A Qualitative Analysis of New York City Based Primary Care and Specialty Providers’ Knowledge of 9/11-Related Health Conditions and Health Care Services

Research Article

Austin J Emergency & Crit Care Med. 2015; 2(5): 1029.

A Qualitative Analysis of New York City Based Primary Care and Specialty Providers’ Knowledge of 9/11-Related Health Conditions and Health Care Services

Welch AE*, Caramanica K, Yip J, Petrsoric LJ and Cone JE

New York City Department of Health and Mental Hygiene, USA

*Corresponding author: Alice Welch, Division of Epidemiology, NYC Department of Health and Mental Hygiene, 42-09 28th Street, 07-24, Queens, NY 11101, USA

Received: July 31, 2015; Accepted: September 05, 2015; Published: September 08, 2015


Introduction: More than 10 years after 9/11, thousands of directly exposed persons have myriad disaster-related physical and mental health conditions. Previous studies suggest affected persons may not be utilizing any of the health programs that were created expressly to address 9/11-related health conditions due, in part, to a lack of referrals from primary care physicians.

Aim: To understand providers’ knowledge of 9/11-related medical conditions, views on and referrals to 9/11 health programs, and how best to provide educational resources to providers and patients.

Methods: We conducted semi-structured in-depth individual telephone interviews with 20 New York City based primary care and relevant specialty providers. The interviews were recorded, transcribed and inductively opencoded for thematic analysis.

Results: Providers were fairly knowledgeable about psychiatric and respiratory conditions commonly associated with 9/11, but less so regarding conditions whose relationships to 9/11 are still under investigation. Most providers considered 9/11 exposure an important part of patients’ medical histories, but did not typically screen for exposure, believing patients would self-report exposure or that exposure was no longer relevant. The majority of providers had positive perceptions of the 9/11 programs, though only some had referred their patients. Providers expressed interest in learning more about 9/11-related health programs and conditions.

Conclusion: NYC based medical providers are an under-utilized source of referrals to the 9/11 health programs. Furnishing providers with detailed information on program locations, eligibility requirements, services, and advantages along with summaries of 9/11 research and patient educational materials may increase provider referrals to the programs.

Keywords: 9/11; World Trade Center; World Trade Center Health Program; Disaster health; Disaster preparedness; Medical providers; Qualitative interviews


More than a decade after September 11, 2001 (9/11), persons directly exposed to the World Trade Center (WTC) attacks continue to demonstrate disaster-related physical conditions, including asthma, shortness of breath, persistent cough and wheezing, gastroesophageal reflux disease, and mental health conditions such as posttraumatic stress disorder (PTSD) and depression [1-8].

While some programs were providing services as early as 2001, the WTC Health Program (WTCHP) for survivors and responders began in July, 2011 as part of the federal James Zadroga Health and Compensation Act of 2010 [9]. In order to provide sustained screening, monitoring, and treatment of 9/11-related physical and mental health conditions, services are available to those impacted by the WTC disaster currently residing in New York City (NYC) or nationwide. Services are provided at no out-of-pocket cost to eligible individuals who either resided, worked, or were present in lower Manhattan on 9/11 (survivors) or who served as rescue, recovery, and clean-up workers and volunteers (responders) [10]. The WTCHP clinical services are provided in the NYC metropolitan area at NYC Health and Hospital Corporation’s WTC Environmental Health Center (EHC) for survivors, and the General Responder Consortium or the WTC Medical Monitoring and Treatment Program of the Fire Department of New York for responders. For persons living outside the NYC metropolitan area, services are provided by a nationwide network of providers.

Studies attributed the observed relatively low mental health service utilization in the six months following 9/11 to inadequate finances or time, beliefs that others are in greater need of services or that individuals can care for themselves, mistrust of mental health professionals, and fear of discussing the attacks [11-13]. In focus groups conducted several years after 9/11, enrollees in the WTC Health Registry (Registry), a cohort study of 71,431 persons with firsthand exposure to the WTC attacks in NYC, mentioned numerous programmatic and personal barriers to care, including limited knowledge of 9/11-related health conditions and lack of awareness of 9/11-related health care programs, as well as perceived stigmatization of receiving mental health care, complicated intake procedures, long waiting lists, and delays in scheduling an appointment [14].

Findings from these focus groups also indicated that primary care providers (PCPs) can play an important role in connecting survivors and responders to 9/11-related specialty care. Participants reported having strong and enduring relationships with their PCPs, and indicated that a lack of referral from their PCP to the programs was one reason why they had not sought services in the past. Participants were also reluctant to seek care from a provider they were concerned would feel like a ‘stranger’ [14].

A recent study examining trends in physician referrals from 1999-2009 in the United States found that the overall probability that a physician visit would result in a referral to another provider increased by 94% over the 10 year period [15]. It is suggested in the biomedical literature that successful patient referrals to specialists require endorsement from the PCP, an understanding of the referral’s purpose by the patient, and coordination between the patient, their PCP, and the specialist [16,17].

Based on the Registry focus group findings, it is evident that PCPs are likely to be a key component of engaging exposed persons in 9/11-related specialty care. The purpose of this study is to understand 1) provider knowledge about 9/11-related medical conditions; 2) how providers currently view 9/11-related health care services (WTC Health Program); 3) motivation to refer patients to the WTC Health Program; and 4) the best methods of engaging providers and providing educational resources.


Interviews were conducted with 20 NYC-based health care providers (18 physicians, 1 psychologist, and 1 physician’s assistant) from June through August of 2013. Recruitment, interviews, and transcription were performed by an outside vendor. A list of potential providers was created, from a variety of sources including the vendor’s database (n=80), online search engines and New York registries (n=361), and physicians identified by the Registry (n=8). The list was reviewed to ensure there was only one provider from each entity, and then randomized for systematic calls. To be eligible for the study, providers had to be practicing currently and have their primary practice in NYC. Upon initial contact (n=347), providers were screened for interest and eligibility to participate in the interviews (n=144). Recruitment ended once 20 providers agreed to participate. In order to best approximate providers likely to be treating 9/11 exposed persons and making referrals to 9/11 specialty care, recruitment parameters required a mix of practice types, provider specialties, and primary practice locations in lower Manhattan, upper Manhattan, the Bronx, Brooklyn, Queens, or Staten Island. Interested and eligible providers were then scheduled for a telephone interview; providers were offered $200 as compensation for their time in the form of an honorarium or donation to the charity of their choice.

Semi-structured telephone interviews lasted approximately one hour. The interviewer’s guide was developed by two of the authors (AEW and KC) and the vendor with input from representatives of the WTC Health Program clinics. Table 1 displays topics and sample questions from the guide. All 20 interviews were recorded and transcribed. The study was approved by the institutional review board of the NYC Department of Health and Mental Hygiene.