Impact of mindfulness-based cognitive therapy on health care utilization: A population-based controlled comparison
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.
References (32)
- et al.
Distressed high utilizers of medical care. DSM-iii-R diagnoses and treatment needs
Gen Hosp Psychiatry
(1990) Clinical and health services relationships between major depression, depressive symptoms, and general medical illness
Biol Psychiatry
(2003)- et al.
The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: a systematic review and meta-analysis
Clin Psychol Rev
(2011) - et al.
Mindfulness therapy for somatization disorder and functional somatic syndromes: randomized trial with one-year follow-up
J Psychosom Res
(2013) Grutters J, olde Hartman T, Lucassen P, Bor H, van Weel C, van der Wilt GJ, Speckens A: mindfulness-based cognitive therapy for patients with medically unexplained symptoms: a cost-effectiveness study
J Psychosom Res
(2013)- et al.
Mindfulness therapy for somatization disorder and functional somatic syndromes: analysis of economic consequences alongside a randomized trial
J Psychosom Res
(2013) - et al.
Mindfulness-based cognitive therapy for generalized anxiety disorder
J Anxiety Disord
(2008) - et al.
Mindfulness-based cognitive therapy (mbct) for patients with medically unexplained symptoms: process of change
J Psychosom Res
(2014) - et al.
A multicenter study of the coding accuracy of hospital discharge administrative data for patients admitted to cardiac care units in ontario
Am Heart J
(2002) - et al.
Unexplained symptoms in primary care: perspectives of doctors and patients
Gen Hosp Psychiatry
(2000)
Effectiveness of a mindfulness-based cognitive therapy program as an adjunct to pharmacotherapy in patients with panic disorder
J Anxiety Disord
The concentration of health care expenditures, revisited
Health Aff (Millwood)
Long-term trends in the concentration of medicare spending
Health Aff (Millwood)
Disability and depression among high utilizers of health care. A longitudinal analysis
Arch Gen Psychiatry
Health care costs of primary care patients with recognized depression
Arch Gen Psychiatry
Randomized trial of a depression management program in high utilizers of medical care
Arch Fam Med
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