Interrelationships between symptom burden & health functioning & health care utilization among veterans w/persistent physical symptoms, 2020, Fried

[Andy]

Background
Between 10 and 50% of primary care patients present with persistent physical symptoms (PPS). Patients with PPS tend to utilize excessive or inappropriate health care services, while being stuck in a deleterious cycle of inactivity, deconditioning, and further worsening of symptoms and disability. Since military deployment (relative to non-deployment) is associated with greater likelihood of PPS, we examined the interrelationships of health care utilization, symptom burden and functioning among a sample of recently deployed Veterans with new onset persistent physical symptoms.

Methods
This study analyzed a cohort of 790 U.S. soldiers who recently returned from deployment to Iraq or Afghanistan. Data for this analysis were obtained at pre- and post-deployment. We used moderation analyses to evaluate interactions between physical symptom burden and physical and mental health functioning and four types of health care utilization one-year after deployment, after adjusting for key baseline measures.

Results
Moderation analyses revealed significant triple interactions between physical symptom burden and health functioning and: primary care (F = 3.63 [2, 303], R2Δ = .02, p = 0.03), specialty care (F = 6.81 [2, 303] R2Δ =0.03, p < .001), allied therapy care (F = 3.76 [2, 302], R2Δ = .02, p = 0.02), but not mental health care (F = 1.82 [1, 303], R2Δ = .01, p = .16), one-year after deployment.

Conclusions
Among U.S. Veterans with newly emerging persistent physical symptoms one-year after deployment, increased physical symptom burden coupled with decreased physical and increased mental health functioning was associated with increased medical care use in the year after deployment. These findings support whole health initiatives aimed at improving health function/well-being, rather than merely symptom alleviation.

Open access, https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-020-01193-y

 

[Peter T]

We really need data on the number of people with such as PPS who learn to avoid where possible any medical contact or to try to hide these symptoms or associated diagnoses when forced to interact with medical services.

 

[rvallee]

Oh, goody, the latest edition of "sick people want medical care and that's unacceptable" is out. It's in the famous "if I don't believe in it it doesn't exist" series of Lacking object permanence magazine. It expresses surprise that the sicker the patients are, the more health care they utilize. They literally find that puzzling. It's as if they don't understand what symptoms mean or are, treating them as mere properties like hair color. Medical training has thoroughly failed those doctors, this is ridiculous.

rather than merely symptom alleviation

Literally the only thing those patients are looking for. And proper use of literally here. It is literally THE ONLY THING these patients are looking for and these people find that boring. Other than a cure, obviously, but precisely because that means all symptoms are gone. I read an old Wessely paper recently that made that same point, that when pwME go see doctors we're not actually there for symptom relief but for whatever stuff he imagines it to be.

It's literally the only thing that matters, and these people have different opinions. This system simply cannot produce competent outcomes. There is complete detachment between supply and demand, between services offered and actual needs.

 

[chrisb]

What sort of funding would a study of that nature take, and what idiots would provide it?

 

[Amw66]

I wonder if Klimas would comment on this paper

 

[Hutan]

Oh, goody, the latest edition of "sick people want medical care and that's unacceptable" is out. It's in the famous "if I don't believe in it it doesn't exist" series of Lacking object permanence magazine. It expresses surprise that the sicker the patients are, the more health care they utilize.

Wonderful post @rvallee, I wish the authors could read it.

that when pwME go see doctors we're not actually there for symptom relief but for whatever stuff he imagines it to be.
It's literally the only thing that matters

I have argued that when doctors have no idea how to treat an illness they can still be useful - in helping to educate loved ones that the debility is real, or providing evidence for insurance claims, or signing an application for disabled parking, or collecting information that might contribute to a better understanding of the disease, or putting the person in touch with a peer support group. But I guess all those are things that might eventually contribute to some symptom relief.

 

[alktipping]

any paper that starts with the words between and then gives itself 40% leeway should just be thrown into the bin . how can this tripe be taken seriously if the writer is to lazy to even find another tripe paper whith erroneous figures to cite .

 

[Hutan]

The HEROES study is a prospective longitudinal observational cohort study of U.S. soldiers who were preparing for deployment to Iraq or Afghanistan at Fort Dix, NJ or Camp Shelby, MS. The HEROES project collected self-reported data from 4 time points: pre-deployment (Phase 1, 2005–2008), immediate post-deployment (Phase 2, 2007–2009), 3 months after return from deployment (Phase 3, 2007–2010), and 1 year after return (Phase 4, 2008–2011). The HEROES study initially recruited 790 Army National Guard and Army Reserve Enlisted Soldiers (ages 18–60 years) at time of their on-base pre-deployment medical processing. Deployments typically lasted 12–13 months. Four hundred twenty-two soldiers (53%) were available for post-deployment assessment and completed Phase 2; 23 declined to continue and 345 could not be located.

So it sounds as though they started with 790 soldiers at pre-deployment. Deployments were typically about a year long. Only 422 soldiers were available for post-deployment assessment at Phase 2 - 345 could not be located. Which sounds rather careless of the army - did they just lose them somewhere on deployment? This is the army - surely if they wanted the soldiers assessed, they could find most of them? This study was done at Phase 4 - 1 year after deployment. I didn't see the number of the soldiers used for this study specifically reported anywhere in the paper but adding up numbers in tables suggests that only 319 soldiers made it to Phase 4. So, there may have been bias in the sample.

Nevertheless, concern about high attrition was mitigated by the fact that physical symptom severity at baseline was not significantly related to the likelihood of being lost to follow-up at one-year post-deployment.

The study acknowledged the big attrition rate. But they say 'never mind, at baseline the soldiers who didn't make it to Phase 4 were no different to the ones who did. Which I would have thought was rather missing the point - it's differences in what happened to them while on deployment that is of most interest.

 

[Hutan]

Veterans were primarily male (89.7%) with an average age of 27.9 years before deployment.

Soldiers with a range of health issues at baseline were excluded from the study. So, young, fit, healthy and primarily male.

We used the Veteran’s Rand-36 (VR-36) to examine physical as well as mental health function at pre- and post-deployment [27]. The VR-36 provides two composite scores (each ranging from 0 to 100), with higher scores representing better physical or mental health functioning [28]. Composite scores are normed to a mean of 50 and a standard deviation of 10 [29]. Physical health function indicates ability to perform daily physical activities (e.g., walk a mile) as well as limitations in the ability to perform social roles (e.g., work) due to physical health. Mental health function indicates mood, vitality and limitations in the ability to perform social roles due to mental health.

So physical health and mental health assessed before and after deployment.

As previously reported [31], mean physical component summary score (PCS) and mean mental component summary score (MCS) - reflecting physical and mental health functioning, respectively - decreased from before deployment (PCS = 55.5 [SD: 5.2], MCS = 48.0 [SD: 9.1]) to 1 year after deployment (PCS = 51.5 [SD:8.8], MCS = 44.9 [SD:12.4]). In contrast, physical symptoms increased significantly (p < 0.05) from before deployment (5.2 [SD:3.9]) to 1 year after deployment (7.7 [SD:5.4]).

Bearing in mind the standard deviations, there's a pretty significant decrease in health given these young people were very healthy at baseline and the measurements were done only about two years later. Of course, there's an effect of aging, but I doubt that you'd see that kind of decline in non-deployed people from age 27 to age 29. Adding in the attrition rate and any bias that might have caused, it's hardly an ad for being in the army. I doubt that that kind of mean health loss would be acceptable in most employment situations.

We tested this hypothesis among U.S. military personnel who were returning from deployment, expecting a sizable portion to develop clinically significant PPS.

I understand military deployment is not a walk in the park, but 'expecting a sizeable portion to develop clinically significant persistent physical symptoms' from a single one-year deployment! Perhaps you might expect that in top-level sport, but those people tend to get paid a whole lot more to put their body on the line than your typical young soldier. I wonder if the people who are expected to pay this price really know what they are signing up for.

 

[Hutan]

There was also a triple interaction between physical symptoms, physical function and mental health function (F = 3.63 [2, 303], R2Δ = .02, p = .03), such that physical symptoms best predicted primary care utilization when physical function was low and mental health function was high (Fig. 1).

Although there was a significant interaction between physical symptoms and physical health function (F = 13.61 [1, 303], R2Δ = .03, p < .001) (such that physical symptoms best predicted specialty care utilization when physical function was low), we failed to detect a significant interaction between physical symptoms and mental health function

Consistent with models 1 and 2, there was a significant triple interaction between physical symptoms, physical health function and mental health function (F = 3.76 [2, 302], R2Δ = .02, p = .02), such that physical symptoms best predicted allied therapy utilization when physical health function was low and mental health function was high

It was further found that mental health care was the only form of utilization that was not significantly elevated among those with persistent physical symptoms

In contrast to expectations, our study found that among Veterans with higher physical symptom burden and lower physical health functioning, those with high mental health function used slightly more medical care than those with either average or low mental health functioning. This is an important finding in that it suggests that mental health problems that cause impairments in daily activities and participation (i.e., mental health function) may impede healthcare-seeking, creating barriers to care for this population. We suspect but cannot confirm that patients with poor mental health function may have trouble organizing the many steps it takes to plan, make and attend a health care appointment.

This is maybe the most important finding. Contrary to the researcher's expectations, it wasn't people with bad mental health that were turning up at the doctor's office most trying to get their symptoms fixed. It was the people with physical symptoms, yes, very clearly, but they were more likely to seek medical care if they had good mental health functioning.

'Damn', you can hear the researchers saying between the lines. 'How can we say that we need to be giving these people mental health care rather than investigating their symptoms?' But fortunately, the sample is mostly male. That leaves half of the population that still might be shoehorned into a hypothesis.

Consequently, the extent to which our findings - co-occurring high physical symptom burden with low physical health function was associated with greater medical care use - apply to females cannot be resolved by this analysis.

Yeah, females might still be choosing to have lots of doctors' appointments without a corresponding symptom burden - 'cos, I don't know, sitting in a waiting room and then being scoffed at by a doctor is the female idea of a good time?

 

[Hutan]

If health care addresses the factors that lead patients to initiate care, such as low physical health function, as seen in our study, we may better address patients’ concerns, while reducing unnecessary appointments focused on determining cause of symptoms. This shift in focus may also improve the satisfaction of providers, who consider patients presenting with physical symptoms to be among the most challenging to treat.

So, the authors seemed to want to differentiate physical symptoms and physical health function, so that they could conclude that there's no need to investigate the cause of symptoms or treat symptoms, but rather concentrate on improving physical health function. Which is perhaps fine if the patient has an amputated leg - the cause may be less important; it is important to get the person walking again with a prosthetic. But it's not so great if the patient has fatigue and headaches - finding the cause may be very important to working out a suitable treatment. .....Unless of course you think CBT and hardening up is the answer to anything with no obvious physical cause.

But the study found that symptom burden and physical health function were actually highly related. Who would have thought?

while reducing unnecessary appointments focused on determining cause of symptoms

That's the sort of attitude that feeds conspiracy theories. If you are a person who has suddenly become so sick that you are unable to work or enjoy the activities you used to enjoy, you deserve a decent and prompt diagnostic effort. If you don't get that decent diagnostic effort, you are likely to become fodder for all sorts of quackery. There doesn't need to be an either/or when it comes to diagnostic effort and focusing on restoring health function. A doctor can fill out a form for disabled parking to make shopping more manageable for their patient while still investigating a cause.

This shift in focus may also improve the satisfaction of providers, who consider patients presenting with physical symptoms to be among the most challenging to treat.

I'm assuming the 'physical symptoms' here is a typo. Doctors find patients presenting with physical symptoms to be among the most challenging to treat? What, because patients presenting without physical symptoms are super-easy - just write 'hypochondriac' in the notes and send them off for CBT - no thinking required?

This study reeks of the data not supporting the hypothesis, but the authors pushing on heroically with their planned conclusion nonetheless.

 

[rvallee]

I'm assuming the 'physical symptoms' here is a typo. Doctors find patients presenting with physical symptoms to be among the most challenging to treat? What, because patients presenting without physical symptoms are super-easy - just write 'hypochondriac' in the notes and send them off for CBT - no thinking required?

Probably meant persistent but this really, again, emphasizes how medicine is split between acute and chronic medicine. One has made enormous progress, the other has not made any improvement in perhaps the last century. If it wasn't for acute medicine being better at handling episodic acute problems that arise in some chronic diseases and technological progress elevating the floor of abject poverty coming as a consequence of chronic health problems, quality of life and life expectancy for people with disabling chronic illnesses would not have significantly improved. Medicine has been essentially a non-factor in improvements that came about as a result of the creation of basic social security and increased industrial outputs making basic goods affordable. The existence of the Internet alone has made far more to improve the mental health of the chronically ill than all the combined efforts from clinical psychology of the last century and it's not even close.

And the main factor responsible for the complete stagnation of improvement in chronic health problems is the damn conversion disorder ideology, the fanatical belief in the power of psychology to be a significant factor in completely unrelated problems. Mainly because it has presented the patient population as pathologically delusional to a degree that excludes even entertaining the idea of engaging with this population, preferring instead to keep a patronizing system of one-sided shallow pedantic "here's what's actually wrong with you" that is as cruel as it is inflexible.

And so-called evidence-based medicine has been the primary driver of this human rights disaster and technological stagnation. While serving no actual purposes in improving outcomes. Chronic medicine may just be the lowest, least effective, least reliable sub-field in all of science, the only technical sub-specialty to have actually regressed. And because there is no accountability in a system that exists in an isolated thought bubble, there is no desire for change, in fact all efforts seem to be motivated by doing more of what fails and even less of what could break this wall of mediocrity.

In a nutshell: this is why we can't have nice things. Even though it benefits no one. I don't understand why people are OK with that. None of this is OK.