Screening and Follow-Up Monitoring for Substance Use in Primary Care: An Exploration of Rural–Urban Variations

BACKGROUND

Rates of substance use in rural areas are close to those of urban areas. While recent efforts have emphasized integrated care as a promising model for addressing workforce shortages in providing behavioral health services to those living in medically underserved regions, little is known on how substance use problems are addressed in rural primary care settings.

OBJECTIVE

To examine rural–urban variations in screening and monitoring primary care- based patients for substance use problems in a state-wide mental health integration program.

DESIGN

This was an observational study using patient registry.

SUBJECTS

The study included adult enrollees (n?=?15,843) with a mental disorder from 133 participating community health clinics.

MAIN OUTCOMES

We measured whether a standardized substance use instrument was used to screen patients at treatment entry and to monitor symptoms at follow-up visits.

KEY RESULTS

While on average 73.6 % of patients were screened for substance use, follow-up on substance use problems after initial screening was low (41.4 %); clinics in small/isolated rural settings appeared to be the lowest (13.6 %). Patients who were treated for a mental disorder or substance abuse in the past and who showed greater psychiatric complexities were more likely to receive a screening, whereas patients of small, isolated rural clinics and those traveling longer distances to the care facility were least likely to receive follow-up monitoring for their substance use problems.

CONCLUSIONS

Despite the prevalent substance misuse among patients with mental disorders, opportunities to screen this high-risk population for substance use and provide a timely follow-up for those identified as at risk remained overlooked in both rural and urban areas. Rural residents continue to bear a disproportionate burden of substance use problems, with rural–urban disparities found to be most salient in providing the continuum of services for patients with substance use problems in primary care.

     

Trends and Quality of Care in Outpatient Visits to Generalist and Specialist Physicians Delivering Primary Care in the United States, 1997–2010

BACKGROUND

Although many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain.

OBJECTIVE

To describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs.

DESIGN

Cross-sectional study and time trend analysis.

DATA

Nationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997–2010.

MAIN MEASURES

Proportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality.

KEY RESULTS

Among 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p?=?0.04). The proportion of medical specialist visits in which the physician self-identified as the patient’s PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p?<?0.01). Medical specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p?<?0.01), primarily for preventive care (54.0 %, p?<?0.01). Quality of care for cardiovascular disease was better in visits to cardiologists than in visits to generalists, but was similar or better in visits to generalists compared to visits to other medical specialists.

CONCLUSIONS

Medical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.     

Factors Associated with Parent–Child Communication About HIV/AIDS in the United States and Kenya: A Cross-Cultural Comparison

This study explored parent–child communication about HIV/AIDS among two populations disproportionately affected by HIV. Similar computer-assisted surveys were completed by parents of pre-teens, including 1,115 African American parents of 9–12-year-old children in southeastern US and 403 parents of 10–12-year-old children in Nyanza Province, Kenya. Multivariate analyses identified factors associated with parental report of ever talking to their child about HIV/AIDS. Twenty-nine percent of US parents and 40% in Kenya had never talked to their pre-teen about HIV/AIDS. In both countries, communication was more likely if parents perceived their child to be ready to learn about sex topics, had gotten information to educate their child about sex, and had greater sexual communication responsiveness (skill, comfort, and confidence communicating about sexuality). Programs are needed that help parents assess children’s readiness to learn about sexual issues; access accurate information about adolescent sexual risks; and acquire the responsiveness needed to discuss sexual issues, including HIV/AIDS.     

Utilization of lipid lowering medications among adults in the United States 1999–2006

ObjectiveWe examined the use of lipid lowering medications and control of dyslipidemia among US adults in 1999–2006.MethodsData were extracted from the National Health and Nutrition Examination Survey 1999–2006.ResultsThe mean low-density lipoprotein-cholesterol (LDL-C) level significantly decreased from 3.25 ± 0.03 mmol/L in 1999–2002 to 3.02 ± 0.02 mmol/L in 2003–2006 in men, and from 3.11 ± 0.03 to 2.98 ± 0.03 mmol/L in women (p < 0.001). Statins and fibrates were the most commonly used medications. Among those diagnosed with hypercholesterolemia, the proportion on treatment increased from 32.4% to 38.9% (p = 0.001) in the 8-year period. The proportion of participants with a history of diabetes treated with a statin increased from 20.9 ± 2.2% in 1999–2002 to 37.6 ± 2.5% in 2003–2006 (p < 0.001). However, only 39.9% of people with diabetes and 45.4% of people with ischemic heart disease (IHD) achieved LDL-C target levels.ConclusionsBetween 1999 and 2006, LDL-C level decreased in US adults and use of lipid lowering medications increased. More effort is still needed to detect and treat dyslipidemia in the community, particularly in people at high cardiovascular risk.     

ESRD From Lupus Nephritis in the United States, 1995–2010

Background and objectives

While ESRD from lupus nephritis (ESLN) increased in the United States after the mid-1990s and racial disparities were apparent, current trends are unknown.

Design, setting, participants, & measurements

Retrospective US Renal Data System data (n=1,557,117) were used to calculate standardized incidence ratios (standardized to 1995–1996) and outcomes of ESLN (n=16,649). For events occurring after initiation of RRT, follow-up ended on June 30, 2011.

Results

Overall ESLN rates (95% confidence intervals [95% CIs]) in 1995–1996 were 3.1 (2.9 to 3.2) cases per million per year. Rates were higher for subgroups characterized by African-American race (11.1 [95% CI, 10.3 to 11.9]); other race (4.9 [95% CI, 4.0 to 5.8]); female sex (4.9 [95% CI, 4.6 to 5.2]); and ages 20–29 years (4.9 [95% CI, 4.4 to 5.4]), 30–44 years (4.6 [95% CI, 4.2 to 5.0]), and 45–64 years (4.0 [95% CI, 3.7 to 4.4]). Standardized incidence ratios for the overall population in subsequent biennia were 1.19 (1.14 to 1.24) in 1997–1998, 1.17 (1.12 to 1.22) in 1999–2000, 1.17 (1.12 to 1.22) in 2001–2002, 1.21 (1.16 to 1.26) in 2003–2004, 1.18 (1.13 to 1.23) in 2005–2006, 1.16 (1.11 to 1.21) in 2007–2008, and 1.05 (1.01 to 1.09) in 2009–2010, respectively. During a median (interquartile range) follow-up of 4.4 (6.3) years, 42.6% of patients with ESLN died, 45.3% were listed for renal transplant, and 28.7% underwent transplantation. Patients with ESLN were more likely than matched controls to be listed for and to undergo transplantation, and mortality rates were similar. Among patients with ESLN, African Americans were less likely to undergo transplantation (adjusted hazard ratio, 0.54 [0.51 to 0.58]) and more likely to die prematurely (adjusted hazard ratio, 1.23 [1.17 to 1.30]).

Conclusions

While ESLN appears to have stopped increasing in the last decade, racial disparities in outcomes persist.     

Jamestown Canyon Virus Disease in the United States—2000–2013

Jamestown Canyon virus (JCV) is a mosquito-borne orthobunyavirus in the California serogroup that can cause an acute febrile illness, meningitis, or meningoencephalitis. We describe epidemiologic and clinical features for JCV disease cases occurring in the United States during 2000–2013. A case of JCV disease was defined as an acute illness in a person with laboratory evidence of a recent JCV infection. During 2000–2013, we identified 31 cases of JCV disease in residents of 13 states. The median age was 48 years (range, 10–69) and 21 (68%) were male. Eleven (35%) case patients had meningoencephalitis, 6 (19%) meningitis, 7 (23%) fever without neurologic involvement, and 7 (23%) had an unknown clinical syndrome. Fifteen (48%) were hospitalized and there were no deaths. Health-care providers and public health officials should consider JCV disease in the differential diagnoses of viral meningitis and encephalitis, obtain appropriate specimens for testing, and report cases to public health authorities.Jamestown Canyon virus (JCV) is a mosquito-borne orthobunyavirus that causes an acute febrile illness, meningitis, or meningoencephalitis.^1–5 Although JCV is widely distributed throughout temperate North America, reports of human JCV infection in the United States are rare.¹ JCV was first isolated in 1961 from a pool of Culiseta inornata mosquitoes in Jamestown Canyon, CO.⁶ Since then, the virus has been isolated from various mosquito species (e.g., Aedes, Coquillettidia, Culex, and Culiseta species) in the northeastern, midwestern, and western United States.^6–19 JCV neutralizing antibodies have been found in various mammals throughout mainland North America,^13,20–36 and identified in humans throughout the United States.^{1–5,34,37–41}JCV is a member of the California serogroup viruses, which include La Crosse virus (LACV), California encephalitis virus, and snowshoe hare virus.⁴² Although the presence of anti-JCV immunoglobulin (Ig) M detected by enzyme-linked immunosorbent assay (ELISA) is usually evidence of a recent JCV infection, it also may indicate infection with another closely related California serogroup virus.^35,42,43 Plaque reduction neutralization tests (PRNTs) can be performed to measure virus-specific neutralizing antibodies and to potentially discriminate among cross-reacting antibodies from closely related California serogroup viruses.^44,45Prior to 2014, testing for JCV infection in the United States was performed at the Arboviral Diseases Branch of the Centers for Disease Control and Prevention (CDC) and at the Wadsworth Laboratory of the New York State Department of Health (NYSDOH). Since 2000, NYSDOH has been able to perform JCV PRNTs on acute and convalescent samples testing positive for California serogroup IgG antibodies by immunofluorescence assay. At the CDC, PRNTs have been used to detect JCV neutralizing antibodies since 1995. All samples testing positive or equivocal for LACV IgM antibodies by ELISA at the CDC have JCV PRNTs performed. A JCV IgM ELISA was developed at the CDC in 2010. Beginning in 2013, all samples submitted to the CDC for domestic arbovirus testing were routinely tested for JCV IgM antibodies by ELISA, and if positive, were confirmed by JCV PRNTs. We describe the demographic and clinical characteristics of laboratory-confirmed cases of JCV disease occurring in the United States during 2000–2013.     

Outpatient Experience of Patients with GERD in the United States: Analysis of the 1998–2001 National Ambulatory Medical Care Survey

This study documents the number of ambulatory visits associated with gastroesophageal reflux disease (GERD) in the United States. Sample data from nearly 80,000 patients captured by the National Ambulatory Medical Care Survey (NAMCS; 1998–2001) were analyzed. Basic demographics of patients with GERD and factors associated with each visit were assessed. Approximately 38.53 million of 2.653 billion adult outpatient visits made in the United States during the study period were GERD-related. GERD-related visits increased by 46.5% from 1998 to 2001. Most GERD-related visits were by women (54.7%) with an average age of 56.0 years, compared with patients without GERD, who were even more likely to be women (62.2%) and younger (52.6 years). Patients with GERD were more likely to have multiple reasons (50.5%) and multiple diagnoses (79.3%) per medical visit versus non-GERD patients (37.6% and 48.4%, respectively). Utilization of data from the NAMCS reveals that GERD-related visits increased annually during the study period. Patients with GERD are more likely to see a physician if they have concomitant medical conditions, making GERD a condition that is very likely untreated in a high percentage of individuals. Dr. Niemcryk is currently affiliated with Bristol-Myers Squibb, Wallingford, Connecticut. This study was conducted by AstraZeneca LP.     

Is Population-Wide Diuretic Use Directly Associated With the Incidence of End-Stage Renal Disease in the United States?: A Hypothesis

BACKGROUND: We introduce the hypothesis that population-wide use of diuretics might be associated with acceleration of the incidence of end-stage renal disease (ESRD). METHODS: Based on the technique of data fusion, pooled-data trends in disease incidence and antihypertensive medication use were examined to determine whether changes in drug use patterns are predictive of disease emergence in the United States. National databases for all-cause cardiovascular disease (CVD) mortality and stroke mortality from the National Vital Statistics Registry, renal failure data obtained from the United States Renal Data Service, and drug information obtained from IMS Health (Fairfield, CT) were examined. RESULTS: A statistically significant inverse relationship was observed between all-cause CVD mortality rates and ESRD incidence rates for the period 1980 to 1998 (r = -0.98948; P < .0001). A statistically significant direct time-lagged relationship was found between both annual changes in diuretic distribution and total diuretic expenditure to annual changes in the ESRD growth rate (r = 0.754, P = .03, r(2) = 0.568, 95% CI for slope = 0.08975 to 1.3010). CONCLUSIONS: Increasing annual diuretic distribution in the US is directly associated with accelerated time-lagged growth rates of ESRD incidence. One potential explanation is that diuretic therapy could promote ESRD expression. A large-scale, randomized, controlled trial to investigate acceleration of ESRD by diuretics would be justifiable. The data invites the hypothesis that reliance on nondiuretic antihypertensive therapies such as calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers might attenuate the epidemic rise of ESRD that is prevalent in the United States.     

Toxoplasma gondii Seroprevalence in the United States 2009–2010 and Comparison with the Past Two Decades

Toxoplasma gondii is a ubiquitous parasite that can cause neurologic and ocular disease. We tested sera from 7,072 people ≥ 6 years of age in the 2009–2010 National Health and Nutrition Examination Survey (NHANES) for immunoglobulin G antibodies and compared these results with two previous NHANES studies. The overall T. gondii antibody seroprevalence among persons ≥ 6 years of age in 2009–2010 was 13.2% (95% confidence limit [CL] 11.8%, 14.5%) and age-adjusted seroprevalence was 12.4% (95% CL 11.1%, 13.7%); age-adjusted seroprevalence among women 15–44 years of age was 9.1% (95% CL 7.2%, 11.1%). In U.S. born persons 12–49 years of age, the age-adjusted T. gondii seroprevalence decreased from 14.1% (95% CL 12.7%, 15.5%) in NHANES III (1988–1994) to 9.0% (95% CL 7.6%, 10.5%) in NHANES 1999–2004 to 6.7% (95% CL 5.3%, 8.2%) in NHANES 2009–2010 (P < 0.001 linear trend). Although T. gondii antibody presence is still relatively common, the prevalence in the United States has continued to decline.     

Patient–Physician Communication in the Primary Care Visits of African Americans and Whites with Depression

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.     

Meteorological Conditions Associated with Increased Incidence of West Nile Virus Disease in the United States, 2004–2012

West Nile virus (WNV) is a leading cause of mosquito-borne disease in the United States. Annual seasonal outbreaks vary in size and location. Predicting where and when higher than normal WNV transmission will occur can help direct limited public health resources. We developed models for the contiguous United States to identify meteorological anomalies associated with above average incidence of WNV neuroinvasive disease from 2004 to 2012. We used county-level WNV data reported to ArboNET and meteorological data from the North American Land Data Assimilation System. As a result of geographic differences in WNV transmission, we divided the United States into East and West, and 10 climate regions. Above average annual temperature was associated with increased likelihood of higher than normal WNV disease incidence, nationally and in most regions. Lower than average annual total precipitation was associated with higher disease incidence in the eastern United States, but the opposite was true in most western regions. Although multiple factors influence WNV transmission, these findings show that anomalies in temperature and precipitation are associated with above average WNV disease incidence. Readily accessible meteorological data may be used to develop predictive models to forecast geographic areas with elevated WNV disease risk before the coming season.     

Decreasing Clostridium difficile–Associated Fatality Rates Among Hospitalized Patients in the United States: 2004-2014

Background

Clostridium difficile infection has emerged as a major public health problem in the United States over the last 2 decades. We examined the trends in the C. difficile–associated fatality rate, hospital length of stay, and hospital charges over the last decade.

Links Between Socio-Economic Circumstances and Changes in Smoking Behavior in the Mexican Population: 2002–2010

While deleterious consequences of smoking on health have been widely publicized, in many developing countries, smoking prevalence is high and increasing. Little is known about the dynamics underlying changes in smoking behavior. This paper examines socio-economic and demographic characteristics associated with smoking initiation and quitting in Mexico between 2002 and 2010. In addition to the influences of age, gender, education, household economic resources and location of residence, changes in marital status, living arrangements and health status are examined. Drawing data from the Mexican Family Life Survey, a rich population-based longitudinal study of individuals, smoking behavior of individuals in 2002 is compared with their behavior in 2010. Logistic models are used to examine socio-demographic and health factors that are associated with initiating and quitting smoking. There are three main findings. First, part of the relationship between education and smoking reflects the role of economic resources. Second, associations of smoking with education and economic resources differ for females and males. Third, there is considerable heterogeneity in the factors linked to smoking behavior in Mexico indicating that the smoking epidemic may be at different stages in different population subgroups. Mexico has recently implemented fiscal policies and public health campaigns aimed at reducing smoking prevalence and discouraging smoking initiation. These programs are likely to be more effective if they target particular socio-economic and demographic sub-groups.     

Rocky Mountain Spotted Fever in the United States, 2000–2007: Interpreting Contemporary Increases in Incidence

Rocky Mountain spotted fever (RMSF), a potentially fatal tick-borne infection caused by Rickettsia rickettsii, is considered a notifiable condition in the United States. During 2000 to 2007, the annual reported incidence of RMSF increased from 1.7 to 7 cases per million persons from 2000 to 2007, the highest rate ever recorded. American Indians had a significantly higher incidence than other race groups. Children 5–9 years of age appeared at highest risk for fatal outcome. Enzyme-linked immunosorbent assays became more widely available beginning in 2004 and were used to diagnose 38% of cases during 2005–2007. The proportion of cases classified as confirmed RMSF decreased from 15% in 2000 to 4% in 2007. Concomitantly, case fatality decreased from 2.2% to 0.3%. The decreasing proportion of confirmed cases and cases with fatal outcome suggests that changes in diagnostic and surveillance practices may be influencing the observed increase in reported incidence rates.