Individualized stepped care of chronic illness.
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Chronic Disease↗
Biomedical subjects
M Von Korff
Publications and source records attributed to M Von Korff.
A comparison of pain, functional limitations, and work status indices as outcome measures in back pain research.
STUDY DESIGN: We conducted a prospective study with a 2-year follow-up. OBJECTIVE: To compare pain, functional limitations, and work status indices as measures of outcome among back pain patients. SUMMARY OF BACKGROUND DATA: Work status, pain, and functional limitations indices are often considered as interchangeable outcome measures in back pain research. This perspective has been criticized by several authors, who argue that each of these outcome measures reflects a different construct that may vary independently of the others. METHODS: The study was conducted on 720 patients, who sought care for back pain in primary care settings of a large health maintenance organization in 1989-90, and were interviewed one month and two years later. X2 analyses and receiver operating characteristic curves were used to compare the accuracy of a pain rating and a modified 16-item Roland-Morris score in classifying patients on work status and on the change in work status over time. RESULTS: Moderate agreement between the pain and functional limitations measures and work status was observed. Pain and functional limitations change scores agreed moderately with improvement in work status, but were poorly associated with decline in work status. CONCLUSIONS: Although the pain, functional limitations, and work status indices examined in this study are related, they are not equivalent and should not be regarded as interchangeable. These results argue for a clearer distinction of outcome measures in back pain research.
Adult↗
Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial.
BACKGROUND: Despite improvements in the accuracy of diagnosing depression and use of medications with fewer side effects, many patients treated with antidepressant medications by primary care physicians have persistent symptoms. METHODS: A group of 228 patients recognized as depressed by their primary care physicians and given antidepressant medication who had either 4 or more persistent major depressive symptoms or a score of 1.5 or more on the Hopkins Symptom Checklist depression items at 6 to 8 weeks were randomized to a collaborative care intervention (n = 114) or usual care (n = 114) by the primary care physician. Patients in the intervention group received enhanced education and increased frequency of visits by a psychiatrist working with the primary care physician to improve pharmacologic treatment. Follow-up assessments were completed at 1, 3, and 6 months by a telephone survey team blinded to randomization status. RESULTS: Those in the intervention group had significantly greater adherence to adequate dosage of medication for 90 days or more and were more likely to rate the quality of care they received for depression as good to excellent compared with usual care controls. Intervention patients showed a significantly greater decrease compared with usual care controls in severity of depressive symptoms over time and were more likely to have fully recovered at 3 and 6 months. CONCLUSIONS: A multifaceted program targeted to patients whose depressive symptoms persisted 6 to 8 weeks after initiation of antidepressant medication by their primary care physician was found to significantly improve adherence to antidepressants, satisfaction with care, and depressive outcomes compared with usual care.
Antidepressive Agents↗
Adult health status of women with histories of childhood abuse and neglect.
PURPOSE: Several recent studies have found associations between childhood maltreatment and adverse adult health outcomes. However, methodologic problems with accurate case determination, appropriate sample selection, and predominant focus on sexual abuse have limited the generalizability of these findings. SUBJECTS AND METHODS: We administered a survey to 1,225 women who were randomly selected from the membership of a large, staff model health maintenance organization in Seattle, Washington. We compared women with and without histories of childhood maltreatment experiences with respect to differences in physical health status, functional disability, numbers and types of self-reported health risk behaviors, common physical symptoms, and physician-coded ICD-9 diagnoses. RESULTS: A history of childhood maltreatment was significantly associated with several adverse physical health outcomes. Maltreatment status was associated with perceived poorer overall health (ES = 0.31), greater physical (ES = 0.23) and emotional (ES = 0.37) functional disability, increased numbers of distressing physical symptoms (ES = 0.52), and a greater number of health risk behaviors (ES = 0.34). Women with multiple types of maltreatment showed the greatest health decrements for both self-reported symptoms (r = 0.31) and physician coded diagnoses (r = 0.12). CONCLUSIONS: Women with childhood maltreatment have a wide range of adverse physical health outcomes.
Adult↗
Validity of an illness severity measure for headache in a population sample of migraine sufferers.
The headache impact questionnaire (HImQ) is used to measure pain and activity limitations from headache over a 3-month recall period. In a prior study, the test-retest reliability of the eight-item HImQ score was found to be relatively high (0.86). In the current study, we examined the validity of the eight-item HImQ by comparing the overall score and individual items to equivalent measures from a 90-day diary. Pain and activity limitations due to headache were assessed in a population-based sample of 132 migraine headache sufferers enrolled in a 90-day daily diary study who completed the HImQ at the end of the study. The HImQ score was derived from four frequency-based questions (i.e. number of headaches, missed days of work, missed days of chores, or missed days of non-work activity) and four summary measures of average experience across headaches (i.e. average pain intensity, and average reduced effectiveness when having a headache at work, during household chores, and in non-work activity). Diary based measures were used as the gold standard in evaluating the HImQ score. Mean and median values of frequency-based HImQ items (e.g. number of headaches) were similar to equivalent diary measures, indicating no systematic bias. In contrast, HImQ measures of average experience across attacks (e.g. average pain intensity) overestimated equivalent diary measures and, in general, better approximated diary measures for migraine headaches, rather than all headaches. The highest correlations between HImQ and diary items were observed for headache frequency and average pain intensity, the two general headache measures, followed by measures of reduced effectiveness. Among frequency-based measures, the strength of the correlation was directly related to the magnitude of the mean. The higher the mean value, the higher the correlation. The correlation between the HImQ score and diary based score was 0.49. The HImQ score is moderately valid. Frequency-based items (e.g. number of missed work days) were found to be unbiased and the highest correlation coefficients were observed for frequency-based items with relatively high mean counts (number of headaches, number of missed non-work days). These findings have implications for measuring severity of chronic episodic conditions like headache, asthma, back pain, arthritis, epilepsy, and panic disorder, which can cause limitations to activities. The validity of illness severity measures may be improved by using frequency-based questions to assess both missed activity days and days with significantly reduced effectiveness or productivity (e.g. by 50% or more). By combining the count for both missed days and days where productivity is substantially reduced, the mean of the frequency-based measure will be increased, a factor which may improve the overall validity of the item. A severity measure can be derived from such items by simple addition and provides a scale with intuitively meaningful units.
Adolescent↗
Prediction of physician visits and prescription medicine use for back pain.
The primary purpose of this study was to examine the extent to which specific patient attitudes and beliefs about medical care and self-care for back pain predict future healthcare use. An automated database allowed examination of the predictive relationships in two primary care patient samples. In general, beliefs that physicians should find a definitive cause and permanent cure for back pain predicted neither physician visits nor prescription medication fills. Patient attitudes endorsing the benefits of medical treatment for back pain (as opposed to a permanent cure) predicted the use of these specific healthcare services. In a third sample of primary care back pain patients, we assessed whether a four-session self-care intervention modified those attitudes and beliefs shown to predict future healthcare use. The group intervention was associated with changes in attitudes about use of physician services but not medication use. A secondary purpose was to examine initial psychometric properties of a proposed back pain Self-Care Orientation Scale made up of the original 11 items. Factor analyses of the item set yielded three factors, but inconclusive results; the internal consistency of the identified sub-scales was only moderate. However, findings that a subset of items predicted physician visits and prescriptions medication fills, and was sensitive to change following a self-care intervention, suggest avenues for improving measurement of self-care orientation. These findings help clarify specific patient attitudes and beliefs that are related to healthcare utilization and suggest that a subset of these beliefs can be modified through a brief educational intervention.
Attitude to Health↗
Headache medication-use among primary care headache patients in a health maintenance organization.
OBJECTIVE: Medication-use among headache patients 2 and 5 years after a primary care headache visit is assessed, and the pattern of medication-use compared before and after the introduction of subcutaneous sumatriptan among migraineurs. SETTING AND PATIENTS: The study was carried out among headache patients visiting a primary care physician at the Group Health Cooperative of Puget Sound in 1989-90. METHODS: We report medication-use patterns 2 and 5 years later for the 530 subjects completing both a 2-year (1991-92) and a 5-year (1994-95) follow-up interview. Medication-use was determined by self-report for the month prior to the interview. Medication-use to control or prevent headache is shown for all headache patients and for those meeting International Headache Society criteria for migraine at the 2-year and the 5-year follow-up. RESULTS: The overall pattern of medication-use was similar at the 2-year and the 5-year follow-up, before and after the introduction of subcutaneous sumatriptan (March, 1993). There was a modest but statistically significant decline in the use of opioid and sedative-hypnotic medications, and in the use of ergotamine. At 5 years, 11% of migraineurs reported use of sumatriptan in the prior month. The large majority of study patients used symptomatic medications, usually non-prescription analgesics, sedative-hypnotics, and opiates. Only one-fifth of the migraineurs reported use of a prophylactic medication for headache. CONCLUSIONS: Continuing use of symptomatic headache medications was characteristic of patients with migraine and other common forms of headache. The introduction of subcutaneous sumatriptan was not associated with notable change in this pattern, although a modest reduction in use of sedative-hypnotics and opiates was observed. Overall, the pattern of use of headache medications was similar before and after the introduction of subcutaneous sumatriptan.
Adolescent↗
Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care.
OBJECTIVE: The authors' goal was to determine whether improved outcomes from enhanced acute-phase (3-month) treatment for depression in primary care persisted. METHOD: They conducted a 19-month follow-up assessment of 156 patients with major depression in the Collaborative Care intervention trials, which had found greater improvements in treatment adherence and depressive symptoms at 4 and 7 months for patients given enhanced acute-phase treatment than for patients given routine treatment in a primary care setting. Sixty-three of the 116 patients who completed the follow-up assessment had received enhanced treatment, and 53 had received routine treatment in primary care. The Inventory for Depressive Symptomatology and the Hopkins Symptom Checklist were used to measure depressive symptoms. Automated pharmacy data and self-reports were used to assess adherence to and adequacy of pharmacotherapy. RESULTS: At 19 months, the patients who had received enhanced acute-phase treatment did not differ from those who had received routine primary care treatment in clinical outcomes or quality of pharmacotherapy. CONCLUSIONS: Even though enhanced acute-phase treatment of depression in primary care resulted in better treatment adherence and better clinical outcomes at 4 and 7 months, these improvements failed to persist over the following year. Continued enhancement of depression treatment may be needed to ensure better long-term results.
Adult↗
A survey of leading chronic disease management programs: are they consistent with the literature?
Caring for patients with chronic illness in an era of cost constraints and performance monitoring has led to a sharp growth in "disease management" efforts by health systems utilizing internal innovators or outside firms. This paper describes surveys and site visits of the chronic disease management activities of 72 programs nominated by experts in the field of chronic illness care as being particularly innovative and effective. The survey and analysis were guided by a Model for Effective Chronic Illness Care derived from a process of literature synthesis and expert review. The model proved to be useful in describing the characteristics consistently shared by successful programs, and the surveys indicated common barriers to further expansion of innovative pilot programs. The survey indicated that most of the nominated programs were limited in their effectiveness and reach by their reliance on traditional patient education, rather than modern self-management support, poor linkages to primary care, and reliance on referrals rather than population-based approaches.
Case Management↗
A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care.
STUDY DESIGN: Randomized, controlled trial. OBJECTIVE: To evaluate a four-session self-management group intervention for patients with pain in primary care, led by trained lay persons with back pain. The intervention was designed to reduce patient worries, encourage self-care, and reduce activity limitations. BACKGROUND DATA: Randomized trials of educational interventions suggest that activating interventions may improve back pain outcomes. Expert opinion increasingly regards effective self-management of back pain as important in achieving good outcomes. In this study, an educational intervention designed to activate patients and support effective self-management was evaluated. METHODS: Six to 8 weeks after a primary care visit for back pain, patients were invited to participate in an educational program to improve back pain self-management. Those showing interest by returning a brief questionnaire became eligible for the study. Participants (n = 255) randomly were assigned to either a self-management group intervention or to a usual care control group. The effect of the intervention, relative to usual care, was assessed 3, 6, and 12 months after randomization, controlling for baseline values. The intervention consisted of a four-session group applying problem-solving techniques to back pain self-management, supplemented by educational materials (book and videos) supporting active management of back pain. The groups were led by lay persons trained to implement a fully structured group protocol. The control group received usual care, supplemented by a book on back pain care. RESULTS: Participants randomly assigned to the self-management groups reported significantly less worry about back pain and expressed more confidence in self-care. Roland Disability Questionnaire Scores were significantly lower among participants in the self-management groups relative to the usual care controls at 6 months (P = 0.007), and this difference was sustained at 12 months at borderline significance levels (P = 0.09). Among self-management group participants, 48% showed a 50% or greater reduction in Roland Disability Questionnaire Score at 6 months, compared with 33% among the usual care controls. CONCLUSIONS: Self-management groups led by trained lay persons following a structured protocol were more effective than usual care in reducing worries, producing positive attitudes toward self-care, and reducing activity limitations among patients with back pain in primary care.
Activities of Daily Living↗
Outcome measures for low back pain research. A proposal for standardized use.
STUDY DESIGN: An international group of back pain researchers considered recommendations for standardized measures in clinical outcomes research in patients with back pain. OBJECTIVES: To promote more standardization of outcome measurement in clinical trials and other types of outcomes research, including meta-analyses, cost-effectiveness analyses, and multicenter studies. SUMMARY OF BACKGROUND DATA: Better standardization of outcome measurement would facilitate comparison of results among studies, and more complete reporting of relevant outcomes. Because back pain is rarely fatal or completely cured, outcome assessment is complex and involves multiple dimensions. These include symptoms, function, general well-being, work disability, and satisfaction with care. METHODS: The panel considered several factors in recommending a standard battery of outcome measures. These included reliability, validity, responsiveness, and practicality of the measures. In addition, compatibility with widely used and promoted batteries such, as the American Academy of Orthopaedic Surgeons Lumbar Cluster were considered to minimize the need for changes when these instruments are used. RESULTS: First, a six-item set was proposed, which is sufficiently brief that it could be used in routine care settings for quality improvement and for research purposes. An expanded outcome set, which would provide more precise measurement for research purposes, includes measures of severity and frequency of symptoms, either the Roland or the Oswestry Disability Scale, either the SF-12 or the EuroQol measure of general health status, a question about satisfaction with symptoms, three types of "disability days," and an optional single item on overall satisfaction with medical care. CONCLUSION: Standardized measurement of outcomes would facilitate scientific advances in clinical care. A short, 6-item questionnaire and a somewhat expanded, more precise battery of questionnaires can be recommended. Although many considerations support such recommendations, more data on responsiveness and the minimally important change in scores are needed for most of the instruments.
Clinical Trials as Topic↗
Persistent pain and well-being: a World Health Organization Study in Primary Care.
CONTEXT: There is little information on the extent of persistent pain across cultures. Even though pain is a common reason for seeking health care, information on the frequency and impacts of persistent pain among primary care patients is inadequate. OBJECTIVE: To assess the prevalence and impact of persistent pain among primary care patients. DESIGN AND SETTING: Survey data were collected from representative samples of primary care patients as part of the World Health Organization Collaborative Study of Psychological Problems in General Health Care, conducted in 15 centers in Asia, Africa, Europe, and the Americas. PARTICIPANTS: Consecutive primary care attendees between the age of majority (typically 18 years) and 65 years were screened (n = 25 916) and stratified random samples interviewed (n = 5438). MAIN OUTCOME MEASURES: Persistent pain, defined as pain present most of the time for a period of 6 months or more during the prior year, and psychological illness were assessed by the Composite International Diagnostic Interview. Disability was assessed by the Groningen Social Disability Schedule and by activity-limitation days in the prior month. RESULTS: Across all 15 centers, 22% of primary care patients reported persistent pain, but there was wide variation in prevalence rates across centers (range, 5.5%-33.0%). Relative to patients without persistent pain, pain sufferers were more likely to have an anxiety or depressive disorder (adjusted odds ratio [OR], 4.14; 95% confidence interval [CI], 3.52-4.86), to experience significant activity limitations (adjusted OR, 1.63; 95% CI, 1.41 -1.89), and to have unfavorable health perceptions (adjusted OR, 1.26; 95% CI, 1.07-1.49). The relationship between psychological disorder and persistent pain was observed in every center, while the relationship between disability and persistent pain was inconsistent across centers. CONCLUSIONS: Persistent pain was a commonly reported health problem among primary care patients and was consistently associated with psychological illness across centers. Large variation in frequency and the inconsistent relationship between persistent pain and disability across centers suggests caution in drawing conclusions about the role of culture in shaping responses to persistent pain when comparisons are based on patient samples drawn from a limited number of health care settings in each culture.
Adult↗
Back pain in primary care. Patient characteristics, content of initial visit, and short-term outcomes.
STUDY DESIGN: Prospective study of patients making primary care visits for back pain. OBJECTIVE: To examine the content of primary care visits for back pain in patients with little interference of pain with activities at the visit and 1 month later; high interference of pain with activities at the visit but not 1 month later; and high interference of pain with activities, both at the visit and 1 month later. SUMMARY OF BACKGROUND DATA: Advice about resumption of activities may be therapeutic for patients with back pain, but little is known about the extent to which primary care providers assess and respond to limitation of activities in patients. METHODS: Audiotapes of primary care visits for back pain were coded for content. Patients indicated their goals for the visit and completed measures of pain and the pain's interference with activities, just before the visit and 1 month later. RESULTS: In most visits, providers did not assess functional limitations related to pain and did not discuss how to resume normal activities, although this was a highly rated goal for most patients. Providers did not appear to assess or respond to patients differently according to how much pain interfered with their activities. However, in patients with high interference of pain with activities, there was more discussion of limitation of activities and how to return to usual activities among those who improved than there was among those who did not improve during the next month. CONCLUSIONS: Although back pain frequently is associated with limitation of activity, pain's interference with activities is assessed inconsistently in primary care visits.
Activities of Daily Living↗
Reliability of an illness severity measure for headache in a population sample of migraine sufferers.
OBJECTIVES: To examine the reliability and related measurement properties of an illness severity measure for headache derived from responses to a 16-item self-administered questionnaire, the Headache Impact Questionnaire (HImQ), and to determine if there is support for combining measures of pain and disability into a single scaled measure of severity. METHODS: A population-based sample of migraine headache sufferers completed the HImQ twice, an average of 38 days apart. The HImQ included questions about number of headaches in the last 3 months, headache duration, last headache, pain intensity (two questions), need for bedrest (two questions), disability in specific domains of activity (seven questions about interference with ability to work, do household chores, and engage in non-work activity), and symptoms (two questions). RESULTS: Test-retest correlations of individual questions ranged from 0.65 to 0.93. In principal components analysis, a single factor with significant loading emerged. One measure of pain intensity (average pain score from 0 to 10) and items related to disability (i.e., missed days due to headache, and reduced effectiveness because of headache) in defined activity domains (work for pay, housework, nonwork activities) had the greatest weights on this single factor, supporting prior work on combining measures of pain and disability into a single scale. The HImQ score was derived as the sum of average pain intensity and total lost time in each of the three domains of activity, expressed as lost days. The latter was derived as the sum of actual missed days in each activity domain and reduced effectiveness day equivalents in each activity with a headache. The test-retest correlation was 0.77 for all eligible subjects and 0.85 when one influential outlier was removed. Cronbach's alpha was 0.83. CONCLUSIONS: The HImQ score, based on eight items, is a highly reliable and internally consistent measure of headache severity.
Activities of Daily Living↗
Reduced labor force participation among primary care patients with headache.
OBJECTIVE: To assess the long-term impact of headache on labor force participation among primary care patients with headache. DESIGN: A 2-year cohort study comparing employment status of primary care patients with headache and that of patients with back pain. PARTICIPANTS: Patients with headache (n = 662) or back pain (n = 1,024) sampled from persons visiting a primary care physician who completed baseline, 1-year and 2-year follow-up interviews. MEASUREMENTS AND MAIN RESULTS: The percentage of subjects unemployed at baseline, 1 year or 2 years was determined, excluding the retired and homemakers. Among all patients, the percentage unable to obtain or keep full-time work in the year prior to each interview because of headache or back pain was also assessed. Over the 3-year period covered by the study interviews, 13% of headache and 18% of back pain patients were unable to obtain or keep full-time work because of their pain condition. Among those in the labor force, 12% of headache patients and 12% of back pain patients were unemployed for any reason at one or more interviews. Among the one in five headache patients with a poor long-term outcome, 36% were unable to obtain or keep full-time work because of headache at some time compared with 4% of headache patients with a good outcome. Among headache patients, women, persons aged 18 to 24 years, those with lower levels of education, persons with depressive symptoms, and migraineurs were more likely to have reduced labor force participation owing to headache. CONCLUSIONS: The likelihood of reduced labor force participation among primary care patients with headache was considerable and concentrated among the one in five patients with a poor long-term outcome. Headache patients at a social disadvantage in attaining occupational role stability (e.g., younger women or poorly educated patients) were more likely to report reduced labor force participation.
Adult↗
Migraine and reduced work performance: a population-based diary study.
OBJECTIVE: This article estimates lost work days and lost work day equivalents in a population sample of migraineurs, differentiating work loss due to headache episodes that met criteria for migraine from migrainous headaches not meeting full criteria and nonmigrainous headaches. METHODS: A random digit dialing survey of 5,071 adults identified 800 subjects with migraine headaches. By clinical examination, a subsample of 225 met migraine diagnostic criteria; 174 of these patients completed at least 11 weeks of daily diaries. This report concerns the subgroup of 122 individuals with regular paid employment. Subjects completed a daily diary over a 3-month period to assess the occurrence of headaches and International Headache Society (IHS) criteria for each headache occurrence. We report estimates of lost work days and lost work day equivalents by type of headache. RESULTS: Participants reported headaches on 8.1 work days, of which 2.2 headache days met criteria for migraine (IHS 1.1, 1.2), and an additional 2.1 headache days were migrainous without meeting full migraine criteria (IHS 1.7). On average, migraineurs missed 1.1 days of work due to headache in 3 months, of which 0.7 lost work days were due to migraine and 0.3 were due to migrainous headaches. When at work with headache, work effectiveness was reduced 41% for migraine headaches, 28% for migrainous headaches, and 24% for other headaches. Over 3 months, migraineurs experienced an average of 3.0 lost work day equivalents, of which 1.4 were due to migraine and an additional 0.7 were due to migrainous headaches. The most disabled 20% of the participants accounted for 77% of the lost work days; 40% of subjects accounted for 75% of the lost work day equivalents. CONCLUSIONS: Employed migraine sufferers experienced considerable work loss and reduced work performance due to headache. The most severely affected migraineurs accounted for most of the reduced work performance. Targeting the most severely affected persons may be necessary to reduce work loss among migraineurs substantially.
Absenteeism↗
Collaborative management of chronic illness.
In chronic illness, day-to-day care responsibilities fall most heavily on patients and their families. Effective collaborative relationships with health care providers can help patients and families better handle self-care tasks. Collaborative management is care that strengthens and supports self-care in chronic illness while assuring that effective medical, preventive, and health maintenance interventions take place. In this paper, the following essential elements of collaborative management developed in light of behavioral principles and empirical evidence about effective care in chronic illness are discussed: 1) collaborative definition of problems, in which patient-defined problems are identified along with medical problems diagnosed by physicians; 2) targeting, goal setting, and planning, in which patients and providers focus on a specific problem, set realistic objectives, and develop an action plan for attaining those objectives in the context of patient preferences and readiness; 3) creation of a continuum of self-management training and support services, in which patients have access to services that teach skills needed to carry out medical regimens, guide health behavior changes, and provide emotional support; and 4) active and sustained follow-up, in which patients are contacted at specified intervals to monitor health status, identify potential complications, and check and reinforce progress in implementing the care plan. These elements make up a common core of services for chronic illness care that need not be reinvented for each disease.
Chronic Disease↗
Population-based care of depression: effective disease management strategies to decrease prevalence.
This paper reviews the concepts of population-based care and disease management of major depression. Population-based care and disease management strategies motivated by health care reform provide approaches for organizing health services to lower the prevalence of common medical and psychiatric illnesses in primary care populations. We apply these concepts to the organization of services for patients with major depression.
Cross-Sectional Studies↗