Children's primary health care services: social-cognitive factors related to utilization

OBJECTIVE: To test social-cognitive influences on parent decision-making processes related to children's health care use. METHODS: Eighty-seven primary caretakers of children ages 4 to 9 years completed measures of child health and behavior, parent functioning, and social-cognitive factors related to parenting and health care use. Primary care use was obtained from the children's primary care physician(s) for the 2 years prior to recruitment. RESULTS: Social-cognitive variables accounted for 13.2% of the variance in primary health care use, above and beyond the influence of child health status and psychosocial variables. The best predictive model, accounting for 29.8% of the variance in primary care use, included the interaction between parental stress and self-efficacy to cope with parenting demands, child behavior problems, self-efficacy for accessing physician assistance, medication use, and parent health care use. CONCLUSIONS: Results documented the relationship between self-efficacy and parent stress in decision making about pediatric primary care use. Social-cognitive theory provides a new perspective for evaluating factors that influence health care use.     

Psychology in primary health care: effects of brief targeted therapy on children's medical care utilization

Evaluated the impact of psychological treatment for 93 children (ages 1-15) with common behavior, toilet, school, and psychosomatic problems. Children and parents, who were members of a health maintenance organization, had 1-6 visits to a primary care-based psychological consultation service. Individualized treatment was guided by problem-specific behavioral protocols. Parent outcome and behavior checklist ratings indicated improvement or resolution for 74% of children and high satisfaction with the psychological service. Children's use of medical services, especially acute primary care visits, was reduced during the year after treatment; a matched comparison group's use was unchanged. Addressing children's unmet mental health needs reduces medical care utilization. A primary health care model of psychological services provides an integrated system for serving the health and mental health needs of children.     

Neurocognitive changes in depressed patients in psychodynamic psychotherapy,therapy with fluoxetine and combination therapy

Background

Randomized controlled trials (RCTs) examining the efficacy of different forms of therapy for depression are relatively common. However, there are not many RCTs comparing neurocognitive effects of these treatments. Neurocognitive changes across three types of treatment for depression were compared. Long-term psychodynamic psychotherapy (LTPP) was compared with fluoxetine treatment, and their combination, in the treatment of moderate depression.

Methods

A 272 adult patients with beck depression inventory (BDI) scores 20–35 were randomized to receive LTPP, fluoxetine monotherapy or their combination for a 24 months period. The Wechsler adult intelligence scale version III (WAIS-III) was the primary neuropsychological measure.

Result

Multilevel mixed model analyses indicated that there were neurocognitive changes within and between treatments, with statistically significant differences over time (p>.01). LTPP and combined treatment seemed to be more efficacious in modifying specific areas of cognition than fluoxetine alone.

Limitations

Sample very homogenous, threatening external validity.

Conclusions

LTPP and its combination with fluoxetine demonstrated to be effective for specific neurocognitive increasing in patients with moderate depression. This study suggests marked differences over time in the neurocognitive effects between the three treatment forms compared. Results found here may be of clinical relevance for building bridges between pharmacotherapy and psychodynamic psychotherapy.     

Barriers to oral health care utilization in Ibadan,South West Nigeria

Background

Barriers to oral health utilization are many, but those that are significant for our environment are not yet clear. The current study was designed to identify and graduate the barriers to receipt of oral health care among a cross-section of patients attending our centre. We also investigated the influence of socio demographic factors on the highly rated barriers.

Methods

This cross-sectional study was conducted among patients visiting UCH, Ibadan using a self-administered questionnaire. Socio-demographic variables and oral health care seeking behaviour were requested and in addition, the respondents were asked to rank 11 listed barriers to receipt of oral health care and any other barriers they may think of in order of strength. Factor analysis was employed in order to identify four factors with the highest loading. The mean scores were compared using t-test and one-way ANOVA and the level of significance was set at 0.05

Results

Only 400 questionnaires were properly filled (84.9%) out of the 471 that were administered. The mean age of these participants was 37.85±15.38 years. Most of the respondents (55.8%) consulted the dentists only when there was pain while 109(27.3%) had never visited the dentist. Fear of dental injection, cost of treatment, feeling of insecurity when the dentist is operating and disturbing noise from dental drill were the major barriers. There was a statistically significant association between age groups and feeling of insecurity (p=006).

Conclusion

The major barriers to oral health care utilization among our patients were fear related.     

Change in self-protect ion and symptoms after dynamic psychotherapy: the influence of pretreatment motivation

The First Experimental Study of Transference-interpretations (FEST) is a dismantling, randomized clinical trial of the long-term effects of transference interpretation. This article looks at the influence of motivation on the ability to self-protect and symptoms. Patients were randomized to receive a moderate level of transference interpretations or no transference interpretation. Assessments were made at pretreatment, midtreatment, posttreatment, and at two follow-ups. The outcome measure, change in ability to self-protect, was cluster 4 of the Structural Analysis of Social Behavior (SASB) Long Form Intrex Introject Questionnaire, a measure close to the SASB-coded treatment process. Symptom change (SCL-90) was also analyzed. Pretreatment motivation was a significant moderator of change in the ability to self-protect and in symptom distress. Those with low motivation had a significant, positive, and long-term treatment effect of transference interpretation. Patients with low motivation showed a significant, negative effect of transference interpretation.     

Health care utilization and perceptions of health among adolescents and adults with Turner syndrome

We surveyed women aged 12 years and older who are members of the Turner Syndrome Society of the United States in regard to their health history, current health status, and health care utilization practices to identify the range of health problems and health care practices in this group. The mean age at diagnosis was 10.8 years, and an endocrinologist (41%) or pediatrician (35%) was most likely to make the initial diagnosis. Individuals over age 35 years were diagnosed with Turner syndrome and begun on estrogen replacement therapy at a significantly older age than those who were in younger age groups. Seventy-five percent of the respondents had required some type of surgical procedure, and 14% had been hospitalized within the previous year. Ninety-four percent of women rated their overall health as good to excellent, while 6% rated it fair to poor. In the 12–17-year age group, 89% of the young women were either currently taking or had previously taken growth hormone. The prevalence of major depressive symptoms was slightly higher than the general population for adolescents but similar to the general population for adults. For adult respondents, ratings of fair to poor health were significantly associated with increased outpatient visits. Growth hormone use was significantly associated with increased visits in the adolescent population. Based on these data, it appears that the clinical care of individuals with Turner syndrome has improved, but that they continue to have relatively high hospitalization rates and utilization of subspecialty services. Despite these health problems, most respondents demonstrated good adjustment as determined by standardized mental health measures.     

Elevated procalcitonin is associated with increased mortality in patients with scrub typhus infection needing intensive care admission

Context:

Procalcitonin is a biomarker of bacterial sepsis. It is unclear if scrub typhus, a rickettsial illness, is associated with elevated procalcitonin levels.

Aim:

To assess if scrub typhus infection is associated with high procalcitonin levels and whether high levels portend a poorer prognosis.

Setting and Design:

Retrospective study of patients with severe scrub typhus infection, admitted to the medical intensive care unit of a tertiary care university affiliated teaching hospital.

Materials and Methods:

Eighty-four patients with severe scrub typhus infection that also had procalcitonin levels were assessed.

Statistical Analysis:

Relationship between procalcitonin and mortality explored using univariate and multivariate analyses.

Results:

The mean (±standard deviation) age was 40.0 ± 15.5 years. Patients were symptomatic for 8.3 ± 4.3 days prior to presentation. The median admission procalcitonin level was 4.0 (interquartile range 1.8 to 8.5) ng/ml; 59 (70.2%) patients had levels >2 ng/ml. Invasive mechanical ventilation was required in 65 patients; 20 patients died. On univariate analysis, admission procalcitonin was associated with increased odds of death [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.03 to 1.18]. On multivariate logistic regression analysis including procalcitonin and APACHE-II score, the APACHE-II score was significantly associated with mortality (OR 1.16, 95% CI 1.06 to 1.30, P = 0.004) while a trend was observed with procalcitonin (OR 1.05, 95%CI 1.01 to 1.13, P = 0.09). The area under the receiver operating characteristic (ROC) curve, AUC, for mortality was 0.77 for procalcitonin and 0.78 for APACHE-II.

Conclusions:

Procalcitonin is elevated in severe scrub typhus infection and may be associated with higher mortality.     

Change in defense mechanisms and coping over the course of short‐term dynamic psychotherapy for adjustment disorder

Short‐term dynamic psychotherapy (STDP) has rarely been investigated with regard to its underlying mechanisms of change, even if psychoanalytic theory informs us about several potential putative mechanisms of change in patients. Change in overall defensive functioning is one. In this study, we explored the role of overall defensive functioning, by comparing it on the process level with the neighbouring concept of overall coping functioning. A total of N=32 patients, mainly presenting adjustment disorder, were included in the study. The patients underwent STDP up to 40 sessions; three sessions per psychotherapy were transcribed and analyzed by using two observer‐rating scales: Defense Mechanism Rating Scales (Perry, 1990 ) and Coping Action Patterns (Perry, Drapeau, Dunkley, & Blake, 2005 ). Hierarchical linear modeling was applied to model the change over the course of therapy and relate it to outcome. Results suggest that STDP has an effect on the target variable of overall defensive functioning, which was absent for overall coping functioning. Links with outcome confirm the importance of the effect. These results are discussed from methodological and clinical viewpoints. © 2010 Wiley Periodicals, Inc. J Clin Psychol 66:1–10, 2010.     

Medical manifestations and health care utilization among adult MyCode participants with neurodevelopmental psychiatric copy number variants

PurposeRecurrent pathogenic copy number variants (pCNVs) have large-effect impacts on brain function and represent important etiologies of neurodevelopmental psychiatric disorders (NPDs), including autism and schizophrenia. Patterns of health care utilization in adults with pCNVs have gone largely unstudied and are likely to differ in significant ways from those of children.MethodsWe compared the prevalence of NPDs and electronic health record–based medical conditions in 928 adults with 26 pCNVs to a demographically-matched cohort of pCNV-negative controls from >135,000 patient-participants in Geisinger’s MyCode Community Health Initiative. We also evaluated 3 quantitative health care utilization measures (outpatient, inpatient, and emergency department visits) in both groups.ResultsAdults with pCNVs (24.9%) were more likely than controls (16.0%) to have a documented NPD. They had significantly higher rates of several chronic diseases, including diabetes (29.3% in participants with pCNVs vs 20.4% in participants without pCNVs) and dementia (2.2% in participants with pCNVs vs 1.0% participants without pCNVs), and twice as many annual emergency department visits.ConclusionThese findings highlight the potential for genetic information—specifically, pCNVs—to inform the study of health care outcomes and utilization in adults. If, as our findings suggest, adults with pCNVs have poorer health and require disproportionate health care resources, early genetic diagnosis paired with patient-centered interventions may help to anticipate problems, improve outcomes, and reduce the associated economic burden.     

The effect of rapid exome sequencing on downstream health care utilization for infants with suspected genetic disorders in an intensive care unit

PurposeThis study aimed to compare downstream utilization of medical services among critically ill infants admitted to intensive care units who received rapid exome sequencing (ES) and those who followed alternative diagnostic testing pathways.MethodsUsing propensity score–weighted regression models including sex, age at admission, and severity indicators, we compared a group of 47 infants who underwent rapid ES with a group of 211 infants who did not receive rapid ES. Utilization and cost indicators were compared between cohorts using negative binomial models for utilization and two-part models for costs.ResultsAfter controlling for patients’ sociodemographic and clinical characteristics, we found no statistically significant difference in outpatient visits, hospitalizations, intensive care unit or total length of stay, or length of stay–associated costs between the cohorts at 12- or 26-month follow-up. Similarly, there was no evidence of higher utilization or costs by the ES group when infants who died were removed from the analysis.ConclusionWhen examining utilization during and beyond the diagnostic trajectory, there is no evidence that ES changes frequency of outpatient visits or use of in-hospital resources in critically ill infants with suspected genetic disorders.     

Psychotherapy alone versus collaborative psychotherapy and psychiatric care in the treatment of depression and anxiety in patients with cancer: A naturalistic,observational study

Objective

At present, there is a paucity of naturalistic studies directly comparing the effectiveness of psychotherapy alone versus collaborative psychotherapy and psychiatric care in the management of depression and anxiety in patients with cancer. This study tested the hypothesis that collaborative psychiatric and psychological care would lead to greater reductions in depression and anxiety symptoms in patients with cancer compared with psychotherapy alone.

Methods

We analyzed treatment outcomes of 433 adult patients with cancer, of which 252 patients received psychotherapy alone and 181 patients received collaborative psychotherapy and psychiatric care. Longitudinal changes in depressive (i.e., PHQ-9) and anxiety symptoms (GAD-7) were examined between groups using latent growth curve modeling.

Results

After controlling for treatment length and psychotherapy provider effects, results indicated collaborative care was more effective than psychotherapy alone for depressive symptoms (γ₁₂ = −0.13, p = 0.037). The simple slope for collaborative care was −0.25 (p = 0.022) and the simple slope for psychotherapy alone was −0.13 (p = 0.006), suggesting collaborative care resulted in greater reductions in depressive symptoms compared with psychotherapy alone. In contrast, there were no significant differences between psychotherapy alone and collaborative psychotherapy and psychiatric care in reducing anxiety symptoms (γ₁₂ = −0.08, p = 0.158).

Conclusions

Collaborative psychotherapy and psychiatric care may individually address unique aspects of mental health conditions in patients with cancer, namely depressive symptoms. Mental healthcare efforts may benefit from implementing collaborative care models where patients receive psychiatric services and psychotherapy to effectively address depressive symptoms in the treatment of this patient population.     

Depression and anxiety among migrants in Austria: A population based study of prevalence and utilization of health care services

Background

Although migrants form a large part of the Austrian population, information about mental health of migrants in Austria is scarce. Therefore, we compared the prevalence of dysphoric disorders (depression and anxiety) and the corresponding utilization of health care services of Eastern European, western and other migrants with the non-migrant population in Austria.

Methods

We performed a telephone survey on a random sample of the general population of Austria aged 15 years and older (n=3509) between October 2010 and September 2011. Depression and anxiety were measured with the Patient Health Questionnaire-4 and utilization of health care services in the last 4 weeks was inquired.

Results

15.0% of our sample had a migration background. Female migrants from Eastern Europe, first and second generation, had a higher prevalence of dysphoric disorders (29.7% and 33.4% respectively) than Austrian women (15.2%) (p<0.001). The prevalence in the other migrant groups did not differ significantly from the Austrian population. There was no gender difference in dysphoric disorders in the Austrian population. After adjustment for age and chronic diseases, having a dysphoric disorder was associated with a higher utilization of health care services among migrant and Austrian women, but not among men.

Limitations

Because of the explorative nature of the study multiple testing correction was not performed. The reason for health care utilization was not assessed.

Conclusions

Mental health of female migrants from Eastern Europe should be studied in more detail; men could be an underserved group, both in migrants and Austrians.