Patients Who Are High Users Of Health Care

It can be frustrating to treat patients who are high users of health care but whose clinical presentation allows us no clear focus for intervention and remediation. Dr. Smith and colleagues¹ clarify that, contrary to popular thinking, the majority of patients who are high users of medical care are not necessarily somatizing, and that most of those patients have minor acute medical illnesses. However, we also should acknowledge that the costs of caring for somatizing patients are disproportionately high.² Special effort is required to intervene if changes in clinical course and utilization are to occur.

Also, it is quite possible that the minor acute medical illness group contains a significant number of patients with psychiatric disorders other than those frequently seen in primary care, such as depression, substance abuse, or anxiety disorders, since as many as 50% or more of patients who present with comorbid psychiatric conditions have physical symptoms rather than psychological symptoms.³ The use of standardized psychiatric measures oriented to primary care populations will better delineate this clinical population and help us respond to their complicated treatment needs.

Rodger Kessler, PhD
Berlin Family Health
Montpelier, Vermont

REFERENCES

1. Smith RC, Gardiner JC, Lyles JS, et al. Minor acute illness: a preliminary research report on the “worried well.” J Fam Pract 2002; 51:24-9.
2. Regier D, Goldberg I, Taube C. The de facto mental health services system. Arch Gen Psychiatry 1978; 35:685-93.
3. Katon W, VonKorff M, Lin E, et al. Distressed high utilizers of medical care; DSM-III-R diagnoses and treatment needs. Gen Hospital Psychiatry 1990; 12:355-62.

Dr Smith responds:

We were surprised to find so many patients who did not fit the criteria for somatization. We had not considered that, among high users of care, we would find anything other than organic disease and somatization along with some patients with predominantly psychiatric illness, such as depression. While much work remains, there appears to be a rather large group of previously unstudied patients with what we have descriptively called minor acute illness (MAI). We are presently studying whether the costs for MAI are similar to those for somatization, and we are studying the psychological and psychiatric profiles of both somatizing patients and patients with MAI. Because we rated only a patient’s primary diagnosis during the year, we agree it is likely that we will find considerable comorbid psychiatric illness in patients with MAI, as well as in somatizing patients. We are conducting a randomized controlled trial to determine if a 12-month intervention by primary care personnel is effective. It uses cognitive-behavioral principles and, for the first time, a strong systematic emphasis on the provider-patient relationship. We also have identified a simple screening test using an administrative database that, with further study, may be useful in identifying somatizing patients for treatment.¹

Robert C. Smith, MD, ScM
Michigan State University
Michigan

REFERENCE

1. Smith RC, Gardiner JC, Armatti S, et al. Screening for high utilizing somatizing patients using a prediction rule derived from the management information system of an HMO — a preliminary study. Med Care 2001; 39:968-78.