Family Practice Advance Access originally published online on February 27, 2008
Family Practice 2008 25(2):92-97; doi:10.1093/fampra/cmn007
Infrequent attendance in general practice after a major disaster: a problem? A longitudinal study using medical records and self-reported distress and functioning
a Netherlands Institute for Health Services Research, 3500 BN Utrecht
b Institute for Psychotrauma, van Heemstraweg West 5, 5301 PA Zaltbommel, The Netherlands
Correspondence to Gé A Donker, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN Utrecht, The Netherlands; Email: g.donker{at}nivel.nl
Received 5 July 2007; Revised 25 December 2007; Accepted 18 January 2008.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Objective. To assess the characteristics and implications for care of infrequent attendance in general practice in the aftermath of disaster.
Methods. A study of the content of electronic medical records (EMRs) in pre- and post-disaster periods linked to an enquiry using self-reported questionnaires administered 3 weeks and 18 months post-disaster. The disaster (explosion of a firework depot in Enschede, The Netherlands) caused 23 deaths, about 1000 people injured and 1200 people who had to relocate. Sample included survivors (N = 922) who participated in two surveys and whose data could be linked to EMRs of GPs. A comparison of reported morbidity in ‘infrequent’ (a maximum of three times in men and four times in women in the first two post-disaster years) and ‘more frequent attenders’ (frequency determined post-disaster) in general practice examined in relation to health status (measured by diagnoses in EMRs, symptom checklist and quality of life instrument) was the main outcome measure.
Results. Infrequent attenders reported approximately three times as few contacts as more frequent attenders in the pre-disaster year (P < 0.001). Multivariate logistic regression analyses revealed that infrequent attenders were likely to be younger, less depressed, have better subjective health and physical functioning and exhibited more hostile behaviour (measured by questionnaire). Infrequent attenders were less often personally bereaved by the disaster, but more often relocated, and had a lower prevalence of psychological problems pre- and post-disaster although this increased stronger (by 10-fold).
Conclusions. Both groups showed the same type of psychological problems post-disaster, but differed in the frequency of contacting the GP.
Keywords. Attendance, disaster, general practice, mental health, symptom checklist.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Little is known about predictors of health care seeking behaviour and even less is known about these predictors after disasters.1,2 From trauma literature, it is known that increased mental health service use is related to being female, having a previous trauma history and having a post-traumatic stress disorder (PTSD) diagnosis.3 Some studies have shown that post-disaster psychological symptoms are related to the increased use of post-disaster mental health services.4,5 Disaster research is often focused on victims with PTSD treated in mental health services.4–8 Fortunately, most survivors do not develop such serious conditions and do not receive specialized care. It is important to understand the natural history of symptoms and disorders in survivors, especially in those seeking management advice from their GPs.9–15 Some survivors attend infrequently after a disaster, but it is unknown if they were less exposed to the disaster or if other factors are more important. The present study explored which personal characteristics and exposure variables contributed to the prediction of post-disaster health care utilization, and whether psychological distress did so. The disaster studied involved an explosion in a firework depot within a residential area (Enschede, The Netherlands; May 13, 2000) which caused 23 immediate deaths, approximately 1000 injured and the relocation of 1200 people due to serious damage to their houses.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Design
This study combined information from two data sources: (i) a longitudinal investigation of diagnostic entries in the patient electronic medical records (EMRs) maintained by their GPs; and (b) self-completed questionnaires among affected residents and rescue workers administered 3 weeks (T1) and 18 months (T2) post-disaster.9,16,17
Recording by GPs in EMRs, established 1 year pre-disaster, was maintained throughout and for the purpose of this study was limited to the first 2 years post-disaster. Survivors on the lists of these GPs were identified from self-reporting and the zip code of their home address at the time of the disaster.9,16 In the monitoring study, 73% of all GPs in the city of Enschede participated and together they covered 89% of the survivors, identified by both sources. Patients were informed about the participation of their GP in this monitoring study and could object to the use of their data (nobody did so). Data collection was performed in accordance with the privacy protection procedures of the Dutch Data Protection Authority. In the Dutch health care system, each citizen is registered on the list of only one GP, who must first be consulted if referral to secondary care is needed.
Data were collected using self-reported questionnaires from adult survivors (18 years and older).17,18 The second questionnaire was broadly similar to the first but excluded questions on immediate injuries. The questionnaire sampled population consisted of 2851 survivors who provided data at T1 and T2. The results of the enquiry at T2, 18 months post-disaster, were considered to reflect patients' coping process to a certain extend. Ethical approval for the study was given by the Medical Ethical Committee of the Netherlands Organization for Applied Scientific Research: all respondents signed an informed consent before participation. There were 922 persons for whom we obtained monitoring data from the EMR and who also completed questionnaires at T1 and T2. Compared with the survivors of the EMR monitoring study who did not complete questionnaires (N = 1929), they were older (43.2 versus 37.6 years, P < 0.001) and more were female (54.4% versus 46.6%, P < 0.001) but they were similarly distributed with regard to health insurance.
Instruments
The general practice EMRs included information on gender, age, type of health insurance and clinical data on patient symptoms, examination findings, diagnoses and interventions registered in accordance with the International Classification of Primary Care, which is compatible with Diagnostic Statistical Manual of Mental Disorders (DSM-IV).19,20 Private health insurance indicates a higher income level and was used as an indicator for social economic status (SES).
The self-reported questionnaires included marital status and the highest educational level achieved. Persons were classified injured or not, relocated or not (due to serious damage to their house) and bereaved or not (loss of relative or friend). Psychological distress was measured using the Dutch adaptation of the Symptom Checklist-90-R (SCL-90-R) at T1 and T2.21,22 In the present study, results for these six subscales measured at T2 were used (anxiety, phobic anxiety, depression, somatization, hostility and sleep disturbance). A five-point Likert scale (1 = not at all and 5 = very much) was used to measure the severity of these symptoms in the preceding week. The validity and reliability of the Dutch SCL-90-R has proven to be satisfactory.23
General health status was measured using a Dutch translation of the RAND36 Health Survey which included eight subscales.24 An additional scale was used at T2 measuring reported change in health (one item). Scale scores were transformed to a 0–100 scale with higher scores indicating higher levels of functioning or well-being.
Data analyses
The definition of infrequent attendance was based on less than four consultations in the 2 years post-disaster in males and less than five consultations in females. Contacts related to pregnancy, delivery and preventive medicine (influenza vaccination and cervical smears) were excluded. Infrequent attenders also included non-attenders. The choice to use different criteria for men and women to define low attendance in general practice was based on Dutch reference data indicating that women have a higher average attendance than men, even after excluding attendance related to pregnancy, delivery and cervical smears.25
For descriptive purposes, we compared the infrequent and the more frequent attenders on the 15 most prevalent clusters of diseases, pre- and post-disaster stratified by gender.
Multiple logistic regression analyses were performed to examine predictors for attendance frequency. The independent variables (entered in one step) included socio-demographic characteristics (i.e. gender, age, insurance type, marital status, education level and immigrant status), exposure variables (injury, relocation and bereavement) and health variables of SCL-90 and RAND36 (as continuous variables per scale). In this way, we explored which personal characteristics and exposure variables contributed to the prediction of post-disaster health care utilization and whether psychological distress did so.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Demographics and morbidity
The ‘infrequent attenders’ reported approximately three times as few contacts as the ‘more frequent attenders’ in the pre-disaster year (P < 0.001, Table1). Infrequent attenders contacted their GPs twice as frequently in the first 2 years post-disaster as compared with their pre-disaster equivalent, but the pre- and post-disaster difference was even greater in more frequent attenders (by a factor 2.6, P < 0.001). In addition, infrequent attenders had less injuries and were less likely to be bereaved (P < 0.01 for both comparisons) but experienced more damage to the house (P < 0.01).
|
Infrequent attenders were younger and had a higher SES and education level (P < 0.001 for all comparisons).
Consistent with the higher attendance rate pre-disaster, the prevalence of disease in all clusters was also higher pre-disaster in the more frequent attenders (Table 2). Post-disaster, the prevalence of psychological problems presented at general practice was higher than all other disease clusters examined in both groups showing a stronger increase (by 10-fold) in infrequent attenders. The greatest difference pre-disaster between the two groups was in the prevalence of hypertension (less in infrequent attenders). Post-disaster, the diagnosis ‘acute stress’ was most prevalent in both groups, although the prevalence in infrequent attenders was less than in more frequent attenders. Other psychological symptoms like insomnia and depression were less prevalent in infrequent attenders pre- and post-disaster.
|
Prevalence of psychological distress and general health status
Mean SCL-90 scores in each of the subscales were lower in male and female infrequent attenders indicating less psychological distress (P < 0.001 for each comparison between more frequent and infrequent attenders, Table 3). Mean RAND36 scores in each of the subscales were higher in male and female infrequent attenders indicating better social, physical and emotional functioning or well-being (P < 0.001 for each comparison, Table 4).
|
|
Multiple logistic regression analysis revealed that infrequent attenders were likely to be younger, more hostile and more likely to have been relocated (Table 5). In addition, they showed better self-reported health and physical functioning, were less likely to be bereaved or to feel depressed (as measured by questionnaire).
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
This is the first study examining consulting behaviour following a disaster in which pre-disaster health-related information could be examined efficiently. We concentrated on the difference between infrequent and more frequent attenders in general practice among disaster survivors. The latter group included patients with an average attendance rate in general practice. Infrequent attenders also had a low attendance pre-disaster and experienced better self-reported health and physical functioning post-disaster. They tended to be younger, less often experienced bereavement and feelings of depression. Bereavement and relocation have been associated with increased use of primary care in disaster literature, findings which were not confirmed for relocated survivors in this study.2,9 The lower attendance rate of relocated survivors in our study could not be attributed to loss to follow-up as the study cohort only included survivors on GP lists for the total study period. Low education and marital status (being single), described as predictors of increased primary care utilization in a study not related to disasters, did predict increased attendance in univariate, but not in multivariate analyses in our study.26 A surprising finding was the greater hostility of infrequent attenders in multivariate analyses in contrast to lower hostility scores in univariate analyses. Adjustment for several variables in the multivariate analyses may have caused this outcome. No literature was found to support greater hostility in infrequent attenders, so more research is necessary to explore this issue.
Research on the World Trade Center terrorist attack has shown that the psychological effects were not limited to those directly exposed. The degree of response was not predicted simply by objective measures of exposure to or loss from the trauma.27,28 When assessing the effects of disaster exposure, controlling for pre-disaster symptoms provides the best research design. The present study combined medical records and post-disaster surveys, offering a unique opportunity to study these effects. The lack of a control group of unexposed persons in the questionnaire-based surveys is a small limitation. Although a control group was available for the GP registration and the survey, these data were not collected in identical populations and could therefore not be matched. Nevertheless, we believe this study has resulted in the development of robust methods for studying the effects of a disaster.
Another methodological issue to be considered is the representativeness of the study sample. Although the study represents a large number of survivors, it is still a minority of the total number of survivors, namely those who participated in two surveys and who were included in the general practice sample. The demographic determinants of better response on the surveys were female sex, being middle aged or older, having a higher educational level and being native Dutch; these determinants of response were not different between the immigrant population and the native Dutch.17 The prevalence of health problems appeared to be hardly affected by the non-response rate when the statistical technique of multiple imputation was applied.29 More in-depth study of health- and disaster-related characteristics in relation to selective participation did not reveal selection bias in study outcome results post-disaster.30 The group of survivors included in the general practice study represented 89% of the disaster survivors. Compared to non-participating survivors, those who were forced to relocate were slightly over-represented in the study, suggesting some selection bias towards severely affected survivors. Furthermore, women and the elderly were slightly over-represented in our study, but the socio-economic indices used in this study did not differ between participating and non-participating survivors.
Summarizing, the profile of infrequent attenders shows a group of survivors with less psychological and somatic health problems pre-disaster, younger, less hit by the disaster in terms of loss of relatives and friends, but more often relocated. Both groups showed acute distress as the most prevalent symptom post-disaster. The difference between the groups does not reflect a large difference in type of psychological morbidity post-disaster, but a difference in contact frequency to handle these problems.
|
Declaration |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Funding: Ministry of Public Health, Welfare and Sports in The Netherlands.
Ethical approval: Medical Ethical Committee of the Netherlands Organisation of Applied Scientific Research.
Conflict of interest: None.
|
Acknowledgments |
|---|
We gratefully acknowledge the contribution of the participating family practitioners.
|
Notes |
|---|
Donker GA, van der Velden PG, Kerssens JJ and Yzermans CJ. Infrequent attendance in general practice after a major disaster: a problem? A longitudinal study using medical records and self-reported distress and functioning. Family Practice 2008; 25: 92–97.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
1 Adamson J, Ben-Shlomo Y, Charturvedi N, Donovan J. Ethnicity, socio-economic position and gender—do they affect reported health-care seeking behaviour? Soc Sci Med (2003) 57:895–904.[CrossRef][Web of Science][Medline]
2 Dorn T, Yzermans CJ, Kerssens JJ, Spreeuwenberg PMM, van der Zee J. Disaster and subsequent health care utilization—a longitudinal study among victims, their family members and controls. Med Care (2006) 44:581–589.[CrossRef][Web of Science][Medline]
3 Elhai JD, North TC, Fruch BC. Health service use predictors among trauma survivors: a critical review. Psychol Serv (2005) 2:3–19.[CrossRef]
4 Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981–2001. Psychiatry (2002) 65:207–239.[Web of Science][Medline]
5 van der Velden PG, Grievink L, Kleber RJ, et al. Post disaster mental health problems and the utilization of mental health services: a four-year longitudinal comparative study. Adm Policy Ment Health Serv Res (2006) 33:279–288.[CrossRef]
6 North C, Nixon S, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA (1999) 282:755–762.
7 Nolen-Hoeksema S, Morrow JA. A prospective study of depression and posttraumatic stress symptoms after a natural disaster: the 1989 Loma Prieta earthquake. J Pers Soc Psychol (1991) 61:115–121.[CrossRef][Web of Science][Medline]
8 Ursano R, Fullerton C, Kao T, Bhartiy V. Longitudinal assessment of posttraumatic stress disorder and depression after exposure to traumatic death. J Nerv Ment Dis (1995) 183:36–42.[Web of Science][Medline]
9 Yzermans CJ, Donker GA, Kerssens JJ, Dirkzwager AJE, Soeteman RJH, ten Veen PMH. Health problems of victims before and after disaster: a longitudinal study in general practice. Int J Epidemiol (2005) 34:810–819.
10 den Ouden DJ, Dirkzwager AJE, Yzermans CJ. Health problems presented in general practice by survivors before and after a fireworks disaster: associations with mental health care. Scand J Prim Health Care (2005) 23:137–141.[CrossRef][Medline]
11 Dirkzwager AJE, Grievink L, van der Velden PG, Yzermans CJ. Risk factors for psychological and physical health problems after a man-made disaster. Br J Psychiatry (2006) 189:144–149.
12 Norris FH, Friedman MJ, Watson PJ. 60,000 disaster victims speak: Part II. Summary and implications of the Disaster Mental Health Research. Psychiatry (2002) 65:240–260.[Web of Science][Medline]
13 Reijneveld SA, Crone MR, Verhulst FC, Verloove-Vanhorick SP. The effect of a severe disaster on the mental health of adolescents: a controlled study. Lancet (2003) 362:691–696.[CrossRef][Web of Science][Medline]
14 Alexander D. Stress among police body handlers: a long-term follow-up. Br J Psychiatry (1993) 163:806–808.
15 Dirkzwager AJE, Yzermans CJ, Kessels FJM. Psychological, musculoskeletal problems and sickness absence before and after involvement in a disaster: a longitudinal study among rescue workers. Occup Environ Med (2004) 61:870–872.
16 Roorda J, van Stiphout WA, Huijsman-Rubingh R. Post-disaster health effects: strategies for investigation and data-collection. Experiences from the Enschede firework disaster. J Epidemiol Community Health (2004) 58:982–987.
17 van Kamp I, van der Velden PG, Stellato RK, et al. Physical and mental health shortly after a disaster: first results from the Enschede firework disaster study. Eur J Public Health (2006) 16:253–259.[Medline]
18 van der Velden PG, Kleber RJ, Christiaanse B, et al. The independent predictive value of peritraumatic dissociation for postdisaster intrusions, avoidance reactions, and PTSD symptom severity: a 4-year prospective study. J Trauma Stress (2006) 19:493–506.[CrossRef][Medline]
19 Lamberts H, Woods M. International Classification of Primary Care (1987) Oxford: Oxford University Press.
20 Kaplan M, Sadock BJ. Synopsis of Psychiatry. Behavioral Sciences/Clinical Psychiatry. Williams & Wilkins 1998, 8th edn, Baltimore, MD.
21 Derogatis LR, Cleary PA. Confirmation of the dimensional structure of the SCL-90: a study in construct validity. J Clin Psychol (1977) 33:981–989.[CrossRef][Web of Science]
22 Arrindell WA, Ettema JHM. SCL-90 Handleiding (1986) Lisse, The Netherlands: Swets & Zeitlinger B.V.
23 Grievink L, van der Velden PG, Christiaanse B, et al. Gezondheid getroffenen vier jaar na de vuurwerkramp Enschede (2004) Bilthoven: RIVM.
24 Ware JE, Sherbourne CD. The MOS 36-item short-form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care (1992) 30:473–481.[Web of Science][Medline]
25 Cardol M, van Dijk L, de Jong DJ, de Bakker DH, Westert GP. Huisartsenzorg: wat doet de poortwachter? Tweede Nationale Studie naar ziekten en verrichtingen in de huisartspraktijk. [Second National Survey] (2004) Utrecht, The Netherlands: Nivel.
26 Vedsted P, Olesen F. Social environment and frequent attendance in general practice. Br J Gen Pract (2005) 55:510–515.[Medline]
27 Cohen Silver R, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V. Nationwide longitudinal study of psychological responses to September 11. JAMA (2002) 288:1235–1244.
28 Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med (2001) 345:1507–1512.
29 Stellato RK, Grievink L, Lebret E. Effects of dropout and item non-response in the follow-up of the victims of the Enschede firework disaster. Epidemiology (2003) 14:S5.
30 Grievink L, van der Velden P, Yzermans CJ, Roorda J, Stellato RK. The importance of estimating selection bias on prevalence estimates shortly after disaster. Ann Epidemiol (2006) 16:782–788.[CrossRef][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||