Bringing Psychotherapy to Primary Care: Innovations and Challenges

[Clin Psychol Sci Prac 17: 191–214, 2010] The segregation of mental health treatment and primary medical care in our health care system is increasingly recognized as anachronistic, as a majority of patients with psychosocial problems are turning to primary care providers. Accordingly, the development and dissemination of evidence‐based psychotherapeutic interventions compatible with the constraints of primary care is becoming increasingly urgent. This article discusses the importance of finding feasible ways to bring psychotherapy to primary care, examines interventions either specifically adapted for primary care or consistent with its constraints, assesses the compatibility of these interventions with the primary care environment, considers barriers inhibiting the widespread integration of such interventions into primary care, and discusses future directions.     

Health Locus of Control in a Primary Care Sample of Alcoholics and Nonalcoholics

Abstract

This study examined differences between alcoholics and nonalcoholics in a primary care population on the internal, chance, and powerful others sub-scales of the Multidimensional Health Locus of Control Scale (MHLC). Two hundred eighty subjects were divided into four groups (alcoholics with a family history of alcoholism, alcoholics with no family history of alcoholism, nonalcoholics with a family history of alcoholism, and nonalcoholics with no family history of the disease) based on DSM-III criteria for alcoholism and a family history of alcoholism. There were no differences between groups on the internal and powerful others scales. Nonalcoholics with a family history of alcoholism scored significantly lower on the chance scale than did alcoholics with a family history of the disease.     

Mental Health Needs of Older Adults and Primary Care: Opportunity for Interdisciplinary Geriatric Team Practice

The convergence of a number of disparate factors has led to opportunities to help address the mental health needs of older adults in primary care (PC) or "integrated care" settings. Older adults are disproportionately high users of health care resources, and cost projections for coming decades have catastrophic implications. Elders shun mental health services, instead turning to their personal physicians when troubled. The PC system is clogged with patients without medical problems or whose medical conditions are exacerbated by psychosocial factors (estimated at 60% to 70%), resulting in overutilization of services and high costs. However, PC physicians detect and adequately treat or refer only 40% to 50% of patients with mental health problems. Early experience with brief and/or structured interventions in PC settings is promising and suggests opportunities for multidisciplinary team geriatric practice.     

Pediatric Caregiver Attitudes Toward Email Communication: Survey in an Urban Primary Care Setting

Background

Overall usage of email communication between patients and physicians continues to increase, due in part to expanding the adoption of electronic health records and patient portals. Unequal access and acceptance of these technologies has the potential to exacerbate disparities in care. Little is known about the attitudes of pediatric caregivers with regard to their acceptance of email as a means to communicate with their health care providers.

Objective

We conducted a survey to assess pediatric caregiver access to and attitudes toward the use of electronic communication modalities to communicate with health care providers in an urban pediatric primary care clinic.

Methods

Participants were pediatric caregivers recruited from an urban pediatric primary care clinic in Baltimore, Maryland, who completed a 35-item questionnaire in this cross-sectional study.

Results

Of the 229 caregivers who completed the survey (91.2% response rate), 171 (74.6%) reported that they use email to communicate with others. Of the email users, 145 respondents (86.3%) stated that they would like to email doctors, although only 18 (10.7%) actually do so. Among email users, African-American caregivers were much less likely to support the expanded use of email communication with health care providers (adjusted OR 0.34, 95% CI 0.14-0.82) as were those with annual incomes less than US $30,000 (adjusted OR 0.26, 95% CI 0.09-0.74).

Conclusions

Caregivers of children have access to email and many would be interested in communicating with health care providers. However, African-Americans and those in lower socioeconomic groups were much less likely to have positive attitudes toward email.     

Gender-based profiling of Quality of Life (QOL) of primary health care (PHC) attendees in central Uganda: a cross sectional analysis

Objective

To analyze gender differences in QOL of patients presenting at PHC centres and to identify the socio-demographic variables associated with poor QOL.

Methods

This was a cross-sectional study. Consecutive adult patients at outpatient departments of three PHC centres were eligible. Those selected were interviewed using the WHOQOL-BREF, a 26-item questionnaire generating four domain scores of physical, psychological, environment and social relationships.

Results

The study had 446 respondents aged 18–84 years. Female parents significantly performed poorly on the physical health domain (OR 2.47: 95 % CI: 1.32 – 4.61). Respondents reported comparable scores on the 3 WHOQOL-BREF domains, except on poor physical health where being a parent had a positive association (OR 2.12; 95% CI: 1.27 – 3.55). Belonging to an age-range of 18–29 years had a positive association with poor physical health (OR 1.74; 95% CI: 1.13 – 2.68).

Conclusion

Generally, women reported poorer physical health. Health workers need orientation and training to appreciate the role of gender in health care. There is need to appreciate the complexities affecting QOL of women that are physically ill. Interventions aimed at improving patients'' QOL at PHC centres should take a gender-based perspective that recognizes the greater vulnerability of women to poor physical health.     

Children's Primary Health Care Services: A Social-Cognitive Model of Sustained High Use

Significant percentages of children exhibit patterns of sustained high use of primary health care services. Unfortunately, current models fail to explain the processes that drive and maintain such patterns. We draw upon the pediatric utilization and social-cognitive literature to develop a model that explains the mechanisms that ultimately drive and maintain patterns of prolonged high use. Specifically, we propose that parental stress and low self-efficacy for coping with various parenting and life demands interact to drive the utilization of pediatric services. We outlined sequelae of frequent physician that serve to maintain high use. This model suggests a number of psychological interventions that clinical health psychologists might undertake to remediate inappropriate, sustained high use of children's primary healthcare services.     

Primary lower limb lymphedema: a focus on its functional, social and emotional impact

Primary lymphedema is a rare, chronic and distressing condition with negative effects on physical, social and emotional level. The purpose of these reports was to present and discuss two different cases of primary lower limb lymphedema with a focus on its physical and mental impact and on some qualitative aspects of patients' self-reported experiences. The patients were recruited as they used occasional services within the University Hospital of Heraklion (Crete, Greece). The functional and mental impact of primary lymphedema was measured using the generic Medical Outcome Study short form-36 questionnaire and open-ended questions led to give more emphasis to patients' experiences. The analysis of short form-36 results in the first patient disclosed a significant functional impairment with a minor impact of the condition on emotional and social domains. For the second patient quality of life scores in the emotional and social domains were affected. Our findings support further the statement that physicians should pay full attention to appraise the patient's physical and emotional condition. General practitioners have the opportunity to monitor the long-term impact of chronic disorders. Posing simple open-ended questions and assessing the level of physical and mental deficits in terms of well-being through the use of specific metric tools can effectively follow-up rare conditions in the community.     

Assessing the Prioritization of Primary Care Referrals for Polysomnograms

Study Objective:

The mortality attributed to obstructive sleep apnea (OSA) is comparable to that of breast cancer and colon cancer. We sought to determine if patients at high risk for OSA were less likely to be referred by their primary care physician for polysomnograms (PSG) than mammograms or endoscopies.

Design:

Prospective cohort study; patients were recruited between January 2007 and April 2007.

Setting:

Academic public hospital system

Patients:

395 patients waiting for family or internal medicine primary care appointments were administered the Berlin questionnaire. Chart abstraction or interview determined demographics; insurance and employment status; body mass index (BMI); comorbidities; and prior PSG, mammography, or endoscopy referrals.

Results:

Mean BMI was 30 ± 7.4 kg/m²; 187 (47%) patients had high-risk Berlin scores. Overall, 19% of patients with high-risk Berlin scores were referred for PSG, compared to 63% of those eligible for mammograms and 80% of those eligible for endoscopies. Women (OR = 2.9, P = 0.02), COPD (OR = 4.6, P = 0.03), high-risk Berlin scores (OR = 3.4, P = 0.009), and higher BMI (OR = 1.1, P < 0.001) were positively associated with PSG referrals. Privately insured patients were less likely to be referred than uninsured patients (OR = 0.3, P = 0.04). There was no significant difference in referrals among those with other forms of insurance. Race was not associated with PSG referrals.

Conclusion:

In a public hospital, primary care patients were less likely to be referred for PSG compared to mammogram and endoscopy. Uninsured patients were more likely to be referred for PSG than those with private insurance. Further studies are needed to address the low PSG referral rates in high-risk populations.

Citation:

Thornton JD; Chandriani K; Thornton JG; Farooq S; Moallem M; Krishnan V; Auckley D. Assessing the prioritization of primary care referrals for polysomnograms. SLEEP 2010;33(9):1255-1260.     

Postnatal care: development of a psychometric multidimensional satisfaction questionnaire (the WOMBPNSQ) to assess women's views

Background

Postnatal care is the neglected area of pregnancy care, despite repeated calls to improve it. Changes would require assessment, which should include women''s views. No suitable satisfaction questionnaire exists to enable this.

Aim

To develop a multidimensional psychometric postnatal satisfaction self-completion instrument.

Setting

Ten maternity services in south west England from 2006-2009.

Method

Sources for questions were literature review, fieldwork, and related published instruments. Principal components analysis with varimax rotation was used to develop the final WOMen''s views of Birth Postnatal Satisfaction Questionnaire (WOMBPNSQ) version. Validity and internal reliability were assessed. Questionnaires were mailed 6-8 weeks postnatally (with one reminder).

Results

The WOMBPNSQ comprises 36 seven-point Likert questions (13 dimensions including general satisfaction). Of 300 women, 166 (55.3%) replied; of these 155 (95.1 %) were white, 152 (93.8%) were married or cohabiting, 135 (81.3%) gave birth in a consultant unit, 129 (78.6%) had a vaginal delivery; and 100 (60.6%) were multiparous. The 12 specific dimensions were: support from professionals or partner, or social support; care from GP and health visitor; advice on contraception, feeding baby, the mother''s health; continuity of care; duration of inpatient stay; home visiting; pain after birth. These have internal reliability (Cronbach''s alpha varying from 0.624 to 0.902). Various demographic and clinical characteristics were significantly associated with specific dimensions.

Conclusion

WOMBPNSQ could be used to assess existing or planned changes to maternity services or as a screening instrument, which would then enable in-depth qualitative assessment of areas of dissatisfaction. Its convergent validity and test-retest reliability are still to be assessed but are an improvement upon existing postnatal satisfaction questionnaires.     

The New Millennium Palliative Care Project (2000-2003): the impact of specialised GP advisors.

This study describes a novel type of support for GPs caring for patients dying at home: the establishment and evaluation of a telephone advisory service for GPs, run by GPs with a special interest in palliative care (GPwSIs) in the Netherlands 2000-2003. A growing number of GPs called for advice, 10% during out of hours. Prognosis of the patients was generally short (days to weeks in 70% of cases). Most advice sought by GPs concerned symptom management and on evaluation, 85% of the GPs followed the advice.     

Recorded quality of primary care for osteoarthritis: an observational study

Background

Osteoarthritis is the most common chronic disease in the UK, with greater prevalence in women, older people, and those with poorer socioeconomic status. Effective treatments are available, yet little is known about the quality of primary care for this disabling condition.

Aim

To measure the recorded quality of primary care for osteoarthritis, and assess variavariations by patient and/or practice characteristics.

Design of study

Retrospective observational study.

Setting

Eighteen general practices in England.

Method

Records of 320/393 randomly selected patients with osteoarthritis (response rate 81%) were reviewed. High-quality health care was specified by nine quality indicators. Logistic regression modelling assessed variations in quality by age, sex, deprivation, severity, time since diagnosis, and practice size.

Results

There was substantial variation in the recorded achievement of individual indicators (range 5% to 90%). The percentage of eligible patients whose records show that they received care in the form of information provision ranged from 17% to 30%. For regular assessment indicators the range was 27% to 43%, and for treatment indicators the range was 5% to 90%. Recorded achievement of quality indicators was higher in those with more severe osteoarthritis (odds ratio [OR] 1.38, 95% CI = 1.13 to 1.69) and in older patients (OR 1.14, 95% CI = 1.02 to 1.28). There were no significant variations by deprivation score.

Conclusion

This study has demonstrated the feasibility of using existing robust quality indicators to measure the quality of primary care for osteoarthritis, and has found considerable scope for improvement in the recording of high-quality care. The lack of variation between practices suggests that system-level initiatives may be needed to achieve improvement. One challenge will be to improve care for all, without losing the equitable distribution of care identified.     

Recorded quality of care for depression in general practice: an observational study

Background

Depression is a leading cause of disease and disability internationally, and is responsible for many primary care consultations. Little is known about the quality of primary care for depression in the UK.

Aim

To determine the prevalence of good-quality primary care for depression, and to analyse variations in quality by patient and practice characteristics.

Design of study

Retrospective observational study.

Setting

Eighteen general practices in England.

Method

Medical records were examined for 279 patients. The percentage of eligible participants diagnosed with depression who received the care specified by each of six quality indicators in 2002 and 2004 was assessed. Associations between quality achievement and age, sex, patient deprivation score, timepoint, and practice size were estimated using logistic regression.

Results

There was very wide variation in achievement of different indicators (range 1–97%). Achievement was higher for indicators referring to treatment and follow-up than for indicators referring to history taking. Achievement of quality indicators was low overall (37%). Quality did not vary significantly by patient or practice characteristics.

Conclusion

There is substantial scope for improvement in the quality of primary care for depression, if the highest achievement rates could be matched for all indicators. Given the lack of variation by practice characteristics, system-level and educational interventions may be the best ways to improve quality. The equitable distribution of quality by patient deprivation score is an important achievement that may be challenging to maintain as quality improves.     

Primary care quality indicators for children: measuring quality in UK general practice

Background

Child health care is an important part of the UK general practice workload; in 2009 children aged <15 years accounted for 10.9% of consultations. However, only 1.2% of the UK’s Quality and Outcomes Framework pay-for-performance incentive points relate specifically to children.

Aim

To improve the quality of care provided for children and adolescents by defining a set of quality indicators that reflect evidence-based national guidelines and are feasible to audit using routine computerised clinical records.

Design and setting

Multi-step consensus methodology in UK general practice.

Method

Four-step development process: selection of priority issues (applying nominal group methodology), systematic review of National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) clinical guidelines, translation of guideline recommendations into quality indicators, and assessment of their validity and implementation feasibility (applying consensus methodology used in selecting QOF indicators).

Results

Of the 296 national guidelines published, 48 were potentially relevant to children in primary care, but only 123 of 1863 recommendations (6.6%) met selection criteria for translation into 56 potential quality indicators. A further 13 potential indicators were articulated after review of existing quality indicators and standards. Assessment of the validity and feasibility of implementation of these 69 candidate indicators by a clinical expert group identified 35 with median scores 8 on a 9-point Likert scale. However, only seven of the 35 achieved a GRADE rating >1 (were based on more than expert opinion).

Conclusion

Producing valid primary care quality indicators for children is feasible but difficult. These indicators require piloting before wide adoption but have the potential to raise the standard of primary care for all children.     

National Trends in Hospitalization for Ambulatory Care Sensitive Conditions among Korean Adults between 2008 and 2019

PurposeThis study aimed to examine 12-year trends in hospitalization rates for ambulatory care sensitive conditions (ACSC) and factors affecting hospitalization.Materials and MethodsThis study used data on Korean National Health Insurance and Medical Aid patients aged 19 and over who used medical services at least once between January 2008 and December 2019 with an ACSC as their major diagnosis. As of 2019, a total of 12324071 patients were included. To check for any changes in hospitalization, age- and sex-standardized hospitalization rates were obtained for each condition and insurance type, and multiple logistic regression was performed to identify factors affecting hospitalization.ResultsThe collective average ACSC hospitalization rate decreased from 5.0% in 2008 to 4.2% in 2019. Specifically, hospitalization rates for hypertension (1.4% in 2008; 0.8% in 2019), diabetes (5.8% in 2008; 3.3% in 2019), and chronic obstructive pulmonary disease and asthma (4.1% in 2008; 3.2% in 2019) decreased, while rates for pneumonia (24.5% in 2008; 28.1% in 2019) and urinary tract infection (UTI) (5.7% in 2008; 6.4% in 2019) increased. The rate for heart failure decreased 2.3% between 2008 and 2012 and then rebounded. The odds of hospitalization among Medical Aid patients were 1.45–4.20 times higher than those of National Health Insurance patients.ConclusionDifferences in trends were confirmed for ACSC hospitalization rates among different conditions and insurance types in Korea. These results suggest the need for policy reforms aimed at reducing hospitalization for heart failure, pneumonia, and UTI, especially among Medical Aid patients.     

Patient-reported areas for quality improvement in general practice: a cross-sectional survey

Background

GPs are often a patient’s first point of contact with the health system. The increasing demands imposed on GPs may have an impact on the quality of care delivered. Patients are well placed to make judgements about aspects of care that need to be improved.

Aim

To determine whether general practice patients perceive that the care they receive is ‘patient-centred’ across eight domains of care, and to determine the association between sociodemographic, GP and practice characteristics, detection of preventive health risks, and receipt of patient-centred care.

Design and setting

Cross-sectional survey of patients attending Australian general practice clinics.

Method

Patients completed a touchscreen survey in the waiting room to rate the care received from their GP across eight domains of patient-centred care. Patients also completed the Patient Health Questionnaire (PHQ-9) and self-reported health risk factors. GPs completed a checklist for each patient asking about the presence of health risk factors.

Results

In total 1486 patients and 51 GPs participated. Overall, 83% of patients perceived that the care they received was patient-centred across all eight domains. Patients most frequently perceived the ‘access to health care when needed’ domain as requiring improvement (8.3%). Not having private health insurance and attending a practice located in a disadvantaged area were significantly associated with perceived need for improvements in care (P<0.05).

Conclusion

Patients in general practice report that accessibility is an aspect of care that could be improved. Further investigation of how indicators of lower socioeconomic status interact with the provision of patient-centred care and health outcomes is required.     

The UK pay-for-performance programme in primary care: estimation of population mortality reduction

Background

General practices in the UK contract with the government to receive additional payments for high-quality primary care. Little is known about the resulting impact on population health.

Aim

To estimate the potential reduction in population mortality from implementation of the pay-for-performance contract in England.

Design of study

Cross-sectional and modelling study.

Setting

Primary care in England.

Method

Twenty-five clinical quality indicators in the contract had controlled trial evidence of mortality benefit. This was combined with condition prevalence, and the differences in performance before and after contract implementation, to estimate the potential mortality reduction per indicator. Improvement was adjusted for pre-existing trends where data were available.

Results

The 2004 contract potentially reduced mortality by 11 lives per 100 000 people (lower–upper estimates 7–16) over 1 year, as performance improved from baseline to the target for full incentive payment. If all eligible patients were treated, over and above the target, 56 (29–81) lives per 100 000 might have been saved. For the 2006 contract, mortality reduction was effectively zero, because new baseline performance for a typical practice had already exceeded the target performance for full payment.

Conclusion

The contract may have delivered substantial health gain, but potential health gain was limited by performance targets for full payment being set lower than typical baseline performance. Information on both baseline performance and population health gain should inform decisions about future selection of indicators for pay-for-performance schemes, and the level of performance at which full payment is triggered.     

Behavioral Health Services in Primary Care: A New Perspective for Treating Depression

This article attempts to provide information, inspiration, and practical guidelines for mental health professionals who want to work with primary care providers. Depression is an ideal initial focus in starting primary care behavioral services because (1) the majority of currently available efficacy studies on primary care behavioral hearth interventions concern depression and (2) depression is highly prevalent in the primary care setting. Several large clinical trials indicate that on-site mental health services help primary care providers improve quality of care to depressed primary care patients. This article examines five key questions and suggests two service delivery models to help mental health providers plan initiatives that Integrate medical and behavioral health care in the primary care setting.     

Primary care access and its relationship with emergency department utilisation: an observational, cross-sectional, ecological study

Background

Recent health service policies in the UK have focused on improving primary care access in order to reduce the use of costly emergency department services, even though the relationship between the two is based on weak or little evidence. Research is required to establish whether improving primary care access can influence emergency department attendance.

Aim

To ascertain whether a relationship exists between the degree of access to GP practices and avoidable emergency department attendances in an inner-London primary care trust (PCT).

Design and setting

Observational, cross-sectional ecological study in 68 general practices in Brent Primary Care Trust, north London, UK.

Method

GP practices were used as the unit of analysis and avoidable emergency department attendance as the dependent variable. Routinely collected data from GP practices, Hospital Episode Statistics, and census data for the period covering 2007–2009 were used across three broad domains: GP access characteristics, population characteristics, and health status aggregated to the level of the GP practice. Multiple linear regression was used to ascertain which variables account for the variation in emergency department attendance experienced by patients registered to each GP practice.

Results

None of the GP access variables accounted for the variation in emergency department attendance. The only variable that explained this variance was the Index of Multiple Deprivation (IMD). For every unit increase in IMD score of the GP practice, there would be an increase of 6.13 (95% CI = 4.56, 7.70) per 1000 patients per year in emergency department attendances. This accounted for 47.9% of the variance in emergency department attendances in Brent.

Conclusion

Avoidable emergency department attendance appears to be mostly driven by underlying deprivation rather than by the degree of access to primary care.