ABSTRACT
OBJECTIVES: Our objectives were to determine how patients who make frequent use of the medical system (high users) with medically unexplained symptoms met our chart-rating criteria for somatization and minor acute illness and what the stability of such diagnoses were over time.
STUDY DESIGN: A chart review was performed at baseline and 1 and 2 years; we re-rated the charts of patients initially rated as having somatization, as well as a 15% sample of those with minor acute illness.
POPULATION: We obtained a random sample of high-use patients (6 visits/year) aged 21 to 55 years who were identified from the management information system.
OUTCOMES: We measured chart review designations as organic disease, somatization, or minor acute illness.
RESULTS: Among 883 high users at baseline, 35% had organic diseases; 14% had somatization; and 51% had minor acute illness as their primary problems. No patients with initial minor acute diagnoses were reclassified as having somatization 1 or 2 years later, and all but 2 patients had minor acute illness in 1 or both follow-up years.
CONCLUSIONS: Minor acute illness was more common among high users than somatization and organic diseases combined. It has not previously been studied but probably has been recognized by clinicians as the “worried well.” Diagnoses of somatization were unstable over 2 years’ follow-up, while minor acute diagnoses were stable, supporting the latter as a valid entity.
KEY POINTS FOR CLINICIANS
- Many high-use patients with medically unexplained symptoms have a syndrome characterized by minor but recurring symptoms that we call minor acute illness.
- Minor acute illness has not been previously described as a research entity, but there are some similarities to what is referred to as the “worried well” in the nonresearch literature.
Using this preliminary research, we report on patients with medically unexplained physical symptoms, who have what we call “minor acute illness.” In contrast to the well-studied chronic somatizing patient in whom medically unexplained symptoms1,2 are of at least 6 months’ duration,3 we define minor acute illness as unexplained symptoms of any type (eg, sore throats, minor sprains, “sinuses”) that resolve completely in less than 6 months (usually days or weeks). Although most patients would not seek care for these minor complaints, some patients with minor acute illness have exaggerated responses to common symptoms and become high users of medical care.4-8 These are probably recognized by many physicians as the “worried well.”
Our review of the literature and discussion with several experts reveal that no research group has given consideration to defining the diagnostic features of minor acute illness or to describing it over time.9,10 Not surprisingly, studies of treatment are nonexistent, and reported treatments are ineffective.5,6,11 We present preliminary research defining minor acute illness, distinguishing it from somatization and organic disease, and evaluating its persistence over time among high-use patients.
Methods
Subjects
All patients were members of a largely primary care, staff model health maintenance organization (HMO) in Lansing, Michigan (Blue Cross Network). Only computerized descriptive information in the HMO’s management information system (MIS) and data in patients’ clinical charts were involved in our study. The MIS includes administrative information on age, sex, all patient encounters with the system, primary diagnoses made at each physician/nurse practitioner/physician assistant visit (International Classification of Diseases—Ninth Revision codes), revenue codes, and charges for services. Subjects whose visits for the year were primarily because of pregnancy, substance abuse, or other recognized psychiatric problems/diagnoses (eg, bipolar disorder, eating disorder) were excluded.
Screening to identify somatizing and minor acute illness patients
We first identified all patients aged 21 to 55 years in the Lansing, Michigan, area who had at least 1 visit during 1995 to a physician, physician assistant, nurse practitioner, specialist, or emergency room; each hospitalization was counted as 1 visit. We did not use older patients, because our goal for another project was to identify chronic somatizing patients with minimal organic disease; the discovery of minor acute illness patients was an unexpected byproduct. Of 15,505 members in 1995, 5423 had 6 or more visits, and 1000 of these patients were randomly selected for further evaluation; to obtain the greatest possible sample, we arbitrarily defined 6 or more visits (65th percentile) as high users. Of the 1000, 94 were excluded because of pregnancy, substance abuse, visits for psychiatric care, or because they were employees of the HMO, and 23 were excluded because of incomplete data. We excluded patients under regular psychiatric care, because we wanted to obtain (for a treatment intervention) patients not receiving psychologic attention. The remaining 883 patients constituted the study population. Excluded patients differed from those in the study group in age, sex, and employer group but not on the amount of copay (P =.58) and relationship to the subscriber (P =.23). Excluded patients were on average younger (35.7 years vs 40.3 years, P <.001), and 88% were women as opposed to 68% for patients included in the overall study (P <.001).