INTERMED--an assessment and classification system for case complexity. Results in patients with low back pain

STUDY DESIGN

Cross-sectional investigation and follow-up of patients with low back pain.

OBJECTIVES

To evaluate the capacity of the INTERMED--a biopsychosocial assessment and classification system for case complexity--to identify patients with a chronic, disabling course of low back pain and to predict treatment outcome.

SUMMARY OF BACKGROUND DATA

An impressive number of biologic and nonbiologic factors influencing the course of low back pain have been identified. However, the lack of a concise, comprehensive, reliable and validated classification system of this heterogeneous patient population hampers preventive and therapeutic progress.

METHODS

The INTERMED was used to assess patients with low back pain, who participated in a functional rehabilitation program (n = 50) and patients with low back pain who applied for disability compensation (n = 50). Patients of the rehabilitation program were observed to assess the effects of treatments.

RESULTS

The INTERMED distinguished between patients in different phases of disability and provided meaningful information about the biopsychosocial aspects of low back pain. In hierarchical cluster analysis two distinct clusters emerged that differed in the degree of case complexity and treatment outcomes.

CONCLUSIONS

This first application of the INTERMED indicates its potential utility as a classification system for patients with low back pain.

[Violence our medical trauma in specialized multidisciplinary consultation]

In this article a particular patient/physician relationship is described and analyzed: The described interaction between patient and physician during a consultative investigation by several specialists differs markedly from the common trustful relation between a patient and his family doctor. In this context the term and phenomenon pain is discussed and the necessity for an understandable, patient-oriented presentation of diagnosis and hypotheses considering the patient's individual bio-psycho-social dimension is stressed. Consequences for student education are mentioned.

"INTERMED": a method to assess health service needs. I. Development and reliability

The purpose of this paper is to describe the development and to test the reliability of a new method called INTERMED, for health service needs assessment. The INTERMED integrates the biopsychosocial aspects of disease and the relationship between patient and health care system in a comprehensive scheme and reflects an operationalized conceptual approach to case mix or case complexity. The method is developed to enhance interdisciplinary communication between (para-) medical specialists and to provide a method to describe case complexity for clinical, scientific, and educational purposes. First, a feasibility study (N = 21 patients) was conducted which included double scoring and discussion of the results. This led to a version of the instrument on which two interrater reliability studies were performed. In study 1, the INTERMED was double scored for 14 patients admitted to an internal ward by a psychiatrist and an internist on the basis of a joint interview conducted by both. In study 2, on the basis of medical charts, two clinicians separately double scored the INTERMED in 16 patients referred to the outpatient psychiatric consultation service. Averaged over both studies, in 94.2% of all ratings there was no important difference between the raters (more than 1 point difference). As a research interview, it takes about 20 minutes; as part of the whole process of history taking it takes about 15 minutes. In both studies, improvements were suggested by the results. Analyses of study 1 revealed that on most items there was considerable agreement; some items were improved. Also, the reference point for the prognoses was changed so that it reflected both short- and long-term prognoses. Analyses of study 2 showed that in this setting, less agreement between the raters was obtained due to the fact that the raters were less experienced and the scoring procedure was more susceptible to differences. Some improvements--mainly of the anchor points--were specified which may further enhance interrater reliability. The INTERMED proves to be a reliable method for classifying patients' care needs, especially when used by experienced raters scoring by patient interview. It can be a useful tool in assessing patients' care needs, as well as the level of needed adjustment between general and mental health service delivery. The INTERMED is easily applicable in the clinical setting at low time-costs.

Subjective experience and behavior in acute stroke: the Lausanne Emotion in Acute Stroke Study

OBJECTIVE

To assess subjective experience in acute stroke and to correlate it with stroke features, acute emotional behavior, and impact on seeking of medical care.

METHODS

The authors studied patients with acute first-ever stroke prospectively. During the first 4 days they rated subjective experience (happiness, sadness, irascibility, and fear); behavioral reactions, using a specifically designed scale; and mood (Hamilton anxiety and depression). Fifty-three patients (30 men, 23 women; age, 60 +/- 19 years) completed the 3-month follow-up.

RESULTS

Seventeen patients failed to seek medical care spontaneously. Sixteen patients presented behavioral reactions of overt sadness, 20 presented indifference, 12 presented aggressiveness, 20 presented disinhibition, and 16 presented denial. Eight patients were anosognosic and 12 were anosodiaphoric. Twenty-four patients expressed happiness, 20 expressed sadness, 7 expressed anger, and 11 expressed fear. Ten patients with aphasia could be interviewed, but four required delayed questioning. Denial reactions and anosognosia were independent. Acute denial reactions were not dependent on the side of stroke, but were more frequent after deep lesions (p < 0.010). Patients with a denial reaction had a tendency to present less subjective experience of fear (p < 0.078) and a higher occurrence of delayed depression (p < 0.02). Intergroup comparison of all measures showed that lack of seeking care was related to reactions of indifference (p < 0.007), a tendency toward a less subjective experience of fear (p < 0.078), poor recall of the acute event (p < 0.001), decreased nosognosia (p < 0.001), and right-side lesions (p < 0.035).

CONCLUSIONS

Patients with acute behavioral denial had a decreased occurrence of subjective experience of fear and a more frequent occurrence of delayed depression. These denial reactions were independent of anosognosia. A subjective experience of fear was related to appropriate care seeking. An impaired subjective experience of fear may contribute, as with anosognosia, to an increased delay in consultation. All other emotional reactions were dissociated from the patients' subjective experience.

"INTERMED": a method to assess health service needs. II. Results on its validity and clinical use

The validity and clinical use of a recently developed instrument to assess health care needs of patients with a physical illness, called INTERMED, is investigated. The INTERMED combines data reflecting patients' biological, psychological, and social characteristics with information on health care utilization characteristics. An example of a patient population in which such an integral assessment can contribute to the appropriateness of care, are patients with low back pain of degenerative or unknown origin. It supports the validity and the clinical usefulness of the INTERMED when clinically relevant subgroups in this heterogeneous population can be identified and described based on their INTERMED scores. The INTERMED was utilized in a group of patients (N = 108) having low back pain who vary on the chronicity of complaints, functional status, and associated disability. All patients underwent a medical examination and responded to a battery of validated questionnaires assessing biological, psychological, and social aspects of their life. In addition, the patients were assessed by the INTERMED. It was studied whether it proved to be possible to form clinically meaningful groups of patients based on their INTERMED scores; for this, a hierarchical cluster analysis was performed. In order to clinically describe them, the groups of patients were compared with the data from the questionnaires. The cluster analysis on the INTERMED scores revealed three distinguishable groups of patients. Comparison with the questionnaires assessing biological, psychological, and social aspects of disease showed that one group can be characterized as complex patients with chronic complaints and reduced capacity to work who apply for a disability compensation. The other groups differed explicitly with regard to chronicity, but also on other variables. By means of the INTERMED, clinically relevant groups of patients can be identified, which supports its use in clinical practice and its use as a method to describe case mix for scientific or health care policy purposes. In addition, the INTERMED is easy to implement in daily clinical practice and can be of help to ease the operationalization of the biopychosocial model of disease. More information on its validity in different patient populations is necessary.

The Family System Test (FAST). A pilot study in families with a young adult member with cancer

The impact of a cancer diagnosis upon a family has become a focus of clinical interest, but few scientific studies have been completed in this area. The objectives of this pilot study were twofold: first, to test the applicability of the Family System Test (FAST) in families (n = 5) with a young adult member with cancer and secondly to evaluate patterns of interactions within these families. Results show that the FAST is applicable and useful to evaluate the different perceptions of hierarchy and cohesion--two essential variables--within these families. The great majority of family members represented their relationships as balanced (i.e., cohesive and moderately hierarchical). However, contrary to nonclinical families, fathers had a less positive view than mothers and patients: fathers more often perceived family and parenteral relations as unbalanced, and also more often perceived a reversal of hierarchy and a cross-generational coalition within the family. Implications for future research and clinical care are discussed.

[Objective diagnosis, relational diagnosis--science or art?]

This paper describes the dilemma the psychotherapist faces when dealing with the psychosomatic disorders that are referred to him by the primary care physician. Psychosocial and psychosomatic evaluation and treatment standards are based on relational and contextual dimensions, in order to assign comprehensive and meaningful perspectives to previously disconnected symptoms. On the other hand, quality management and cost-benefit criteria require the use of objective diagnosis, decisional trees and treatment guidelines. The author proposes an ethical compromise and a doctor-patient negotiated partnership as a solution to the dilemma.

Comparison of the clientele of an anonymous HIV test centre and persons tested in the general population

This study compares the clientele of a Swiss anonymous test centre with the general population tested. Information was obtained through similar questionnaires submitted to two samples of HIV-tested people aged from 17 to 45 years: the first administered in the context of a general population telephone survey (n = 245) and the second completed during face-to-face interviews of the clientele of an anonymous test centre (n = 250). The test centre sample has higher proportions of younger and single people. Attenders for anonymous testing were more likely to have acquired a new regular partner during the year preceding the interview (48.0% versus 14.4%). These differences remain when controlling for age and gender. Decision to test comes mostly from the respondent's own initiative, but suggestion from a doctor is more frequent in the general population (23.8% versus 0.8%), whereas suggestion from partner or friends is more frequent in the anonymous centre (44.4% versus 3.0%). The anonymous test centre clientele is not different from the general population tested except for the relational situation and origin of decision for testing. The test centre has become a place where the general population finds a response to a situation-specific need for HIV testing.

Genetic detection: the need for psychosocial support in modern cancer prevention

During recent years the gap between the rapid implementation of new technologies in cancer prevention and the slow development of a complementary psychological framework to conceptualize the transmission of genetic informations to patients has been deplored. Such a framework should include all psychological aspects surrounding the genetic consultation, reaching from the information and education of the general public to the impact of prophylactic surgery. While some of the psychological consequences of modern cancer prevention can not be fully foreseen and have first to be documented and analysed, others can easily be anticipated. The authors will try to outline a psychological framework that could help in facing potential negative effects of these beneficial preventive possibilities.

Supportive and palliative care at the University Hospital Lausanne

The development of supportive and palliative care services within the Canton of Vaud in Switzerland is traced, and the current situation and future plans are outlined.

[Palliative and supportive care: at the frontiers of medical omnipotence]

Cancer patients have physical, social, spiritual and emotional needs. They may suffer from severe physical symptoms, from social isolation, spiritual abandonment, and emotions such as sadness and anxiety, or feelings of deception, helplessness, anger and guilt. In some of them, the disease is rapidly progressing and ultimately they die. Their demanding care evokes intense feelings in health care providers, the more since these incurable patients represent a challenge, which could be condensed under the heading "the challenge of medical omnipotence". We suppose that the way health care providers cope with these circumstances has a profound influence on the way these patients are cared for. The attitudes towards the emerging heterogeneous movement of palliative and supportive care and towards its different models of implementation can be viewed from this point of view. We try to demonstrate these interrelations and to discuss the danger that may arise if they remain obscure and unreflected.

[Oncogenetic consultation: various relational, psychological and ethical aspects]

The authors describe the gap between the implementation of a new technology in medicine and the development of a psychological and ethical framework that is thought to complement this implementation in order to guarantee the conditions for an optimal information of the patient and his relatives. As a second goal, the authors tries to anticipate the individual and systemic psychological impact these new technologies may have and the possibilities to overcome potential negative impacts. To conclude, a modification of the relations between physicians and patients and a different distribution of their roles and responsibilities is predicted permitting to face a medicine of the future, which will lead to considerable existential challenges.

Palliative and supportive care: at the frontier of medical omnipotence

Cancer patients have physical, social, spiritual an emotional needs. They may suffer from severe physical symptoms, from social isolation and a sense of spiritual abandonment, and emotions such as sadness and anxiety, or feeling of deception, helplessness, anger and guilt. In some of them, the disease is rapidly progressive and they ultimately die. Their demanding care evokes intense feelings in health care providers, the more so since these incurable patients represent a challenge, which can be characterized as one of 'medical omnipotence'. It may be assumed that the way health care providers cope with these circumstances profoundly influences the way these patients are cared for. Attitudes regarding the emerging heterogeneous movement of palliative and supportive care and its different models of implementation can be viewed form this vantage point. Here we look at these interrelations and discuss the potential pitfalls if they are ignored and remain unexamined.

[Perception of anxiety in patients requesting anonymous HIV testing]

To determine the manifestations of anxiety in subjects seeking anonymous HIV testing and the aptitude of professionals to perceive it, we administered a semi-structured questionnaire to 481 persons, 281 before and 200 after instructing the practitioners to better decode anxiety during the consultation. The perception of anxiety by the care-givers was analyzed using the Covi scale. The results show that subjects requesting an HIV test often report stressful relational events. Their anxiety its often underestimated by the care-givers, and aptitude to recognise the patient's emotions can be improved. Prevention and quality of counselling depend on correct perception of the emotions which prompt the subject to request a test.