Abstract
Introduction
Prior studies suggested that a greater number of return visits is associated with greater symptoms of depression and greater symptom intensity.
Methods
All new adult patients presenting for musculsoskeletal specialty care between October 2017 and October 2018 were included. Patients completed the PROMIS Global Health, the PHQ-2, and the GAD-7 as part of usual care.
Results
Accounting for confounders, having a return visit was associated with lower PROMIS Global Health, greater symptoms of depression, and greater symptoms of anxiety.
Conclusions
These findings provide support for the importance of 1) improved coordination with non-specialist referring clinicians, and 2) interdisciplinary care teams.
Level of evidence
Level II, Prognostic.
Keywords: Return visits, Specialty care, Symptoms of depression, Anxiety, Capability, PROMIS
1. Introduction
An in-person visit to a musculoskeletal specialist may involve time off work, transportation, child-care arrangements, and out-of-pocket expenses (co-pays, deductibles, transportation, parking, etc.).1 Prior studies of patients presenting for upper extremity care at an academic institution indicated that a notable percentage of patients with non-trauma pain conditions see a musculoskeletal specialist once and then manage on their own.2,3 A prospective cohort study of patients with upper extremity fractures with a relatively easy recovery trajectory (e.g. adequately aligned metacarpal fractures, non-displaced or minimally displaced distal radius fractures) found that the majority prefer not to schedule a return visit, and fewer than 50% return to the office regardless of their initial stated preference.4 There is evidence that a greater number of return visits is associated with greater symptoms of depression (for every 5-point increase in PROMIS Depression scores, there are 1.6 more office visits per 100 people)3 and a greater tendency to limit activity owing to pain (greater pain interference: for every 5-point increase in pain interference, there were 2.8 more office visits per 100 people).2,3 Assessing patient and clinician factors associated with a return visit can provide insight into how we might increase the value of musculoskeletal specialty care.
Our institutional database of routinely collected Patient-Reported Outcome Measures (PROMs) allowed us to investigate how psychological, demographic, and clinician factors affect the rate of return visits for common orthopedic illnesses. We asked: (1) What factors are independently associated with a return visit to the same subspecialty unit? (2) What factors are associated with a return visit to any orthopedic subspecialty?
2. Patients and methods
2.1. Study design and setting
This study was approved by our Institutional Review Board (IRB). We performed a retrospective database study of all adult (age 18 years or older) patients who presented for musculoskeletal care between October 2017 and October 2018. We tracked care for the 1-year period following a new patient visit. All data were de-identified prior to analysis. The database includes patient demographics (age and sex), insurance type, orthopedic subspecialist team, and the number of attended visits. The four orthopedic subspecialist teams in our department are Upper Extremity, Lower Extremity, Back and Neck, and Sports. Additionally, patients were asked to complete the Patient Reported Outcome Measurement Information System (PROMIS) Global Health, Patient Health Questionnaire-2 (PHQ-2), and the Generalized Anxiety Disorder-7 (GAD-7) scale. Missing questionnaires were due to infrequent technological issues that occurred at random. All patients with missing questionnaires were excluded from analysis.
A total of 1341 patients met our inclusion criteria: the mean age was 52 ± 15 years. Five hundred forty-eight (41%) were men. Forty one percent of patients (554 of 1341) had one or more return visits, with a median number of 1 visit to the same subspecialty unit, and a median of 1 return visit for any subspecialty (Table 1).
Table 1.
Patient demographics.
| Variables | Value |
|---|---|
| N | 1341 |
| Age | 52 ± 15 |
| Gender | |
| Women | 793 (59%) |
| Men | 548 (41%) |
| Insurance | |
| County insurance/self-pay | 784 (58%) |
| Commercial | 390 (29%) |
| Medicare | 147 (11%) |
| Othera | 20 (1.5%) |
| Subspecialty | |
| Lower extremity | 448 (33%) |
| Upper extremity | 407 (30%) |
| Back and neck | 230 (17%) |
| Sports | 256 (19%) |
| Questionnaires | |
| PROMIS Global Health | 31 ± 8.0 |
| Global Mental Health | 47 ± 9.5 |
| Global Physical Health | 40 ± 8.9 |
| PHQ-2 (median, IQR) | 0 (0–3) |
| GAD-7 (median, IQR) | 0 (0–2) |
| Office visits | |
| One or more return visits for the same subspecialty unit | 554 (41%) |
| Lower extremity | 227 (51%) |
| Upper extremity | 120 (29%) |
| Back and neck | 87 (38%) |
| Sports | 120 (48%) |
| One or more return visits for all subspecialty units | 653 (49%) |
Continuous variables as mean ± standard deviation or median (interquartile range [IQR]); discrete variables as percentage (number). PHQ-2 = Patient Health Questionnaire-2; GAD-7 = Generalized Anxiety Disorder-7.
Other = Medicaid, Medicaid Managed Care, and Tricare.
2.2. Questionnaires
At every office visit, patients completed the Patient Reported Outcome Measurement Information System (PROMIS) Global Health, a validated measure with 2 subdivisions: Global Physical health and Global Mental Health. PROMIS questionnaires are normed to the United States general population, with mean of 50 and a standard deviation of 10. Higher scores indicate better physical and mental health.5 Patients also completed the Patient Health Questionnaire-2 (PHQ-2), a 2-item measure that inquires about symptoms of depression over the past 2 weeks.6 Scores range from 0 to 6, and higher scores indicate more symptoms of depression. The Generalized Anxiety Disorder-7 (GAD-7) is a 7-item measure inquiring about symptoms of anxiety over the past 2 weeks.7 The total score ranges from 0 to 21, and higher scores indicate more anxiety.
2.3. Statistical analysis
To detect differences in patient characteristics between patients who did and did not have a return visit, we used multivariable logistic regression, accounting for age, gender, insurance type, and orthopedic subspecialty. Since there were substantial correlations between the PROMIS measures (Global Health, Global Mental Health, and Global Physical Health), the PHQ-2, and the GAD-7, each of these PROMs were entered in a separate model that accounted for potential confounding variables; the bivariate and multivariable Odds ratios were reported. Due to low numbers, the insurance categories ‘Medicaid Managed care’, ‘Medicaid’, and ‘Tricare’ were pooled into ‘other’. For the secondary null hypotheses, multivariable logistic regression was used, and we reported the Odds ratios (OR), 95% Confidence Intervals (95% CI), standard errors, and P values. All P values below 0.05 were considered statistically significant. As a tertiary hypothesis, we calculated Spearman rank correlations between PROMIS Global and its physical health and mental subsets, the PHQ-2, and the GAD-7.
3. Results
In multivariable logistic regression accounting for patient and clinic factors but excluding questionnaire data, a return visit to the same subspecialty was independently associated with older age (OR 1.01; 95% CI 1.00 to 1.03; P = 0.014) and the insurance category ‘other’ (OR 4.1; 95% CI 1.4 to 12; P = 0.008), while commercial insurance (OR 0.71; 95% CI 0.53 to 0.96; P = 0.024) and upper extremity subspecialty (OR: 0.43; 95% CI: 0.32 to 0.57; P < 0.001) were associated with lower odds of a return visit. Due to anticipated co-linearity, the questionnaire data were analysed in separate multivariable models accounting for age, sex, insurance, and subspecialty. In these models, a return visit was associated with lower PROMIS Global Health (OR 0.97; 95% CI: 0.95 to 0.98; P < 0.001) and both its mental and physical function subdivisions, greater symptoms of depression (OR 1.02; 95% CI 1.01 to 1.04; P = 0.013), and greater symptoms of anxiety (OR 1.03; 95% CI 1.01 to 1.05; P = 0.006) (Table 2).
Table 2.
Logistic regression analysis of factors associated with having a return visit to the same subspecialty.
| Variables | Odds Ratio |
Standard error | P value | Akaike Information Criterion (AIC) |
|---|---|---|---|---|
| (95% Confidence Interval) | ||||
| 1767 | ||||
| Age | 1.01 (1.00–1.03) | 0.0047 | 0.014 | |
| Gender | ||||
| Women | reference value | |||
| Men | 0.93 (0.74° 1.2) | 0.11 | 0.561 | |
| Insurance | ||||
| County insurance/self-pay | reference value | |||
| Commercial | 0.71 (0.53–0.96) | 0.11 | 0.024 | |
| Medicare | 0.67 (0.44–1.0) | 0.14 | 0.055 | |
| Otherb | 4.1 (1.4–12) | 2.2 | 0.008 | |
| Subspecialty | ||||
| Lower extremity | reference value | |||
| Upper extremity | 0.43 (0.32–0.57) | 0.063 | < 0.001 | |
| Back and neck | 0.81 (0.55–1.2) | 0.16 | 0.263 | |
| Sports |
1.1 (0.75–1.5) |
0.18 |
0.771 |
|
| Unadjusted Odds Ratio | Adjusted Odds Ratioa | P value | Akaike Information Criterion (AIC) | |
| (95% Confidence Interval) |
(95% Confidence Interval) |
|||
| PROMIS Global Health | 0.96 (0.95–0.97) | 0.97 (0.95–0.98) | < 0.001 | 1753 |
| PROMIS Global Mental Health | 0.98 (0.97–0.99) | 0.98 (0.97–0.99) | 0.005 | 1761 |
| PROMIS Global Physical Health | 0.96 (0.95–0.97) | 0.97 (0.96–0.98) | < 0.001 | 1753 |
| PHQ-2 | 1.04 (1.01–1.06) | 1.02 (1.01–1.04) | 0.013 | 1763 |
| GAD-7 | 1.04 (1.02–1.06) | 1.03 (1.01–1.05) | 0.006 | 1762 |
Bold indicates statistical significance, P < 0.05. PHQ-2 = Patient Health Questionnaire-2; GAD-7 = Generalized Anxiety Disorder-7.
Accounting for age, gender, insurance, and subspecialty.
Other = Medicaid, Medicaid Managed Care, and Tricare.
Not accounting for questionnaire data, greater odds of having a return visit to any subspecialty unit was associated with older age (OR 1.01; 95% CI 1.00 to 1.02; P = 0.041), the insurance category ‘other’ (OR 3.2; 95% CI 1.1 to 9.1; P = 0.027), while the upper extremity subspecialty was associated with lower odds (OR 0.45; 95% CI 0.34 to 0.59; P < 0.001). In separate multivariable models accounting for age, sex, insurance, and subspecialty, greater odds of having a return visit to any subspecialty was associated with worse PROMIS Global Health (OR 0.97; 95% CI 0.96 to 0.99; P = 0.001), and both its mental and physical function subdivisions, greater symptoms of depression (OR 1.02; 95% CI 1.00 to 1.04; P = 0.016), and greater symptoms of anxiety (OR 1.02; 95% CI 1.00 to 1.05; P = 0.031) (Table 3).
Table 3.
Logistic regression analysis of factors associated with having a return visit to any subspecialty.
| Variables | Odds Ratio |
Standard error | P value | Akaike Information Criterion (AIC) |
|---|---|---|---|---|
| (95% Confidence Interval) | ||||
| 1817 | ||||
| Age | 1.01 (1.00–1.02) | 0.0045 | 0.041 | |
| Gender | ||||
| Women | reference value | |||
| Men | 0.89 (0.71–1.1) | 0.10 | 0.291 | |
| Insurance | ||||
| County insurance/self-pay | reference value | |||
| Commercial | 0.78 (0.58–1.0) | 0.12 | 0.092 | |
| Medicare | 0.91 (0.60–1.4) | 0.19 | 0.634 | |
| Otherb | 3.2 (1.1–9.1) | 1.7 | 0.027 | |
| Subspecialty | ||||
| Lower extremity | reference value | |||
| Upper extremity | 0.45 (0.34–0.59) | 0.064 | < 0.001 | |
| Back and neck | 1.0 (0.71–1.5) | 0.20 | 0.868 | |
| Sports |
1.0 (0.71–1.4) |
0.17 |
0.981 |
|
| Unadjusted Odds Ratio | Adjusted Odds Ratioa | P value | Akaike Information Criterion (AIC) | |
| (95% Confidence Interval) |
(95% Confidence Interval) |
|||
| PROMIS Global Health | 0.97 (0.95–0.98) | 0.97 (0.96–0.99) | 0.001 | 1807 |
| PROMIS Global Mental Health | 0.98 (0.97–0.99) | 0.99 (0.98–0.99) | 0.035 | 1814 |
| PROMIS Global Physical Health | 0.97 (0.96–0.98) | 0.97 (0.96–0.99) | < 0.001 | 1805 |
| PHQ-2 | 1.03 (1.02–1.05) | 1.02 (1.00–1.04) | 0.016 | 1813 |
| GAD-7 | 1.03 (1.01–1.05) | 1.02 (1.00–1.05) | 0.031 | 1814 |
Bold indicates statistical significance, P < 0.05. PHQ-2 = Patient Health Questionnaire-2; GAD-7 = Generalized Anxiety Disorder-7.
Accounting for age, sex, insurance, and subspecialty.
Other = Medicaid, Medicaid Managed Care, and Tricare.
In a tertiary analysis, all measures of physical health were correlated, and better mental health was strongly associated with better physical health for each measure (Table 4).
Table 4.
Spearman rank correlations between PROMIS Global health and its physical and mental health subset, PHQ-2, and GAD-7.
| Variables | PROMIS Global Health | PROMIS Global Mental Health | PROMIS Global Physical Health | PHQ-2 | GAD-7 |
|---|---|---|---|---|---|
| PROMIS Global Health | – | ||||
| PROMIS Global Mental Health | 0.85 | – | |||
| PROMIS Global Physical Health | 0.85 | 0.60 | – | ||
| PHQ-2 | −0.52 | −0.46 | −0.48 | - | |
| GAD-7 | −0.56 | −0.58 | −0.44 | 0.52 | – |
Bold indicates statistical significance, P < 0.05. PHQ-2 = Patient Health Questionnaire-2; GAD-7 = Generalized Anxiety Disorder-7.
4. Discussion
A better understanding of the variation in utilization of care might help optimize stewardship of resources and help us tailor care. We studied a large database of adult patients who presented for musculoskeletal specialty care with routinely collected measures of patient-reported physical and mental health. We found that worse physical and mental health (greater anxiety and symptoms of depression) were associated with having one or more return visits.
This study had several limitations. First, patients with incomplete questionnaires were excluded from analysis, which is a potential source of bias. Missing questionnaires in our setting are related to periodic technical issues and are unlikely to be related to patient, clinician, or illness factors, so the influence of these missing data is expected to be very limited. Second, there was wide variability in the diagnoses, and this could not be accounted for in our multivariable model. Studies of specific diagnoses might have different findings, but this study is representative of the daily work of a multi-specialty orthopedic practice. Third, we did not have measures of socioeconomic status, which might impact the rate of utilization of care. Of note, more than half the patients in our office have county insurance, which indicates lower socioeconomic status. Patients on county insurance have no co-pays or deductibles as potential barriers to care. Fourth, there was substantial collinearity between all measures of mental health and between the measures of mental health and self-reported activity limitations, so we could not evaluate their combined influence on utilization. It is important to keep in mind that the various subgroups in our unit have somewhat different payer mixes and variable strategies for offering and scheduling return visits.
We confirmed that most people visit a musculoskeletal specialist a single time and found that a return visit—to the same subspecialty unit or any other—is associated with psychological distress and specialty. We interpret these associations as indicating that most people seek expertise that allows them to manage their health independently, particularly when that strategy is encouraged (upper extremity team). Psychological distress is associated with continued care, which may reflect lower levels of agency and self-efficacy. This interpretation of the findings is consistent with the line of evidence demonstrating that lower symptom intensity and activity intolerance are associated with greater patient activation, greater self-efficacy, less unhealthy cognitive bias about pain, less fusion with that cognitive bias, and less psychological distress2,3,8,9 (as confirmed in this study), and less care-seeking behavior.9, 10, 11, 12, 13, 14 There are other potential reasons for people to deprioritize care that seem less likely. For instance, studies using claims data or databases from relatively contained health systems identify low rates of resuming care with another specialist.2,3,15, 16, 17 Furthermore, although this study did not address patient experience, other studies in our context as well as ongoing experience monitoring our clinical unit document high ratings of satisfaction, communication effectiveness, and perceived clinician empathy.18,19 It is plausible that symptoms of depression might lead people to deprioritize care (lack of motivation for self-care), but in our study greater symptoms of depression were associated with greater care-seeking, a finding that is consistent with other studies.9, 10, 11, 12, 13 This line of evidence suggests that specific care strategies that anticipate most patients' demonstrated desire for independence, and also anticipate, identify, and address psychological distress may have the potential to improve health, promote active participation in care, and decrease limitations while simultaneously reducing the number of specialty office visits for a given musculoskeletal diagnosis. We interpret the observed association of upper extremity subspecialty with lower rates of return visits as due largely to practice style, although the types of diseases might also be a factor. The upper extremity unit always gives the option of booking a return visit and follows the patient's preference, which is, more often than not, to try to manage on their own. Other units use different approaches. The upper extremity unit also emphasizes the many ways of obtaining access to the team (portal, email, phone, video, in-person) are also emphasized (for instance, email use is encouraged). This strategy of patient choice and improved access may account for the reduced number of return visits on this unit, but additional study is needed. Older age is usually associated with higher rates of return visits,20,21 most likely due to burden of disease. The observation that the insurance group ‘other’ was associated with having a return visit and that commercial insurance was associated with lower rates of return visits may be due to differences in the amount of co-pays and deductibles between these categories, but may also be a reflection of socioeconomic status, which we could not account for.
In an unplanned analysis, better patient-reported global health was strongly associated with lower symptoms of anxiety and depression, which is consistent with prior studies.22, 23, 24, 25, 26, 27, 28 This finding suggests that anticipating and addressing mental health opportunities in non-specialty and specialty care of musculoskeletal symptoms has the potential to alleviate symptoms and increase activity tolerance.
People often see a musculoskeletal specialist a single time and then manage on their own. The observation that those with greater symptom intensity and activity intolerance and greater psychological distress are more likely to return is consistent with mounting evidence that biopsychosocial and comprehensive treatment strategies—with more attention to stress, distress, and unhelpful cognitive bias about pain—have the potential to improve health with strategic stewardship of resources. Areas of future investigation for innovations in the care of people with musculoskeletal illness might include measurement of the impact of 1) better coordination with non-specialists regarding health priorities, mental health opportunities in particular; 2) increased use of e-consults and improved disease information to assist non-specialists in the patient's overall care and strategies for referral; 3) alternatives to in-person care for access to musculoskeletal specialty expertise; and 4) strategies for anticipating and adequately addressing mental health opportunities in specialty care, among others.
Declaration of competing interest
One of the authors (DR) certifies that he, or a member of his immediate family, has or may receive payment or benefits from Skeletal Dynamics (USD less than 100,000, Wright Medical for elbow implants (USD less than 10,000), Deputy Editor for Clinical Orthopaedics and Related Research, Universities and Hospitals, and Lawyers outside of the submitted work. All other authors have nothing to disclose.
References
- 1.Alokozai A., Crijns T.J., Janssen S.J. Cost in hand surgery: the patient perspective. J Hand Surg Am. 2019;44(11):992.e1–992.e26. doi: 10.1016/j.jhsa.2019.01.009. [DOI] [PubMed] [Google Scholar]
- 2.Bernstein D.N., Crijns T.J., Mahmood B., Ring D., Hammert W.C. Patient characteristics, treatment, and presenting PROMIS scores associated with number of office visits for traumatic hand and wrist conditions. Clin Orthop Relat Res. 2019;447(10):2345–2355. doi: 10.1097/CORR.0000000000000742. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Crijns T.J., Bernstein D.N., Teunis T. The association between symptoms of depression and office visits in patients with nontraumatic upper-extremity illness. J Hand Surg Am. 2020;45(2):159.e1–159.e8. doi: 10.1016/j.jhsa.2019.03.019. [DOI] [PubMed] [Google Scholar]
- 4.Finger A., Teunis T., Hageman M.G., Thornton E.R., Neuhaus V., Ring D. Do patients prefer optional follow-up for simple upper extremity fractures: a pilot study. Injury. 2016;47(10):2276–2282. doi: 10.1016/j.injury.2016.06.029. [DOI] [PubMed] [Google Scholar]
- 5.Barile J.P., Reeve B.B., Smith A.W. Monitoring population health for healthy people 2020: evaluation of the NIH PROMIS® global health, CDC healthy days, and satisfaction with life instruments. Qual Life Res. 2013;22(6):1201–1211. doi: 10.1007/s11136-012-0246-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Löwe B., Kroenke K., Gräfe K. Detecting and monitoring depression with a two-item questionnaire (PHQ-2) J Psychosom Res. 2005;58(2):163–171. doi: 10.1016/j.jpsychores.2004.09.006. [DOI] [PubMed] [Google Scholar]
- 7.Löwe B., Decker O., Müller S. Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Med Care. 2008;46(3):266–274. doi: 10.1097/MLR.0b013e318160d093. [DOI] [PubMed] [Google Scholar]
- 8.Lozano Calderon S.A., Paiva A., Ring D. Patient satisfaction after open carpal tunnel release correlates with depression. J Hand Surg Am. 2008;33(3):303–307. doi: 10.1016/j.jhsa.2007.11.025. [DOI] [PubMed] [Google Scholar]
- 9.Kim Y., Soffler M., Paradise S. Depression is associated with recurrent chest pain with or without coronary artery disease: a prospective cohort study in the emergency department. Am Heart J. 2017;191:47–54. doi: 10.1016/j.ahj.2017.06.003. [DOI] [PubMed] [Google Scholar]
- 10.Meltzer A.C., Bregman B., Blanchard J. Depression is associated with repeat emergency department visits in patients with non-specific abdominal pain. West J Emerg Med. 2014;15(3):325–328. doi: 10.5811/westjem.2013.7.15635. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Musey P.I., Patel R., Fry C., Jimenez G., Koene R., Kline J.A. Anxiety associated with increased risk for emergency department recidivism in patients with low-risk chest pain. Am J Cardiol. 2018;122(7):1133–1141. doi: 10.1016/j.amjcard.2018.06.044. [DOI] [PubMed] [Google Scholar]
- 12.Lowthian J, Straney LD, Brand CA. Unplanned early return to the emergency department by older patients: the Safe Elderly Emergency Department Discharge (SEED) project. Age Ageing. 2016;45(2):255–261. doi: 10.1093/ageing/afv198. [DOI] [PubMed] [Google Scholar]
- 13.Carlos E.C., Peters C.E., Wollin D.A. Psychiatric diagnoses and other factors associated with emergency department return within 30 Days of ureteroscopy. J Urol. 2019;201(3):556–562. doi: 10.1016/j.juro.2018.09.062. [DOI] [PubMed] [Google Scholar]
- 14.Behr J.G., Diaz R. Emergency department frequent utilization for non-emergent presentments: results from a regional urban trauma center study. PloS One. 2016;11(1):e0147116. doi: 10.1371/journal.pone.0147116. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Crijns T.J., Ring D., Valencia V. Factors associated with the cost of care for the most common atraumatic painful upper extremity conditions. J Hand Surg Am. 2019;44(11):989.e1–989.e18. doi: 10.1016/j.jhsa.2019.01.001. [DOI] [PubMed] [Google Scholar]
- 16.Wilkens S.C., Ring D., Teunis T., Lee S.-G.P., Chen N.C. Decision aid for trapeziometacarpal arthritis: a randomized controlled trial. J Hand Surg Am. 2019;44(3):247.e1–247.e9. doi: 10.1016/j.jhsa.2018.06.004. [DOI] [PubMed] [Google Scholar]
- 17.Becker S.J.E., Teunis T., Blauth J., Kortlever J.T.P., Dyer G.S.M., Ring D. Medical services and associated costs vary widely among surgeons treating patients with hand osteoarthritis. Clin Orthop Relat Res. 2015;473(3):1111–1117. doi: 10.1007/s11999-014-3912-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Kortlever J.T.P., Ottenhoff J.S.E., Vagner G.A., Ring D., Reichel L.M. Visit duration does not correlate with perceived physician empathy. J Bone Joint Surg Am. 2019;101(4):296–301. doi: 10.2106/JBJS.18.00372. [DOI] [PubMed] [Google Scholar]
- 19.Keulen M.H.F., Teunis T., Vagner G.A., Ring D., Reichel L.M. The effect of the content of patient-reported Outcome measures on patient perceived empathy and satisfaction: a randomized controlled trial. J Hand Surg Am. 2018;43(12):1141.e1–1141.e9. doi: 10.1016/j.jhsa.2018.04.020. [DOI] [PubMed] [Google Scholar]
- 20.Lee S., Herrin J., Bobo W.V., Johnson R., Sangaralingham L.R., Campbell R.L. Predictors of return visits among insured Emergency Department mental health and substance abuse patients, 2005-2013. West J Emerg Med. 2017;18(5):884–893. doi: 10.5811/westjem.2017.6.33850. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Biese K., Massing M., Platts-Mills T.F. Predictors of 30-day return following an emergency department visit for older adults. N C Med J. 2019;80(1):12–18. doi: 10.18043/ncm.80.1.12. [DOI] [PubMed] [Google Scholar]
- 22.Brown L.F., Kroenke K., Theobald D.E., Wu J., Tu W. The association of depression and anxiety with health-related quality of life in cancer patients with depression and/or pain. Psycho Oncol. 2010;19(7):734–741. doi: 10.1002/pon.1627. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Husain M.O., Dearman S.P., Chaudhry I.B., Rizvi N., Waheed W. The relationship between anxiety, depression and illness perception in tuberculosis patients in Pakistan. Clin Pract Epidemiol Ment Health. 2008;26(4):4. doi: 10.1186/1745-0179-4-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Paschalides C., Wearden A.J., Dunkerley R., Bundy C., Davies R., Dickens C.M. The associations of anxiety, depression and personal illness representations with glycaemic control and health-related quality of life in patients with type 2 diabetes mellitus. J Psychosom Res. 2004;57(6):557–564. doi: 10.1016/j.jpsychores.2004.03.006. [DOI] [PubMed] [Google Scholar]
- 25.Aarons G.A., Monn A.R., Leslie L.K. Association between mental and physical health problems in high-risk adolescents: a longitudinal study. J Adolesc Heal Off Publ Soc Adolesc Med. 2008;43(3):260–267. doi: 10.1016/j.jadohealth.2008.01.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Cohen B.E., Maguen S., Bertenthal D., Shi Y., Jacoby V., Seal K.H. Reproductive and other health outcomes in Iraq and Afghanistan women veterans using VA health care: association with mental health diagnoses. Women’s Heal issues Off Publ Jacobs Inst Women’s Heal. 2012;22(5):e461–e471. doi: 10.1016/j.whi.2012.06.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Scott K.M., Lim C., Al-Hamzawi A. Association of mental disorders with subsequent chronic physical conditions: world mental health surveys from 17 countries. JAMA psychiatry. 2016;73(2):150–158. doi: 10.1001/jamapsychiatry.2015.2688. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Galper D.I., Trivedi M.H., Barlow C.E., Dunn A.L., Kampert J.B. Inverse association between physical inactivity and mental health in men and women. Med Sci Sports Exerc. 2006;38(1):173–178. doi: 10.1249/01.mss.0000180883.32116.28. [DOI] [PubMed] [Google Scholar]