Impact of mindfulness-based cognitive therapy on health care utilization: A population-based controlled comparison

https://doi.org/10.1016/j.jpsychores.2014.06.009Get rights and content

Highlights

  • High anxiety and depression symptoms may drive increased health care utilization.

  • Mindfulness-based cognitive therapy (MBCT) may reduce high health care utilization.

  • We compared 10,633 MBCT recipients to age-, sex-, and non-MBCT therapy controls.

  • There is 1 fewer non-mental health visit for every 2 MBCT patients treated.

  • MBCT may be useful in reducing health care utilization related to somatization.

Abstract

Objective

Elevated rates of mood and anxiety disorders among high utilizers of health care have been suggested as one driver of increased service use. We compared the impact of Mindfulness Based Cognitive Therapy (MBCT), a structured group treatment, on the rates of health care utilization with matched control participants receiving non-MBCT group therapy.

Methods

Using Ontario health administrative data, we created a retrospective cohort of population-based patients receiving MBCT and an age- and gender-matched (3:1) cohort of non-MBCT group therapy controls. Subjects were recruited between 2003 and 2010 and stratified according to high/low rates of primary care utilization, with the high utilization cohort being the cohort of interest. The primary outcome was a reduction in an aggregate measure of non-mental health utilization comprising Emergency Department, non-mental health primary care, and non-psychiatrist specialist visits.

Results

There were 10,633 MBCT recipients, 4851 (46%) of whom were high utilizers. The proportion of high utilizers was 13,274 (45%, N = 29,795) for non-MBCT group therapy controls. Among high utilizers, there was a significant reduction in non-mental health utilization among MBCT recipients compared to non-MBCT group therapy recipients (0.55 (0.21–0.89)) suggesting that for every two MBCT patients treated, there is a reduction in 1 non-mental health visit.

Conclusion

Among high utilizers of primary care, MBCT reduced non-mental health care utilization 1 year post-therapy compared to non-MBCT, group therapy controls. The reductions suggest that MBCT, an established treatment modality for a variety of mental illnesses, has the added benefit of reducing distress-related high health care utilization.

Introduction

In most segments of health care delivery, a relatively small proportion of individuals utilize the majority of service resources [1], [2]. In the primary care setting, “high-utilizers” of primary care services have been systematically evaluated [3], [4], [5], [6]. Approximately half of high-utilizers of primary health care are distressed, and a substantial proportion of these individuals meet diagnostic criteria for major depression, dysthymic disorder, generalized anxiety disorder or somatization disorder [3]. Interventions to systematically assess and manage psychiatric conditions among high-utilizers have been implemented, initially with positive results with respect to improved depression outcomes [7], with more recent studies unable to replicate the earlier positive findings [8]. While the outcomes for depression remain mixed, there is little evidence to suggest that interventions aimed at high utilizers of health care resources, whether they address underlying distress or target high health care use specifically, reduce their high service utilization patterns.

Mindfulness-based cognitive therapy (MBCT) is a structured, evidence-based psychotherapy that combines elements of cognitive behavior therapy with mindfulness meditation. It is delivered in a group format over 8 weekly, 2 h sessions. Initially, MBCT was designed to prevent relapse among those suffering from recurrent depression [9], [10], but has since been applied to individuals with chronic pain [11], anxiety [12], and somatization conditions [13], [14]. There is recently published evidence that MBCT is effective at improving mental and social functioning for individuals who are frequent health care utilizers with medically unexplained symptoms [15]. The study suggested shifts in health care utilization towards increasing mental health care and reduced hospitalization, but was likely underpowered to detect health care utilization and cost differences [16]. Other studies have shown that MBCT has significant economic benefits such as reduced duration of disability days and/or disability insurance costs for somatization disorder, a more severe and disabling form of the phenomenon of somatization [17]. One reason for MBCT's effectiveness with somatizing patients may lie in the reduction of anxious and depressive symptoms [3]—a consequence of the program's original focus on mood disorders. More intriguingly, however, is the fact that MBCT trains adaptive skills in attentional control [18] and teaches patients how to reduce excessive attending to somatic sensations and rumination about the potential negative consequences of bodily sensations [19] . As recent qualitative data indicate, [20] these skills enable patients to tolerate greater degrees of uncertainty and encourage accepting, rather than resisting, distressing thoughts and emotions. As such, they may be especially relevant to individuals who are high-utilizers of primary care and other health services [3] because, as one recent qualitative study indicated, they promote approach and acceptance rather than resistance. If, as the literature suggests, one of the drivers of high service utilization is the uncertainty, worry and fear that is reduced by primary care consultation [21], it is reasonable to assume that treatment with MBCT would reduce service utilization by raising the subjective threshold for this type of worry fueled outreach to primary care [22].

The objective of the present study was to determine whether a population-based sample of high-utilizers uses fewer health care resources following exposure to MBCT. We conducted a controlled study, using individuals who received traditional, non-MCBT group therapy to test the specificity of any changes observed that could be attributable to MBCT versus the benefits provided by generic group treatment. We hypothesized that MBCT would reduce non-mental health service utilization, but would not have an impact on mental health service utilization.

Section snippets

Setting and design

This study used a retrospective cohort design and took place in Ontario, Canada where physician visit billings, hospitalizations, and Emergency Department visits are captured in administrative health databases under Ontario's universal health care setting.

Data sources

Demographic data such as age, gender, and income quintile (measured as average income from patients' neighborhoods, and based on census data) were obtained from the Registered Persons Database. Emergency Department (ED) visit data were

Results

We identified 10,633 individuals who received MBCT between April 1, 2003 and March 31, 2010 and 29,795 matched non-MBCT group therapy control subjects. For the MBCT group, 4851 (45.6%) had 5 or more primary care physician visits in the 12 months prior to MBCT initiation, and were categorized as high utilizers; 13,274 (44.5%) matched non-MBCT control subjects were high utilizers.

Demographic and medical comorbidity values for the two groups are presented in Table 1. Compared to non-MBCT group

Discussion

This study compared health care utilization measures before and after individuals who are high primary care utilizers received either MBCT or generic group therapy. Receiving MBCT resulted in a significant reduction in non-mental health utilization, our primary outcome. The reduction translates into 1 less non-mental health visit in a 12 month period for every 2 individuals treated with MBCT. MBCT also resulted in a relative reduction in non-psychiatrist specialist visits and a large relative

Conflict of interest statement

All authors have no conflicts of interest to report related to this manuscript.

Acknowledgments

This study was funded by the Canadian Institutes of Health Research (MT81164). This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.

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