Barbara Williams

A study of the diagnostic accuracy of the PHQ-9 in primary care elderly

BackgroundThe diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) for assessment of depression in elderly persons in primary care settings in the United States has not been previously addressed. Thus, the purpose of this study was to evaluate the test performance of the PHQ-9 for detecting major and minor depression in elderly patients in primary care.MethodsA prospective study of diagnostic accuracy was conducted in two primary care, university-based clinics in the Pacific Northwest of the United States. Seventy-one patients aged 65 years or older participated; all completed the PHQ-9 and the 15-item Geriatric Depression Scale (GDS) and underwent the Structured Clinical Interview for Depression (SCID). Sensitivity, specificity, area under the receiver operating characteristic (ROC) curve, and likelihood ratios (LRs) were calculated for the PHQ-9, the PHQ-2, and the 15-item GDS for major depression alone and the combination of major plus minor depression.ResultsTwo thirds of participants were female, with a mean age of 78 and two chronic health conditions. Twelve percent met SCID criteria for major depression and 13% minor depression. The PHQ-9 had an area under the curve (AUC) of 0.87 (95% confidence interval [CI], 0.74-1.00) for major depression, while the PHQ-2 and the 15-item GDS each had an AUC of 0.81 (95% CI for PHQ-2, 0.64-0.98, and for 15-item GDS, 0.70-0.91; P = 0.551). For major and minor depression combined, the AUC for the PHQ-9 was 0.85 (95% CI, 0.73-0.96), for the PHQ-2, 0.80 (95% CI, 0.68-0.93), and for the 15-item GDS, 0.71 (95% CI, 0.55-0.87; P = 0.187).ConclusionsBased on AUC values, the PHQ-9 performs comparably to the PHQ-2 and the 15-item GDS in identifying depression among primary care elderly.

The Effects of a Community-Based Exercise Program on Function and Health in Older Adults: The EnhanceFitness Program:

This study examined the effectiveness of participation in EnhanceFitness (EF) (formerly the Lifetime Fitness Program), an established community-based group exercise program for older adults. EF incorporated performance and health status measure testing in year 2000. Initial performance was compared to age and gender-based norms to classify participants as within or at or above normal limits (WNL) or below (BNL). In 2,889 participants who participated in outcomes testing, improvements were observed at 4 and 8 months on performance tests for both subgroups. Participants’ self-rating of health improved at 8 months. All participants improved on performance tests. Implementation of performance-based measures in community studies is possible. Challenges included selecting measures, staff training, collecting performance measures, and deciding on time points for data collection. Older adults can maintain and/or improve physical function through participation in EnhanceFitness.

Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms.

AbstractOBJECTIVE: To determine whether managed care is associated with reduced access to mental health specialists and worse outcomes among primary care patients with depressive symptoms. DESIGN: Prospective cohort study. SETTING: Offices of 261 primary physicians in private practice in Seattle. PATIENTS: Patients (N=17,187) were screened in waiting rooms, enrolling 1,336 adults with depressive symptoms. Patients (n=942) completed follow-up surveys at 1, 3, and 6 months. MEASUREMENTS AND RESULTS: For each patient, the intensity of managed care was measured by the managedness of the patient’s health plan, plan benefit indexes, presence or absence of a mental health carve-out, intensity of managed care in the patient’s primary care office, physician financial incentives, and whether the physician read or used depression guidelines. Access measures were referral and actually seeing a mental health specialist. Outcomes were the Symptom Checklist for Depression, restricted activity days, and patient rating of care from primary physician. Approximately 23% of patients were referred to mental health specialists, and 38% saw a mental health specialist with or without referral. Managed care generally was not associated with a reduced likelihood of referral or seeing a mental health specialist. Patients in more-managed plans were less likely to be referred to a psychiatrist. Among low-income patients, a physician financial withhold for referral was associated with fewer mental health referrals. A physician productivity bonus was associated with greater access to mental health specialists. Depressive symptom and restricted activity day outcomes in more-managed health plans and offices were similar to or better than less-managed settings. Patients in more-managed offices had lower ratings of care from their primary physicians. CONCLUSIONS: The intensity of managed care was generally not associated with access to mental health specialists. The small number of managed care strategies associated with reduced access were offset by other strategies associated with increased access. Consequently, no adverse health outcomes were detected, but lower patient ratings of care provided by their primary physicians were found.

Comparison of Prescription and Medical Records in Reflecting Patient Antihypertensive Drug Therapy

OBJECTIVE: To determine the completeness of prescription records, and the extent to which they agreed with medical record drug entries for antihypertensive medications. SETTING: Three clinics affiliated with two staff model health maintenance organizations (HMOs). PARTICIPANTS: Randomly selected HMO enrollees (n=982) with diagnosed hypertension. METHODS: Computer-based prescription records for antihypertensive medications were reviewed at each location using an algorithm to convert the directions-for-use codes into an amount to be consumed per day (prescribed daily dosage). The medical record was analyzed similarly for the presence of drug notations and directions for use. RESULTS: There was a high level of agreement between the medical record and prescription file with respect to identifying the drug prescribed by drug name. Between 5 and 14 percent of medical record drug entries did not have corresponding prescription records, probably reflecting patient decisions not to have prescriptions filled at HMO-affiliated pharmacies or at all. Further, 5–8 percent of dispensed prescription records did not have corresponding medical record drug entry notations, probably reflecting incomplete recording of drug information on the medical record. The percentage of agreement of medical records on dosage ranged from 68 to 70 percent across two sites. Approximately 14 percent of drug records at one location and 21 percent of records at the other had nonmatching dosage information, probably reflecting dosage changes noted on the medical record but not reflected on pharmacy records. CONCLUSIONS: In the sites studied, dispensed prescription records reasonably reflect chart drug entries for drug name, but not necessarily dosage.

Healthcare Cost Differences with Participation in a Community-Based Group Physical Activity Benefit for Medicare Managed Care Health Plan Members

OBJECTIVES: To determine whether participation in a physical activity benefit by Medicare managed care enrollees is associated with lower healthcare utilization and costs.

Low-socioeconomic status workers: their health risks and how to reach them.

Objective: To help workplace health promotion practitioners reach low–socioeconomic status workers at high risk for chronic diseases. Methods: We describe low–socioeconomic status workers’ diseases, health status, demographics, risk behaviors, and workplaces, using data from the Behavioral Risk Factor Surveillance System, Medical Expenditure Panel Survey, and Bureau of Labor Statistics. Results: Workers with household annual incomes less than

Understanding Older Adults’ Motivators and Barriers to Participating in Organized Programs Supporting Exercise Behaviors

35,000, or a high school education or less, report more chronic diseases and lower health status. They tend to be younger, nonwhite, and have much higher levels of smoking and missed cholesterol screening. They are concentrated in the smallest and largest workplaces and in three low-wage industries that employ one-quarter of the population. Conclusions: To decrease chronic diseases among low–socioeconomic status workers, we need to focus workplace health promotion programs on workers in low-wage industries and small workplaces.

Older Adults' Perceptions of Clinical Fall Prevention Programs: A Qualitative Study

Little is known about older adults’ perceptions of organized programs that support exercise behavior. We conducted semi-structured interviews with 39 older adults residing in King County, Washington, who either declined to join, joined and participated, or joined and then quit a physical activity-oriented program. We sought to explore motivators and barriers to physical activity program participation and to elicit suggestions for marketing strategies to optimize participation. Two programs supporting exercise behavior and targeting older persons were the source of study participants: Enhance®Fitness and Physical Activity for a Lifetime of Success. We analyzed interview data using standard qualitative methods. We examined variations in themes by category of program participant (joiner, decliner, quitter) as well as by program and by race. Interview participants were mostly females in their early 70s. Approximately half were non-White, and about half had graduated from college. The most frequently cited personal factors motivating program participation were enjoying being with others while exercising and desiring a routine that promoted accountability. The most frequent environmental motivators were marketing materials, encouragement from a trusted person, lack of program fees, and the location of the program. The most common barriers to participation were already getting enough exercise, not being motivated or ready, and having poor health. Marketing messages focused on both personal benefits (feeling better, social opportunity, enjoyability) and desirable program features (tailored to individual needs), and marketing mechanisms ranged from traditional written materials to highly personalized approaches. These results suggest that organized programs tend to appeal to those who are more socially inclined and seek accountability. Certain program features also influence participation. Thoughtful marketing that involves a variety of messages and mechanisms is essential to successful program recruitment and continued attendance.

Managed Care, Access to Specialists, and Outcomes among Primary Care Patients with Pain

Objective. To investigate motivational factors and barriers to participating in fall risk assessment and management programs among diverse, low-income, community-dwelling older adults who had experienced a fall. Methods. Face-to-face interviews with 20 elderly who had accepted and 19 who had not accepted an invitation to an assessment by one of two fall prevention programs. Interviews covered healthy aging, core values, attributions/consequences of the fall, and barriers/benefits of fall prevention strategies and programs. Results. Joiners and nonjoiners of fall prevention programs were similar in their experience of loss associated with aging, core values they expressed, and emotional response to falling. One difference was that those who participated endorsed that they “needed” the program, while those who did not participate expressed a lack of need. Conclusions. Interventions targeted at a high-risk group need to address individual beliefs as well as structural and social factors (transportation issues, social networks) to enhance participation.

Promoting health and preventing disability in older adults: lessons from intervention studies carried out through an academic-community partnership.

OBJECTIVE To determine whether managed care controls were associated with reduced access to specialists and worse outcomes among primary care patients with pain. DATA SOURCES/STUDY SETTING Patient, physician, and office manager questionnaires collected in the Seattle area in 1996-1997, plus data abstracted from patient records and health plans. STUDY DESIGN A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle. DATA COLLECTION Patients completed a waiting room questionnaire and follow-up surveys at the end of the first and sixth months to measure access to specialists and outcomes. Intensity of managed care controls measured by plan managed care index and benefit/cost-sharing indexes, office managed care index, physician compensation, financial incentives, and use of clinical guidelines. PRINCIPAL FINDINGS A financial withhold for referral was associated with a lower likelihood of referral to a physician specialist, a greater likelihood of seeing a specialist without referral, and a lower patient rating of care from the primary physician. Otherwise, patients in more managed offices and with greater out-of-network plan benefits had greater access to specialists. Patients with more versus less managed care had similar health outcomes, but patients in more managed offices had lower ratings of care provided by their primary physicians. CONCLUSIONS Increased managed care controls were generally not associated with reduced access to specialists and worse health outcomes for primary care patients with pain, but patients in more managed offices had lower ratings of care provided by their primary physicians.