ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Efforts to improve primary care depression treatment should penetrate to vulnerable uninsured populations.Objective.To assess a primary care intervention’s impact on treatment and quality-of-life outcomes in uninsured and insured depressed patients during the acute treatment phase.Research Design.Twelve community primary care practices were randomized to ‘enhanced’ (intervention) and usual care conditions. Physicians, nurses and administrative staff in enhanced care practices received training to improve detection and management of depression.Subjects.In 1996 to 1997, 383 nonelderly depressed patients who were either uninsured or covered by private insurance/Medicaid were enrolled; 343 (89.6%) completed six-month follow-up.Measures.Adequate pharmacotherapy (≥3 months of antidepressants at therapeutic doses); adequate psychotherapy (≥8 counseling visits); improvement in mental-health-related-quality-of-life (MHQOL), assessed by Mental Component Summary scale for SF-36.Results.Multivariate results showed that 54.6% of uninsured enhanced care (UEC) patients received adequate pharmacotherapy, compared with 14.3% of uninsured usual care (UUC) patients (P= 0.0005); however, receipt of adequate psychotherapy was comparable between these two groups (18.2% UEC, 11.9% UUC;P= 0.42). Intervention effects on insured patients’ treatment were modest to minimal. Among usual care patients, the insured had 5.4 points greater improvement in MHQOL at 6 months than the uninsured (12.4 points insured, 7.0 points uninsured;P= 0.02); however, among patients receiving the intervention, the insured and uninsured had comparable MHQOL improvement (12.3 points insured, 11.6 points uninsured;P= 0.76).Conclusions.The intervention improved antidepressant treatment rates in uninsured patients and helped resolve quality-of-life outcome disparities observed between insured and uninsured patients receiving usual care.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Objectives.This paper presents a profile of the use of antipsychotic medications in the treatment of schizophrenia in a national health system.Methods.Prescription drug records written for antipsychotic medications between June 1999 and September 1999 were collected for patients diagnosed with schizophrenia in the Department of Veteran Affairs (VA). Indicators were constructed describing whether patients received multiple antipsychotic medications and whether the total weekly dose was outside of the range specified in the treatment recommendations developed by the schizophrenia Patient Outcomes Research Team (PORT). Generalized estimation equations were used to identify patient and facility characteristics that are associated with adherence to PORT recommendations.Results.Of the 34,925 patients in the final sample, 2,383 (6.8%) received prescriptions for more than one antipsychotic (polypharmacy). A higher number of patients (4,554 or 13.0%) were dosed above the PORT recommendations on an antipsychotic medication and even more (8,148 or 23.3%) were dosed below the recommended PORT dosage. Older patients, minorities, and those with comorbid depression or substance abuse were generally less likely to receive multiple antipsychotics or be dosed above PORT recommendations. Neither academic emphasis (the percentage of the mental health budget spent on research and education) nor fiscal stress was significantly associated with adherence to recommendations.Conclusions.In the nation’s largest mental health system, a relatively small number of patients were prescribed multiple antipsychotic medications, but more than a third were dosed outside of the PORT recommended range.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Depression is common in primary care, but rates of adequate care are low. Little is known about the role of patient treatment preferences in encouraging entry into care.Objectives.To examine whether a primary care based depression quality improvement (QI) intervention designed to accommodate patient and provider treatment choice increases the likelihood that patients enter depression treatment and receive preferred treatment.Methods.In 46 primary care clinics, patients with current depressive symptoms and either lifetime or current depressive disorder were identified through screening. Treatment preferences, patient characteristics, and use of depression treatments were assessed at baseline and 6 months by patient self-report. Matched clinics were randomized to usual care (UC) or 1 of 2 QI interventions. Data were analyzed using logistic regression models.Results.For patients not in care at baseline, the QI interventions increased rates of entry into depression treatment compared with usual care (adjusted percentage: 50.0% ± 5.3 and 33.0% ± 4.9 for interventions vs. 15.9% ± 3.6 for usual care; F = 12.973,P<0.0001). Patients in intervention clinics were more likely to get treatments they preferred compared with those in usual care (adjusted percentage: 54.2% ± 3.3 and 50.7% ± 3.1 for interventions vs. 40.5% ± 3.1 for usual care; F = 6.034,P<0.003); however, in all clinics less than half of patients preferring counseling reported receiving it.Conclusions.QI interventions that support patient choice can improve the likelihood of patients receiving preferred treatments. Patient treatment preference appears to be related to likelihood of entering depression treatment, and patients preferring counseling may require additional interventions to enhance entry into treatment.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Objectives.To characterize the tests ordered for surveillance of breast cancer recurrence in the 4 years after breast cancer diagnosis by surgeons, medical oncologists, and radiation oncologists.Research Design.303 stage I or II breast cancer patients age 55-years or older and diagnosed at 1 of 5 Boston hospitals. Patient interviews and medical record abstracts provided the data to characterize patient demographics, the breast cancer stage and its primary therapy, and the surveillance procedures ordered.Results.279 of the 303 women had some surveillance testing. Among those who received some surveillance, a mean of 22.0 tests were ordered, most by their medical oncologists (mean = 14.4), followed by their surgeons (mean = 9.7) and their radiation oncologists (mean = 5.7). The most common test was a mammogram (mean = 3.9). Women ages 75 to 90 years old were at higher risk for failure to complete four consecutive years of surveillance and for receipt of less than guideline surveillance. Younger women, women treated at a breast cancer center with a unified patient chart, and women who worked full or part time were at lower risk for failure to complete 4 years of surveillance.Conclusion.Most women in this cohort received some surveillance after completing primary therapy for breast cancer. Although no woman’s surveillance corresponded exactly to existing guidelines, the oldest women were least likely to receive guideline surveillance. Surveillance after breast cancer therefore joins the list of aspects of breast cancer care–breast cancer screening, diagnosis, prognostic evaluation, and primary therapy–for which older women receive less than definitive care.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Neck and low back pain are leading causes of morbidity and health care utilization. However, little is known about the characteristics that differentiate those who seek from those who do not seek health care for their pain.Objectives.The objectives of this study were to: 1) describe health care utilization for neck and back pain; 2) determine the characteristics of individuals seeking health care for neck and back pain; and 3) identify the characteristics of patients who consult medical doctors, chiropractors, or both.Design.Population-based cross-sectional mailed survey.Subjects.Subjects were randomly selected adults from the Saskatchewan Health Insurance and Registration File.Measures.Demographic, socio-economic, general health, comorbidity, health-related-quality-of-life, pain severity and health care utilization data were collected. The main outcome was whether subjects with prevalent neck or low back pain visited a health care provider in the previous month.Results.Twenty-five percent of individuals with neck or low back pain visited a health care provider. Seeking health care was associated with disabling neck or back pain, digestive disorders, worse bodily pain and worse physical-role-functioning. Compared with medical patients, fewer chiropractic patients lived in rural areas or reported arthritis, but they reported better social and physical functioning. More patients consulting both providers reported disabling neck or back pain.Conclusions.Individuals seeking care for neck or back pain have worse health status than those who do not seek care. Patients consulting chiropractors alone report fewer comorbidities and are less limited in their activities than those consulting medical doctors.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Somatization is a common, costly problem with great morbidity, but there has been no effective screening method to identify these patients and target them for treatment.Objectives.We tested a hypothesis that we could identify high utilizing somatizing patients from a management information system (MIS) by total number of visits and what we termed “somatization potential,” the percentage of visits for which ICD-9 primary diagnosis codes represented disorders in the musculoskeletal, nervous, or gastrointestinal systems or ill-defined complaints.Methods.We identified 883 high users from the MIS of a large staff model HMO as those having six or more visits during the year studied (65th percentile). A physician rater, without knowledge of hypotheses and predictors, then reviewed the medical records of these patients and identified somatizing patients (n = 122) and nonsomatizing patients (n = 761). In two-thirds of the population (the derivation set), we used logistic regression to refine our hypothesis and identify predictors of somatization available from the MIS: demographic data, all medical encounters, and primary diagnoses made by usual care physicians (ICD-9 codes). We then tested our prediction model in the remaining one-third of the population (the validation set) to validate its usefulness.Results.The derivation set contained the following significant correlates of somatization: gender, total number of visits, and percent of visits with somatization potential. The c-statistic, equivalent to the area under the ROC curve, was 0.90. In the validation set, the explanatory power was less with a still impressive c-statistic of 0.78. A predicted probability of 0.04 identified almost all somatizers, whereas a predicted probability of 0.40 identified about half of all somatizers but produced few false positives.Conclusions.We have developed and validated a prediction model from the MIS that helps to distinguish chronic somatizing patients from other high utilizing patients. Our method requires corroboration but carries the promise of providing clinicians and health plan directors with an inexpensive, simple approach for identifying the common somatizing patient and, in turn, targeting them for treatment. The screener does not require clinicians’ time.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Background.Preventive care service use is commonly compared across health plans, clinics, or individual providers, yet little is known about the influence of the clinic versus patient factors on utilization of these services.Objectives.To measure the relative influence of the facility (clinic) versus patient factors (demographic, behavioral and functional characteristics) on patients’ utilization of mammography, Pap smears, cholesterol screening, and retinal exams for those with diabetes.Research Design.Retrospective analysis, using administrative and patient survey dataSubjects.Enrollees in 2 University-based clinics and a county hospital-based clinic serving a predominantly low-income population with limited access to health care. Eligibility for cervical cancer screening, screening mammography, cholesterol screening, or annual retinal exam (diabetes) was defined by age, sex, and diagnosis.Measures.Multivariate models, one using readily available administrative data, and another using detailed health status and behavior data gathered from a clinics-wide survey.Results.Unadjusted screening rates for three of four procedures were significantly and substantially lower at the county hospital based clinic than the two University-based clinics. After adjusting for patient characteristics, utilization of three screening services at the county hospital remained significantly below the University-based clinics (Odds Ratios [95% CI]: mammogram 0.15 [0.06–0.35]; Pap smear 0.32 [0.21–0.50]; cholesterol 0.19 [0.09–0.38]; diabetes retinal exam10.68 [0.93–3.01]). The models with detailed survey data performed only marginally better than the models using only administrative data.Conclusions.Patient characteristics were much less important than the clinic for predicting whether patients received primary care preventive services. Our results suggest that case mix adjustment is unlikely to explain away discrepancies in performance between clinics or provider groups.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Objectives.To determine the best predictors of the amount of children’s health care use.Research Design.Child health, psychosocial, and family status variables were collected. Families were then followed prospectively for 2 years to gather health care use data. Multivariate regression analysis was used to determine factors related to volume of child health care use.Subjects.367 mothers and children ages 5 to 11 years continuously enrolled in a staff model HMO.Measures.Child health care visits obtained from a computerized database comprised the dependent variable. Independent variables were organized into a 5-component framework including: Demographic Characteristics; Family Characteristics; Child Health and Prior Health Care Use; Child Behavior and Mental Health; and Mothers’ Mental Health and Health Care Use.Results.The volume of a child’s past health care use was the best predictor of future health care use, with the presence of past acute recurring illnesses, child pain and mother’s retrospective health care use also serving as significant predictors in the model. Analysis of a second model was conducted omitting children’s past use of health care. In this model the mother’s worry about child health was the best predictor of use, with child health and child and maternal psychosocial variables significantly contributing to explained variance in the model.Conclusions.This study supports prior research indicating past use is the best predictor of future health care use. In addition, the study suggests that maternal perceptions of child health and maternal emotional functioning influence the decision-making process involved in seeking health care on behalf of children. Effective management of pediatric health care use needs to address broader needs of the child and family beyond solely the child’s health, most notably maternal functioning.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

Objective.To examine the distribution of risk and the correlation between risks in a home care population with regard to several important adverse outcomes.Background.Researchers and policy makers have long recognized the heterogeneity of home care populations. Most research in this area focuses on identifying predictors of adverse outcomes. The degree of the heterogeneity of risks is much more poorly understood. Yet understanding the degree of risk heterogeneity at the population level is important because it has implications for the extent to which the level of care should vary among recipients.Study setting.Patients enrolled in the Arizona Health Care Cost Containment System (AHCCCS) program, between the December 1992 and April 1998.Outcome measures.Estimating the risk for nursing home placement, hospitalization, death, and functional decline.Methods.Estimating discrete time hazard models. From these models the predicted risk for each outcome is estimated and the distribution and correlation of predicted risks is examined. Model fit is assessed through split sample techniques and by examining the ratio of predicted to actual outcomes for selected sub-groups.Results.The estimates reveal a wide variation in predicted risk. The ratio of predicted risk at the 90th percentile relative to the 10th percentile ranges from 4.99 for nursing home admission to 6.65 for hospitalization. The distributions of predicted risks are all skewed, particularly the distributions for death and nursing home admission. Predicted nursing home risk is highly correlated with the predicted risk for death (&rgr; = 0.71). The predicted risk for hospitalization is not strongly correlated with the predicted risk for either death or nursing home admission.Conclusion.The wide variation in risk among home care patients suggests that efficient allocation of resources would require variation in spending and targeting of services based on patient characteristics. Greater research regarding the effectiveness of home care for different sub-populations is called for.

ISSN:0025-7079    

出版商:OVID    

年代:2001

数据来源: OVID