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T.M.Maximova, E.P.Kakorina, T.A.Korolkova, D.I.Ismailova, N.P.Lushkina

N.A.Semashko Institute for Research on Social Hygiene, Public Health, Economics and Management of the Russian Academy of Medical Sciences

Morbidity and peculiarities of medical care among disabled persons

Disability is a very important problem in present time, because there are many persons with limited possibility for realization their life and social functions. The society is becoming aware of its responsibility for providing the necessary life quality to disabled persons.

For solving problems connected with disabled persons first of all it is necessary to know size and composition of disabled people’ contingents and their needs for social and medical care. Social-hygienic evaluations of disabled health status in comparison with health forming of the other population contingents will help to reveal specific problems of disabled people’ health and to develop concrete targets and directions for problems solving. These problems can be general for all disabled persons and characteristic for the concrete age groups (children, persons able to work, elderly people).

For morbidity analysis and revealing of medical care providing problems the groups of disabled were considered from viewpoint of age. Subgroups of children with limited possibility were distinguished: these are children with grave progress of chronic pathology growing up in family and being under observation of medical establishments, disabled children growing up in family and those from house for disabled children (the data related to Moscow).

Children with grave defects in health status (children growing up in a house for disabled and in family, children with grave progress of chronic pathology), especially in houses for disabled, have considerably higher general morbidity level than children population as a whole. It concerns the absolute majority of recorded diseases. The rates of acute respiratory diseases are similar to those of general children population and in some kinds of infectious diseases (chickenpox, rubella) the rates of general children population morbidity is higher than those of children with limited possibility (Table 1).

The children from the house for disabled have the maximum general morbidity basically owing to diseases of respiratory organs and mental disorders. It is so because we studied the morbidity in the house for disabled children having disorders of neuro-mental development

The highest rates of infectious and parasitic (in the main helminthiasis) diseases were revealed among children from the house for disabled, but children’s droplet infections are recorded more seldom among disabled persons than a whole, including growing up children in family without contacts with other children of the same age.

Children with mental retardation from the house for disabled have not all hygienic habits as a result of this they often have helminthiasis. And the medical personal is responsible for it. This situation must be known to public and to social wardship agencies planning personal and material resources for these houses.

The high frequency of diseases of the skin and hypodermic cellulose as a result of skin and hypodermic cellulose infections (carbuncles, furuncles, panarises, intertrigo and so on) is the other specific feature of disabled persons morbidity in the house for disabled. It shows that the care of children is not well enough. There is also higher level of traumatism there (in the main contusions, purulent wounds, abrasions).

The rates of blood and hemopoietic organs diseases among children from the house for disabled are the lowest (isolated cases of anemia), the highest rates are revealed among children with grave progress of chronic pathology growing up in family.

In comparison with the other children groups children from houses for disabled persons have the lowest rates of digestive system diseases (the highest rates are among children with grave progress of chronic pathology), urinogenital system diseases (the highest rates are also among children with grave progress of chronic pathology), osteomuscular system and connective tissues diseases (the highest rates among disabled children growing up in family, neoplastic diseases (the highest rates are among children living in their own families).

Morbidity levels of respiratory system diseases are similar among children with chronic pathology and those with recognized disability. But there are the differences inside of this class. For instance rates of acute respiratory diseases and influenza are lower in disabled children in comparison with the other groups; the children with grave progress of chronic pathology who are under dispensary observation and disabled children who live in their families have the highest level of this morbidity. The highest morbidity of bronchial asthma is in disabled children growing up in their families and in those with grave progress of chronic pathology, but the highest morbidity of chronic bronchitis is among children from the house for disabled persons.

Disabled children differ from the others by combination of several diseases. 45% of children from the house for disabled, 29,7% of disabled growing up in their families and 27,1% of children with grave progress of chronic pathology have more than six diseases (Table 2).

The basic disease most often lead to application for medical services. From 22% to 30,8% of applications for medical services are connected with accompanying diseases in disabled children and those with grave progress of chronic pathology, but in all children population this rate on the average usually is from 1,5% to 5% (Table 3). In general children population 55 - 75% of all diseases end in recovery, but in disabled persons who live in their families and in disabled of the other groups this rates are 18,2% and 27,6-27,8% accordingly. 45,4 - 60,0% of children in these groups in spite of providing treatment have health status without changes. Health status changes for in a worse side are seldom noted by physicians in disabled children with chronic pathology.

Health status of children suffering from infantile cerebral paralysis (ICP) was been studied in detail because this disease is the main cause of disability among children.

Disabled children with ICP have many combining disorders of mental and physical development that make difficult communication, education and self-servicing. According to our data ability to move and to make accurate movements is reduced among children with ICP in almost 80% of cases, ability to keep one posture - in 50% of cases, to speak - in 48%, to see, to control their own actions and to conduct themselves adequately - in 30%, endurance -in 25%, ability to control themselves physiological functions - in 18% and to hear - in 8,8% of cases.

According to the data of L.O.Badaljan with co-author in consultative children neurological polyclinics of Moscow in patient with ICP speech disturbances are noted in 70-80% of cases, convulsion symptoms - in 14-65%, visual disturbances - in 40-50% of cases and strabismus makes a half of the latters. From 3% to 25% of children have hearing disorders, 50% have oligophrenia, from 69% to 95% have disorders of vegetative functions.

T.I.Serganova, who carried up medical examinations of children having ICP in their medical history, noted visual disturbances in 43,5%, locomotor disorders - in 50% and disturbances of speech development -in 96,4% of children.

According to our data in 50% children ICP is diagnosed on the date of birth, in 20,5% - during the second six months of life and only in 11,5% - after first year of life.

61,2% of ill children were born from mothers at the age of 28 and over and 38,8% - from mothers under 28 years of age. Among first-borns 72% of children having ICP were born from mothers at the age of 28 - 42 years.

In spite of grave form of ICP (tetraplegia in 30% of cases) physicians suppose that recovery is possible in 7,7% of children, improvement - in 29,5%, and only in 16,7% steady decreasing of working capacity remains and in 1,3% it will be increase.

Chronic diseases are the main cause of disability in adults (Table 4).

The proportion of disabled persons in the population increases with age and in men this process is more intensive than in women (Table 5).

In the older age groups it is difficult to differentiate pensioners and disabled persons in connection with the influence of social privileges on registration of social status.

According to the data of Central Statistical Board of the Russian Federation cardio-vascular diseases are in the first place among the causes of disability connected with general disease (22,6%), they are followed by malignant tumors (20,5%), injuries (12,6%), respiratory organs diseases and tubercle (8,06%), mental disorders are in the fifth place (2,7%).

In general number of disabled persons among urban residents is larger than among rural inhabitants. Cardio-vascular system diseases lead to disability in rural inhabitants half as much as in urban residents, malignant tumors - half as seldom again urban residents. The rates of disability due to injuries, mental disorders and tubercle are slightly higher in rural inhabitants.

According to applications for medical services morbidity of disabled persons in Moscow is 4632,9 cases per 1000, among men - 3936,8, among women - 5075,7‰. As a whole morbidity of all adult population is 1345 cases per 1000.

The highest numbers of disabled persons are registered among the people at the age of 60 and over.

In this article we submit the results of disabled morbidity study in that age group.

Morbidity of disabled persons at the age of 60 and over is 5111,1‰, in men - 4443,9‰, in women - 5472,4‰. These rates are higher than in the other population at the same age (2212,2, 1840,0 and 2375,4‰ accordingly) (Table 6).

Cardio-vascular system diseases (2218,6‰), including ischemic disease of heart (734,8‰), cerebrovascular diseases (697,1‰), hypertensive disease (519,7‰), atherosclerosis (177,4‰) are in the first place in structure of disabled persons morbidity.

The level of cardiovascular diseases morbidity in disabled persons is almost 2,5 times as high as this in the population at the same age without disability.

Diseases of nervous system and organs of sense (514,7‰) are in the second place in morbidity structure of disabled persons at the age of 60 and over. It is necessary to note eye and adnexa oculi diseases: cataract (225,8‰), glaucoma (30,5‰), refraction and accommodation disorders (168,4‰). These rates are 2-6 times as high as in the population without disability.

Digestive system diseases morbidity in disabled persons is 539,4‰, that level is 3 time as much as this in the people without disability at the age of 60 and over. The same is noted also in the main nosologic unit of this class: cholecystitis and cholelithic diseases (213,2‰), gastritis and duodenitis (102,1‰). Gastric and duodenal ulcer morbidity in disabled persons (57,3‰) is 4 times as much as in the people without disability.

Osteomuscular system and connective tissues diseases morbidity is higher in disabled persons (446,2‰), than in the people without of disability (245,9‰); vertebral osteochondrosis presents more than a half of these diseases cases.

Almost all diseases registered in disabled persons during a year are earlier known chronic diseases (82,9%); acute diseases constitute only among 7,6%. Acute diseases in the population as a whole form 35,9% of all cases, in persons at the age of 60 and over this rate is 11,7%. The proportions of chronic diseases in all population (53,4%) and in persons at the age over than this of working ability (77,8%) are more little (Table 7).

The data of studies provide possibility not only for analysis of general morbidity in disabled persons but also for giving qualitative and quantitative characteristics of morbidity by forms, heaviness and results of diseases.

The basic disease has complicated by after-effects slightly more often in disabled persons (7,1%), than in all adult population (3,7%). Disabled persons also have accompanying diseases more often than the population of other groups (38,5% and 18,3% accordingly) (Table 8).

It should be noted that one disease causing disability was registered during a year only in 18,6% of disabled men and 9,9% of disabled women. Many disabled persons have complex pathology. The proportion of persons having 6 diseases and more in all population is 8,5%, in persons at the age of 60 and over - 17,7% and in disabled people’ -43,5% (Table 9).

High morbidity level, plural pathology, and frequent complications in disabled persons show that they have worse health status in comparison with the other groups of population, including the people at the pensionary age.

This is confirmed by prognostic evaluations of results of diseases in disabled persons during a year in medical institutions, excluding hospital (according to the data received from physicians). Health improvement is not expected in more than 70% of disabled persons but health worsening, including death, is probable in 3,2% of disabled persons (Table 10). Chronic pathology prevalence in disabled persons was studied according to the results of medical examinations of urban residents and rural inhabitants. It constitutes 5260,7 and 4342,1 cases per 1000 population accordingly (Table 11).

The morbidity structures in disabled persons living in city and in those living in the country are different.

In morbidity of disabled persons living in city diseases of cardiovascular system (1621,4‰), nervous system and organs of sense (1078,6‰), respiratory organs (446,4‰), osteomuscular system and connective tissues (296,4‰) are in the leading places. In disabled persons living in the country diseases of nervous system and organs of sense (1052,6‰), respiratory organs (631,6‰), mental disorders (342,1‰), cardiovascular system (315,8‰), osteomuscular system and connective tissues (315,8‰) are noted more often.

Medical examinations revealed stomatologic pathology in all disabled persons. Most examined people were in need of treatment and making a prosthetic appliance because of a great number of disorders.

Study of morbidity according to the data on applications for medical services is the basis for definition of the real extent of medical care for different contingents. For this study the information about all kinds of contacts of children and adults, including disabled persons, with physicians of different specialties during a year and also information on extent and nature of medical procedures and diagnostic examinations were been copied from primary documents of outpatient clinics and social services.

Applications of the population for physicians - specialists are the main characteristics of medical care extent. Almost each of children (in a number of cities - 90-92%) and about a half of adults visit physician every year, each fifth visit is on the initiative of medical service.

About one third of all children visited district polyclinic up to 5 times during the year (Table 12).

It is interesting to note that the same numbers of children from different groups (40-44,2 %) visit physician more than 11 times a year. There are more contacts of children with physicians (84,0%) only in the house for disabled children, what is natural because children are under regular medical observation there.

Most of visits are connected with disease treatment (72,4% of all visits of children as a whole and 65,2% of visits the children from the house for disabled). Children with grave chronic pathology and disabled children living in their families visit physician more seldom (56,3% and 58,2% accordingly). Among the latter group 9,3% of visits are made to receive documents for Physician expert commission defining working capacity (Table 13).

The most part of diagnostic examinations fall on the children from the house for disabled (6,2 of medical examinations per child), half as much as this number fall on disabled children living at home and on those with grave chronic pathology (3,8), among children population as a whole this rate is 2,1 of medical examinations per child. Analyses of stool, including analyses for ovums of helminths, constitute more half of all medical investigations among children from house for disabled. 3,4 of stool analyses a year fall on a child from the house for disabled, 0,8 (20,9%) - on a child growing up in his family, 0,9 (23,4%) - on a child with grave chronic diseases. As a whole the rate is 0,6 of stool analyses per child, what constitutes 29% of all investigations.

Blood counts are made enough often in the house for disabled persons - 2,4 of blood counts per child, what constitutes 39,4% of all diagnostic procedures. In other groups rates are 2,3 of blood counts per child, in all children population - 0,7 of blood counts per child (Table 14).

Disabled children growing up in their families and those with grave chronic pathology as a rule are exposed to 1-5 medical examinations like all children population, but in the house for disabled this rate is 6-10 examinations per child (Table 15). It is advisable to definite sufficiency and validity of this set of examinations for children with chronic conditions.

Certain peculiarities were revealed in different children groups in process of studying forms of treatment So, in houses for disabled persons means for correction are not prescribed to children and physiotherapy, massage, therapeutic physical training and also sanatorium and spa treatment are used more rarely. All treatment of children in the house for disabled is reduced to prescriptions of drugs (Table 16).

Drug therapy constitutes about 99% of all kinds of treatment of disabled children, 82% of all kinds of treatment of children being under dispensary observation and 74% of all kinds of treatment of children population as a whole. As a result of this the dysbacteriosis often have place in disability children living in their families (40,0‰) and in those with grave pathology (46,9‰)(in all children population - 6,9‰).

Treatment of disabled children living in their families is in another level. These children more often received physiotherapy (0,4 of procedures per child), therapeutic physical training (0,2 per child), massage (0,3 per child), sanatorium and spa treatment (0,08 per child), means for correction, including glasses and lenses (0,07 per child) (Table 16). But need for vision correction among children of different groups is significantly higher than mentioned indexes.

So, for example, ophthalmologic examinations of children in a number of cities reveal that visual acuity are lower than 0,1 of unite in 1,8-3,5%, 0,2-0,4 of unite - in 3,5-6,3%, 0,5-0,7 of unite - in 8,9-9,7%, 0,8-1,0 of unite - in 81,3-92,0% of children.

Revealed disorders of ocular refraction and accommodation required visual correction by the use of glasses and contact lens in 175,3-186,5 children per 1000. Consequently about 5 millions of children, including disabled children, must use glasses or contact lens.

Special examination of children with ICP showed that 20% of them needed to live in a house for disabled, but in 80% of cases proposed help was not been accepted by families. It was revealed also that 23% of children needed to be educated at home, half of children needed periodical treatment in a specialized department of hospital. As to means for correction, 50% of children with ICP need special orthopedic shoes, 30% need wheel chair for disabled persons, 23% - glasses, 3,4% - hearing apparatus, 2,5% - extremity prostheses and 14% - other special devices.

We calculated the need of disabled children for several forms of social help and means for correction (Table 17).

The composition of adults’ visits to physician is steady enough in different territories and cited orientations can be considered as regulars and typical (Table 18).

The most visits to physician are connected with treatment and diagnosis (69,9%). 23,9% of adults visit physician in connection with prophylactic measures. This scope of the work can be changed essentially, because it is determined by directive documents of the authorities of public health.

The average rate of visits to medical services is 3,7 per 1 inhabitant (without of visits connected with diseases of teeth and oral health). Numbers of visits rise with age, this is in line with morbidity rising in the older age groups of the population. But in several territories numbers of visits of people at the age of 60 and over to health services decrease; that fact apparently reflects the mutual relations arisen under present economic conditions among health services and elderlies.

The scope of medical services giving to disabled persons is not the same that to the other population. Almost 90% of disabled persons have a contact with health service every year. The rate is 9,5 of visits to physicians per one disabled person during a year. 82% of visits fall on treatment and diagnostic help and consultations. It is evident that the scope of prophylactic work among this contingent of the population is minimal, but substantial number of visits (14,7%) is made to receive the documents for Physician expert commission defining working capacity. The question about a real number of contacts with medical services is connected with this of advisability of undergoing an examination by experts for testifying pathologic conditions causing disability. Disabled persons visit physicians for the different psychosocial consultations more often in comparison with the other groups of the population. The frequency and the structure of adults’ examinations reflect the use of different diagnostic methods in medical care of disabled persons and correspond with level and structure of this contingent morbidity. The medical examinations of disabled persons have places more often than those of other groups of the population; the rate constitutes 3519,7 per 1000 disabled persons. In disabled persons analyses of the urine and sputum and functional and diagnostic examinations have places more often in comparison with all population as a whole and with people at the age of 60 and over (Table 19).

Drug therapy remains the main kind of treatment as before and constitutes 95,5% of all curative prescriptions for disabled persons. On the average 9 forms of pharmaceutical preparations are prescribed to one disabled persons during a year, at the same time in all population the average rate is 2-3 forms per one adult.

Physiotherapy, massage and therapeutic physical training are used sufficiently intensively in medical care of disabled persons (Table 20).

So, the study of disabled persons morbidity and extent of medical care given them and comparison this data with those about all population reveal peculiarities in each considered group. These data must contribute to optimal provision with medical care of separate contingents of children and adult population.

Table 20

Morbidity of children of different groups according to the data about application for medical services (per 1000 children at the age 0-14 years)

Diseases classes and several nosologic forms

All children population

Children from the house for disabled

Children living in their families

Children with grave progress of chronic pathology

Infectious and parasitic diseases

155,3

468,5

98,2

156,2

chikenpox

63,4

31,5

17,9

62,5

measles

2,0

18,0

17,9

-

rubella

16,8

9,0

8,9

-

helminthiasis

31,6

351,3

26,8

39,1

Neoplasms

7,9

9,0

62,5

31,2

Diseases of endocrine system, disorders of nutrition,metabilism and immunity,

45,5

99,1

169,6

148,4

diseases of thyroid gland

2,0

9,0

35,7

-

Diseases of blood and hemopoietic organs

22,8

9,0

35,7

85,9

Mental disorders

90,0

1004,5

321,4

343,8

neurotic disorders

20,8

-

17,9

39,1

vegetovascular dystonia

25,7

13,5

35,7

78,1

enuresis

15,8

27,0

26,8

54,7

Specific arrests of development

11,7

9,0

44,6

85,9

mental retardation

3,0

887,4

160,7

23,4

Diseases of nervous system and organs of senses

150,3

955,0

321,4

281,2

infantile cerebral paralysis

2,5

162,2

169,6

-

refraction and accommodation

84,1

153,1

178,6

171,9

strabismus

2,0

180,1

71,4

15,6

Diseases of blood circulation system

12,9

9,0

71,4

62,5

Diseases of respiratory organs

1071,2

1328,8

1330,4

1359,4

acute respiratiry diseases

917,9

815,3

1026,8

1171,8

chronic diseases of tonsils and adenoids

36,6

135,1

133,9

62,5

influenza

77,2

13,5

44,6

70,3

chronic bronshitis and bronshial asthma

9,9

103,6

98,2

46,9

Diseases of digestive organs

132,5

58,6

366,1

515,9

chronic gastritis

20,8

4,5

80,4

101,6

hernia

10,9

22,5

53,6

15,6

dyskinesia of biliary tructs

34,6

4,5

53,6

156,3

Diseases of urinogenital system

31,6

49,6

116,1

156,2

nephritis, nephrosis

1,0

-

26,8

7,8

chronic pyelonephritis

8,9

18,0

44,6

62,5

cystitis

5,9

-

-

46,9

Diseases of skin and hypodermic cellulose

74,2

869,4

151,8

171,9

skin infections

24,7

689,2

76,4

31,2

dermatitis

34,6

54,0

44,6

93,8

Diseases of osteomuscular system and connective tissues

77,2

63,1

214,3

171,9

curvature of the spine

13,8

27,0

53,6

39,1

Congenital anomalies

54,4

254,0

526,8

398,4

anomalies of nervous system

2,0

67,6

71,4

15,6

anomalies of blood

       

circulation system

5,9

103,6

98,2

46,9

anomalies of digestive organs

15,8

4,5

-

125,0

anomalies of osteomuscular system

12,9

81,1

169,6

85,9

Separate conditions arising during perinatal period

61,3

-

44,6

382,8

Syndroms, signs and illegibly Definited conditions,

63,3

135,1

35,7

109,4

Functional changes of the cardiovascular system

17,8

-

17,9

46,9

Injuries and poisonings

63,3

184,7

116,1

148,4

dysbacteriosis

6,9

-

44,6

46,9

T o t a l

2113,7

5707,2

4571,4

4523,4

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