Determinants of complaint symptoms in a Swedish health care practice--results of a questionnaire survey

Development and psychometric testing of a measure of older adult patients' attitudes towards mobility during hospitalization (ATM-H)

This paper describes the development and psychometric testing of a questionnaire evaluating attitudes towards mobility during hospitalization of older adults, an understudied phenomenon that lacks a valid and reliable measure. An instrument development procedure, followed by an empirical study, was conducted between December 2013 and June 2014. Instrument development included item generation and analysis of content validity, which was established by six experts. The validation study used a prospective within-patients design with a sample of 100 patients, age 70+, hospitalized in general medical units in a large medical center. Internal consistency, reliability, and divergent and predictive validity of the measure were tested. Reliability analysis revealed an acceptable estimate for the total score (0.76). Predictive validity was good. The divergent validity coefficient was in the expected direction. Preliminary psychometric properties of the measure showed acceptable results. The measure should be explored further in different cultural settings.

Prevalence and course of somatic symptoms in patients with stress-related exhaustion: does sex or age matter

BACKGROUND

Both mental and somatic symptoms are commonly reported in patients with stress-related problems. We have explored the prevalence of somatic symptoms in patients seeking medical care for stress-related mental health problems and followed the course of illness alongside with that the patients receive multimodal treatment.

METHOD

This study comprises data from 228 patients (69% women, mean age 43 years) who fulfilled the criteria for Exhaustion Disorder (ED). Somatic symptoms were assessed at baseline and after 3, 6, 12 and 18 months using the one-page questionnaire Primary Care Evaluation of Mental Disorders. Prevalence of different symptoms was compared between men and women and patients, over and below 40 years of age, and possible predictors of recovery were explored.

RESULTS

Tiredness and low energy are the core symptom reported by the patients. Almost all (98%) reported at least one somatic symptom and 45% reported six symptoms or more, which was similar for men and women. Nausea, gas or indigestion are the most common symptoms (67%) followed by headaches (65%) and dizziness (57%). The number of symptoms reported was significantly related to the severity of mental health problems. The only difference between the sexes was that "chest pain" and "pain or problems during sexual intercourse" were more common among males. Patients over forty more often reported "pain in arms, legs or joints, knees, hips" and this was also the only symptom that did not significantly decline during treatment. Neither sex, age, symptom duration before seeking medical care, education or any other predictor tested was shown to predict recovery in patients reporting six symptoms or more.

CONCLUSION

A heavy burden of somatic symptoms was generally seen in most patients with stress-related exhaustion. Somatic symptoms are equally common in males and females and in younger and older patients. The somatic symptoms seem to be mostly stress-related since all symptoms, except musculoskeletal pain, reduce with individualised treatment designed for stress-related mental problems. This study brings to attention the complicated burden of both somatic and mental symptoms in patients with stress-related exhaustion, raising several clinical implications of interest to discuss.

What bothers the sick-listed employee with severe MUPS?

Aims: The aim of this study was to explore what employees with severe medically unexplained physical symptoms (MUPS) experience as causes of distress with regard to employees with mild or no MUPS. Methods: This study is an additional analysis of a cross-sectional study in which 486 sick-listed employees, were assessed with Patient Health Questionnaire (PHQ)-15 for self-rated levels of MUPS. A cut-off score of 15 (≥15) was used to categorise employees with severe MUPS. Distress was qualitatively categorised with the answers on the open question in the PHQ-15 “if you experience distress at this moment, what are you distressed about?” Results: Sick-listed employees with severe MUPS were most distressed by their medical, mental, and financial problems. Employees with mild or no MUPS by their medical, work-related, and return to work-related problems. Employees with severe MUPS had more often distress by their mental and financial problems, compared to the employees with mild and no MUPS, who had more often no problems. Conclusions: There are differences in the causes of distress in sick-listed employees with severe MUPS compared to those with mild or no MUPS. Exploring these causes create possibilities for the physician to improve the quality of explanations and reassurance to the employee and to remove barriers for the return to work process.

Symptom load and functional status: results from the Ullensaker population study

Background

There is evidence to support that the number of self-reported symptoms is a strong predictor of health outcomes. In studies examining the link between symptoms and functional status, focus has traditionally been on individual symptoms or specific groups of symptoms. We aim to identify associations between the number of self-reported symptoms and functional status.

Methods

A questionnaire was sent to people in seven age groups (N = 3227) in Ullensaker municipality in Southern Norway. The Standardised Nordic Questionnaire and the Subjective Health Complaints Inventory were used to record 10 musculoskeletal symptoms and 13 non-musculoskeletal symptoms, respectively. Four COOP-WONCA charts were used to measure functional status.

Results

We found a strong linear association between the number of self-reported symptoms and functional status. The number of symptoms explained 39.2% of the variance in functional status after adjusting for the effects of age and sex. Including individual symptoms instead of only the number of symptoms made little difference to the effect of musculoskeletal pain but affected the influence of non-muscular symptoms. Including even minor problems captured substantially more of the variance in functional status than including only serious problems.

Conclusions

The strong association between the number of symptoms and functional status, irrespective of type of symptom, might indicate that the symptoms share some common characteristics. The simple act of counting symptoms may provide an approach to study the relationships between health and function in population studies and might be valuable in research on medically unexplained conditions.

Managing nonspecific low back pain: do nonclinical patient characteristics matter?

STUDY DESIGN

A fully blocked experimental design using clinical vignettes to query primary care physicians on prescription for management of acute nonspecific low back pain.

OBJECTIVE

To identify how nonclinical patient factors, specifically sex, patient presentation, and socioeconomic status, influence physician treatment recommendations for assessing and treating acute nonspecific low back pain.

SUMMARY OF BACKGROUND DATA

Adherence to evidence-based practice guidelines for nonspecific low back pain remains inconsistent. Therefore, it is important to understand what factors guide physician management of these cases.

METHODS

One vignette and questionnaire was distributed to primary care and emergency department clinical physicians during meetings at five teaching hospitals. The questionnaire asked for diagnostic and treatment recommendations including specific tests, medications, therapeutic procedures, activity, referral to other services, and patient education for the case represented in the vignette.

RESULTS

Subjects included 284 physicians and approximately 75% had less than 5 years of clinical practice experience. Multivariate logistic regression showed seven significant associations of patient factors with treatment recommendations for acute nonspecific low back pain (one sex, two socioeconomic status, and four patient presentation; P < 0.05).

CONCLUSION

All three assessed nonclinical factors influenced physician decisions regarding diagnostic and treatment recommendations for acute nonspecific low back pain. Patient presentation, suggestive of a patient's emotional state, was shown to be the most influential.

Daily patterns of symptom reporting in families with adolescent children

OBJECTIVES

This study was designed to investigate how symptom reporting varies by time of day, day of the week, gender and generation.

DESIGN

Concurrent symptom reporting was assessed prospectively using a computer-assisted self-report method.

METHODS

A computer-assisted self-observation method was used to assess concurrent somatic complaints six times a day for 7 consecutive days. Parents and adolescents from 173 families (568 individuals) filled in questionnaires during a normal workweek. A generalized linear model approach for multi-level models was used to analyse the multiple daily observations.

RESULTS

Results show a curvilinear within-day pattern for the reporting of somatic complaints, such that complaints were reported most in the morning and evening and least in the middle of the day. On weekends, participants reported fewer complaints in the evening. Women reported more symptoms throughout the day. Adolescents show an earlier and more pronounced increase in symptom reporting towards the evening. In addition, a slight decline in symptom reporting over the observation period was observed.

CONCLUSIONS

Symptom reporting changes throughout the day, and is influenced by gender, generation and day of the week.

Sick-listed employees with severe medically unexplained physical symptoms: burden or routine for the occupational health physician? A cross sectional study

Background

The two primary objectives of this study were to the assess consultation load of occupational health physicians (OHPs), and their difficulties and needs with regard to their sickness certification tasks in sick-listed employees with severe medical unexplained physical symptoms (MUPS). Third objective was to determine which disease-, patient-, doctor- and practice-related factors are associated with the difficulties and needs of the OHPs.

Methods

In this cross-sectional study, 43 participating OHPs from 5 group practices assessed 489 sick-listed employees with and without severe MUPS. The OHPs filled in a questionnaire about difficulties concerning sickness certification tasks, consultation time, their needs with regard to consultation with or referral to a psychiatrist or psychologist, and communication with GPs. The OHPs also completed a questionnaire about their personal characteristics.

Results

OHPs only experienced task difficulties in employees with severe MUPS in relation to their communication with the treating physician. This only occured in cases in which the OHP attributed the physical symptoms to somatoform causes. If they attributed the physical symptoms to mental causes, the OHPs reported a need to consultate a psychiatrist about the diagnosis and treatment.

Conclusions

OHPs experience few difficulties with their sickness certification tasks and consultation load concerning employees with severe MUPS. However, they encounter problems if the diagnostic uncertainties of the treating physician interfere with the return to work process. OHPs have a need for psychiatric expertise whenever they are uncertain about the psychiatric causes of a delayed return to work process. We recommend further training programs for OHPs. They should also have more opportunity for consultation and referral to a psychiatrist, and their communication with treating physicians should be improved.

Severe MUPS in a sick-listed population: a cross-sectional study on prevalence, recognition, psychiatric co-morbidity and impairment

Background

Medically unexplained physical symptoms (MUPS) have a high prevalence in the general population and are associated with psychiatric morbidity. There are indications that MUPS are an important determinant of frequent and long-term disability.

The primary objective was to assess the prevalence of MUPS in sick-listed-employees and its associations with depressive disorders, anxiety disorders, health anxiety, distress and functional impairment. Secondary objectives were to investigate the classification of the occupational health physicians (OHPs), their opinions about the causes as well as the attributions of the employee.

Methods

In a cross-sectional study of 489 sick-listed employees from 5 OHP group practices, MUPS, depressive disorders, anxiety disorders, health anxiety, distress and functional impairment were assessed with the Patient Health Questionnaire (PHQ), the Whitely Index (WI), the Four- Dimensional Symptom Questionnaire (4DSQ) and the Short-Form 36 Health Survey (SF-36).

We used a cut off score of 15 on the PHQ for the categorisation of severe MUPS.

The opinions of the OHPs were evaluated by means of a separate questionnaire with regard to the presence of employees physical symptoms, and the symptoms attributions, and the diagnoses of the OHPs.

Results

Severe MUPS had a prevalence of 15.1% in this population of sick-listed employees. These employees had 4-6 times more depressive and anxiety disorders, and were more impaired. Female gender and PHQ-9 scores were determinants of severe MUPS.

Most of the time the OHPs diagnosed employees with severe MUPS as having a mental disorder. The employees attributed their physical symptoms in 66% to mental or to both mental and physical causes.

Conclusion

The prevalence of severe MUPS is higher in long-term sick-listed employees than in the non-sick- listed working population and at least equals the prevalence in the general practice population.

Severe MUPS are associated with psychiatric morbidity and functional impairment and must therefore be specifically recognised as such. Validated questionnaires, such as the PHQ-15, are useful instruments in order to help OHPs to recognise severe MUPS.

Health status, not head injury, predicts concussion symptoms after minor injury

OBJECTIVE

Postconcussion (PC) syndrome etiology remains poorly understood. We sought to examine predictors of persistent PC symptoms after minor injury.

METHODS

Health status, symptom, and injury information were obtained on a sample of patients presenting to the emergency department after minor injury. Postconcussion and cognitive symptoms were assessed at 1, 3, and 12 months.

RESULTS

Among 507 patients enrolled, 339 had head injury. Repeated-measures logistic regression modeling of PC and cognitive symptom presence across time indicated that baseline mental health status and physical health status were most predictive of persistent symptoms. In contrast, head injury presence did not predict persistent PC syndrome.

DISCUSSION

Baseline mental health status and physical health status were associated with persistent PC syndrome after minor injury, but head injury status was not. Further studies of PC syndrome pathogenesis are needed.

Psychological distress among Kurdish immigrants in Sweden

AIMS

To analyse whether there is an association between sex and poor self-reported health (SRH) and psychological distress in Kurdish immigrants.

METHODS

This cross-sectional study is based on a sample consisting of immigrants, aged 27- 60 years, with self-reported Kurdish ethnicity (n=111, men; n=86, women) in Sweden originating from Iran and Turkey. It is based on data collected in 1996 from the first Swedish National Survey on the living conditions of immigrant groups conducted by Statistics Sweden. The prevalences of reporting poor health, sleeping difficulties, general fatigue and anxiety were estimated by sex. The association between sex and SRH and psychological distress was analysed by an unconditional logistic regression model estimating odds ratios (OR) with 95% confidence intervals. The final model was adjusted for age, marital status, education, housing and employment. Immigrant-specific migration-related variables were used to explore possible reasons for the sex differences.

RESULTS

Kurdish men and women had a high prevalence of poor SRH and psychological distress. Age-adjusted odds ratios for anxiety were higher in Kurdish women. Sex differences in anxiety remained even when marital status, education, housing and employment were taken into account.

CONCLUSIONS

Kurdish men and women report a high prevalence of poor SRH and indicators of psychological distress. Women had a higher risk for anxiety than men. Negative experiences of pre-migration as well as post-migration experiences, such as economic difficulties, preoccupation with the political situation in the home country, perceived discrimination, and feelings of poor control over one's life, were associated with the outcomes.

The influence of complaint symptoms on health care utilisation, medicine use, and sickness absence. A comparison between retrospective and prospective utilisation

OBJECTIVE

The main aim was to examine the impact of reported individual symptoms on health care utilisation (HCU) in a primary health care practice population and to evaluate the impact of these symptoms on utilisation over time.

METHOD

The study was performed in 1055 out of 1442 consecutive adult patients visiting a Swedish health care centre. Logistic regression analyses were applied to assess the relationships between symptoms and HCU outcomes.

RESULTS

Each of the 30 symptoms was related to consultations with GPs and a provider of alternative medicine, use of medications and herbals, and sickness absence. Depression and tension groups were the strongest predictors of utilisation. Multisymptomatics had higher OR for most of the outcome variables than those with no symptoms.

CONCLUSION

The results of this study show a linear correlation between the numbers of symptoms and increasing GP consultations, medicine use and sickness absences days, and this persisted during the years 2001 and 2002.

Determinants of complementary alternative medicine (CAM) use

OBJECTIVE

The aim of this study was to describe the pattern of use of complementary alternative medicine (CAM) and identify the determinants of CAM use in a multi-ethnic Swedish primary health care practice population.

METHODS

A questionnaire was handed out to 1433 patients aged 16 years and above who visited the Jordbro Health Centre (JHC) in Stockholm, Sweden, between 14 January and 30 June 2002. The results were linked to computerised medical records.

RESULTS

Seventeen percent of respondents had consulted a CAM provider during the preceding year and many patients had consulted several types of CAM providers. The most frequently CAM used was massage, followed by acupuncture, chiropractic and naprapathy. In the logistic regression, when adjusting for the influence of possible confounders, chronic disease and physical activity were the most important predictors of consultations with CAM providers. Users of CAM had had a higher number of consultations with medical professionals than had non-users of alternative medicine.

CONCLUSIONS

In our study population CAM, defined here as "manual therapy", was used in addition to traditional therapies and was related to high use of health care services. Chronic disease and physical activity were significantly and independently related to use of CAM.