Depression among high utilizers of medical care

OBJECTIVE: To determine the prevalence of unrecognized or unsuccessfully treated depression among high utilizers of medical care, and to describe the relation between depression, medical comorbidities, and resource utilization. DESIGN: Survey. SETTING: Three HMOs located in different geographic regions of the United States. PATIENTS: A total of 12,773 HMO members were identified as high utilizers. Eligibility criteria for depression screening were met by 10,461 patients. MEASUREMENTS AND MAIN RESULTS: Depression status was assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Depression screening was completed in 7,203 patients who were high utilizers of medical care, of whom 1,465 (20.3%) screened positive for current major depression or major depression in partial remission. Among depressed patients, 621 (42.4%) had had a visit with a mental health specialist or a diagnosis of depression or both within the previous 2 years. The prevalence of well-defined medical conditions was the same in patients with and patients without evidence of depression (41.5% vs 41.5%, p = .87). However, high-utilizing patients who had not made a visit for a nonspecific complaint during the previous 2 years were at significantly lower risk of depression (13.1% vs 22.4%, p < .001). Patients with current depression or depression in partial remission had significantly higher numbers of annual office visits and hospital days per 1,000 than patients without depression. CONCLUSIONS: Although there was evidence that mental health problems had previously been recognized in many of the patients, a large percentage of high utilizers still suffered from active depression that either went unrecognized or was not being treated successfully. Patients who had not made visits for nonspecific complaints were at significantly lower risk of depression. Depression among high utilizers was associated with higher resource utilization.     

Physician and patient factors associated with ordering a colon evaluation after a positive fecal occult blood test

OBJECTIVE: Successful colorectal cancer screening relies in part on physicians ordering a complete diagnostic evaluation of the colon (CDE) with colonoscopy or barium enema plus sigmoidoscopy after a positive screening fecal occult blood test (FOBT). DESIGN: We surveyed primary care physicians about colorectal cancer screening practices, beliefs, and intentions. At least 1 physician responded in 318 of 413 (77%) primary care practices that were affiliated with a managed care organization offering a mailed FOBT program for patients aged >/=50 years. Of these 318 practices, 212 (67%) had 602 FOBT+ patients from August through November 1998. We studied 184 (87%) of these 212 practices with 490 FOBT+ patients after excluding those judged ineligible for a CDE or without demographic data. Three months after notification of the FOBT+ result, physicians were asked on audit forms if they had ordered CDEs for study patients. Patient- and physician-predictors of ordering CDEs were identified using logistic regression. MEASUREMENTS AND MAIN RESULTS: A CDE was ordered for only 69.5% of 490 FOBT+ patients. After adjustment, women were less likely to have had CDE initiated than men (adjusted odds, 0.66; confidence interval, 0.44 to 0.97). Physician survey responses indicating intermediate or high intention to evaluate a FOBT+ patient with a CDE were associated with nearly 2-fold greater adjusted odds of actually initiating a CDE in this circumstance versus physicians with a low intention. CONCLUSIONS: Primary care physicians often fail to order CDE for FOBT+ patients. A CDE was less likely to be ordered for women and was influenced by physician's beliefs about CDEs.     

Clinical and ultrasonography evaluation of thyroid tumor screening in symptomatic patient of Bajulmati primary care center,Banyuwangi, East Java,Indonesia

This study aims to assess the prevalence, clinical, and ultrasonography (US) in thyroid screening in healthy subjects with general symptoms of thyroid abnormality in low iodine intake in Bajulmati primary care center, East Java Indonesia. We retrospectively reviewed US thyroid examination of 74 subjects with symptoms of mass in the neck, shaky, sleep difficulties, over sweating, and chronic fatigue on September 15^th, 2021. Following the WHO guidelines, subjects also underwent physical examination in which the result were classified into 3 categories, that is, no palpable nor visible goiter, palpable but no visible goiter, as well as palpable and visible goiter. We evaluate US thyroid characteristics following Korean Society of Thyroid Radiology guidelines. Image analysis was reviewed by 4 general radiologists with 2 to 13 years’ experience. Categorical variables were compared using chi-squared or Fisher exact tests. Correlation between variables was measured with gamma statistics. Statistical analyses were conducted using IBM SPSS Statistics 23.0. A P-value < .05 was considered to indicate statistical significance. Of the 74 subjects, 32 (43.2%) show abnormalities. Statistical analysis showed no significant differences in the result of thyroid US in subjects with complaint fatigue (P = .464), insomnia (P = .777), over sweating (P = .158), and tremor (P = .778), but there were significant differences with the complaint of mass in the neck (P = .008). Furthermore, there was also a strong correlation between goiter palpation and US thyroid result (R = 0.773, P = .00). We conclude there were significant differences in US result of patients with and without complaint of mass in the neck. We also found a strong correlation between goiter palpation and US examination. Clinical findings, laboratory examination, cytology and molecular markers, patients’ age, nodules size, and ultrasound features should be considered for the treatment planning.     

Disparities in screening mammography

OBJECTIVE: This paper describes trends in screening mammography utilization over the past decade and assesses the remaining disparities in mammography use among medically underserved women. We also describe the barriers to mammography and report effective interventions to enhance utilization. DESIGN: We reviewed medline and other databases as well as relevant bibliographies. MAIN RESULTS: The United States has dramatically improved its use of screening mammography over the past decade, with increased rates observed in every demographic group. Disparities in screening mammography are decreasing among medically underserved populations but still persist among racial/ethnic minorities and low-income women. Additionally, uninsured women and those with no usual care have the lowest rates of reported mammogram use. However, despite apparent increases in mammogram utilization, there is growing evidence that limitations in the national survey databases lead to overestimations of mammogram use, particularly among low-income racial and ethnic minorities. CONCLUSIONS: The United States may be farther from its national goals of screening mammography, particularly among underserved women, than current data suggests. We should continue to support those interventions that increase mammography use among the medically underserved by addressing the barriers such as cost, language and acculturation limitations, deficits in knowledge and cultural beliefs, literacy and health system barriers such as insurance and having a source regular of medical care. Addressing disparities in the diagnostic and cancer treatment process should also be a priority in order to affect significant change in health outcomes among the underserved.     

Screening mammography: Is it suitably targeted to older women who are most likely to benefit?

OBJECTIVES: To determine whether screening mammography is suitably targeted to older women who are most likely to benefit. DESIGN: Prospective cohort study. SETTING: New Haven County, Connecticut. PARTICIPANTS: Eight hundred forty-four community-dwelling older women were interviewed as part of the 1990 New Haven Established Populations for the Epidemiologic Study of the Elderly (EPESE) program. MEASUREMENTS: Mammography use was ascertained from Medicare Part B claims data. A four-level prognostic mortality index was developed using items previously shown to be predictive of mortality. Mammography use and all-cause mortality were evaluated by prognostic stage over a 5-year period, January 1, 1991, to December 31, 1995. RESULTS: Five-year mortality increased steadily with each prognostic stage (12% to 68%, P = .001), whereas the 5-year mammography use rate declined (48% to 7%, P = .001). Over half the women (53%) in the most favorable prognostic group did not receive a mammogram, whereas 13% in the two worst prognostic groups received at least one mammogram. CONCLUSION: Screening mammography may be underutilized among older women who are the most likely to benefit and overutilized among those who are unlikely to benefit.     

Outpatient treatment entry and health care utilization after a combined medical/substance abuse intervention for hospitalized medical patients

CONTEXT: Drug-abusing patients utilize extensive amounts of health services resources, yet the acute medical hospitalization has typically not been used effectively to engage patients in substance abuse treatment. OBJECTIVES: To assess the effect of an integrated substance abuse/acute medical care day hospital (DH) intervention. DESIGN AND SETTING: Prospective, consecutive chart review of patients referred to a day hospital program from the medicine service at an urban tertiary care teaching hospital. From the referral cohort, a comparison group receiving usual care was identified. PARTICIPANTS: One hundred twenty adult medicine inpatients with active substance abuse and self-identified motivation to enter treatment. MAIN OUTCOME MEASURES: Outpatient substance abuse treatment entry and post-intervention health services utilization. RESULTS: Following DH treatment, 50.6% entered further outpatient substance abuse treatment (vs 2.4% comparison patients; P<.001). There was a significant increase in ambulatory medical visits for DH patients (pre-6 month 0.49 vs post-6 month 3.46; P<.001), greater than the change noted for comparison patients. However, there was no difference noted in pre-post hospitalization or emergency department utilization following the DH intervention. CONCLUSIONS: A DH program for substance abusing hospitalized medicine patients that introduces substance abuse treatment during treatment for an acute medical illness does appear to improve outpatient substance abuse treatment entry and ambulatory care utilization after hospital discharge. This project was supported in part by the Lattman Family Foundation and by Public Health Service Grant NIDA K23 DA 13988-01.     

Associations of patient-centered medical home with quality of care,patient experience,and health expenditures: A STROBE-compliant cross-sectional study

In efforts to improve the delivery of quality primary care, patient-centered medical home (PCMH) model has been promoted. However, evidence on its association with health outcomes has been mixed. The aim of this study was to assess the performance of PCMH model on quality of care, patient experience, health expenditures.This was a cross-sectional study of the 2015–2016 Medical Expenditure Panel Survey-Medical Organization Survey linked data, including 5748 patient-provider pairs. We examined twenty-four quality of care measures (18 high-value and 6 low-value care services), health service utilization, patient experience (patient-provider communication, satisfaction), and health expenditure.Of 5748 patients, representing a weighted population of 56.2 million American adults aged 18 years and older, 44.2% were cared for by PCMH certified providers. 9.3% of those with PCMHs had at least one inpatient stay in the past year, which was comparable to the 11.4% among those with non-PCMHs. Similarly, 17.4% of respondents cared for by PCMH and 18.5% cared for by non-PCMH had at least one ED visit. Overall, we found no significant differences in quality of care measures (neither high-nor low-value of care) between the two groups. The overall satisfaction, the experience of access to care, and communication with providers were also comparable. Patients who were cared for by PCMHs had less total health expenditure (difference $217) and out-of-pocket spending (difference $91) than those cared for by non-PCMHs; however, none of these differences reached the statistical significance (adjusted P > 0.05 for all).This study found no meaningful difference in quality of care, patient experience, health care utilization, or health care expenditures between respondents cared for by PCMH and non-PCMH. Our findings suggest that the PCMH model is not superior in the quality of care delivered to non-PCMH providers.     

Changes in the use of do-not-resuscitate orders after implementation of the patient self-determination act

OBJECTIVE: To determine changes in the use of do-not-resuscitate (DNR) orders and mortality rates following a DNR order after the Patient Self-determination Act (PSDA) was implemented in December 1991. DESIGN: Time-series. SETTING: Twenty-nine hospitals in Northeast Ohio. PATIENTS/PARTICIPANTS: Medicare patients (N = 91,539) hospitalized with myocardial infarction, heart failure, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, pneumonia, or stroke. MEASUREMENTS AND MAIN RESULTS: The use of "early" (first 2 hospital days) and "late" DNR orders was determined from chart abstractions. Deaths within 30 days after a DNR order were identified from Medicare Provider Analysis and Review files. Risk-adjusted rates of early DNR orders increased by 34% to 66% between 1991 and 1992 for 4 of the 6 conditions and then remained flat or declined slightly between 1992 and 1997. Use of late DNR orders declined by 29% to 53% for 4 of the 6 conditions between 1991 and 1997. Risk-adjusted mortality during the 30 days after a DNR order was written did not change between 1991 and 1997 for 5 conditions, but risk-adjusted mortality increased by 21% and 25% for stroke patients with early DNR and late DNR orders, respectively. CONCLUSIONS: Overall use of DNR orders changed relatively little after passage of the PSDA, because the increase in the use of early DNR orders between 1991 and 1992 was counteracted by decreasing use of late DNR orders. Risk-adjusted mortality rates after a DNR order generally remained stable, suggesting that there were no dramatic changes in quality of care or aggressiveness of care for patients with DNR orders. However, the increasing mortality for stroke patients warrants further examination.     

Improved preventive care following an intervention during an ambulatory care rotation

Recent studies have shown that physician compliance with recommended preventive care guidelines can be improved. Little is known, however, about whether a successful intervention aimed at improving performance applied in one setting will carry over to another. To explore this issue, the authors examined the impact of an intervention involving lecture, feedback, and checklists introduced during an ambulatory care rotation at one hospital (SPR) on resident performance of six preventive care measures at a second outpatient clinic (VA). The performance of 15 residents who had been exposed to the program was compared with that of 13 who had not been exposed to the program. The mean proportion of indicated measures performed by the exposed residents was significantly higher than that of the residents without exposure to the program (0.49 vs. 0.36, p<0.05). Improvement was found for all measures but was statistically significant only for influenza vaccination (0.28 vs. 0.07, p=0.03). Post-intervention performance at SPR was also significantly improved (0.53 vs. 0.36, p<0.001). The authors conclude not only that the intervention improved resident performance of preventive care but also that the improvement was carried over to practice in a second outpatient setting. Received from the Section of General Internal Medicine, University of Minnesota, and the Minneapolis Veterans Administration Hospital, Minneapolis, Minnesota; and the St. Paul-Ramsey Medical Center, St. Paul, Minnesota. Presented at the Midwest Meeting of the American Federation for Clinical Research, October 30, 1986, Chicago, Illinois. Supported in part by the Cost Effective Care Program, St. Paul-Ramsey Medical Center and Ramsey Clinic.     

Utilization of hospital resources by alcoholic and nonalcoholic patients

Objective:To measure any difference in the utilization of hospital resources between alcoholic patients and nonalcoholic patients (controls) in a department of internal medicine. Design:Prospective comparative study. Alcoholics were identified as patients with Michigan Alcoholism Screening Test (MAST) scores of ≥8. Controls were defined as patients with MAST scores of ≤4, and matched with alcoholics for sex, age, and time of admission. The length of stay, as well as several indicators of utilization of diagnostic and therapeutic procedures, was used for the comparison of resource utilization. Setting:General wards of internal medicine of a 1,000-bed city and teaching hospital in Lausanne, Switzerland. Participants:One bundred and three alcoholic patients and 103 controls aged 20–75 years, admitted from September 1, 1988, to March 18, 1989. Results:Alcoholics had the same lengths of stay (16 days), durations of intravenous infusions (six days), and durations of bladder catheterization (one day). Statistically nonsignificant differences were found between alcoholics and nonalcoholics regarding the charges for routine laboratory examinations [693 vs. 734 Swiss francs (Sfrs)], antibiotic therapies (218 vs. 145 Sfrs), and x-ray procedures (568 vs. 774 Sfrs; p=0.06). The average number of electrocardiograms (two vs. five; p<0.005) and the duration of intensive care unit (ICU) stay (one vs. two days; p<0.05) were significantly lower for alcoholics than for controls. A total hospital charges index was also lower for alcoholics than for controls (11,900 Sfrs vs. 12,800 Sfrs), but not significantly. Conclusion:The authors’ results suggest that alcoholics do not use more hospital resources per admission than do nonalcoholics. Moreover, alcoholics tend to use less frequently some procedures, such as the ICU, electrocardiography, and x-ray examinations. Several hypotheses are developed to explain these results in relation to those of previous studies, which showed more use of medical care by alcoholics than by nonalcoholics. Support by a grant from the Swiss National Research Foundation (no 3200-009282) and by a grant from the “Fondation du 450^eme Anniversaire de l’Université de Lausanne.”     

Uncontrolled Asthma in a Commercially Insured Population From 2002 to 2007: Trends,Predictors, and Costs

Objective. Uncontrolled asthma leads to preventable morbidity and increased health care utilization. The authors examined trends, predictors, and costs of uncontrolled asthma over 5 years in a large health plan population. Methods. The authors retrospectively examined administrative health claims data from mid-2000 to mid-2007 on patients with asthma aged 1 to 56 years (n = 54,653 patient-years, 28,595 unique patients). Uncontrolled asthma events were defined as ≥2 oral steroid fills or ≥5 short-acting β₂-agonist (SABA) fills over 12 months, or an asthma-related hospitalization or emergency department (ED) visit. Multivariate generalized mixed regression models determined patient- and neighborhood-level predictors for uncontrolled asthma events. The authors compared asthma-related costs for patients with and without uncontrolled asthma events. Results. In 2002–2003, 39% of patients had ≥1 uncontrolled asthma event. Most frequent were high use of rescue asthma medications. Asthma-related hospitalizations and ED visits were infrequent. The percentage having uncontrolled asthma events decreased significantly over time to 27% in 2006–2007, due to a decreased rate of frequent SABA fills. Males and adults ≥24 years had higher odds of medication-based uncontrolled asthma events, whereas residence in neighborhoods with more minorities and lower educational attainment was associated with ED visits or hospitalizations. Patients with uncontrolled asthma events had significantly higher asthma-related costs. Conclusions. In this population, the proportion of patients with uncontrolled asthma, particularly as indicated by high SABA fills, decreased over a 5-year period. Several individual- and neighborhood-level characteristics were associated with uncontrolled asthma events. Clinicians and health plans can identify higher-risk patients in order to target asthma management strategies and reduce asthma-related morbidity and its associated costs.     

Perceived Discrimination and Adherence to Medical Care in a Racially Integrated Community

Background Past research indicates that access to health care and utilization of services varies by sociodemographic characteristics, but little is known about racial differences in health care utilization within racially integrated communities. Objective To determine whether perceived discrimination was associated with delays in seeking medical care and adherence to medical care recommendations among African Americans and whites living in a socioeconomically homogenous and racially integrated community. Design A cross-sectional analysis from the Exploring Health Disparities in Integrated Communities Study. Participants Study participants include 1,408 African-American (59.3%) and white (40.7%) adults (≥18 years) in Baltimore, Md. Measurements An interviewer-administered questionnaire was used to assess the associations of perceived discrimination with help-seeking behavior for and adherence to medical care. Results For both African Americans and whites, a report of 1–2 and >2 discrimination experiences in one’s lifetime were associated with more medical care delays and nonadherence compared to those with no experiences after adjustment for need, enabling, and predisposing factors (odds ratio [OR] = 1.8, 2.6; OR = 2.2, 3.3, respectively; all P < .05). Results were similar for perceived discrimination occurring in the past year. Conclusions Experiences with discrimination were associated with delays in seeking medical care and poor adherence to medical care recommendations INDEPENDENT OF NEED, ENABLING, AND PREDISPOSING FACTORS, INCLUDING MEDICAL MISTRUST; however, a prospective study is needed. Further research in this area should include exploration of other potential mechanisms for the association between perceived discrimination and health service utilization.     

Increasing breast and cervical cancer screening in low-income women

OBJECTIVE: To determine if women would have higher breast and cervical cancer screening rates if lay health advisers recommended screening and offered a convenient screening opportunity. DESIGN: Controlled trial. SETTING: Urban county teaching hospital. PARTICIPANTS: Women aged 40 years and over attending appointements in several non-primary-care outpatient clinics. INTERVENTIONS: Lay health advisers assessed the participants’ breast and cervical cancer screening status and offered women in the intervention group who were due for screening an appointment with a female nurse practitioner. MEASUREMENTS AND MAIN RESULTS: Screening rates at base-line and at follow-up 1 year after the intervention were determined. At follow-up, the mammography rate was 69% in the intervention group versus 63% in the usual care group (p=.009), and the Pap smear rate was 70% in the intervention group versus 63% in the usual care group (p=.02). In women who were due for screening at baseline, the mammography rate was 60% in the intervention group versus 50% in the usual care group (p=.006), and the Pap smear rate was 63% in the intervention group versus 50% in the usual care group (p=.002). The intervention was effective across age and insurance payer strata, and was particularly effective in Native American women. CONCLUSIONS: Breast and cervical cancer screening rates were improved in women attending non-primary-care outpatient clinics by using lay health advisers and a nurse practitioner to perform screening. The effect was strongest in women in greatest need of screening. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, D.C., May 2, 1996. This research was supported by a grant (R01-CA52994-02) from the National Cancer Institute, Dr. Margolis was supported by an American Cancer Society Clinical Oncology Career Development Award for Primary Care Physicians while this work was carried out.     

Race/ethnicity and patient satisfaction

OBJECTIVE: To determine whether an established patient satisfaction scale commonly used in the primary care setting is sufficiently sensitive to identify racial/ethnic differences in satisfaction that may exist; to compare a composite indicator of overall patient satisfaction with a 4-item satisfaction scale that measures only the quality of the direct physician-patient interaction. DESIGN: Real-time survey of patients during a primary care office visit. SETTING: Private medical offices in a generally affluent area of northern California. PARTICIPANTS: Five hundred thirty-seven primary care patients selected at random from those entering a medical office. MAIN OUTCOME MEASURES: Patient satisfaction using 1) a composite, 9-item satisfaction scale (VSQ-9); and 2) a 4-item subset of that scale that measures only satisfaction with direct physician care. RESULTS: The 9-item, composite scale identified no significant difference in patient satisfaction between white and nonwhite patients, after controlling for patient demographics and other aspects of the visit. The 4-item, physician-specific scale indicated that nonwhite patients were less satisfied than white patients with their direct interaction with the physicians included in the study (P 相似文献   

Measuring the Quality of Colorectal Cancer Screening: The Importance of Follow-Up

Purpose As evidence mounts for effectiveness, an increasing proportion of the United States population undergoes colorectal cancer screening. However, relatively little is known about rates of follow-up after abnormal results from initial screening tests. This study examines patterns of colorectal cancer screening and follow-up within the nation's largest integrated health care system: the Veterans Health Administration. Methods We obtained information about patients who received colorectal cancer screening in the Veterans Health Administration from an existing quality improvement program and from the Veterans Health Administration's electronic medical record. Linking these data, we analyzed receipt of screening and follow-up testing after a positive fecal occult blood test. Results A total of 39,870 patients met criteria for colorectal cancer screening; of these 61 percent were screened. Screening was more likely in patients aged 70 to 80 years than in those younger or older. Female gender (relative risk, 0.92; 95 percent confidence interval, 0.9–0.95), Black race (relative risk, 0.92; 95 percent confidence interval, 0.89–0.96), lower income, and infrequent primary care visits were associated with lower likelihood of screening. Of those patients with a positive fecal occult blood test (n = 313), 59 percent received a follow-up barium enema or colonoscopy. Patient-level factors did not predict receipt of a follow-up test. Conclusions The Veterans Health Administration rates for colorectal cancer screening are significantly higher than the national average. However, 41 percent of patients with positive fecal occult blood tests failed to receive follow-up testing. Efforts to measure the quality of colorectal cancer screening programs should focus on the entire diagnostic process. Supported by the Robert Wood Johnson Foundation Clinical Scholars Program (Etzioni), Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), and National Cancer Institute Colorectal Cancer (CRC) Quality Enhancement Research Initiative (QUERI) Service Directed Research (Project # CRS 02-163). The views expressed in this article are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or the Department of Veterans Affairs.