Personal Health Improvement Program Helps Heavy Medical Users Improve Their Health
From 1999 to 2000, researchers at Harvard Pilgrim Health Care, a Boston-based managed care organization, conducted a study to determine whether a system of identifying and counseling patients whose physical symptoms had a psychological basis could improve their health and satisfaction and reduce health care costs.
The counseling intervention, called the Personal Health Improvement Program, taught patients skills for managing relationships in stressful situations. The study compared a group of patients who received the intervention to a group who received usual care.
- Six months after the intervention, patients in the intervention group reported a greater improvement in physical symptoms, and less depression and anxiety than did patients in the comparison group.
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $49,999.
Many heavy users of medical services display physical symptoms of psychological distress or a psychiatric problem, but physicians often fail to recognize these causes. Fruitless efforts to diagnose and treat physical causes may lead to dissatisfaction with care, increased emergency room use and "doctor shopping."
One approach to treating these patients is an intervention called the Personal Health Improvement Program (formerly known as Ways to Wellness). In contrast to other mind/body programs, the Personal Health Improvement Program places greater emphasis on teaching skills for managing relationships in stressful situations. The intervention consists of six weekly 90-minute to two-hour interactive classroom sessions with groups of 1015 patients. The session leaders are licensed medical or mental health clinicians who receive training in the program.
Prior studies of the program had found that subjects receiving the intervention had decreased physical and emotional distress relative to a comparison group, and had fewer medical visits after the intervention than before.
The study described here sought to determine whether screening and treating such patients in a clinical setting could reduce distress, increase patient satisfaction and reduce health care costs. Researchers originally planned to recruit 250 patients from four similar group practice settings, expecting to have roughly 100 members each in an intervention group and a comparison group. Inadequate project staffing, a lack of enthusiasm from staff at the study sites, financial difficulties at Harvard Pilgrim and other problems impeded the recruitment effort. Ultimately the researchers were able to recruit 39 patients for the intervention group from one clinic and 78 comparison subjects from a second clinic.
Project staff screened patients at the clinics using self-report questionnaires that asked about their physical symptoms, increased sensations of pain and noise, and how often they used medical care in the past. Intervention subjects completed self-report questionnaires measuring medically unexplained complaints, preoccupation with health, and psychiatric distress after completing the intervention classes, and again six months later. Comparison subjects also completed the questionnaires six months after being recruited. Otherwise, the comparison subjects received only their usual care.
In addition to the patient questionnaires, the research team examined health utilization and cost data from Harvard Pilgrim Health Care to determine whether the treated patients sought medical help less often and whether the intervention was cost-effective.
Because the sample was not selected randomly, any differences between the intervention and comparison groups might reflect underlying differences between the client pools at the two clinics, rather than the effects of the intervention. Furthermore, the small sample size made it impossible to evaluate the cost-effectiveness of screening for patients who might benefit from the intervention.
The project director reported the following to RWJF:
- The study confirmed previous findings of the clinical effectiveness of the Personal Health Improvement Program. Six months after the intervention, patients in the intervention group reported a greater improvement in physical symptoms, and less depression and anxiety than did patients in the comparison group.
The research team has not published any articles reporting findings of this study. During the grant period, team members did write articles and give presentations on the intervention being studied. See the Bibliography for details.
- Given a limited budget, a project might be more effective as a feasibility study. The budget was unrealistically low for an outcome study planned for 250 subjects. A feasibility study would have shown that the need for full-time research assistants, not just at each site, but in each waiting room, would have made the study too costly and impractical. (Project Director)
- While using work-study students may reduce project costs, their academic schedules may not coincide with the needs of the study. (Project Director)
- In selecting sites for a study, researchers should be sure the site is not undergoing any major changes that might make it hard to devote the necessary attention to the study. Because the support staff was overwhelmed with learning a new computer system in one site, they had no time to recruit people for the study. (Project Director)
- Staff enthusiasm for the project is crucial in considering which sites to include in the study. Unenthusiastic staff nurses and primary care physicians upon whom the study depends to screen subjects can jeopardize recruitment efforts. (Project Director)
AFTER THE GRANT
The investigators are completing an article for submission to an academic journal.
GRANT DETAILS & CONTACT INFORMATION
Demonstration of the Personal Health Improvement Program
Harvard Pilgrim Health Care (Boston, MA)
Dates: June 1998 to December 2001
Steven E. Locke, M.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Locke SE and Larsson KM. "Clinical Presentation, Screening, and Treatment of Somatization in Primary Care Settings." In Primary Care Meets Mental Health: Tools for the 21st Century, JD Haber and GE Mitchell (eds). Tiburon, Calif.: CentraLink Publications, 1998.
Locke SE, Chan PP, Morley DS, McLeod CC, Budd MA and Orlowski M. "Behavioural Medicine Group Intervention for High-Utilising Somatizing Patients: Evaluation Across Seven Unrelated Healthcare Organizations." Disease Management and Health Outcomes, 6(6): 387404, 1999.
Burnes HG and Locke SE. Headache. Boston: Harvard Vanguard Medical Associates, 2000. (Clinical manual for use as supplement with the Personal Health Improvement Program.)
Larsson K and Locke SE. Fatigue. Boston: Harvard Vanguard Medical Associates, 2000. (Clinical manual for use as supplement with the Personal Health Improvement Program.)
Presentations and Testimony
Patricia Ford and Steven E. Locke, "A Behavioral Medicine Collaborative Care Program for High Utilizers," at the annual meeting of the Disease Management Association of America, October 19, 1999, San Francisco.
Steven E. Locke, "Clinical and Cost-Effectiveness of Mind/Body Group Approaches to Management of Somatization," at the annual meeting of the American Psychosomatic Society, March 16, 2002, Barcelona, Spain.
Steven E Locke, Katharine Larsson and Patricia Ford, "Mind/Body Group Approach to Managing Somatization," at the annual meeting of the American Psychosomatic Society, March 16, 2002, Barcelona, Spain.
Report prepared by: Diane O'Connell
Reviewed by: Robert Narus
Reviewed by: Marian Bass
Program Officer: Rosemary Gibson