Utilization of ambulatory medical care by women: United States, 1997-98.

OBJECTIVES: This report presents national estimates of the volume and characteristics of ambulatory medical care provided to women 15 years of age and over in the United States. Included is information on the characteristics of the patients, providers, and visits. A section on comparative differences in use by sex is also included. SOURCE OF DATA: This report is based on an analysis of data from the 1997 and 1998 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 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: Approximately 500 million visits were made by women to ambulatory medical care providers annually in 1997 and 1998, representing an age-adjusted rate of 4.6 visits per woman per year. The rate of ambulatory medical care visits increased with age (3.8 per woman 15-44 years of age, 4.7 visits per woman 45-64 years of age, and 7.1 visits per woman 65 years of age and over). Six out of ten visits to office-based physicians and hospital outpatient departments had no mention of therapeutic or preventive services provided. Nonnarcotic analgesics, antidepressant, and estrogen/progestin were the three most common classifications of medications mentioned. Compared with visits by men, visits by women (with nonpregnancy-related diagnoses) were more frequent at younger ages and more likely to be to primary care physicians and outpatient departments.

Racial differences in hormone replacement therapy prescriptions.

OBJECTIVE: To examine racial differences in hormone replacement therapy (HRT) use by analyzing the relative risks and rates of HRT prescriptions for black and white women. METHODS: Data on visits to hospital outpatient departments and office-based physicians by black and white women aged 45-64 years were obtained from 25,203 visits sampled in the 1993-1995 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. The relative effect of race on the provision of an HRT prescription at an ambulatory visit was estimated by controlling confounders using logistic regression. Population-based rates of physician visits and visits with HRT prescriptions were also calculated to address issues involving access to care. RESULTS: Approximately 98,787,000 annual visits were made by black and white women 45-64 years of age, 9.2% of which involved prescriptions for HRT. The percentage of visits by black women in which prescriptions for HRT were reported (4.5%) was roughly half that of white women (9.7%). The association persisted after controlling for type of physician, practice type, geographic region, payment source, and non-HRT prescription(s) (odds ratio 2.1; 95% confidence interval 1.5, 2.9). The rate of ambulatory care among black women (3.82 visits per year per woman) was virtually identical to that of white women (3.94 visits per year), whereas the rate of visits with HRT prescriptions for white women was twice as high as for black women (0.38 and 0.17 visits per year, respectively). CONCLUSION: Apparent racial differences in HRT use persist after controlling for physician and visit factors not explored in previous studies.

Estrogen replacement therapy and incidence of self-reported physician-diagnosed arthritis.

BACKGROUND: This longitudinal study examined the association between use of estrogen replacement therapy and incidence of self-reported, physician-diagnosed arthritis. METHODS: Data of 2,416 postmenopausal women who participated in the National Health and Nutrition Examination Survey Epidemiological Follow-Up Study were used in this study. Women, free of self-reported arthritis at entry into study and for 3 years thereafter, were questioned about use of estrogen and physician-diagnosed arthritis at each of the follow-up waves of study. Proportional hazard regression models were used for the analysis. RESULTS: Use of ERT was found to be associated with higher risk of incident arthritis, after adjusting for potential confounders (RR = 1.61, CI 1.37-1.89). Whenever use of ERT was replaced by duration of use in the regression model, ERT users for a year or less significantly increased their risk of incident arthritis (RR = 1.37, CI 1.07-1.74). The risk increased by 30 and 96% with hormone use for 1 to 4 and 4 to 10 years, respectively, and by 104% with hormone use for 10 or more years. CONCLUSION: Results suggest that users of ERT were at higher risk of developing arthritis and the longer the use of the hormone, the higher the risk.

Hormone replacement therapy and breast cancer risk in a nationally representative cohort.

BACKGROUND: The relative risk of breast cancer associated with the use of postmenopausal hormone replacement therapy (HRT) continues to be debated. We used a nationally representative cohort to study the issue. METHODS: This analysis utilized data from the NHANES I Epidemiologic Follow-up Study. Subjects were interviewed in 1971 through 1974 and four waves of follow-up interviews were conducted through 1992. Survival analysis of 5,761 postmenopausal women provided estimates of the relative risk of breast cancer in users of HRT when compared with non-users, controlling for potential confounders. RESULTS: There were 219 incident cases of breast cancer in 73,253 person-years of follow-up. The incidence rate was 326 per 100,000 person-years in women who had never used HRT and 255 per 100,000 in women who had ever used HRT. There was no statistically significant association between the HRT use and subsequent development of breast cancer: relative risk (RR) = 0.8, 95% confidence interval 0.6, 1.1. There was no trend in RR by length of HRT use: less than 3 years HRT use, RR = 0.9; 3 to 9 years , RR = 0.5; 10 or more years, RR = 0.8. CONCLUSIONS: This study, based on a nationally representative cohort followed for up to 22 years, failed to find an increased risk of breast cancer associated with the use of HRT. It provides further evidence that if there is an increased risk of breast cancer associated with HRT use, this risk is small.

Visits to emergency departments for gynecologic disorders in the United States, 1992-1994.

OBJECTIVE: To assess rates of visits to emergency departments for gynecologic disorders among women of reproductive age in the United States. METHODS: Data from the National Hospital Ambulatory Medical Care Survey for 1992-1994 were analyzed to determine rates of visits to emergency departments among women, ages 15-44 years. Average annual rates per 1000 women were calculated using age, race, and region-specific population estimates. Rate ratios were used to compare rates among subgroups. RESULTS: Approximately 1.4 million gynecologic visits were made to emergency departments annually, for an average annual rate of 24.3 visits per 1000 women, ages 15-44 years (95% confidence interval [CI] 22.0, 26.6). The most frequent diagnoses were pelvic inflammatory disease (average annual rate 5.8, 95% CI 5.0, 6.6), lower genital tract infections including sexually transmitted diseases (average annual rate 5.7, 95% CI 4.8, 6.6), and menstrual disorders (average annual rate 2.9, 95% CI 2.3, 3.5). Nearly half of all gynecologic visits resulted in diagnoses of genital tract infections. Younger women (ages 15-24 years) were 2.3 (95% CI 2.0, 2.6) times as likely as older women (ages 25-44 years), and black women were 3.6 (95% CI 2.9, 4.3) times as likely as white women, to visit emergency departments for gynecologic disorders. Rate ratios for genital tract infections were 10-20 times higher for younger black women than for older, white women. CONCLUSION: Almost half of gynecologic visits to emergency departments were related to genital tract infections, which largely are preventable.

Male and female occupation in relation to miscarriage and preterm delivery in central North Carolina.

PURPOSE: This study was undertaken to evaluate the role of parental occupation in miscarriage and preterm delivery. Previous studies raise the possibility that both male and female exposures could affect pregnancy. METHODS: Data from a population-based study of miscarriage and preterm delivery in central North Carolina were used to examine potential associations with male and female occupation. Medically treated miscarriage cases (n = 418), preterm delivery cases identified through hospital record review (n = 582), and term, normal birth weight controls (n = 787) were sought for telephone interview. The interview included information on jobs the woman held before and during the pregnancy, reports of her partner's job around the time of pregnancy, and information on potential confounding factors. RESULTS: Female employment overall, or in specific jobs, around the time of conception or early pregnancy was not associated with the risk of miscarriage, whereas working during pregnancy, especially in the seventh month, was inversely associated with risk of preterm delivery. Male employment in several industrial occupations was weakly associated with miscarriage (adjusted odds ratios (OR) of 1.6 to 1.8), and somewhat more strongly associated with preterm delivery, particularly for chemists and sheet metal workers (adjusted OR over 3). Restriction to married men strengthened the associations. CONCLUSIONS: Our results are limited by nonresponse, imprecision, incomplete identification of miscarriages, and lack of detailed occupational exposure information. Nonetheless, we found greater support for further examination of male compared to female jobs in relation to pregnancy outcome.

Epidemiology of hysterectomy in the United States: demographic and reproductive factors in a nationally representative sample.

We describe the epidemiology of hysterectomy, overall as well as for specific indications. Data were obtained from the Epidemiologic Follow-up to the First National Health and Nutrition Examination Survey, a nationally representative cohort followed prospectively from the mid-1970s through 1992. Black and white women 25-49 years of age, interviewed during follow-up, were included in the analyses. The probability of undergoing a hysterectomy was estimated by demographic and reproductive factors. Hysterectomy as confirmed by hospital records was our main outcome measure. We found that women who had completed 9-11 years of education were more likely to have undergone a hysterectomy than were women with either more or less education. Women who had completed 9-11 years of education were also more likely to have had a hysterectomy because of menstrual problems. Three or more miscarriages, especially if caused by uterine prolapse, increased the probability of hysterectomy. Having had no live births decreased the probability of hysterectomy for menstrual disorders and uterine prolapse, but women who had their first child before age 20 were at increased risk of hysterectomy because of endometriosis. Hysterectomy appears to be associated with low education, high parity, and a history of multiple miscarriages. The influence of these factors varies depending on the primary indication for the hysterectomy.

Use of postmenopausal hormone replacement therapy: estimates from a nationally representative cohort study.

The objective of this study was to describe trends in the use of hormone replacement therapy (HRT) in the United States by demographic, life-style, and heart disease risk factors. Data were obtained from the Epidemiologic Followup Study to the First National Health and Nutrition Examination Survey, a nationally representative cohort followed from the mid-1970s until 1992. A total of 5,602 women who had become menopausal by their last follow-up interview were included. An estimated 45% of the cohort of menopausal US women 25-74 years of age in the early 1970s used HRT for at least one month and 20% continued use for 5 or more years. Between 1987 and 1992, as the younger members of the cohort became menopausal, the proportion of this cohort who had ever used HRT and used it for 5 or more years increased by 32% and 54%, respectively. A higher probability of HRT use was found among women who were white, who were more highly educated, and who lived in the West, or who had experienced a surgical menopause. Women who were overweight or who abstained from alcohol were less likely to use HRT. These data support the hypothesis that HRT use is associated with sociodemographic factors, and that women tend to discontinue use within several years.

Employment, job strain, and preterm delivery among women in North Carolina.

OBJECTIVES: A population-based case-control study was conducted in central North Carolina to assess the relationship between occupational stress and preterm delivery. METHODS: Four hundred twenty-one women delivering infants before 37 weeks' gestation and 612 women delivering infants at term were interviewed a median of 6 months after delivery. Exposure information was collected for all jobs held for at least 1 month during pregnancy. RESULTS: Work in a "high strain" job (i.e., high demand and low control) was not associated with increased risk of preterm delivery compared with work in "low strain" jobs (all other combinations of job demand and control). Narrowing the exposure window to the third trimester did not modify the results. However, women who worked at a high-strain job full-time (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 0.9, 2.0) or for 30 or more weeks (OR = 1.4, CI = 1.0, 2.2) had a modestly increased risk. Several analyses suggested that Black women were at greater risk from job strain than White women. CONCLUSIONS: This study suggests that chronic exposure during pregnancy to work characterized by high demand and low control may be modestly associated with preterm delivery.

Male and female employment in the textile industry in relation to miscarriage and preterm delivery.

To address potential reproductive hazards in textile manufacturing, we conducted a community-based case-control study in central North Carolina. Miscarriage cases were identified from medical records (280 interviewed cases): preterm delivery cases and term, normal birth weight controls (454 and 605, respectively) were identified from area hospitals. Exposures were based on job title, an interview concerning textile-related exposures, expert imputation of exposure based on job titles and interviews, and self-reported exposures by women. Relative to women and men working in nonhazardous occupations, workers in the textile industry were not at increased risk of miscarriage or preterm delivery, with the possible exception of preterm delivery among women and men employed in sectors other than knitting and yarn mills and men employed in yarn mills. Inferred exposures to specific agents were also not associated with adverse pregnancy outcome. Subject to uncertainty in exposure assessment and nonresponse, these data indicate an absence of adverse effects of the textile workplace environment on these pregnancy outcomes.

Movement patterns of persons with HIV receiving treatment in public clinics in the Southern Health Region, Puerto Rico.

PIP: A survey conducted among 187 HIV-infected patients from publicly supported HIV clinics in the Puerto Rican Southern Health Region (SHR) failed to substantiate health planners' concern that this group travels frequently to the US to receive medical services. Respondents were questioned about all places of residence and all sites of HIV treatment in the past 12 months. Movement was defined as being anywhere outside of the SHR for 2 weeks or longer. 7% of the sample had moved at least once in the past year; 4% had moved outside the SHR but within Puerto Rico, while 3% had been in the continental US. Compared to the heterosexual risk group, intravenous drug users and men who have sex with men were 7-8 times more likely to have moved. The attainment of at least a high school education was also significantly and independently associated with increased probability of movement. Medical care was not identified by any of these respondents as the primary reason for travel. 58% indicated they were in their current place of residence to be near family, friends, and relatives. Both the small sample size and the low socioeconomic status of respondents may have limited the ability of this study to identify the so-called "air bridge," however.^ieng

Long-term survival after coronary heart disease. Comparisons between men and women in a national sample.

This study examined the sex differential in long-term survival after incident coronary heart disease (CHD) in the Epidemiologic Followup Study to the First National Health and Nutrition Examination Survey. This cohort was first contacted in 1971 to 1975 with follow-up through 1987. Of the 1407 white participants for whom CHD was identified at some point during the study, 56% of men and 46% of women died during the follow-up period. After adjustment for age at incidence, traditional heart disease risk factors, and initial coronary disease diagnosis, the relative risk of death among women compared to men was 0.70. Women's survival advantage after myocardial infarction was 0.81. Women who had ever taken post-menopausal estrogens were most likely to survive after CHD or myocardial infarction compared to men (relative risks [RRs] = 0.42 and 0.57, respectively), although women who did not take estrogen were also significantly more likely than men to survive after CHD (RR = 0.79) but not after myocardial infarction (RR = 0.88).

Hysterectomy use: the correspondence between self-reports and hospital records.

Studies of the relationship between hysterectomy use and sociodemographic factors tend to use self-reported data. In the current study, data were collected from a representative sample of US women who have been prospectively followed since 1971. Hysterectomy status was obtained by self-report and from hospital records. Although these two measures of hysterectomy were highly related, more women reported hysterectomy than could be confirmed by hospital records. The two measures showed similar associations between several obstetric and demographic characteristics and hysterectomy status, suggesting that the use of self-reported hysterectomy data does not bias analyses of potentially associated factors.

Medically treated miscarriage in Alamance County, North Carolina, 1988-1991.

The authors attempted to identify all medically treated miscarriages in Alamance County, North Carolina, between September 1988 and August 1991. Clinical and demographic characteristics of the cases were evaluated, and risks were calculated in relation to total pregnancies, including induced abortions. Miscarriage cases usually had positive pregnancy tests, and a sizable proportion (66% of whites, 72% of blacks) had a pathology report indicating the presence of a conceptus. Nineteen percent of the cases were identified in hospitals, a more common source for women who were unmarried, young, of low education, and had pregnancies of advanced gestational age. The risk of medically treated miscarriage was 7.7% among whites and 5.5% among blacks, with higher risks among older women. The lower risk among blacks, especially those with lower levels of education, suggests underascertainment, possibly resulting from a failure to seek treatment.

Differences between black and white women in the use of prenatal care technologies.

OBJECTIVE: The purpose of this study was to determine whether the content of prenatal care received by black and white women in the United States differs, as measured by the use of amniocentesis, ultrasonography, and tocolysis. STUDY DESIGN: This study uses data from birth certificates issued for births occurring in the United States in 1990. Multivariate analyses were used to calculate the relative risk of receipt of each technology by black women compared with white women. RESULTS: Amniocentesis was used substantially less frequently by black women (relative risk 0.6), whereas ultrasonography was received by black women slightly less frequently than white women (relative risk 0.9). Tocolysis used varied by plurality. Black women with singleton births were slightly more likely to receive tocolysis than were white women (relative risk 1.1), although the risk of idiopathic preterm delivery is estimated to be three times higher in black women. Black women with multiple births received tocolysis two thirds as often as white women. CONCLUSIONS: These results suggest that differences exist in the content of prenatal care received by black and white women in the United States. This finding should be followed up with more detailed studies to identify its cause and possible interventions.

Active morbidity surveillance after Hurricane Andrew--Florida, 1992.

OBJECTIVE: To describe the health status of and to detect disease outbreaks in the population affected by Hurricane Andrew in south Dade County, Florida. DESIGN: The Florida Department of Health and Rehabilitative Services and the US Army conducted active surveillance for gastrointestinal illness, respiratory illness, injury, and other index conditions by monitoring civilian and service member visits to care sites (civilian and military free care sites and hospital emergency departments) from August 30 (1 week after the hurricane's landfall) through September 30, 1992. SETTING: South Dade County, Florida. MAIN OUTCOME MEASURES: Proportional morbidity: the number of daily visits for each index condition divided by the total number of visits, expressed as a percentage. Morbidity rate: the total number of daily visits by service members divided by the total number of service members, expressed as a percentage. RESULTS: Six index conditions accounted for 41.3% of visits to civilian free care sites: diarrhea (4.7%), cough (4.7%), other infection (9.6%), rash (5.4%), animal bite (1.2%), and injury (15.7%). At military free care sites, five index conditions accounted for 75.7% of civilian visits: injury (23.7%), dermatologic illness (12.4%), respiratory illness (9.9%), gastrointestinal illness (5.3%), and other medical conditions (24.4%). Two index conditions accounted for 54.1% of service member visits: injury (36.2%) and dermatologic illness (17.9%). During the 5 weeks after the hurricane, proportional morbidity from injury decreased; proportional morbidity from respiratory illness increased; and proportional morbidity from diarrhea was stable. No infectious disease outbreaks occurred. CONCLUSIONS: Injuries were an important source of morbidity throughout the surveillance period, especially among service members. Enteric and respiratory agents did not cause disease outbreaks, despite alarming rumors to the contrary.