The burden of giving a diagnosis to patients who have no discernible clinical findings is often frustrating and anxiety provoking for the primary care clinician. This frustration is magnified when that patient returns on a frequent basis. These patients have been called the worried well, but there is no good CPT code for this diagnosis.
Smith et al1 have taken a novel approach to evaluating patients who are frequent users of primary care services. In this preliminary report they develop a classification process that helps define the distinction between somatization disorder and the “worried well.” In the process, they give the reader a longitudinal look at this group of patients.
There is a poor fit between the frequent user and the existing nomenclature. One of the striking findings by Smith and colleagues was that only a minority of the patients who presented for frequent care actually fit the definition of somatization disorder when studied over the 3-year period. Furthermore, the authors point out that there has been very little study about this phenomenon. Although every practice deals with these visits in its own way, little has been done to describe or to quantify this group of patients. Much less has been done to assist with clinical interventions.
The authors put forward a nomenclature for the worried well, showing that 14% of frequent users without physical findings had somatization disorder at baseline, 35% had an organic disease, and 51% had a minor acute illness. The authors watched health care use by these cohorts over 3 years and found that more than half of the patients initially defined as having somatization disorder were reclassified to the minor acute illness class within the next 2 years. There is a persistence of high utilization in 17% of the minor acute patients and 33% of the somatizing patients. For the clinician, these 2 groups often present clinical dilemmas in terms of understanding how to care for them and what resources to use in their care.
More questions and the search for answers
This preliminary study presents many clinically relevant issues. Although the patients studied were members of a health maintenance organization (HMO) in Michigan, the frequency of this problem in non-HMO practice is significant. Is there greater use of the system by patients who choose an HMO model of health care delivery? It might also be of interest to see if the frequent use was physician dependent. Many clinical practices have very little trouble with frequent users, while others are overwhelmed by the problem. Is there something in the style or arrangement of the practice that fuels frequent use? In the non-HMO model, these patients are at risk of obtaining care from multiple health care providers.
The problem of how to treat frequent users of the health care system is common in primary care. Management strategies have been poorly documented, and the diagnosis of these patients is extremely frustrating for primary care clinicians. It is clear that further research is required. Practice-based research networks can quantify the problem of the patients with minor acute illness and determine which intervention strategies will be effective. This study is an important start down that road.