A “What Matters Index” (WMI) for Adolescents : The Journal of Ambulatory Care Management

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Original Article

A “What Matters Index” (WMI) for Adolescents

Wasson, John H. MD

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Journal of Ambulatory Care Management ():10.1097/JAC.0000000000000456, January 23, 2023. | DOI: 10.1097/JAC.0000000000000456
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Abstract

A “WHAT MATTERS INDEX” (WMI) represents a distillation of many self-reported measures into the few that matter. Over several decades, a primary care research group developed and tested a multipurpose, 5-item WMI to rectify the significant mismatch observed between what matters to adult patients and what clinicians know (Wasson, 2021; Wasson, Soloway, et al., 2018). This brief and immediately interpretable WMI efficiently communicates important needs to health professionals and identifies strategies that can improve health care and overall health. The Adult WMI also stratifies patients at risk for future costly care (Wasson, Ho, et al., 2018).

The fact that the Adult WMI effectively stratified people with no common chronic conditions strongly suggested that it should be applicable to generally healthy adolescents. Therefore, the Adult WMI can be a model for examining the value of a similar tool for adolescents. This report examines that hypothesis.

METHODS

An Adolescent WMI

The Adolescent WMI elements were derived from the analogous Adult WMI. The Adult WMI relies on 5, single-item measures, each of which guides specific actions, and their composite sum identifies the risk for subsequent hospital and emergency use. The 5 items for adults are self-reported: insufficient health confidence, bothersome pain, bothersome emotional problems, polypharmacy, and a suspicion that medications may be causing illness.

Since adolescents are much less likely than adults to be taking chronic medications, 2 items relating to medications were not included in the Adolescent WMI. In addition, because most adolescent respondents have little experience managing chronic conditions, a broader construct of “insufficient problem-solving” is an alternative to “insufficient health confidence.”

The resultant Adolescent WMI for public health or community settings (eg, in schools or Web browsers) and clinical settings is illustrated in Figure 1. When automated, the Adolescent WMI provides the responder a summary and suggested resources tailored to responses. Examples include a problem-solving tool that promotes a personal, cognitive-behavior therapeutic approach and a more comprehensive assessment when the WMI score is greater than zero (https://howsyourhealth.org/; Wasson, 2021).

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Figure 1.:
A What Matters Index (WMI) for Adolescents. Each item identifies a need and the sum of the WMI stratifies respondents into categories of risk.

Data source

The WMI items for adolescents are included in an extensive health assessment called HowsYourHealth.org. HowsYourHealth.org provides an immediate and standard source of information about a respondent's function, diagnosis, symptoms, health habits, preventive needs, capacity to self-manage chronic conditions, and experiences of care (Nelson et al., 2015; Wasson et al., 2011). Adolescent users of the Web site are asked about 30 items with primary emphasis on core measures that matter identified by adolescents: pain, emotion, physical fitness, schoolwork, social support, family communication, health habits, and problem-solving (Wasson et al., 1994; Wasson et al., 1995).

Of 9804 adolescent respondents, about 5% were in a school setting, 30% were associated with clinical settings, and the remainder accessed the Web site in the community. Fifty-three additional adolescents with health concerns listed steps to improve their confidence for managing and controlling most of their health problems.

Analysis

All data are cross-sectional. Because cause and effect cannot be established with such data, only associations are illustrated and described.

RESULTS

The Adolescent WMI for public health and community use

Table 1 sorts adolescent responses by their WMI scores using “Insufficient problem-solving” in the calculation. The table demonstrates that respondents with a WMI of 1 and higher have many disadvantages compared with the 70% of respondents with a WMI of zero. The table also illustrates how the WMI can be a convenient proxy for multiple measures of clinical problems, symptoms, adverse situations, and concerns. Although adolescents with a WMI of zero have many advantages relative to peers who have a higher WMI, some with a score of zero will have situational problems, concerns, and symptoms. However, the overall burden is much lower.

Table 1. - Self-Report From Adolescents Illustrating How an Adolescent What Matters Index Is an Expedient Proxy for What Else Might Matter
Categories WMI = 0 (6880) WMI = 1 (1975) WMI = 2+ (949)
What Matters Index items triggered
Poor problem-solving 0 16 61
Bothersome emotional problems 0 48 90
Bothersome pain 0 38 76
Demographics
% Female 53 69 74
% Age (14-17), y 83 85 85
Any self-reported diagnosis
Respiratory 16 22 28
Other 7 12 23
Using chronic medication(s) 19 29 39
Situational
Family dysfunction 30 42 57
Inadequate health care experience 16 29 45
Inadequate social support 9 21 38
Bothersome attention deficit 8 30 64
Concerns about
Exercise needs 26 38 43
Nutrition needs 20 35 45
Mental health and suicide 10 33 58
Sex and birth control 9 15 25
Alcohol and drugs 6 12 25
Violence and abuse 6 13 22
STDs 7 9 16
Common clinical symptoms
Headaches 9 36 61
Fatigue 9 33 61
Menstrual related 7 18 32
Skin 7 15 28
Gastrointestinal 4 21 41
Respiratory 3 11 21
Chest pain 2 8 26
Abbreviations: STDs, sexually transmitted diseases; WMI, What Matters Index.

Although cause and effect cannot be assumed, the adverse associations with higher WMI score are reflected in adolescents' personal behaviors and outcomes (Table 2). Bed-days are noteworthy because they detract from time in school and social interactions and often greatly inconvenience parents. Figure 2 illustrates the statistical strength of the association between the Adolescent WMI and any days spent at home in bed during the past 3 months.

Table 2. - Association of an Adolescent What Matters Index With Personal Behaviors and Outcomes
Categories WMI = 0 (6880) WMI = 1 (1975) WMI = 2+ (949)
What Matters Index items triggered
Poor problem-solving 0 16 61
Bothersome emotional problems 0 48 90
Bothersome pain 0 38 76
Personal behaviors
No regular exercise 15 30 36
>2-h screen time each day 14 18 26
Poor personal preventive behaviors 6 15 34
Engaging in risky behaviors 4 9 22
Outcomes
Any bed sick-days in past 3 mo 20 31 46
Self-assessed obesity 13 18 27
Poor school performance 6 17 36
Poor physical condition 6 13 24
Abbreviation: WMI, What Matters Index.

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Figure 2.:
An illustration of the strength of association between an Adolescent What Matters Index (WMI) and any days spend in bed for illness during the previous 3 months. WMI indicates What Matters Index.

Adolescents' communication patterns for addressing problems that matter

When adolescents identified significant health and social problems, automated algorithms directed them to indicate whether they had talked to anyone, to whom they talked (family, friend, doctor, teacher, other), and to indicate their perception of communication effectiveness. Table 3 lists these important problem domains and the people most often consulted by the adolescents for each domain.

Table 3. - Important Problem Domains Identified by Adolescents and Health Professionals and the Most Common Sources Adolescents Sought for Information
Problem Domains Percentage of Adolescents Impacted Percentage of People Most Commonly Consulted
Family communication 35 Friends: 72; family: 28
Emotions 18 Friends: 76; family: 46
Pain 15 Family: 82; MD: 55
Social support 14 Friends: 64; family: 52
School work 12 Family: 65; teachers: 60
Risky health habits 11 Friends: 76; family: 52
Abbreviation: MD, Medical Doctor, Health Professional.

Peers are the primary sources for information for 4 of the 6 listed domains. Physicians were only commonly consulted for pain.

Information value to adolescents can be calculated as a function of the frequency of their consultations and its quality. The product of the frequency and a positive assessment of information quality by the adolescents are illustrated in Figure 3. The findings indicate that regardless of the domain, adolescents who regard themselves as insufficient problem-solvers are likely to have less useful information than adolescents who have sufficient problem-solving capacity. However, Figure 3 also illustrates that most adolescents with better problem-solving capacities are still not obtaining helpful information.

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Figure 3.:
The effectiveness of information acquisition strategies pursued by adolescents based on their self-reported problem-solving capacities.

Health confidence

Although the broad construct of “problem-solving” is applicable to all adolescents, for some who have chronic conditions and frequent clinical encounters, the construct of “health confidence” can be helpful for guiding health-related behavior changes. For example, among 53 adolescents who responded to the automated query about what they think they would need to attain greater health confidence, three-quarters identified personal changes such as engaging in wellness activities and seeking better information.

DISCUSSION

The hypothesis that the Adult WMI can be a model for examining the value of a similar tool for adolescents is supported by these analyses when value is defined by quality divided by cost. In terms of quality, both the Adult and Adolescent WMIs greatly simplify the assessment of what matters to guide care, serve as proxies for many other measures that matter, and stratify populations based on need. When a WMI is completed before a planned visit to a health professional, health professionals can identify which patients may benefit from a longer interaction and more resources. Thereby, unwanted professional variance in interpretation of needs is reduced and more reliable planning is facilitated.

In terms of cost as a determinant of value, neither the Adolescent WMI nor the Adult WMI has a direct cost and the few items require little effort to complete.

When adolescents have problems, they are very likely to reach out to friends (presumably the Internet has accelerated adolescent contact with distant acquaintances as well). The brevity of the WMIs enables them to be easily accessible on ubiquitous smartphones. Based on the pattern of responses, users receive immediate links for relevant information, additional assessment, and helpful tools. From a public health perspective, rather than being overly dependent on friends and online acquaintances, an automated WMI can target trustworthy information and tools to increase adolescent knowledge, improve behaviors, and self-management of health problems.

In summary, there is a strong case for the value of an Adolescent WMI.

REFERENCES

https://howsyourhealth.org/. Your personal guide for the best health and medical care. Retrieved from https://howsyourhealth.org/. Accessed January 18, 2023.
Nelson E. C., Eftimovska E., Lind C., Hager A., Wasson J. H., Lindblad S. (2015). Patient reported outcome measures in practice. BMJ, 350, g7818.
Wasson J. H. (2021). Standardized assessment, information, and networking technologies (SAINTs): Lessons from three decades of development and testing. Quality of Life Research, 30(11), 3145–3155.
Wasson J. H., Benjamin R., Johnson D., Moore L. G., Mackenzie T. (2011). Patients use the internet to enter the medical home. The Journal of Ambulatory Care Management, 34(1), 38–46.
Wasson J. H., Ho L., Soloway L., Moore L. G. (2018). Validation of the What Matters Index: A brief, patient-reported index that guides care for chronic conditions and can substitute for computer-generated risk models. PLoS One, 13(2), e0192475.
Wasson J. H., Kairys S. W., Nelson E. C., Kalishman N., Baribeau P. (1994). A short survey for assessing health and social problems of adolescents. Dartmouth Primary Care Cooperative Information Project (The COOP). Journal of Family Practice, 38(5), 489–494.
Wasson J. H., Kairys S. W., Nelson E. C., Kalishman N., Baribeau P., Wasson E. (1995). Adolescent health and social problems. A method for detection and early management. The Dartmouth Primary Care Cooperative Information Project (COOP). Archives of Family Medicine, 4(1), 51–56. doi:10.1001/archfami.4.1.51
Wasson J. H., Soloway L., Moore L. G., Labrec P., Ho L. (2018). Development of a care guidance index based on what matters to patients. Quality of Life Research, 27(1), 51–58. doi:10.1007/s11136-017-1573-x
Keywords:

adolescent health; public health adolescents; What Matters Index

© 2023 The Authors. Published by Wolters Kluwer Health, Inc.