Ambulatory health care visits by children: principal diagnosis and place of visit

OBJECTIVES: This report presents national estimates of ambulatory health care use by children under 15 years of age according to principal diagnosis, place of visit (physician office, hospital outpatient department, and hospital emergency department), and patient characteristics (age, sex, and race). METHODS: Data were from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Data were from 1993-95. RESULTS: In 1993-95 children under 15 years of age made 165.3 million visits per year (289 visits per 100 children). Visit rates were highest among infants and varied inversely with age. Visit rates were 43 percent higher among white children than black children. Three-quarters of ambulatory visits occurred in physician offices, 8 percent in hospital outpatient departments, and 14 percent in hospital emergency departments. Visits by white children were more likely to occur in physician offices than visits by black children (81 percent and 54 percent). Conversely, visits by black children were more likely to occur in hospital outpatient departments (19 percent and 7 percent) and hospital emergency departments (28 percent and 12 percent) than visits by white children. The following principal diagnoses accounted for almost 40 percent of visits: well-child visit, 15 percent; middle ear infection, 12 percent; and injury, 10 percent. Rates for well-child visits were almost 80 percent higher among white infants than black infants. Continued monitoring of these differences in use of ambulatory care among children are needed, particularly in view of the possible impact of changes in the health care system on these differences.     

Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1996

OBJECTIVE: This report describes ambulatory care visits in the United States across three ambulatory care settings--physician offices, hospital outpatient departments, and hospital emergency departments. Statistics are presented on selected patient and visit characteristics for all ambulatory care visits and separately for each setting. METHODS: The data presented in this report were collected by means of the 1996 National Ambulatory Medical Care Survey (NAMCS) and the 1996 National Hospital Ambulatory Medical Care Survey (NHAMCS). These surveys are part of the ambulatory care component of the National Health Care Survey that measures health care utilization across a variety of providers. The NAMCS and NHAMCS are national probability sample surveys of visits to office-based physicians (NAMCS) and visits to the outpatient departments and emergency departments of non-Federal, short-stay and general hospitals (NHAMCS) in the United States. Sample data are weighted to produce annual estimates. RESULTS: During 1996 an estimated 892 million visits were made to physician offices, hospital outpatient departments, and hospital emergency departments in the United States, an overall rate of 3.4 visits per person. Visits to office-based physicians accounted for 82.3 percent of ambulatory care utilization, followed by visits to emergency departments (10.1 percent) and outpatient departments (7.5 percent). Persons 75 years and over had the highest rate of ambulatory care visits. Females had significantly higher rates of visits to physician offices and hospital outpatient departments than males did. About two-thirds of ambulatory care visits by black persons were to physician offices. There were an estimated 129.3 million injury-related ambulatory care visits during 1996 or 48.9 visits per 100 persons.     

Triptorelin acetate administration in early pregnancy: case reports and review of the literature

OBJECTIVE: The report estimates the treatment costs, cost-offset effects, and cost-effectiveness of Collaborative Care of depressive illness in primary care. STUDY DESIGN: Treatment costs, cost-offset effects, and cost-effectiveness were assessed in two randomized, controlled trials. In the first randomized trail (N = 217), consulting psychiatrists provide enhanced management of pharmacotherapy and brief psychoeducational interventions to enhance adherence. In the second randomized trial (N = 153). Collaborative Care was implemented through brief cognitive-behavioral therapy and enhanced patient education. Consulting psychologist provided brief psychotherapy supplemented by educational materials and enhanced pharmacotherapy management. RESULTS: Collaborative Care increased the costs of treating depression largely because of the extra visits required to provide the interventions. There was a modest cost offset due to reduced use of specialty mental health services among Collaborative Care patients, but costs of ambulatory medical care services did not differ significantly between the intervention and control groups. Among patients with major depression there was a modest increase in cost-effectiveness. The cost per patient successfully treated was lower for Collaborative Care than for Usual Care patients. For patients with minor depression. Collaborative Care was more costly and not more cost-effective than Usual Care. CONCLUSIONS: Collaborative Care increased depression treatment costs and improved the cost-effectiveness of treatment for patients with major depression. A cost offset in specialty mental health costs, but not medical care costs, was observed. Collaborative Care may provide a means of increasing the value of treatment services for major depression.     

Mixed anxiety and depression.

Reviews evidence from community, primary care, and psychiatric samples to determine whether there is a group of patients who have mixed symptoms of anxiety and depression that are below diagnostic thresholds for either group of disorders. A review of the data strongly suggests that such a group of patients exists and that, despite lacking sufficient symptoms to meet diagnostic thresholds from the revised 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III—R; American Psychiatric Association, 1987), they often have significant impairment in social and vocational functioning. Because many of these patients also suffer from medically unexplained somatic symptoms, they may be more likely to frequently use nonpsychiatric medical care. Longitudinal studies suggest that persons with mixed anxiety-depression symptoms may represent a population who are at increased risk for more severe mood and anxiety disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

National trends in the use of antibiotics by primary care physicians for adult patients with cough

BACKGROUND: Increased antibiotic use for outpatient illnesses has been identified as an important determinant of the recent rise in antibiotic resistance among common respiratory pathogens. Efforts to reduce the inappropriate use will need to be evaluated against current trends in the outpatient use of antibiotics. OBJECTIVES: To examine national trends in the use of antibiotics by primary care physicians in the care of adult patients with cough and identify patient factors that may influence antibiotic use for these patients. METHODS: This study was based on a serial analysis of results from all National Ambulatory Medical Care Surveys beginning in 1980 (when therapeutic drug use was first recorded) to 1994 (the most recent survey year available). These surveys are a random sampling of visits to US office-based physicians in 1980, 1981, 1985, and annually from 1989-1994. Eligible visits included those by adults presenting to general internists, family practitioners, or general practitioners with a chief complaint of cough. A total of 3416 visits for cough were identified over the survey years. Survey results were extrapolated, based on sampling weights in each year, to project national rates of antibiotic use for patients with cough. Additional analyses examined the rates of antibiotic use stratified by patient age, race, and clinical diagnosis. RESULTS: Overall, an antibiotic was prescribed 66% of the time during office visits for patients with cough: 59% of patient visits in 1980 rising to 70% of visits in 1994 (P = .002 for trend). In every study year, white, non-Hispanic patients and patients younger than 65 years were more likely to receive antibiotics compared with nonwhite patients and patients 65 years or older, respectively. CONCLUSIONS: The rate of antibiotic use by primary care physicians for patients with cough remained high from 1980 to 1994, and was influenced by nonclinical characteristics of patients.     

Access and outcomes of elderly patients enrolled in managed care

OBJECTIVE: To determine differences in access to care and medical outcomes for Medicare patients with an acute or a chronic symptom who were enrolled in health maintenance organizations (HMOs) compared with similar fee-for-service (FFS) nonenrollees. DESIGN: A 1990 household telephone survey of Medicare beneficiaries who reported joint pain or chest pain during the previous 12 months. SAMPLE: Stratified random sample of HMO enrollees (n = 6476) and comparable sample of FFS Medicare beneficiaries (n = 6381). ACCESS AND OUTCOME MEASURES: Care-seeking behavior, physician visits, diagnostic procedures performed, therapeutic interventions prescribed, follow-up recommended by a physician, and symptom response to treatment. RESULTS: After controlling for demographic factors, health and functional status, and health behavior characteristics, HMO enrollees with joint pain (n = 2243) were more likely than nonenrollees (n = 2009) to have a physician visit (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.03 to 1.38) and medication prescribed (OR, 1.35; 95% CI, 1.14 to 1.60). Patients with chest pain who were enrolled in HMOs (n = 556) were less likely than nonenrollees (n = 524) to have a physician visit (OR, 0.50; 95% CI, 0.30 to 0.82). For both joint and chest pain, HMO enrollees were less likely to see a specialist for care, have follow-up recommended, or have their progress monitored. There were no differences in complete elimination of symptoms, but HMO enrollees with continued joint pain reported less symptomatic improvement than nonenrollees (OR, 0.72; 95% CI, 0.59 to 0.86). CONCLUSIONS: Reduced utilization of services for patients with specific ambulatory conditions was observed in HMOs with Medicare risk contracts, with less symptomatic improvement in one of the four outcomes studied.     

Why do adults with mucoviscidosis refuse a medically recommended course of intravenous antibiotic therapy?

OBJECTIVE: To better understand the needs of spouses who provide care to spinal cord injury (SCI) survivors, by comparing their self-perceptions and complaints with those of their partners with disabilities and with those of spouses who do not provide care. DESIGN: Survey, including demographics, health concerns questionnaire, and administration of the Center for Epidemiologic Studies Depression Scale (CES-D), the Perceived Stress Scale (PSS), the Life Satisfaction Index (LSI-Z), and the Quality of Life and Individual Needs Questionnaire. SETTING: Two British SCI treatment centers, serving a defined population-based catchment area. PARTICIPANTS: One hundred twenty-four spouses of a longitudinally followed sample of SCI survivors, all of whom had been injured 23 or more years when the study was conducted in 1993. OUTCOME MEASURES: Scores on the above standardized tests, and responses to survey questions. RESULTS: Spouses had more depressive affect (p < .001) than their partners with disabilities, as measured by the CES-D. On the PSS, they exhibited no significant differences. Compared with spouses who were not caregivers, the caregiving spouses reported more physical stress (p = .005), emotional stress (p = .011), burnout (p = .007), fatigue (p = .002), and anger and resentment (p = .029). On the CES-D, they had more symptoms of depressive affect (p = .004) and somatic depression (p = .005). CONCLUSIONS: Spouses of long-term SCI survivors who fulfill a caregiving role report more symptoms of stress and depression than their partners with disabilities and other spouses who are not caregivers.     

National Hospital Ambulatory Medical Care Survey: 1992 Emergency Department Summary

OBJECTIVE: This report presents data on the provision and utilization of ambulatory medical care services in hospital emergency departments during 1992. Ambulatory medical care services are described in terms of patient, visit, and facility characteristics. Among these are the patient's reason for the visit, diagnostic and screening services ordered or provided, diagnosis, and medications provided or prescribed. Cause of injury data are presented for injury-related visits. METHODS: Data presented in this report are from the 1992 National Hospital Ambulatory Medical Care Survey (NHAMCS), a national survey of non-Federal, general and short-stay hospitals, conducted by the Division of Health Care Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention. This report reflects the survey's first year of data collection. A four-stage probability sample design was used, resulting in a sample of 524 non-Federal, general and short-stay hospitals. Ninety-two percent of eligible facilities participated in the survey. Hospital staff were asked to complete Patient Record forms for a systematic random sample of patient visits occurring during a randomly assigned 4-week reporting period, and 36,271 forms were completed by participating emergency departments. Diagnosis and cause of injury were coded according to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Reason for visit and medications were coded according to systems developed by the National Center for Health Statistics. RESULTS: An estimated 89.8 million visits were made to the emergency departments of non-Federal, general and short-stay hospitals in the United States during 1992-357.1 visits per 1,000 persons. Persons 75 years of age and over had a higher visit rate than persons in five other age categories. White persons accounted for 78.5 percent of all visits. However, the visit rate for black persons was significantly higher than for white persons overall and for every age category except 65-74 years and 75 years and over. More than half of all visits were illness related and more than one-third were injury related. Stomach and abdominal pain and chest pain were the most frequently mentioned reasons for visiting the emergency department, accounting for about five million visits each, or 10.7 percent of the total. Accidental falls accounted for the largest share of injury-related visits (22.7 percent).     

Predictors of mortality in the prospective Dubbo study of Australian elderly

BACKGROUND: A study was undertaken to examine the relationship between first-contact care, an essential feature of primary care, and expenditures for frequent ambulatory episodes of care in a nationally representative sample. METHODS: A nonconcurrent cohort study was conducted using data from the 1987 National Medical Expenditure Survey. Ambulatory claims data of respondents with an identified primary care source were used to develop 20,282 episodes of care for 24 preventive and acute illness conditions. The study examined the relationship of first-contact care, defined as the use of an identified primary care source for the first visit in an episode, and ambulatory episode-of-care expenditures. RESULTS: Episodes that began with visits to an individual's primary care clinician, as opposed to other sources of care, were associated with reductions in expenditures of 53% overall ($63 vs 134, P<.001), 62% for acute illnesses ($62 vs $164, P<.001), and 20 for preventive care ($64 vs $80, P<.001). For 23 of the 24 health problems studied, first-contact care was associated with reductions in expenditures. Multivariate regression analyses that controlled for sociodemographic characteristics, health status, case-mix, length of the episode, and number of visits to the emergency room did not substantively alter these results. CONCLUSIONS: First-contact care was associated with reductions in ambulatory episode-of-care expenditures of over 50% in a nationally representative sample. These findings suggest that systems of care may reduce ambulatory expenditures.     

The clinical course of patients with acute myocardial infarction who are unsuitable for thrombolytic therapy because of the presenting electrocardiogram. UK Heart Attack Study Investigators

OBJECTIVE: To examine the clinical characteristics and 30-day fatality rate among patients with electrocardiograms (ECGs) ineligible for fibrinolysis in a consecutive series in four general hospitals in the UK. METHODS: We studied 2439 consecutive patients who were identified from regular ward visits, surveillance of results from hospital laboratories, and hospital discharge coding. RESULTS: Thirty percent (732) of patients did not have ECGs eligible for fibrinolysis therapy, while indications were uncertain in 55 (2%). Within the ineligible group, patients presenting with ST depression (n = 294) had a higher 30-day fatality rate than those with ST elevation or left bundle branch block (26% versus 17%; P < 0.001); they represented 40% of the group ineligible for fibrinolysis therapy, or 12% of the total cohort. Thirty-day fatality rates in patients presenting with pathological Q waves and no diagnostic ST segment changes (n = 130), those with T wave changes but no other abnormality (n = 168) and those with a normal ECG (n = 128) were 10%, 5% and 3%, respectively. Despite their high fatality rate, fewer patients with ST depression were admitted to coronary care units than those with ECGs eligible for fibrinolysis therapy (61% versus 85%; P < 0.001) and 23% did not receive heparin. The coronary anatomy in a subset of patients with ST depression showed two- or three-vessel disease in 79% and left main stenosis in 9%. The rates of coronary revascularisation were low in all groups (< 10%). CONCLUSION: Patients with ECGs ineligible for fibrinolysis therapy are a disparate group, with a high rate of fatality occurring in patients who present with ST depression. The high prevalence of multiple vessel coronary disease in patients with ST depression suggests that a more active management strategy is required.     

Symptom profiles of depression among general medical service users compared with specialty mental health service users

BACKGROUND: Since depressive disorders are now eminently treatable and early detection and treatment could bring substantial benefits, it is critical to address alternative presentations of depression in the general medical setting. Concern regarding under-diagnosis of depression in general medical settings has given rise to the question of whether the clinical disorder of depression differs qualitatively or only quantitatively across care settings. METHODS: Symptom profiles of depression were compared across care sectors to investigate how the presentation of depression among general medical service users might differ qualitatively from specialty mental health service users. Data on depression symptoms within 6 months of interview gathered in three community surveys that were part of the NIMH Epidemiologic Catchment Area Program were analysed using methods developed to assess item bias. The subjects were 4931 and 363 persons who reported a visit to the general medical sector or to specialty mental health respectively, within 6 months of interview. RESULTS: Compared with specialty mental health service users, general medical service users were less likely to present dysphoria (adjusted Odds Ratio, aOR = 0.57; 95% Confidence Interval, CI = 0.38-0.84) and feeling worthless, sinful, or guilty (aOR = 0.63; 95% CI = 0.40-0.98), but were more likely to present fatigue (aOR = 1.71; 95% CI = 1.09-2.69), even after holding constant other characteristics that might influence reporting of symptoms as well as level of depression. CONCLUSIONS: These results suggest that there are qualitative differences in depression presenting in general medical care compared with specialty mental health care and call for a re-conceptualization of depression in the general medical setting.     

Infants conceived using in-vitro fertilization do not over-utilize health care resources after the neonatal period

Health outcomes during the first year for 95 infants born following in-vitro fertilization (IVF) were compared with those of 79 naturally conceived controls whose mothers were of identical parity and similar age. Primigravid women were enrolled prospectively at 30 weeks gestation, perinatal and neonatal data were collected during pregnancy and following birth, and details of health care resource use were obtained from mothers at 4 and 12 months. Median (range) number of medical problems during the first year tended to be less for IVF infants, 4 (0-41) versus 5 (0-12) (P = 0.07), whilst total number of visits to health care workers was similar for IVF and control infants, 19 (2-47) versus 19 (1-47). IVF infants were more likely to have an excessive number of visits to Early Childhood Health Care Centres [odds ratio (OR; 95% confidence interval, CI) = 2.44 (1.11-5.56)], but less likely to have an excessive number of visits to general medical practitioners [OR = 0.45 (0.22-0.93)] and other health care workers [OR = 0.48 (0.23-0.99)]. These data provide some degree of reassurance about medium-term health outcomes for children conceived using IVF. Although they are more likely to utilize the resources of neonatal intensive care units, IVF infants do not appear to have an increased number of medical problems or to over-utilize health care resources during the remainder of their first year of life.     

Evaluation of the impact of podiatrist care in the primary prevention of foot problems in diabetic subjects

OBJECTIVE: To evaluate the influence of podiatrist activities on the outpatient care of diabetic patients in terms of knowledge of diabetic foot care, self-care, and minor foot problems. RESEARCH DESIGN AND METHODS: There were 733 patients, aged 10-79 years, identified from the national diabetes register. Patients without recent visits to a podiatrist and without an obvious need for foot care were randomized into a podiatric care group (education and primary prevention measures, n = 267) and a control group (written instructions only, n = 263). The patients were examined by an independent study podiatrist at baseline and after 1 year. RESULTS: Patients in the podiatrist group had greater improvement in knowledge of diabetic foot care (P = 0.004) and self-care (P < 0.001) scores compared with control subjects. The prevalence of callosities in regions other than the calcaneal region decreased more (P = 0.009) in the podiatrist group (from 54.5 to 39.5%) than in the control group (from 51.3 to 48.2%), and the size of the callosities decreased more (P < 0.001) in the podiatrist group than in the control group. Reduction in the prevalence of callosities was associated with younger age (< 50 years). CONCLUSIONS: Education and primary preventive measures provided individually by a podiatrist result in significant improvements in knowledge and foot self-care scores and in improvements in the prevalence of some minor foot problems. Long-term studies are needed to evaluate whether the intervention of podiatrists starting at an early phase would lead to a reduction in major foot problems.     

Private health insurance and veterans use of Veterans Affairs care. RATE Project Committee. Rate Alternative Technical Evaluation

OBJECTIVES: This study examined the effect of private health insurance on the use of medical, surgical, psychiatric, and addiction services for patients eligible for publicly supported care. METHODS: The authors assembled administrative databases describing 350,000 noninstitutionalized veterans who had been discharged from a Veterans Affairs (VA) inpatient medicine or surgery bed section during a 1-year period. Patient use of care was followed for 1 year after the index discharge. Patient insurance information came from Medical Care Cost Recovery Billing and Collection files obtained separately from each of 162 VA Medical Centers. Distances between VA and non-VA sources of care were estimated from the Health Care Financing Administration's Hospital Distance File. RESULTS: Insured patients were less likely to seek surgical care but were 12 times (65 years of age and older) and 73 times (63 years of age and younger) more likely to initiate outpatient medical visits than were their counterparts, adjusted for patient demographic, diagnostic, and index facility characteristics. Patients who had private health insurance also were 3.4 (> or = 65) and 2.6 (< or = 64) times less likely to use VA surgical care in response to changes in available surgical staff-to-patient ratios than were their uninsured counterparts. CONCLUSIONS: Private health insurance may substitute (reduce) or complement (increase) the continued use of publicly supported health care services, depending on patient age, care setting, and service type.     

Depressed versus nondepressed young adult tobacco users: Differences in coping style, weight concerns and exercise level.

Undergraduates age 18 to 24 years (n=656) completed questionnaires assessing tobacco use, depressive symptoms, coping responses, weight concerns, and exercise. The majority of participants were female (72%), White/non-Hispanic (95%), and in the 1st or 2nd year of college (80%). Current tobacco users (n=236) had a higher frequency of depression (40%) than never tobacco users (32%; p=.05). Tobacco users classified as depressed (Center for Epidemiological Studies Depression Scale [CES-D] score a 16) reported greater weight concerns and more frequent maladaptive coping in response to negative mood than tobacco users classified as nondepressed (CES-D score     

In situ hybridization with riboprobes: an overview for veterinary pathologists

Although preliminary reports indicate that fatigue is a common symptom of human immunodeficiency virus (HIV) disease, little empirical research has focused on its prevalence or characteristics among patients with acquired immunodeficiency syndrome (AIDS). We assessed the frequency of fatigue and its medical and psychological correlates, in a cross-sectional survey of ambulatory AIDS patients. Ambulatory patients with AIDS who participated in a study of quality life (N = 427) were classified into fatigue/no fatigue groups based on their responses to fatigue items on the Memorial Symptom Assessment Scale (MSAS) and the AIDS physical symptom checklist. Self-report inventories were also administered to assess psychological distress, depressive symptoms, and overall quality of life. Medical information was elicited through clinical interview and review of medical chart. Fifty-four percent of the patients endorsed both of the fatigue items from the MSAS and the AIDS physical symptom checklists, and were classified as having fatigue. Women were significantly more likely to report fatigue than men (chi square = 5.28, df = 1, P < 0.03), and patients reporting homosexual contact as their transmission risk factor were significantly less likely to report fatigue than were patients reporting injection drug use or heterosexual contact (chi square = 5.13, df = 2, P < 0.03). The presence of fatigue was significantly associated with the number of current AIDS-related physical symptoms [t(425) = 8.00, P < 0.0001], current treatment for HIV-related medical disorders (chi square = 12.51, df = 1, P < 0.0001), anemia [t(174) = -2.35, P < 0.02], and pain (chi square = 36.36, df = 1 P < 0.0001). Patients with fatigue also had significantly poorer physical functioning ability [Karnofsky: t(422) = -6.27, P < 0.0001], as well as greater degree of overall psychological distress and lower quality of life [F(5,418) = 23.79, P < 0.0001], as measured by the Brief Symptom Inventory, Beck Depression Inventory, Beck Hopelessness Scale, Functional Living Inventory for Cancer (modified for AIDS), and the MSAS Psychological Distress Subscale. Fatigue is a common symptom in ambulatory AIDS patients and is associated with significant physical and psychological morbidity.     

The changing pattern of prenatal care utilization in the United States, 1981-1995, using different prenatal care indices

CONTEXT: Two measures traditionally used to examine adequacy of prenatal care indicate that prenatal care utilization remained unchanged through the 1980s and only began to rise slightly in the 1990s. In recent years, new measures have been developed that include a category for women who receive more than the recommended amount of care (intensive utilization). OBJECTIVE: To compare the older and newer indices in the monitoring of prenatal care trends in the United States from 1981 to 1995, for the overall population and for selected subpopulations. Second, to examine factors associated with receiving intensive utilization. DESIGN: Cross-sectional and trend analysis of national birth records. SETTING: The United States. SUBJECTS: All live births between 1981 and 1995 (N=54 million). MAIN OUTCOME MEASURES: Trends in prenatal care utilization, according to 4 indices (the older indices: the Institute of Medicine Index and the trimester that care began, and the newer indices: the R-GINDEX and the Adequacy of Prenatal Care Utilization Index). Multiple logistic regression was used to assess the risk of intensive prenatal care use in 1981 and 1995. RESULTS: The newer indices showed a steadily increasing trend toward more prenatal care use throughout the study period (R-GINDEX, intensive or adequate use, 32.7% in 1981 to 47.1 % in 1995; the Adequacy of Prenatal Care Utilization Index, intensive use, 18.4% in 1981 to 28.8% in 1995), especially for intensive utilization. Women having a multiple birth were much more likely to have had intensive utilization in 1995 compared with 1981 (R-GINDEX, 22.8% vs 8.5%). Teenagers were more likely to begin care later than adults, but similar proportions of teens and adults had intensive utilization. Intensive use among low-risk women also increased steadily each year. Factors associated with a greater likelihood of receiving intensive use in 1981 and 1995 were having a multiple birth, primiparity, being married, and maternal age of 35 years or older. CONCLUSIONS: The proportion of women who began care early and received at least the recommended number of visits increased between 1981 and 1995. This change was undetected by more traditional prenatal care indices. These increases have cost and practice implications and suggest a paradox since previous studies have shown that rates of preterm delivery and low birth weight did not improve during this time.     

Community patterns of psychiatric disorders after the Exxon Valdez oil spill

OBJECTIVE: This study examined the relationship between exposure to the Exxon Valdez oil spill and subsequent cleanup efforts and the prevalence of generalized anxiety disorder, posttraumatic stress disorder (PTSD), and depressive symptoms in 13 Alaska communities. METHOD: A community survey of 599 men and women was conducted approximately 1 year after the spill occurred. Questions from the National Institute of Mental Health Diagnostic Interview Schedule were used to assess symptoms of generalized anxiety disorder and PTSD. The Center for Epidemiologic Studies Depression (CES-D) Scale was used to assess levels of depressive symptoms. RESULTS: The post-spill (i.e., 1-year) prevalence of generalized anxiety disorder and PTSD for the study communities with all degrees of exposure was 20.2% and 9.4%, respectively. The prevalence of respondents with CES-D Scale scores above 16 and 18 was 16.6% and 14.2%, respectively. When compared with the unexposed group, members of the high-exposure group were 3.6 times as likely to have generalized anxiety disorder, 2.9 times as likely to have PTSD, 1.8 times as likely to have a CES-D Scale score of 16 and above, and 2.1 times as likely to have a CES-D Scale score of 18 and above. Women exposed to this event were particularly vulnerable to these conditions, and Alaska Natives were particularly vulnerable to depressive symptoms after the oil spill. CONCLUSIONS: The results suggest that the oil spill's impact on the psychosocial environment was as significant as its impact on the physical environment. The Exxon Valdez experience suggests a number of implications for the mental health needs of disaster victims, particularly in primary care settings.