Σεξουαλικά μεταδιδόμενες λοιμώξεις (Σ.Μ.Λ.) και δημόσια υγεία: ποιότητα ζωής, ψυχολογική επιβάρυνση, κόστος - δαπάνες

Abstract

Introduction: Health-Related Quality of Life (HRQL) measurement tools are gaining importance for assessment, within the framework of medical intervention. These tools have contributed to a great extent, especially in dermatology, in areas where other indicators, such as mortality, are not applicable. Sexually transmitted infections (STIs) disturb the balance in patients’ lives and they usually entail social stigmatization and feelings of guilt. Furthermore, the psychological burden of patients suffering from genital warts (condylomata accumminata) has been documented in various studies, with patients undergoing tremendous stress due to the potential impact of the disease on their social relationships, stigmatization because of the venereal disease, the uncertain outcome of treatment (either successful or not), as well as the time needed for them to be cured. Patients are also concerned about the consequences of the disease on their love life and sexual life, as well as transmitting it to others. Finally, as for any case of disease, determining the cost of treatment is a basic tool for managing and allocating available resources accordingly. Aim: Measurement of the HRQL and psychiatric morbidity in patients with genital warts, at the time of diagnosis and after one month. Also, research on patients’ potential changes in behavior, as regards their sexual practices and quality of sexual life in general. Finally, estimation of the cost per episode of care for warts. Material – Method: The Short Form 36 Health Survey (SF-36), a generic measurement tool for assessing HRQL, was used to measure the HRQL of patients suffering from condylomata accumminata. The patients (cases) attended the (Venereal and Skin Diseases) ―A. Syggros Hospital‖ and they were diagnosed with genital warts for the first time. Measurement of the HRQL was realized twice: upon diagnosis (t=0) and a month after (t=1). The group of healthy subjects (controls) comprised individuals attending the same hospital in order to obtain a health certificate. Psychiatric morbidity was estimated using the Clinical Interview Schedule – Revised (CIS-R). Changes in sexual behaviors were examined according to questions posed during similar studies on other STIs and, finally, the cost per episode of care was 190 determined by taking into account the direct costs and productivity losses per course of treatment. To compare results between cases and controls, t-tests and chi-square tests were conducted for continuous and categorical variables respectively; for longitudinal comparisons, either t-tests or non-parametric tests for paired proportions of data (Mc-Nemar) were used respectively. For correlations between putative positive qualifiers upon diagnosis and mental health outcomes after a month, models of logistic or linear regression were employed (for categorical and continuous measurements of mental health outcomes respectively), initially targeting gender and age; additional putative confounding factors were taken into consideration afterwards (multi-factorial models). Results: 90 cases diagnosed with genital warts and 53 controls attending the hospital to obtain a certificate of health participated in the research. Patients were mostly men (74%) at an average age of 26.4 years and did not differ from controls in any socio-demographic sense. The HRQL, measured using the SF-36 Health Survey generic tool, does not seem to be affected in patients with warts. No statistically significant difference was shown between cases and controls in the areas examined; a minor improvement (statistically significant difference) was observed in patients between the two subsequent measurements (t=0 and t=1), on two aspects of the Health Survey – vitality and mental health. This improvement could be attributed to the acquired familiarity with the disease. Finally, a small-scale aggravation (statistically significant difference) was observed with regard to social functioning. The psychological burden was measured using a self-report tool, the Clinical Interview Schedule – Revised (CIS-R). A statistically significant difference was evidenced in the psychiatric outcomes examined [overall psychological burden indicator (CIS-R score), suicidal tendencies, ICD-10 diagnoses] between t=0 cases and controls; those results applied mainly to women, while men presented the same differences as women, without statistically significant values. At the time of diagnosis, mental health was more deeply affected in women rather than men suffering from warts, compared to controls. After a month and during treatment, a statistically significant improvement in mental health was evidenced in patients. 191 The longitudinal study showed a statistically significant improvement in patients’ mental health (both men and women), as measured by their overall CIS-R score. The one-moth interval seemed to positively affect patients’ psychological state in the present study. Afterwards, putative positive qualifiers leading to recovery from psychiatric symptomatology as well as improvement in patients’ mental health with genital warts were sought. In both cases, gender, overall aggravation indicator and a low support framework constitute putative positive qualifiers. More specifically, women stood better chances of recovery and improvement compared to men. Additionally, patients with reduced functionality due to a substantial mental health burden showed more significant recovery and improvement compared to patients with less severe psychiatric symptoms. Finally, patients with a low support framework and, consequently, low sociability, stood better chances of psychiatric recovery and improvement in mental health than patients with a higher level of social support. It was also noted that stressful disorders at the time of diagnosis are related to better psychological outcomes, rather than depression, while possible improvements in mental health after the diagnosis do not seem to correlate with the initial severity of the STI. At the same time, patients whose clinical image of warts showed signs of improvement were more likely to show improvement in mental health as well, compared to those who showed stability or aggravation; no correlation was evidenced with the initial severity of the STI, confirming the correlation between improvement in mental health and recovery from warts. As far as patients’ sexual life is concerned, it was shown that the majority of patients increased the frequency of condom use after being diagnosed with warts. It seems that knowledge of the disease is a crucial factor in changes of behavior and the use of condom. This result comes in accordance with other studies on behaviors related to health, such as smoking. A statistically significant correlation was also evident between changes in the quality of sexual life and the level of education. It seems that in patients of a lower education level, the quality of sexual life is less affected. Concerning costs and expenses related to the treatment of warts, it was found that the average cost of treatment per episode and per patient was €62.88. The cost 192 was much higher in the case of imiquimod cream (€107.20), followed by cryotherapy (€48.68) and podophyllotoxin solution (€11.96). In total, the average cost per episode of care (direct health cost and productivity loss) was €206.21 per patient - €216.99 for imicuimode treatment, €208.94 for cryotherapy and €140.87 for podophyllotoxin treatment. Conclusions: Based on the aforementioned results, the creation and application of a specific HRQL measurement tool in everyday clinical procedures could be proposed for assessing patients with condylomata accumminata. Moreover, measuring psychiatric morbidity is possible with the use of a self-report tool in everyday clinical procedures of STI clinics. Depending on the patient’s individual score, the necessity for psychological intervention or referral to a psychiatrist – in the case of patients with high scores – will be documented accordingly. Finally, the cost of treatment for warts should be a factor during the decision-making process about the proposed course of treatment. As a result, the desirable clinical outcome can be combined with a more effective management and allocationof resources for the treatment of warts.