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1.
Chossis I Lane C Gache P Michaud PA Pécoud A Rollnick S Daeppen JB 《Journal of general internal medicine》2007,22(8):1144-1149
Background Brief alcohol interventions (BAI) reduce alcohol use and related problems in primary care patients with hazardous drinking
behavior. The effectiveness of teaching BAI on the performance of primary care residents has not been fully evaluated.
Methods A cluster randomized controlled trial was conducted with 26 primary care residents who were randomized to either an 8-hour,
interactive BAI training workshop (intervention) or a lipid management workshop (control). During the 6-month period after
training (i.e., from October 1, 2003 to March 30, 2004), 506 hazardous drinkers were identified in primary care, 260 of whom
were included in the study. Patients were interviewed immediately and then 3 months after meeting with each resident to evaluate
their perceptions of the BAI experience and to document drinking patterns.
Results Patients reported that BAI trained residents: conducted more components of BAI than did controls (2.4 vs 1.5, p = .001); were more likely to explain safe drinking limits (27% vs 10%, p = .001) and provide feedback on patients’ alcohol use (33% vs 21%, p = .03); and more often sought patient opinions on drinking limits (19% vs 6%, p = .02). No between-group differences were observed in patient drinking patterns or in use of 9 of the 12 BAI components.
Conclusions The BAI-trained residents did not put a majority of BAI components into practice, thus it is difficult to evaluate the influence
of BAI on the reduction of alcohol use among hazardous drinkers.
Dr. Chossis died May 10, 2007.
A poster on this study was presented at the 2006 RSA Annual Scientific Meeting held in Baltimore, Maryland, June 26, 2006. 相似文献
2.
Screening for Posttraumatic Stress Disorder in VA Primary Care Patients with Depression Symptoms
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Background Unrecognized posttraumatic stress disorder (PTSD) is common and may be an important factor in treatment-resistant depression.
Brief screens for PTSD have not been evaluated for patients with depression.
Objective The objective was to evaluate a 4-item screen for PTSD in patients with depression.
Design Baseline data from a depression study were used to evaluate sensitivity, specificity, and likelihood ratios (LRs) using the
PTSD checklist (PCL-17) as the reference standard.
Subjects Subjects are 398 depressed patients seen in Veterans Affairs (VA) primary care clinics.
Measures The Patient Health Questionnaire (PHQ) for depression, PCL-17, and 4-item screen for PTSD were used.
Results Patients had a mean PHQ score of 14.8 (SD 3.7). Using a conservative PCL-17 cut point “(>50)”, the prevalence of PTSD was
37%. PCL-17 scores were strongly associated with PHQ scores (r = 0.59, P < 0.001). Among the 342 (86%) patients endorsing trauma, a score of 0 on the remaining 3 symptom items had a LR = 0.21, score
of 1 a LR = .62, score of 2 a LR = 1.36, and score of 3 a LR = 4.38.
Conclusions Most depressed VA primary care patients report a history of trauma, and one third may have comorbid PTSD. Our 4-item screen
has useful LRs for scores of 0 and 3. Modifying item rating options may improve screening characteristics. 相似文献
3.
Gaynes BN Rush AJ Trivedi MH Wisniewski SR Balasubramani GK McGrath PJ Thase ME Klinkman M Nierenberg AA Yates WR Fava M 《Journal of general internal medicine》2008,23(5):551-560
Background Whether the acute outcomes of major depressive disorder (MDD) treated in primary (PC) or specialty care (SC) settings are
different is unknown.
Objective To compare the treatment and outcomes for depressed outpatients treated in primary versus specialty settings with citalopram
in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (www.star-d.org), a broadly inclusive effectiveness
trial.
Design Open clinical trial with citalopram for up to 14 weeks at 18 primary and 23 specialty sites. Participants received measurement-based
care with 5 recommended treatment visits, manualized pharmacotherapy, ongoing support and guidance by a clinical research
coordinator, the use of structured evaluation of depressive symptoms and side effects at each visit, and a centralized treatment
monitoring and feedback system.
Participants A total of 2,876 previously established outpatients in primary (n = 1091) or specialty (n = 1785) with nonpsychotic depression who had at least 1 post-baseline measure.
Measurements and Main Results Remission (Hamilton Depression Rating Scale for Depression [Hamilton] or 16-item Quick Inventory of Depressive Symptomatology-Self-Rated
[QIDS-SR16]); response (QIDS-SR16); time to first remission (QIDS-SR16). Remission rates by Hamilton (26.6% PC vs 28.0% SC, p = .40) and by QIDS-SR16 (32.5% PC vs 33.1% SC, p = .78) and response rates by QIDS-SR16 (45.7% PC vs 47.6% SC, p = .33) were not different. For those who reached remission or response at exit, the time to remission (6.2 weeks PC vs 6.9 weeks
SC, p = .12) and to response (5.5 weeks PC vs 5.4 weeks SC, p = .97) did not differ by setting.
Conclusions Identical remission and response rates can be achieved in primary and specialty settings when identical care is provided.
Trial registry name: Sequenced Treatment Alternatives to Relieve Depression (STAR*D)
Registration identification number: NCT00021528
URL for the registry: 相似文献
4.
Brevetti G Oliva G Giugliano G Schiano V De Maio JI Chiariello M 《Journal of general internal medicine》2007,22(5):639-644
BACKGROUND Peripheral arterial disease (PAD) is undertreated by general practitioners (GPs). However, the impact of the suboptimal clinical
management is unknown.
OBJECTIVE To assess the mortality rate of PAD patients in relation to the type of physician who provides their care (GP or vascular
specialist).
DESIGN Prospective study.
SETTING Primary care practice and academic vascular laboratory.
PARTICIPANTS GP patients (n = 60) were those of the Peripheral Arteriopathy and Cardiovascular Events study (PACE). Patients managed by specialists (n = 82) were consecutive subjects with established PAD who were referred to our vascular laboratory during the enrolment period
of the PACE study.
MEASUREMENTS All-cause and cardiovascular mortality.
RESULTS After 32 months of follow-up, specialist management was associated with a lower rate of all-cause mortality (RR = 0.04; 95%
CI 0.01–0.34; p = .003) and cardiovascular mortality (RR = 0.07; 95% CI 0.01–0.65; p = .020), after adjustment for patients’ characteristics. Specialists were more likely to use antiplatelet agents (93% vs
73%, p < .001), statins (62% vs 25%, p < .001) and beta blockers (28% vs 3%, p < .001). Survival differences between specialists and GPs disappeared once the use of pharmacotherapies was added to the
proportional hazard model. The fully adjusted model showed that the use of statins was significantly associated with a reduced
risk of all-cause mortality (RR = 0.02; 95% CI 0.01–0.73, p = .034) and cardiovascular mortality (RR = 0.02; 95% CI 0.01–0.71, p = .033).
CONCLUSIONS Specialist management of patients with symptomatic PAD resulted in better survival than generalist management. This effect
appears to be mainly caused by the more frequent use of effective medicines by specialists. 相似文献
5.
Ghods BK Roter DL Ford DE Larson S Arbelaez JJ Cooper LA 《Journal of general internal medicine》2008,23(5):600-606
Background Little research investigates the role of patient–physician communication in understanding racial disparities in depression
treatment.
Objective The objective of this study was to compare patient–physician communication patterns for African-American and white patients
who have high levels of depressive symptoms.
Design, Setting, and Participants This is a cross-sectional study of primary care visits of 108 adult patients (46 white, 62 African American) who had depressive
symptoms measured by the Medical Outcomes Study–Short Form (SF-12) Mental Component Summary Score and were receiving care
from one of 54 physicians in urban community-based practices.
Main Outcomes Communication behaviors, obtained from coding of audiotapes, and physician perceptions of patients’ physical and emotional
health status and stress levels were measured by post-visit surveys.
Results African-American patients had fewer years of education and reported poorer physical health than whites. There were no racial
differences in the level of depressive symptoms. Depression communication occurred in only 34% of visits. The average number
of depression-related statements was much lower in the visits of African-American than white patients (10.8 vs. 38.4 statements,
p = .02). African-American patients also experienced visits with less rapport building (20.7 vs. 29.7 statements, p = .009). Physicians rated a higher percentage of African-American than white patients as being in poor or fair physical health
(69% vs. 40%, p = .006), and even in visits where depression communication occurred, a lower percentage of African-American than white patients
were considered by their physicians to have significant emotional distress (67% vs. 93%, p = .07).
Conclusions This study reveals racial disparities in communication among primary care patients with high levels of depressive symptoms.
Physician communication skills training programs that emphasize recognition and rapport building may help reduce racial disparities
in depression care. 相似文献
6.
Campbell DG Felker BL Liu CF Yano EM Kirchner JE Chan D Rubenstein LV Chaney EF 《Journal of general internal medicine》2007,22(6):711-718
BACKGROUND Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe
psychiatric symptomatology and factors that complicate treatment.
OBJECTIVE To estimate PTSD prevalence among depressed military veteran primary care patients and compare demographic/illness characteristics
of PTSD screen-positive depressed patients (MDD-PTSD+) to those with depression alone (MDD).
DESIGN Cross-sectional comparison of MDD patients versus MDD-PTSD+ patients.
PARTICIPANTS Six hundred seventy-seven randomly sampled depressed patients with at least 1 primary care visit in the previous 12 months.
Participants composed the baseline sample of a group randomized trial of collaborative care for depression in 10 VA primary
care practices in 5 states.
MEASUREMENTS The Patient Health Questionnaire-9 assessed MDD. Probable PTSD was defined as a Primary Care PTSD Screen ≥ 3. Regression-based
techniques compared MDD and MDD-PTSD+ patients on demographic/illness characteristics.
RESULTS Thirty-six percent of depressed patients screened positive for PTSD. Adjusting for sociodemographic differences and physical
illness comorbidity, MDD-PTSD+ patients reported more severe depression (P < .001), lower social support (P < .001), more frequent outpatient health care visits (P < .001), and were more likely to report suicidal ideation (P < .001) than MDD patients. No differences were observed in alcohol consumption, self-reported general health, and physical
illness comorbidity.
CONCLUSIONS PTSD is more common among depressed primary care patients than previously thought. Comorbid PTSD among depressed patients
is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment. Providers should
consider recommending psychotherapeutic interventions for depressed patients with PTSD. 相似文献
7.
Professional Characteristics and Job Satisfaction Among SGIM Members: A Comparison of Part-time and Full-time Physician Members
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Levine RB Harrison RA Mechaber HF Phillips C Gallagher TH 《Journal of general internal medicine》2008,23(8):1218-1221
BACKGROUND As more physicians work part-time (PT), the faculty, institutions, and organizations that represent them should understand
the factors that motivate and satisfy these physicians.
OBJECTIVE Compare factors associated with job satisfaction among PT and full-time (FT) academic physicians.
DESIGN Cross-sectional survey.
PARTICIPANTS Members of the Society of General Internal Medicine (SGIM), a national, academic Internal Medicine organization.
RESULTS Fifty percent (1,396 of 2,772) of SGIM members responded, 11% work PT. Compared to FT, PT physicians were more often female
(85% vs 38%, p < .001), clinicians (Cs) or clinician–educators (CEs) (84% vs 56%, p < .001), and of a lower rank (77% vs 61%, p = .001). Job satisfaction was similar between PT and FT Cs and CEs. For PT Cs and CEs, record of publication (11% vs 21%,
p = .04) and local and national recognition (24% vs 36%, p = .03) were less important to overall job satisfaction compared to FT Cs and CEs. In multivariate analysis, academic rank
(odds ratio [OR] = 7.18, 95%CI = 1.40–36.50) was associated with higher satisfaction among PT Cs and CEs.
CONCLUSIONS PT and FT C and CE SGIM members report similar satisfaction, but different factors contribute to satisfaction. Knowing what
motivates and satisfies PT physicians may allow medical centers to retain faculty and create positions to help them to fulfill
their potential.
Portions of this paper were presented at the 2006 Society of General Internal Medicine national meeting, Los Angeles, CA,
USA. 相似文献
8.
OBJECTIVE To examine inpatient intensive care unit (ICU) and intensive procedure use by race among Medicare decedents, using utilization
among survivors for comparison.
DESIGN Retrospective observational analysis of inpatient claims using multivariable hierarchical logistic regression.
SETTING United States, 1989–1999.
PARTICIPANTS Hospitalized Medicare fee-for-service decedents (n = 976,220) and survivors (n = 845,306) aged 65 years or older.
MEASUREMENTS AND MAIN RESULTS Admission to the ICU and use of one or more intensive procedures over 12 months, and, for inpatient decedents, during the
terminal admission. Black decedents with one or more hospitalization in the last 12 months of life were slightly more likely
than nonblacks to be admitted to the ICU during the last 12 months (49.3% vs. 47.4%, p <.0001) and the terminal hospitalization (41.9% vs. 40.6%, p < 0.0001), but these differences disappeared or attenuated in multivariable hierarchical logistic regressions (last 12 months
adjusted odds ratio (AOR) 1.0 [0.99–1.03], p = .36; terminal hospitalization AOR 1.03 [1.0–1.06], p = .01). Black decedents were more likely to undergo an intensive procedure during the last 12 months (49.6% vs. 42.8%, p < .0001) and the terminal hospitalization (37.7% vs, 31.1%, p < .0001), a difference that persisted with adjustment (last 12 months AOR 1.1 [1.08–1.14], p < .0001; terminal hospitalization AOR 1.23 [1.20–1.26], p < .0001). Patterns of differences in inpatient treatment intensity by race were reversed among survivors: blacks had lower
rates of ICU admission (31.2% vs. 32.4%, p < .0001; AOR 0.93 [0.91–0.95], p < .0001) and intensive procedure use (36.6% vs. 44.2%; AOR 0.72 [0.70–0.73], p <.0001). These differences were driven by greater use by blacks of life-sustaining treatments that predominate among decedents
but lesser use of cardiovascular and orthopedic procedures that predominate among survivors. A hospital’s black census was
a strong predictor of inpatient end-of-life treatment intensity.
CONCLUSIONS Black decedents were treated more intensively during hospitalization than nonblack decedents, whereas black survivors were
treated less intensively. These differences are strongly associated with a hospital’s black census. The causes and consequences
of these hospital-level differences in intensity deserve further study. 相似文献
9.
Patient Literacy and Question-asking Behavior During the Medical Encounter: A Mixed-methods Analysis
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Background Although patient participation in the medical encounter confers significant benefits, many patients are reluctant to ask questions
of their physicians. Patients’ literacy level may affect their level of participation and question-asking behaviors.
Objective To examine the effect of literacy on the number and types of questions asked by patients during primary care office visits.
Design Convenience sample recruited between April and November 2004. Physician–patient visits were audiotaped, and patient questions
from complete encounters (N = 57) were coded using an adaptation of the Roter Interaction Analysis System.
Patients Participants were predominantly middle-aged (mean age = 56.7 years), female (75.4%), and African American (94.7%). Low literacy
skills (≤6th grade reading level) were present in 38.6%.
Measurements We hypothesized prospectively that low-literacy patients would ask fewer total questions and fewer questions about key aspects
of their medical care.
Results Low-literacy adults asked significantly fewer questions about medical care issues (median = 4 vs 6 among patients with higher
literacy levels, p = .014). They also tended to ask fewer questions overall (median = 7 vs 10, p = .070). Low-literacy patients were more likely to ask the physician to repeat something (p = .013), indicating an initial lack of understanding. They were less likely to use medical terminology, refer to medications
by name, request additional services, or seek new information. Question-asking behavior was not significantly related to patient
gender, age, years of education, or physician–patient gender concordance.
Conclusions Literacy level appears to be an important determinant of patients’ participation in the medical encounter. Low-literacy patients
ask fewer questions about their medical care, and this may affect their ability to learn about their medical conditions and
treatments. 相似文献
10.
Fortney JC Pyne JM Edlund MJ Williams DK Robinson DE Mittal D Henderson KL 《Journal of general internal medicine》2007,22(8):1086-1093
Background Evidence-based practices designed for large urban clinics are not necessarily portable into smaller isolated clinics. Implementing
practice-based collaborative care for depression in smaller primary care clinics presents unique challenges because it is often not feasible
to employ on-site psychiatrists.
Objective The purpose of the Telemedicine Enhanced Antidepressant Management (TEAM) study was to evaluate a telemedicine-based collaborative care model adapted for small clinics without on-site psychiatrists.
Design Matched sites were randomized to the intervention or usual care.
Participants Small VA Community-based outpatient clinics with no on-site psychiatrists, but access to telepsychiatrists. In 2003–2004,
395 primary care patients with PHQ9 depression severity scores ≥12 were enrolled, and followed for 12 months. Patients with
serious mental illness and current substance dependence were excluded.
Measures Medication adherence, treatment response, remission, health status, health-related quality of life, and treatment satisfaction.
Results The sample comprised mostly elderly, white, males with substantial physical and behavioral health comorbidity. At baseline,
subjects had moderate depression severity (Hopkins Symptom Checklist, SCL-20 = 1.8), 3.7 prior depression episodes, and 67%
had received prior depression treatment. Multivariate analyses indicated that intervention patients were more likely to be
adherent at both 6 (odds ratio [OR] = 2.1, p = .04) and 12 months (OR = 2.7, p = .01). Intervention patients were more likely to respond by 6 months (OR = 2.0, p = .02), and remit by 12 months (OR = 2.4, p = .02). Intervention patients reported larger gains in mental health status and health-related quality of life, and reported
higher satisfaction.
Conclusions Collaborative care can be successfully adapted for primary care clinics without on-site psychiatrists using telemedicine technologies. 相似文献
11.
Cunningham CO Kunins HV Roose RJ Elam RT Sohler NL 《Journal of general internal medicine》2007,22(9):1325-1329
Background Illicit drug use is common among HIV-infected individuals. Buprenorphine enables physicians to simultaneously treat HIV and
opioid dependence, offering opportunities to improve health outcomes. Despite this, few physicians prescribe buprenorphine.
Objective To examine barriers to obtaining waivers to prescribe buprenorphine.
Design Cross-sectional survey study.
Participants 375 physicians attending HIV educational conferences in six cities in 2006.
Approach Anonymous questionnaires were distributed and analyzed to test whether confidence addressing drug problems and perceived barriers
to prescribing buprenorphine were associated with having a buprenorphine waiver, using chi-square, t tests, and logistic regression.
Results 25.1% of HIV physicians had waivers to prescribe buprenorphine. In bivariate analyses, physicians with waivers versus those
without waivers were less likely to be male (51.1 vs 63.7%, p < .05), more likely to be in New York (51.1 vs 29.5%, p < .01), less likely to be infectious disease specialists (25.5 vs 41.6%, p < .05), and more likely to be general internists (43.6 vs 33.5%, p < .05). Adjusting for physician characteristics, confidence addressing drug problems (adjusted odds ratio [AOR] = 2.05, 95%
confidence interval [95% CI] = 1.08–3.88) and concern about lack of access to addiction experts (AOR = 0.56, 95% CI = 0.32–0.97)
were significantly associated with having a buprenorphine waiver.
Conclusions Among HIV physicians attending educational conferences, confidence addressing drug problems was positively associated with
having a buprenorphine waiver, and concern about lack of access to addiction experts was negatively associated with it. HIV
physicians are uniquely positioned to provide opioid addiction treatment in the HIV primary care setting. Understanding and
remediating barriers HIV physicians face may lead to new opportunities to improve outcomes for opioid-dependent HIV-infected
patients. 相似文献
12.
Gender Differences in Aspirin use Among Adults With Coronary Heart Disease in the United States 总被引:1,自引:0,他引:1
Background Aspirin reduces mortality for men and women with coronary heart disease (CHD). Previous research suggests women with acute
coronary syndromes receive less aggressive care, including less frequent early administration of aspirin. The presence of
gender differences in aspirin use for secondary prevention is less clear.
Objective To determine if a gender difference exists in the use of aspirin for secondary prevention among individuals with CHD.
Design We analyzed data from the nationally representative 2000–2002 Medical Expenditure Panel Surveys to determine the prevalence
of regular aspirin use among men and women with CHD.
Participants Participants, 1,869, 40 years and older who reported CHD or prior myocardial infarction.
Results Women were less likely than men to use aspirin regularly (62.4% vs 75.6%, p < .001) even after adjusting for demographic, socioeconomic and clinical characteristics (adjusted OR = 0.62, 95% CI, 0.48–0.79).
This difference narrowed but remained significant when the analysis was limited to those without self-reported contraindications
to aspirin (79.8% vs 86.4%, P = .002, adjusted OR = 0.68, 95% CI, 0.48–0.97). Women were more likely than men to report contraindications (20.5% vs 12.5%,
P < .001). Differences in aspirin use were greater between women and men with private health insurance (61.8% vs 79.0%, P < .001, adjusted OR = 0.48, 95% CI, 0.35–0.67) than among those with public coverage (62.5% vs 70.7%, P = .04, adjusted OR = 0.74, 95% CI, 0.50–1.11) (P < .001 for gender–insurance interaction).
Conclusion We found a gender difference in aspirin use among patients with CHD not fully explained by differences in patient characteristics
or reported contraindications. These findings suggest a need for improved secondary prevention of cardiovascular events for
women with CHD. 相似文献
13.
Barry DT Moore BA Pantalon MV Chawarski MC Sullivan LE O'Connor PG Schottenfeld RS Fiellin DA 《Journal of general internal medicine》2007,22(2):242-245
Background Factors associated with satisfaction among patients receiving primary care–based buprenorphine/naloxone are unknown.
Objective To identify factors related to patient satisfaction in patients receiving primary care–based buprenorphine/naloxone that varied
in counseling intensity (20 vs 45 minutes) and office visit frequency (weekly vs thrice weekly).
Design and Participants One hundred and forty-two opioid-dependent subjects.
Measurements Demographics, drug treatment history, and substance use status at baseline and during treatment were collected. The primary
outcome was patient satisfaction at 12 weeks.
Results Patients’ mean overall satisfaction score was 4.4 (out of 5). Patients were most satisfied with the medication and ancillary
services and indicated strong willingness to refer a substance-abusing friend for the same treatment. Patients were least
satisfied with their interactions with other opioid-dependent patients, referrals to Narcotics Anonymous, and the inconvenience
of the treatment location. Female gender (β = .17, P = .04) and non-White ethnicity/race (β = .17, P = .04) independently predicted patient satisfaction. Patients who received briefer counseling and buprenorphine/naloxone
dispensed weekly had greater satisfaction than those whose medication was dispensed thrice weekly (mean difference 4.9, 95%
confidence interval 0.08 to 9.80, P = .03).
Conclusions Patients are satisfied with primary care office-based buprenorphine/naloxone. Providers should consider the identified barriers
to patient satisfaction.
The findings of this study were presented in part at the 67th annual scientific meeting of the College on Problems of Drug
Dependence, Orlando, FL, 22 June 2005. 相似文献
14.
Risk factors for cardiovascular disease and endothelin-1 levels in Takayasu arteritis patients 总被引:1,自引:0,他引:1
Alexandre Wagner Silva de Souza Henrique Ataíde Mariz Edgard Torres Reis Neto Anne Elizabeth Diniz Arraes Neusa Pereira da Silva Emília Inoue Sato 《Clinical rheumatology》2009,28(4):379-383
The objective of this study was to evaluate traditional risk factors for cardiovascular disease (CVD) and endothelin-1 (ET-1)
levels in Takayasu arteritis (TA) patients. Twenty-two TA patients and 37 controls were evaluated. TA patients had a higher
prevalence of hypertension (63.6% vs. 21.6%, p = 0.001) and higher levels of triglycerides (129.5 mg/dL ± 70.8 vs. 88.4 mg/dL ± 60.8, p = 0.017) than controls. Mean number of CVD risk factors was 1.64 ± 1.22 in TA patients and 1.03 ± 1.44 among controls, p = 0.030. More TA patients presented at least one CVD risk factor when compared to controls (77.2% vs. 51.3%, p = 0.048). ET-1 levels were higher in patients than in controls (1.49 pg/mL ± 0.45 vs. 1.27 pg/mL ± 0.32, p = 0.034), however no significant difference was found between patients with active and inactive disease. In this study, TA
patients presented a higher prevalence of hypertension, higher levels of triglycerides, and ET-1 than controls. 相似文献
15.
Ross JT TenHave T Eakin AC Difilippo S Oslin DW 《Journal of general internal medicine》2008,23(9):1379-1385
BACKGROUND Minor depression is almost twice as common in primary care (PC) as major depression. Despite the high prevalence, few evidence-based
algorithms exist for managing patients with minor depression or patients presenting solely with distress.
OBJECTIVES The aim of this study was to test the effectiveness of a telephone-based close monitoring program to manage PC patients with
minor depression or distress.
DESIGN Subjects were randomly assigned to either the control arm (usual care; UC) or the intervention arm (close monitoring; CM).
We hypothesized that those randomized to CM would exhibit less depression and be less likely to have symptoms progress to
the point of meeting diagnostic criteria.
SUBJECTS Overall, 223 PC subjects with minor depression or distress consented to participation in this trial.
MEASUREMENTS At baseline, subjects completed a telephone-based evaluation comprised of validated diagnostic assessments of depression and
other MH disorders. Outcomes were assessed at six months utilizing this same battery. Chart reviews were conducted to track
care received, such as prescribed antidepressants and MH and primary care visits.
RESULTS Subjects in the CM arm exhibited fewer psychiatric diagnoses than those in the UC arm (χ2 = 4.04, 1 df, p = 0.04). In addition, the intervention group showed improved overall physical health (SF-12 PCS scores) (M = 45.1, SD = 11.8
versus M = 41.5, SD = 12.4) (χ2 = 5.90, 1 df, p = .02).
CONCLUSIONS Those randomized to CM exhibited less MH problems at the conclusion of the trial, indicating that the close monitoring program
is effective, feasible and valuable. The findings of this study will allow us to enhance clinical care and support the integration
of mental health services and primary care. 相似文献
16.
Armstrong K McMurphy S Dean LT Micco E Putt M Halbert CH Schwartz JS Sankar P Pyeritz RE Bernhardt B Shea JA 《Journal of general internal medicine》2008,23(6):827-833
Context Although health care-related distrust may contribute to racial disparities in health and health care in the US, current evidence
about racial differences in distrust is often conflicting, largely limited to measures of physician trust, and rarely linked
to multidimensional trust or distrust.
Objective To test the hypothesis that racial differences in health care system distrust are more closely linked to values distrust than
to competence distrust.
Design Cross-sectional telephone survey.
Participants Two hundred fifty-five individuals (144 black, 92 white) who had been treated in primary care practices or the emergency department
of a large, urban Mid-Atlantic health system.
Primary measures Race, scores on the overall health care system distrust scale and on the 2 distrust subscales, values distrust and competence
distrust.
Results In univariate analysis, overall health care system distrust scores were slightly higher among blacks than whites (25.8 vs
24.1, p = .05); however, this difference was driven by racial differences in values distrust scores (15.4 vs 13.8, p = .003) rather than in competence distrust scores (10.4 vs 10.3, p = .85). After adjustment for socioeconomic status, health/psychological status, and health care access, individuals in the
top quartile of values distrust were significantly more likely to be black (odds ratio = 2.60, 95% confidence interval = 1.03–6.58),
but there was no significant association between race and competence distrust.
Conclusions Racial differences in health care system distrust are complex with far greater differences seen in the domain of values distrust
than in competence distrust. This framework may be useful for explaining the mixed results of studies of race and health care-related
distrust to date, for the design of future studies exploring the causes of racial disparities in health and health care, and
for the development and testing of novel strategies for reducing these disparities. 相似文献
17.
Okelo SO Wu AW Merriman B Krishnan JA Diette GB 《Journal of general internal medicine》2007,22(7):976-981
Background Racial differences in asthma care are not fully explained by socioeconomic status, care access, and insurance status. Appropriate
care requires accurate physician estimates of severity. It is unknown if accuracy of physician estimates differs between black
and white patients, and how this relates to asthma care disparities.
Objective We hypothesized that: 1) physician underestimation of asthma severity is more frequent among black patients; 2) among black
patients, physician underestimation of severity is associated with poorer quality asthma care.
Design, Setting and Patients We conducted a cross-sectional survey among adult patients with asthma cared for in 15 managed care organizations in the United
States. We collected physicians’ estimates of their patients’ asthma severity. Physicians’ estimates of patients’ asthma as
being less severe than patient-reported symptoms were classified as underestimates of severity.
Measurements Frequency of underestimation, asthma care, and communication.
Results Three thousand four hundred and ninety-four patients participated (13% were black). Blacks were significantly more likely
than white patients to have their asthma severity underestimated (OR = 1.39, 95% CI 1.08–1.79). Among black patients, underestimation
was associated with less use of daily inhaled corticosteroids (13% vs 20%, p < .05), less physician instruction on management of asthma flare-ups (33% vs 41%, p < .0001), and lower ratings of asthma care (p = .01) and physician communication (p = .04).
Conclusions Biased estimates of asthma severity may contribute to racially disparate asthma care. Interventions to improve physicians’
assessments of asthma severity and patient–physician communication may minimize racial disparities in asthma care. 相似文献
18.
Rossi M Mosca M Tani C Franzoni F Santoro G Bombardieri S 《Clinical rheumatology》2008,27(12):1485-1488
A number of studies based on conventional ultrasound scanning (CUS) gave contrasting results about the occurrence of early
atherosclerosis in patients with systemic lupus erythematosus (SLE), while no study on early arterial sclerosis in the same
patients are available. Recently, information on early arterial sclerosis can be provided by the integrated backscatter (IBS)
analysis which reflects the collagen and calcium content within the vascular wall. In order to evaluate if atherosis and/or
sclerosis of carotid arteries are early features of SLE, we performed carotid CUS and IBS analysis in 16 SLE patients (15
females; aged 37 ± 10 years), free from clinically evident cardiovascular diseases and cardiovascular risk factors, with the
only exception of five patients who had arterial hypertension. The same investigations were performed in 16 sex- and age-matched
healthy control subjects. No statistically significant difference was observed either in carotid corrected IBS values or in
carotid intima–media thickness (IMT) values between SLE patients and control subjects (−17.9 ± 2.5 dB vs −19.0 ± 1.7 dB, p = 0.14; 0.66 ± 0.08 mm vs 0.62 ± 0.13 mm, p = 0.35, respectively). The little sub-group of hypertensive SLE patients exhibited a significantly higher carotid corrected
IBS mean value compared to control subjects (−16.4 ± 3.1 dB vs −19.0 ± 1.7 dB, p = 0.026), while it did not significantly differ in carotid IMT value from control group (0.67 ± 0.09 mm vs 0.62 ± 0.13 mm,
respectively; p = 0.86). These findings show that neither atherosis nor sclerosis of carotid arteries are early features of SLE patients
free from cardiovascular risk factors. Further studies are needed to clearly demonstrate that early carotid sclerosis affects
hypertensive SLE patients. 相似文献
19.
Claudia Mendoza-Pinto Mario García-Carrasco Hilda Sandoval-Cruz Margarita Muñoz-Guarneros Ricardo O. Escárcega Mario Jiménez-Hernández Pamela Munguía-Realpozo Manuel Sandoval-Cruz Margarita Delezé-Hinojosa Aurelio López-Colombo Ricard Cervera 《Clinical rheumatology》2009,28(5):579-585
The aim of the current study was to analyze the role of traditional and systemic lupus erythematosus (SLE)-related risk factors
in the development of vertebral fractures. A cross-sectional study was performed in women with SLE attending a single center.
A vertebral fracture was defined as a reduction of at least 20% of vertebral body height. Two hundred ten patients were studied,
with median age of 43 years and median disease duration of 72 months. Osteopenia was present in 50.3% of patients and osteoporosis
in 17.4%. At least one vertebral fracture was detected in 26.1%. Patients with vertebral fractures had a higher mean age (50 ± 14
vs. 41 ± 13.2 years, p = 0.001), disease damage (57.1% vs. 34.4%, p = 0.001), lower bone mineral density (BMD) at the total hip (0.902 ± 0.160 vs. 982 ± 0.137 g/cm2, p = 0.002), and postmenopausal status (61.9% vs. 45.3%, p = 0.048). Stepwise logistic regression analysis revealed that only age (p = 0.001) and low BMD at the total hip (p = 0.007) remained as significant factors for the presence of vertebral fracture. The high prevalence of vertebral fractures
in the relatively young population implies that more attention must be paid to detect and treat vertebral fractures. 相似文献
20.
Objective To describe the development and psychometric testing of the Multidimensional Trust in Health Care Systems Scale (MTHCSS).
Methods Scale development occurred in 2 phases. In phase 1, a pilot instrument with 70 items was generated from the review of the
trust literature, focus groups, and expert opinion. The 70 items were pilot tested in a sample of 256 students. Exploratory
factor analysis was used to derive an orthogonal set of correlated factors. In phase 2, the final scale was administered to
301 primary care patients to assess reliability and validity. Phase 2 participants also completed validated measures of patient-centered
care, health locus of control, medication nonadherence, social support, and patient satisfaction.
Results In phase 1, a 17-item scale (MTHCSS) was developed with 10 items measuring trust in health care providers, 4 items measuring
trust in health care payers, and 3 items measuring trust in health care institutions. In phase 2, the 17-item MTHCSS had a
mean score of 63.0 (SD 8.8); the provider subscale had a mean of 40.0 (SD 6.2); the payers subscale had a mean of 12.8 (SD
3.0); and the institutions subscale had a mean of 10.3 (SD 2.1). Cronbach’s α for the MTHCSS was 0.89 and 0.92, 0.74, and 0.64 for the 3 subscales. The MTHCSS was significantly correlated with patient-centered
care (r = .22 to .62), locus of control—chance (r = .42), medication nonadherence (r = −.22), social support (r = .25), and patient satisfaction (r = .67).
Conclusions The MTHCSS is a valid and reliable instrument for measuring the 3 objects of trust in health care and is correlated with patient-level
health outcomes. 相似文献