Friedrich Stiefel

“INTERMED”: a method to assess health service needs

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.

Comprehensive assessment of patients in palliative care: a descriptive study utilizing the INTERMED.

Documentation in palliative care is often restricted to medical and sociodemographic information, and the assessment of physical and psychological symptoms or the quality of life. In order to overcome the lack of comprehensive information, we have evaluated the utility of the INTERMED-a biopsychosocial assessment method to document integrated information of patients needs-in 82 consecutive patients for whom a palliative care consultation was requested. Results confirm the biopsychosocial heterogeneity of the sample, and the importance of integrated information to clinical, scientific, educational, and health care policy agendas. The INTERMED could become a useful method to tailor interdisciplinary interventions based on comprehensive patient needs assessment.

Identification of case complexity and increased health care utilization in patients with rheumatoid arthritis.

OBJECTIVESnTo document biopsychosocial profiles of patients with rheumatoid arthritis (RA) by means of the INTERMED and to correlate the results with conventional methods of disease assessment and health care utilization.nnnMETHODSnPatients with RA (n = 75) were evaluated with the INTERMED, an instrument for assessing case complexity and care needs. Based on their INTERMED scores, patients were compared with regard to severity of illness, functional status, and health care utilization.nnnRESULTSnIn cluster analysis, a 2-cluster solution emerged, with about half of the patients characterized as complex. Complex patients scoring especially high in the psychosocial domain of the INTERMED were disabled significantly more often and took more psychotropic drugs. Although the 2 patient groups did not differ in severity of illness and functional status, complex patients rated their illness as more severe on subjective measures and on most items of the Medical Outcomes Study Short Form 36. Complex patients showed increased health care utilization despite a similar biologic profile.nnnCONCLUSIONSnThe INTERMED identified complex patients with increased health care utilization, provided meaningful and comprehensive patient information, and proved to be easy to implement and advantageous compared with conventional methods of disease assessment. Intervention studies will have to demonstrate whether management strategies based on INTERMED profiles can improve treatment response and outcome of complex patients.

Internal consistency of the INTERMED in patients with somatic diseases

IntroductionThe INTERMED has been developed in the past years asa method to assess case complexity and resulting care needsin order to foster coordinated and integrated health care [1–4]. The INTERMED is an observer-rated instrument thatclassifies information from a structured medical historytaking. We demonstrated its interrater reliability [1,5],validity [2], and clinical utility in detecting complex patientswith a diminished treatment response [3,4,6,7]. In this study,we studied its internal consistency in order to evaluate ifcase complexity as a one-dimensional construct is measuredreliably with the INTERMED.MethodsSampleData were derived from previously published studiesand studies in process, consisting of patients admitted tointernal medicine (n=302 andn=89) [4,10], patientsreferred to a CL-psychiatry service (n=100) [8], outpatientswith diabetes (n=61) [6], rheumatoid arthritis (n=75) [7],low back pain (n=102) [3], multiple sclerosis (n=152),under dialysis (n=80), and neurological outpatients(n=71). INTERMED scores of these 1032 patients weremerged and analyzed together.INTERMEDThe four domains of the INTERMED—biological, psy-chological, social, and health care—are assessed in thecontext of time (history, current state, and prognosis)resulting in 20 variables (see Fig. 1) that are scored 0–3based on a structured interview [9].Data analysisCronbach’s a as an indicator for internal consistency wascalculated for the total sample and for the individualsamples in order to evaluate the generalizability of thefindings. To further study the structure of the INTERMED,we calculated Pearson correlation coefficients amongdomain scores.ResultsAs illustrated in Table 1, the mean INTERMED scores ofthe different samples vary between 15.5 and 29.6 with lowback pain patients showing the highest biopsychosocialcomplexity. All a’s are above .75 indicating satisfactoryinternal consistency in each of the samples, with the highesta in the low back pain population. The a of the total sampleis .87 and between .86 and .89 with a 95% level ofconfidence interval.Correlations among the domain scores are significantlypositive correlated in all samples, except for three. In theCL-psychiatry sample, the biological domain score was notsignificantly correlated to the scores on the psychologicaland social domain. Also, in the diabetes sample, thebiological domain score was not significantly correlated tothe psychological domain. In the total sample, the lowest

Prevention of Major Depression in Complex Medically Ill Patients: Preliminary Results From a Randomized, Controlled Trial

BACKGROUNDnDepression is highly prevalent in patients with physical illness and is associated with a diminished quality of life and poorer medical outcomes.nnnOBJECTIVEnThe authors evaluated whether a multifaceted intervention conducted by a psychiatric consultation-liaison nurse could reduce the incidence of major depression in rheumatology inpatients and diabetes outpatients with a high level of case complexity.nnnMETHODnOf 247 randomized patients, the authors identified 100 patients with a high level of case complexity at baseline and without major depression (65 rheumatology and 35 diabetes patients). Patients were randomized to usual care (N=53) or to a nurse-led intervention (N=47). Main outcomes were the incidence of major depression and severity of depressive symptoms during a 1-year follow-up, based on quarterly assessments with standardized psychiatric interviews.nnnRESULTSnThe incidence of major depression was 63% in usual-care patients and 36% in the intervention group. Effects of intervention on depressive symptoms were observed in outpatients with diabetes but not in rheumatology inpatients.nnnCONCLUSIONnThese preliminary results based on subgroup analysis suggest that a multifaceted nurse-led intervention may prevent the occurrence of major depression in complex medically ill patients and reduce depressive symptoms in diabetes outpatients.

Communication with terminal cancer patients in palliative care: are there differences between nurses and physicians?

The aim of this study was to find whether there were interprofessional differences in specific elements of communication with terminal cancer patients and decision-making processes that concern such patients. Given that interdisciplinary team work is one of the basic values in palliative care, if there are conflicting views between professions on such important issues it is most important to know about these and to understand them. A questionnaire utilized in an earlier survey of palliative care physicians and addressing their attitudes to and beliefs about specific elements of communication and decision making was sent to a sample of palliative care nurses working in the same regions, i.e. the French-speaking parts of Switzerland, Belgium and France. After a second mailing (reminder), 135 of the 163 questionnaires (83%) were returned. There was general agreement between nurses and physicians on questions dealing with perceptions of patients knowledge of their diagnosis and stage of disease, patients need for information, do not resuscitate orders and ethical principles in decision-making processes. Statistically significant, but small, differences between professional groups were only observed for a minority of the questions. Interprofessional differences in specific elements of communication with terminal cancer patients and decision-making processes affecting these patients were not so marked that they could be called conflicting interprofessional views.

Collusions Between Patients and Clinicians in End-of-Life Care: Why Clarity Matters

Collusion, an unconscious dynamic between patients and clinicians, may provoke strong emotions, unreflected behaviors, and a negative impact on care. Collusions, prevalent in the health care setting, are triggered by situations which signify an unresolved psychological issue relevant for both, patient and clinician. After an introductory definition of collusion, two archetypal situations of collusion-based on material from a regular supervision of a palliative care specialist by a liaison psychiatrist-and means of working through collusion are presented. The theoretical framework of collusion is then described and the conceptual shortcomings of the palliative care literature in this respect discussed, justifying the call for more clarity. Finally, cultural aspects and societal injunctions on the dying, contributing to the development of collusion in end-of-life care, are discussed.

Communication in cancer care: is there enough to talk about?

Looking through the first five manuscripts of this issue of Supportive Care in Cancer, one observes that they have one central topic in common; communication. Glaus et al. [4] in their special article use communication as their main research tool to approach the problem of fatigue and tiredness in cancer patients. Montazeri et al. [5] investigate different modes of communication in research and its possible influences on outcome. Carlsson and Strang [2] remind us with their study that psychosocial support structures cannot be implemented without first communicating with the patient. Buchanan et al. [1] point to another central aspect of communication by showing with their survey that a majority of the patients prefer collaborative consensus in clinical decision making. Fossil et al. [3] uncover in their investigation the perception discrepancy between patients and physicians with regard to somatic morbidity and psychosocial stress. Such differences will only decrease if communication increases. As illustrated in these manuscripts, research in clinical and psychosocial oncology has reached the

Palliative care in the University Hospital Lausanne: from consultations to an integrated regional program.

F. Stiefel, M.D. Service de Psychiatrie de Liaison, Centre Hospitalier Universitaire Vaudois, CH-1011 Lausanne, Switzerland We have reported previously on the development of palliative care in Lausanne and the Canton of Vaud, where different structures in different places covering different needs have been developed over the last decade [1]. In the University Hospital Lausanne, an 800-bed facility and academic center for the region, a Palliative Care Unit was established in October 1996 with the primary goal of consultation within the University Hospital. In the last 3 years, this unit has developed rapidly, to the point where the question of a further step forward towards an integrated regional palliative care program has to be discussed. We will report briefly on current activities and then discuss some of the possibilities for a wider, more comprehensive and better coordinated program for the future and some of the obstacles to its realization.

Assessment of Biopsychosocial Complexity and Health Care Needs: Measurement Properties of the INTERMED Self-Assessment Version

Objective The INTERMED Self-Assessment questionnaire (IMSA) was developed as an alternative to the observer-rated INTERMED (IM) to assess biopsychosocial complexity and health care needs. We studied feasibility, reliability, and validity of the IMSA within a large and heterogeneous international sample of adult hospital inpatients and outpatients as well as its predictive value for health care use (HCU) and quality of life (QoL). Methods A total of 850 participants aged 17 to 90 years from five countries completed the IMSA and were evaluated with the IM. The following measurement properties were determined: feasibility by percentages of missing values; reliability by Cronbach &agr;; interrater agreement by intraclass correlation coefficients; convergent validity of IMSA scores with mental health (Short Form 36 emotional well-being subscale and Hospital Anxiety and Depression Scale), medical health (Cumulative Illness Rating Scale) and QoL (Euroqol-5D) by Spearman rank correlations; and predictive validity of IMSA scores with HCU and QoL by (generalized) linear mixed models. Results Feasibility, face validity, and reliability (Cronbach &agr; = 0.80) were satisfactory. Intraclass correlation coefficient between IMSA and IM total scores was .78 (95% CI = .75–.81). Correlations of the IMSA with the Short Form 36, Hospital Anxiety and Depression Scale, Cumulative Illness Rating Scale, and Euroqol-5D (convergent validity) were −.65, .15, .28, and −.59, respectively. The IMSA significantly predicted QoL and also HCU (emergency department visits, hospitalization, outpatient visits, and diagnostic examinations) after 3- and 6-month follow-up. Results were comparable between hospital sites, inpatients and outpatients, as well as age groups. Conclusions The IMSA is a generic and time-efficient method to assess biopsychosocial complexity and to provide guidance for multidisciplinary care trajectories in adult patients, with good reliability and validity across different cultures.