050EP TOG LONG AGO. CANNOT REMEMBER
OS 1JR AT HOME, RESTING, RETURNED FROM BEACH WERE HAD BEEN
SWIMMING. REMEMBERS FOUL GAS FUMES FROM SEWER, BELIEVES
AGGRAVATED ANGINA. RETURNED TO HOME, LAID DOWN
036GS AT HOME, SEXUAL ACTIVITY
064DT AT HOME, INDOORS, GOT UP FROM COUCH, WALKING DOWN HALL.
"CAN'T REMEMBER THE BIG ONES — I TOTALLY BLOCK IT
GUT, "
037CK AT HOME:, IN BED; FOR TWO HOURS TRYING TO SLEEP BUT
UNABLE TO BECAUSE OF FAIN
OITLC PUTTERING AROUND HOUSE, INDOORS. FIRST REALLY SERIOUS
ANGINA ATTACK. "THOUGHT IT HAS A HEART ATTACK."
1063D INDOORS AT HOME, PLAYING AROUND WITH ROOMMATE.
INTERVIEWER FROMP"; "00 YOU MEAN DURING PRIVATE
ACTIVITIES WITH VOUR ROOMMATE?" "YES."
001HA AT HOME, ON PATIO, DOING SAWING AND NAILING
030RH AT HOME\ INDOORS, SITTING AND THINKING ABOUT NEXT DAY IN
COURT
103RM AROUND THE HOUSE. "LIKE TO PUT OUT OF MY MIND —
DIFFICULT TO REMEMBER THESE THINGS."
067SW INDOORS, RECEPTION HALL, DANCING WITH WIFE AT PARTY.
046EM AT HOME IN KITCHEN, SITTING AND DRINKING COFFEE
032WH IN DOCTORS OFFICE, HAVING MEDICAL EXAM FOR HIGH BLOOD
PRESSURE PROBLEM
007FB "DON'T REMEMBER — ABOUT 1975 BEFORE FIRST HEART
ATTACK."
OSSEP AT HOME IN LIVING ROOM, WATCHING TELEVISION
09 4EG AT COURTHOUSE IN DIVORCE COURT. JUDGE RULED AGAINST
HIM: "LOST HOUSE AND KIDS."
0G3JS OUTSIDE WORKING BETWEEN GARAGE & YARD ON BOYS' BIKES
000JB TOOK BUS TO MORMON TEMPLE IN WEST LA. WALKED BACK DOWN
HILL TO BUS
062JT TRAVELING IN MEXICO, TIJUANA, SHOPPING. HAD BEEN
WALKING ALL DAY. WALKING UP RAMP TO INSPECTION AREA,
RETURNING TO U.S.
022CE DUPING THE MIDDLE OF THE NIGHT WHILE SLEEPING IN
BEDROOM
QUESTION 27B
043'-'i_ OTHER-WENT TO VA — MILD HEART ATTACK
082JM OTHERSWENT TO VA
01 SRC GTHER=TO HOSPITAL — CATHETER I ZED
004EB OTHER=WENT TO HOSPITAL
0O9DB OTHER="SOT UP. WALKED AROUND. TOOK DEEP BREATHS. AND
WENT OUTSIDE. MOVED ARMS. SLOWLY'. PAIN WENT AWAY .
THEN SAT DOWN AND WAITED FOR MORNING SUNRISE — NO i K,-R
OFF. "
1 00WO HOST IMPORTANT MEANS OF REL t EF ~ "NO REL F EF ' ''
-------
030WR IN COLORADO, OUTDOORS, CLIMBING STAIRS TO RESTAURANT
024AF DOING STRESS TEST FOR UCI EXPERIMENTAL STUDY ON CARBON
MONOXIDE EFFECTS. SCREENING TEST. NO CO THIS DAY.
SICK FOR TWO WEEKS AFTER.
01 SRC WALKING FAST ACROSS PARKING LOT TO KEEP DOCTORS
APPOINTMENT,
034EB AT HOME. THINKING; WORRYING ABOUT NEPHEW WHO HAD
BORROWED CAR AND WENT TO MEXICO. OCCURRED "BEFORE I
LEARNED TO MODIFY MY LIFESTYLE BETTER."
UU'?Df BEDROOM,, SLEEPING
100WC JUST HAD GOTTEN UP; GOING TO WATCH CHAMPICNSHIP FOOTBALL
GAME ON TV. "WAS DOING NOTHING, WATCHING TV. ALL I HAD
DONE PREVIOUSLY WAS WALK OUT TO GET THE NEWSPAPER."
012JB BED, SLEEPING, HAD FORGOTTEN TO TAKE MEDICINE BEFORE
GOING TO BED. WOKE UP 3-4AM
02IRE OUTDOORS IN YARD, TAKING GUT "RASH CANS TO CURB. "AFTER
IN BED WIFE REMINDS ME TRASH ISN'T GUT. PUT ON GLOVES,
AND SHOES AND SLACKS. THROW CANS AROUND AND GET TO THE
STREET." WAS ANGRY — DOESN'T MATTER IF CANS DON'T GET
OUT. SUBJECT NOTED ONLY SMALL VARIATION IN ANGINA —
WAS DIFFICULT TO COME UP WITH EXAMPLE OF WORST
005CB SAME AS TYPICAL — "JUST DON'T NOTICE ANY GREAT
VARIATION
108J A INTERVIEWER DID NOT ASK 22B TO 2SB
013LD AT HOME, NIGHT SLEEP. HAD HAD CHEST PAINS ON AND OFF
DURING THE PREVIOUS DAY.
052HR WORKING AT OUTDOOR JOBSITE. ALONE, TRYING TO HANDLE
ELECTRICAL CABLE — HEAVY EXERTION
091IM "MY LAST WAS THE WORST." — SEE PREVIOUS ANSWER FOR
TYPICAL
006WB AT HOME INDOORS.. ARGUING WITH DAUGHTER-IN-LAW ON PHONE
023WF AT HOME. HAD WORKED IN YARD DURING DAY AND GONE TO BED
EARLY, IN BED ABOUT 2 HOURS
039KC IN LAS VEGAS HOTEL ROOM, STANDING, TALKING TO FRIENDS ON
PHONE. TIRED
072PD AT HOME, INDOORS. SITTING TALKING WITH FAMILY IN
EVENING, "THIS WAS THE FIRST EPISODE THAT I REALLY
REMEMBER — IT WAS THE WORST IN TERMS OF SEVERITY OF
PAIN. CAUSED ME TO THINK ABOUT MY HEART HEALTH."
033RH PLAYING GOLF IN EARLY MORNING
107JB INDOORS AT HOME DOING LIFTING WORK
031 EH INDOORS AT HOME. WATCHING BALLGAME UN TV
075TS TRAVELING TO UNION TRAIN STATION IN LA; HAD ANGINA
ATTACK WHILE CHANGING FLAT TIRE
079L5 DOING STRESS TEST FOR UCI EXPERIMENTAL STUDY ON CARBON
MONOXIDE EFFECTS. SCREENING TEST., MO CO
01.6GC COMING INTO HOUSE AFTER WALKING THE DOG
039HK INPATIENT AT LB'-'A. SITTING tN CHA CR BESIDE BED
003GD OUTDOORS ON TENNf S COURT , HITTING A FEW BALLS WITH
oTUDEN T.. "NOTHING TOG ACTIVE. ''
-------
021 RE
01SLD
006WB
023WF
039KC
U j i LH
016GC
039HK
003GB
1 09 mm
05 1JR
o8£>G3
037CK
017LC
001 HA
1 03RM
0673W
046LM
032WH
007FB
03SEP
094PG
033J 8
003 J B
022CE
OTHER=RELAX
07HER=WENT TG HOSPITAL
OTHER=HUNG UP PHONE, TOLD SELF TO RELAX
OTHER=REST IMG IN BED — TOCR' THREE NITRO — WENT TG
HOSPITAL WHEN' NO PAIN RELIEF
OTHER=F'ARAMEDICS TOOK TO HOFITAL — $13,000 COST
OTHER=WENT TO DOCTOR WHO ADMINISTERED DEDICATION
QTHER=700K ALKA SELTZER
OTHEF-CALLED NURSE, MOVED T3 ICU AND HAD MORPHINE SHOT
qther=we;mt home and THEN ~o hospital
OTHER-PARAMEDI OS TOOK SUEJECT TQ HOSPITAL
OTHER=WENT TO HOSPITAL EMERGENCY ROOM
ONLY TIME SUBJECT HAS EVER TAKEN NITROGLYCERIN
OTHER=WENT TQ VA HOSPITAL. "VA COULDN'T STOP IT (THE
PAIN)," SUBJECT ADMITTED TO ICU/CC'J
~ THER-SIJBJECT WENT TO '-'A WHERE HE WAS GIVEN A NITRO TO
RELIEVE THE PAIN — DID NOT STAY OVERNIGHT
OTHER=WENT TO VA HOSPITAL
"R AN 3 "R RED
J/CCU, At-!!
OTHER-WENT TO VA HOSPITAL,
GIVEN MORPHINE INJECTION
PAIN WAS NOT RELIEVED BY FIRST NITRO, SO TOOK A SECOND
OTHER-PARAMEDICS CALLED, AWOKE IN HOSPITAL, "COULD HEAP
BUT MOT SEE THEM."
OTHER-WENT TO HOSPITAL
OTHER-HOSPITALIZED AT VA
OTHER-PARAMEDICS ADMINISTERED MORPHINE
OTHER=PAIN NOT RELEIVED LASTED HOURS. ADMITTED TO
HOSPITAL ICU/CCU. PAIN KILLERS ADMINISTERED, CHEST PAIN
LASTED HOURS
CALLED WIFE, WENT TO THE HOSFITAL
WAITED ON BUS: 3 NITRO'3 INSIDE OF 5 MINUTES
TOOK 2 NITR03. "FELT KIND OF FUNNY." CHEST PAIN LEADS
TO ANXIETY WHICH LEADS TO DEPRESSION. TOOK MITRO PAIN
OVER FAST. "WAS OVER ABOUT A3 FAST AS IT STARTED—I
DON'T KNOW (IF NITRO WORKED)—THEY ALL ARE OVER PRETTY
FAST." "MOST GO AWAY IF I JUST STOP AND REST."
QUESTION 23B
043VL SUBJECT DID NOT WANT TO ALARM SISTER WHOM HE LIVED WITH
— SUFFERED WITH CHEST DISCOMFORT ALL DAY BEFORE DRIVING
SELF TQ VA AT 4PM III AFTERNOON
9D8 OTHEF'-TREATMENT ITSELF IS A HASSLE. THINKING OF BOTHER
OF DEALING WITH INSURANCE, MEDICAL TEAMS, ETC
021 RE OTHER-THINKING OF GETTING INTO UCI LASER TREATMENT
PROGRAM
01SLD COST OF HOSPITALIZATION TOTALLED $30,000 FOR 19-20 DAY
STAY. INSURANCE PAID MOST OF THIS etLL. SUBJECT HAD TO
RETURN TO HOSPITAL AFTER A COUPLE DAYS AT HOME — "ILL
OWES HOSPITAL S50U0 FOR THAT TIME
023Wi- VERY SEVERE PAIN III ARM
-------
08?r- C HOSPITALIZATION COST *13,000 SINCE WAS NOT HOSPITALIZED
AT VA FACILITY OR PRE-SCHEDULED
033RH THIS EPISODE CAUSED THE SUBJECT TO SEE A CARDIOLOGIST --
EVENTUALLY WENT TO UCI'S DR. TOBIS FOR ANGIOPLASTY
031EH PAIN AND DISCOMFORT WERE THE "ONLY THINGS ON MY MIND"
109MM OTHER-"JUST -HAVING DISEASE"
05 i JR OTHER="IMM INENT DEATH"
064DT OTHER®"DON'T KNOW WHAT IT WAS."
030FH OTHER®"THINKING ABOUT COURT CASE THE NEX~ DAY —DID NOT
WORRY PARTICULARLY A3OUT DISCOMFORT OR HCT FLASH
(REACTION TO MI7R0)."
103RM OTHER—"DEATH"
094PG OTHER="REALLY MORE CONCERNED ABOUT DIVORCE RESULTS."
033JS CONCERN ABOUT FAMILY "WHAT WOULD THEY DO WITHOUT ME?"
062JT 01"HER=DEATH. CONCERN ABOUT POTENTIAL HEART ATTACK ON
QUESTION 22C
025JF AT HOME. INDOORS, WASHING WINDOWS
057RS OUTDOORS, GOING FISHING., ANXIETY AND WALKING
043VL INDOORS AT HOME, WATCHING TELEVISION
0S2JM SUBJECT DOES NOT NOTICE ANGINA DURING THE DAY — ONLY A
PROBLEM AT NIGHT (E.G., MOVING CARS INTO GARAGE) —
EVEN THEN SUBJECT CHARACTERIZES AS MILD..VIRTUALLY
SAME AS TYPICAL••
030WR "HARD TO SAY, HAPPENS WHEN I'M SITTING DOWN — JUST
THINK ABOUT OTHER THINGS — GET MY MIND OFF OF IT. IT
IS SORT OF LIKE WHAT WE TALKED ABOUT (TYPICAL EPISODE; .
CAN'T SAY."
024AF "DON'T REMEMBER."
015RC SAME AS DESCRIBED FOR TYPICAL
084E5 "JUST DON'T HAVE MILD BECAUSE I KNOW MY LIMIT AND I STAY
UNDER IT. THERE ARE MANY THINGS I'D LIKE TO DO BUT
CAN'T BECAUSE OF PAIN. USED TO BE ANGRY AMD UPSET THAT
I COULDN'T DO BUT NOW STAY BELOW THAT THE3H0LD. WOULD
LOVE TO DO CERTAIN ACTIVITIES. BUT HAVE LEARNED MOT
TO ' "
OO^DB SAME AS DESCRIBED FOR TYPICAL
100WC INDOORS AT HOME, DOING LIFTING WORK AROUND THE HOUSE,
EVERYDAY. ARM NUMBS — TAKE A NITRO. LIGHTHEADED
012JB AT WORK, WALKING. SUBJECT COULD NOT CITE ANY EXAMPLE OF
A RECENT MILD EPISODE SO HE GAVE THE BEST GENERAL I TY !-E
COULD
02IRE OUTDOORS AT HOME, PUTTING BOAT ON ROOF TOP CARRIER ON
VAN
005C3 SANE AS DESCRIBED FOR TYPICAL. CAN HAPPEN "ANYTIME,
ANYWHERE, STANDING OR WALKING."
103A INTERVIEWER DID NOT ASK 22C TO 23C
0 • cLJ SAMI- AS DESCRIBED FOR fYFICAL
052HR SANE A3 DESCRIBED FOR TYPICAL. "MOST CASES -RE M iLC, "
ANGINA SONET I I'll-S OCCURS WALK ING AT A SLuW r'^Lu.
SOMETIMES AT REST; SUBJECT 13 ADLE TO SLOW DOWN OR REST
WITHOUT T A1: 11' IG A NI T R 0
-------
091 IM "DIFFICULT TO REMEMBER" HARD TQ RECALL" A SPECIFIC
INSTANCE, COULD BE ANYWHERE. DOING ANYTHING.
006WB INDOORS AT HOME, SITTING, THINKING ABOUT PAYING BILLS
023WF OUTDOORS, PLAYING GOLF
OS'PKC CAN'T REMEMBER EXACTLY, ANYTIME, ANYWHERE. "COULD BE
DOING ANYTHING — RESTING, WALKING, ANYTHING,"
072PD SAME AS DESCRIBED FOR TYPICAL. SUBJECT STATES HE RAR
TOOK NITRQ, JUST SLOWING DOWN WAS SUFFICIENT TO RELIE'
Ph IN. HE IS HAVING NO EPISODES NOW THAT HE HAS STORP
DI ABENESE MEDICATION. THE TYPICAL EPISODES WERE MILD
AND NEVER REQUIRED STOPPING ACTIVITIES — JUST SLOWED
DOWN. HAD ANGINA EPISODES 2, 3, 4 TIMES PER WEEK WHIf
ON DIABENESE
033RH "CANNOT REMEMBER,"
107.JB "DIFFICULT TO RECALL A MILD ATTACK. BUT TYPICALLY I
WAIT — SOMETIMES "AKE A NITRO. STRESS RELATED USUAL'
BUT ALSO -.OCCURRED) DURING PHYSICAL ACTIVITY. "
031 EH AT HOME IN FAMILY ROOM WATCHING TELEVISION — "EXCITE
WATCHING WRESTLING".
075TS INDOORS AT HOME, GOING UPSTAIRS FELT SLIGHT PRESSURE
079L3 OUTDOORS AT HOME, WATERING YARD
016GC AT HOME IN BED, "WHEN YOU JUST GET UP."
039HK AT HOME IN BED, WAKING, GETTING UP
003G3 WALKING FOR EXERCISE ON NEIGHBORHOOD STREETS
109MM OUTDOORS AT HOMETAKING TRASH CANS TO CURBS IDE
050E3 OUTDOORS AT HOME, DOING YARDWORK
051JR WALKING FOR EXERCISE ON NEIGHBORHOOD STREETS. "CAN'T
REMEMBER ANYTIME, BUT USUALLY WHEN OUT ON WALKS.
VARIES. SOMETIMES I CAN GO QUITE A WAYS, OTHER TIMES
JUST A FEW BLOCKS."
0S63S OUTDOORS IN PARKING LOT, WALKING. SUBJECT HAD TO PAR!
DISTANCE AWAY FROM DESTINATION. HE WALKED, FELT PAIN
CLIMBED STAIRS AND FELT MORE PAIN. THEN RESTED ON
BENCH
064DT INDOORS, AT JOBSITE (CLIENT'S HOME), DOING VACUUMING,
AND DUSTING. "UP AND DOWN" WORK
03~CK WALKING FOR EXERCISE ON NEIGHBORHOOD STREETS
017LC "CANNOT REALLY RECALL, MOST DAYS ARE NOT TOO GOOD. !
REALLY HAVING PAIN BUT DO NOT FEEL GOOD."
1063D COULD NOT RECALL. SUBJECT NOTED: "ALWAYS TAKE NITRO
PADS — MY NEIGHBOR DOESN'T USE HIS AND GIVES THEM TO
ME. I WILL WEAR THEM AT TIMES."
001 HA "CANNOT RECALL — NO LONGER HAVE ANGINA. THEY JUST W!
i-iWt-i i .
030RH OUTDOORS, BICYCLING FOR EXERCISE ON BIKE PATH. ALSO I'
TYPICAL. ANGINA IS ALWAYS MILD. "WOULD BE HARD TO
THINK OF AN EXAMPLE. JUST SITTING HERE RIGHT NOW I
THINK I COULD FEEL IT A LITTLE — NOW THAT MIGHT BE
PSYCHOSOMATIC VOL! KNOW. " CODED BICYCLE AS EXAMPLE Or
MILD SF I SODE
-------
103RM
067SW
046EI1
032 WH
007F3
033EP
074PG
033J S
t.) o3JB
062J T
022CE
OUTDOORS, AT WORK, SHOWING PROPERTY TO SOME CLIENTS,
SUBJECT WAS UNLOCKING THE LOCK BOX TO GET KEY TC OPEN
THE FRONT DOOR. SUDDENLY, THE OWNER OPENED THE DOOR.
"IT SHOCKED BOTH OF US." SUBJECT LET THE CLIENTS IN THE
HONE TO LOOK AROUND, THEN HE TOOK A NITRO
INDOORS AT HOME, DURING THIS INTERVIEW WHILE TALKING ON
THE TELEPHONE
COULD NOT RECALL
INDOORS AT HOME, WATCHING TELEVISION. "IF A CAR
BACKFIRES OR THERE 13 A SUDDEN NOISE. GET LIGHT-
HEADED. "
CANNOT RECALL —"DON'T LET IT (ANGINA) BUG ME — C A:\rT
LET IT GET TO YOU."
AT HOME. JUST AFTER GETTING INTO BED FOR NIGHT SLEEP
INDOORS AT HOME. SITTING, MOVING ABOUT THE HOUSE. WHEN
SUBJECT FORGETS TO TAKE MEDICATION
DON'T REMEMBER
AT NIGHT EVERY ONCE IN AWHILE. WHEN SLEEPING
"LIKE WHAT WE TALKED ABOUT BEFORE ARFOUND THE SHOP."
INTERVIEWERS NOTE; SUBJECT OWNS DIESEL REPAIR SHOP.
VERY MILD. DO NOT HAPPEN EVERY DAY. COUPLE A WEEK AT
MOST.
QUESTION 270
025JF
023WF
031 EH
051JR
067SW
032WH
094FG
008J B
STOPPED AND LET ARMS REST WHILE STANDING THERE. DID
SEVERAL TIMES. "PAIN WOULD START AGAIN SO I 5T0PFED AND
NEXT DAY I FINISHED (WASHING WINDOWS)."
OTHER=GO GOLFING EARLY IN THE MORNING TO AVOID HEAT
STOPPED WATCHING TV AND SLEPT
OTHERS'REMOVE MYSELF FROM THE NOISE AND PEOPLE — WALK
WHEN OTHERS ARE NOT AROUND."
CONTINUE AT THE SAME PACE. FIRST TAKE ANTACID. "THIS
MORNING THE PAIN STARTED BEFORE YOU CALLED. I AM JUST
WORKING AROUND THE HOUSE. TOOK ONE (ANTACID) THIS
MORNING AL.READY. THEN- IF IT DOESN'T WORK I TAKE A
NITRO. NO NITRO AS YET TODAY.»
OTHER-SUBJECT RUBS SIDE OF NECK (CAROTID)
ANSWERED #5 — "JUST TAKE MY MEDS — I FORGET
SOMETIMES."
OTHER-CHANGE POSITIONS: "IF I CAN CATCH IT EARLY, CAN
JUST ROLL OVER, GET OF" LEFT SIDE. MAY HAVE TO GET UP
FOP NITRO."
"MIGHT FULL OVER TO PROTECT PEOPLE ON HIGHWAY AND MY
FAMILY. WAIT A MINUTE."
-------
QUESTION 2SC
~25JF OTHER="NO BIG DEAL, JOB JUST GOT FINISHED THE NEXT
DAY, "
03 7RS ANSWERED 1*3 — CONCERN TO FAMILY "ALWAYS"
052HR OTHER="NOTHlNG"
006WB OTHER="NONE — SO SELDOM (OCCURS) , JUST KEEP ON. "
INTERVIEWER NOTE: AFTER FINISHED ASKING MILD EPISODE
QUESTIONS THE SUBJECT SAID "NO, SCRATCH THAT — i HAD
JUST TAKEN ALL MY VITAMINS AND I NEEDED TO CAT,"
FF'OBEi "CAN YOU THINK OF ANY OTHER ILLUSTRATIONS OF MILD
ANGINA?" "NO, THE'-'' HAPPEN SO SELDOM. DON'T STOP —
JUST KEEP ON. NO BIG DEAL, ONLY AWARE OF FAIN FOR 2-3
MINUTES — VERY MILD,"
107JB ANSWERED "VERY LITTLE" PAIN AND DISCOMFORT. *4. "REALLY
NONE OF THE ABOVE'1 — BUT " IF HAD TO CHCOSE:' THEN S4.
CODED AS #4
0166C OTHER-"DON'T THINK ABOUT IT."
051JR OTHER="ALREADY LOST THE OTHERS (INCOME, ETC.) — MO BIG
DEAL — IMMINENT DEATH."
067SW OTHER="NOTHING — PAIN EXISTS.' DOESN'T WANT TO GO AWAY."
SUBJECT ALSO NOTED THAT HE SOMETIMES GETS ANGINA WHILE
SWIMMING. IT IS USUALLY MILD; HE SIMPLY STOPS FOR 10
MINUTES AND RESTS. ANGINA USUALLY HAPPENS DURING CRAWL
STROKE — SO CHANGES OFF TO BREAST STROKE, , NOW
ALTERNATES STROKES: BREAST, LEGS, CRAWL.
033EP ' OTHER="NONE"
OOSJB OTHER="JUST MAD AT MYSELF AT HAVING THE PROBLEM." FAIN
AND DISCOMFORT - A LITTLE.
QUESTION 31
024AF ALL ANSWERS TO #31 WERE INITIALLY ASSIGNED A 10 BY THE
SUBJECT. INTERVIEWER PROMPT: "IS THERE JUST ONE THAT
YOU WOULD SAY IS JUST A LITTLE MORE BOTHERSOME"1"G"
SUBJECT WOULD NOT RANK REMAINING EFFECTS ANY LOWER THhN
? HOWEVER. A , B, C, D, E, F, AND H WERE CODED AS 9, AND G
WAS CODED AS 10
01SRC HAD HEART ATTACK DURING SURGERY
OS-MSB 31A RANKED AT 1 BECAUSE OF VA BENEFITS. 3 IB — "WOULD
LIKE TO BE MORE PRODUCTIVE." 31G — "WOULD LIIE PTCA AT
MAY0."
009DB 3 IE — NOT APPLICABLE, RETIRED
100WC 31C — NOT APPLICABLE, OH DISABILITY
103JA 31B AND 31E — NOT APPLICABLE. 31A=i — SUBJECT'S
MEDICAL EXPENSES ARE TAKEN CARE OF ON MEDICAL
0 I Sl.D 31C — NOT ANSWERED.. 31E IS PROBABLY MOST IMPORTANT BUT
THERE IS VERY LITTLE DIFFERENCE. B;, D,E,F,G, AND H WERE
ALL CODED 10.
0'~J2HR 3 ID AND 3 IE — NOT APPLICABLE
-------
006WB
023WF
072PD
033RH
107JB
031 EH
075TS
016 SO
109MM
050EP
051JR
064DT
037CK
001 HA
103F- m
067SW
31G — SUBJECT STATED THAT G IS SLIGHTLY MORE IMPORTANT
THAN A AND F (ALSO RATED 9) BUT G IS NOT A 10. 316
CODED AS 9. 31H INITIALLY RATED A 4, UPON INTERVIEWER
PROMPT SUBJECT THEN RE-RATED TO 1. 31H CODED AS A 1 .
31B AND 31 E — NOT APPLICABLE
3 IE AND 3 IF.BOTH RATED 10 — "BOTH EQUAL IN
IMPORTANCE." INTERVIEWER NOTE: SUBJECT DID NOT HAVE TH
QUESTIONNAIRE IN FRONT OF HIM DURING THE INTERVIEW —
HAD TO READ OVER THE LIST THREE TIMES TO BE SURE OF
CORRECT ANSWERS — CONFIRMED TO INTERVIEWER'S
SAT ISFACTI ON.
31B AND E — NOT APPLICABLE
3IB WAS INITIALLY RATED
THE LOWEST OF ALL THE
MGVI
EFFECTS. AFTER INTERVIEWER PROMPT, SUBJECT LATE."
TO A 1. PROBED ABOUT HOW M0VIN6 313 FROM 3 70 1 AFFEC
THE SCALE ASSIGNMENT OF THE OTHER EFFECTS, SUBJECT
RESPONDED "NO
FOR ME — IT'S
31B AND 31E —
31B AND 3 IE —
CHANGE, THE 3 TG
OK — THE LEAST
NOT APPLICABLE
NOT APPLICABLE
1 IS NOT A BIG DIFFERENCE
BOTHERSOME,"
"ALL BOTHERSOME"
CHOOSE WHICH WOULD
MAYBE D." "COULD
BE THE
ANY OF
31B — NOT APPLICABLE
SUBJECT RATED ALL EFFECTS 10 —
INTERVIEWERE PROMPT;"IF HAD TO
M05T BOTHERSOME?" "ALL WOULD.
THESE BE A 1?" "NO."
31B AND 31E —: NOT APPLICABLE '
31G AND 31H RATED AS 10 — "IF HAD. TO CHOOSE GUESS H
WOULD BE SLIGHTLY MORE, BUT COULDN'T MOVE G DOWN TG A
9, "
31G RATED 3 — "CANNOT HAVE CABG AGAIN."
31E — NOT APPLICABLE. D.F,G, AND H RATED 10. A,B, AND
C RATED 1. INTERVIEWER PROMPT:"15 ANY ONE ITEM THAT YOU
MARK A 10 MORE BOTHERSOME THAN THE OTHERS?" "NO."
SIMILARLY SUBJECT WAS UNABLE TO DISTINGUISH A DIFFERMCE
BETWEEN THOSE EFFECTS RANKED 1.
3IB AMD 3IE — NOT APPLICABLE
31A INITIALLY RATED 2 — A'rTER INTERVIEWER PROMPT: 31A
MOVED DOWN TO 1 AS LEAST BOTHERSOME- NO OTHER SCALE
ADJUSTMENTS FOR THE OTHER EFFECTS. 31A CODED AS 1.
3 1A,31B, AND 31C INITIALLY RATED 2 — AFTER INTERVIEWER
PROMPT, EACH MOVED DOWN TO 1 AS LEAST BOTHERSOME. NO
DIFFERENCE BETWEEN A
OK' C.
:iA„31B, AND 31C CODED
O-i-SEM 31E — NOT APPLICABLE
032WH 3 i 3 — NOT AI-'F'L I CAt-LE
094PG WHEN THE SUBJECT INITIALLY READ OFF HIS PREPARED ANSWERS
HE DID NOT HAVE AN ITEM RANKED AT 1. WITH THE
INTERVIEWER'S HELP HE REVIEWED ALL THE EFFECTS AND MADE
SOME DOWNWARD SHIFTS. 31A WAG INITIALLY CODED AS a AND
WAS MOVED TO 2. 31C WAS INITIALLY CODED AS 4 AND MOVED
TO i — "PROBABLY LEAST IMPORTANT". NO OTHER CHANGES TO
TINGS
FFERENCE
3 IE AND 31!" WERE MOST BOTHER SO ME — "NO
-------
SUBJECT RANKED ALL 8-10. COMMENTS WERE THAT NOBODY
WANTS MORE EXPENSES, BUT IF THERE IS NO CHOICE, ITS WHAT
"YOU'VE GOT TO DO." "NOBODY WANTS TO HAVE LESS ABILITYr
TO EARN INCOME." "DON'T WANT TO BE A VESTABLE ?•: CAUSE
HONEY WORRY TO FAMILY" "FAMILY IS ALL YOU'VE GOT AFTER
YOUR JOB." -
IF PAYING MEDICAL EXPENSES WOULD 3E MOST BOTHERSOME„ BUT
just extra trips to get medical care is bother.
LESS ABILITY TO EARN INCOME HAD NO ANSWER AS HE HAD
ALREADY LOST THE JCB. NON-MEDICAL EXPENSES WOULD BE
MANAGED, IT WOULD JUST TAKE LONGER.
QUESTION 32
TREATMENT 2 — 5200 WAS TOO MUCH. "WOULD TAKE TOO MUCH
AWAY FROM FAMILY, ESPECIALLY WIFE."
TREATMENT 22 — $200 WAS TOO MUCH "WITH INCOME COMING
IN I COULDN'T AFFORD IT. IF AFFECTED THINGS I LIKE TO
DO THEN I'D PAY 5200. IF IT GOT ALOT WORSE MIGHT BE AT
HOME AND SAVE 5200 SINCE I WOULDN'T EE GOING OUT. I'D
SPEND THAT THEN."
TREATMENT 27 — WOULD PAY $1000 "IF I HAD TO AND IF IT
REALLY WORKED 1"
TREATMENT .21 — USED TO TAKE NITRO 20 TIMES A WEEK, BUT
CHANGED LIFESTYLE & MEDICATION
TREATMENT 24— IF WORKING WOULDN'T BE A PROBLEM. KEEP
WORKING 2 JOBS - -
TREATMENT 2 — LAST CHOICE WOULD BE TOG MUCH, THREATENS
FAMILY, "WOULDN'T PUT OUT ON STREET."
TREATMENT 3 — DECLINED TO ANSWER; "JUST LIKE ASKING
QUESTION BEFORE ABOUT MONEY SALARY."
TREATMENT 9 — INTERVIEWER PROMPT; "EVEN 10 CR 12
EPISODES MORE PER MONTH?" RESPONSE WAS "NO, NOT WORTH
IT. "
TREATMENT 5 — "ASSUMING RISK OF MI WOULD DECREASE, THEN
YES I WOULD BE WILLING TO 'PAY THESE AMOUNTS- 0,K. TO DO
THIS?" INTERVIEWER INDICATED THAT IT WAS OK TO ASSUME
RISK OF MI DECREASED BY AVOIDING ANGINA
TREATMENT 3 — ANGINA CAN CONTROL ACTIVITIES SO HE
CAN'T. PAIN NOT SO IMPORTANT, IT GOES AWAY. IMPORTANT
TO DO THINGS YOU WANT. WOULD PAY ANYTHING FOR PERFECT
HEART
TREATMENT 28 — "WHATEVER IT WOULD COST—WHEN IT COMES
TO HEART TROUBLE. YOU TAKE CAPE OF IT. MY NEIGHBOR died
OF A HEART ATTACK LAST MONDAY."
TREATMENT 25 — "RENT IS *225. INCOME (SSI) $490.
DOESN'T LEAVE MUCH — I MIGHT PAY 3200 IF IT WAS REALLY
SERIOUS ANGINA. BUT I COULDN'T AFFORD -NY MORE., '
TREATMENT 21 — SUBJECT UNDECIDED- "WCULDN" Y EE - 1-LE r0
DECIDE RIGHT NOW.. "
-------
0:33J5 ANSWERED NO. "WHAT I10NEY YOU'VE GOT DETERMINES WHAT YOU
CAN SPEND. BOTH ON SOCIAL SECURITY, NO MONEY TO SPEND.
IF I HAD $50, I'D PAY IT. IF I HAD $200 OR $400, I'D
.•> - ' '1
. hf i .
062JT ANSWERED YES, YES, NO. "ANYTHING WITHIN MY ABILITY TO
SORROW."
QUESTION 33
025J F IF COMPLETELY RELIEVED
0A3VL "ALL I COULD AFFORD RIGHT MOW."
032 J M SUBJECT; "YOU ARE STARTING TO ASK A LOT OF FINANCIAL
QUESTIONS. IS THIS A MEDICAL OR FINANCIAL STUDY?"
INTERVIEWER: "THAT IS A GOOD QUESTION. IT IS BOTH. WE
ARE CONCERNED WITH THE BEHAVIORAL ADJUSTMENTS YO'J MAKE
IN YOUR LIFESTYLE AND the COSTS TO YOU OF YOUR ANGINA. I
WILL EXPLAIN OUR MOTIVATIONS WHEN WE COMPLETE THE
QUESTIONNAIRE." SUBJECT: "OK."
080WR "WOULD DC SAME FOR WIFE OR FAMILY MEMBERS." INTERVIEWER
PROBE: "WOULD YOU SELL YOUR HOME OR CAR?" "YES. OF
COURSE I WOULD. AND I WOULD DO IT FOR MY WIFE TOO IF
SHE HAD IT."
015RC WOULD SELL HOUSE IF HAD ONE—SELL CAR, ANYTHING NOT
TO HAVE ANGINA
034E3 "I WOULD PAY SIZEABLE AMOUNT OF AN INCOME IF I HAD IT.
BUT NOT TO THE POINT OF HAVING TO BE A STREET PERSON.
IT WOULD BE RELATIVE TO THE AMOUNT I MADE."
02IRE IF MEANT SAVING LIFE WOULD PAY
013LD SUBJECT DESCRIBED A CYCLICAL PATTERN—"IF I HAD MONEY
I'D PAY, BUT IF I HAD MONEY. I'D BE WORKING PROBABLY
WOULDN'T HAVE ANGINA. I HAVE TO CONSIDER WHAT HAPPENS
TO MY FAMILY IF I PAY ALL THE MONEY FOR GETTING RID OF
ANGINA. IF MADE $ i MILLION, WOULD PAY 5900,000."
052.HR "BUT HOW MUCH IS TOO MUCH?' CERTAINLY I WOULD
JEOPARDIZE MY FAMILY BY PAYING FOR THIS." OOSWBOTHER;
CAN'T IMAGINE HOW AN ANGINA EPISODE COULD BE AVOIDED BY
FAY1Mb o'JNLTH 1 Ma. "
023WF "NO MONEY VALUE INVOLVED—I JUST PARI? MY ASS AND REST,
IF SEVERE OR LINKED TO HEART ATTACK I'D MORTGAGE HOUSE
TO GUARANTEE TO BE RID OF ALL AND LEAD A PRODUCTIVE
LIFE. I WOULD MORTGAGE MY HOUSE AND PAY 2100,000 TO BE
RID OF ALL MY ANGINA—BUT WOULD NOT PAY TO AVOID S
EPISODES."
107JB INTERVIEWER PROMPT: "WOULD YOU PAY ANYTHING TO AVOID
THE FEELING? rES, I WOULD FAY ANYTHING. EVERYTHING I
HAVE."
033RI-I "ANY AMOUNT, PERIOD. I'D PAY . . "
•) I5-.3C DOESN'T MATTER UNLESS HEART IS IN GOOD CONDITION.
ANGINA IS JUST A SIGNAL, IT DOESN'T BOTHER HIM I'M A T MUCH
I"0 HAVE MORE OR LESS ANGINA. WHAT'S IMPORTANT 13 HIS
HEART CONDITION BEING IMPROVED.
-------
109MM COULDM'7 REALLY AFFORD EVEN 5100.
105JR OTHEF, = DQN' 7 HAVE RESOURCES. IF HAD RESOURCES WOULD BE
WILLING 70 PAY 310,000.
064D7 OMLY BECAUSE 0" LIMITED INCOME
106BD LESS THAN $300/MO. YOU PAY WHA7 YOU CAN AFFCRD, IF BACK
WORK IN6 A 7 %40 . 000 . " PROMPT; "MORE 7HAM $300?" "YES,"
OTHER=HARD 70 SAY—YOU PAY WHAT YOU CAN AFFORD.
001 HA PROMPT: ALL ASSETS? "WE3:, EVER Y7HIHQ„ "
033J S ANSWEFED NO, " IF INSURANCE WOULD COVER. AMY AMD UN 7 .
BUT I ,-,kVE NO :-!CNEY SO I COULDN7 7 PAY. " CTHER="IF YOU
HAD THE MONEY. v'CU'D PAY 17 BECAUSE MONEY CAN' T BR IMG
BACK LIFE. NO ;1QNEY REPLACES LIFE,"
008JB ANSWERED $0 AMD #3. "NOT FOR JUST ONE EACH WEEK. "
PROMPT j :'NHY-"' 3UBJEC7; "FIRS7 OFF, I COULDN'T
AFFORD IT, ' "JLJ57 ,107 WGR7H ~'AY ING MONEY FOR. "
0-2JT INTERVIEWER NCTE: WOULD PAY SOMETHING BUT NOT AN
INFINITE AMCL-N7. "M07 A FEAL QUES7IQN — 70 ME THAT'S
HOW MUCH DC YOU VALUE YOUR LIFE, ANGINA REALLY GRINDS
ME j I FEEL ON 7HE EDGE. I DCN'7 LIKE 70 FEEL 7HA7 WAY.
I WOULD DO ANY7HIT -IG WITHIN MY ABILITY TO PAY. EVEN
BORROW."
022CE ANSWERED $200. "I'D PAY ALL I COULD AFFORD. AT THIS
TIME, I'D REALLY HAVE TO SCRATCH THE BOTTOM OF THE
BARREL. CUT MY GROCERIES DOWN TO ZERO = BUT I WOULD PAY
S200/M0." "THESE QUESTIONS ARE KIND OF REVERSE TO ME.
BY ELIMINATING FAIN, I'D 3IVE YOU $200/M0 WITHOUT ANY
QUESTION FROM MY CHECK. I'M A PROUD MAN, I WOULD BE
CONTRIBUTING TO MY FAMILY'S LIFE (SIC - LIVIHOOD)
WITHOUT THE PAIN COULD WORK AND PAY. BUT RIGHT NOW I
CAN'T AFFORD ANY THING — ZERO."
067SW IF IT WOULD DEFINITELY HELP.
032WH OTHER=I WOULD NOT BE ABLE TO AFFORD $10 EASILY,
ESPECIALLY NOW.
007FB "IF I HAD THE BUCKS, SHIT, I'D GO THE LIMIT—BUT YOU
.GOTTA SAVE SOME FOR BOOZE, YA KNOW WHAT I MEANT"
094P3 "YOU PAY AS MUCH A3 YOU CAN AFFORD."
-------
QUESTION 35
REASON SURGERY MOT RECOMMENDED
02IRE MO INDICATION OF MEED
005C3 NEVER EVEN DISCUSSED IT
ICSJA DON'T KNOW WHY
018LD MOT A CANDIDATE
OSvKC "MOT A CANDIDATE WAS AUL HE S.Al'2"
050EP "LITTLE ARTERIES EXPANDED ENOUGH 70 TAKE OVER"
037CK MOT A GOOD CANDIDATE FOR SURGERY
053 J S "JUST SAID I DI DM ' T MEED IT."
022CZ "COULD NOT SURVIVE IF I HAD IT. "
REASON FOR NO SURGERY AFTER POSITIVE RECOMMENDATION
0S4EB RANDOMIZED TO MEDICAL THERAFY, HOUSTON STUDY
009DS "I DON'T THINK IT IS NECESSARY YET."
012JS CHOSE TO TAKE CHELATION THERAPY INSTEAD
006 W 3 JUST DON'T LIKE THE IDEA OF HAVING BYPASS SURGERY
033RH HAD ANGIOPLASTY
109MM RISK TOO HIGH
051JR DID NOT BELIEVE NECESSARY AND ITS TOO EXFENSI V'E
086GS WOULD PREFER TO HAVE ANGIOPLASTY
001HA HAD ANGIOGRAM, FOUND SURGERY WAS NOT NECESSARY
032WH TRIED MEDICAL THERAPY FIRST; RECENT ANGIOGRAM SHOWED
OCCLUSIONS WERE LESS.
0S4EB ANSWERED #3 - DOCTOR TOLD ME IT WAS NOT HARMED BUT A
WARN IMG
009DB OTHER. = NO HARM TO HEART, BUT INDICATES NEED TO CHANGE
DIET
072PD ANSWERED #1 - "TO SOME EXTENT. " A WARNING SIGNAL TO SLOW
DOWN, BUT DOES BELIEVE HEART IS HARMED AND DOES NOT
HEAL.
016G0 ANSWERED - EXCEPT" FOR BIG ON £
050EP OTHER—DON*T KNOW
OOOJB ANCWEPED #3 - SEVERE ANGINA. WHEN LIFTING OR WALKING,
THEN WARNING SIGNAL
U62J T ANSWERED #3 - YES. IF PRESSED ON DEFINITELY WOULD CAUSE
HARM.
-------
QUESTION 39
080WR OTHER-"PRESSURE ON ME—FEELS LIKE ITS CLOSING If.; ON
ME. "
01 SRC COMMENTED WATCH TV AT START OF DAY AND PLANNED
accordingly'.
052HR OTHER=CHEST HURTS FIRST,, THEN ITS HIGH'
034EB "HOWEVER. IN LAST YEAR OR TWO ON A SM0G3Y DAY, I AM .'1CFE
CONTENT TO STAY AT HOME."
100WC INTERVIEWERS NOTE; AT THIS POINT, SUBJECT SCONCED
EXTREMELY BORED,
023WF OTHER=IF HOT, AVOID
07PLB CTHEF-BREATHING
039HK OTHER=ANGINA INCREASES. "KNOW IT IS POLLUTION, CARSON
MONOXIDE. BECAUSE IF I USE OXYGEN CYLINDER OR
ATMOSPHERIC AIR CYLINDER, I HAVE NO ANGINA.
INTERVIEWER'S NOTE: THIS SUBJECT PARTICIPATED IN
EARLIER COMMUNITY MONITORING RESEARCH; HE CARRIED A
PERSONAL EXPOSURE MONITOR AND WORE EC3 RECORDER."
051JR
051JR OTHER-REDUCES WALKING CAPACITY
008JB "IN THIS NEIGHBORHOOD DO NOT GET AIR QUALITY. IN CAR,
AIR CONDITIONER IS ON, AIR IS CLEAN.
022CE INTERVIEWERS NOTE; SUBJECT LIVES NEAR FREEWAY.
SUBJECT: AIR POLLUTION HANGS AROUND MY HOUSE ON
CERTAIN DAYS."
QUESTION 40
034EB "AIR POLLUTION & SMOKERS DON7 ! USUALLY BOTHER ME, SOME
IN LAST FEW YEARS BUT DON'T REALLY CARE, WILL V131T WITH
ANYONE, IF THEY WILL COME AROUND."
001 HA COMMENT BY SUBJECT: "NEVER AFFECTS ME—NEVER BOTHERS ME
AT ALL. I CAN GET ALONG FINE, BUT AFFECTS NY NEIGHECRS
ABOUT EVERY DAY."
10c BD DON'T KNOW HCW OFTEN THERE IS A[R FCLLUTION, NEVER FOR
ME, BUT IT DOES BOTHER MY NEIGHBORS—." PROMPT: OK. FOR
THE HEALTH OF OTHERS?
016(30 DOESN'T KEEP TRACK
-------
QUESTION 41
025JF OTHER-GO TO DESERT FOR 3-6 DAY?
AND WAIT IT OUT FOR A WHILE.
01SRC QTHER=KEEP FANE RUNNING
072FD DOES NOT BELIEVE ANGINA
POLLUTION IN HIS CASE.
Olc-GC OT;-EF:=DOrr T NOTICE IT,
•03RM other=rest IN bed.
04oeM
-------
043VL
OSOWR
015RC
084EB
100WC
021 RE
DURING CALL TO SET UP APPOINTMENT TO DO INTERVIEW.
SUBJECT WANTED TO KNOW REASONS FOR ASKING QUESTION 31.
"THOUGHT PERHAPS THE GOVERNMENT HAD CUT BACK YOUR
RESEARCH FUNDS AND YOU WERE GOING TO ASK FOR FUNDS. "
ALSO WANTED TO KNOW IF PERHAPS WE HAD SOME MEDICAL
TREATMENT THAT WE KNEW WOULD GET RID OF ANGINA BUT
WEREN7 T MAKING PUBLIC. ASSURED HIM WE WERE NOT AWARE OF
ANY MIRACLE DRUG BUT OF COURSE THERE WAS CONTINUAL
RESEARCH IN THIS FIELD AS IN OTHER DISEASES; OUR PURPOSE
WAS A HYPOTHETICAL QUESTION TO EXPLORE LIFESTYLE
ADJUSTMENTS AND WHAT MODIFICATIONS ONE WOULD BE WILLING
TO MAKE TO AVOID ANGINA. ASSURED HIM CUR FUNDING WAS
COMPLETE AND QUESTION 32 DID NOT REGARD RESEARCH FUNDS.
FULLY DEBRIEFED AFTER THE QUESTIONNAIRE WAS COMPLETED.
EXPLAINED MOTIVATION AND REASONING BEHIND QUESTIONS.
SUBJECT SEEMED SATISFIED. HE SAID HIS SISTER MAY HAVE
ANSWERED THE QUESTIONNAIRE VERY DIFFERENTLY, MUCH HIGHER
DOLLAR AMOUNTS DUE TO SEVERE AND DEBILITATING HEART
PROBLEMS. HE HIMSELF CHARACTERIZES HIS PROBLEM AS MILD,
"JUST NOT WORTH IT TO PAY MONEY TO AVOID HAVING ONE OR
TWO ANGINA EPISODES—I JUST TAKE A NITRO NOW—BUT IF I
HAD A REAL BAD ONE LIKE OTHER POEPLE, THEN I WOULD BE
WILLING TO PAY A LOT MCRE." (SISTER PASSED AWAY WITHIN
LAST YEAR FROM HEART CONDITION.)
DURING DEBRIEFING, "WAS IN KLEINMAN STUDY." "DIDN'T
HAVE CHEST PAIN THEY WANTED." "WHAT IS ANGINA?"
EXPLAINED WHAT ANGINA WAS IN TERMS OF A SUPPLY-DEMAND
MODEL. ALSO EXPLAINED WHY CO IS BELIEVED TO BE A
PROBLEM.
DURING INTERVIEW SUBJECT COMMENTED THAT BEFORE SURGERY
WAS TAKING 200 NITRO7S PER MONTH.
DURING INTERVIEW SUBJECT COMMENTED THAT FIRST TWO OR
THREE YEARS AFTER HEART PROBLEMS WERE DIAGNOSED, HE WAS
AT THE HOSPITAL 3, 4. 5 TIMES A YEAR. HAD A HARD TIME
MAKING AN ADJUSTMENT IN LIFESTYLE. WANTED TO DO MCRE
THAN WAS ABLE. EVEN THE "FACT THAT I WAS ILL WAS
STRESSFUL.. FINALLY RESIGNED MYSELF AND CHANGED MY
LIFESTYLE."
CANNOT PUT A MONETARY VALUE ON THE FRUSTATI ON AT
BEING ABLE TO DO DESIRED ACTIVITIES LIKE WORKING
JOB—ALSO LOSS OF SELF-ESTEEM, DIGNITY. ANXIETY
HAVING A HEART ATTACK DIFFICULT TO VALUE. CANNOT 60
ANYWHERE TO EAT, NO RESTAURANTS SERVE HEART DIET FOOD.
ALL I CAN HAVE IS SALADS. THIS 13 A CAMPING SKI IMG
FAMILY, CANNOT DO ANY OF THOSE THINGS ANYMORE.
BECAUSE OF DIABETES AND HYPERTENSION AND THEIR EFFECTS
ON ORGANS. I LIKE TO KEEP IN AS GOOD SHAPE AS POSSIBLE.
THEREFORE KEEP UP LAWN AND CEMENT WORK INSTEAD OF
EXERCISE IN ARTIFICIAL SENSE; I.E., EXERCISE BIKE.,
ROWING EQUIPMENT., JOINED SPA TO STAY FIT BUT HAVEN'T
USED IN ONE f-iND A HALF /EARS. IT HAS A JACUZZI AND
SWIMMING POOL TO USE /EAR ROUND BUT DON*T . EXERCISE
AND LOSE WEIGHT 3E3T WAY FO STAY FIT BU T REALLY STRUGGLE
WITH WEIGHT.
NOT
AT A
ABOLH
-------
SUBJECT HAD JUST WALKED IN DOOR WHEN CALLED FOR
INTERVIEW. INTERVIEWER OFFERED TO MAKE APPOINTMENT AND
CALL BACK ANOTHER TINE BUT SUBJECT PREFERRED TO LAY DOWN
ON BED AND DO INTERVIEW AS IT WOULD HELP HIM TC TAKE HIS
MIND OFF WORRIES. GOT REAL "UPSET" YESTERDAY.
COULDN'T SLEEP WELL LAST NIGHT. TIRED AND FEELING
POORLY; CANE HOME FROM WORK. WHILE DOING INTERVIEW. HE
WAS "SWEATY" ON ARMS AND BODY. THIS IS AS BAD A3 IT
GETS, BUT EVEN MILC ANGINA GET SAME TREATMENT, NITRO,
REST AMD NAP. HAS NOT SEEN -EELING WELL LATELY. HAS
APPOINTMENT AT ''A rCMORRCW,
WORKED FOR YEARS AS PIPEFITTER, WELDER. IN 1981 SET UP
OWN SHEET METAL Sri OF . RAN IT FOR ABOUT A YEAR. DOCTOR
TOLD HIM TO GET CUT. COULD NO LONGER HANDLE IT 30
TURNED IT OVER TO HIS SON AND SON-IN-LAW. KEPT PUT"ING
MONEY INTO IT TO KEEr' IT AFLOAT. BUT HAD TO DECLARE
BANKRUPTCY.
"HOW DC YCU ASK PEOPLE THESE THINGS? HARD TC VALUE."
MANAGES SELF-STORAGE COMPLEX, HOME ON PREMISES.
WAS ELECTROCUTED AT WORK IN 1933. AFTERWARD DEVELOPED
HEART PROBLEMS. LUNGS AND HEART MORE SENSITIVE TO SMOG.
ANGINA IS DIFFERENT BY SEASON. WILL SEND INFORMATION
BUT COULD NOT FIND DIARY HE KEEPS ON ANGINA FREQUENCY.
WHEN HE DEVELOPED HEART PROBLEMS, WAS OFF WORK IS
MONTHS. WHEN RETURNED TO WORK, WANTED TO BE RETRAINED
FOR ANOTHER POSITION BUT WAS NOT ACCEPTED. IS WORKING
MANY HOURS, GRAVEYARD SHIFT - SAN ONOFRE NUCLEAR.
SUBJECT HAD TIME FOR QUICK REVIEW OF QUESTIONNAIRE OVER
PHONE. WILLING TO DO QUESTIONNAIRE WHEN CALLED. HAD
QUESTIONNAIRE IN FRONT OF HIM AS INTERVIEWED. AT END OF
QUESTIONNAIRE SAID THAT FOR OTHERS, FINANCES MISHT BE
MORE IMPORTANT. NOT PARTICULARLY FOR ME, I WORRY ABOUT
ME. KILLED TWO KIDS IN TRUCK/AUTO ACCIDENT. WENT
THROUGH THERAPY. I AM RESPONSIBLE TO MYSELF.
AT END OF QUESTIONNAIRE, SUBJECT SAID IT WAS A GOOD
QUESTIONNAIRE, WOULD NOT ADD ANYTHING. LIVED IN
AUSTRALIA FOR IT YEARS OFF AND ON.
SUBJECT WELL EDUCATED IN CARDIOVASCULAR FUNCTIONING,
HIGHLY EDUCATED WITH DEGREE IN BIOMEDICAL ENGINEERING.
QUESTIONNAIRE COMPLETED DURING TWO SESSIONS. FIRST
SESSION COMPLETED QUESTIONS 1-33. REMAINDER OF
QUESTIONNAIRE DURING SECOND SESSION. SUBJECT MANAGES
MINI-WAREHOUSE AND THEREFORE LIVES AND WORKS AT HOME.
WAS ENGINEER. IN MACHINE TOOL INDUSTRY, CURRENTS.- NEAR.
FREEWAY IN AIRPORT AREA. SUBJECT STATED THAT THE
ANTICIPATION OF THE ATTACK, THE DISCOVERY THAT YOU ARE
ABOUT TO HAVE AN EPISODE INCREASES THE CHANCE, THE
[N TENSITY AND THE DURA 1" I ON OF THE ATTACK- NOW I NO ONE'S
LIMI FATICMS, HELPS TO MINIMIZE THE EFFECTS. DREAD OF
THE ATTACK: OH WELL., MERE IT COMES. SIT DOWN,
CONCENTRATE, MEDITATE.
-------
033RH SUBJECT HAD CAREFULLY CGMPLETED QUESTIONNAIRE.-
CGMPLETELY QUESTIONNAIRE QUICKLY. HAD TQ STOP HIM CN
GCCASI ON TO MAKE SURE HE HAD CAREFULLY CONSIDERED EACH
QUEST I ON.
075TS SUBJECT LIVES ON COAST AND DOES NOT BELIEVE THERE IS TOG
MUCH 3MGG. "
079L3 SUBJECT DID NOT LIKE FINANCIAL QUESTIONS. FELT THEY
WERE UNRELATED,
03^HK SUBJECT DID MOT HAVE QUESTIONNAIRE IN FRONT OF HIM.
BUS HE.-3. AUTQS ARE VERY BAD TO DRIVE BEHIND, HAVE TG PULL
70 SIDE GF ROAD AND WAIT IF STUCK BEHIND ONE.
003GB SUBJECT WAS ASKED AT END GF INTERVIEW IF HE HAD AN/
ADDITIONAL COMMENTS. HE STATED QUESTIONNAIRE WAS
THOROUGH, BUT THAT THERE WERE MO QUESTIONS ON HIGH BLOOD
J.09MM SPAM I Sh SPEAKING HOUSEHOLD. SOME QUESTIONS REALLY EASY
TO ANSWER. SOME CONFUSING AT FIRST. PRETTY FAIR
UNDERSTANDING OF QUESTIONNAIRE AND ANSWERED
CONSCIENTIOUSLY.
050EP SUBJECT IS EXPERIENCING DIFFERENT PAIN THAN HE HAS HAD
BEFGRE. HE IS MOT SURE THE PAIN HE HAS NOW IS ANGINA.
03663 SUBJECT WAS EDUCATED IN GPTHAMGLOGY IN ENGLAND,
PRACTICED IN ENGLAND & AFRICA BEFORE CGMIN6 TO U.S.
037CK SUBJECT MAILED QUESTIONNAIRE BACK TO RESEARCHER.
ADDITIONAL QUESTIONS WERE OBTAINED DURING PHONE CALL.
107LC ' SINCE CABS' 9 YEARS AGO, ONLY ANGINA PAIN IN NECK AMD
JAW. THEN PAIN BECAME MORE SHARP (LIKE A KNIVE) NOW VA
HAS RE-EVALUATED AND SAYS ANGINA PAIN IS BELIEVED TG
HAVE TAPER CFF AND NEW PAIN IS DUE TO REGURGITATED ACID
IRRITATING SIDE GF THROAT. WILL GET COMPLETE DIAGNOSIS
WITHIN WEEK. JUST STARTING ON MYLANTA, SEEMS TO GIVE
SCME RELIEF FROM SHARP PAIN IN NECK. FOR A PERIOD GF
TIME, COULD NOT LAY DOWN AND GET TG SLEEP, NOW CAM TAKE
MYLANTA. "THROAT PAIN REPLACED ANGINA PAIN."
001 HA SUBJECT DEBRIEFED MINIMALLY, HE DID NOT REALLY SEEM
INTERESTED TO HEAR ABOUT IT AT THIS TIME, DOES WANT TO
HAVi- -v E P 0 R T SENT TO KIM. SUBJECT NOTED DURI MS ANSWER OF
GUEST ION 32, THAT NEIGHBOR DIED TWO DAYS A60 GF A HEART
A i .
030RH "THE WAY SOCIETY TREATS YOU IS DIFFERENT—FRIEND TREATS
ME DIFFERENTLY BECAUSE OF THE HEART ATTACK. THEY THINK
YOU ARE GOING TO DROP DEAD. WHEN MOVING FILE CAD I NETS,
FRIEMD HESITATES AND WORRIES."
1 3T! QUESTIONNAIRE RETURNED VIA MAIL. ADDITIONAL QUESTIONS
WERE ASKED DURING FOLLOW-UP INTERVIEW.
-------
RESEARCH SUBJECT HAS VERY SHORT ATTENTION SPAN. JUMPS
AROUND FROM QUESTION TO QUESTION, WANTS TO RUSH THROUGH
SOME QUESTIONS AND THEN BINGE ON OTHERS, DIFFICULT TO
INTERVIEW, HAS LOST WEIGHT DURING LAST YEAR, IN GENERAL
ANGINA HAS BEGONE LESS OF A PROBLEM SINCE THEN. IS
FEELING BETJER, SWIMS DAILY. MINIMIZES HOURS WORKED
BECAUSE WANTS TO KEEP UP HEALTH, LEAVES TINE FOR
EXERCISE AND NAP EACH DAY, SUBJECT MERCHANDIZES
DESIGNER BOXES THAT HE HOLDS PATENT ON FROM HOME. ST ILL
TAKING LITHIUM FROM WESTWOOD VA.
WHEN FIRST ON DISABILITY IN 776 WITH MI, WAS A MESS,
TOOK 3 OR 6 YEARS TO GET USED TG IDEA AND ADJUST
LIFESTYLE, WOULD SIT HALF A DAY AND WORRY AND FEEL
USELESS, NO NEED TO GO ON, WHY An I HERE? NOW, LEARNED
TO ACCEPT IT. CAN'T CHANGE IT AND CAN7 T STEW AND FRET
ABOUT WHAT I CAN7"" CHANGE.
USED TO BE ALL RECREATIONAL—HUNT, FISH. BOTH FRESH AND
SALTWATER, CAMP, WALK, HIKE, PLAYING BASEBALL. NOW I
FISH ONCE IN A WHILE. CAN7 T DO THESE THINGS NOW. USED
TO REALLY UPSET ME*
WIFE READ OFF ANSWERS UNTIL QUESTION 22. THEN RESEARCH
SUBJECT WAS AVAILABLE.
"I AM GETTING SO I HAVE TO FORCE MYSELF TO DO THINGS I
REALLY LIKE TO DO, NICE BOAT ON TRAILER, NEVER THINK
ABOUT IT ANYMORE. I NEVER USE IT, HAVEN'T BEEN OUT IN
TWO YEARS. AFFECTED MY OTHER FAMILY SO MUCH THAT MY EX-
WIFE LOST CONFIDENCE IN ME 3 C0ULDN7T HANDLE IT SO WANTED
A DIVORCE. LOST HOUSE AND KIDS. HAVE NOW REMARRIED."
HAD NOT BEEN FEELING TOO GOOD FOR COUPLE OF WEEKS, HAD
A FEELING OF A STAKE DRIVEN INTO BACK JUST BELOW THE
SHOULDER BLADES. WENT TO SEE THE DOCTOR. NO RESULTS,
WENT TO A CONCERT, FELT BAD, WIFE TOOK HIM HOME EARLY,
TOOK ALCO SELTZER, FELT BETTER. NEXT MORNING, WIFE
WENT TO WORK. HE WENT OUT TO WORK ON BIKES FOR
GRANDSON AND FELT BAD, CAME IN AND FELT WORSE. SWEAT,
PAIN THEN DOWN ON FLOOR. WHEN COULD FINALLY MOVE,
CALLED WIFE WHO TOOK HIM TO LOCAL HOSPITAL. WAS THERE
14 DAYS. SWITCH TO VA AS UNABLE TO PAY REMAINING COSTS
AFTER INSURANCE. HAVE LEARNED TO ADAPT, ARE RAISING
TWO TEENAGE (13 14) GRANDSONS LIVING WITH HIM. CAN7 T
DO AS MUCH AS HE'D LIKE, HAS TC CONSIDER WHETHER TRIP
15 WORTH THE PHYSICAL EXERTION. OLDEST GRANDSON HAS
DIABETES AND IS AT LA CHILDREN7 S HOSPITAL 3 TIMES A
MONTH.
-------
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-------
Appendix 4
-------
Itemized costs of health services used in the estimation of societal cost of
illness. Charges are based upon accounting information from the UC Irvine
Medical Center and the Southern California Physicians' Billing Service
Procedure Cost
Standard Office Visit $60
(At least 1 resting ECG at $50 is
assumed to accompany regular checkup
schedule.)
Emergency Room Charges
Hospital Room Charges
ICU/CCU
Cardiac Ward
Semi-Private Medical
Coronary Arterv Bypass Graft Surgery (CABG)
(Includes 6-hours operating room, general
anesthesia materials, recovery room,
5-day stay, and ancillary charges.
Does not include professional fees.)
$100 (+ ECG at $50)
$1271 per day
$615 per day
$414 per day
$15,738
Angioplasty (PTCA) $5,379
(Includes OR costs, anesthesia,
technicians, but does not include
professional fees.)
Heart Tests
Standard 12-lead Resting ECG $50
Treadmill Stress Test $180
Echocardiogram $270
Chest X-rav Exam $55
Blood Gases $120
Intraveneous Line
$25
-------
sns
3BS
SUBJECT
SWKLOSS
twkloss
SWl.D
1
1
0. 0
0. 0
0. 00
2
3
37500.0
37500.0
0. 00
3
5
17500.0
17500.0
0. 00
4
6
260. 5
434. 2
260.55
5
7
0. 0
0. 0
0. 00
S
e
3000.0
3000. 0
0. 00
7
9
0. 0
0. 0
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a
12
0. 0
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9
15
0. 0
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i a
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17
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i a
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1 3
22
32500.0
32500.0
0. 00
1 4
23
0. 0
0. 0
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1 5
24
0. 0
0. 0
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1 6
25
7500.0
7500.0
0. 00
1 7
30
0. 0
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1 9
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2 1
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32500.0
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26
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32
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40
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576. 9
576. 9
576.92
4 1
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0. 0
0. 0
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42
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65000.0
65000.0
0. 00
43
91
42500.0
425O0.0
0. 00
44
94
90B6.5
9006.5
961.54
45
1 00
55000.0
55000.0
0. 00
46
1 03
2500.0
2500.0
0. 00
47
106
47500.0
47500.0
0. 00
4 Q
107
230. O
230. Q
230.77
49
1 0B
12500.0
12500.0
0. 00
50
109
0. 0
0. 0
0. 00
15i48 TIJESUOY, DECEM
TULO UKHED JOBLDSS
0. 00
0. 00
0
0. 00
0. 00
37500
0. 00
0. 00
1 7500
434.24
0. 00
0
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0. 00
0
0. 00
3000.00
0
0. 00
0. 00
0
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32500
0. 00
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0
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0
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2500
0. 00
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64. 10
270B.33
0
2942. 31
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32500
0. 00
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0. 00
65000
0. 00
0. 00
0
0. 00
0. 00
7500
0. 00
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0
376.92
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42500
961.54
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0
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230.7 7
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0. 00
12500
0. 00
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0
-------
Listing of prices charged for heart-related medications taken by fHD subjects. Unless otherwise noted, prices are per 100 capsules/tablets and
Itemized by generic and name brand classifications tor a major chain pharmacy, a privately-owned pharmacy, and the pharmacy of the Long Beach
Veteran's Administration Medical Center. Mean prices are presented for generic and name brands sold by the chain and private pharmacies.
MEDICATION
Coda Dosage
PRICE AT
CHAIN PHARMACY
GENERIC NAME BRAND
PRICE AT
PRIVATE PHARMACY
GENERIC NAME BRAND
MEAN MEAN
GENERIC NAME BRAND
PRICE PRICE
OVERALL
MEAN PRICE
VETERAN'S ADMIN
GENERIC NAME
050 Experimental Drugs
unypectliod
100 Nitrale capsules
unspocifiod
-----
101 Nitroglycerin tablets
3 85 3 85
5 40 5 40
4 63 4 63
4 63
102 Isordil
5mg
10 mg.
20 mg.
645 1630
6 85 1600
7 55 25 20
6 35 13 80
6 75 16 60
13.25 23 85
6 40 1505
6 80 16.30
1040 24 53
10/3
11 55
17.46
103 Isosorbide dmitrate
5mg
10 mg.
20 mg
6.45 1630
6 85 1600
7 55 2520
6 35 13 80
6 75 1660
13 25 23 85
640 1505
6.80 16.30
10 40 24 53
10/3
11 55
17 46
10-1 Nitro bid capsules
2 5 mg.
6 5 mg
7 55 21.95
8 35 26 55
8 0 5 20 50
9.55 2535
7. BO 21.23
895 2595
14.51
17 45
1C5 Cardilalo
S mg.
10 mg.
21.10"
27 55"
DO NOT STOCK
DO NOT STOCK
21.10"
27 55"
21.10
27 55
1G6 Perilrato
10 mg
?0 mg
80 mg
5 50 14 25
4 50 16 80
9.65 S 3165
6 25 11 60
6 25 14 30
9 65 29 20
5 88 1293
538 15.55
9 65 30.43
9 40
10 46
20 04
10/ Persantine (dipyridamole")
25 mg.
50 mg.
75 mg. (chow)
10 35 22 95
13 95 33 10
19 45 44 00
7 20 21.35
11 05 30 30
15 95 37 00
8.78 22.15
12 50 31.70
17.70 40 95
15 46
22 10
29 33
1C8 Sorburale
5 nig
10 mg
5 mg.
6 45 16 30
6 85 16 00
6 35 13 80
6 75 16 05
13 80
6 40 1505
6 80 IB 03
13.80
10 73
11.41
13 80
150 Nitrate ointment, unspecilied
-----
sc-e codo 797
'licm not carnod by pharmarcy. Price would chango if stocknd.
-------
pagu 2
MEDICATION
Code Ooage
PRICE AT
CHAIN PHARMACY
GENERIC NAME BRAND
PRICE AT
PRIVATE PHARMACY
GENERIC NAME BRAND
MEAN MEAN
GENERIC NAME BRAND
PRICE PRICE
OVERALL
MEAN PRICE
VETERAN'S ADMIN
GENERIC NAME
151 Nilropatch (transdormnitro)
packets ol 30
5 mg.
10 mg.
15 mg.
4090
45 40
5000
—
4090
45.40
5000
40.90
45 40
50.00
152 Hiiro bid ointment (Nilo)
60 applications
60 mg.
9 70
915
9.43
9 43
153 Nitrol
60 mg
13 20
10 45
1183
11.83
155 Nitrong
156 Nitrostal
all strengths
60 mg. ointment
385
1120
585
485
11.20
4 85
11 20
200 Calcium Channel Blockers,
unspeciliced
___
201 Calan (verapamil)
80 mg
120 mg.
37 00
4880
3290
41.60
3495
4520
34 95
45 20
202 Cardi/em (dilua/em)
30 mg.
60 mg
30.70
4895
3080
44.95
30 75
46 95
30.75
46 95
203 Procardia (nilodipine)
10 mg
20 mg
3125
2940
56.75
3033
56 75
30 33
56 75
205 Isoptin (verapamil)
80 mg
120 mg.
3700
48 80
3280
4160
34 90
4020
34 90
45.20
300 Beta Blockers, unspeciliced
301 Corgard (nadolol)
40 mg.
80 mg.
120 mg
53 30
7055
9195
45.75
64 80
84 20
4953
6768
88.08
49.53
67 68
88 08
302 Corzido (nadolol)
40.'5 formulation, 40 mg
80/5 formulation. 80 mg.
72.00
94 95
— 78 35
59 60
75 18
77 28
75 18
77 28
-------
pnrje 3
MEDICATION
Code Dosage
PRICE AT
CHAIN PHARMACY
GENERIC NAME BRAND
PRICE AT
PRIVATE PHARMACY
GENERIC NAME BRAND
MEAN MEAN
GENERIC NAME BRAND
PRICE PRICE
OVERALL
MEAN PHICE
VETERAN'S ADMIN
GENERIC NAME
3C3 Indurul (propranolol)
10 mg
20 mg
40 mg
80 mg
1035 1390
10.95 18.10
15 55 23 70
27 25 43 20
11 25 14 20
12 55 1995
1695 25.10
30 00 3875
10.80 14 05
11.7b 19 03
16 25 24 40
2863 4098
12 43
15 39
20 33
34 80
3tM In da ride (propranolol;
40.25 formulalion, 40 mg.
80/25 lormulalion, 80 mg.
43 20
59 20
37.10
48 95
4015
54 00
40.15
54 08
305 loprossor (mel/opolol Uirl/alo)
50 mg
100 mg.
30 50
5055
27.00
4100
28 75
45 78
28 75
4578
306 Tenormin (atonolol)
50 mg.
100 mg
5105
75 80
48 50
72 30
49 78
74 05
49 78
74 05
307 Vislien (pindolol)
5 mg
10mg
33 55
45 70
30 70
39 10
3213
42 40
32 15
42 40
400 CXnnidino sulfalo. unspocifiod
200 mg.
300 mg.
11.45 1145
21 15 26 55
12 25 11.45S
1185 11.45
21.15 2655
11 65
23 05
401 Quinidox (quinidino)
300 mg.
4780
40 70
44 25
44.25
402 Cardioquin (quinidino)
2/5 mg.
57 60
4535
5148
51 48
403 Quinidine Gluconate
—
28 50 56 48
2850 5646
42 49
500 Digoxin, digitalis, un^pecihod
501 1 anonn (digonn)
.125 mg
?50 mg.
500 mg.
5 50
550
1595
630
630
590
5 90
1595
5 90
5 90
15.95
5C2 Lanoxicaps (digoxin)
050 mg
100 mg.
.200 mg
15 00
15 90
17 50"
13 30
15.00
15.90
1540
15.00
15 90
15 40
5C3 Cryslodigin (riigilalis
glycosido)
800
8 00"
8 00
**J(em nor carried by pharmacy. P/ice would change if siockod.
-------
pago A
Code
MEDICATION
Dosage
PRICE AT
CHAIN PHARMACY
GENERIC NAME BRAND
PRICE AT
PRIVATE PHARMACY
GENEHIC NAME BRAND
MEAN
GENERIC
PRICE
MEAN
NAME BRAND
PRICE
OVERALL
MEAN PRICE
VETERAN'S
GENERIC
ADMIN
NAME
600
Procainamide} hydrochloride,
unspecified
250 nig
375 mg
500 rng
10 35
13 55
14.15
27 65
37 30
4 7.65
10 30
12 10
13 85
25 40
33 15
40 50
10 33
12 82
14 00
26 53
35.23
44 08
18.43
24 03
29 04
601
Proneslyl (procainamide)
250 mg
375 nig
500 mg.
10 35
13 55
14 15
27 65
37 30
47 65
10 30
12 10
13 85
25 40
33 15
40 50
10 33
12 82
14 00
26 53
35 23
44 08
10 43
24 03
29 04
700
An ti-hypertensives,
unspecified
701
Hydrochlorothiazide,
unspocifiod
25 mg
50 mg
4 60
4 05
4 60
4.85
4 60
4 85
702
Aldacla/ide
13 30
29 05
1205
28 95
12 68
29.00
20.84
703
Aldactone
14.15
20.45
13 15
27 00
13 6b
28 23
20.94
704
Calapres (clonidine)
.1 mg
2 mg.
3 mg
13 15
28 70S
24 60
39 75
54 30
21.30
28 70
26 80
37 35
44 55
17 23
28.70
25.70
3B 55
49 43
21.46
33 63
49.43
705
Hydrodiuril
25 mg.
50 mg
5 00
5 00
14 30
16 05
4.60
4 05
11.75
12 20
4 80
4.93
13 03
14 13
8 91
9 £3
7C6
Hygrolon
25 mg
50 mg.
100 mg
11 55
13 55
15 00
31 35
39.05
63 10
1565
12.75
14.15
27 95
33 20
50 25
13 60
13 15
14 58
29.65
36.13
56.68
21 63
24 64
35 63
70 7
Mmipioss (prazosin)
1 mg
2 mg.
5 mg
22 00
32 55
51 55
22 60
28 35
43 50
22.30
30.45
4 7.53
22 30
30 45
4 7 53
708
Mini/ido (prazosin)
1 mg
2 mg.
32 70
39 00
32.70
39 00
32.70
39 00
-------
pngo 5
MEDICATION
Coda Dosage
PRICE AT
CHAIN PHARMACY
GENERIC NAME BRAND
PRICE AT
PRIVATE PHARMACY
GENERIC NAME BRAND
MEAN MEAN
GENERIC NAME BRAND
PRICE PRICE
OVERALL
MEAN PRICE
VETERANS ADMIN
GENERIC NAME
703 Nmopross
710 Tonortrun
50 mg.
100 mg.
5105
7580
4850
72 30
49 78
74.50
49 70
74 05
/II Cyanide
2145
2235
21.90
21.90
712 Hydropross
2b mg.
50 mg.
930 2295
10 35 3230
5 40 21.40
9 55 29 50
7 35 22.18
9.95 30.90
14.76
20 43
713 Hydroxyzine Hydrocloride
10 mg.
25 mg
50 mg
100 mg.
11 75 33 35
17 20 48 50
18 75 58 95
13 75 33 35S
17 90 58.95S
17.30
12.75 33 35
17 20 48 50
1833 5895
17 30
23 05
32.85
38 64
17 30
750 Capolen (caplopril)
12 5 ing
25 0 mg.
50.0 mg
100 0 mg.
31.75
35 00
5945
103 85
34 60
37 50
5905
33 18
36 25
5825
103 85
33.18
36 25
58 25
103 85
797 Pursanune (dipyridamole)
25 mg
50 mg.
75 mg
10 35 2295
13 95 33 10
19 45 44 00
7 20 21 35
11 05 30 30
15 95 37 90
8 78 22 15
12.50 31.70
17 70 40 95
15 46
22 10
29 33
798 Coumadin, oral (warfarin
sodium)
2.0 mg
2 5 mg
5 0 mg.
7 5 mg
23 40
24 10
2595
27 85
21.85
22.50
23 70
22 63
23 30
2483
27 85
22 63
23.30
24 83
27 85
/99 Aspirin
.99 2 69
1 39 4 99
1.19 3 84
2 51
BOO Diuretic, unspocified
601 f-urosonndo, unspocihod
20 mg
40 mg.
80 mg.
7 55 15 80
9 20 14 25
22.10 27 55
9 10 13 15
1105 15 10
16 GO 25 30
8 33 14 48
10 18 1468
1935 26 43
11 40
12 40
22 09
802 Lasix (lurosomide)
20 mg
40 mg
80 mg.
7.55 15 80
9 20 14 25
22.10 27 55
9.10 13 15
1105 15 10
16 60 25 30
8 33 14 48
10 18 14G8
19 35 26 43
11 40
12 40
22 89
-------
porjO 6
MEDICATION
Code/Dosage
PRICE AT
CHAIN PHARMACY
GENERIC NAME BRAND
PRICE AT
PHIVATE PHARMACY
GENERIC NAME BRAND
MEAN MEAN
GENERIC NAME BRAND
PRICE PRICE
OVERALL
MEAN PRICE
VETERANS ADMIN
GENERIC NAME
803 Maxzide (K sluing wilh
hydiochlorolhiazido)
50 mg.
3G.65
28 55
32.70
32 70
BC4 Spironolaclono
25 mg.
14 15 29 4 5
13 15 29.45 S
13 65 29.45
21 55
B05 rolassjum replacement
SluwK
Micro K
K Tab
Klotnx
1160
13.15
18 00
17 20
1499
14 99
850 Cholestorol lowonng modi-
cations, unspocitiod
851 Coloblid
30 packots
22 00
2200
22 00
852 Pormacol
-----
853 Probucul (torelco)
45 60
34 10
39 85
39 85
300 Insulin, unspecified
u -100. 10 cc
8 69 12.95 S
9 65 1295
9.17 12.95
11.06
951 Dubineso
100 mg.
250 mg
9 50 24 50
11 55 31 85
11 05 23 70
12 05 34 25
10 28 24 10
11 80 33 05
17.19
22 43
952 Micronaso
1 25 mg.
2 50 rng.
5 00 mg.
1850
2700
44 15
1705
25.85
34 75
17 78
26 43
39 45
17 78
26 43
39 45
9S3 Orinase
250 mg.
500 mg
" - 1575
10 35 24 75
1120 19.60
1575
10 78 22 18
15 75
16 48
954 Tolirwaso (tolazamide)
100 mg
250 mg.
500 nig.
1860 24 80
32 25 4740
61 45 9285
2520 34 9b
67.45
1860 24 00
28 73 41.18
61 45 80.15
21 70
34 95
70 00
-------
page 7
MEDICATION
Code Dosage
PRICE AT
CHAIN PHARMACY
GENERIC NAME BRAND
PRICE AT
PRIVATE PHARMACY
GENERIC NAME BRAND
MEAN MEAN
GENERIC NAME BRAND
PRICE PRICE
OVERALL
MEAN PRICE
VETERAN'S ADMIN
GENERIC NAME
OSS Insulin (Lonto. Ullralbnlo)
10 cc's
8 69
965
9.17
9 17
9S6 Insulin. NPH
10 cc's
9 65
965
9 65
SS7 Chlorpropamide
100 mg.
2SO mg.
9 50 2450
11 50 3 1 85
11 05 23 70
1205 3-1 25
1028 24 10
11 78 3305
17.19
22.41
9S8 Penday
960 Tranquilizers. unspecified
~~
•—
960 Valium
2 mg.
S mg.
10 mg
1035 2290
1395 26 60
19 05 4745
12 85 20 95
1885 20 45
30.10 43 90
11 GO 2193
16 40 27 53
24.88 45 68
16.76
21.96
35 28
960 Xanax
.25 mg.
.50 mg.
1 00 mg.
31.20
" " 40.40
GO 80
28 75
35 25
50.20
29.98
37.83
55.50
29 98
37 83
55.50
960 Mopfobarnaiti
200 mg
400 mg.
590
480
5 95
480
593
4 80
5 93
-------
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