Differential Effectiveness of Depression Disease Management for Rural and Urban Primary Care Patients

CONTEXT: Federally qualified health centers across the country are adopting depression disease management programs following federally mandated training; however, little is known about the relative effectiveness of depression disease management in rural versus urban patient populations. PURPOSE: To explore whether a depression disease management program has a comparable impact on clinical outcomes over 2 years in patients treated in rural and urban primary care practices and whether the impact is mediated by receiving evidence-based care (antidepressant medication and specialty care counseling). METHODS: A preplanned secondary analysis was conducted in a consecutively sampled cohort of 479 depressed primary care patients recruited from 12 practices in 10 states across the country participating in the Quality Enhancement for Strategic Teaming study. FINDINGS: Depression disease management improved the mental health status of urban patients over 18 months but not rural patients. Effects were not mediated by antidepressant medication or specialty care counseling in urban or rural patients. CONCLUSIONS: Depression disease management appears to improve clinical outcomes in urban but not rural patients. Because these programs compete for scarce resources, health care organizations interested in delivering depression disease management to rural populations need to advocate for programs whose clinical effectiveness has been demonstrated for rural residents.     

Diabetes Care and Outcomes: Disparities Across Rural America

We examined differences in receipt of diabetes care and selected outcomes between rural and urban persons living with diabetes, using nationally representative data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS). “Rural” was defined as living in a non-metropolitan county. Diabetes care variables were physician visit, HbA1c testing, foot examination, and dilated eye examination. Outcome variables were presence of foot sores and diabetic retinopathy. Analysis was limited to persons 18 and older self-reporting a diagnosis of diabetes (n = 29,501). A lower proportion of rural than urban persons with diabetes reported a dilated eye examination (69.1 vs. 72.4%; P = 0.005) or a foot examination in the past year (70.6 vs. 73.7%; P = 0.016). Conversely, a greater proportion of rural than urban persons reported diabetic retinopathy (25.8 vs. 22.0%; P = 0.007) and having a foot sore taking more than four weeks to heal (13.2 vs. 11.2%; P = 0.036). Rural residence was not associated with receipt of services after individual characteristics were taken into account in adjusted analysis, but remained associated with an increased risk for retinopathy (OR = 1.20, 95% CI = 1.02–1.42). Participation in Diabetes Self-Management Education (DSME) was positively associated with all measures of diabetes care included in the study. Availability of specialty services and travel considerations could explain some of these differences.     

Improving Diabetes Care for Minority,Uninsured and Underserved Patients

A local safety net clinic provides pharmacy directed Diabetes Disease Management (DDM). The purpose of the study was to determine if a program like this would be successful in an underserved, uninsured poor minority population. Clinic providers referred patients to the DDM visits. Body Mass Index (BMI), low-density lipoprotein, high-density lipoprotein (HDL), triglycerides and hemoglobin A1c (HbA1c) were recorded pre- and post-intervention. Those who participated in pre-intervention and post-intervention visit were included in the study and laboratory values were compared. Participants in the pilot study showed statistically significant improvements in HbA1c, triglycerides and BMI. HDL values did not show statistical change. Pharmacy directed DDM can be effective in the reduction of HbA1c and triglycerides. It also may be an effective weight loss intervention for patients with diabetes.     

Long-Term Clinical Outcomes of Care Management for Chronically Depressed Primary Care Patients: A Report From the Depression in Primary Care Project

PURPOSE Recent studies examining depression disease management report improvements in short-term outcomes, but less is known about whether improvements are sustainable over time. This study evaluated the sustained clinical effectiveness of low-intensity depression disease management in chronically depressed patients.METHODS The Depression in Primary Care (DPC) intervention was introduced in 5 primary care practices in the University of Michigan Health System, with 5 matched practices selected as control sites. Clinicians were free to refer none, some, or all of their depressed patients at their discretion. Core clinical outcomes of remission and serial change in Patient Health Questionnaire (PHQ-8) scores for 728 DPC enrollees observed for up to 18 months after enrollment were compared with those for 78 patients receiving usual care who completed mailed questionnaires at baseline, 6, 12, and 18 months.RESULTS DPC enrollees had sustained improvement in remission rates and reduced-function days over the full 18 months. Mean change in the PHQ-8 score over each 6-month interval was more favorable for DPC enrollees than for usual care patients, and the proportion of DPC enrollees in remission was higher at 6 months (43.4% vs 33.3%; P = .11), 12 months (52.0% vs 33.9%; P=.012), and 18 months (49.2% vs 27.3%; P = .004). Multivariate analysis controlling for age, sex, ethnicity, baseline severity, and comorbid medical illness confirmed that DPC enrollees had significantly more reduction in depressive symptom burden over 18 months.CONCLUSIONS The DPC intervention produced sustained improvement in clinical outcomes over 18 months in a cohort of chronically depressed patients with persistent symptoms despite active treatment.     

Multimorbidity in Patients Attending 2 Australian Primary Care Practices

PURPOSE

Multiple chronic conditions in a single patient can be a challenging health burden. We aimed to examine patterns and prevalence of multimorbidity among patients attending 2 large Australian primary care practices and to estimate disease severity burden using the Cumulative Illness Rating Scale (CIRS).

METHODS

Using published CIRS guidelines and a disease severity index calculated for each individual, we extracted data from the medical records of all 7,247 patients (58.5% female) seen over 6 months in 2008 who were rated for chronic conditions across 14 anatomical domains.

RESULTS

Fifty-two percent of patients had multimorbidity in 2 or more CIRS domains, ranging from 20.6% if younger than 25 years, 43.7% if aged 25 to 44 years, 75.5% if aged 45 to 64 years, 87.5% if aged 65 to 74 years, and 97.1% if aged 75 years and older. Using a cutoff of 3 or more CIRS domains, 34.5% had multimorbidity ranging from 4.8% if younger than 25 years, 22.3% if aged 25 to 44 years, 56.1% if aged 45 to 64 years, 74.6% if aged 65 to 74 years, and 92.0% if aged 75 years and older. Musculoskeletal, singularly or in combination with others, was the commonest morbidity domain. The moderate severity index category increased with increasing age.

CONCLUSIONS

Multimorbidity is a significant problem in men and women across all age-groups, and the moderate severity index increases with age. The musculoskeletal domain was most commonly affected. Mild and moderate severity index categories may underrepresent disease burden. Severity burden assessment in the primary care setting needs to take into account the severity index, as well as levels of domain severity within the index categories.     

Cost-Effectiveness of a Technology-Facilitated Depression Care Management Adoption Model in Safety-Net Primary Care Patients with Type 2 Diabetes

Background

The Diabetes-Depression Care-Management Adoption Trial is a translational study of safety-net primary care predominantly Hispanic/Latino patients with type 2 diabetes in collaboration with the Los Angeles County Department of Health Services.

The Ability of Aggregate Data to Predict Self-Sufficiency Levels in Subsidized Rural Primary Care Practices

American rural health policy has as its long-term goal the reallocation of health facilities and manpower to permit equitable access to primary care for all citizens. Rural health centers subsidized by governmental and philanthropic programs frequently have been placed in places of high need for their services. Yet both government and philanthropic policymakers expect these primary care practices to become economically self-sufficient within a few years of practice. The problem is how to assign rural practices to communities with a planning process that will enhance the likelihood that these conflicting goals of serving need and financial self-sufficiency will be achieved. This study uses actual 1980 self-sufficiency data from 167 randomly selected rural primary care clinics as the dependent variable. Independent variables for the corresponding communities five or more years earlier were taken from a database often used by policymakers to make site evaluations. These data tend to be selected from aggregate county level measures. Regression analysis were used to determine how well these data could predict actual self-sufficiency in later years. The result of the analysis is that these aggregate level data have little capacity to predict the ability of rural primary care practices to achieve self-sufficiency. Much better predictions can be made on the basis of local, practice-specific variables. Therefore, planning for economically viable rural practices calls for a much different forecasting approach.     

Ethical Disparities: Challenges Encountered by Multidisciplinary Providers in Fulfilling Ethical Standards in the Care of Rural and Minority People

ABSTRACT:  Context: Health care disparities are well documented for people living in rural areas and for people who are members of ethnic minorities. Purpose: Our goal was to determine whether providers report greater difficulty in providing care for rural than urban residents and for ethnic minorities than patients/clients in general in 4 practice areas of ethical relevance: attaining treatment adherence, assuring confidentiality, establishing therapeutic alliance, and engaging in informed consent processes. Methods: We received survey responses from 1,558 multidisciplinary medical and behavioral providers across rural and non-rural areas of New Mexico and Alaska in 2004 to assess a wide range of issues in providing health care. Findings: Providers reported some difficulties in fulfilling various ethical practices for all types of patients, but not more difficulty when caring for minority compared to nonminority patients/clients. However, they do report more frequent additional problems related to the practice issues of treatment adherence, therapeutic alliance, informed consent, and confidentiality with minority patients than others. Difficulties and more frequent additional problems are greater for providers in rural than in non-rural areas. Results generalize across both Alaska and New Mexico with few differences. Conclusions: We obtained evidence for disparity in care for patients/ clients who were minority group members, and clear evidence of disparity for people residing in rural compared to non-rural areas of 2 states with large rural areas.     

The Effects of Chronic Disease Management in Primary Health Care: Evidence from Rural China

Health systems globally face increasing morbidity and mortality from chronic diseases, yet many - especially in low- and middle-income countries - lack strong chronic disease management in primary health care (PHC). We provide evidence on China’s efforts to promote PHC management using unique five-year panel data in a rural county, including health care utilization from medical claims and health outcomes from biomarkers. Utilizing plausibly exogenous variation in management intensity generated by administrative and geographic boundaries, we compare hypertension/diabetes patients in villages within two kilometers distance but managed by different townships. Results show that, compared to patients in townships with median management intensity, patients in high-intensity townships have 4.8% more PHC visits, 5.2% fewer specialist visits, 11.7% lower likelihood of having an inpatient admission, and 3.6% lower medical spending. They also tend to have better medication adherence and better control of blood pressure. The resource savings from avoided inpatient admissions substantially outweigh the costs of the program.     

Healthcare Disparities in Hispanic Diabetes Care: A Propensity Score-Matched Study

Hispanics represent the largest minority group in the US. Research has shown that the ethnic minority especially Hispanics have a disproportionate burden of illness associated with diabetes mellitus. However, many have been focused on small sample sizes with potential selection bias. This study aims to examine the ethnicity disparity in health care utilization and expenditures between Hispanic and non-Hispanics after controlling for confounding variables. Cross-sectional with propensity score-matched design. The study revealed that Hispanics with diabetes had higher poverty rates, lower education, less physical activity, and less health care utilization/expenditures than did non-Hispanics. The assessment of ethnicity differences in health care is challenging because of the potential biases that require careful adjustment. This study successfully identified and controlled for confounding bias and concluded the Hispanics disparity in health care utilization still exists.     

农村社区糖尿病患者健康管理效果评价

目的评价农村社区卫生服务全科团队对糖尿病患者进行健康管理的效果。方法对径山镇社区卫生服务中心2012年和2013年两年间糖尿病患者健康管理情况进行统计分析。结果部分糖尿病患者的血糖水平得到了缓解与控制。对2012年和2013年干预前后指标比较分析发现,糖尿病患者血糖水平在4.40~6.10 mmol/L之间,分别增加了9.97%和21.34%,差异均具有统计学意义。结论社区健康管理对于缓解糖尿病患病现状具有较大的现实意义。应探索个性化健康管理,提升干预效果;建立社区健康小屋,引导患者自我管理;创新健康教育方式,提高患者的知晓率。     

Quality of Disease Management and Risk of Mortality in English Primary Care Practices

Objective

To investigate whether better management of chronic conditions by family practices reduces mortality risk.

Data

Two random samples of 5 million patients registered with over 8,000 English family practices followed up for 4 years (2004/5–2007/8). Measures of the quality of disease management for 10 conditions were constructed for each family practice for each year. The outcome measure was an indicator taking the value 1 if the patient died during a specified year, 0 otherwise.

Study Design

Cross-section and multilevel panel data multiple logistic regressions were estimated. Covariates included age, gender, morbidity, hospitalizations, attributed socio-economic characteristics, and local health care supply measures.

Principal Findings

Although a composite measure of the quality of disease management for all 10 conditions was significantly associated with lower mortality, only the quality of stroke care was significant when all 10 quality measures were entered in the regression.

Conclusions

The panel data results suggest that a 1 percent improvement in the quality of stroke care could reduce the annual number of deaths in England by 782 [95 percent CI: 423, 1140]. A longer study period may be necessary to detect any mortality impact of better management of other conditions.     

Improvements in Care and Reduced Self-management Barriers Among Rural Patients With Diabetes

CONTEXT: Improved preventive care and clinical outcomes among patients with diabetes can reduce complications and costs; however, diabetes care continues to be suboptimal. Few studies have described effective strategies for improving care among rural populations with diabetes. PURPOSE: In 2000, the Park County Diabetes Project and the Montana Diabetes Control Program collaboratively implemented a countywide effort, which included health systems interventions and coordinated diabetes education, to improve the quality of diabetes care. METHODS: Clinical data from the diabetes registries in 2 primary care practices, in addition to baseline and follow-up telephone surveys, were used to evaluate improvements in care, outcomes, education, and barriers to self-management. FINDINGS: In the cohort of patients, the proportion receiving the following services increased significantly from 2000 to 2003: annual foot examination (43% to 58%), influenza (30% to 53%), and pneumoccocal immunizations (39% to 70%). The median hemoglobin A1c values decreased significantly from baseline to follow-up (7.2% to 6.8%). Mean systolic and diastolic blood pressure decreased significantly over the 2 time periods (139 mmHg to 135 mmHg, and 78 mmHg to 75 mmHg, respectively). Significant decreases were also observed in barriers to self-management, including lack of knowledge (decrease from 12% to 5%), difficulties making lifestyle changes (36% to 27%), cost of monitors and test strips (25% to 16%), cost of medications (37% to 24%), and diabetes education (22% to 4%). CONCLUSIONS: Findings suggest that system changes in primary care practices and the implementation of accessible diabetes education can improve care and reduce barriers for rural patients with diabetes.     

Primary and Specialty Medical Care Among Ethnically Diverse, Older Rural Adults With Type 2 Diabetes: The ELDER Diabetes Study

PURPOSE: Residents in rural communities in the United States, especially ethnic minority group members, have limited access to primary and specialty health care that is critical for diabetes management. This study examines primary and specialty medical care utilization among a rural, ethnically diverse, older adult population with diabetes. METHODS: Data were drawn from a cross-sectional face-to-face survey of randomly selected African American (n=220), Native American (n=181), and white (n=297) Medicare beneficiaries > or =65 years old with diabetes in 2 rural counties in central North Carolina. Participants were asked about utilization of a primary care doctor and of specialists (nutritionist, diabetes specialist, eye doctor, bladder specialist, kidney specialist, heart specialist, foot specialist) in the past year. FINDINGS: Virtually all respondents (99.0%) reported having a primary care doctor and seeing that doctor in the past year. About 42% reported seeing a doctor for diabetes-related care. On average, participants reported seeing 2 specialists in the past year, and 54% reported i seeing >1 specialist. Few reported seeing a diabetes specialist (5.7%), nutritionist (10.9%), or kidney specialist (17.5%). African Americans were more likely than others to report seeing a foot specialist (P < .01), while men were more likely than women to have seen bladder specialist (P = .02), kidney specialist (P = .001), and heart specialist (P = .004), after adjusting for potential confounders. Predictors of the number of specialists seen include gender, education, poverty status, diabetes medication use, and self-rated health. CONCLUSIONS: These data indicate low utilization of specialty diabetes care providers across ethnic groups and reflect the importance of primary care providers in diabetes care in rural areas.