Health Insurance Board Research Articles

Acceptability and Validity of Use of a Patient-Reported Cost Diary To Capture Health Resource Utilization and Costs Associated with Deep Venous Thrombosis and Post-Thrombotic Syndrome.

OBJECTIVE: To assess the acceptability and validity of a patient-reported cost diary to estimate health resource utilization (HRU) and costs associated with deep vein thrombosis (DVT) and post-thrombotic syndrome (PTS).METHODS: We developed a cost diary for use in the Venous Thrombosis Outcomes (VETO) Study, a prospective multicenter cohort study of long-term outcomes after DVT. The VETO cost diary is a 28-item patient-reported questionnaire used to capture information pertaining to HRU and direct and indirect costs attributable to DVT and PTS. Data for HRU and direct costs included hospitalizations, physician visits, purchase of prescription and over-the-counter medications, use of transportation and other medical services and purchase or rental of equipment. Data pertaining to indirect costs included time lost from work by patients or their caregivers. Patients were asked to complete the cost diary monthly for 1 year, then for 3 randomly chosen months for the 2nd year. Acceptability of the cost diary was assessed by estimating the percent of time coverage per patient over the study follow-up period. Internal consistency was assessed by comparing data reported by patients in the cost diary to similar data collected in nurse-administered study questionnaires. External validity was assessed by comparing HRU data reported in the cost diaries to patient-specific data obtained from the administrative database of the Province of Quebec Health Insurance Board (RAMQ) for the same time period.RESULTS: 387 patients with objectively diagnosed DVT participated in the VETO Study, of whom 359 from 7 hospitals in Quebec, Canada contributed to this analysis (∼ 40% developed PTS). Analyses showed that acceptability of the cost diary was high, with more than 82% of patients reporting data for > 90% of the study follow-up period. Internal consistency analyses revealed discrepancies in reporting of hospitalizations in cost diaries compared to nurse-administered questionnaires (144 vs. 97 hospitalizations, respectively, reported in the first year of the study). Analyses of external validity showed that for the first 4-month study period, the mean number of DVT-related prescriptions reported in the cost diary was comparable to that reported in the RAMQ database (2.48 vs. 3.84, respectively), as was the mean number of DVT-related medical visits (6.39 vs. 7.18, respectively).CONCLUSION: Overall, the VETO cost diary appears to be an acceptable and valid patient-reported instrument that can be used to estimate HRU, direct and indirect costs attributable to DVT and PTS. Further analyses are needed to identify the factors affecting the internal consistency of the cost diary.

Adherence to Atypical Antipsychotic Treatment Among Newly Treated Patients

Lack of adherence to drug treatment is a major obstacle to disease control. Although many studies have examined adherence to antipsychotic treatment, they have generally suffered from lack of differentiation between persistence and compliance as 2 separate components of adherence. In an outpatient population, to (1) measure the proportion of atypical antipsychotic users who were still on antipsychotic treatment after 12 months, (2) measure the proportion of compliant users among them, and (3) identify the determinants of persistence and of compliance. We carried out a population-based cohort study using the Quebec Health Insurance Board database. Patients previously diagnosed with schizophrenia (ICD-9 criteria) and initiated on clozapine, olanzapine, quetiapine, or risperidone treatment between January 1, 1997, and August 31, 1999, were included. Patients still undergoing treatment with any atypical antipsychotic drug 1 year after their first prescription were considered persistent. Of these patients, those with a supply of drugs for at least 80% of the days were deemed compliant. To identify the characteristics associated with both outcomes, we built a multivariate logistic regression model using a stepwise procedure and calculated odds ratios and their 95% confidence interval. Of 6662 individuals initiated on treatment with atypical antipsychotics, 4495 (67.5%) were still on the treatment after 1 year, and 3534 (78.6% of those who persisted) were compliant. Patients more likely to be both persistent and compliant were those initiated on clozapine, those who received a treatment of medium or high intensity, those who had used atypical antipsychotics, those without a history of substance-use disorder, and those on welfare. On the other hand, patients who were prescribed their first atypical antipsychotic by a psychiatrist were more likely to be persistent, whereas those with a high comorbidity index and those aged 35 years or more were more likely to be compliant. One year after treatment initiation, almost a third of patients were no longer treated with atypical antipsychotics. Of those still being treated, more than 20% were noncompliant. Further studies should focus on means of improving such erratic treatment behaviors.

Suboptimal Use of Cardioprotective Drugs in Newly Treated Elderly Individuals With Type 2 Diabetes

Cardiovascular disease is the main complication experienced by elderly individuals with diabetes (1). Despite randomized trials showing the benefits of individual (2–4) or combined (5) pharmacological treatments of cardiovascular risk factors in diabetes, observational studies have shown suboptimal use of medications (6–8). However, little is known about the use of cardioprotective medication among elderly individuals who were not already taking it before diabetes treatment was undertaken. We therefore studied a population of elderly individuals with type 2 diabetes in the province of Quebec, Canada, who had not been treated with any antihypertensive, lipid-lowering, or antiplatelet drugs in the year before oral antidiabetes drug initiation. We assessed whether they used a comprehensive cardioprotective regimen (CCR) of those three medications in the year following oral antidiabetic initiation. We also identified the determinants of a CCR use. We carried out a population-based inception cohort study using the Quebec Diabetes Surveillance System, which is the product of linking public health administrative databases managed by the Quebec Health Insurance Board. It includes information on patient demographics, physician and hospital services, and data from the public drug plan for individuals who had been diagnosed with diabetes. We selected individuals aged ≥66 years who had initiated an oral antidiabetes medication treatment between 1 January 1998 and 31 December 2002. The date of the first claim was the index date. We excluded individuals who had …

Increase in Nonfatal Digestive Perforations and Haemorrhages following Introduction of Selective NSAIDs: a Public Health Concern

tion of selective NSAIDs on overall prescription patterns of NSAIDs and associated gastroprotective agents (GPAs), and on the rate of nonfatal digestive perforations and haemorrhages. Methods: A retrospective, closed cohort study was conducted using the Quebec Health Insurance Board databases, for a 3-year period overlapping the introduction of selective NSAIDs. All adult subjects who were continuously registered with the Public Prescription Drug Program (PPDP) between 1 January 1999 and 31 December 2001 (n = 2 052 231) were included. Prescriptions for NSAIDs (selective [celecoxib, rofecoxib and meloxicam] and nonselective), concomitant use of GPAs and nonfatal digestive perforations or haemorrhages diagnosed in hospital were compiled. Data were analysed on an annual basis according to age, sex and patient risk of gastrointestinal (GI) complications. Results: The listing of selective NSAIDs in the PPDP formulary was followed by a 28.2% increase in the prevalence of NSAID use from 19.5% in 1999 to 25% in 2001. The proportion of long-term users also evolved rapidly with a 135% increase over 3 years. From 1999 to 2001, there was a 75.9% increase in the rate of nonfatal digestive perforations and haemorrhages in the presence of NSAIDs. Conclusion: The introduction of selective NSAIDs stimulated NSAID use and coincided with an increased incidence of nonfatal digestive perforations and haemorrhages in the presence of NSAIDs. Selective NSAIDs should be prescribed with caution to persons at risk for GI complications.

Relationship between climate, pollen concentrations of Ambrosia and medical consultations for allergic rhinitis in Montreal, 1994–2002

The aim of this study is to evaluate the influence of meteorological factors on Ambrosia pollen concentrations and its impact on medical consultations for allergic rhinitis of residents from various socio-economic levels in Montréal (Québec, Canada) between 1994 and 2002. The study was conducted to recognize the sensitivity of pollen productivity to daily climate variability in order to estimate the consequences on human health vulnerability in the context of global climate change. Information related to medical consultations for allergic rhinitis due to pollen comes from the Quebec Health Insurance Board (Régie de l'assurance-maladie du Québec). Ambrosia pollen concentration was measured by the Aerobiology Research Laboratories (Nepean, Ontario). Daily temperature (maximum, minimum, and mean) and precipitation data were obtained from the Meteorological Service of Canada. Socio-economic data come from the 1996 and 2001 census data of Statistics Canada. Between 1994 and 2002, during the Ambrosia pollen season, 7667 consultations for allergic rhinitis due to pollen were recorded. We found a significant association between the number of medical consultations and pollen levels. Significant associations were detected for over-consultation the day of exposure, 1, 2, 3 and 5 days after exposure to high levels of pollen. The consultation rate is higher from low-income residents (3.10 consultations per 10,000 inhabitants) than for high-income (1.65 consultations per 10,000 inhabitants). Considering the demonstrated impact of pollen levels on health, it has become critical to ensure adequate monitoring of Ambrosia and its meteorological sensivity in the context of the anticipated climate change and its potential consequences on human health.

How to improve cooperation with political leaders and other decision-makers to improve prevention of cardiovascular disease: lessons from Poland

Cardiovascular diseases (CVD) are the main health problem in Poland. We decided to use modern social marketing methods to present the current epidemiological situation to political and key opinion leaders in Poland. The surveys were carried out in the following groups: members of the Polish parliament, members of the executive bodies of the two largest trades unions in Poland, participants at the Polish Hygiene Society Congress, representatives of the health insurance board in the district of Pomerania, and press and radio journalists. The study consisted of a questionnaire, anthropometric measurements, blood pressure measurements, and cholesterol and glucose level tests. The results were presented to examined subjects individually and in the form of an educational conference held on the same day. In the examined groups of political and opinion leaders awareness of one's own blood pressure was declared by 40.6-86% of the subjects, increased blood pressure was found in 36-43.5%, overweight or obesity (body mass index 25 kg/m) in 40.6-67.3%, smoking was declared by 16.5-30%. The results were compared with those obtained in corresponding age groups in the general population. The idea of presenting the current epidemiological burden caused by CVD in Poland by means of an assessment of individual and collective CVD risk among political and opinion leaders appeared to be an effective method of education and constructive lobbying for the fight against an epidemic of myocardial infarctions and strokes in Poland.

Non-compliance on the part of the professional community with a national guideline: An argumentative policy analysis

In 1997, the National Health Insurance Board of the Netherlands (CVZ) introduced a guideline for the use of a new anti-epileptic drug, Lamotrigine. The goal was to limit the use of this relatively expensive drug to patients with difficult-to-treat epilepsy. A survey had shown that only a minority of neurologists were familiar with the guideline, and even fewer applied it in practice. In the present study, interviews were held with stakeholders to obtain a better understanding of why this policy measure failed. The results indicate that the problem definitions of policy maker and practicing neurologists differed widely, and that the policy measure was conflicting with certain professional beliefs. In such cases, the theory of argumentative policy predicts that policy is unlikely to succeed, unless policy makers take actions to ensure a greater congruence in interpretative frames between them and their target population.

Statin wars following coronary revascularization – Evidence-based clinical practice?

Randomized clinical trials (RCTs) have shown that statins provide substantial heath benefits. Pharmaceutical companies spend enormous amounts of money on both clinical trials and marketing. The relative influence of information from clinical trials on physician prescription patterns for statins is unknown. To examine the correlation between statin prescription patterns and the quality of evidence from RCTs. Using the computerized administrative databases of the Quebec Health Insurance Board, the choice of statin for elderly patients (older than 65 years of age) following a coronary revascularization procedure (percutaneous coronary intervention or coronary artery bypass graft surgery) performed between January 1, 1994, and June 30, 2003, was examined. Prescriptions for each statin were compared with their evidence base obtained from a cumulative systematic literature review of RCTs that recorded mortality as an outcome and were published before December 31, 2002. The study cohort comprised 27,979 elderly revascularized patients who received at least one statin prescription. In 1996, the year atorvastatin was introduced, simvastatin and pravastatin had 38.3% and 37.1% of the market share, respectively. By 2003, atorvastatin had 44% of the market share, compared with 29.9% and 24.1% for simvastatin and pravastatin, respectively. In contrast, RCTs published up to the end of 2002 had culminated in 133,341 and 140,565 patient-years of follow-up for simvastatin and pravastatin, respectively, and only 1459 patient-years for atorvastatin. Prescription patterns regarding the choice of statin do not appear to be determined uniquely from high-quality RCTs. Further research into the other possible determinants of physician prescription patterns is necessary.

Bone mineral density measurement and osteoporosis treatment after a fragility fracture in older adults: regional variation and determinants of use in Quebec

BackgroundOsteoporosis (OP) is a skeletal disorder characterized by reduced bone strength and predisposition to increased risk of fracture, with consequent increased risk of morbidity and mortality. It is therefore an important public health problem. International and Canadian associations have issued clinical guidelines for the diagnosis and treatment of OP. In this study, we identified potential predictors of bone mineral density (BMD) testing and OP treatment, which include place of residence.MethodsOur study was a retrospective population-based cohort study using data from the Quebec Health Insurance Board. The studied population consisted of all individuals 65 years and older for whom a physician claimed a consultation for a low velocity vertebral, hip, wrist, or humerus fracture in 1999 and 2000. Individuals were considered to have undergone BMD testing if there was a claim for such a procedure within two years following a fracture. They were considered to have received an OP treatment if there was at least one claim to Quebec's health insurance plan (RAMQ) for OP treatment within one year following a fracture. We performed descriptive analyses and logistic regressions by gender. Predictors included age, site of fracture, social status, comorbidity index, prior BMD testing, prior OP treatment, long-term glucocorticoid use, and physical distance to BMD device.ResultsThe cohort, 77% of which was female, consisted of 25,852 individuals with fragility fractures. BMD testing and OP treatment rates were low and gender dependent (BMD: men 4.6%; women 13.1%; OP treatment: men 9.9%; women 29.7%). There was an obvious regional variation, particularly in BMD testing, ranging from 0 to 16%. Logistic regressions demonstrate that individuals living in long term care facilities received less BMD testing. Patients who had suffered from vertebral fractures, or who had received prior OP treatment or BMD testing, regardless of gender, subsequently received more BMD testing and OP treatments. Furthermore, increasing the distance between a patient's residence and BMD facility precluded likelihood of BMD testing.ConclusionBMD testing rate was extremely low but not completely explained by reduced physical access; gender, age, social status, prior BMD testing and OP treatment were all important predictors for future BMD testing and OP treatment.

Volume and market share of anti-epileptic drugs in the Netherlands: impact of new drugs

In the past decade, several new anti-epileptic drugs (AEDs) were introduced in The Netherlands. These new drugs, one of which is lamotrigine, are 6 to 10 times more expensive than conventional anti-convulsants. In 1997, the high cost of lamotrigine, together with a lack of clinical data supporting its superiority over conventional drugs, prompted the Dutch Health Insurance Board to release a guideline in which the use of lamotrigine was restricted to difficult-to-treat patients. Other new drugs that were marketed after 1997 also became subject to this guideline. The utilisation of new AEDs and the cost consequences are the subject of this paper. Data from extramurally prescribed AEDs was obtained from the Dutch Drug Information Project, which is a database containing prescriptions for about 5.5 million inhabitants of the Netherlands. This data was used to study the impact of new AEDs on volume and market share of AEDs in the period from 1995 to 2001 in The Netherlands. Between 1995 and 2001, the total volume of AEDs increased by 130%, 60% of which consisted of new AEDs. Gabapentin, lamotrigine and oxcarbazepine were the most frequently prescribed new compounds. The volume share of new AEDs increased from 5% in 1995 to 18% in 2001. The market share amounted to 21.5 million euros in 1995 and rose to 47 million euros in 2001; 80% of this increase was due to the introduction of new AEDs. Although in 2001 the volume share of new AEDs was still modest, their introduction has led to a strong increase in the cost. New data is emerging on the effectiveness and cost-benefit sum of the new AEDs; this may change the place in therapy of these drugs. Because of their strong potential to force up cost, the positioning of new AEDs requires further attention.

The Development of a Quality System for Neuromodulation in the Netherlands

We present here a descriptive article on the development of a national quality system for neuromodulatory techniques in the Netherlands. In 1994, due to reimbursement difficulties in the Netherlands, a Neuromodulation Working Group (WGN) undertook an initiative to develop a national quality system for neuromodulation. It was believed that with official recognition of neuromodulation as a therapy by the health authorities in the Netherlands, a quality system for monitoring would then follow. To that purpose an observational study was performed. Integration of this entire primary process (from intake to control phase) was based upon an inventory of the practices of the most experienced medical specialists practicing neuromodulation in the Netherlands. Based on the study data, nine quality indicators were identified that would allow monitoring of the quality of care to patients in the Netherlands. The study resulted in a positive feedback to the National Health Insurance Board and the Ministry of Health in the Netherlands. Neuromodulation for chronic pain and disabling spasticity is now recognized and fully reimbursed within the limits of the newly developed quality system. We therefore conclude that developed quality systems can provide a basis for medical specialists to cooperate around groups of patients or diseases. These quality systems can facilitate implementation and innovation within the health care system. The role of medical specialists and their will to cooperate is essential.

Cartography of Emergency Department Visits for Asthma – Targeting High‐Morbidity Populations

Asthma education should be offered with priority to populations with the highest asthma-related morbidity. In the present study, the aim was to identify populations with high-morbidity for asthma from the Quebec Health Insurance Board Registry, a large administrative database, to help the Quebec Asthma and Chronic Obstructive Pulmonary Disease Network target its interventions. All emergency department (ED) visits for asthma were analyzed over a one-year period, considering individual and medical variables. Age- and sex-adjusted rates, as well as standardized rate ratios related to the overall Quebec rate, among persons zero to four years of age and five to 44 years of age were determined for 15 regions and 163 areas served by Centres Locaux de Services Communautaires (CLSC). The areas with rates 50% to 300% higher (P<0.01) than the provincial rate were defined as high-morbidity areas. Maps of all CLSC areas were generated for the above parameters. There were 102,551 ED visits recorded for asthma, of which more than 40% were revisits. Twenty-one CLSCs and 32 CLSCs were high-morbidity areas for the zero to four years age group and five to 44 years age group, respectively. For the most part, the high-morbidity areas were located in the south-central region of Quebec. Only 47% of asthmatic patients seen in ED had also seen a physician in ambulatory care. The data suggest that a significant portion of the population seeking care at the ED is undiagnosed and undertreated. A map of high-morbidity areas that could help target interventions to improve asthma care and outcomes is proposed.

Germany: Cancer Pain and Palliative Care—Current Situation

Guidelines of the World Health Organization (WHO) for cancer pain management have been adopted by several German medical societies. 1,2 In 1996, the drug commission of the German Medical Board produced guidelines on cancer pain management that follow the WHO recommendations closely. A second edition was published in 2000, also including an evaluation of the medical evidence behind these recommendations. 3 The Agency for Quality in Medicine, a central non-governmental organization supported by health insurance and German Medical Board, started a guideline evaluation program in 1998 and has chosen cancer pain as the second topic for this guideline clearinghouse. 4 The report produced in 2001 evaluated 13 guidelines for cancer pain management, including three published by German authors, and rated development, form and practicability with standardized scores. The guidelines of the German Medical Board received the highest ranking, with 33 of 40 points, closely followed by the guidelines of the Agency for Health Care Policy and Research (AHCPR) with the same score. The WHO recommendations were placed on rank 9 with a score of 25. The guideline clearing report also suggested areas and topics that should be included in cancer pain guidelines and gave examples from the existing guidelines for these areas. A catalogue of measures is currently in preparation. Although pain management, including cancer pain management, is not a specialty, it has been introduced as a subspecialty by the medical boards in most German states, with the exception of Bavaria, Brandenburg and Hessen. Despite these advances, the common practice of cancer pain treatment still shows serious deficiencies. In a recent survey among physicians not specializing in pain management, the majority reported knowledge of the WHO recommendations, though more than 15% rated transdermal fentanyl as a weak opioid or even a nonopioid analgesic. 5 In a representative survey from 1200 physicians in Lower Saxony, only 33.1% said that they know the analgesic ladder of the WHO. 6 Medical education also shows major deficits in pain management, which implies that no change will be achievable in near time. In a survey among medical students in the final term from six German universities, only 65% reported that they knew the analgesic ladder of the WHO, and onethird of these students did not even know the correct number of steps on this ladder. 7

Vasectomy and prostate cancer in Québec, Canada

The present investigation measured the association between vasectomy and prostate cancer (PC) in the male population of Québec, Canada. The Québec Health Insurance Board and the Québec Cancer Registry were our principal sources of information. Lung cancer cases and the male population of Québec served as controls for comparative purposes. Within a retrospective design, our preliminary results indicate an association between vasectomy and PC. Among the 1925–39 birth cohort of individuals diagnosed with PC in 1990–93, the global odds ratio was 2.6 (95% CI=1.7–4.3) while it was compared with lung cancer as the control group. This risk increased with the length of time between vasectomy and the diagnosis of cancer. An historical design indicated strong cohesion of the results. Besides, the risk does not vary when we control for the place of residence of the individuals. Vasectomy seems to increase the risk of PC at least 10 years after the operation, but we cannot exclude the impact of a possible detection bias among vasectomized individuals.

Ambulatory Use of Inhaled β2-Agonists for the Treatment of Asthma in Quebec: A Population-Based Utilization Review

To assess whether the utilization of inhaled short-acting beta(2)-agonists (ISAB) and inhaled long-acting beta(2)-agonists (ILAB) for the treatment of asthma was appropriate according to the 1996 Canadian Asthma Consensus Conference recommendations. Population-based retrospective drug utilization review using pharmacists' billing data of the Prescription Drug Insurance Plan administered by the Quebec health insurance board. However, the database used did not contain complete patient clinical information to accurately assess severity of asthma. Province of Quebec, Canada. Persons who received at least one outpatient prescription of ISAB (age range, 5 to 45 years) or ILAB (age range, 12 to 45 years) for the treatment of asthma between August 1997 and April 1998. Percentages of patients whose use was appropriate according to three criteria regarding the average daily dose of ISAB (criterion 1), the renewal interval of ILAB (criterion 2), and the concomitant daily use of corticosteroids for the expected length of utilization of ILAB (criterion 3). Overall proportions of appropriate use according to criterion 1 were as follows: 75% (without inhaled corticosteroids [ICS]) and 84% and 43% (with one or more than one prescription of ICS, respectively). Appropriateness was slightly higher for female patients, younger patients (5 to 18 years old), and those treated by pediatricians. However, appropriateness was only 9% among patients who received at least two prescriptions of ISAB during the study period. The proportion of appropriate use was 19% according to criterion 2 and 15% according to criterion 3; there were few differences by gender or by age, but the appropriateness according to criterion 2 was somewhat higher for patients of respirologists. Compared to the 1996 Canadian asthma consensus conference recommendations, ISAB are overused, ICS are underused, and ILAB are often used improperly. Close collaboration between health professionals and patients is essential to improve the pharmacotherapy of asthma.

Determinants of ambulatory physician utilization among adults with chronic diseases in Quebec.

To test the explanatory power of a model of ambulatory service use and to determine the relative roles of the main determinants of physician utilization for two chronic medical conditions in adults in Quebec. A behavioral model based on Andersen's model was developed and tested by linking two databases: the Quebec health survey as regards patient characteristics, and the Quebec health insurance board data on physician characteristics and service use. Path analysis was used for data analysis. The model explained a little less than 20% of the variation in service use. The number of hospitalizations, physician's specialty and perceived health were the most important predictors of the volume of visits. Further specification of utilization, relating it to a particular medical condition, does not necessarily lead to an increase in the explanatory power of the model. We recommend that future research should put more emphasis on provider-related determinants rather than focusing on the type and purpose of utilization.

Use of physician services among family caregivers of elderly persons with dementia

It is well known that there is an excess of physical and psychological health problems among family caregivers of elderly persons with Alzheimer's disease and other dementias. The objective of this study was to determine whether the higher level of morbidity translates into a higher level of medical care utilization. Data from a previously completed longitudinal study of caregivers for elderly persons with dementia were merged with data on physician visits obtained from the computerized records of the Quebec Health Insurance Board. Utilization of physician care (adjusted for age, sex, number of chronic diseases, and depression) was no higher for family caregivers of elderly patients with Alzheimer's disease and other dementias than for comparable family members of older persons without dementia. The annual cost of physician care was almost identical among caregivers and noncaregivers. However, the pattern of utilization for the two groups was somewhat different: there was a significantly higher frequency of physician utilization among caregivers for services billed by psychiatrists and internal medicine specialists. In multivariate analysis, physician utilization was significantly associated with having more than one chronic condition and with increased age. Future studies should focus on determining whether caregivers neglect their own health care needs as a result of the exigencies of the caregiving role.

Medical insurance in Republic of Ireland

EDITOR,--Alan Murdoch's report on medical insurance in the Republic of Ireland is misleading.1 He states that the Voluntary Health Insurance Board was set up “to provide medical cover …

An adoption study of somatoform disorders. I. The relationship of somatization to psychiatric disability.

The relationship between psychiatric impairment and disability due to somatic complaints was studied in 859 women adopted at an early age by nonrelatives in Sweden. The clinical data were derived from the comprehensive registrations for all medical treatment and sick-leave compensation that are kept about Swedish residents by the National Health Insurance Board. The adoptees were compared with nonadopted controls who were individually matched for social and demographic variables. We identified a somatization syndrome that is consistently associated with psychiatric impairment and repeated brief periods of disability with chief complaints of headache, backache, and abdominal distress on different occasions. A method for clinically distinguishing "somatizers" from other women was derived in one sample and was shown to have a classification accuracy of 97% in a replication sample. Somatizers accounted for 36% of all cases of psychiatric disability and 48% of all sick-leave occasions in adopted women. Compared with nonadoptees, there was an excess of somatizers in adoptees, a population known to have an excess of biological parents who are criminal and/or alcoholic.