Study Finds Healthcare Usage Significantly Altered After September 11 Attacks

Researchers from the Rollins School of Public Health at Emory University analyzed insurance claims from January 2000 to March 2002 for more than two million people living in the New York City region and enrolled in healthcare plans offered by Aetna. They then evaluated overall and specific healthcare usage in relationship to how far people lived from the World Trade Center (WTC). The study examined insurance claims for mental health conditions as well as a variety of physical conditions that may be triggered or aggravated by emotional stress.

"We were interested in learning how the attacks on the World Trade Center affected healthcare use in the weeks and months following the disaster," explained corresponding author James W. Buehler, MD, research professor, Center for Public Health Preparedness and Research and Department of Epidemiology at Rollins School of Public Health. "The alterations we found have implications for other disasters."

Dr. Buehler and his colleagues found that healthcare use slowed in the weeks immediately following the terrorist attacks. In addition, distance from the WTC affected the utilization of some health services, with the greatest declines observed among those residing closest to the WTC. For example, office visits were the most frequent form of healthcare use, and office visits declined 11 percent overall and 15 percent for those living within the 10-mile radius of the WTC. This drop in office visits represented 75,000 fewer office visits than expected during the 3 weeks after 9/11.

"This decline was probably related to the disruptions in access to healthcare services or transportation, particularly for those living closest to the WTC. In addition, many people may have decided to postpone routine healthcare visits in order to attend to more immediate concerns," Dr. Buehler suggests.

While increased mental healthcare needs were widely reported following September 11 terrorist attacks, mental health claims remained below expected levels for six months following the attacks on the WTC. Dr. Buehler says, "One possible explanation is that people took advantage of free mental health services. Another is that in the wake of the disaster, many may not have recognized their need for mental health services. Another possible explanation is that for many with emotional stress related to the disaster, this stress appeared as physical illness, and this led to increases in healthcare use for conditions such as irregular heat beats, fainting, chest pain, or ulcers."

In fact, following declines in use in September, the greatest climbs in claims in the remaining months of 2001 were concentrated in such conditions and the increases were greatest among those living within 10 miles of the WTC. For example, visits for ulcers increased by 21 percent and care for fainting rose 43 percent, as did visits for rashes and urticaria, or hives, which increased 12 and 28 percent, respectively. Overall, the increase in office visits represented an increase of more than 200,000 visits over expected levels between October 2001 and March 2002.

Dr. Buehler offers explanations: "The particular cardiovascular, gastrointestinal, and skin diseases we examined are known to have a link to stress. Additionally, cases of skin infections and severe respiratory disease caused by anthrax subsequent to the WTC attacks were featured prominently in the media, and it is also possible that some of the increase in healthcare use may have been prompted by concerns about anthrax."

The team of researchers is well aware of the practical implications of their research. If a similar episode of terrorism were to happen in the United States, the researchers hope their findings will help healthcare providers anticipate healthcare needs and usage. As Dr. Buehler says, "By understanding how healthcare use was affected for a variety of different types of conditions following such a disaster, we also sought to inform healthcare providers about the types of health problems to expect among patients in the wake of other disasters."

Funding for the research was provided by the Agency for Healthcare Research and Quality and the O. Wayne Rollins Foundation.

Principal investigator of the project and lead author was Diane C. Green, PhD, MPH, currently at the Centers for Disease Control and Prevention and formerly research assistant professor, Emory Center on Health Outcomes and Quality, Rollins School of Public Health. Ruth L. Berkelman, MD, professor and director, Center for Public Health Preparedness and Research, Rollins School of Public Health, Emory University, was senior author. Other authors included Emory doctoral student Benjamin J. Silk, MPH; Nancy J. Thompson, PhD, MPH, associate professor of behavioral sciences and health education, Rollins School of Public Health; and Mitchel Klein, PhD, epidemiologist and statistician from the Department of Environmental and Occupational Health, and Laura Schild, information analyst, Emory Center on Health Outcomes and Quality, Rollins School of Public Health.