Perceived health and high consumers of care: a study of mental health problems in a Swedish primary health care district.

Many patients with mental health problems are treated in primary health care services. They are often multi-users of care. In the present investigation we have studied patients visiting primary health care clinics who have been assessed for mental health problems according to the Hopkins Symptom Check List (HSCL-25). Two quality-of-life instruments (the Nottingham Health Profile and the Mood Adjective Check List) were applied to describe further the perceived health of the sample. A random sample of 93 patients was chosen out of 388 patients visiting a primary health care clinic in a Swedish health care district during four weeks in January and February 1990, and these patients were followed prospectively during one year. High consumers of health care during the follow-up period scored a poor perceived health. 'Feeling worthless', predicted a high number of days of sickness absenteeism. Hidden cases, not detected by the GPs, consumed more resources than those identified by the GPs. The importance of training and educating general practitioners in the early detection of patients with mental health problems is discussed.

Perceived health in hip-fracture patients: a prospective follow-up of 100 patients.

We report the impact of the treatment and rehabilitation in hip-fracture patients by using self-assessment instruments of perceived health and relate them to objective outcome assessments, such as ADL (personal hygiene/dressing), walking ability and technical complications. Subjective and objective status for 100 hip-fracture patients admitted from their own home, and rehabilitated in primary health care, were registered over 1 year after fracture. Mean age was 74, and 80% of the patients were women. Two self-assessment questionnaires: the Nottingham Health Profile (NHP part 1) and the Mood Adjective Checklist (MACL) were answered by the patients 6 and 12 months after fracture and compared with functional status (ADL, and walking ability) 4 months after fracture. Problems related to the hip fracture such as pain and physical mobility had most effect on the self-assessment questionnaire (NHP) and were in accordance with the district physiotherapists' evaluation of function. Patients with complications (resulting in nail extraction and total hip replacement) after the primary hip osteosynthesis and patients with a poor function 4 months after fracture had scores in the self-assessment questionnaires indicating a more pronounced and distressing impact of the disease. Small changes in subjective mood (MACL) were found. In an acute, curable, disease such as hip fracture the objective outcome seems as informative as the subjective evaluations of patients' self-assessment.

Outcome after hip fracture in different health care districts. Rehabilitation of 837 consecutive patients in primary care 1986-88.

The social and functional outcome for 837 consecutive hip fracture patients rehabilitated in primary care was studied during 1986-1988. Of patients coming from their own home (59%) the majority (76%) were back at home four months after fracture and had a good functional status, while 9% were dead. Predictors of managing ADL (dressing/personal hygiene) four months after hip fracture were age, type of fracture, sex, and having regular social contacts outside the home before fracture. Health care districts differed in the incidence of hip fractures, the patients hospital stay, housing, type of fracture, and age. These differences had consequences on costs. Total costs per patient were lowest in districts where most of the patients were discharged to their own homes. No significant differences in fracture incidence were seen between rural and urban primary health care districts.

Costs of hip fracture. Rehabilitation of 180 patients in primary health care.

Costs related to functional status were calculated for 180 consecutive hip fracture patients (mean age 78 years) who were admitted from their own home and rehabilitated in primary health care. Within 4 months after the fracture, 75 percent of the patients had been discharged to their own home, 9 percent were dead, and the short-term medical treatment costs per patient were SEK 43,000, whereas the total costs including communal help and costs for living accommodations after discharge were twice as high. The total costs per patient for long-term medical treatment (from 4 months up to 3 years after fracture) were 7 percent of the short-term medical treatment costs. Patients with a cervical fracture discharged to their own home and with good functional status consumed only one fifth of the resources that patients with a trochanteric fracture discharged to institutional care and who had reduced functional status consumed. A substantial part of the costs can be saved by improved organization of rehabilitation after discharge from the hospital. A further cost reduction would require a combination of technologic, social, and organizational changes aimed at early discharge and continued follow-up in primary health care.