The Effect of Labeling on Perceived Ability to Recover from Acute Illnesses and Injuries

Since the early 1970s, concerns have been raised about the adverse consequences associated with diagnostic labeling. Some of the earliest research examined parental responses to childhood cardiac diagnoses and misdiagnoses.^1,2 Subsequent studies extended those findings to the results of newborn screening tests,^3,4 preschool developmental screening,⁵ and sickle cell disease screening.⁶ The greatest body of published research in this regard involves the diagnosis of hypertension. Haynes and colleagues⁷ first observed that Canadian steel mill workers found to have hypertension through workplace screening had increased absenteeism from work that persisted for at least 4 years, and Johnston and coworkers⁸ found that this diagnosis was associated with lower mean annual incomes at 5 years postscreen. Subsequently, researchers have consistently found some patients, after being told that their blood pressures are too high, perceive their overall health to be worse and report more depressive symptoms and lower quality of life.⁹ In 1 study, even close relatives of patients with hypertension seemed to be adversely affected.¹⁰

To our knowledge, no one has looked at the effect of the diagnosis of hypertension on patients’ perceptions of their ability to recover from completely unrelated illnesses, such as infections and injuries. Such information may be important, particularly if labeling may affect health care utilization.

Methods

We recruited 22 patients waiting to see family practice residents and faculty in a family medicine clinic at an academic medical center during the summer of 1995. To participate, patients had to be aged 21 years or older and not mentally retarded, severely depressed, schizophrenic, demented, or acutely ill. We constructed the sample to include 11 patients with diagnosed hypertension within the past 5 years and 11 with no diagnosis of hypertension.

After signing informed consent, each participant was asked questions designed to elicit demographic information, recent experience with upper respiratory tract infection (URI), urinary tract infection (UTI), and ankle sprain; self-rated overall health using a single COOP chart; and estimates of how long it would take for them to recover from a URI, a UTI, and an ankle sprain now and 5 years ago. These conditions were chosen because they have no known pathophysiologic relationship to hypertension and represent 3 different kinds of acute illness: a self-limited viral infection, a bacterial infection that is usually treated with antibiotics, and an acute musculoskeletal injury. Medical records were reviewed for possible confounders, such as cigarette smoking, chronic lung disease, asthma, allergic rhinitis, diabetes, congestive heart failure, and payer source.

We entered the data into a standard statistical software program (Statistix, Analytical Software, Tallahassee, Fla) and used the chi-square test to make comparisons between the hypertensive and nonhypertensive groups with respect to age, sex, race, marital status, educational attainment, and self-rated health. Mean estimated times required to recover from each of the 3 acute conditions, both current and past, were compared using Student t tests.

We considered 6 separate linear regression models with estimated time to resolution for each of the 3 conditions at present and in the past as the dependent variables. Age, sex, race, education, and diagnosis group were initially entered into each model and removed 1 at a time until the best model was obtained in each case. We defined the best model as the one associated with an overall P value <.05 that maximized R2 while minimizing the number of variables with individual P values >.05.

Results

The characteristics of patients in each of the 2 groups are shown in Table 1. Patients with hypertension were likely to be older, male, African American, and less educated. However, none of these differences was statistically significant. The control group of nonhypertensives had more comorbidities, were more likely to smoke cigarettes, and had worse perceived health (also nonsignificant). There was no difference in payer source. In the control group, 5 of 11 reported having a URI within the past 6 months, 1 had experienced a UTI, and 2 had ankle sprains. In the hypertensive group, 3 of 11 reported a URI, none had a UTI, and 1 had a sprained ankle.

Table 2 shows the estimates of time to resolution of a URI, a UTI, and an ankle sprain both now and 5 years ago. Patients with hypertension estimated that it took them almost twice as long, on average, to recover from a URI both in the present and in the past. This was a significant difference. They also seemed to believe that it would take them longer to heal an ankle sprain. This, however, did not reach statistical significance, primarily because of the substantial variability of the estimates. There appeared to be no difference at all and very little variability in the perceived times for recovery from a UTI.

Table 3 shows the linear regression models for URI, current and past. Both URI models included diagnosis group as a significant predictor of estimated recovery time. No satisfactory regression models could be constructed for present or past UTI, or for past ankle sprain. The present ankle sprain model did not include hypertensive status as a predictor.

We constructed a model for estimated time to recover from a URI in the present as a function of the demographic variables (age, sex, race, and education), estimated recovery time for URI in the past, UTI in the past and present, and ankle sprain in the past and present . A model that included past recovery from URI (P <.001), present (P=.004) and past (P <.001) recovery from ankle sprain, and hypertension diagnosis (P=.008) explained 93% of the variability.

Discussion

Despite the small sample size, the results of our study are striking. Not only did patients with hypertension estimate that it took them twice as long to recover from a URI now, but they believed that it had taken them twice as long to recover even before receiving the diagnosis. These findings seem consistent with previous research on the adverse effects of labeling. Alternative explanations for our results include an unknown biological association between hypertension and the ability to fight viral infections, and other unknown confounders. For example, patients with hypertension may be more attuned to the medical system and their own health status and therefore more accurate in their estimates of recovery times.

It is more difficult to interpret the data about ankle sprains. The standard deviations of the estimates were large, and age, race, and education were significant predictors for ankle sprain in the present. Study participants were less likely to have experienced an ankle sprain than a URI, and ankle sprain severity is more likely to range from mild to severe, making estimation of recovery time more difficult.

There was no effect of hypertension status on perceived time to recover from a UTI. Estimates of time to recovery from UTI were not correlated with estimated recovery times for either of the other 2 conditions. This may be because UTIs are believed to be predictably cured by antibiotics regardless of a person’s general medical condition.

Although there were baseline differences between the 2 groups, none was statistically significant. Controlling for these differences did not eliminate the significant effect of a diagnosis of hypertension on a patient’s perceived time to recovery from a URI. We conclude that being given the diagnosis of hypertension may change patients’ perceptions of physical resiliency.

Although this apparent adverse effect of labeling is troubling, we have no direct evidence that it has an adverse impact on health or health care utilization. If, however, patients with hypertension believe that it will take them twice as long to recover from a URI, they may be more likely to seek medical attention or use medications for URI episodes. Consistent with the findings of Haynes and colleagues,⁷ they may stay out of work longer.

Is there a way to diagnose hypertension and lower blood pressure without stigmatizing the patient? Do the potential benefits of giving a diagnosis of hypertension outweigh the hazards? We suggest further research to confirm our findings and to explore these questions.

Since the early 1970s, concerns have been raised about the adverse consequences associated with diagnostic labeling. Some of the earliest research examined parental responses to childhood cardiac diagnoses and misdiagnoses.^1,2 Subsequent studies extended those findings to the results of newborn screening tests,^3,4 preschool developmental screening,⁵ and sickle cell disease screening.⁶ The greatest body of published research in this regard involves the diagnosis of hypertension. Haynes and colleagues⁷ first observed that Canadian steel mill workers found to have hypertension through workplace screening had increased absenteeism from work that persisted for at least 4 years, and Johnston and coworkers⁸ found that this diagnosis was associated with lower mean annual incomes at 5 years postscreen. Subsequently, researchers have consistently found some patients, after being told that their blood pressures are too high, perceive their overall health to be worse and report more depressive symptoms and lower quality of life.⁹ In 1 study, even close relatives of patients with hypertension seemed to be adversely affected.¹⁰

To our knowledge, no one has looked at the effect of the diagnosis of hypertension on patients’ perceptions of their ability to recover from completely unrelated illnesses, such as infections and injuries. Such information may be important, particularly if labeling may affect health care utilization.

Methods

We recruited 22 patients waiting to see family practice residents and faculty in a family medicine clinic at an academic medical center during the summer of 1995. To participate, patients had to be aged 21 years or older and not mentally retarded, severely depressed, schizophrenic, demented, or acutely ill. We constructed the sample to include 11 patients with diagnosed hypertension within the past 5 years and 11 with no diagnosis of hypertension.

After signing informed consent, each participant was asked questions designed to elicit demographic information, recent experience with upper respiratory tract infection (URI), urinary tract infection (UTI), and ankle sprain; self-rated overall health using a single COOP chart; and estimates of how long it would take for them to recover from a URI, a UTI, and an ankle sprain now and 5 years ago. These conditions were chosen because they have no known pathophysiologic relationship to hypertension and represent 3 different kinds of acute illness: a self-limited viral infection, a bacterial infection that is usually treated with antibiotics, and an acute musculoskeletal injury. Medical records were reviewed for possible confounders, such as cigarette smoking, chronic lung disease, asthma, allergic rhinitis, diabetes, congestive heart failure, and payer source.

We entered the data into a standard statistical software program (Statistix, Analytical Software, Tallahassee, Fla) and used the chi-square test to make comparisons between the hypertensive and nonhypertensive groups with respect to age, sex, race, marital status, educational attainment, and self-rated health. Mean estimated times required to recover from each of the 3 acute conditions, both current and past, were compared using Student t tests.

We considered 6 separate linear regression models with estimated time to resolution for each of the 3 conditions at present and in the past as the dependent variables. Age, sex, race, education, and diagnosis group were initially entered into each model and removed 1 at a time until the best model was obtained in each case. We defined the best model as the one associated with an overall P value <.05 that maximized R2 while minimizing the number of variables with individual P values >.05.

Results

The characteristics of patients in each of the 2 groups are shown in Table 1. Patients with hypertension were likely to be older, male, African American, and less educated. However, none of these differences was statistically significant. The control group of nonhypertensives had more comorbidities, were more likely to smoke cigarettes, and had worse perceived health (also nonsignificant). There was no difference in payer source. In the control group, 5 of 11 reported having a URI within the past 6 months, 1 had experienced a UTI, and 2 had ankle sprains. In the hypertensive group, 3 of 11 reported a URI, none had a UTI, and 1 had a sprained ankle.

Table 2 shows the estimates of time to resolution of a URI, a UTI, and an ankle sprain both now and 5 years ago. Patients with hypertension estimated that it took them almost twice as long, on average, to recover from a URI both in the present and in the past. This was a significant difference. They also seemed to believe that it would take them longer to heal an ankle sprain. This, however, did not reach statistical significance, primarily because of the substantial variability of the estimates. There appeared to be no difference at all and very little variability in the perceived times for recovery from a UTI.

Table 3 shows the linear regression models for URI, current and past. Both URI models included diagnosis group as a significant predictor of estimated recovery time. No satisfactory regression models could be constructed for present or past UTI, or for past ankle sprain. The present ankle sprain model did not include hypertensive status as a predictor.

We constructed a model for estimated time to recover from a URI in the present as a function of the demographic variables (age, sex, race, and education), estimated recovery time for URI in the past, UTI in the past and present, and ankle sprain in the past and present . A model that included past recovery from URI (P <.001), present (P=.004) and past (P <.001) recovery from ankle sprain, and hypertension diagnosis (P=.008) explained 93% of the variability.

Discussion

Despite the small sample size, the results of our study are striking. Not only did patients with hypertension estimate that it took them twice as long to recover from a URI now, but they believed that it had taken them twice as long to recover even before receiving the diagnosis. These findings seem consistent with previous research on the adverse effects of labeling. Alternative explanations for our results include an unknown biological association between hypertension and the ability to fight viral infections, and other unknown confounders. For example, patients with hypertension may be more attuned to the medical system and their own health status and therefore more accurate in their estimates of recovery times.

It is more difficult to interpret the data about ankle sprains. The standard deviations of the estimates were large, and age, race, and education were significant predictors for ankle sprain in the present. Study participants were less likely to have experienced an ankle sprain than a URI, and ankle sprain severity is more likely to range from mild to severe, making estimation of recovery time more difficult.

There was no effect of hypertension status on perceived time to recover from a UTI. Estimates of time to recovery from UTI were not correlated with estimated recovery times for either of the other 2 conditions. This may be because UTIs are believed to be predictably cured by antibiotics regardless of a person’s general medical condition.

Although there were baseline differences between the 2 groups, none was statistically significant. Controlling for these differences did not eliminate the significant effect of a diagnosis of hypertension on a patient’s perceived time to recovery from a URI. We conclude that being given the diagnosis of hypertension may change patients’ perceptions of physical resiliency.

Although this apparent adverse effect of labeling is troubling, we have no direct evidence that it has an adverse impact on health or health care utilization. If, however, patients with hypertension believe that it will take them twice as long to recover from a URI, they may be more likely to seek medical attention or use medications for URI episodes. Consistent with the findings of Haynes and colleagues,⁷ they may stay out of work longer.

Is there a way to diagnose hypertension and lower blood pressure without stigmatizing the patient? Do the potential benefits of giving a diagnosis of hypertension outweigh the hazards? We suggest further research to confirm our findings and to explore these questions.

Since the early 1970s, concerns have been raised about the adverse consequences associated with diagnostic labeling. Some of the earliest research examined parental responses to childhood cardiac diagnoses and misdiagnoses.^1,2 Subsequent studies extended those findings to the results of newborn screening tests,^3,4 preschool developmental screening,⁵ and sickle cell disease screening.⁶ The greatest body of published research in this regard involves the diagnosis of hypertension. Haynes and colleagues⁷ first observed that Canadian steel mill workers found to have hypertension through workplace screening had increased absenteeism from work that persisted for at least 4 years, and Johnston and coworkers⁸ found that this diagnosis was associated with lower mean annual incomes at 5 years postscreen. Subsequently, researchers have consistently found some patients, after being told that their blood pressures are too high, perceive their overall health to be worse and report more depressive symptoms and lower quality of life.⁹ In 1 study, even close relatives of patients with hypertension seemed to be adversely affected.¹⁰

To our knowledge, no one has looked at the effect of the diagnosis of hypertension on patients’ perceptions of their ability to recover from completely unrelated illnesses, such as infections and injuries. Such information may be important, particularly if labeling may affect health care utilization.

Methods

We recruited 22 patients waiting to see family practice residents and faculty in a family medicine clinic at an academic medical center during the summer of 1995. To participate, patients had to be aged 21 years or older and not mentally retarded, severely depressed, schizophrenic, demented, or acutely ill. We constructed the sample to include 11 patients with diagnosed hypertension within the past 5 years and 11 with no diagnosis of hypertension.

After signing informed consent, each participant was asked questions designed to elicit demographic information, recent experience with upper respiratory tract infection (URI), urinary tract infection (UTI), and ankle sprain; self-rated overall health using a single COOP chart; and estimates of how long it would take for them to recover from a URI, a UTI, and an ankle sprain now and 5 years ago. These conditions were chosen because they have no known pathophysiologic relationship to hypertension and represent 3 different kinds of acute illness: a self-limited viral infection, a bacterial infection that is usually treated with antibiotics, and an acute musculoskeletal injury. Medical records were reviewed for possible confounders, such as cigarette smoking, chronic lung disease, asthma, allergic rhinitis, diabetes, congestive heart failure, and payer source.

We entered the data into a standard statistical software program (Statistix, Analytical Software, Tallahassee, Fla) and used the chi-square test to make comparisons between the hypertensive and nonhypertensive groups with respect to age, sex, race, marital status, educational attainment, and self-rated health. Mean estimated times required to recover from each of the 3 acute conditions, both current and past, were compared using Student t tests.

We considered 6 separate linear regression models with estimated time to resolution for each of the 3 conditions at present and in the past as the dependent variables. Age, sex, race, education, and diagnosis group were initially entered into each model and removed 1 at a time until the best model was obtained in each case. We defined the best model as the one associated with an overall P value <.05 that maximized R2 while minimizing the number of variables with individual P values >.05.

Results

The characteristics of patients in each of the 2 groups are shown in Table 1. Patients with hypertension were likely to be older, male, African American, and less educated. However, none of these differences was statistically significant. The control group of nonhypertensives had more comorbidities, were more likely to smoke cigarettes, and had worse perceived health (also nonsignificant). There was no difference in payer source. In the control group, 5 of 11 reported having a URI within the past 6 months, 1 had experienced a UTI, and 2 had ankle sprains. In the hypertensive group, 3 of 11 reported a URI, none had a UTI, and 1 had a sprained ankle.

Table 2 shows the estimates of time to resolution of a URI, a UTI, and an ankle sprain both now and 5 years ago. Patients with hypertension estimated that it took them almost twice as long, on average, to recover from a URI both in the present and in the past. This was a significant difference. They also seemed to believe that it would take them longer to heal an ankle sprain. This, however, did not reach statistical significance, primarily because of the substantial variability of the estimates. There appeared to be no difference at all and very little variability in the perceived times for recovery from a UTI.

Table 3 shows the linear regression models for URI, current and past. Both URI models included diagnosis group as a significant predictor of estimated recovery time. No satisfactory regression models could be constructed for present or past UTI, or for past ankle sprain. The present ankle sprain model did not include hypertensive status as a predictor.

We constructed a model for estimated time to recover from a URI in the present as a function of the demographic variables (age, sex, race, and education), estimated recovery time for URI in the past, UTI in the past and present, and ankle sprain in the past and present . A model that included past recovery from URI (P <.001), present (P=.004) and past (P <.001) recovery from ankle sprain, and hypertension diagnosis (P=.008) explained 93% of the variability.

Discussion

Despite the small sample size, the results of our study are striking. Not only did patients with hypertension estimate that it took them twice as long to recover from a URI now, but they believed that it had taken them twice as long to recover even before receiving the diagnosis. These findings seem consistent with previous research on the adverse effects of labeling. Alternative explanations for our results include an unknown biological association between hypertension and the ability to fight viral infections, and other unknown confounders. For example, patients with hypertension may be more attuned to the medical system and their own health status and therefore more accurate in their estimates of recovery times.

It is more difficult to interpret the data about ankle sprains. The standard deviations of the estimates were large, and age, race, and education were significant predictors for ankle sprain in the present. Study participants were less likely to have experienced an ankle sprain than a URI, and ankle sprain severity is more likely to range from mild to severe, making estimation of recovery time more difficult.

There was no effect of hypertension status on perceived time to recover from a UTI. Estimates of time to recovery from UTI were not correlated with estimated recovery times for either of the other 2 conditions. This may be because UTIs are believed to be predictably cured by antibiotics regardless of a person’s general medical condition.

Although there were baseline differences between the 2 groups, none was statistically significant. Controlling for these differences did not eliminate the significant effect of a diagnosis of hypertension on a patient’s perceived time to recovery from a URI. We conclude that being given the diagnosis of hypertension may change patients’ perceptions of physical resiliency.

Although this apparent adverse effect of labeling is troubling, we have no direct evidence that it has an adverse impact on health or health care utilization. If, however, patients with hypertension believe that it will take them twice as long to recover from a URI, they may be more likely to seek medical attention or use medications for URI episodes. Consistent with the findings of Haynes and colleagues,⁷ they may stay out of work longer.

Is there a way to diagnose hypertension and lower blood pressure without stigmatizing the patient? Do the potential benefits of giving a diagnosis of hypertension outweigh the hazards? We suggest further research to confirm our findings and to explore these questions.