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JNIIV HEALTH CELL

The Rural Health Study: A Comparison of
Hospital Experience between Farmers and Nonfarmers in a
Rural Area of AAinnesota (1976-1977)

Uroh Biomedical Test Lab., Salt Lake City
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Prepared for

National Inst, for Occupational Safety and Health, Cincinnati, OH
Jul 78

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2.

I. Kryort Ni»,

BIBLIOGR/J’HIC DATA
SHEET

NIOSH 78-184

4. I idr and bulitidc

5. Kcpoft D.ite

July 1978________

Rural Health Study in Minnesota - 1976-1977
6.

7. Authot(s)

8. I’cilornun/; (h^ani.*jiion Kept.
No.

9. Pcrlctnnnf. Orfcan;;anon Nari.c c>nJ Adurcj.*.

10. I'tofcct/l Ask/U v:k Unit No.

John A. Burkart, Ph.D.; Christiane F. Egleston,
Rf ch.nrd J. Voss_________________________ _

Utah Biomedical Test Laboratory
University of Utah Research Institute
520 Wakara Way
Salt Lake City, UT 54108_________________________

11. Contruct/Grant Nu.

210-76-0153

17. bjK’nioiinf. (h^A.'iixAdon Nar-.c and Addica*

13. Type ©f Report A* Period
Coveted

National Institute for Occupational Safety and Health
4676 Columbia Parkway
Cincinnati, Ohio 45226

14.

15. Supplr..»cntAry Note*

16. Ab’.JiaCt*

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PB 297770

1

TECHNICAL REPORT
-F

RURAL HEALTH STUDY
in MINNESOTA 1976 -1977

MPMCUCtO fT

NATIONAL TECHNICAL
INFORMATION SERVICE
U.k MFAeiMfNT C# CO««(«ct
intuitu©, VK U1U

u. 5. DfKRTMfST or HKITH. IDUCATIOV AND WlHARf
Public Health ’‘entice
(enter Io* Diceace Control
Nabonai Institute lor Occupational Safrtv and Health

■nt

The Rural Health Study: A Comparison
of Hospital Experience between Fanners
and Nonfarmers in a Rural Area of Minnesota

John A. Burkart, Ph.D.
Christiane F. Egleston
Richard J. Voss
Utah Biomedical Test Laboratory
University of Utah Research Institute
520 Wakara Way
Salt Lake City, Utah 84108

Contract No. 210-76-015^

U. S. department of Health, Education, and Welfare
Public Health Service
Center for Disease Control
National Institute for Occupational Safety and Health
Division of Surveillance, Hazr.rd Evaluations A Fi.^ld Studies
Cincinnati, Ohio 45226
July 1978

Mtmss'sflrwwtw*-

DISCLAIMER
The contents of this report are reproduced herein as received
from the contractor.
The opinions^ findings and conclusions expressed herein are
not necessarily those of the National Institute for Occupational
Safety and Health, nor doer, mention of company names or products
constitute endorsement by the National Institute for Occupational
Safety and Health.

NIOSH Project Officer: Virginia Behrens
UBTL Project Director: John Burkart

DHEW (NIOSH) Publication No. 78-184

il

Abstract
The Rural Health Study was undertaken to use hospital records and
brief occupational histories as a means of identifying problem health
areas for agricultural workers and residents in a selected area of the
Midwest. A pcpulation-based analysis by place of residence for two
r-ral counties and a larger case-control analysis by years of agri­
cultural exposure with data from six rural hospitals were utilized.
Overall, patients with an agricultural background seem to be as
healthy or slightly healthier than patients with no agricultural his­
tory. Nevertheless, the following possible problem areas were identi­
fied: Males and females both showed increased risks for diseases of the
blood and blood-forming organs, osteoarthritis, gall bladder disease,
hernia of the abdominal cavity, diseases of the veins and lymphatics,
and eye conditions. In addition, farm males showed increased risks for
beni*n prostatic hypertrophy and farm females had increased risks for
uterovaginal prolapse, acute myocardial infarctions, diseases of the
skin and subcutaneous tissue, and neoplasms. Females over 6S years of
age with 20 years or more of agricultural exposure were the only farm

group whose overall health was worse than the corresponding nonfarm
group.

Data on smoking histories, collected for adjustment purposes, corroborated national findings by giving evidence of relationships between
cigarette smoking and lung cancer, ulcers, and several circulatory and
respiratory problems.

ill

CONTENTS
Page no.
Hi

Abstract
List of Tables

v

List of Figures

vi

INTRODUCTION

1

METHODOLOGY

3

Initial Project Plans

3

Revised Project Plans

4

Study Variables . . .

S

Study Design

10

Statistical Methods .

15

THE USE OF HOSPITAL DATX IN EPIDEMIOLOGICAL RESEARCH . .

17

DATA COLLECTION

19

Questionnaire Administration

19

Coding and Receipt of Data.

19

Data Quality

20

Population Estimates. . . .

22

27

RESULTS AND DISCUSSION

1

J

Analysis of Population-Based Hospitals

27

Case-Control Analysis

34

Comparative Hospital Statistics

38

Comparison of Results with Published Statistics . .

47

CONCLUSIONS AND RECOMMENDATIONS

S3

Agricultural Health

53

Methodology . . . .

53

ACKNOWLEDGEMENTS

57

REFERENCES

59

APPENDICES

I.

Relative Risks for Population-Based Hospitals

II.

Case-Control Relative Risks

III. Relative Risks for Smoking and Selected Diagnoses

iv

1
*»«■»■'ST

LIST OF TABLES
Page No.
Table 1

Study Hospital Characteristics

6

Table 2

Population Characteristics of Study Counties

8

Table 3

Agricultural Characteristics of Study Counties

11

Table 4

Rural Health Study Cases - April 1976-March 1977

21

Table S

Rates of Errors and Inconsistencies

23

Table 6

Population by Age, Sex, and Residence - Estimated
1976

25

Table 7

Male Farm Workers by Age - Estimates 1976

26

Table 8

Patient Origin Study, November 1976, Kandiyohi
and Douglas Counties

28

Diagnostic Categories with Increased Relative Risks
for Farm Residents as Compared to Nonfarm
Residents - Males

30

Diagnostic Categories with Increased Relative Risks
for Farm Residents as Compared to Nonfarm
Residents - Females

31

Relative Risks for Current Farm Workers - Males,
Age 25-64

33

Table 9a

Table 9b

Table 10

Table Ila Diagnoses with High Relative Risks Associated with an
Agricultural Occupational History,
Ages 25-64

36

Table 11b Diagnoses with High Relative Risks Associated with an
Agricultural Occupational History,
Ages i65

37

Table 12a In-Hospital Characteristics by Final Diagnosis Mai es

39

Table 12b In-lospital Characteristics by Final Diagnosis Females

41

"able 15

Comparative Pregnancy and Newborn Statistics

Table 14

Comparisons of Original Respondents, Telephone
Respondents, and Nonrespondents - Douglas
County

44

Comparisons of Medical Characteristics of Ques­
tionnaire Respondents and N-ynrespondents

45

Table 16

Comparisons of Discharge Rates

48

Table 17

Comparative Percentage Distributions for Selected
Diagnoses

49

Diagnoses Significantly Associated with a C’garette
Smoking History

52

Table 15

Table 13

v

(

43

LIST OF FIGURES

Figure 1 Distribution of Hospitals in the Study Area
Figure 2 The PAS System - Case Abstract
Figure 3 Agricultural Occupation and Smoking Questionnaire

4

Vi

Page No.
7
9
13

INTRODUCTION *

The Utah Biomedical Test Laboratory (UBTL) recently completed a
survey of the existence and availability of occupationally related
injury and illness data in agriculture in the United States [1].

Case

data were available primarily from two sources: the Workmen’s Compensa­
tion System and the National Safety Council’s Farm Accident Survey.

Workmen's Compensation agricultural data were available from six states,
with only California providing a substantial amount of data.

The other

state provided little or no data due vo the exclusion of coverage to
farm workers or due to the small number of hired farm workers covered.

A Farm Accident Survey had been completed in twenty-one states at the
time of this report.

Additional injury and illness data that may be

occupationally related to agriculture are collected by the Bureau of
Labor Statistics, the National Center for Health Statistics, the Public

Health Service, and individual state health agencies; however, detail is

lacking and specific problem areas are difficult to identify.
Several deficiencies in available agricultural health statistics

were obvious from the survey.

Most data do not contain illness informa­

tion, especially of long-term etiolo^v; the large agricultural areas of
the midwest are under represented; and accurate estimates of the number
of workers at risk arc difficult to obtain to use with the available

accident statistics.

The Rural Health Study was designed to investigate alternate data

sources which did not contain the deficiencies described above; namely,

a study to obtain illness information in the midwest, from which rates
could be calculated, was the primary goal.

A secondary purpose was to

develop and test a method which has utility as a screening technique to
identify possible occupational health problems in a population, as an

alternative to a much more costly cohort study.

t

The data source chosen to be investigated was hospital records.

Houten.

Bross, and Viadana [2,5] successfully used hospital records and occupa­
tional histories in a retrospective survey of the relationships between
*A study based on data from a ftotal1 of *.2,222
16,598 discharge cases collected
from six hospitals for the period from April1 J. 1976, through March 31,
1977.

1

occupation and cancer. The Rural Health Study attempts to look at
illnesses other than cancer and to pair hospital records and occupa­
tional histories with population estimates, where possible.

>

/

1

I

METHODOLOGY

Initial Project Plans
The original plan for designing a study which met the desired

criteria was to select a rural midwestern county which contained one
centrally located, wel1-equipped hospital such that practically ^11 of

the county's hospital u.vperience would be captured by the one hospital.

Using county census estimates of the farm and nonfarm populations and
farm and nonfarm workers, rates could be calculated and relative risks

computed of farm to nonfarm residents and workers for a variety of

medical conditions,

The county selected was to contain no large known

hazardous occupational groups so as to provide a relatively clean non-

farm comparison group.

The Commission on Professional and Hospital Activities (CPHA) in
Ann Arbor, Michigan, was identified as an independent agency involved in

the standardized abstracting and collection of hospital records through

the Professional Activity Study (PAS).

Over 4G°a of the short-term

hospital discharges in the United States arc included in CPIL\ programs.

To eliminate costly and time-consuming abstracting or’ hospital records,
it was deemed advantageous to enlist CPHA cooperation and limit the
study to hospitals participating in the PAS system.

Relevant data,

routinely collected through the PAS system, include demographic char­
acteristics of the patient plus dates of hospitalization, type of

discharge, and diagnoses coded by th? Hospital Adaptation of the Inter­
national Glassification of Diseases, H-ICDA (I).
Information concerning place of residence and occupation was not
available in the PAS system but such data could be independently ob­

tained at participating hospitals and coded into otherwise unused fields

on the PAS form by hospital personnel without extensive training and

without excessive burden to the patient,

CPI LX agreed to provide peri-

odic data tapes of selected dvmographi c and medical information plus the

<• ‘ditional occupational information.

This data set and census estimates

could be used to compare the hospital experience of different occupa­

tional groups.
3

Several candidate hospitals in South Dakota, Iowa, and Minnesota
met the initial criteria for study and were further evaluated as to

their suitability for the Rural Health Study.

•>

Douglas County Hospital

in Alexandria, Mir.r.., rta, was the final selection.

Formal agreements

were made with the hospital and CPHA for the collection of data over a
one-year period.

Revised Proiect Plans
Prior to the initiation of data collection, a NIOSH review board
suggested expansion of the study.

This posed problems in that it was

difficult to find a large, rural area where all of the hospitals belonged to PAS or a similar system and where the service area could be
defined by estimable or county boundaries,

An additional problem was

that it would be imperative to have cooperation from all of the hos­

pitals in the area.
A number of hospitals in rural west central Minnesota, near Alexan­
dria, belonged to PAS.

The largest hospital, in Willmar, Minnesota,

basically met the requirements for being centralized, well equipped, and
servicing the county population, but the smaller hospitals could not be

tied to an estimable service area,

it was decided to enroll as many of

the hospitals as possible for inhospital comparisons to complement the

population-based comparisons from Willmar and Alexandria.
Preliminary estimates suggested that 20,000 total discharges would
yield at least 2,000 males and 2,000 females who had spent most of their

lives on farms.

For inhospital comparisons (case-control), these num­

bers were deemed sufficient to detect a relative risk of two of farmers

to nonfarmers (a®.05, 6s.SO) for any diagnosis accounting for roughly
one-half of one percent of all diagnoses.

Using data from the National

Health Survey [S], most circulatory, respiratory, digestive, and genito­
urinary conditions and several prevalent cancers met this criterion.

Ten candidate hospitals (including Alexandria and Willmar) were

identified and contacted icgarding participation in the Rural Health

4

Study.

Initial cooperation was received from nine of the hospitals; two

of the larger hospitals later declined due to the magnitude of the work
involved; and one of the smaller hospitals was terminated after the
start of the study due to nonperformance of the required duties.

The

remaining six hospitals were expected to provide data on about 16,000

total discharges.

Table 1 presents hospital characteristics of parti­

cipating hospitals and Figure 1 shows the distribution of these hos­

pitals in the study area.

Table 2 provides a description of the popu­

lation in the study area.
Study Variables
Pertinent data already collected by CPHA that was requested was

patient number, age, sex, dates of hospitalization, height, weight,
admission blood pressure, discharge status, final diagnosis explaining

admission, and supplementary diagnoses (diagnoses coded by H-ICDA).
Figure 2 shows the PAS data abstracting form.

It was necessary to com­

pose a questionnaire to be administered to all patients which would

provide information on variables of interest not available in the CI'HA
data set.

Th i^*l'n format ion could then be merged with the medical and

demographic data collected by CPHA.

Lacking from the CPHA data set was any occupational or residence
information.

Since farming is a lifestyle in addition to an occupation,

it was decided to obtain information on whether a patient resided on a

farm plus whether he worked on a farm.

Since farm workers are spread

over a large area, to obtain information on a large number of current

farm workers would require a huge study in more hospitals than the scope
of this study.

Therefore, a patient's work history regarding agri­

culture was examined so that illnesses in retired farm workers could also

be investigated in relationship to their farm exposure.

This would also

provide data on people leaving agriculture due to health problems.
Type of farm was originally thought to be an important variable for

comparison, but after studying the agricultural characteristics of the

area, most farmers were engaged in similar but multiple activities such
that meaningful discrimination would be difficult.

Type of farm was

included on an earlier draft of the questionnaire and caused problems in

5

••••••••

Table 1.

• ••••

!

Study Hospital Characteristics

' ’ S’’•?a*

Locat ion

County

«of Peds

/\d:?.issions/Ycar

A1 bany Con-nun i t y

Albany

Stearns

26

1000

2

Fa^ily Practice

Doufjas County

Alexandria

Douglas

101

4600

25

Family Pra-. ice,
Int>—nal Me 'icine,
Gcn.ral Sur .cry,
Pediatrics, Orthopedics,
Opt »3tt.ology, Urology

Glacial Ridge

Glenwood

Pope

34

900

2

Panily Prac.ice

Melrose

Melrose

Stearns

28

1500

4

Fan ily Practice

Paynesville
Community

Paynesville

Stearns

43

1400

4

Family Practice

Rice Memorial

Ki Ilnar

Kandiyohi

175

7300

50

Family Practice,
Internal Medicine,
General Surgery,
Pediatrics, Urology,
Pathology, Radiology,
Opthamology,
Psychiatry, ENT

cr

* Thysicians

Physi- ian Specialties

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Table 2.

Population Characteristics of Study Counties
i
I9~0 Ccn>u* Statistics

County

Dcuilas

kun41> ohi

Place*
Mth Study
Hospitals
Alexjun Jria

»*U» r

Places wtth
•ion-study
Hospitals
None

None

197(» County
Pcpulation
2S.000

33.000

* Males

50

50

•Aon-white
0.1

0.2

t 18-64
Years Old

50
'HvJian
- 31
Age
52

3 of Those
Over 16
Employed in
Agriculture

Rural f.T«

Rural Nonfarn

Urban

23

28

42

30

17

25

33

42

29

43

34

23

12

20

40

40

1 Population Dittrilution

• ‘

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r-Jcdian
• 31
Age
Pope

Glenwod

Cfi

Starbuck

12.000

51

0.2

48

Median
Afe
• 3t
Srcarnj

Albany
Me 1 rose

Paynesville

St. Cloud
Sauk Center

104,000

50

0.4

51

I'ledian

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THE PAS SYSTEM

7T.

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1975 CASE ABSTRACT

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Figure 2.
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a pretest.

The biggest problems were the time involved to explain and

define the types of farr’S and the patient’s inability to choose a cate­
gory since his farm consisted of multiple commodities.

Table 3 sum­

marizes agricultural characteristics of the area.
Since smoking is related to some of the diseases under investi-

gation, it was decided to include smoking history on the questionnaire
for the purpose of stratification, since farmers are generally regarded

to smoke less than nonfarmers [6],
In addition to the above ideas, the questionnaire would have to he

easily understood, should leave little room for indecision on the part
of the interviewer or patient, should be short so as to minimize patient
and interviewer burden, and should be precoded so the data could be
added to the CPIIA forms with a minimum of errors,

figure 3 presents the

questionnaire in its final form.

2?11 j)esir.n
The final study design attempted to obtain valid information on the
health of agricultural workers via three different approaches.

Hope­

fully, common problem areas would be evident through several of the
comparison^.

By obtaining information on place of residence, data from the two
populution-based hospitals in Douglas and Kandiyohi Counties can bo
combined with census population estimates updated to the time of the

study and diagnosis-spccific hospital discharge rates can be calcu­
lated.

Iron the rates, estimates of the relative risk of farm residents

to nonf.irm residents can be calculated.

The rates will be underesti­

mated because not all of the hospitalizations of county residents will

be captured, but by looking at data from some of the hospitals in
neighboring counties, it can be determined whether the people from the
study counties going to hospitals outside the county possess the same
characteristics as county residents admitted to the in-county hospitals.

If this is true, then estimates of relative risk are valid; otherwise,
adjustments should be made.
•«

10

Table 3.

Agricultural Characteristics of Study Counties

County

Number uft Farms

Land in Farms

Mean Farm Size
(Acres)
: Employing Hired
Workers

Douglas

Kandi yohi

Pone

Stearns

All Farms

1469

1575

1095

33S3

Class 1-5 Farms

1266

1453

1019

3031

All Farms

77

81

SO

81

Class 1-5 Farms

73

78

78

All Farms

218

256

311

205

Class 1-5 Farms

240

270

327

219

38

36

29

37

39

5S

31

92:

92rt..

92'-

94*.

• O



s:

2:

r.

r.

2 s:

so:

6i:

17:

162

57:

13"

All Fams

Class 1-5 Farms

Fam Ownyrshin__ (C1 ass 1-5 I-arms)

Individual or Family

Partnership
Corporation or Other

(Class 1-5 Farms)

Dairy

4«:

Livestock

ig:

Cash-grain

2c:

45:

General

5:

5:

Poult ry

n

3:

1:

2:

Other

5:

3:

3:

5:

11

'

Table 3.

T*".

**■•-*•

Agricultural Characteristics of Study Counties (continued)
County

% Farms Raising
(Class 1•5 Farms)

Douglas

Kandivohi

Pope

Stearns

Livestock or Poultry

84

75

82

93

Cattle

78

63

73

84

Milk Cows

57

40

44

67

Hogs 6 Pigs

28

27

27

41

Poultry

19

13

12

18

Sheep 6 Lambs

4

5

3

2

Oats

55

59

75

79

Alfalfa

78

62

7

84

Corn

77

87

84

87

Wheat

50

43

57

8

Barley

21

10

1

Soybeans

19

42

13

Source:

(»6

1974 Census of Agriculture^ U. S. Department of Commerce,
Bureau of the Census, Volume 1. State Reports, Part 23,
Minnesota. State and County Data, D. S. Government Printing
Office, 1977.

•Class 1-5 farms arc farms with sales over $2S00/ycar.

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By obtaining information on occupation, similar estimates of dis­
charge rates and relative risks of farm workers to nonfarm workers can
be made.

The number of people evaluated in this manner will be substan­

tially less since the primary group of interest would be males between
25 and 64 years of age.
To effectively use all of the data from participating hospitals, a

case-control, inhospital comparison can be undertaken.

This type of

analysis makes use of data from small hospitals (reducing any bias due

to hospital size, such as cost) and includes data on patients using the
two population-based hospitals who reside in another county and who were

not evaluated in the first two analyses.

Evaluating years of agricul­

tural exposure is more valid than previous analyses for retired or
exfarmers, for farm workers not living on farms, and for farm residents

not working on farms.

By using all the data, a case-control study effec­

tively doubles the number of cases from the population-based analysis.
Selection of an inhospital control group for the above analysis is

an important but difficult task.

Relative risks from the population­

based analysis should give good information on the types of diagnoses
for which farmers and nonfarmers are at equal risk and, hence, should be

suitable for use as control diagnoses.

Through the addition of smoking

histories, it is possible to adjust for smoking habits, an adjustment
not generally possible in the population-based analyses.

To complement the above analyses, a variety of inhospit.!'

tistics can be calculated for farmers and nonfarmers, such as diagnosis­
specific lengths of stay, age and sex distributions, and admission

blood pressures.

Birth statistics such as percent of abnormalities or

stillbirths, average age of mothers, complications, etc., may provide

valuable information.

Hospital mortality statistics are not necessarily

valid in this study since mortality can be affected by distance to the

hospital and since m my patients dying in the hospital would have incomnle*^

*t ional and smokin ’, histories.

It is hoped that by looking at data from a variety of hospitals in
several different types of analyses, a reasonable picture of the relative health of farmers and nonfarmers in rural Minnesota can bo provided.

11

• - -»!

Statistical Methods

lor the population-based hospitals, sex-specific discharge rates,
age adjusted by the direct method to the nonfarm population were cal­

culated for the groups of interest.

The ratios of farm to nonfarm rates

were used to calculate relative risks.

Data from the two counties and

hospitals were combined to obtain sufficient numbers of cases for

meaningful comparisons.

For the case-control analysis, estimates of

relative risk were calculated as given by the Cornfield [7] approxi­

mation.

Relative risks of the farm exposure categories to the nonfarm

group for the individual smoking and age categories were made for diag­

noses of interest and then summarized over age and smoking categories

using the estimator "R" of Mantel and llaenszel [8].
Since it was necessary to provide an assessment of the relative
importance of each relative risk, tests of statistical significance were
used as a moans of identifying diagnoses whose increased relative risk

for farmers exceeded chance fluctuations.

One-sided significance tests

were used since the purpose of this study was to identify possible

problem health areas in agriculture.

lor the population-based hospitals, differences in the age adjusted
rates were compared by computing the standard errors of the rates as
given by Keyfitz [9] and then by calculating a z-statistic for the dif­

ference between two rates.

In the case-control analysis, a Mantcl-

Haenszcl chi-square statistic [8,10] was first used to test for a dose­
response type relationship between years of exposure and summary rela­
tive risks. For each exposure category, another Mantel-llaenszel chi-

square statistic tested the significance of each summary relative risk,
disregarding whether a dose-response relationship exi stcd.

IS

u

THE USE OF HOSPITAL DATA IN EPIDEMIOLOGICAL RESEARCH

The aforementioned study plan has as its basis hospital records,

summary

jA

the advantages and disadvantages of using hospital data is

important to the understanding of the significance and limitations of
the rer.Jts of the study.

This type of study is meant to be a rough

screening over a variety of conditions and does not replace a carefully

directed population study involving examinations and case histories.
The use of hospital data in epidemiological research has been
described by Masi [11] and in a report sponsored by the National Center
for Health Statistics [12].

Advantages include the availability of a

large number of cases of varying diagnoses plus cases which can be used

for controls; the possibility of collecting information on independent
variables of interest such as smoking; the high degree of diagnostic

accuracy in defining case and control population; and, certainly, time
and cost considerations.

Limitations include the possibility that hospital-detected cases
may be selective subjects of the true disease cases; adequate control

groups often arc difficult to determine; and often the population at
risk cannot be precisely defined.

parability among hospitals.

Data can vary in quality and com-

Estimates of the incidence of chronic

disease arc less valid than for acute attacks.

The use of only hospital

data loses the diseases and conditions treated on an outpatient basis

and the mortality occurring outside the hospital.

Berkson [13] has

pointed out problems in validity which arise when admission rates for
cases and controls arc different and arc related to the independent
variable under study.

The use of secondary diagnoses is not necessarily

valid since the secondary diagnosis alone often would not result in

hospitalization.
Another problem area is the reliability of hospital discharge

abstracts.

If the researcher has enough time and resources, he can

perform a carefully controlled abstracting of the medical records for
his own purposes, but usually the researcher can only use already
17

Preceding page blank

u

j
abstracted data from existing sources.

The National Academy of Sciences

Institute of Medicine sponsored a study of the reliability of hospital

discharge abstracts [11] in which data from six abstracting services,
including CPil\, were evaluated.

Items such as age, sex, and dates of

stay were found to be at least 98*6 reliable upon reabstracting but the

reliability of the fourteen chosen target diagnoses in the sample
varied,

using H-ICDA coding, four-digit reliability was 65OO and three-

digit reliability was 74no.

A CPHA study gave 88°o reliability for diag­
Factors such as training of abstrac­

noses coded to four digits [IS].

tors, procedures and supervision in the medical record department,
thoroughness of record review, and the necessity of relying on pro­

fessional judgment due to the inadequacy of nomenclature, coding guide­

lines, or the presence of multiple diagnoses are influential in deter­
mining reliability.

Since these studies, CPIIA and the other abstracting

service have attempted to correct some of the reliability problems.
Diamond and Lilicnfeld [16] studied tie effects of misclassification of
diagnosis or patient status with regard to the independent variable

under study.

Problems arise when the misclassification rates are dif­

ferent between cases and controls.
The Institute of Medicine report gave recommendations for using

hospital data.

Analysis involving age, sex, and length of stay are

reliable and data on principal diagnoses arc adequate for general

program management and monitoring purposes.

For research and evalua­

tion, diagnoses should be coded to three rather than four digits and
even coarser groupings of diagnoses will provide greater reliability.

Kith regard to the previous discussion, attempts were made in the
Rural Health Study design to incorporate as many of the suggestions as

possible, notably the use of multiple hospitals to balance selective
admissions, the use of several analyses to evaluate the adequacy of
controls and the use of three-digit and cruder H-ICDA coding.

18

u

DATA COLLECTION

Questionnaire Administratinn

Questionnaires were administered by hospital personnel to all
patients 18 years of age and older.

Those patients under 18 years were

required to have only the county and place of residence recorded on the
questionnaire form,

One questionnaire was to be submitted for each

discharge, even if only the county of residence and patient number were
recorded.

If a patient would not or could not respond to the ques-

t ionnaire. it was suggested to obtain as much information as possible
from the patient's records.

Because of differing hospital procedures and workloads, it was left
to the hospital to determine the best time, person, and place to ad­

minister the questionnaires.

Some hospitals used admitting personnel,

some used nurses, and some used special persons designated to collect
the information.

Time of administration in some hospitals was during

admittance, while in others administration came after the patient had

been settled in his room or after his condition had stabilized.

To

minimize missing data, the former method was preferable but the latter

method is thought to give more reliable information since more time was
taken.
In one hospital, it was necessary to complement the post admittance
administration with a telephone follow-up, since a large number of

patients with short stays was missed,

for patients with more than one

admission during the study period, some hospitals repeated adminis­

tration of the quest ionn.ii re unless the patient objected, while other
hospitals did not repeat the questionnaire.

Repeat adninist rat ion is

the preferred mode of action to get an estimate of the reliability of
questionnaire i.c.o.

Cod i n,I and Rece ipt of P.it.i
At the end of each month of the study (when preparing the patient

abstracts to be sent to (TIL\), the medical records personnel added the

19

precoded questionnaire responses to predetermined, previously unused

fields on the PAS abstract form.

CPHA then provided quarterly data

tapes of the required medical and demographic information, plus the
questionnaire responses.

Completed questionnaires were then sent by the

hospitals to the UBTL after the responses had been recorded each month.
These were used to compare with the cata tapes to check for transcrip­
tion errors and were used when editing of the data tapes revealed

inconsistencies.

After nine months of the study were completed, one of the hospitals
changed abstracting services from CPHA to the MED-ART system of Diver­
sified Computer Services (DCA) of Palo Alto, California.

Data for the

last three months of the study were then obtained from DCA.

The change­

over did not disrupt data collection or quality; coding was the same or

similar to that previously used; the only differences related to the
study were in format.
Data Quality

A total of 16,598 discharge cases were collected from the six

hospitals for the period from April 1, 1976, through March 31, 1977.

Of
(

these, 3594 cases were under IS years of age and minimal questionnaire

information required.

for the remaining 13,004 cases, Table 4 gives a

breakdown of the number of cases, and the cases with missing or in-

complete data, both on a per hospital basis and a per county resident

As a function of the method

basis for the population-based hospitals.

of questionnaire administration, Douglas County Hospital showed a high

proportion of missing data.

Telephone follow-up was conducted only for

residents of Douglas County, reducing the missing data proportions for

the county residents to acceptable levels.

Before counting a case as

missing, it was checked for additional admissions with complete data
during the study period.

lor the first few months, .ill questionnaires were compared to the

computer listings and errors tabulated.

sample was compared.

After that, approximately a 25°>

Computer editing revealed incorrect codes, missing

data, shifts in coding, and inconsistency in responses, while the

20

• •••

Table 4.

• •••

Rural Health Study Cases - April 1976-March 1977

Per Cent Cases With Missing Data
lor Selected Quest jonnai re Itccss
Tut al So.
of Cases

Nu. of Cases <18 Yc.»r$
Newborn
Other

No. cf Cases
z!8 Years

No. of Cases ?!8 Years
With Complete U.ntn
(i'er Cent)

Question 2

Question J

Question 7

Mi Cases

7512

664

635

5813

5’05

(931)

0.4

1.5

1.9

County Residents
Only*

4244

520

4 79

324 5

3173

(97.8)

0.5

1.7

2.2

Ail Cases

4534

414

493

367’

3312

(90.2)

7.5

9.7

9.8

County Residents
Only*

34 50

330

352

2768

2621

(94.7)

2.8

5.3

5.3

Me I r >

Ml Cases

1512

166

199

1127

1121

(99.5)

0.1

0.5

0.5

I iynesv iI*e

All Cases

1371

218

186

967

929

(96.1)

1.8

3.4

3.9

A I*' »ny

All Cases

97$

120

135

720

719

(99.9)

0.0

0.0

0.1

All Case*

8.4

72

67

705

69 7

(98.9)

0.1

0.9

l.l

All Cases

16593

1674

1920

13004

12483

(96.0)

2.4

3.7

4.0

County Residents
Only*

7t9S

850

831

6013

$ 764

(96.4)

1.6

3.4

3.6

••: 1:

J

:.li

Tutd

!

'I kIcs data from all study h-spttals.

comparison of questionnaires and listings revealed errors in trans­
cription which would not ordinarily be found during computer editing.
Table 5 summarizes the frequencies of various types of errors and

inconsistencies in questionnaire responses.

When questionnaires differed among multiple admissions, it was
decided to use the first response in the analysis, so that the data were
comparable to all of the patients with single admissions,

Conflicts

within admissions, however, were resolved by using the most consistent
answers or by taking the positive answer (i.e., if a person stated that

he had never been a farmer and then stated that he had worked in agri­
culture for 20 years, it was assumed that the first answer had been
recorded erroneously).

CPiLV data had been previously edited and were used as they were
received, subject to the limitations described earlier.

From multiple

admissions, an occasional difference in age or sex was noticed, however,
and could be resolved.

Popu1 a t ion I.s t i ma tes

Pi/pulation estimates were not available for the categories desired
except from the 1970 census.

Current estimates were made as a combina­

tion of 1970 census figures and any new relevant information.

U. S.

census data for 1970 were the basis for making estimates of the number of

farm and nonfarm residents plus the number of farm and nonfarm workers
in Kandiyohi and Douglas Counties.

The Minnesota State Planning Agency

is the official census designate in Minnesota and makes yearly estimates
and projections of the population of Minnesota counties, including

breakdowns by age and sex [17].
mates arc made.

\o farm, non fa rm, or employment csti-

Thc Minnesota Department of Fmploymcnt Services in

conjunction with the U. S. Department of Agriculture Statistical Re­

porting Service makes county monthly employment estimates of farm
and non farm employment but uses different definitions than the census
*•

and does not distinguish by age and sex.
Using 1970 census figures and 1975 State Planning Agency figures
for county and major city populations (Willmar in Kandiyohi County and

Alexandria in Douglas County), projections were made for the 1976 total

4
Tabic 5.

Rates of I'rrors anJ Inconsistencies

i yp e of i rror or I neons i stoney

No. of Cases with Errors
or Inconsistencies

Total Possible Cases

Rate

227

12,063

1.99.

Inconsistency • thin Case

261

12,063

Inconsistency among Multiple Admissions
(Average of 3.6 questions
per admission)

661

4,266

2.2°j
15.6‘o

Coding or Transcription Error

(15,338
responses)

(4.3* per
question)

population, the difference between the county and city populations

being the ru^.U population.

Using 1970 census ratios of rural farm to

rural nonfarm, the projected 1976 farm population was determined, with
the city and rural nonfarm population comprising the nonfarm population.

Farm and nonfarm age and sex proportions from the census were adjusted

to the 1975 Planning Agency age and sex proportions, and then applied to
the 1976 projections.

The end result was 1976 estimates of the farm and

nonfarm population by age and sex.

Table 6 gives these figures.

As a

check, straight line projections of 1970 age, sex, and residence cate­

gories w^re not far from the estimates in Table 6.

In determining the number of workers, the 1976 population estimates
were multiplied by the 1970 census proportions of each age group who
were in the labor force, thus obtaining the labor force.

Rates of

increase in the number of farm workers and nonfarm workers as obtained
from the Minnesota Department of Employment Services for 1970 to 1976
were used in conjunction with 1970 census figures t. divide the labor

force into farm and nonfarm workers.

Table 7 presents the estimates.

Comparisons of these estimates and the 1970 ccnsu; figures show the ratio
of farm to nonfarm workers to be about the same.

*

Table 6
POPULATION BY AGE, SEX, & RESIDENCE

Females

Males

Kandiyohi County

ESTIMATED 1976

Age Category

Farm

Non Farm

Ratio

Farm

Non Farm

Ratio

<15

1184

2786

2.4

1040

2747

2.6

15 - 24

919

2751

3.0

611

2734

4.S

25

34

298

1378

4.6

374

1360

3.6

35

44

473

1085

2.3

506

1082

2.1

45

54

492

1507

2.7

491

1294

2.6

55 - 64

559

1244

2.2

372

1439

3.9

74

241

1G32

4.4

169

1144

6.8

i75

139

665

4.8

97

1005

10.4

Total
Population
(33,038)

4505

12,268

2.8

3660

12,805

3.5

65

Foma 1es

Ma 1 c s

Douglas County
Farm

Non Farm

Rat io

Earn

Non Farm

Rat io

<15

904

2084

2.3

1003

1952

1.9

15 - 24

764

1835

2.4

592

1891

3.2

25

34

322

937

2.9

297

997

3.4

35

44

375

729

1.9

369

793

2.1

45

54

129

786

1.8

592

G72

55

64

497

863

1.7

581

957

2.5

65 - 74

529

2.5

202

1002

5.0

•75

112

725

6.5

104

9( 1

8.7

Total
Population
(25,215)

3732

8778

2.4

3340

95(5

2.8

Age Category

25

Tabic 7.
MALE FARM WORKERS BY AGE - ESTIMATES 1976

I Houglas County

Kandiyohi County

Age Category

Farm
Workers

Other Workers

Ratio

Farm
Workers

Other Workers

Ritio

25 - 34

249

1,342

5.4

253

961

3.S

35 - 44

314

1,139

3.3

327

760

2.3

45 - 54

407

1,104

2.7

36o

696

1.9

55 - 64

4 SO

1,055

2

476

717

1.5

TOTAL

1,480

4,620

3.1

3,134

2.2

2(>

RESULTS /VXD DLSCUS^IOX

Analysis of I’opulat ion-B.isod HoS|>ita 1 s

1.

Analysis by Place ol l‘vsiJencc.

Primary diagnoses were tabu­

lated by age and sex for current farm and .nonfarm residents.

Age group­

ings used ten-year intervals with those patients under 13 and '5-andolder comprising the end groupings.

Age adjusted discharge rates were

calculated for three groupings of residents: less than 25 years old, 2561 years old, 05 years and older.

The ratios of the age adjusted rates

for farmers to nonfarmers gave the relative risks.

Since the rates are

known to be underestimated for both farm and nonfarm residents, only the
relative risks and number of cases are presented.

Bata from both

counties are combined in order to maxinice the number of cases and to
ensure privacy ot an individual hospital’s data.

Patient origin studies during November, 1976, as conducted foz*

Minnesota Hospital Research and Educational Trust, were used to test the
adequacy of the assumption that most of the hospital experience of
residents from Douglas and Kandiyohi County was captured.
presents the results of the one-r.K>nth study.

Table 8

Eighty percent of Douglas

and Kandiyohi County residents went to study hospitals; however, most of

the patients attending other hospitals went to large referral hospitals

where a bias in hospital selection for farmers is not suggested.

In

fact, 9r« of the county residents going to hospitals in the immediate
area went to study hospitals.

In. the Rural Health Study, data on only thirty Douglas County
residents were obtained from other study hospitals; almost all went to
Glenwood. No discernible differences in the proport ion of farmers could

be seen between these thirty patients and those attending Douglas County
Hospita1.

Kandiyohi County residents Koing to other study hospitals numbered

1«2, 169 of these going to Paynesville Connunity Hospital, which is two

miles from Kandiyohi County, and eleven cases going to the Glenwood

f

Table 8.

Origin Study, November 1976,
Kandi;.oni ana oougiaS Counties

Hospital Destination for County Residents

Douglas
County

Kandiyohi
County

Total

Hospital in the Same County as Residence

270

249

S19

Neighboring* Study Hospital

1

8

9

Neighboring* Non Study Hospital

18

13

31

Non Neighboring Non Study Hospital

8

Rtfcrral Hospitals in Twin Cities.
Rocheste-, St. Cicud

42

48

90

Total

339

325

664

Per cent of county residents going to
study hospitals

so;

79;

so;

Per cent of county residents going .o
study hospitals as a per cent of coi.nty
residents going to hospitals in th*,
immediate area

94;

95;

94;

Neighboring hospitals
*■

15

the hospitals which arc the closest hospitals

Minnesota Hospital Research -S Educational Trust.

25

V

Hospital, twenty-six miles from the county line.

About 40% percent of

Kandiyohi County residents admitted to the out-of-county study hospitals

lived on farms, as opposed to about 20% admitted to in-county hospital.

Willmar Hospital is the largest in the western part of the State so it
would lose patients to a smaller hospital usually only when distance or
cost was a factor.

Since Paynesville is so close to the county border,

it naturally attracts many Kandiyohi County residents tc it; but only

two other hospitals would be closer than Willmar for a few Kandiyohi
County residents.

Based on the patient origin study plus the size,

distance away, and number of neighboring hospitals, at most 150-200

county residents per year would choose these hospitals.

As for deter­

mining relative risks, the differential in percentage of farm residents
attending the in- and out-of-county hospitals could result in under­

estimating the farm hospital discharges by 30-40 cases; and, likewise,
overestimating the nonfarm discharge • by the same amount, a possible 7

percent underestimation of the overall relative risk for Kandiyohi
County farm residents.
Cases were counted and relative risks tabulated using the major
disease classifications from H-ICDA.

These major classifications were

further broken down using H-ICDA subclassifications and, in some in­
stances, to three-digit coding when the number ot cases was sufficiently

large.

For patients with multiple admissions, only the first admission

in the disease class, subclass, or individual code under study was used.
In this way, a patient would only be used once for each major classi­

fication, but might also be found in several of the subclassifications,

so the totals of the subclasses do not necessarily equal the totals in
the major classifications.

Appendix I presents the number of cases and

relative risks of living on a farm compared to not living on a farm.

Tables 9a and 9b summarize the primary diagnoses for which farm
residents show increased relative risks over nonfarm residents.

The

only statistically significant increased relative risks were for lacera­
tions and open wounds for male patients loss than 25 ycais of age;
diseases of the liver, gall bladder, and pancreas (primarily gall blad­

der) for male patients 25-64 years old; and pneumonia, hernia of the
abdominal cavity, and benign prostatic hypertrophy in male patients

older than (5 years of age.

Female farm residents over 65 showed

29

• •••

Tabic 9a.

Diagnostic Categories with Increased Relative Risks for Farm
Residents as Compared to Non Farm Residents - Males

Males

Diagnostic Category

Age
Age 25-64

Age >65

o

N.S.

H-ICDA Codes

No. of Cases
Farm
Non Farm

Relative
Risk

Significancc

Appendiciti s

540-545

15

17

1 .9

N.S.

Lacerations 8 Open bounds

S70-S97

9

9

2.6

p<.OS

Diseases of the Dlood ii Blood
Forming Organs

280-289

2

1

4.4

N.S.

Diseases of the Liver, Gall
Bladder, 8 Pancreas

570-577

16

19

2.0

P<.05

Infective 8 Parasitic Diseases

001-136

5

9

2.0

N.S.

Endocrine, Nutritional, 8
Metabolic Di seises

240-27y

17

2.3

N.S.

Diseases of the Blood 8 Blood
Forming Organs

280-289

4

6

5.5

N.S.

Diseases of the Fye

370-378

7

20

1.9

N.S.

.-'cute Upper Respiratory
In feetions

460-470

2

5

4.3

N.S.

Pncu.T.on ia

430-486

17

35

2.3

p<.05

Hernia of the Abdominal Cavity

550-553

17

24

2.7

p<. 05

Diseases of the Urinary System

580-599

IS

46

1.6

N.S.

Benign I'rostatic Hypertrophy

600

19

49

1.8

p<. 03

Osteomyelitis f. Other Diseases
of Bone 8 -Joint

720-729

6

7

5.0

N.S,

Not statistically significant, a = .05

Table 9b.

Diagnostic Categories with Increased Relative Risks for Farm
Residents as Compared to Non Farm Residents - Females
No. of Cases
Farm
Non Farm

Signficancc

6

2.2

N.S

5

3.3

N.S

3

2.6

N.S

4

8

1.8

N.S

623

8

13

1.7

N.S

Diseases of the Skin G Sub­
cutaneous Tissue

680-709

7

10

2.1

N.S

Cerebrovascular Disease

430-438

8

40

1.9

N.S

Diseases of Veins, Lymphatics,
G Other Circulatory Diseases

450-458

5

26

1.7

N.S

Diseases of Gall Bladder

575

11

17

5.1

p<.01

Uterovaginal Prolapse

623

3

14

1.7

N.S.

Diagnostic Category

Age <25

Diseases of the Gall Bladder

S75

3

Age 25-64

Diseases of the Eye

370-378

5

Diseases of the Arteries,
Arterioles, G Capillaries

440-448

Append icit i s

540-543

Uterovaginal Prolapse

Age -65

N.S.

Relative

Risk

H-ICDA Codes

Females

Not statistically significant. a = . 05

u

1
$

1
statistically significant increased relative risks for only diseases of
the gall bladder.
The relative risks of farm to nonfarm residents for all diagnoses

(one admission per patient) was 0.8 for patients less than 25 years old
and patients 25 to 64 years of age.

risk jumped to 1.3.

For patients over 65, the relative

This may indicate a problem health area for older

farm residents but could also indicate problems with identifying farm

residence in older retired farmers.

Many older persons mignt report,

living on farms which would not be classified as farms by the census

because no goods were sold.

Over all age groups, farm residents had

slightly lower hospitalization rates than nonfarm residents.
Of special note is the category "Injuries and Adverse Effects" for

which the relative risks are always close to one for the age and sex
groups.

If farm and nonfarm residents are at equal risk, then this

broad classification with a large number of occurrences and no one

frequently occurring condition could be an appropriate control group for
the case-control comparison.
2-

Analysis by Occupation.

Tabic 10 presents numbers of cases

and age-adjusted relative risks for current male farm workers, ages 25-

64.

Since the number of cases is sharply decreased, only relative risks

for the major disease classifications are given.

Farm workers showed

lower relative risks than nonfarm workers for almost all disease clas­
sifications.

A possible explanation could be that active farm workers

are being compared to a group of nonfa*m workers which includes a large

number of sedentary occupations.

This result could also reflect the

true relative health of farmers but might indicate problems due to the

lack of precise estimates of the number of farm workers.

Douglas County

relative ris.'.s were lower than those from Kandiyohi County, so the

problem may be in Douglas County estimates.

Again of notice is the

relative risk for injuries and adverse effects.

The relative risk is

near one (equal to one for Kandiyohi County), which strengthens the

assumption that injuries and adverse effects could be used as a control
group.

32

TABLE 10.

RELATIVE RISKS FOR CURRENT FARM WORKERS - MALES. AGE 25-64
No. of Cases

ll-ICDA Codes

Farm
Workers

Non Farm
Workers

Relative
Risk

Infective u Parasitic Diseases

001-156

1

19

0.1

Neoplasms

140-239

3

25

0.2

Endocrine, Nutritional, 6
Metabolic Diseases

240-279

2

15

0.4

Diseases of the Bicod 5
Blood Forming Organs

230-239

1

2

.Mental Disorders

290-318

2

27

1.0
0.1

Diseases of ’he Nervous System
h Sense Oi ans

320-3S9

6

19

0.8

Diseases of the Circulatory
System

390-458

26

82

0.8

Diseases of the Respiratory
System

460-519

5

21

0.6

Diseases of the Digestive
System

52O-S77

33

112

0.7

Diseases of the Genitourinary
System

580-629

11

60

0.4

Diseases of the Skin
cutaneous Tissue

bS0-709

3

17

0.4

Diseases of the Musculo­
skeletal System
Connective
T issue

710-739

8

38

0.6

Signs, Symptoms, III Defined
Conditions

770-795

8

49

0.4

Injuries 5 Adverse Effects

800-999

22

72

0.8

All Diagnoses

001-999

131

558

0.6

Diagnostic Category

u*

Sub

u

Case-Control Anu 1ysis

because of problems in the accurate estimation of populations nt

risk and in the collection of all hospital experience in the study
counties, plus the limited number of cases used in the population-based

analysis, a third type of analysis attempts to utilize all of the data

from the six hospitals.

Selection of a control group is of primary

importance for an inhospital comparison.

Because of the consistency of

relative risks near one in the previous analyses, the group of cases of
primary diagnoses of injuries and adverse effects (H-ICDA code* 800-999)
was selected for use as a control group.

This category, composed of

acute conditions, is also suitable for comparison because the indepen­

dent variable under consideration is ’’Years of farming," which is not
necessarily related to acute conditions due to the number of exfarmers

or retired farmers.

The "Injuries and Adverse Effects" category is

composed of a variety of conditions, none of which occurred with high

frequency.

By comparing all other diagnoses of interest to this control

group, diagnoses with large relative risks for farmers can be identificd.

At the very least, such an analysis can give an idea of the

rcl.rive importance of various health problems for the farming popu-

lat ion.

"Years of Farming" was divided into three categories:

19 years, and 20 years and over.

none,
none, one to

The relative frequencies of these

' /’categories in the control and test groups were then compared by diag-

nosis.

For the age 65-and-older groups, the exposure category 1-19

years was eliminated due to the small number of patients in the category
(especially for the control diagnoses).

The relative risks were ob-

. .tamed by calculating summary relative risks from the farming-diagnosis
breakdown, stratified by age and smoking history.

Relative risks are

given separately for the age 25- to 61-year-old group, stratified by
ages 25-H and 45-64, and by "never smoked", "previously smoked",

"current smokers"; and for the 65 years and older group, stratified by
ages 63-74 and 7S-and-older, and by "never smoked"

and "ever smoked”.

Appendix II presents the number of cases and the summary relative risks

31

for all diagnoses containing sufficient numbers of cases in the strati­

fied groups.

,\s in the population-based hospital analysis, only a

patient s first discharge is tabulated within a disease class or sub­
classification and only primary diagnoses arc used.
Tables Ila and 11b summarise the diagnoses for which patients with

farming exposure show increased relative risk.

For patients 25-64 years

of ago, there were statistically significant relationships between years
of farming exposure and relative risk (as tested by the Mantel-llaenszcl

test) for benign prostatic hypertrophy and osteoarthritis and allied
conditions in males, and for acute myocardial infarction and utero­
vaginal prolapse in females.

Females also showed significantly elevated

relative risks for patients in the 1-19 year exposure category for

diseases of the urinary tract, diseases and conditions of the eye, and
ulcer of the duodenum.

for patients over 65 years of age, males with greater than 20 years
of agricultural exposure showed relatively few increased relative risks

while females with the same exposure had a large number of increased
relative risks.

Signifleant 1y large relative risks for this group of

faim females were tor the diagnoses: neoplasms (including primarv malig­
nant neoplasms); diseases of the respiratory system; diseases of the

gall bladder; diseases of veins, lymphatics and other circulatory di­
seases; diseases of the digestive system (including diseases of the

esophagus, stomach, and duodenum); diseases of the genitourinir'’ svstem

(including uterovaginal prolapse); and osteoarthritis and allied conditions.
Over a 11 diagnoses for patients between 25 and 64 years of age,

those patients with farming exposure showed relative risks near or

Slightly less than one, as compared with patients with no farming
exposure.

Males over

with farming exposure had an overall relative

risk of 0.7, while females over (>5 with the same exposure had a relative

risk of 1.5.
Only 111 discharges were recorded for current hired ♦'arm workers,
60 tor males and 48 tor females.

Because of the small numbers, no

attempts were made to evaluate differences in diagnosis patterns be­
tween hired farm workers and family farm workers.

55

Table Ila.

Diagnoses with High Relative Risks Associated with an
Agricultural Occupational History,
Ages 25-64

Diagnosis Category
Males

Females

H-ICDA Codes

Relative Risks
1-19 Yrs. in Ag.

(No. of Cases)
£20 Yrs. in Ag.

Diseases of the Blood 6
Blood Forming Organs

280-289

0.0

(0)

3.5

(4)

Psychoses not Attributable
to Physical Conditions

306-309

1.7

(6)

3.1

(6)

Heart Failure

427

2.9

(1)

5.1

(S)

Phlebitis 5 Thrombo­
phlebitis

451

1.8

(3)

2.1

(6)

Hemorrhoids

455

1.3

(5)

2.1

(ID

Bronchitis, Emphysema,
Asthma

489-496

0.9

(3)

2.2

(14)

Inguinal Hernia

560

1.5

(30)

1.6

(43)

Biliary Calculus

574

2.4

(3)

1.7

(4)

Other Bladder Disease

596

1.9

(1)

4.9

(5)

♦ Benign Prostatic Hypertrophy 600

1.0

(6)

2.2* (29)

♦ Osteoarthritis 8 Allied
Conditions

713

5.2

(4)

5.9* (11)

Cancer of Large Intestine

153

0.0

(0)

2.5

(4)

Diabetes Mel 1itus

250

0.6

(5)

2.2

(12)

Diseases G Conditions of
the Eye

360-379

2.0* (10)

0.6

(4)

410

1.3

(3)

8.0

(9)

Cerebrovascular Disease

430-438

3.0

(4)

2.3

(3)

Disease of Arteries,
Arterioles, Capillaries

440-448

0.5

(1)

2.0

(5)

Ulcer of Duodenum

532

4.8* (6)

1.4

(3)

Intestinal Obstruction

560

0.3

(1)

2.1

(3)

Diverticular Disease of
Intestine

562

0.8

(2)

2.1

(S)

Other Diseases of Urinary
Tract

599

5.9**(7)

3.2

(4)

Endometrios i s

619

2.2

(10)

1.4

(5)

♦ Acute Myocardial Infarction

623

0.5

(4)

3.2**(27)

Diseases of Skin
Sub­
cutaneous Tissue

680-709

0.9

(6)

3.3

(12)

Osteoarthritis -5 Allied
Conditions

713

2.1

(4)

1.3

(5)

♦ Uterovaginal Prolapse

Statistically sign11 leant relationship to years of exposure, p <.05.
’*

Relative risk statistically significantly greater than 1, p <.05, p <.01.

36

u

Tabic 11b.
Diagnoses with High Relative Risks Associated with a
Agricultural Occupational History
Ages 265
H-ICDA Codes

Diagnosis Category

Males

Females

Relative Risk (No. of Cases)
£20 Yrs. in Ag.

Psychoses not Attributable to
Physical Conditions

306-309

2.0

(5)

Diseases of Veins, Lymphatics,
S Other Circulatory Diseases

450-45S

2.3

(24)

Diseases of the Gall Baldder

575

1.6

(31)

Other Symptoms Referable to
Cardiovascular 5 Lymphatic
System

775

2.0

(7)

Neoplasms

140-239

1.7* (94)

Primary Malignant Neoplasms

140-195

1.6* (60)

Malignant Neoplasm of Large
Intestine

153

2.1

(13)

Secondary Malignant Neoplasms

196-199

2.0

(14)

Diseases of the Blood G Blood
Forming Organs

280-239

2.1

(9)

Diseases of Veins, Lymphatics,
€ Other Circulatory Diseases

450-4SS

1.9* (39)

Diseases of the Respiratory
System

460-519

1.7* (69)

Pneumonia

480-486

1.8

Other Diseases of the Respiratory
System

500-519

2.5

Diseases of the Digestive System

520-577

(ID
1.6**(140)

Diseases of the Esophagus, Stomach,
Duodenum

530-537

1.8* (38)

Gastritis f, Duodenitis

535

3.6

(8)

Hernia of Abdominal Cavity

550-553

2.0

(14)

Biliary Calculus

574

1.9

Diseases of Gall Bladder

575

(14)
1.9* (36)

Diseases of Genitourinary System

580-629

1.8* (73)

Diseases of th' Breast

610-611

2.7

Uterovaginal Prolapse

623

(9)
3.1**(25)

Infections of the Skin 6 Sub­
cutaneous Tissue

6S0-6S6

2.7

Osteoarthritis 6 Allied Conditions

713

(28)

(9)
2.3**(53)

Relative risk statistically significiantly greater than 1, p<.0S, p<-.01

37

Co rip a rat ivc Hospital Statistics
lor the major disease classifications, comparisons of several
hospital statistics are given in Tables 12a and 12b.

These statistics

are tabulated for patients never having worked in agriculture versus
those who have worked in agriculture.

/\n obvious result of this di-

chulomizat ion is that the patients ..I:’.* a../ :»gricultrrn 1 occupational
history are older than those patients not having worked in agriculture.
Therefore, the statistics describing mean length of stay, case mortality

rates, and admission blood pressure have all been age-adjusted to the

Over all diagnoses, patients with farming

combined age distribution.

exposure had almost identical lengths of stay, case mortality rates,

and admission blood pressures as those patients having never worked in
agriculture.
A comparison of pregnancy and newboc:-. . tat i sties fo:

and nonfarm residents or workers is shown in Table 15.

.1 .• farm

No large dif­

ferences can be seen in the outcome of pregnancies between the farm and

nonfarm groups.

Current farm workers or housewives hod a slightly

larger percentage of spontaneous abortions than the nonfarm females, but

the difference is not statistically significant (\* [1 d.f.]:2.37).
Medical characteristics of patients for whom no (Questionnaire data
were obta i**' 1 we** ’

nairc data.





» j •«. ~

•?

Table II presents the results,

• • , . -.

lor Douglas County, where a

telephone follow-up interview was used to obtain data on patients who

did not h.ve a completed (Questionnaire during their hospital stay, the
characteristics of original respondents, telephone respondents, and nonI ron these tables, as can be

resp..»nd’nt • ar<* compared in lable 15.

easily seen, there is a much higher proport ion of deaths in the nonre­
spondent gre'ip; patients died before (Questionnaire could be adminis­

tered.

Ibis t act plus the fact th it study data do not contain infor-

m.»t ion on qutsou'. dying outside of the hospital
•n anin.;f il mortal itv compari

make any attempt at

ms in these data tenuous.

The high?r

project ion of circulatory diseases in nonrespondents reflects the most
comr.on c.ru.es of death.

Nonrcspandents and respondents were basically

the .amc age but the nonre pendents had a slightly shorter length of

5S

e

t I

i

Table I2a. In-llo.pital Cb.arac ter i st its by Final Diagnosis - Males

Medi an

H-ICbA

bia;:nostic Catcgory

lam
Exposure

No. of
Case;

(Years)

Mean
length of
a
Stay (Days)

Mean Admission
Blood Pressuroj_
Systolic
Diastolic

Infective G Parasitic
Di souses

001-136

Ever Famed
Nev -r Famed

53
IS

63
41.5

5.0
4.6

1.2
3.2

142.4

Neoplasms

i:n-25i)

I vor Fimed
Never I a med

244
121

73
67

12.2
10.9

13.3
22.8

139.7

Ever Famed
Never tamed

51
30

69
39.5

7.7
6.7

5.6
3.9

137.4

Ever Famed
Never Famed

IS
6

73
63

10.2
5.7

10.8
0.0

134.3

132.0

134.8

85.2
74.0
78.1
76.8

80.3
84.2

endocrine. Nutri­
tional, G Metabolic
Di senses

240-2’9

Diseases of the Blood 5
Blood Fuming Organs

2 SO-cSO

Mental Disorders

290-31S

Ever Famed
Never Famed

96
.89

5S
41

7.4
S.O

0.0
0.0

141.0

137.6

85.7
85.4

Diseases of the Nervous
System G Sense Organs

520-3S9

Ever Famed
Never Famed

115
3(>

69
34

4.9

5.8

0.6
0.0

142.6
133.2

83.4
75.5

Diseases of the Cir­
culatory S.sten

390-438

Ever Famed
Never Farmed

441

8.8
9.3

11.9
10.7

14S.8
145.4

85.6
85.6

Diseases of :he Re­
spiratory ystem

460-319

Ever Farmed
Never Farmed

1’3
117

7.5

9.4
6.3

157.3
155.2

77.6
76.6

Diseases of the Di­
gest jvc Sy>te:n

520-5”

Ever Famed
Never t amed

51

6.9
(>.7

1.6

3n2

1.9

158.4
137.5

80.3
SO. 1

Diseases of Genito­
urinary System

5S0-629

[ ver Famed
Never Famed

34 3

70
60

6.5
6.2

0.7
0.7

144.1
142.1

S2.3
82.9

Diseases of the Skin
l\ Subcutaneous Tissue

bS;)-709

Ever Famed
Never Famed

48

63.3
30.5

9.5
7.5

1.3
0.0

141.2
131.7

78.6
79.7

tzl

I

Case
Mortality
Rate

63

60

63

179
40

146.4

120.0

67.5
65.0

Table 12a. In-Hospital Characteristics by Final Diagnosis - Males

No. of
Cases

Median
Age
(Years)

Diseases of the Musculo- 710-739
skeletal System G
Connective Tissue

Ever Farmed
X'ever Farmed

147
110

65
48.5

7.7
7.5

0.0
0.0

142.0
142.8

84.1
83.0

Congenital Anomalies

740-759

Ever Farmed
Never Farmed

15
14

54
39.5

4.2
5.8

0.0
0.0

141.2
134.9

87.8
78.3

Signs, Symptoms G
770-796
Ill-Defined Conditions

Ever Farmed
Never Farmed

149
150

62
46

3.9
4.3

1.2
1.0

138.3
141.9

80.6
80.2

Injuries G Adverse
Effects

880-999

Ever Farmed
Never Farmed

288
272

57
30

6.5
6.1

1.1
1.5

137.8
137.9

80.9
78.9

All Diagnoses

001-999

Ever Farmed
Never Farmed

2306
1658

67
51

7.3
7.3

4.8
5.6

141.5
139.8

81.9
81.0

Diagnostic Category

o

a

Mean
Length of
Stay (Days) a

Farm
Exposure

Age adjusted

H-ICDA
Codes

Case
Mortality
Rate -a

Mean Admission^
Blood Pressure*.
Diastolic
Sysrolic

Tabic 12b. In-Hospital Characteristics by Final Diagnosis Fennies

Farm
Exposure

No. of
Cases

Median
Age
(Years)

Ever Farmed
Never Farmed

S3
81

63
36

4.6

4.8

1.4
2.0

134.0
127.8

74.2
75.2

Henn
Length of
a
Stay (Days)

Case
Mortality
Rate e.a

Mean Admission Q
Blood Press::rc‘
Systolic
Diastolic

Diagnostic Category

H-ICDA
Cedes

Infective 6 Parasitic
Diseases

001-155

Neoplasms

140-259

Ever Farmed
Never Farmed

253
250

65
4S

9.2
9.6

6.3
7.1

138.0
133.3

78.6
80.1

Endocrine, Nutrit ional, 6 Metabolic
Diseases

240-279

Ever Farmed
Never Famed

63
55

6S
60

10.0
5.6

0.0
0.0

144.7
146.8

78.3
80.7

Diseases of the Blood
5 Blood Forming
Organs

2S0-2S9

Ever Farmed
Never Farmed

18
16

67
57.5

8.1
4.1

0.0
0.0

131.5
151.5

70.6
77.4

Mental Disorders

290-318

Ever Farmed
Never Farmed

92
174

61
43.5

9.6
8.2

0.0
0.6

155.6
140.3

82.8
84.1

Diseases of the Nervous 320-389
System 6 Sense Organs

Ever Farmed
Never Farmed

150
155

72.5
66

6.3
7.0

0.6
0.0

143.4
143.7

80.0
SI.2

Diseases of the Cir­
culatory System

390-4S3

Ever Farmed
Never Farmed

337
290

75
70.5

10.1

S.3

10.9

8.4

149.3
149.2

84.2

Diseases of the Res­
piratory System

400-519

Ever Farmed
Never Farmed

107
125

74
54

8.2
7.4

2.2
1.4

135.2
136.5

75.3
75.1

Diseases of the
Digestive System

520-577

Ever Farmed
Never Farmed

309
371

66
50

7.5
7.8

1.5
0.4

134.7
136.0

78.8
76.6

Diseases of Genito­
urinary System

550-629

Ever Farmed
Never Farmed

293
417

52
41

5.0
4.0

0.2
0.0

133.5
129.7

77.6
76.2

Ever Farmed
Never Farmed

483
1224

26
24

3.4
3.5

0.0
0.0

124.6
122.8

74.3
74.3

Delivery 6 Compli­
651-678
cations of Pregnancy,
Childbirth,
the
Puerperium

83.8

o

il?
7 :;i r

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tn c.
m ri

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3

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c co

O Cl

O 05

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t/j t£>

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X

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5

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—• c.
x r*

O *- Z.

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m 7n

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V) ir.

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• •. Zt
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-J

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12

n

Table 13.
Comparative Pregnancy and Newborn Statistics

Females .Age 1S-5S

H-ICPA Codes

Current Farm Worker
or Housewife

Not Current Farm
Worker or Housewife

Number of Cases

631-67S

529

2364

Complications of
. Pregnancies

631-639

29 (5.5’-)

157 (5.8“.)

643

24 (4.5t)

73 (3.It)

650-664

311(58.St)

1152(48.7t)

201(64.6t of
Deli verics)

7SS(()S.4t of
Del ivories)

Spentanfous
Abortion
Delivery
Delivery Without
Complicat ions

630

Median Age of
Mothers (years)

25

H-ICIU Codes

Farm Residence

Total births

Y2O-V32

500

St i1Iborn

Y3O-Y32

Liveborn

Y20-Y29

496

Congenital Anomalies

74n-''59

11 (2.2*)

22 (2.(K)

Diseases of Newborn
Infants

760-~6S

35 (7.K)

81 (7.4^)

Other Secondary
Diagnoses

All others

9 (1.St)

33 (S.Ot)

Birx hs

\11

4 (0.8M

Non-Farm Residence
1098

6 (0.5S)

1092

Secondary hiarnoses
of Liveborn

Liveborn Statistics

7 lb. 10 o:.

Median Length of Stay

7 lb. 13 o:.
3 days

No. of Males (t)

266 (54t)

561 (Sit)

No. of heaths (t)

1 (0.2t)

2 (0.2t)

Median Birthweight

43

3 days

u

Table 14.

C
Comparisons of Original Respondents, Telephone
Respondents, and Nonrespondent-S - Douglas County

Original Tel ephone
Respondents Respondents Xonresnondents

Total no. of cases (% of all cases)

4S4

Number of deaths (% of total)

68

Mean length of stay (days)
Median age (years)

(15%) 77

(21%) 75
(3.0%)

(18%)
27

(3°c)

(35.1%)

7.4

4.6

7.5

62

52

60

Diagnostic Category

H-ICDA Codes

Cases

Infective ti Parasitic
Diseases

001-136

44

Neoplasms

140-239

Endocrine, Nutritional, 6
Metabolic Diseases

(82%) 412

2279

Patients living on a farm (% of total)

Cases

%

1.9%

14

201

8.8°

16

Cases

c

3.4°,

1

1.3;

3.9*

4

5.2°.

0.5°,

2

2.6C?

240-279

58

2.5°o

Diseases of the Blood 6
Blood Forming Organs

280-289

17

0.7%

->

0.50?

0

Mental Disorders

0.0°c

290-318

92

4.0'o

15

3.6;

3

3.9;

320-3S9

101

4.4’o

13

3.2;

1

1.3‘

390-458

318

14.O’o

59

14.3;.

26

33.3;

460-519

139

6.1%

19

4.6oo

5

6.5%

520-577

310

13.6%

52

12.6%

4

5.2%

580-629

230

10. 1%

51

12.4%

11

14.3%

631-678

290

56

13.6%

13

16.9%

680-709

32

1.4%

4

1. O’

0

0.0%

Diseases of the Nervous
System q Sense Organs

Diseases of the Circula­
tory System
Diseases of the Respi ratory System

Diseases of the Digestive
System
Diseases of the Genito­
urinary System

Delivery 6 Complications of
Pregnancy, Childbirth, fi
the Peurperium
Diseases of the Skin 6
Subcutaneous Tissue
Diseases of the Musculo­
skeletal System 6 Connect ivc Tissue

Congenital Anomalies
Signs, Symptoms, 6 Illdefined Conditions

Injuries 6 Adverse
Effcct s
Supp1 omenta ry C1 a s s i f i cat ions

710-739

94

4.1%

13

3.2%

2

2.6%

’40-759

8

0.4%

3

0.7%

0

0.0%

770-796

152

6.7%

39

9.5%

2

2.6%

800-999

170

7.5%

42

10.2%

3

3.9%

Y00-Y86

23

1.0%.

12

2.9%

0

0.0%

1

44

Table 15. Comparisons of Medical Characteristics of
Questionnaire Respondents and Nonrespondents

Males

Females

Respondents Nonrespondents Respondents Nonrespondents
Total number of cases

5032

257

Number of deaths (% of total)

232 (4.6?o)

49

Median hge (years)

63

64

47

46. S

Mean length of stay (days)

7.2

6.3

6.4

5.1

% Cases

% Cases

(19.1%)

7431

264

112 (1.5%)

27

(10.2%)

Diagnostic Category

H-ICDA
Codes

Cases

Infective G Para­
sitic Diseases

001-136

99

2.0%

3

1.2% 142

1.9%

4

1.5%

Neoplasms

140-239

4S4

9.6%

10

3.9% 569

7.7%

13

4.9%

Endocrine, Nutri­
tional u Metabolic
Diseases
240-279

87

1.7%

1

0.4% 142

1.9%

5

1.9%

Diseases of the
Blood and Blood
Forming Organs

280-289

24

0.5%

0

0.0%

46

0.6%

0

0.0%

Mental Disorders

290-318

263

5.2%

21

8.2% 354

4.8%

10

3.8%

Diseases of the
Nervous System 6
Sense Organs

320-389

184

3.6%

2

0.8% 317

4.3%

11

4.2%

Diseases of the
Circulatory System 390-458

852

16.9%

62

24.1% 711

9.6%

34

12.9%

Diseases of the Re­
spiratory System
460-519

336

6.7%

15

5.8% 248

3.3%

6

2.3%

Diseases of the Di­
gestive System
520-577

810

16.0%

23

8.9% 780

10.5%

16

6.1%

Diseases of the
Gen i touri nary
System

574

11.4%

19

7.4% 768

10.3%

29

11.0%

1842

24.8%

68

25.8%

94

1.3%

0

0.0%

•1. S’, j 14

5.3%

580-629

Delivery
Compli­
cations of Preg­
nancy, Childbirth
G the Pcurpcrium
631-678
Diseases of the
Skin G Subcutane­
ous Tissue
680-709
Diseases of the
Musculoskeleta1
System % Connec­
tive Tissue
710-739

92

1.8%

1

0.4%

276

5.5%

16

6.2% 316
45

% Cases

u

1

Table 15 (continued). Comparisons of Medical Characteristics
of Questionnaire Respondents and Nonrespondcnts
H-ICDA

Diagnostic Category Codes
Congenital Anomalies 740-759
Signs, Symptoms G

Cases

•s Cases

% Cases

% Cases

%

31

O.(v.

1

0.4-,

16

0.2^

1

0.4°,

770-796

316

6.3Av

21

8.2* 401

s.n

20

7.6*>

Injuries fj Ad­
verse Effects

-800-999

583

11.5 •

59

23.0’ 505

6.85>

24

9.1®c

• Supplementary
Classifications

Y00-Y86

41

0.8°o

3

1.2% ISO

2.4*>

9

3.4S

Ill-Defined Condi­
tions

46

stay.

Telephone respondents were younger with shorter lengths of stay

than original respondents but the percentage of patients living on farms
was close to the same for both sets of respondents indicating that there
was no bias as to place >f residence in the nonrespondents.
From the case-control analysis, all delivery and complications of

childbirth and the puerperium cases showed relative risks near one for
females in the low exposure farming group.

The high exposure group is

composed of older women and is not necessarily a valid comparison.

Comparison of Results with Published Statistics
National Center for Health Statistics Reports. A Nationa1
1.
Center ftHealth Statistics publication presents health characteristics
by geographic region and place of residence for 1969-70 [IS].

The

number of discharges per 1,000 persons per year is given for the North
Central Region (12 states) by sox, tabulated by farm and nonfarm (out­

side of SMSA’s) places of residence.

Table 16 gives a comparison ot

these rates with the Douglas and Kandiyohi County rates.

These county

rates arc acknowledge!y underestimated but they seem to underestimate
the NCHS rates by similar proportions for farm and nont arm breakdowns.
Another NCHS report (5] presents the relative frequency and sevelit.y of selected health conditions. Table 17 provides a comparison of

1974 NCHS statistics and all of the discharge data included in this
study.

The percentage distributions were fairly comparable between the

Rural Health Study and the NCHS survey, indicating that the study area
hospital experience is somewhat representative oi national experience.

A state-of-the-art report on occu­
2
pation il .'af-tv and health in agriculture done by the University of Iowa
assessed the relative health of farmers (191. lhc health ot tamers was
compared in a study in Iowa and nationally using National Center for

Health Statistics reports.

It was rnnrhidrd
concluded that farmers
farirors are not as


healthy as generally thought.
Data on injuries were somewhat equivocal.

Nationally, farm rcsi-

dents had more days of b-l disability for injuries than did nonfarm

47

u

Table ’6.

Comparisons of Discharge Rates

Disch»*;o0 per 1 ,000 persons per year
Males

Females

Nonfarm

Farm

Nonfarm

Farm

NCHS North Central
Region (1969-70)

122

88

179

121

Douglas County
(1976-77)

102

S3

157

95

Kandiyohi County
(1976-77)

97

72

141

111

Counties Combined
(1976-77)

99

77

148

103

48

Table 17.

Comparative Percentage Distributions for Selected Diagnoses

Diagnosis Category

H-ICDA Codes

Percent Distribution of
Total Discharges
NCHS
Rural Health
Survey
Study

Diarrheal Disease

009

1.0

1.3

Malignant Neoplasms

140-209

4.7

5.4

Benign Neoplasms 8 Neo­
plasms of Unspecified Nature

210-239

2.1

Diabetes Mellitus

250

1.5

1.2

Acute Myocardial Infarction

410

1.3

1.6

Other Ischemic Heart Disease

411-414

0.8

l.S

Cerebrovascular Diseases

430-438

1.9

2.0

Acute Respiratory Infections
except Influenza

460-466

1.7

1.1

Pneumonia, All Forms

480-486

2.1

2.0

Hypertrophy of Tonsils
and Adenoids

500

2.5

1.3

Ulcer of Stomach, Duodenum,
Peptic Ulcer of Unspecified
Site ft Castro jejunal Ulcer

531-534

1.3

1.3

Inguinal Hernia

550-552

1 .6

2.1

Cholelithiasis, Cholecyst i t is,
and Cholangitis

574-576

1.8

2.S

Disorders of Menstruation

626

1.7

1.3

Complications of Pregnancy,
Childbirth, •S the Pucrper

631-67S

11.0

13.3

Fractures, All Sites

800-829

3.6

4.3

Lacerations G Open Wounds

870-897

1.0

0.9

Mean Length of Stay

7.8 davs

6.6 days

Percent Males

4 0".

4 3".

Fatality Rate (per 100
d ischargcs)

2.6

2.6

49

residents. Farm residents under 45 had fewer injuries than nonfarm
residents but those farm residents over 45 had higher injury rates than
their nonfarm counterparts.

Acute conditions with more days of bed disability for farm resi­
dents than for nonfarm residents were infective and parasitic diseases;

respiratory conditions other than upper respiratory conditions and
influenza; and digestive conditions.

For chronic conditions, farmers

were found to be more likely to have hernias of the abdominal cavity,

gall bladder conditions, and ulcers of the stomach and duodenum.

Other

possible problem areas for farmers were suspected angina pectoris,

hypertension, arthritis, psychological distress, and hearing problems.
Smoking and Health.

A large number of health problems h.ve

been attributed to the smoking of cigarettes [20].

In the Rural Health

Study, data on smoking habits were collected to be used as a cnvariate

in the adjustment for the differential in smoking habits between farm
and nonfarm workers and residents in the analysis of the diseases as­

sociated with smoking.

By using the independent variable (farming

exposure) as a covariate and by changing the covariate (smoking) to the

independent variable, the relationship between smoking and various
diseases (adjusted for farming exposure) can be investigated.

Data from

the Rural Health Study were used in this way as a means of validating

known smoking relationships with th' data collected by the procedures

outlined in this report, so as to lend credence to the use of these

procedures
Appendix III presents age and farming adjusted relative risks for
lung cancer, circulatory diseases, respiratory diseases, and ulcers for
" i* ’ ent

with low and hi,.h smoking histories.

Those patients in the

high smoking group smoked one pack or more per day for at least 10

years, or less than one pack per day for at
.it least 20 years.

Patients in

the low smoking group consisted of all other patients with a cigarette

smoking history.

The control group was again injuries and adverse

offert s,

.'o

Table 18 summarizes the significant relationships between smoking
and diagnostic categories,

’’ ii< >H.«enszel chi square statistics were
used to test for dose-icspor-' relationships between amount of smoking
;»ad increased risk. Two- i .
•is of significance were used in this
case in order tn !<• <.onputable to other studies.
I1* teased relative risks were found for all of the diagnosis cate-

‘d“- -?s studied, with a number of those increased risks statistically
significant.

Circulatory problems related to smoking seemed to be more

prevalent in the 25-64 year old age groups and respiratoiy problems wore

more often associated with smoking in the 65-and-older age groups.
The observations that many of the known relationships between

smoking and disease were confirmed in this study using crude smoking
categories seems to substantiate that data collection procedures, such

as those used in the Rural Health Study, have some validity and utility
in the assessment of health problems.

SI

Table 18.

Diagnoses Significantly Associated with a
Cigarette Smoking History

Age and Sex
Group
Diagnosis Category

Males
25-64

on

(10)

0.9

(37)

1.6

(179)

412

0.4

(1)

2.0

(27)*

440-443

5.3

(3)

8.5

(20)*

532

2.7

(9)

5.7

(25)*

162-163

0.4

(1)

2.8

(19)*

413

6.3

(3)

12.1

(9)*

439-496

1.8

(ID

2.8

(37)

Chronic Obstructive
Lung Disease

496

2.7

(5)

3.9

(19)**

Ulcer of Duodenum

532

1.8

(4)

2.9

(14)*

Acute Myocardial Infarction

410

3.1

(2)

13.2

(14)

430-438

1.6

(D

4.7

(7)

532

1.6

(2)

3.6

(D*

162-163

14.7

(D

11.4

(2)**

460-470

2.1

(D

3.6

( D*

162-163

Diseases of the Circula­
tory System

390-458

Diseases of the /Xrteries,
Arterioles, and Capil­
laries

Ulcer of Duodenum
Malignant Neoplasm >f
Trachea, Bronchus, tnd
Lung

Angina Pectoris
Bronchitis, Emphysema,
Asthma, and Related
Cond i t ions

Females
25-o4

Cerebrovascular Disease

Ulcer of Duodenum
Malignant Neoplasm of
Trachea, Bronchus, and
Lung

Females
2 65

Acute Upper Respiratory
Infect ions
♦♦♦

Bid1 atlvc »<Dks (No. of Cases)
Low Smoking j High SmoMnQ
(0)

Malignant Neoplasm of
Trachea. Bronchus, and
Lung

Chronic Ischemic Heart
Disease

Males
2 65

H-ICDA Codes

Statistically significant relationship between risk and
amount smoked, p'-'.OS, p<.01, p<.001.

s

52

CONCLUSIONS AND RECOMMENDATIONS
Agricultural Health
The results of this study show that the health of farmers and the

health of nonfarmers in a rural raidwestern setting are not radically
different when hospital records are the basis for comparison.

Overall,

patients with an agricultural background even seem to be slightly
healthier than patients with no agricultural history.

Nevertheless,

over all the analyses, several diagnoses consistently showed increased
risks for people with farm backgrounds.

These include the following

conditions for both males and females:

diseases of the blood and blood

forming organs; osteoarthritis and allied conditions; diseases of the

gall bladder; hernia of the abdominal cavity; diseases of the veins,
lymphatics, and other circulatory diseases; and diseases and conditions

of the eye.

In addition to these increased risks, farm males showed

increased risks for benign prostatic hypertrophy, and farm females

showed increased risks for uterovaginal prolapse, acute myocardial in­

farction, diseases of the skin and subcutaneous tissue, and neoplasms.

This increased risk for neoplasms is somewhat surprising and is an area
in which more research might be warranted.

Females over 65 years of age

with 20 years or more agricultural exposure exhibited the largest number
of increased risks and is the only group of farm workers cr housewives

whose overall health was worse than the corresponding nonfarm group.
Data on smoking history collected by this study gave evidence of

relationships of cigarette smoking to lung cancer, ulcers, and several

circulatory and respiratory problems.

This may be taken as support for

the data collection procedures used in this study since these findings

corroborate national findings on smoking and disease.
Met hodnIngy
The method of administering occupational questionnaires to hos­

pitalized patients and then using such data in conjunction with ab­

stracted hospital data available from abstracting services such as

53

u
t

can work efficiently.

In this study, hospitalizations to both farm

residents and past and present farm workers were evaluated, since it is

hard to separate those "working" and "living" on a farm.

In choosing

agriculture as a target occupational group, a large area (including many

small hospitals) must be investigated.

This can pose problems such as

obtaining cooperation from a large number of hospitals; obtaining con­
sistent questionnaire administration, record abstracting, and data
coding; and being able to define the hospital's service area including
making accurate population estimates.

To use the methodology in studying other occupational groups, the
following recommendations are made:

The studv should be limited to

specific age and sex groups in areas with sufficient estimable numbers

of workers at risk.

All hospitals in the area of interest should be

included; contacts with hospital associations and local medical socie­

ties would be of assistance in obtaining cooperation.

Sufficient mone­

tary compensation should be awarded and, if feasible, additional persons

should be employed to assist with the study so as to minimize hospital
staff burden.

The amount of monetary compensation could also effect

cn-.^cs in hospital procedures rather than limit the investigator to
existing nonrescarch-orientcd procedures.

pertaat J

Hospital selection is im-

to the amount and quality of cooperation that must be

received.
It is important, but not necessary, that all hospitals subscribe to
an abstracting service or have an equally effective inhospital data

handling system.

To help in identifying areas where there is full or
almost full coverage by PAS, CPIIA publishes a list of such areas in the

U. S. [21].

If only a few of the hospitals do not belong to any ab­

stracting service, it might be possible for the investigator to pay the

fee for enrolling in such a program for several years or, if absolutely

necessary, the records could be abstracted independently in order to
complete full coverage in an area.

Patient origin studies done by the

hospitals or hospital associations are of great assistance in deter­
mining hospital service areas.

51

Questionnaire design should incorporate the features of being short

and relevant but should try to obtain the required occupational infor­
mation in several ways so that confidence in the responses can be

maximized.

Available population estimates of the woikers at risk

should be examined so that questions cun ue 5ui.tvvarcJ to give answers

based on the same definitions as those used in the population estimates.
The selective collection of data on other variables of interest, such as
smoking, is recommended.

These questions should be structured to be

comparable to similar questions in related studies.

Valuable infor­

mation about biases in hospital utilization among different groups of

workers could be obtained by collecting data on insurance coverage,
since the presence of insurance coverage may determine whether■ a person
would go to the hospital and which hospital he might choose,

These data

are routinely available in many hospital data sets.
Adn.ini st rat ion of the questionnaire should be as soon as the

patient can provide reliable answers.

Ml attempts should be made to

retrieve missing data such as the use of telephone follow-up or by

contacting relatives.

In this current study, there were only a few

patients who refused to participate; obtaining cooperation is a function

of how and when the questions arc uM.cd.

A re-administration of the

questionnaire to a random sample of patients, utilizing telephone follow-up,

might prove productive in assessing the reliability of questionnaire
responses.

A paid interviewer or .it least the use of a small number of

well-trained hospital personnel would also benefit data quality.
Precoded questionnaire forms help minimize transcription errors.

Questionnaire data do not actually have to be added to the abstracting

forms.

The completed questionnaires could be sent to the investigator

for coding and data handling and then paired with the data files sup­

plied by the abstracting service, using the patient number and date of

discharge.
Prior to entering into another study, it would oc advantageous to
try to validate the use of these procedures as a screening technique.

This would involve the evaluation of hospital records in an area where
health problems have already been discovered by a more thorough study.

3.'

u

If these procedures can also detect the same health problems, as well as

fail to detect health problems which were also not evident in the more
thorough study, then the procedures would seem to have utility as a

relatively low-cost screening technique.
The recommended method of study is the population-based study.

The

case-control approach can be used when it is necessary to cover a wide
area to obtain enough worker cases.

It might also be possible to

convince CPI1A or other abstracting services to include occupation as
part of the required abstract information; however, occupation usually

cannot be described by a single question.

The problem would be for­

midable to construct a single, relevant, occupational classification
system.
The use of a small population-based study as a means of selecting

control groups and verifying results of a much larger case-control study
is a valuable tool when large scale population-based studies are not
fcasible.

5b

u

ACKNOWLEDGEMENTS

The authors would like to thank the following people and organiza­

tions for their contributions:
, Mr. Norman F. deGroot, previous Head of Information Systems Section,
Agricultural Research Program, Utah Biomedical Test labora­
tory.
The administrators and staff of the six participating hospitals.
The many cooperative people at state and hospital agencies in
Minneapolis and St. Paul.

Commission on Professional and Hospital Activities, Ann Arbor,

Michigan.

Diversified Computer Applications, Palo Alto, California.
and especially

Dr. J. T? T. Higgins, Department of Epidemiology, School of Public
He 1th, University ot Michigan, for his valuable comments,
criticisms, and ideas throughout the study.

u
4

KefeFences

1.

Burkart, J. A., X. F. deGroot, and 1.. B. Koi fen son. Second Annual
^po22_J2JL_2£'^ill^
and Injury Hata in Apriculturo, llfah
Biomedical lest Laboratory, IR 201-003, “-larch, 1970^
Oecouf’e, P. , K. Stanislawczyk, L. Houten, I. !). J. Bross, and
L. V lauana, A Rctrosncc^cc ?.jivev of Cancer in Relation to Occti111112?..• National Institute for Occupational Safety and lieaTFh
Research Report, DHEIV (N’lOSH), Publication No. 77-178, 1977.

3.

Houten, L., I. P0.
Bross, and li. Viadana, ’’Hospital Ao:;.i>sion
Records: A Source for Identifyinj; Occup.itional Groups
. ; at Risk
of Cancer,” Occupationa1 Carci nogenesis, \nnals of the ‘Jew York
Ac ader v o f S c j e!)y t-_s , 2 iTJsT-'TST^

4.

HI
Hosni t.i 1
— -------- --- ——_—J2lL2.cJ11’ Comission on Processional and
Hospital Activities, Ann Arbor, Michigan,
"i'chi^an, V. 1, 1973.

5.

GlicL-nn, I

. hyrLtL«lia.i.H :ation_of _Shorr-Stav Hospitals be

no... u.e A,non.ll health ur.ey. Series 13, \o. 30, [ill!/.-.
Publication .No. 7 -1783, 1977.

6.

ll.ienscel, li. , M. H, Shinkin, and II. P. Hiller, Tobacco <

Public Health Service ■•.•^^••h'' n. IS
I'Hl.h lITiSj Publication Ao. doS 1<>3()

Cornfield, J., "A 'lethod of Istiratin’ 1Cor-parat ive Rates fron
Clinical Bata, Applications to ( ancer o f the I.ung, Breast, and
Cervix,” Journal of the National Cancer Institute. ££ • 12 6 9•12 7 5,
1931.
S.

•lintel,
;v. ||.lcIIS;e!i ••statistical Aspects of the Analvsis
o Itrot. Retrospective Studies of Hisease.” Journal of the
•Sj l11 EL* C Cancer 1
t ut e, 22 19- 748 1 959.
-------------------------

9.

Kcvf’.tx, \
llnri.iii Bio!

10.

of'1the,'i'’.;t’ .?ni'S'!'‘NN'rCSt:i "i!’1 C,,e l’t'i:r<’e of l ree'!^ Intensions
o« t.K imtU-ll.uns.el 1 rocedure.” .Imiml of the Vterienn <tt i < t i c . 1
Ajy-oc i
ion, £8:(.9ii.7eo, 19u5.
19o3.
-------------------------------------------------------- A—

1 I.

x- T-. ’’Potential Uses and Lirr.nrations

of Hospital Hata in
l.pidcnioloe.ic Research,” A:\e_rican Journal
___ 1 of rub!ic 11 ra!th,
: (>38-o<>7, 19t>5.

Preceding page blank

.v1)1'-Vi2ri,‘nce ul* St;,,kJ;“d i :e.l Mortality Rates,”

S9

Refercnccs (con11nucd):

12.

U. S. National Committee on Vital and Health Statistics, Use of
Hospital Data for Epidemiologic and Medical-Care Research, National
Center for Health Statistics, Series 4, No. 11, DHEW, June, 1969.

13.

Berkson, J., "Limitations of the Application of Four-fold Table
Analysis to Hospital Data,” Biometrics Bulletin, £:47-53, 1946.

14.

Reliability of Hospital Discharge Abstracts, Institute of Medicine,
National Academy of Sciences, Washington, February 1977.

15.

Loup, R. 1., ’’Consistency of Final Diagnosis Coding in a Hospital
Patient Record Data System,” paper presented at the Seventh Annual
Interdisciplinary Conference on Health Records, Chicago, Illinois,
June 1976.

16.

Diamond, E. L. , and A. M. Lilienfeld, ’’Effects of Errors in Classi­
fication and Diagnosis in Various Types of Epidemiological Studies,”
American Journal of Public Health, 52:1137-1144, 1962.

17.

Minnesota Population Projections, 19'0-2000, Office of the State
Demographer, Minnesota State Planning Agency, St. Paul, Minnesota,
November 1975.

IS.

Namey, C. h ., *.r' ’ !? W. Wi 1 rar., ! 'ypj
rharnct cri st : c< by
ranh i c
Rev.ion, I.arge 'let ropoI i tan Areas , .ird <)t hev Places of Residence,
H?"s .7~i"969 - i oTo, Vital and Health Statistics, data from the National
Hea’l t’if Su r v ey , Sc r i os 10, No. 86, DHI.K (I IRA), Publication No. 74-1513,
1974.

19.

Burmeister, L. I-'., “The Relative Health of the Farming Occupation,”
State-of-tiie-Art Report on Occunat jonal Safety and Health in Arri cu 11ure7~77.’ . .
,
ursiiy of Iowa Institute
of Agricultural Medicine, 1974.

20.

The Health Consequences of Smoking: A Reference Edition, Selected
Lhapteis from 1971 through 1973 Reports, Dlll.h, 19*6.

21.

i'AS lull Coverage Xrc.ts in the United States, ('PH.\ 715-6-74,
Conn'fs’bi"cnTm I’rofcsion71 and Hospital .Activities, Ann Arbor,
Michigan, 1976.

(.0

u
1

J

I
}

APPENDIX I
RELATIVE RISKS FOR POPULATION-BASED HOSPITALS

A.

FArcl/NOSFARM RELATIVE RISKS FOR POPULATION’ BASED HOSPITALS - MALES
Age £ 65
No. of Cases

Age 25-64
No. of Cases

Age <23
No. of Cases

Farm

Non
Farm

Relative
Risk

Farm

Non
Farm

Rclative

HICDA Codes

Risk

Farm

Non
Farm

Relative
Risk

Infective & Parasitic
D i seises

001-136

6

26

0.6

3

20

0.4

5

9

2.0

Neoplasms

140-239

1

S

0.5

6

33

0.3

14

77

0.8

Ma I i gnant N’eop 1 a sms

140-209

0

1

0.0

4

23

0.3

14

72

0.3

Endocrine, Nutritional, 6
Metabolic Diseases

240-279

2

6

0.9

4

15

0.6

7

17

2.3

Diseases of the flood 4
Elood Forming Organs

2S0-2S9

1

2

1.5

2

1

4.4

4

6

3.5

Mental Disorders

290-31S

3

11

0.7

5

37

0.2

1

22

9.2

Di senses of the Nervous
System 6 Sense Organs

320-339

2

50

0.2

6

23

0.7

11

28

1.9

Diseases of the Eye

570.378

1

11

0.2

5

10

1.3

7

20

1.9

Diseases of the Circulatory
System

390-438

1

0.3

36

103

0.8

59

167

1.0

Ischemic Heart Disease

110-414

0

0

15

50

0.7

16

59

1.1

Acute Myocardial
Infarction •

4 10

0

0

10

30

0.8

6

26

0.8

Chronic Ischemic
Heart Disease

412

0

0

7

13

0.8

8

35

1.0

4

14

0.7

12

39

1.2

8

0.5

3

26

0.6

21

1.4

2

10

0.9

Diagnostic Category

A.

A.

A.

1.

B.

Cerebrovascular Disease

450-458

0

0

C.

Diseases of Arteries,
Arterioles,
Capillaries

440-448

0

1

0.0

Diseases of Veins, Lynpbatics,
other Cir­
culatory Diseases

450-458

1

5

0.5

D.

13

A. FAR.M/NOXFARM RELATIVE RISKS FOR POPULATION BASED HOSPITALS - MALES

Diagnostic Category

iHCD.A Codes

Age <25
No. of Cases
Non
Relative
Farm
Farm
Risk

Age 25-64
No. of Cases
Non
Relative
Farm
Farm
Risk

Age 5 65
No. of Cases
Non
Rclat ivc
Farm
Farm
Risk

Diseases of the Respiratory
Syst?m

160-519

19

100

0.5

9

25

0.8

26

66

1.8*

Acute Upper Respiratory
Infect ions

460-470

6

30

0.5

->

3

1.2

2

3

4.3

3

6

0.9

17

35

2.3*

A.

B.

Pneumonia

4SO-486

5

2S

0.4

C.

Bronchitis, Emphysema
Asthma 6 Related
Cond it ions

489-496

6

IS

0.8

2

6

O.S

6

27

0.9

Diseases of the Digestive
System

520-577

26

58

1.1

SO

128

O.Q

33

105

1.3

530-537

1

4

0.6

10

23

0.9

2

25

0.3

A.

Diseases of the Esophagus,
Stomach q Duodenum

B.

Append it it is

540-543

13

17

1.9

2

11

0.4

0

1

0.0

C.

Hernia of Abdominal
Cavity

550-553

10

27

0.9

21

51

1.0

17

24

2.7*

Other Diseases of Intestine
6 Peritoneum

560-569

1

3

0.8

1

19

0.1

4

22

0.7

Diseases of the Liver,
Gall Bladder, 8 Pancreas

570-377

0

->

0.0

16

19

2.0*

9

35

1.2

575

0

1

0.0

9

13

1.6

5

-> 2

0.9

580-629

5

28

0.4

22

61

0.8

40

99

1.8**

16

0.3

12

37

O.S

18

46

1.6

0.6

11

25

1.0

23

56

1.9*

7

11

1.3

19

49

1.8*

D.
E.

1.

Diseases of the Gal 1
Bladder

Diseases of the Genitourinary
System
A.

B.

Diseases of the Urinary
System

530-599

Disease of the Male Genital
Organs

600-607

3

12

600

0

0

1.

Benign Prostatic
Hypertrophy

• •••

A.

• •••

FAiCf/XO\'FAR.M RELATIVE RISKS FOR POPULATION’ BASED HOSPITALS - MXLES

Age <23
No. of Cases

Age 25-64
No. of Cases

Age a 65
No. of Cases

HICDA Cedes

Fam

Non
Farm

Relative
Risk

Fam

Non
Fam

Relat ive
Risk

Fam

Non
Farm

Relative
Risk

P1 eascs of the Skin u
Subcutaneous 1 issue

650-709

6

12

1.3

2

19

0.2

1

6

1.1

Diseases of the Musculo­
skeletal System
Connective Tissue

710-739

S

15

1.4

14

43

0.7

10

24

1.6

10

0.4

5

15

1.4

Diagnostic Category

A.

Arthritis S Rheumatism

710-718

1

1

2.4

2

B.

Osteomyelitis 6 other
Diseases of Bone Ji
Joint

720-729

5

13

1.0

11

20

1.3

6

7

3.0

50

0.4

19

59

0.7

10

33

1.3

Signs, Symptoms, Ill
Defined Conditions

770-796

Injuries J. Adverse Effects

800-999

4;

98

1.2

33

85

0.9

14

57

1.1

A.

Mu s c u 1 o s k •» 1 e t a 1 Injuries

800-849

21

49

1.2

23

49

1.1

7

31

1.1

B.

Lacerations & Open
Wounds

870-897

9

9

2.6*

2

12

0.4

0

3

0.0

001-999

126

4 14

0.8

207

619

0.8

184

608

1.3

All diagnoses

, **

Rate for fam residents is statistically significantly greater than rate for non-fam residents

p<.05.

p<.01

••••

B.

rvr!/.\’O.\rARM jxvhve risks isr populvtios based hospitals - n: iai.i.s

Dia.noetic Category
Infective
Disc isos

Age <25
No. of Cases
Non
ReIntive
Farm
farn
Risk

HILDA Cede-.

Age 25-64
No. of Cases
Fa mi

Non
Fam

Age ? 65
■No. of C.i’.cs

Relative
Risk
!• *'Fam

Non
F a rra

Rclativc
Risk

Parasitic

X’co pl asms

0.5

01)1-156

9

29

1.0

6

22

0.S

1

140-259

4

18

0.9

28

101

0.8

12

73

1.2

1.3

15

56

1.1

8

65

1.0

5

15

0.6

1

24

0.2

5

6

1.2

1

6

0.8

Malignant .Xcoplasms

1 10-209

Endocrine, Nut ri t ionaI, X
Metabolic Diseases

240-279

A.

••••

0.5

1

I

i

Diseases of the Blood ft
Blood Forming Organs

280-289

Mental Disorders

290-51S

19

0.5

11

65

0.3

I

4

5o

0.9

Diseases of the Nervous
System 6 Sense Organs

520-589

20

1.0

15

27

1.8

i

9

82

0.9

Diseases of the t.ye

3'0-5’S

5

1.4

5

5

5.5

8

65

1.1

Discas.s of th** Circulatory
Sys* cm

590-458

9

1.0

70

1.0

51

192

1.4

Ischemic Heart Disease

410-414

0

0

5

18

0.9

10

69

1.2

Infarction

4 10

9

0

5

10

0.9

4

55

0.9

Chronic Ischemic
Heart Disease

412

0

0

I

S

0.8

5

54

1.4

I

5

0.9

S

40

1.9

A.

A.

I.

0

5

0

Acute Myocardial

B.

Cerebrovascular Disease

450-458

0

0

C.

Diseases of Arteries,
Arterioles, f4 Capillaries

4 10-448

0

1

0.0

5

2.6

4

27

1.4

Diseases of Veins, Lym­
phatics,
other Cir­
culatory Diseases

450-458

8

1.1

50

0.7

5

26

1.7

I).

I

I

••••

B.

FAR.’!/:;O:,TAR.M RELATIVE RISKS FOR POPULATION BASED HOSPITALS Age <25
No. of Cases

PRIMES

I

Age 25-64
No. of Ca es

Age £ 65
No. of Cases

HICO\ Codes

Farm

Non
F a rm

Rd at ivc
Risk

Farm

Non
Farm

Relative
Risk

Farm

Non
Farm

Relative
Risk

Diseases of the Respiratory
System

460-SIP

20

73

0.7

12

32

1.1

S

56

1.1

Vutc Upper Respiratory
’. rifec t i ■;! .

460-470

3

26

0.3

*>

8

0.7

1

9

1.2

R.

Pnvmonia

4 SO-486

7

17

1.1

3

11

0.8

3

24

0. J

C.

Broachi t i s, I rphysena
\sthma 6 Related
489-496

4

13

0.8

3

9

0.9

3

15

1.6

Di a.•...»•> st ic Category

. '.’id it ions

Lis
' of the I'itiestivc
Svstem

520-577

15

54

0.9

31

13S

0.7

21

94

A.

Diseases of the Esophagus,
Stomach f. Duodenum

530-537

2

S

0.6

2

26

0.3

6

30

8.

'.ppend ic i t is

540-543

6

28

0.7

4

8

1.8

1

0

Hernia of \bdc:~inal
Cavity

550-553

2

3

1.5

2

17

0.4

0

8

0.0

Other Diseases of Intestine
■ri Peri toncun

560-569

1

5

0.9

6

25

0.7

5

32

0.6

Diseases of the Liver, Gall
LI adder 6 Pancreas

570-577

3

9

1.5

17

61

0.9

11

25

3.6* *

L.

I.

Diseases of the Gall
Bl ad kr

1.4

573

3

6

2.2

9

28

1.0

11

17

S.l**

Diseases of the Genitourinarv
Sy stun

380-629

8

66

0.4

51

190

0.7

8

56

1.0

Di cases of the Urinary
Seston

580-599

4

29

0.4

8

27

0.8

3

30

0.8

612-617

1

20

0.2

3

10

0.8

0

0

».

F’is■Mses of the ilvary,
I il lopi ci Tu’-.

••••

B.

FAIUI/NONFARM RELATIVE RISKS FOR POPULATION BASED HOSPITALS - FEMALES

Diagnostic Category
C.

O'

Diseases of Uterus 6
Female Genital Organs
1. Uterovaginal Prolapse

Disorders of Menstrual
Cycle
Diseases of the Skin fi Sub­
cutaneous Tissue
Diseases of the Musculo­
skeletal System 6
Connective Tissue
A. Arthritis 6 Rheumatism
8. Osteomyelitis G other
Diseases of Bone fi
Joint
Signs, Symptoms, Ill
Defined Conditions

HICDA Codes

Age <25
No. of Cases
Non
Relative
Farm
Farm
Risk

Age 2S-64
No. of Cases
Non
Relative
Farm
Farm
Risk

Age i 65
No. of Cases

Farm

Non
Farm

Relative
Risk

1.3
1.7

0.8
1.7

3

8

126
13

3

19
14

1.1

16

71

0.6

0

1

0.0

5

0.9

7

10

2.1

3

15

1.4

0.8

0

10
0

7
3

48
13

0.4
0.6

6
4

50
29

1.1
1 .1

720-729

I

7

0.5

3

25

0.4

2

14

l.S

770-796

6

33

0.4

21

60

0.9

10

63

1.1

13

119

619-629
623

3

16

0

0

626

2

7

6S0-709

1

710-739
710-718

2

0.7

37

i

800-999

18

56

1.0

27

70

1.1

Musculoskeletal Injuries

800-349

7

26

0.9

16

39

1.2

6

93

1.0
0.6

Lacerations 6 Open
Wounds

870-897

3

6

1.2

I

3

0.9

0

3

0.0

001-999

92

370

0.8

232

828

0.8

117

752

1.3

Injuries & Adverse Effects
A.
B.

••••••

All Diagnoses

(Not including Conditions of
Pregnancy and Delivery

Rate for farm residents is statistically significantly greater than rate for non-farm residents p<.05.

p<.01

APPENDIX II
CASE-CONTROL RELATIVE RISKS

A.

Case-Control Relative Risks for Farming Exposure • Males

Arc > 65

Arc 25-C4

I
I!-ICt A
C -dr

I

I

Never
larrcJ

NO. Of

FarncJ 1*!9 Yc.ir»

larncJ > 20 Year

NO. of
Cj-c>

No. of
Caves

.

Rel it ivo

I

Rivk

I

Re Iut ivv
MKk

Never
rarecd

Farmed » 20 Years

Caves

No. of
Cases

35

101

10

22

0.6

So. of

Rc |..t Jvc

J<L1__

itnii.rxc< ■« Adverse

Infceme C I’arasitic
l‘i>C nc*

1. 6xarrhe.il Oxsease
Xcop’.a^’S

142

60

no:-13o

27

7

0.6

13

0.7

001 - 00>

12

3

0.5

12

1.3

7

16

Ou 9

9

0 4

10

1 .4

4

13

0.7
0.8

l-’i‘-23?

51

14

0.7

37

0.8

67

166

0.8

14'-15j

29

7

0.6

26

1.1

S8

155

0.8

ISO-!53

8

2

0.8

12

1.6

16

32

0,7

153

4

0

0

1.8

9

13

0.5

16C-165

5

3

1.7

0.6

10

13

0.5

112- i<‘5

5

3

1.7

0.6

10

13

0.5

180.IS?

9

1

0.3

0.9

28

S3

1.0

US

4

0

0

1.3

20

57

1.0

I* S

2

6

22

1.2

73

A. I'ri r .r.- ’!il Xx*3n:

flair
Tr.ichea
F-rar.^hus 4 Lan;

3. Prxr. ir» M.lxf.n.in:
Nev; l-J'S of C.-nxtoarinary Org.is.s

2

a. MiH;- in? Ntof I-*'" of fr ’itate
b. Nil;in.i-.t ' .apljiR vf i/I.’Jaer

I

1.2

s
2

l.l

• ••••

A.

• •••

Case-Control Relative Risks for Fanning Exposure - Males

» 6$

Farmed 1-19 Years

famed 4 20 Years

Never
Famed

Farmed * 20 Years

No. of
Ca>vs

No. »»f
Cases

Relative
Risk

Ko. of
Coses

No. of
Crises

35

104

0.7

7

12

0.6

0.3

4

6

0.5

10

1.0

12

24

0.7

2.0

9

1.1

1.8

8

1.0

10
9

18
18

0.6
0.6

0

0.0

4

3.5

3

12

1.2

56

24

0.9

28

0.9

13

30

1.0

296-305

10

4

1.0

6

1.1

3

11

1.5

336-309

7

6

1.7

6

3.1

I

5

2.0

0.8

5

9

0.8

Never
Famed
H-ICOA
Code

No. of
Cases

8C0-999

142

60

196-199

7

0

U. 0

5

21O-22S

11

4

0.9

4

f. Metabolic Diseases

240-279

IS

9

1.8

Diseases of Other
Endocrine Glands

250.258

11

8

llitus

250

11

7

Diseases cf the Blood 5
Blood-Fominj Organs

230-2E9

2

Mental Disorders

290-318

A. Organic Brain
Syr..!ro-.es
B. Psychoses Not
Attributed to
Ph) six. al Conditions

I'i »rno*t ic Catenary

Rclativc
I
Risk

Relative

1 Rmk

cc-.iUOE CROUP
iln.turics G Adverse
E f feet s'

ii. Secondary Malignant
Neoplasms

C. Benign Scapla^ms

75

Endocrine. Nutritional.

1. Diabetes

12

3

0.6

6

0. Personality Disorders 6
Certain Other Ncnpsychotic Mental
311-514
Pi >ordcrs

8

13

1.1

9

0.6

5

5

0.3

313

21

12

1.2

9

0.6

4

4

0.4

320-253

26

13

1.2

23

1.2

20

68

1.2

C. Neurones

I. AlCohn 115 i
Diseases of the Nervous
System G Scn--e Organs

310

• •••

A.

Case-Control Relative Risks for Faming Exposure - Males

Arc » 65

Arc 25-64

Farmed i 20 Years

Keyer
Far&cd

Farmed i 20 Year*

Relative
Risk

No. of
Cases

No. of
Cases

55

104

Never
Farmed

Farmed 1-19 Tears

Pi ignostic Catexory

II • 1CDA
Code

No. of
Caves

No. of
Casey

No. of
Cases

CCMROL GROUP
(Injuries 6 Adverse
effects)

830-999

142

60

A. Disease of Nerves 6
Peripheral Canglia

55O-3SS

6

2

B. Disease and Condition's
360-379
of the Lye

10

374

6

Diseases of the Cir­
culatory System

390-458

A. Hypertensive Disease

4CO-40>

*. Essential Benifi
Hypertension

401

B. Ischc-sic Heart Disease 410-414

1. Cataract

x

,

Relative

|

Risk

75

I

Relat ivc
Risk

0.8

5

1.7

5

8

0.8

7

1.8

11

1.2

14

55

1.5

5

0.9

5

1.1

14

50

1.2

159

44

0.7

99

0.9

129

250

0.6

12

2

0.5

6

0.8

5

10

1.5

12

2

0.5

6

0.8

0

10

55

18

0.8

42

0.9

55

84

0.5

Cyl

1. Acute Myocardial
Infarct ion

410

34

9

0.7

25

0,8

28

5Q

0.4

2. Chronic Ischesi:
Heart Disease

412

13

8

1.6

14

1.5

22

41

0.6

3. Angina pectoris

413

9

I

0.5

5

0.8

5

8

1.1

C. Disorders of Heart
Rhyl hm

415-416

6

2

0.7

7

1.6

15

19

0.4

D. Other Fores of
Heart Disease

420-429

10

2

0.3

6

0.8

18

48

0.8

I. Heart Failure

427

1

1

2.9

5

5.1

16

46

0.8

E. Cerebrovascular
Disease

430-438

17

7

1.0

15

0.9

29

60

0.5

435

4

2

1.6

5

1.6

8

14

0.4

1. Transient ischendc
Attack

A.

Case-Control Relative Risks for Farming exposure - Males
>CC > 05

Afc 2 5-01

Never
I aravJ

l-H Year*

I

Kclat ive
Hi>k

lurat'd a 20 Year*
No. of

Re Lit ive
Risk

Never
I al>cj

lai’i.rd / 2U Year*

No. of
Cases

No. of
C.i'cs

35

104

Re)at 1vc
Risk

So. of

No. o f
Ca'e»;

142

<>0

4 5b

7

3

1.1

5

0.7

14

:s

0.6

4 J3-4JS

16

2

0.5

6

0.5

17

29

0.5

10

14

0.3

4

24

2.3

1.2

H-IC-A
I' I

i. .iR.'L ..r-. • •r

. but

73

111-

Vascular I’ i * c 3' e

Artvr ;ol
. 6
Caj’» l!a: ics

4S0

10

2

0.7

3

0.4

G. ’Ji c »<c5 <•!’ Vein-, and
I i ;•? it i« v . and Other
I ; :va<i-« of Circ
r.- Sys
4:0-439

28

11

0.9

23

1.3

451

4

3

1.8

6

2.1

3

8

45$

9

5

1.3

11

2.1

0

b

4OJ.513

43

IS

0.8

34

0.9

SI

104

0.6

I. Artcriosclernsi'

2. I r^crrJ-jxds
ri*c.i*ei nf the Respira­
tory SystvT

A. Acute U;nt r Respiratory
inrvtti.rs
4i.G-4?C
3.

ia
1. Fur ."-.'ti: a,
Oryanisa !» Type
.N-'t Specified

C. Bronx hr t is,
Ast;.' I. s Related
Ct-nJrt ioni
1. Asthm

9

2

0.6

4

0.8

4

9

0.2

4*9-4$6

14

3

0.5

14

1.2

24

48

O.o

486

11

1

0.2

10

1.0

17

37

0.6

4S9-496

8

3

0.9

11

2.2

21

35

0.6

495

3

0

0.0

5

1.7

4

4

0.3

• ••••

A.

Case-Control Relative Risks for farming Exposure - Males

Aje 2 65

Age SS-O'J

Nr. er
Far-'-cd

I

Farmed 1-19 Years

No. of
C iv s

No .of
(.r-c*

142

CO

496

5

1

0. Other Diseases of the
Respiratory System

5C0-S19

18

Diseases of the Digestive
System

520-577

177

A. Diseases of Esophagus.
51 cmach, and l uodcr.ua

530-53’

47

11- I CHA

CUM KOI. i .l' lll’
(Injuries t Adverse
tf fee? s)

J

Chn aic Obstructive
tun . disease, Sot

Ui

• ••••

1. URer
a. Ulcer of DuoJer.ufl

2. Gastritis and
Duodcr.it 1 s

R< Lit i vc
Hi A
!

I

|

Farmed 2 20 Year*!

Never
Fanned

Jk-1 ,»t i vc
!«is4

No. t»f
Gives

N-». uf
r i- .•»

I

73

ranged 2 20 Year*
I

No. of

Re I nr > vc

Cases

M»«a

35

104

I
0.5

1

C.3

10

14

0.6

1.0

3

0.3

3

12

1.2

1.1

129

1.1

R2

170

0.7

90

1.6

24

0.'

16

30

0.6

30

20

0.8

5 31-554

30

II

1.0

14

0.7

9

0.3

11

0.8

0.6

6

10

20

7

532

1.5

S

0.5

5

0.3

15

in

5

533

2

2

0.3

8. Appendicitis

540-543

16

9

1.3

10

1.4

C. Ilcrr.ia of Alder.;..al
Cavity

$7

1 .6

0.9

3!

1.3

S3

S3

25

550-553

43

l.u

0.8

30

1.5

38

42

IS

550

8

13

0.6

13

0.8

32

0.6

34

$63-569

0

0.0

I

4

18

3

0.5

1.5

$'/:

1. Inguinal Hernia
hlthuut Mention of
Obstruct ion
D. Other Diseases of
Ir.tcst ine and
rerit'-nc’;.“i

I. intestine 0‘otrvct ion

• ••••

A.

Case-Control Relative Risks for Faming Exposure - Males

Apo 2S-G4

O

Age > 6S

Never

Never
Famed

taracd 1-19 Years

l>iTEno<tic Category

ll-ICDA
Cede

No. of
Cases

No. of
Cases

CO'-TTOL GROUP
(Injuries C Adverse
I fleets)

SOO-999

112

60

2. Functional Dis­
order of Intestine

S64

8

1

L. DIsc.ihc* of the Liver,
Gallbladder and
Pancreas

S7O-S77

28

J.

Relative
Risk

Faracd 1 20 Years

Famed

Famed I 20 Years

Relative
Risk

No. of
Cases

No. of
Cases

35

104

No. of
Cases

I

73

Relative

1 Rtsk

0.2

2

0.S

2

9

1.2

14

1.2

29

1.5

24

S4

0.9

4

1.7

11

1$

0.6

1. Bi!iary Calculus

574

3

3

2.4

2. Other Diseases of
GalIbladder

575

1$

9

1.3

14

1.2

6

31

1.6

Diseases of the Genito­
urinary Systea

580-629

89

34

0.9

72

1.1

75

210

1.0

A. Other Diseases of
Urinary Systca

590-599

S3

19

0.8

30

0.9

32

64

0.7

1. Calculus of Kidney
and Ureter

S92

30

8

0.6

17

0.8

6

6

0.4

2. Other Diseases of
Bladder

596

1

1

1.9

5

4.9

12

22

0.6

3. Stricture of Urethra
(ecatus)

598

7

2

0.8

3

0.7

2

6

0.9

4. Other Diseases of
Urirary Tract

599

1

2

2.2

1

2.4

3

16

1.6

8. Diseases of the Male
Cenical Organs

600-607

34

IS

1,1

44

1.6

42

149

1.3

600

14

6

1.0*

29

2.2'

40

128

1.2

680-709

21

10

1.0

11

1.1

7

18

0.9

1. Benign Prostatic
Hypertrophy

Diseases of the Skin and
Subcutaneous Tissue

• ••••

A.

• •••

Case-Control Relative Risks for Farming Exposure - Haler

A£O 25-64

IU££Host ic Category

Code

Never
Farmed
No. of
Cases

CUM KOI. f.RDtlp
(injuries f, Adverse
£ ri sen)

800-999

142

1I-1CDA

A. Infections of Skin and
Subcutaneous Tissue 680- 686
1. Other Cellulitis and
Abscess
682

Diseases of the Musculo­
skeletal System C
Connective Tissue
710-739
A. Arthritis 6 Rheumatism
Except Rheumatic
Fever
710-718
1. Osteoarthritis 6
Allied Conditions
713
B. Ostconvelit is and Other
Diseases of Bone and
Joint
720-729
1. .Internal Derangement
of Joint
724
2. Disorders of Inter­
vertebral Disc
72S

F-imed 1-19 Years

Farmed Jt 20 Years

No. of
Cases

No. of
Cases

60

Relative
Risk

Rclat vo
Risk

75

Never
Farmed

Ago I 6C

Farmed l 20 Years

NO. Ot

No. of
Cases

55

104

Rclat ivo
Risk

8

1.3

8

1.3

2

8

1.5

9

4

1.0

7

1.6

2

7

1.3

63

23

0.9

36

0.8

30 •

66

0.8

12

6

0.9

18

1.9

21

SO

0.8

2

4

S.2*

11

5.9*’*

17

39

0.9

44

17

1.0

IS

o.s

9

17

0.8

13

7

1.4

3

0.4

1

3

1.0

21

6

0.8

4

0.3

S

7

0.7

Congenital Anunalics

740-759

8

S

1.4

6

1.0

2

3

0.4

Signs. Symptoms 6 Illdefined Conditions

77O-7&6

88

30

0.8

50

0.9

36

55

0.5

774

6

2

1.0

7

1.3

S

3

0.3

A. Symptom Referable
to Heart 6 Vessels

• •••

A.

• ••••

• ••

Case-Control Relative Risks for Farming Exposure • Males

Sever
Famed

Ako 25-64
FaracJ 1-J9 Years

Farecd i 20 Years
No. of
Cases

IM CPA
Cede

So. of
Cases

Ko. of

SCO-9^9

142

CO

B. Other SyT-.ips’s
Fvfcr.iblc to Cardio*
vai.ula* 1
lyaphatic Systee

77$

7

2

0.7

C. Sysptoss deferable to
AbJeren t, Fcrit^-.e-.in

750

13

3

1.1

0. Other 'yopto^s Referable
to musculoskeletal
Sys’.ce

739

20

5

OPl-79?

735

273

!>» kntxtic C£tcgory

Rclativc
Risk

Helalivo
Risk

Ke ver
ParseJ
>'o. of

Cases

Ace S C!>
Farced * 20 Years

No. o f
Ciscs

Rol.it ivc

1 Risk

IVMROI.

(Inr.iric^ 4 Adverse
Lit eUS)

All Pl.ItllOAp*
(Lavvpt Control)



73

3$

0.4

1

7

2.0

11

0.9

3

6

0.6

0.6

8

0.7

2

3

n.s

0.9

$09

0.9

467

1.019

0.7

Relative risk statistically sign. ficantly greater than one p<.05

......
I
• Statistically significant opc^ur .■•risk relationship over tho two risk categories p*.05.

B.

Case-Control Relative Risks for Fanning Exposure - Females
Age ZS-CS

Never

Age 2 65

Never
FarTcJ

r.noed 1-19 Yean

r.iri*<.’J » 20 Years

Tarred

F:*r»cJ * 20 Years

Ko. c f
Cases

No. of

No. O t

t’SCS

ltcl.it ivo
Pisk

No. of
Cases

Cases

101

37

116

117

CM-136

43

12

0.6

13

0.7

17

23

1. 3

Incest ins I Infec­
tious Pi- 3»C* iK> I -C Vj

30

6

0.5

0

0.7

?3

18

1.

ll-lCL’k
C

0 > ■>,; n m tie Otef -]_r v

|

Relative
Risk

No. <> f

He I ativc
Kisk

co:, raoi crjup
ltn;uric* 6 Adverse
111vet s)

Infective i Far
IU seaics
A.

Ui.i rr‘,.al
D i se ises

I.

00 J

23

3

0.3

5

0.7

12

10

c.s

UO-239

165

37

0.5

76

1.1

64

94

1.

140-195

56

10

0.5

31

1.2

43

60

Fri-srv •talignint
Neo;’1.1* • s of
PivcM t -c Organs
It Tcrit-'neum
152-159

5

0

0.0

5

2.2

17

26

1.9

1S3

3

0

0.0

4

2.5

8

13

2.1

Frjr.ary ’Mli-nant
.is:: vf Skin 5
Breast
170-174

24

3

0.4

14

1 .0

14

19

1.4

20

2

0.3

14

1.3

’2

16

1.4

Neoplasms
A.

Pri^a.-y ‘tai:gnan:
Neoplasms
I.

3.

a.

1

‘lal.^nj-it

Neoplasm of
lar^e Intes­
tine. except
Rcctu.e
2.

41

.Mai i jjnsnt
Neo, Ins* of
Bre ist

174

1

• •••

6.

• •••

Case-Control Relative Risks for Farming Exposure - Females

Age 25-65

Never
Farxed 1-19 Years

Farmed » 20 Years

Never
Famed

Famed * 20 Years

No. of
Cases

No. of
Cases

No. of
Cases

116

J17

Diaenottic Category

H-1CDA
'•ode

Ko. of
Cases

Ko. of
Cases

COVTROi. GROUP
(Injuries 4 Adverse
Lf feels)

800-1>99

101

37

150-189

23

6

0.8

10

1.4

10

9

15

2

0.4

.3

l.l

0

1

3.

Primary Malignant
Neoplasm of
Genitourinary
Organs

a.

Q

Age > 65

Furled

Malignant Neoplasa of Cervix
Uteri

, Relative
I
Risk

Bclat ive
Kisk

41

Relative
Risk

1.2

B.

Secondary Malignant
Neopl k«s

106-199

10

0.6

5

1.2

11

14

c.

Benign .coplas^s

21O-22S

101

23

0.6

37

0.9

13

14

1.2

2.0

1.

Uterine Fibrom

218

37

6

0.4

IS

0.9

1

0

0.0

2.

Or'.er Benign Neo­
pl.isa of Uterus

219

23

14

1.3

10

1.0

4

2

0.5

3.

Bc.’ign Ncoplasa
of Ovary

220

16

0

0.0

4

1.5

0

1

Endocrine, Nutrlti-'.al, 5
?JO-279
Mctjlxalic Diseases

25

10

0.9

14

1.7

24

33

5

0.7

12

2.1

18

24

1.3

0.6

12

2.2

18

23

1.3

A.

Diseases of Other
Endocrine Glands

1.4

?50-2S8

16

I. Diabetes Nellitus

2>0

14

Diseases of the Blood 8
Blood-ForrJ.ng Organs

280-2119

11

1

0.2

6

1.1

5

9

2.1

Mental Disorders

290-318

99

26

0.7

26

0.8

37

25

0.8

296-305

4

0

0.0

1

0.7

11

5

0.5

A.

Organic Brain
S/Duro^cs

3

• •••

B.

• •••

Case-Control Relative Risks for Farming Exposure - Females
Age 2 f>5

Age 25-65

Never

Never
Famed

fanned 1-19 Year*

Di.-.gnostic Category

II-1CDA
Code

No. of
Coses

Ko. of
Cases

CONTROL CROUP
(Injuries t> Adverse
Effects)

800-999

101

37

Psychoses Not
Attributed to
Physical Conditions 306-309

30

7

0.7

7

0.8

6

3

0.9

19

3

0.5

5

1.0

3

1

0.7

1.0

IS

1.3

15

14

1.1

B.

1.

Schizophrenia

306

( Relative
j
Risk

Famed 2 20 Year*

Famed

Fsracd i 20 Year*

No. of
Cases

No. of
Cases

No. of
Cases

116

117

Relative
Risk

41

Relative

1 Risk

C.

Neuroses

310

37

12

0.

Personality Disorders C
Certain Other Nunpsychotic Mental
311-314
Disorders

It

5

1.3

3

1.0

1

0

0.0

311

9

4

1.4

2

1.8

1

0

0.0

Diseases of the Nervous
Systea i Sense Organs

320-339

49

23

1.1

18

0.7

72

82

1.2

Diseases of Nerves 5
Peripheral Ganglia

3S0-358

IS

5

0.9

8

1.0

4

2

0.7

13

10

2.0*

4

0.6

61

71

1.2

4

0.9

57

59

1.1

1.

A.

B.

Personality
Disorders

Diseases and Conditions
of the Lye
360-379

374

9

7

2.4

380-389

13

4

0.6

3

0.4

4

3

0.9

Disease* of the Circulatory
390-458
Systea

98

31

0.9

55

1.3

177

218

1.3

Hypertensive Disease

400-405

12

3

0.7

7

1.0

15

18

l.S

Essential Benign
Hypertension

401

9

3

1.0

6

1.0

12

14

l.S

410-414

17

s

1.0

11

1.3

SI

53

1.1

1.
C.

A.

Disease of the Ear 6
Mastoid Process

1.
B.

Cataract

IsHier.ic Heart
Disease

• •••

B.

Case-Control Relative Risks for Farming Exposure - Females

Arc » 65

Arc 25-55
Never
Famed

Farmed 1-1? Years

hi.i;r.ostic Category

H-TCDA
C'.le

No. of
Cares

No. of
Cases

CONIROI t.ROL’F
(Injuries 6 Adverse
Effects)

693-999

101

57

Acute '!)ocardial
Infarct ion

41U

8

3

Chronic Ischceic
Heart Disease

412

7

1

415-416

12

416

420-429

I.

2.
C.

Disorders of Heart
Rhythm
1.

D.

Orher Foms of Heart
Disease

Farmed * 20 Years

Re1 at ivc
Risk

No. cf
Cases

No. of
Cases

116

117

No. c f
Cases

41

Rclative
Risk

9

8.()••»*

22

18

0.9

0.5

I

0.2

25

55

1.5

2

0.7

4

9.6

14

17

1.7

10

2

0.8

5

0.5

12

9

1.0

3

2

1.3

1

0.8

25

21

0.9
0.9

427

2

1

1.9

1

0.9

22

430-438

5

4

3.0

3

2.3

39

55

1.5

Transient Isch sic
Attack

43>

1

0

0.0

2

15.9

S

11

l.G

Acute, but IllDefined, Cerebro­
vascular Disease

4 36

2

2

4.4

0

0.0

14

24

1.5

Diseases of Arteries,
Arterioles. G
440-418
Capillaries
440
1. Arteriosclerosis

5

1

0.5

5

2.0

22

30

1.3

3

0

0.0

2

5.4

12



1.5

39

1 .9’

Heart Failure

Cerebrovascular
Disease

1.
2.

F.

Fai-ficd 1 20 Years

Famed

20

1.

E.

Ether Disorders <of
the Heart Rhythm

Relative
j
Risk

Never

Di<e.i-»ei of Veins and
lywpl.at its. and Other
Disc »*c> of Cir­
450-458
culatory System

/

I

I

47

16

0.8

25

1.4

23

• •••

B.

• •••

Case-Control Relative Risks for Farming Exposure - Females

I Never

Age 25-65

Never
Farmed
Oingnostic Catcgary

I

Age 2r ( 5

Farmed 1-19 Years

Farmed 2 20 Years

Farmed

Farmed '<e 20 Years

No. of

Cases

No. o f
Cases

No. of
Cases

No. of
Cases

300-999

101

57

116

117

451

12

5

H-ICDA
Code

No. of

. Relative
I
Risk

Cases

ilclat ivc
Risk

Rel.it ivc

1 Risk

CONTROL CROUP
I Injuries (■ Adverse
Effects)
I.

l*lilob i t i * .muI
ihro";bu|>!ilcbit is

2.

Varicose Veins of
Louer Extremities

3.

Ilc-orrhoids

45S

Diseases of the Respiratory
System
460-519

B.

41

1.0

9

1 .6

8

8

1.2

1.8

14

8

1.3

6

0.8

7

11

14

2

0.3

4

0.9

0

4

62

10

0.5

15

0.6

43

69

Acute Upper Respiratory
Infect ions
460-470

18

1

0.2

4

0.5

10

13

1.5

480-486

19

4

0.5

3

0.6

16

28

1.8

Pneumonia
1.

rneunon i a,
Organism f, Type
Not Specified

4S6

14

5

U.S

3

0.8

12

17

1 .4

C.

Bronchitis, Emphysema,
Astl.'ta. 5 Related
Condi t ions
4S9-496

13

4

1.1

2

0.3

IS

18

1.3

0.

Other Diseases of the
Respiratory System 500-519

14

1

0.1

6

1.2

A

11

2.S

Diseases of the Digestive
System
A.

220

72

0.9

75

0.8

92

14 0

1.6“*

Diseases of Esophagus,
Stomach and Duodenun
530-537

48

17

1.3

10

0.4

23

38

1.8*

531-534

10

10

2.2

9

1.0

IS

24

1.5

531

10

3

1.3

S

1.0

9

12

1.7

1.

Ulcer

a. Ulcer of
Stomach

J.

I
§

• •••

B.

• •••

• •••

Cas$ Control Relative Risks for Farming Exposure - Females
Age i 65

Ago 25-6$

Never
farmed

Parsed 1-19 Years

Diagnostic Category

M-IC0A
Code

No. of
Cases

No. of
Cases

COVIROL Gl’Our
(Injuries 6 Adverse
Effects)

SOO-999

101

37

b. Ulcer of
Duodent s

S32

5

6

2.

Gastritis and
Ih todenitis

Relative
Risk

Faraod » 20 Years

Never
Formed

Farmed I 20 Years

Relative
Risk

No. of
Casos

No. of
Cases

116

117

No. of
Cases

41

4.8*

Relative
Risk___

3

1.4

7

6

0.8

3.6

53S

20

7

1.2

1

0.1

2

8

B.

Appendicitis

S40-543

13

S

0.7

6

1 .4

1

1

C.

Hernia of Abdominal
Cavity

SS0-5S3

26

6

0.5

S

0.8

8

14

2.0

SSI

15

2

0.3

4

O.8

3

7

3.2

Other Diseases of
Intestine and
Fcritoncua

560-SO9

46

12

0.7

17

1.2

33

35

1.1

Intestine Ob­
struction

560

5

1

0.3

3

2.1

7

1?

1.6

Diverticular Disease
of Intestine

562

7

2

0.8

5

2.1

7

9

1.1

functional Disorder
of Intestine

564

20

3

0.3

6

1.0

10

7

0.9

Diseases of the Liver,
Gallbladder, and
570-577
Pracrcas

85

29

0.9

34

0.8

30

S3

2.0

1.9
1.9-

1.

0.

1.
2.

3.

E.

Other Hernia of
Abdominal Cavity
Without Mention
of Obstruction

I

1.

Biliary Calculus

S74

4C

15

0.9

15

0.8

9

14

2.

Other Diseases of
Gallbladder

575

42

14

0.8

18

0.9

21

36

• • ••

B.

• •••

Case-Control Relative Risks for Farming Exposure - Females
Ago 2S-6S

Age I 65

Never
Famed

Farmed 1-19 Years

Farmed * 20 Years

Never
Famed

ll-ICOA
Code

No. of
Cases

No. of
Cases

No. of
Casos

No. of
Cases

No. of
Cases

800-999

101

37

116

117

580-629

296

79

0.7

125

1.0

50

73

i.r*

590-599

45

12

0.7

24

1.1

28

30

1.2

590

9

1

0.3

1

0.3

4

3

0.9

Cystitis

592
595

18
5

3
0

0.4
0.0

8
4

0.8
1.4

5
5

4
5

0.9
1.3

Other Diseases of
Urinary Tract

599

4

7

5.9«*

4

3.2

7

11

1.9

610-611

48

5

0.3

10

0.5

5

9

2.7

610
Diseases of Ovary,
Fol lopian Tube,
Parametrium
612-617
1. Other Diseases of
Ovary and
Fallopian Tube
615

45

5

0.3

10

0.5

5

5

1.5

20

6

0.9

3

V 5

9

6

1.9

3

1.1

184

56

0.7

88

1.1

16

29

2.4*

IH.igncstic Category

Rolative
Risk

Pclativo
Risk

Farmed 2 20 Years
. Relative

I

Risk

CCKTHOL GROUP
(Injuries 4 Adverse
Lffccts)

Diseases of the Genito­
urinary System
A. Other Diseases of
Urinary System
1. Infection of
Kidney
2. Calculus of
Kidney and Ureter

tn

3.
4.

8.

Diseases of the
Breast

1.

C.

D.

Fibrocystic
Disease of
Drcast

Diseases of the Uterus
6 Other Female
Genital Organs
<
619-629

41

• •••

B.

Case-Control Relative Risks for Farming Exposure - Females
Age i 6$

Age 2S-6S

Never
Tarred

Farmed 1-19 Years

[>i ignostic Category

H-ICDA
Code

No. of
Cases

No. of
Cases

CONTROL (’
.ROUP
(Injuries 6 Adverse
L(feels)

800-999

101

37

l.ndorretl iosis

619

9

10

2.2

5

1. I

Uterovaginal
Prolapse

623

17

4

0.5*

27

3.

Other Diseases of
Uterus

625

26

8

0.8

4.

Disorders of
Menstrual Cycle

626

107

25

S.

Menopausal
Postmenopausal
Symptoms

627

14

Del ivory a-id Compl icat ions
of Pregnancy, Child­
birth 6 the
Pucrperium
i631-678

1.

cr

A.

B.

Farmed i 20 Years

No. of
Cases

No. of
Cases

No. of
Cases

116

117

3.2**>*

10

25

3.f

13

0.8

1

1

2.1

0.5

27-

0.7

1

0

0.0

0

0.0

12

0.9

2

0

0.0

599

263

0.8

52

0.5

Rclat ive
Risk

Rclativc
Risk

<11

Complications of
Pregnancy

631-639

51

23

0.8

4

0.3

1.

Hemorrhage of
Pregnancy

632

10

5

0.9

1

0.5

2.

Other Complications
Mainly Related to
Pregnancy

634

25

14

1.0

2

0.4

640-M6

33

1.3

10

1 .4

Abortion

1.

C.

Farmed S 20 Years

Never
Farmed

Spontaneous
Abortion

Delivery

643

32

20

1.3

9

1.3

650-664

546

233

0.8

42

0.5

|

Relat ivc
Risk

B.

C^e-Control Relative Risks for Farming Exposure - Females
A|;o 2S-65

Never
F.’. med

Farmed 1-19 Years

No. of
Cases

No. of
Cases

SOO-999

101

37

Without Mention
of Complication

650

362

154

0.7

26

0.4

2.

i’cI i very
Complicated by
Dystoclc Position
of Fetus

656

25

10

0.7

0

0.0

3.

Del ivory
Complicated by
Prolonged Labor
of Other Origin
Del ivory with
Laceration of
Perineum Without
Mention of Other
Lacerat ion
Delivery with
Other
Coraplications

657

10

5

0.6

2

1.1

658

64

35

1.1

8

0.S

664

38

17

0.9

4

0.6

680-709

17

6

0.9

12

680-686

7

5

1.5

700-709

8

0

0.0

II-ICDA
Ci'de

I>i »unn<t ic Cit epory< UM IUH. CROUP
(Injuries ' Adverse
Effects)
I.

4.

5.

, Relative
I
Risk

A£c J 6S

Farmed 2 20 Years
No. of
Rc1 a t i ve
Cases
Risk

Never
Farmed
No. of
Cases

Cases

41

116

117

3.3

14

26

1.8

4

2.2

3

9

2.7

4

3.0

7

12

1.8

I

Farmed t 20 Years

No. of

Relative
Risk

Lie 1 i very

Diseases of the Skin
and Subcutaneous
Tissue
A.

Infections of Skin
and Subcutaneous
Tissue

B.

Other Diseases of
Skin .ml Sub­
cutaneous Tissue

• •••

B.

••••

• •••

Case-Control Relative Risks for Farming Exposure - Females

Agr 25-6S

Age * 65

Never
Farmed

Fanned 1-19 Year?

Farmed i 20 Years

No. of
Cases

Never
Farmed
No. of
Cases

No. of
Cases

116

117

Farmed X 20 Years

diagnostic Category1

ll-ICDA
Code

No. of
Cases

No. of
Cases

COMROL CROUP
(Injuries G Adverse
effects)

SOO-999

101

37

710-739
Arthritis 8 Rheuma­
tism except
Rheumatic Fever
710-718
1. Osteoarthritis &
\* Iied Conditions
713
Osteomyelitis and
Other Diseases of
Bone and Joint
720-729
1. Disorders of
Intervertebral
Disc
725
Other Diseases of
Musculoskeletal
System
730-739

73

20

0.7

34

1.1

55

80

1.5

19

4

0.5

12

1.0

31

63

2.2-*

6

4

2.1

5

1.3

24

S3

2.3

40

13

0.8

16

1.0

19

11

0.6

24

4

0.3

6

0.7

4

0

0.0

Diseases of the Mus­
culoskeletal System
6 Connective Tissue

A.

B.
co

c.

Ritat ivo
Risk

Relative
Risk

41

Relative
Risk

15

3

0.6

7

1.4

6

7

1.4

Signs. Symptoms G
Ill-Defined Conditions 770-796

184

35

0.7

55

1.3

54

60

1.2

1.

Otner Symptoms
Referable to
Cardiovascular
6 Lymphatic
System

775

6

1

0.5

5

1.2

6

11

1.6

2.

Symptoms Referable
to Abdomen G
Peritoneum

780

32

12

0.6

14

1.6

8

12

1.9

• •••

B.

•••••

••••••

Case-Control Relative Risks for Farming Exposure - Females
AjiC 25-65

Ago a 65

L’2£U£iIi£ Category

II- 1CDA
Code

Never
Famed
Ko. of
Cases

COXfRCI. GROUP
(Injuries C Adverse
(.ffccts)

SOO-999

101

5’

7;.9

17

5

0.8

5

0.8

10

7

0.7

001-799

1,732

586

0.8

S30

1.0

628

802

1.3

3.

Other Symptoms
Referable to
Muscu1oskc1etal
System

All Diagnoses

Farmed 1-19 Years
No. of , Relative
Cases
|
Risk

Farmed > 20 Years
No. of
Relative
C-aCS
Risk

Never
Farmed
No. of
Cases

Farmed » 20 Yrars
No. of
Relative
Cases
J Risk

4]

116

117

Rol-tive risk statistically j igniflcantly greater than one p<.05, p<.01.

Statistically significant exposure - risk relationship over the two risk categories p<.(5.

KI

APPENDIX III
RELATIVE risks for smoking and selected diagnoses

t

• •••

• •••

• ••••

Relationships Between Smoking History and Selected Diagnoses - Males

A.

Age 2S-64

Never
Smoi ••A

Low Smoking

Ago i 65

High ’wbokii.if

Pi.ivjh'stic Catcgary

H-ICD-X Codes

\’o. or
Cases

No. of
Cases

Control Croup
(Injuries (, Adverse
Lf fects)

S09-M9

82

84

Malignant Neoplasm of Trachea
Bronchus & Lung

162-163

0

0

Pisca>cs of the Circulatory
System

390-4S8

66

37

0.9

179

400-405
410-414

3
30

S
6

1.4
0.4

410

19

2

412
413

7
2
3

A. Hypertensive Disease
B. Ischemic Heart Diseases
1. Acute Myocardial
Infaict ion

Relative
Risk

Never
Smoked

Low Smoking

High Smoking

No. of
Cases

No. of

109

63

31

10

5

1

0.4

19

2.8*

1.6**

187

59

0.6

178

1.1

12
79

3.5
1.4

4

2.2
1.1

6
69

1.5

$6

4
29

0.2

47

1.3

27

12

0.9

37

1.4

1
3

0.4
2.9

2.0*

2.8

14
3
7

1.0
6.3
0.7

1.2
12.1*

1.2

28
1
IS

28
9

3

27
11
9

13

1.1

5

3

1.0

10

1.2

37

6

0.3

25

0.8

9

5

1.0

23

1.3

54

10

0.4

34

0.7

1.8

8

6.1

11

1

0.1

14

1.5

Relative
Risk

Vo. of
Cases

Cases

Relative
Risk

No. of
Cases

Relative
Risk

56

1.3

2. Chronic Ischemic
Heart Disease

3. Angina Pectoris

C. Disorders of Heart Rhythm 415-416
D. Other Forms of Heart
Disease
420-429
L. Cerebrovascular Disease
430-438

1.9

1. Transient Ischemic
Attack

435

1

2. Acute, but Ill-defined
Cerebrovascular Disease

4 36

4

2

1.0

9

1.1

24

2

0.1

19

1.0

F. Diseases of Arteries,
Arterioles, 6 Capillaries

410-418

1

3

5.5

20

8.5*

25

6

0.4

25

l.i

440

1

2

4.2

12

15

15

1.2

32

14
13

1
2

0.2

450-458

5.1
1.4

0.4

13
18

1.0
1.3

4S1

4

5

1.9

4

0.6

S

1

n.s

3

1.2

455

7

3

0.5

15

1.6

3

0

0.0

3

0.9

1. Arteriosclerosis
G.

Diseases of Veins
Lymphatics 5 Other
Circulatory Diseases
1.
Phlebitis & Thrombo­
phlebitis
2.

Hemorrhoids

J

• ••••

• •••

• ••••

F
s
i

A.

Relationships Between S.noking History and Selected Hiagnoses - Males

Age

Age 25-64

Never
Smoked

No. of

High Smoking

Low Smoking

Rclat ivc
Risk

No. of
Cases

£«i.ir tost ic Cat ego i'V

II-ICPA Codes

Cases

No. of
Cases

Control Croup
(Injuries and A Iverse
Effects)

800-999

32

84

Diseases of the Respiratory
System

400-519

25

IS

0.8

57

ICO -470

3

2

0.6

9

G5

l.ow Smokinr,

Relative
Risk-

.’•’ u . o f
Cases

No. of
C.i 'CS

63

31

1.4

71

19

0.5

2.2

9

1

0.9

40

5

Pel nt ivc
Risk

109

A. Acute Upper Respiratory
Infections

: ver
: .iokcd

lit ph Smoking

No. of
Cases

!
I

Rvlatjvc
Risk

56

82

1.3

0.2

5

0.7

0.2

34

1.0

B. Pneumonia

480-486

11

3

0.4

17

C. Bronchitis, Emphysema,
Astk.-'i 5 Related
C.nditsons

439-496

4.

5

3.0

16

2.1

14

11

1.8

37

2.8

0.4

4

3

1.8

1

0.2

2.8

5

5

2.7

19

3.9**

1. As th ‘.a

493

3

2

1.7

3

2. Chronic Ob--.tract ivc
Lung Disease

496

1

0

0.0

6

D. Other Diseases of the
Respiratory System

500-519

8

S

0.6

IS

1.3

8

3

0.6

7

531-534

10

1.3

35

9

6

1.0

23

3

9

2.7

25

4

4

1 .8

14

2.9*

532

2.0
S.7*

1.1
2.6*

10

(Except Controls) 001-799

433

310

0.8

816

1.2

681

255

0.7

720

1.1

ra

Ulcer

A. Ulcer of Duodenum
All Diagnoses

Statistically significant relationship between amount smoked and relative risk

p<.05.

pc.Ol

4

••••

• •••

B.

••••

••••

Relationships Between Smoking History and Selected Diagnoses - Females

Age 2S-64

Nover
S...okcd

;c Category

H-JCD\ CoJcs

No. Of
Cases

Control Croup
(Injuries 6 Adverse Effects)

SOO-999

9S

45

162-163

1

0

Syston

390-45S

104

A. Hypertensive Disease

40 ;-405

15

I

'L»i ignar.t Nv’.'plasn of Trachea,
?ro.icmis i Lung

II

Diseases of the Circulatory

B. Ishccrsic Heart Disease

1. Acute Myocardial
I a fret i v n

i

Low Sr.oking

2. Chronic Ische-.ic
heart Disease’
C. Disorders of Heart Rhythm

410-414
410

No. of
Cases

Rcl .it ive
Kisk

Age x OS

High Smoking

No. of
Cases

Ke 1 ativc
Kisk

Never
S:..okcd

Di seas?

E. Cerebrovascular Disease
F. Diseases of Arteries,
Arteri'ler- ar.d
Ca;-11 i ar it t

1. Arteriosclerosis

No. of
Cases

231

5

7.4

3

1

14.7

2

39

1. rali-bitis (,
Ihrj-tonhlcbitis

Re I ative
Risk

No. of
Cases

Re!ative
Risk

14

0.0

3

25

0.5

55

1.4

380

IS

2.0

33

1.5'

3

0.4

4

0. 7

29

2

2.2

4

IS

2.2

2

0.S

16

2.4

100

4

2.1

12

2.0

4

2

3.1

11

13.

38

2

2.6

6

2.3

11.4

412

7

0

0.0

2

0.6

56

2

2. fi

415-416

4

8

1.4

2

0.6

8

2.0

26

1

l.S

6

3.6

1

0.7

0

0.0

46

1

1.3

2

0.8

1

1.6

7

1.7

97

2

1.4

5

1.2

420-429

I

S

4 30-4 38

440-419

7

3

1.8

1

0.3

48

0

0.0

440

5

2.0

1

3

14.7

1

2.9

29

0

0.0

2

1.4

52

16

0.5

20

1.1

60

5

3.1

2

0.6

0.5

5

0.9

14

2

3.6

1

1.0

G. ?ise.:ses of kcins,
!'h it i < s, 4 Other
Cirv Jatory Diseases

High Snoking

No. of

D. Other For s of Heart
I

Low Sr.okir.g

45C-4S8

451

1/

r

B.

Relatio.iships Between Smoking History and Selected Diagnoses - Females
Age 2;-G4

Never
S.nokcd

Lew Sacking

A c x GS
High Sacking

Never
Sacked

Nu. of
Casos

No. of
Cases

Lew Soo ing

High Sacking

No. of
Cases

No. of
Cases

803-999

95

45

2. Varicose Veins of Lower
I\t remitics

454

19

6

0.5

3

0.5

17

2

5.1

0

0.0

5. iL-orrhoids

4$S

9

3

0.5

8

2.0

6

0

0.0

0

0.0

460-519

38

24

1.0

25

1.4

10S

3

1.3

13

2.2

460-47U

10

9

1.6

4

0.7

19

1

2.1

4

3.6*

4S0-486

9

8

1.5

9

2.1

44

1

1.2

4

1.7

439-496

9

3

0.5

7

1.7

30

0

0.0

5

2.6

500-519

11

5

0.5

5

1.0

18

1

3.5

0

0.0

531-53!

16

7

l.H

14

2.1

33

2

2.’

3

1.2

A. Ulcer of Stomach

5 31

8

5

2.4

5

1.4

19

1

1.8

2

1.7

o. Ulcev uf DuoJc.nua

$32

5

2

1.6

7

3.6*

12

1

417

0

0.0

0C1-799

>127

333

0.7

451

1.0

1400

75

2.2

99

1.1

pc.0$,

P<.01,

>

t ic Category

H-ICHA Codes

tr.'I Croup
(Injuries 5 Adverse Effects)

Relative
Risk

Rclat ive
Risk

59

of

4-

i dative
Risk

S

231

No. of
Cases

Relative
Risk

14

u. ric'.’.ises of Veins.
l.> - ■*> »t ics , G Other
Cj 1tulatory Diseases'
(x-ont.)

t»f the Respiratory
c L’r.cr Respiratory
In fee th is
c

B.

O

C. Prcicbu is, rmthyseeta,
' tr.-u, i Related

f
a
•-•O

l.’.nhticiij

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Xe^piratory System

2
53
W

f

n

5

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5 I regn.j-.cy)

o

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