Patterns of care in patients utilizing both primary health care and psychiatric care in a Swedish health district

Patterns of care in all patients (N = 546) establishing contact with both primary health care and psychiatric care were studied during 1984 (N = 252) and 1986 (N = 294) in a Swedish health district. Utilization of primary health care was not affected by the sectorization of the psychiatric care organization, while there was a significant increase in utilization of outpatient psychiatric care. Patients with a higher number of visits in outpatient psychiatric care had a lower number of visits in primary health care. The utilization of care was unevenly distributed in the sample; 25% of the patients accounted for almost 60% of the visits in both care organizations. The mental health problems were identified in primary health care in 40% of the patients. This group of patients seemed to be defined as belonging neither to specialized psychiatric care nor to the general practitioner level of primary health care.     

Predictors and outcomes of outpatient mental health care: a 4-year prospective study of elderly Medicare patients with substance use disorders

BACKGROUND: Many elderly inpatients have substance use disorders; recent treatment guidelines suggest that they should receive regular outpatient mental health care after discharge from hospital. OBJECTIVE: The prevalence, predictors, and outcomes of outpatient mental health care obtained by elderly Medicare patients with substance use disorders were examined. RESEARCH DESIGN: A longitudinal prospective follow-up was performed. SUBJECTS: Data from Medicare Provider Analysis and Review Record and Part B Medicare Annual Data were used to identify elderly inpatients with substance use disorders (n = 4,961) and determine their outpatient mental health care 4 years following hospital discharge. RESULTS: Only 12% to 17% of surviving elderly substance abuse patients received outpatient mental health care in each of 4 years after discharge. Cumulatively over 4 years, approximately 18% of surviving patients obtained diagnostic/evaluative mental health services, 22% obtained psychotherapy, and 9% received medication management. Of patients who obtained outpatient mental health care, 57% made 10 or fewer outpatient mental health visits over the entire 4 years. Younger, non-black, and female patients were more likely to obtain mental health outpatient care, as were patients with prior substance-related hospitalizations, dual diagnoses, and fewer medical conditions. Prompt outpatient mental health care was predictively associated with higher likelihood of mental health readmissions and, among patients with drug disorders, lower mortality. CONCLUSION: Very few elderly Medicare substance abuse patients obtain outpatient mental health care, perhaps because of health or economic barriers.     

Older patients with serious mental illness: sensitivity to distance barriers for outpatient care

OBJECTIVES: To inform health services delivery and to demonstrate the appropriateness of understanding access at the individual's level, we evaluated how patient characteristics affect sensitivity to access barriers. We examined one dimension of access: geographic accessibility. We assessed age differences in sensitivity to distance barriers for outpatient psychiatric and nonpsychiatric care among active Department of Veterans Affairs (VA) patients with serious mental illness. METHODS: Among 142,055 VA patients with bipolar disorder, schizophrenia, or other psychoses in fiscal year 2000, separate random intercepts mixed models were estimated (cluster: nearest site) for outpatient psychiatric and nonpsychiatric visit day volume. In addition to distance and age group (<45, 45-65, or >65), covariates included gender, ethnicity, rural location, psychiatric diagnosis type, Charlson comorbidity level, initial treatment location, and psychiatric diagnosis X distance interactions. Differential distance effects by age were assessed using age X distance interaction terms. RESULTS: Among VA patients with serious mental illness, distance limits the volume of VA outpatient visits. For nonpsychiatric outpatient care, patients older than 65 were substantially more sensitive to distance barriers (P < 0.0001). For psychiatric outpatient care volume, patients aged 45-65 had slightly increased sensitivity; however, this difference did not have clinical significance. DISCUSSION: The impact of geographic accessibility barriers depended on personal characteristics of the individual and the outpatient service type. For nonpsychiatric outpatient care, older VA patients were most negatively affected by distance barriers. Results may inform efforts to reduce barriers to health care among patients with serious mental illness.     

Oral health‐related quality of life and dental status in an outpatient psychiatric population: A multivariate approach

Research related to oral health in people with mental health problems may deepen our understanding of the quality of life of such individuals. This study aimed to investigate the relationship between oral status, health perceptions and life satisfaction, and their impacts on oral health‐related quality of life (OHQoL). Data were collected from 113 patients in outpatient psychiatric care using a structured interview and an oral examination. Six multivariate models (one comprising the total population, three separate diagnostic groups, and two sex groups) investigated the variance in OHQoL. In the total population, the number of teeth, subjective life satisfaction, perception of physical health, sex, and relying on chance accounted for 40% of the variance. In the group consisting of patients diagnosed with schizophrenia 41% of the variance was explained by the variables ‘number of teeth’ and ‘perception of physical health’. In the group diagnosed with mood disorders, the variable ‘number of teeth’ accounted for 58% of the variance. The variance in the remaining group of diagnoses was explained, up to 38%, by life satisfaction and reliance on chance. The sex models revealed significant differences: men considered the responsibility of caring for their oral health as a health matter, while women saw oral health as a more subjective issue. The perception of OHQoL was found to be dependent on the particular psychiatric diagnosis and sex. Such findings can be of use in the development of rehabilitation, as well as preventive strategies that could be individually tailored to maintain OHQoL and oral health.     

A single-item approach to screening elders for oral health assessment

BACKGROUND: Oral health contributes significantly to overall health. Finding a single item that can be used by primary care providers to screen elders who are in need of oral care is important. OBJECTIVES: The objective of this article was to evaluate usefulness of the item: "Do you have regular dental checkups?" as a means to decide whether an oral health assessment or further referral is indicated. Answering no is postulated as a positive predictor of poor oral health and need for care. METHODS: This study was a secondary analysis of a nutritional survey of 240 community-dwelling elders. Examiner-rated Kayser-Jones Brief Oral Health Status Examination; self-reported General Oral Health Assessment Index; number of remaining teeth; and pattern of checkups (regular vs. irregular) were evaluated by a trained gerontological nurse practitioner during an in-home assessment. RESULTS: A dental visit within the past year for any reason was reported by 132 subjects (55.0%), but only 81 (33.8%) reported some sort of regular dental checkups. For dentate elders (n = 147), an irregular checkup was associated with lower educational level, Protestant faith, and Black race. People with irregular checkups scored significantly lower on all three oral indices. The negative predictive values and likelihood ratio negative values ranged 98.7-100.0% and 0.00-0.98, respectively, indicating that this item of interest is valid for ruling-out dentate subjects with good oral health. For edentulous elders (n = 93), the item was less effective. DISCUSSION: A single item, "Do you have regular dental checkups?" can be used effectively to rule out dentate elders with good oral health and identify those who are in need of further oral health assessment or referrals.     

Dental and other health care visits among U.S. adults with diabetes

OBJECTIVE: This study compared yearly dental visits of diabetic adults with those of nondiabetic adults. For adults with diabetes, we compared the frequency of past-year dental visits with past-year visits for diabetes care, dilated eye examinations, and foot examinations. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study using a sample of 105,718 dentate individuals aged > or =25 years, including 4,605 individuals with diabetes who participated in the 1995-1998 Behavioral Risk Factor Surveillance System in 38 states. RESULTS: Dentate adults (i.e., those with at least some natural teeth) with diabetes were less likely than those without diabetes to have seen a dentist within the preceding 12 months (65.8 vs. 73.1%, P = 0.0000). Adults with diabetes were less likely to have seen a dentist than to have seen a health care provider for diabetes care (86.3%); the percentage who saw a dentist was comparable with the percentage who had their feet examined (67.7%) or had a dilated eye examination (62.3%). The disparity in dental visits among racial or ethnic groups and among socioeconomic groups was greater than that for any other type of health care visit for subjects with diabetes. CONCLUSIONS: Promotion of oral health among diabetic patients may be necessary, particularly in Hispanic and African-American communities. Information on oral health complications should be included in clinical training programs. Oral and diabetes control programs in state health departments should collaborate to promote preventive dental services, and the oral examination should be listed as a component of continuous care in the American Diabetes Association's standards of medical care for diabetic patients.     

口腔修复治疗前患者口腔健康状况的调查分析

目的评估口腔修复治疗患者行口腔修复治疗前口腔健康状况,为口腔修复综合治疗方案提供科学依据。方法选取口腔修复治疗的250例初诊患者,通过问卷及口腔检查的方式获得其牙齿龋损、充填、牙齿缺失及修复等口腔健康数据。结果年轻人组患龋率高发区主要在磨牙区人均患龋1颗／人,患龋率67％,老年人组患龋高发区在前牙,人均患龋1．09颗／人,患龋率47％,中年人组有比较高的人均补牙数3．4颗／人。全牙列的患龋概率与身体健康状况有关,身体健康状况自评为良或以下者牙齿患龋风险是健康状况评价好以上者的3．68倍,OR的95％CI（1．83—7．40）,P〈0．05,牙弓缺失牙风险与牙齿部位有有关：磨牙区〉前磨牙区〉前牙区。年龄因素与牙列龋病、补牙、牙齿缺失、修复有相关性,年龄越大,有较高的缺失牙数。结论口腔修复治疗患者口内存在多发口腔疾病,合理的口腔修复综合治疗方案应该依据患者口腔健康状况具体分析制定。     

Use of Rn Case Management and Costs and Utilization of Outpatient Mental Health Services: A Pilot Study

The majority of outcome studies on case management seem to have been studied on the chronically mentally ill patients. Little is known regarding the use of a case management approach with general psychiatric populations, which include non-chronically mentally ill patients in an outpatient setting. This study examined the effect of a registered nurse case management (RNCM) model on the delivery and cost of mental health services during an 18-month period for clients in an outpatient psychiatric setting. Sixty clients met the criteria for sample selection. The data indicated that the use of the RNCM model resulted in more nursing than psychiatric care. Despite more frequent visits to the RNCM and longer RNCM visits, RNCM services appeared cost effective and were related to decreased length of hospital stay. A subgroup of high-risk clients was identified, and a significantly greater use of services by this group was substantiated.     

Community mental health care in Botswana: approaches and opportunities

AIM: The purpose of this article is to provide an insight into the developmental trends in community mental health care in Botswana. Different approaches are discussed and the opportunities that have emanated from them. BACKGROUND: Care of the mentally ill in Botswana is provided at different levels of coverage and sophistication. There is a single mental hospital in the country. Attached to the district hospitals are psychiatric outpatient clinics run by psychiatric nurses and a psychiatrist who visits them on monthly basis. Mental health care in Botswana has gone through a paradigm shift, from the prepenal years, penal years and institutional to community based care, which reflects a philosophy of citizen involvement and collaboration. CONCLUSION: Several approaches have been utilized in the development of community mental health care. However, difficulties and challenges still exist in the provision of community mental health care.     

The role of psychiatric diagnosis in satisfaction with primary care: data from the department of veterans affairs

BACKGROUND: Although patient satisfaction is widely used as a quality indicator, most such measures do not account for patient subgroups such as those with psychiatric illness. There is also very little data on satisfaction of psychiatric patients with their medical care. OBJECTIVE: The objective of this study was to assess the role of psychiatric illness in satisfaction with outpatient primary care services in the Department of Veterans Affairs (VA). METHOD: Data from the VA Customer Feedback Survey (n = 50,532) were merged with administrative data to determine diagnoses and other characteristics. Satisfaction ratings were compared across psychiatric diagnoses and across various aspects of satisfaction with care. RESULTS: After controlling for patient characteristics (eg, gender, age, disability, acute vs. routine visit) and subjective health, patients with schizophrenia, posttraumatic stress disorder, drug abuse, depression, and other psychiatric disorders reported significantly lower satisfaction with their outpatient primary care. Dissatisfaction was particularly reported for access to care and overall coordination of care. CONCLUSIONS: Despite VA characteristics that might be thought to improve satisfaction (eg, easier access to specialty mental health services as a result of the integrated VA system), patients with psychiatric disorders are significantly less satisfied than patients without such disorders. Possible explanations include both lower technical quality of care and poorer interpersonal communication between providers and patients with mental illness, including the negative effects of stigma. These findings highlight the need for satisfaction ratings to be case-mix-adjusted, including the incorporation of health and mental health diagnoses, and the need for further research that elucidates the reasons behind lower satisfaction ratings.     

糖尿病牙种植患者定期复诊的影响因素及针对性护理措施实施效果研究

目的 探讨影响糖尿病牙种植患者定期复诊的相关因素及针对性护理措施的应用效果.方法 选取2014年1月~2015年3月该院完成口腔种植义齿修复半年以上的糖尿病牙种植患者50例为研究对象,采用自拟问卷调查表调查患者遵医行为,分析影响患者定期复诊的相关因素.按随机数字表法分为对照组和观察组各25例.对照组采用常规护理,观察组采用针对性护理,探讨针对性护理措施对糖尿病牙种植患者的干预效果.结果 糖尿病牙种植患者各医嘱执行合格率较低,合格率排列最低前3位为自我监测、饮食控制、日常口腔护理行为;年龄、文化程度、病程、家庭月收入、患者个人因素、就医环境均为影响糖尿病牙种植患者定期复诊的相关因素;观察组干预6个月SBI、PLI 0级所占比例均高于对照组,但仅SBI比较差异有统计学意义(P<0.05);干预6个月,观察组患者PD低于对照组(P<0.05),而日常口腔护理行为、定期复诊、按时服药、自我监测合格率高于对照组(P<0.05).结论 糖尿病牙种植患者定期复诊合格率受多因素影响,加强对患者的针对性护理,强化健康教育及口腔护理,可促进患者口腔功能恢复.     

东莞地区居民口腔保健知识与行为的调查分析

目的调查分析东莞地区居民口腔保健知识与行为并给予健康宣教。方法随机选取2019年1—7月东莞地区常住居民450名,对其口腔保健知识误区进行“个体化”与“群体化”相结合的健康宣教。健康宣教前发放问卷450份,回收419份,有效回收率93.11%;健康宣教后发放问卷450份,回收426份,有效回收率94.67%。结果健康宣教后被调查居民关于“每年至少做1次口腔检查;牙齿好坏是天生的;洁牙对预防牙龈出血没用;吃糖可造成龋齿;漱口是保持口腔清洁的最有效办法”的回答正确人数均高于健康宣教前,差异有统计学意义(P<0.05);健康宣教后,被调查居民关于“刷牙方式、每天刷牙次数、使用牙线情况、使用牙膏情况”的正确行为人数均高于健康宣教前,差异有统计学意义(P<0.05);健康宣教后调查居民关于“就医地点、定期口腔检查、牙痛时做法、牙齿有洞但不痛”的正确就医观念和行为人数高于健康宣教前,差异有统计学意义(P<0.05)。结论东莞地区居民关于口腔健康知识及行为知晓水平仍较低,通过对居民进行口腔健康知识宣教,可有效提高其口腔健康行为,促进身心健康发展。     

Oral health status of psychiatric patients

Many patients suffering from long-term psychiatric illness are on medication for long periods. These medications frequently cause xerostomia leading to an increased risk of caries, gingivitis, periodontitis and stomatitis. Oral hygiene is therefore of the utmost importance for these patients. Nurses interact with patients on a daily basis, and therefore they are the psychiatric caregivers of choice to support these patients. The main aim of this study was to describe the oral health status of patients in short-term and long-term psychiatric care by means of oral assessment. A second aim was to discover whether the assessment guide used could distinguish any differences between these two groups. A modified version of the Oral Assessment Guide (OAG) developed by Eilers et al. (1988) was used. In addition, new items/categories were developed, forming the Oral Assessment Guide for Psychiatric Care (OAG-PC). A total of 57 patients in psychiatric care, short-term (n = 32) and long-term (n = 25), were assessed by the OAG-PC. Patients in long-term psychiatric care had significantly higher scores on the total OAG-PC compared with those in short-term psychiatric care, indicating a worse oral health status. Statistically significant differences were also found in relation to the following OAG-PC categories: odour from the mouth, mucous membranes, gums, teeth or dentures, calculus on teeth and appearance of teeth. Further research should be focused on the difficulties for nurses in approaching their patients in order to perform oral care and on evaluating the effect of teaching and training psychiatric nurses in oral care, preferably with the assistance of the OAG-PC. This assessment guide may thereby also be valuable for nurses' documentation in estimating, planning, implementing and evaluating their psychiatric patients' oral care needs.     

Do baby teeth really matter? Changing parental perception and increasing dental care utilization for young children

IntroductionParent/caregivers' inability to recognize the importance of baby teeth has been associated with inadequate self-management of children's oral health (i.e. lower likelihood of preventive dental visits) which may result in dental caries and the need for more expensive caries-related restorative treatment under general anesthesia. Health behavior theories aid researchers in understanding the impact and effectiveness of interventions on changing health behaviors and health outcomes. One example is the Common-Sense Model of Self-Regulation (CSM) which focuses on understanding an individual's illness perception (i.e. illness and treatment representations), and subsequently has been used to develop behavioral interventions to change inaccurate perceptions and describe the processes involved in behavior change.MethodsWe present two examples of randomized clinical trials that are currently testing oral health behavioral interventions to change parental illness perception and increase dental utilization for young children disproportionately impacted by dental caries in elementary schools and pediatric primary care settings. Additionally, we compared empiric data regarding parent/caregiver perception of the chronic nature of dental caries (captured by the illness perception questionnaire revised for dental: IPQ-RD constructs: identity, consequences, control, timeline, illness coherence, emotional representations) between parent/caregivers who did and did not believe baby teeth were important.ResultsCaregivers who believed that baby teeth don't matter had significantly (P < 0.05) less accurate perception in the majority of the IPQ-RD constructs (except timeline construct) compared to caregivers who believed baby teeth do matter.ConclusionThese findings support our CSM-based behavioral interventions to modify caregiver caries perception, and improve dental utilization for young children.     

Dental health behaviour among 25-44-year-old Danes

The purpose of the present investigation was to describe dental health behaviour in an adult Danish population and to study whether oral hygiene habits and consumption of sweets were affected by living conditions. The study group comprised 749 persons in the age group 25-44 years (82% of the original sample) and data on general health behaviour and dental health behaviour were collected by interviews. Regular dental visits were reported by 86%, 83% declared that they brush their teeth at least twice a day and toothbrushing after breakfast was reported by 51%. Regular use of toothpicks was reported by 45%, while dental floss was used by 22%. Dental visits varied according to education, income, work in shifts, sex, and self-assessment of dental health, while toothbrushing habits were affected by urbanization, sex, education, number of children in family, and self-assessment of dental health. Daily consumption of cakes/pastry was reported by 10%, six per cent consumed chocolate/liquorice every day, while soft drinks were drunk every day by 10%. Consumption of sweets varied according to education, shift work, sex, strained life situations, and the number of children in family. Among the regular dental visitors, oral hygiene habits were also influenced by living conditions. Thus, the challenges to general dental practice as regards dental health education are great.     

Psychiatric symptoms and psychosocial problems in primary health care as seen by doctors

All visits at a primary health care centre in Sweden were studied during four weeks. The frequency of psychiatric symptoms or psychosocial problems noted by the doctors was recorded on a special form in addition to routine registration of diagnoses. Such problems were noted in 553 out of 3 205 visits, corresponding to 17.3%. Considerable variation in registering problems was found between individual physicians and between different categories of doctors. The most common problems were nervousness, anxiety, psychosomatic disorders, and depression. Mental problems were especially common in connection with gastritis, precordial pain, and abdominal pain. There was a difference between the sexes: 20% of the female patients had mental problems registered compared with 14% of the male patients. Psychiatric diagnoses, however, were registered in only 6% of all cases. Of the 553 patients with mental problems, 16% were considered in need of a specialist, 52% could be dealt with at the health centre, and for 32% no special treatment for the mental problems was regarded necessary. One conclusion is that the routine registration of diagnoses at the health centre covers only some of the mental problems and is therefore insufficient in terms of planning psychiatric resources and the training of doctors. Possible reasons for the differences found are discussed.     

The Diagnostic Use of Radioactive Isotopes

Dentists and their medical colleagues must approach old patients as they would younger ones. They should not accept loss of teeth as a physiologic process associated with aging but should strive to prevent dental caries and periodontal diseases, the major causes of loss of teeth.

Communities should provide equipment through hospitals or clinics for dental care of home bound patients. Even the edentulous patient should have regular oral examinations to prevent some of the deaths caused by oral cancer.     

PS2-24: 60 Seconds or Less: Factors Influencing the Likelihood of a Mental Health Discussion During Periodic Health Exams

Background/Aims The majority of patients with mental health concerns turn to their primary care physician (PCP). We investigate whether periodic health exams (PHEs) may be a good opportunity for these patients to receive mental health services. We examine the impact of patients' need for mental health care, competing demands from biomedical issues, and the availability of behavioral health providers on the probability of discussing mental health. Methods The study uses audio recordings of 308 unique patients' PHEs with 59 PCPs. Visits took place in 22 clinics of an integrated delivery system in metropolitan Detroit between 2007-2009. Administrative data and electronic medical records spanning 12-months before the PHE are also used. Patients are aged 50 to 80; all were deemed to be potentially in need of mental health services because of their Personal Health Questionnaire (PHQ2) score, prior diagnosis of mental illnesses, use of behavioral health services, or psychotropic medication use. We coded the audio to capture visit contents and time spent on each "topic" (defined as an issue that had at least two complete exchanges between patient and physician). We examined the probability of a mental health discussion using a logit generalized estimating equation (GEE) regression. Results The median length of patient-physician interaction was 26 minutes. The median number of "topics" was 19. Biomedical discussions were present in all visits; 38% (118 of 308) of the visits included a mental health discussion. The median length of a mental health discussion was 47 seconds. Logit results suggest the likelihood of mental health discussion increased if the patient had a PHQ2 =3 (odds ratio [OR]=5.30, p<0.01), was on psychotropic medication (OR=2.47, p<0.05), had a mental health diagnosis in prior year (OR=2.52, p<0.05), and was female (OR=1.88, p<0.05). The likelihood decreased if the clinic has co-located behavioral health (OR=0.47, p<0.05). Percent time spent on biomedical issues did not significantly impact the probability of a mental health discussion. Conclusions Many discussions occurred during PHEs with patients potentially needing mental health care. Only 38% (118 of 308) of all visits contained mental health discussions, and in those that did more than half lasted less than a minute.