Strategies to Protect the Health of Deployed U.S. Forces Medical Surveillance, Record Keeping, and Risk Reduction (1999) / Chapter Skim
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Appendix A: Population and Need-Based Prevention of Unexplained Physical Symptoms in the Community
Appendix A: Population and Need-Based Prevention of Unexplained Physical Symptoms in the Community
Pages 173-212
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From page 173... ...
. Katon SYNOPSIS How might military medicine respond to existing research on the epidemiology, burden, natural history, and management of medically unexplained physical symptoms (MUPS)
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Eventually, we are impressed that military medicine's innovations in this area may provide an important model for civilian health care organizations seeking solutions to the difficult challenge of MUPS. UNDERSTANDING MEDICALLY UNEXPLAINED PHYSICAL SYMPTOMS The absence of a discerned cause for physical symptoms is best viewed through the lens of the scientific uncertainty necessarily involved in any one-toone doctor-patient visit.
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, putative triggers (e.g., multiple chemical sensitivity) , a central descriptive feature (e.g., chronic fatigue syndrome)
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TABLE A-1 Some Symptom-Based Diagnoses and the Specialties that Commonly Diagnose and Encounter Them Specialty Clinical Syndrome Specialty Clinical Syndrome Orthopedics Low back pain Patellofemoral syndrome Dentistry Temporomandibular dysfunction Gynecology Chronic pelvic pain Rheumatology Fibromyalgia Premenstrual syndrome Myofascial syndrome Siliconosis Ear-Nose- Idiopathictinnitus InternalMedicine Chronic fatigue syn Throat drome Neurology Idiopathic dizziness Infectious Diseases Chronic Lyme disease Chronic headache Chronic Epstein-Barr virus Chronic brucellosis Chronic candidiasis Urology Chronic prostatitis Gastroenterology Irritable bowel syn Interstitial cystitis drome Urethral syndrome Gastroesophageal reflux Anesthesiology Chronic pain syndromes Physical Medicine Mild closed head in Jury Cardiology Atypical chess pain Occupational Multiple chemical Idiopathic syncope Medicine sensitivity Mitral valve prolapse Sick building syn drome Pulmonary Hyperventilation syn- Military Medicine Gulf War Syndrome drome Endocrinology Hypoglycemia Psychiatry Somatoform disorders
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From page 177... ...
communities and found that 25 percent reported chest pain, 24 percent reported abdominal pain, 23 percent reported dizziness, 25 percent reported headache, 32 percent reported back pain, and 25 percent reported fatigue.9~ Thirty-one percent of symptoms were medically unexplained, and the type of symptom was unrelated to the absence of explanation. Eighty-four percent of symptoms caused respondents to seek health care, take a medicine, or curtail activities.9~ Over 4 percent of people had a lifetime history of multiple, chronic, unexplained symptoms and an exacerbation within the past year.38 ~42 Other studies have shown that MUPS are associated with a high proportion of populationwide disability and health care utilization, largely because they are so common.3974 For example, the 1989 National Ambulatory Medical Care Survey estimated that physical symptoms account for 57 percent of all U.S.
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From page 178... ...
Most other primary care research suggests that etiologies are unknown for at least 25 to 30 percent of patients with either painful or nonpainful physical symptoms.87 92 93 An extensive scientific literature has shown that MUPS are strongly and consistently associated with psychosocial distress, psychiatric disorders, decreased quality of life, and increased health care utilizations ~8 25 38 39 56 76 90 92 ~29 ~35 Depression and anxiety are consistently associated with MUPS across many studies that have used wide-ranging methodologies including crosssectional ~35 case-control,73 82 ~40 ~52 ~56 and longitudinal designs35° Some evidence suggests that associated high health care utilization leads to more harm and patient dissatisfaction than benefit.86 ~45 Natural History of MUPS MUPS are characteristically chronic and intermittently relapsing, although the natural history is reasonably variable in severity and periodicity. Factors responsible for variability in clinical outcomes may be classified as predisposing, precipitating, and perpetuating factors.
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From page 179... ...
A high level of previous health care use suggests that a poor long-term outcome characterized by chronic MUPS is relatively likely.78 ~36 A large number of prospective studies have consistently found that the presence of stressors, distress, and psychiatric disorders, especially when they are chronic, predict persistent MUPS and related disability.9 ~3 22 29 57 65~05~09~9~26 A higher number of comorbid physical symptoms ("symptom count"~53 and longer symptom durational 22 89 95 ~48 also predict a poor outcome. Past poor functioning including occupational functioning suggests a poor prognosis.37 50 94 A patient's historical level of functioning can serve as a marker for a myriad of issues that diminish the amount of reserve that an individual can muster when symptoms worsen.
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From page 180... ...
solving Tracking Tracking Tracking Tracking Tracking Vulnerability Precipitating Symptoms and Chronicity Disability Factors Health Concerns FIGURE A-1 A stepped-care approach to the population management of medically unexplained physical symptoms. Advantages of Population-Based Intervention Rosen has noted, "a large number of people exposed to a small risk may generate many more cases than a small number exposed to a high risk" (p.
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~t ' At/' do -- ~- - 10 Q _~~ ~,y~ ~-5 ~ ~ '; ;'' i ~'2"~ I- ~ 1 1 my, ..... 0 1 2 3 4 5 6 181 7 8 9 10 11 12 13 14 15 16 Symptom Count - lo FIGURE A-2 Contrasting the population-based and needs-based approaches to reducing morbidity related to medically unexplained physical symptoms.
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From page 182... ...
Rosen described health care-based preventive approaches as "the high risk strategy" because the effort is to identify individuals at especially high health risk or with especially great need for health care. The time-limited nature of clinical practice requires that providers rapidly recognize patients who require special attention.
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From page 183... ...
Even so, the long symptom duration and large number of episodes among those few individuals with an incident case of MUPS who develop chronic MUPS ensure that those with chronic MUPS are disproportionately represented in the population at any point in time. This overrepresentation of those with chronic and recurrent MUPS versus those with brief and acute MUPS is greater in specialty care than primary care and greater in referral facilities than local facilities.
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targets the important morbid consequences of chronic MUPS: psychosocial distress, psychiatric disorders, and disability. From the equation, we would expect that the first three strategies might reduce the population prevalence of MUPS.
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Problem list and symptoms Visits and admissions Pharmacy use Orders and procedures Health care costs FIGURE A-3 Components of an IS used in population-based health care for MUPS and their relationship to one another. ES = expert computer systems, HIS = health information system, and HMS = health monitoring system .
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From page 186... ...
may allow careful empirical evaluation of whether risk factors and interventions alter militarily relevant MUPS outcomes. The combined use of ESs, HISs, HMSs, and AISs may provide for careful longitudinal tracking of the health status of individuals with MUPS who have recently deployed.
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From page 187... ...
If primary care physicians can achieve success within the context of a reorganized clinic process, they may eventually find that behavioral management of MUPS and related distress and disability is rewarding and worthwhile. Therefore, we recommend the development, implementation, and use of structured and carefully monitored health care programs that use primary care practice teams.
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Figure A-1 summarizes the stepped approach that we currently envision. It employs five basic steps: preevent prevention, postevent prevention, routine primary care, collaborative primary care, and intensive multidisciplinary care.
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From page 189... ...
Step Two: Postevent Primary Prevention We suggest narrowing the focus of postevent prevention to specific units and associated families that have recently deployed or faced other events that might precipitate subsequent health concerns. Within these units smaller groups at especially elevated risk of MUPS may be identified on the basis of the presence or absence of past MUPS or other predisposing factors.
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From page 190... ...
Similarly, town hall meetings offer opportunities for personnel and significant others to articulate and even ventilate important event-related health concerns. If the event or deployment involved sufficiently large numbers, telephone hot lines may be useful, too, providing personalized contact for people with questions, concerns, or previously undiscovered events or exposures.
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From page 191... ...
Therefore, a key to secondary prevention may involve early primary care recognition and timely management of MUPS to reduce the impact of precipitating and perpetuating factors on physical symptoms, emotional distress, and disability. IS technologies may remind primary care physicians which of their patients are most symptomatic, most concerned about their health, and most distressed regarding undiagnosed illness.
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From page 192... ...
Comforting involves off~ce-based patient education and often centers on the health effects of adverse life events and toxic exposures, the impacts of anxiety and mood on physiology, symptoms, and functioning, the limits of medical testing, and the impacts of medication side effects on functioning. Self-help materials such as audiotapes and books about physical activation, relaxation
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From page 193... ...
It is often useful to have patients graph their incremental progress toward their goals and review the graphs with them at their follow-up appointments. Examples of good areas for goal formulation are occupational, household, or social task performance, physical activation, sleep hygiene, or medication adherence.
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From page 194... ...
Family or friends can help clarify concerns, illness beliefs, symptoms, and deficits in functioning. Often, the patient's most important concerns are related to those closest to the patient, and their involvement in care can make or break the clinician's ability to successfully engage the patient in a constructive dialogue about the patient's health concerns.
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From page 195... ...
MUPS-related clinical training experiences may add to the overall quality of patient care by improving the routine primary care management of associated, frequently unrecognized, and treatable psychiatric disorders. Research suggests that an excessively biomedical approach to MUPS or coexisting chronic medical illness markedly diminishes physician attention to psychosocial aspects of care such as recognition of treatable anxiety and depressive disorders.
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From page 196... ...
Some clinicians are better than others at identifying treatable psychiatric disorders in their patients.~°~ Conversely, distressed patients will more readily share their emotional concerns with those clinicians who are best at addressing them.5~ Appropriate medical education emphasizing communication skills, MUPS, and the recognition and treatment of anxiety and depressive disorders by primary care providers may improve clinical outcomes and provider confidence in addressing patients' psychosocial issues. Efforts to improve physicians' communication skills are critical to improving the routine primary care management of MUPS.
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From page 197... ...
Katon and colleagues79 completed a randomized trial of psychiatric consultation for "distressed high utilizers of primary care" at Group Health Cooperative of Puget Sound, a health maintenance organization serving over 350,000 enrollees in Washington State. Distressed high utilizers were defined as the top 10 percent of ambulatory care utilizers over the year prior to study who were identified as distressed either by their primary care physician or by high scores on a validated paper-and-pencil measure.
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From page 198... ...
Components have included screening; on-site mental health consultation; cognitive-behavioral and problem-solving therapies aimed at medication adherence, depression, MUPS, physical activation, and relapse prevention; videotapes, pamphlets, and other education materials on selfcare; structured follow-up strategies; and standardized written primary care instructions. Other efforts to enhance primary care clinicians' ability to tackle the multiple needs of their patients have employed "academic detailing," feedback to clinicians from their patients' automated pharmacy or health care utilization records, and case management.
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From page 199... ...
However, for the major depression patients, the multifaceted intervention offered significantly greater cost-effectiveness than usual primary care349 Given the added expense associated with collaborative models, we suggest that they be held in reserve for patients for whom routine primary care management strategies for MUPS fail. Symptom duration is a key step four indicator to monitor using IS-generated reports.
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From page 200... ...
Empirical trials have shown the benefits of CBT for a range of MUPS including chronic fatigue,~3~ irritable bowel syndrome,~7 ~46 temporomandibular disorders,32 burning mouth syndrome,~° hypochondriasis,~57 and multiple MUPS.64 96 ~38 Wessely's group30 in London found that 63 percent of patients with chronic fatigue syndrome (CFS) showed significant improvement in their physical functioning after random assignment to CBT and physical activation, whereas only 19 percent assigned to relaxation training showed significant improvement.
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Functioning, fatigue, and depression but not anxiety were also significantly improved. As one would hypothesize under a model of treatment with CBT, illness beliefs and coping were more positively altered for those assigned to CBT than for those assigned to usual care.
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Although explanations of"stress" or "somatization" for unexplained physical symptoms serve an important clinical purpose for many MUPS patients, they are often used to minimize the needs of affected patients. Another barrier at present is the lack of an institutionalized niche for specialized care for MUPS, especially after combat and deployments.
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From page 203... ...
Where, how, and why veterans with postdeployment health concerns seek their care and their satisfaction with that care is currently completely unknown within the military and is of great importance to prevention, treatment, and risk communication efforts. Fourth, we suggest that physicians and policy makers move as rapidly as possible toward population-based models of health care and create system incentives for local-level development of novel interdisciplinary approaches to MUPS, interventions that span the spectrum of precare, primary care, collaborative primary care, and intensive specialty care.
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Outcome and prognosis of patients with chronic fatigue vs. chronic fatigue syndrome.
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The natural history of concurrent sick building syndrome and chronic fatigue syndrome. Journal o/Psychiatric Research 1997;31~14:51-7.
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Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome.
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Prevalence of irritable bowel syndrome in chronic fatigue. Journal of the Royal College o/Physi cians of London 1996;30~64:512-3.
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Russo J Chronic fatigue syndrome criteria.
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Use of exercise for treatment of chronic fatigue syndrome. Sports Medicine 1996;21~14:35-48.
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How primary care physicians treat psychiatric disorders: A national survey of family practitioners. American Journal o/Psychiatry 1985; 142(1)
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et al. Cognitive behaviour therapy for the chronic fatigue syndrome: A randomized controlled trial.
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Prognosis in chronic fatigue syndrome: A prospective study on the natural course. Journal of Neurology, Neurosurgery and Psychiatry 1996;60~54:489-94.
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