Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care

BACKGROUND: Primary care treatment of depression needs improvement. OBJECTIVE: To evaluate the efficacy of 2 augmentations to antidepressant drug treatment. DESIGN: Randomized trial comparing usual care, telehealth care, and telehealth care plus peer support; assessments were conducted at baseline, 6 weeks, and 6 months. SETTING: Two managed care adult primary care clinics. PARTICIPANTS: A total of 302 patients starting antidepressant drug therapy. INTERVENTIONS: For telehealth care: emotional support and focused behavioral interventions in ten 6-minute calls during 4 months by primary care nurses; and for peer support: telephone and in-person supportive contacts by trained health plan members recovered from depression. MAIN OUTCOME MEASURES: For depression: the Hamilton Depression Rating Scale and the Beck Depression Inventory; and for mental and physical functioning: the SF-12 Mental and Physical Composite Scales and treatment satisfaction. RESULTS: Nurse-based telehealth patients with or without peer support more often experienced 50% improvement on the Hamilton Depression Rating Scale at 6 weeks (50% vs 37%; P =.01) and 6 months (57% vs 38%; P =.003) and on the Beck Depression Inventory at 6 months (48% vs 37%; P =. 05) and greater quantitative reduction in symptom scores on the Hamilton scale at 6 months (10.38 vs 8.12; P =.006). Telehealth care improved mental functioning at 6 weeks (47.07 vs 42.64; P =.004) and treatment satisfaction at 6 weeks (4.41 vs 4.17; P =.004) and 6 months (4.20 vs 3.94; P =.001). Adding peer support to telehealth care did not improve the primary outcomes. CONCLUSION: Nurse telehealth care improves clinical outcomes of antidepressant drug treatment and patient satisfaction and fits well within busy primary care settings.     

Home-Based,Peer-Led Chronic Illness Self-Management Training: Findings From a 1-Year Randomized Controlled Trial

PURPOSE Studies suggest peer-led self-management training improves chronic illness outcomes by enhancing illness management self-efficacy. Limitations of most studies, however, include use of multiple outcome measures without predesignated primary outcomes and lack of randomized follow-up beyond 6 months. We conducted a 1-year randomized controlled trial of Homing in on Health (HIOH), a Chronic Disease Self-Management Program variant, addressing these limitations.METHODS We randomized outpatients (N = 415) aged 40 years and older and who had 1 or more of 6 common chronic illnesses, plus functional impairment, to HIOH delivered in homes or by telephone for 6 weeks or to usual care. Primary outcomes were the Medical Outcomes Study 36-ltem short-form health survey‘s physical component (PCS-36) and mental component (MCS-36) summary scores. Secondary outcomes included the EuroQol EQ-5D and visual analog scale (EQ VAS), hospitalizations, and health care expenditures.RESULTS Compared with usual care, HIOH delivered in the home led to significantly higher illness management self-efficacy at 6 weeks (effect size = 0.27; 95% CI, 0.10–0.43) and at 6 months (0.17; 95% CI, 0.01–0.33), but not at 1 year. In-home HIOH had no significant effects on PCS-36 or MCS-36 scores and led to improvement in only 1 secondary outcome, the EQ VAS (1-year effect size = 0.40; CI, 0.14–0.66). HIOH delivered by telephone had no significant effects on any outcomes.CONCLUSIONS Despite leading to improvements in self-efficacy comparable to those in other CDSMP studies, in-home HIOH had a limited sustained effect on only 1 secondary health status measure and no effect on utilization. These findings question the cost-effectiveness of peer-led illness self-management training from the health system perspective.     

Urinary tract infection and adverse outcome of pregnancy

Urinary tract infections (UTIs) during pregnancy are among the commonest health problems world wide, specially in developing countries, including Egypt. It has several adverse outcomes not only on the mother but also on the fetus as well.. The aim of this study is to determine the incidence of UTIs during pregnancy, study the main risk factors associated with such infections and find the impact of these infections on some pregnancy outcomes namely the gestational age and birth weight. A follow-up study on 249 pregnant women attending the ante natal care clinic at Zagazig university hospital. They were recruited over a period from 1st of September to 30th of or November, 2005. The outcome could be recorded for 201 of them. Data were collected through a pretested questionnaire, repeated urine analyses and recording of outcome of pregnancy. The study revealed that the incidence of UTIs during pregnancy was 31.3%. The commonest organisms were Klebsiella and E-coli. Several socio-demographic characteristics were found significantly associated with UTIs, age being 30 years and more, illiterates and low educational level, low socio-economic level and those with unsatisfactory personal hygiene and those using underwear clothes other than cotton. Significant associations with UTIs were also found in multigravidae 4th and more, those having more than one child and those who previously suffered UTIs. The only predicting variable with UTIs was low socio-economic level. The study revealed that the probability of delivering premature infants and low birth weights was significantly higher among those who experienced UTIs during pregnancy. Multivariate analysis revealed that UTI was one of the main contributors to pre-mature deliveries. Conclusion and Recommendations: Urinary tract infections with pregnancy still constitute a big problem with high incidence. It has a great impact on pregnancy outcome mainly pre-mature labor. So, the study recommends health education about personal hygiene, repeated urine cultures early in pregnancy and during the third trimesters, specially for low socio-economic pregnant women. Specific antibiotics should be prescribed to avoid adverse pregnancy outcome.     

Two-year health and employment outcomes among injured workers enrolled in the Washington State Managed Care Pilot Project.

BACKGROUND: Increasing numbers of injured workers are being treated through managed care delivery systems, yet little is known about the long-term effects of care provided through these systems. We analyzed health outcomes, return to work, and employment status at 2 years post-injury among a cohort of workers who were previously enrolled in the Washington State Managed Care Pilot Project. METHODS: Data on functional status, satisfaction with quality of life, return to work and employment status were gathered via telephone interviews and mailed questionnaires from a subset of 374 injured workers who had a time loss claim that involved 4 or more days of lost work time. Of these 374 subjects, 106 were treated through managed care and 268 through fee-for-service (FFS) arrangements. Health outcomes were assessed through the SF-36, the Health Assessment Questionnaire (HAQ), and the Satisfaction with Quality of Life (QOL) instruments. Standard univariate and multivariate statistical methods were used to compare the two groups with respect to the health and employment outcomes. RESULTS: There were no statistically significant differences between the two groups in functional status, satisfaction with quality of life or employment outcomes, except in regard to perceived recovery. FFS patients were more likely to indicate their recovery at 2 years post injury was going well (62 vs. 45%, P = .01). Almost 90% of the injured workers returned to work at some point following their injury and 72% reported working during the 4 weeks prior to their 2-year follow-up interview. CONCLUSIONS: Injured workers treated through managed care, based upon an occupational-medicine model, appear to experience similar long-term health and employment outcomes as workers treated through traditional FFS.     

Physician satisfaction with Medicaid managed care: the Missouri experience

BACKGROUND: Medicaid managed care is important to health reform at the state level. However, little is known about physician satisfaction with these programs. We sought to measure this satisfaction in Missouri and determine its predictors. METHODS: We surveyed a random sample of primary care physicians participating in Medicaid managed care (n = 670) or traditional Medicaid (n = 670). Primary outcomes measured were physicians' satisfaction Medicaid managed care, traditional Medicaid and commercial managed care. Satisfaction was measured on a 5-point Likert-type scale. RESULTS: The response rate was 52%. Physicians participating in Medicaid managed care were less likely to be satisfied or very satisfied with Medicaid managed care (28.6%) than with commercial managed care (40%) or their previous experience with traditional Medicaid (39.7%). Among physicians participating in traditional Medicaid, 29.8% were satisfied or very satisfied with traditional Medicaid. Physicians participating in Medicaid managed care were less satisfied with clinical autonomy under that system in comparison with their previous experience with traditional Medicaid (relative difference = 10.8%, P =.001). In multiple linear regression analyses, clinical autonomy (R2 = 0.40) was a strong predictor of overall satisfaction with Medicaid managed care. CONCLUSIONS: Enhancing physicians' clinical autonomy may result in improved satisfaction with Medicaid managed care. State Medicaid agencies should include physician satisfaction as a measure of Medicaid managed care plans' quality.     

Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial

PURPOSE

Health Plans are uniquely positioned to deliver outreach to members. We explored whether telephone outreach, delivered by Medicaid managed care organization (MMCO) staff, could increase colorectal cancer (CRC) screening among publicly insured urban women, potentially reducing disparities.

METHODS

We conducted an 18-month randomized clinical trial in 3 MMCOs in New York City in 2008–2010, randomizing 2,240 MMCO-insured women, aged 50 to 63 years, who received care at a participating practice and were overdue for CRC screening. MMCO outreach staff provided cancer screening telephone support, educating patients and helping overcome barriers. The primary outcome was the number of women screened for CRC during the 18-month intervention, assessed using claims.

RESULTS

MMCO staff reached 60% of women in the intervention arm by telephone. Although significantly more women in the intervention (36.7%) than in the usual care (30.6%) arm received CRC screening (odds ratio [OR] = 1.32; 95% CI, 1.08–1.62), increases varied from 1.1% to 13.7% across the participating MMCOs, and the overall increase was driven by increases at 1 MMCO. In an as-treated comparison, 41.8% of women in the intervention arm who were reached by telephone received CRC screening compared with 26.8% of women in the usual care arm who were not contacted during the study (OR = 1.84; 95% CI, 1.38, 2.44); 7 women needed to be reached by telephone for 1 to become screened.

CONCLUSIONS

The telephone outreach intervention delivered by MMCO staff increased CRC screening by 6% more than usual care among randomized women, and by 15.1% more than usual care among previously overdue women reached by the intervention. Our research-based intervention was successfully translated to the health plan arena, with variable effects in the participating MMCOs.     

A randomized trial of augmented prenatal care for multiple-risk, Medicaid-eligible African American women

OBJECTIVES: This project investigated whether augmented prenatal care for high-risk African American women would improve pregnancy outcomes and patients' knowledge of risks, satisfaction with care, and behavior. METHODS: The women enrolled were African American, were eligible for Medicaid, had scored 10 or higher on a risk assessment scale, were 16 years or older, and had no major medical complications. They were randomly assigned to augmented care (n = 318) or usual care (n = 301). Augmented care included educationally oriented peer groups, additional appointments, extended time with clinicians, and other supports. RESULTS: Women in augmented care rated their care as more helpful, knew more about their risk conditions, and spent more time with their nurse-providers than did women in usual care. More smokers in augmented care quit smoking. Pregnancy outcomes did not differ significantly between the groups; however, among patients in augmented care, rates of preterm births were lower and cesarean deliveries and stays in neonatal intensive care units occurred in smaller proportions. Both groups had lower-than-predicted rates of low birthweight. CONCLUSIONS: High-quality prenatal care, emphasizing education, health promotion, and social support, significantly increased women's satisfaction, knowledge of risk conditions, and perceived mastery in their lives, but it did not reduce low birthweight.     

The Kaiser Permanente prenatal smoking-cessation trial: when more isn't better, what is enough?

INTRODUCTION: The effectiveness of low-cost smoking interventions targeted to pregnant women has been demonstrated, although few gains in absolute cessation rates have been reported in the past decade. Under conditions of typical clinical practice, this study examined whether outcomes achieved with brief counseling from prenatal care providers and a self-help booklet could be improved by adding more resource-intensive cognitive-behavioral programs. DESIGN: Randomized Clinical Trial. SETTING: A large-group-model managed care organization. PARTICIPANTS: 390 English-speaking women 18 years of age or older who self-reported to be active smokers at their initial prenatal appointment. INTERVENTION: Participants were randomized to one of three groups: (1) a self-help booklet tailored to smoking patterns, stage of change, and lifestyle of pregnant smokers; (2) the booklet plus access to a computerized telephone cessation program based on interactive voice response technology; or (3) the booklet plus proactive telephone counseling from nurse educators using motivational interviewing techniques and strategies. No attempt was made to change smoking-related usual care advice from prenatal providers. MAIN OUTCOME MEASURE: Biochemically confirmed abstinence measured by level of cotinine in urine samples obtained during a routine prenatal visit at approximately the 34th week of pregnancy. RESULTS: Twenty percent of participants were confirmed as abstinent with no significant differences found between intervention groups. Multivariate baseline predictors of cessation included number of cigarettes smoked per day, confidence in ability to quit, exposure to passive smoke, and educational level. No differential intervention effects were found within strata of these predictors or by baseline stage of readiness to change. Cessation rates among heavier smokers were strikingly low in all intervention groups. CONCLUSION: Neither a computerized telephone cessation program nor systematic provision of motivational counseling improved cessation rates over a tailored self-help booklet delivered within the context of brief advice from prenatal providers. Innovative strategies need to be developed to increase the effectiveness of existing prenatal smoking interventions. Special attention should be paid to the needs of heavier smokers.     

Satisfaction and patient outcomes of a telephone-based nurse triage service

PURPOSE: Describe patient satisfaction and patient-reported outcomes after voluntary use of a telephone-based nurse triage service. METHODS: A random sample of symptomatic callers who contacted the triage service in 1999 was identified. A computer-assisted telephone survey was conducted, resulting in a response rate of 58.9 percent and a sample size of 35,374. SUMMARY: Overall satisfaction with the service was 90.4 percent and did not vary greatly when stratified by demographic and health status characteristics. Of all callers who reported following the triage recommendation to use self-care instructions while monitoring the condition for change (n = 12,037), 11.5 percent scheduled an office visit and 1.5 percent used hospital emergency-room (ER) services for further care. CONCLUSIONS: Overall satisfaction with telephone-based nurse triage services was high and did not vary substantially by caller characteristics.     

The impact of unit-based self-management by nurses on patient outcomes.

OBJECTIVE. Patients discharged from a self-managed nursing unit are compared with patients from traditionally managed units on postdischarge outcomes. DATA SOURCES AND STUDY SETTING. Primary data were collected on patients discharged from eight nursing units in three clinical areas in one hospital from August through November 1990. STUDY DESIGN. A case series of eligible patients discharged from four self-managed nursing units (n = 140) are compared with patients from four matched traditionally managed units (n = 138) on postdischarge outcomes: perceived health status, perceived functional status, needs for care, unmet needs for care, unplanned health care visits, and readmissions to the hospital within 31 days of discharge. DATA COLLECTION METHODS. Patients were interviewed by telephone at approximately two weeks postdischarge, and data from hospital records were merged with interview data. PRINCIPAL FINDINGS. Bivariate and multiple logistic regression analyses showed no significant effects (either positive or negative) of self-managed units on the postdischarge outcomes studied. CONCLUSIONS. Self-managed nursing units, previously shown to improve nurses' work satisfaction and retention, have no impact on patient postdischarge outcomes.     

Employer satisfaction with workers' compensation health care: results of the Washington State Workers' Compensation Managed Care Pilot

Developing more effective approaches to disability prevention has been a longstanding challenge for the workers' compensation system. A major obstacle to this goal has been the lack of communication and interaction between employers and physicians who care for injured workers. From 1995 through 1997, the Washington State Department of Labor and Industries sponsored a major demonstration program, known as the managed care pilot (MCP), to assess the effects of managed care on medical and disability costs, patient satisfaction and employer satisfaction. We developed a telephone survey and administered it to 243 employers as part of the MCP evaluation. Topics covered in this survey include satisfaction with treatment rendered, duration of lost work time, work modifications, and satisfaction with communication received during the employee's recovery period. Employers in the intervention (managed care) condition were more satisfied with the managed care/occupational medicine system than the employers in the comparison group were with the fee-for-service system. MCP employers were satisfied particularly with the frequency and quality of communication received from the health care provider regarding return to work and work modification issues. Improved employer-provider communication may foster early return to work and thereby have a beneficial effect on health and employment outcomes for injured workers.     

Assessing Beneficiary Health Outcomes and Disease Management Initiatives in Medicare

Introduction: Provisions in the Balanced Budget Act of 1997 directed the US Centers for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration) to begin focusing attention on the standardized measurement of health outcomes of Medicare beneficiaries as well as testing the effectiveness of various disease management interventions at improving these outcomes.The CMS, in collaboration with the US National Committee for Quality Assurance, developed the Medicare Health Outcomes Survey (HOS) as the first health outcomes measure from the patient’s perspective in Medicare managed care. This new source of data, using the Medical Outcomes Study Short Form 36-Item Health survey (SF-36®) as its core measure, provides valuable standardized health outcomes information about Medicare managed care enrollees in general and the chronically ill in particular. Study design: From May through July 1998, a longitudinal, self-administered survey which utilized the SF-36® (a health status measure which assesses both physical and mental functioning) was administered to 1000 randomly sampled Medicare beneficiaries who were continuously enrolled for a 6-month period in a Medicare managed care health plan. This cohort was re-surveyed from April though June of 2000. We analyzed data from the cohort I baseline and re-measurement analytic sample of 51 700 individuals. Results: Using the change in SF-36® physical component summary scores and mental component summary scores over a 2-year period, we demonstrated that the presence of chronic disease has a negative impact on both the physical and mental health functioning of Medicare managed care enrollees over time. With few exceptions, the negative effect of chronic disease on physical and mental health is found to be independent of gender, race, and socioeconomic status as measured by level of educational attainment. Differences in mean health status scores across levels of chronic conditions suggest that preventing the onset of disease is best for maintaining optimal health. Conclusions: Disease management interventions which are properly designed and implemented have been shown to measurably improve patient outcomes by providing high quality, cost-effective care. Recognizing the need for standardized outcome measures and scientifically validated disease management interventions, the CMS has taken a leadership role by developing and implementing the Medicare HOS and disease management demonstration projects.     

Application of a depression management office system in community practice: a demonstration

BACKGROUND: Recent studies provide new insights about strategies that improve depression outcomes. We explored the feasibility of implementing these strategies in community practices. METHODS: Clinicians followed an office system approach to management of depression. There were no controls. The office system was based on established routines performed by a primary care clinician working in a prepared practice, a telephone care manager, and a collaborating psychiatrist, all using a common severity monitoring tool. Five practices with 18 clinicians participated. Sixty-six adult patients had depression diagnosed, and 60 (91%) received care according to the model through 8 weeks of follow-up visits. Depression outcomes were assessed using PHQ-9. RESULTS: At baseline, 48 (80%) patients met criteria for major depressive disorder, chronic depression, or both, while others had less severe symptoms. Of 32 patients with moderately severe or severe depression, the 8-week follow-up severity score decreased by > or = 50% for 23 (70%). Of patient barriers to adherence, ambivalence about treatment and medication side effects were most common. Most patients received three care manager telephone calls requiring 6 to 10 minutes each. CONCLUSION: Application of the office system was feasible in this demonstration project. If results are confirmed in further studies, this approach will be appropriate for widespread application.     

The physician's role in educating patients. A comparison of mailed versus physician-delivered patient education

BACKGROUND: Patients value receiving educational information during office visits, but physicians often lack the time or training to satisfy this need. We examined whether an increased physician role in educating patients is an effective means of improving patient satisfaction. METHODS: Using a nonrandomized controlled research design, we compared patient satisfaction with self-care information provided by traditional direct-mail approaches and by physicians during routine office visits. We also studied a control group of patients receiving usual care. RESULTS: Patients who received a medical self-care book from a physician were significantly more likely to be satisfied with their office visit than those who received the book in the mail or those who experienced usual care. The intervention group reported greater satisfaction with 11 out of 13 variables related to physician-patient communication and quality of care. There were no significant differences between the control group and the direct-mail group. CONCLUSIONS: The patients who received self-care information from their physicians were significantly more satisfied with their care and their physician-patient communication experience than those in either the direct-mail group or the control group. Our findings lend support to the growing evidence that patients informed by their physicians are more satisfied with their care.     

Home care program for patients at high risk of hospitalization

Objective: To assess the efficacy of a home care program designed to improve access to medical care for older adults with multiple chronic conditions who are at risk for hospitalization. Study Design: Randomized controlled trial in which participants were assigned to the home care intervention (Choices for Healthy Aging [CHA]) program or usual care. Methods: The intervention group consisted of 298 older adults at risk of hospitalization as determined by a risk stratification tool. Measures included satisfaction with medical care, medical service use, and costs of medical care. Results: The intervention group reported significantly greater satisfaction with care than usual care recipients (t test = 2.476; P = .014). CHA patients were less likely than usual care patients to be admitted to the hospital (25.6% and 37.1%, respectively; P = .02). There were no differences in terms of costs of care between the home care and usual care groups. Conclusions: Provision of home care to older adults at high risk of hospitalization may improve satisfaction with care while reducing hospitalizations. Lack of difference in medical costs suggests that managed care organizations need to consider targeting rather than using risk stratification measures when designing programs for high-risk groups.     

Hysterectomy status,estrogen use and quality of life in older women: The Rancho Bernardo study

OBJECTIVE: To examine the long-term effects of hysterectomy and use of estrogen replacement therapy on health related quality of life and symptom subscales in community dwelling postmenopausal women. METHODS: Information on menopausal history including hysterectomy and oophorectomy status, and history of estrogen use was obtained from a sample of 801 women aged 50-96 years at a clinic visit between 1992 and 1996. Within 1 week of the clinic visit, a standardized, validated quality of well-being (QWB) scale was administered over the telephone by a trained interviewer. RESULTS: Among these women, 25.2% reported hysterectomy with bilateral oophorectomy an average of 28 years earlier, and 11.0% reported hysterectomy with ovarian conservation an average of 26.5 years earlier. Age-adjusted comparisons indicated that women with natural menopause had slightly higher total QWB scores and lower symptom subscale scores than women in either of the hysterectomy groups (p's = 0.06). However, after additional adjustment for estrogen use and other potentially confounding covariates, there was no significant difference in total QWB score or on any subscale scores by hysterectomy and oophorectomy status. After adjustment for age, women who never used estrogen had significantly higher total QWB scores (p = 0.03) and significantly lower symptom subscale scores, indicating fewer symptoms, than those who were past or current users (p = 0.01). These differences persisted after adjustment for age, type of menopause, and behavioral and lifestyle covariates (p's = 0.008). CONCLUSIONS: There are no long-term adverse effects of hysterectomy or bilateral oophorectomy on health related quality of life. Lower total QWB and greater symptom subscale scores by women currently using estrogen may reflect an adverse effect of hormone use on health related quality of life in older postmenopausal women.     

Is vaginal douching associated with preterm delivery?

BACKGROUND: To examine the hypothesized association between vaginal douching and preterm delivery, we conducted a study among women in a managed care organization in Atlanta, GA. METHODS: We drew a stratified random sample of 262 preterm (20-36 weeks' gestation) and 804 term deliveries that occurred between January 1996 and April 1997. Data were collected from telephone interviews and medical records. We used proportional hazards regression to compute gestation-specific conditional probabilities of delivery. The risk of preterm delivery associated with douching was examined, adjusted for potential confounders. RESULTS: Douching during pregnancy increased the overall risk of preterm delivery (hazard ratio = 1.9, 95% confidence interval = 1.0-3.7). CONCLUSIONS: Further research to clarify the relation between douching and preterm delivery should pay particular attention to the role of vaginal infections.     

Distance from practice moderates the relationship between patient management involving nurse telephone triage consulting and patient satisfaction with care

The ESTEEM trial was a randomised-controlled trial of telephone triage consultations in general practice. We conducted exploratory analyses on data from 9154 patients from 42 UK general practices who returned a questionnaire containing self-reported ratings of satisfaction with care following a request for a same-day consultation. Mode of care was identified through case notes review. There were seven main types: a GP face-to-face consultation, GP or nurse telephone triage consultation with no subsequent same day care, or a GP or nurse telephone triage consultation with a subsequent face-to-face consultation with a GP or a nurse. We investigated the contribution of mode of care to patient satisfaction and distance between the patient׳s home and the practice as a potential moderating factor. There was no overall association between patient satisfaction and distance from practice. However, patients managed by a nurse telephone consultation showed lowest levels of satisfaction, and satisfaction for this group of patients increased the further they lived from the practice. There was no association between any of the other modes of management and distance from practice.