High utilizers of medical care: A crucial subgroup among somatizing patients

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Abstract

Objective

Patients with somatoform disorders (SFD) are likely to overutilize healthcare services. This study investigates (a) whether extraordinarily high medical costs can be predicted from patient characteristics or psychopathology, and (b) whether high-utilizing patients respond differently to cognitive–behavioral treatment.

Methods

We compared 42 SFD high utilizers with 53 SFD average utilizers and 29 patients suffering from other than SFD mental disorders. High utilization was defined by healthcare expenditures of ≥€2500 during the past 2 years. Costs were computed from medical and billing records of health insurance companies. Somatization distress, hypochondriasis, depression, dysfunctional cognitions related to bodily symptoms, general psychopathology, personality profiles, and psychosocial disabilities were assessed before treatment.

Results

High utilizers had higher levels of self- and observer-rated illness behavior, self-perceived bodily weakness, and psychosocial disabilities. Although they did not report more somatization symptoms, their subjective symptom distress was higher. There were no differences between high and average utilizers concerning general psychopathology, DSM-IV comorbidity, and personality profiles. Treatment improvements were similar.

Conclusion

High- and average-utilizing somatizers represent distinguishable subgroups. The results emphasize the importance of mechanisms specifically related to SFD and may enhance the early detection of patients who are likely to develop overutilization.

Introduction

Patients with somatoform disorders (SFD) are bothered by physical complaints for which no sufficient medical explanations can be found. Despite negative medical tests, many of these patients continue to believe that their symptoms are caused by organic dysfunction or disease [1]. They therefore tend to visit additional physicians and specialists, demand further medical investigations, and undergo treatments that are often not clearly indicated. This pattern of behavior has been termed inadequate illness behavior [2] because patients adopt a sick role despite the absence of a medical disease. From a socioeconomical perspective, illness behavior is likely to lead to increased utilization of healthcare services and unnecessary expenditures [3].

A few studies have indeed indicated an association between SFD and healthcare overutilization [4], [5], [6]. We have recently demonstrated that adequate treatment may lead to cost reductions [7]. However, high utilization is not an unavoidable characteristic of SFD. It may develop if patients persistently hold false beliefs about the nature of their symptoms and unrealistic expectations about treatment effects. Illness behavior may also develop from inadequate clinical management strategies in primary care [8]. Thus, while only a subgroup of somatizing patients develops a pattern of high utilization behavior, it is not known how well this subgroup can be differentiated from SFD patients with normal healthcare utilization. This question has been addressed by the research presented here. We compared high- and average-utilizing patients and attempted to identify clinical characteristics that are able to differentiate both groups. Since this study was conducted in an inpatient treatment unit, we also analyzed whether both groups differed with respect to their treatment improvements.

Section snippets

Method

We studied 95 patients fulfilling the diagnostic criteria of SFD according to DSM-IV [9]. All patients were investigated at the Roseneck Center for Behavioral Medicine in Prien, Germany, as part of a larger study evaluating the efficacy and cost effectiveness of cognitive–behavioral treatment for SFD. The study period was from 1995 to 2000. The major results and details of the methods were described in a recently published article [7]. Only a short description will be given here.

Differences between high and average utilizers

We analyzed on which measures high- and average-utilizing SFD patients were different. Table 3 lists those variables for which statistically significant group differences were obtained, ordered according to their strength of group differentiation as indicated by the amount of explained variance. The data displayed in Table 3 were assessed at admission to the hospital. The largest differences were found for utilization-related variables such as costs, hospitalization, and work disability

Discussion

Socioeconomical perspectives play an increasing role in the discussion of how mental and psychophysiological disorders should be treated. It will be important to identify clinical groups who are likely to overuse the medical system. One crucial group is the SFD. Because somatizing patients develop bodily complaints, which are not due to organic pathology, the value of usual medical treatment is limited. If psychosocial factors are not recognized, inadequate utilization of medical services over

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