L. Jay Helms

Patient gender differences in the diagnosis of depression in primary care.

Our purpose was to explore why women are more likely than men to be diagnosed as depressed by their primary care physician. Women were found to have more depressive symptoms as self-reported on the Beck Depression Inventory (BDI). Women having high BDI scores (reflecting significant depression) were more likely than men with high BDI scores to be diagnosed by their primary care physician (p = 0.0295). Female patients made significantly more visits to the clinic than men. For both sexes, patients with greater numbers of primary care clinic visits were more likely to be diagnosed as depressed. Logistic regression revealed that gender has both a direct and indirect (through increased use) effect on the likelihood of being diagnosed as depressed. Patient BDI score, clinic use, educational level, and marital status were all significantly related to the diagnosis of depression. Controlling all other independent variables, women were 72% more likely than men to be identified as depressed, but this effect did not achieve statistical significance (p = 0.0981). In gender-specific analyses, BDI and clinic use were again significantly related to the diagnosis of depression for both sexes. However, educational and marital status predicted depression diagnosis only for women. Separated, divorced, or widowed women were almost five times as likely to be diagnosed as depressed as those who were never married, all other factors being equal. Clinic use and BDI scores were found to be important correlates of the diagnosis of depression. There was some evidence of possible gender bias in the diagnosis of depression.

Comparing the Use of Physician Time and Health Care Resources Among Patients Speaking English, Spanish, and Russian

BACKGROUND AND OBJECTIVES The number of US residents with limited English proficiency (LEP) is 14 million and rising. The goal of this study was to estimate the effects of LEP on physician time and resource use. DESIGN This was a prospective, observational study. SETTING AND SUBJECTS The study included 285 Medicaid patients speaking English (n = 112), Spanish (n = 62), or Russian (n = 111) visiting the General Medicine and Family Practice Clinics at the UC Davis Medical Center in 1996-1997 (participation rate, 85%). Bilingual research assistants administered patient questionnaires, abstracted the medical record, and conducted detailed time and motion studies. MAIN OUTCOME MEASURES We used seemingly unrelated regression models to evaluate the effect of language on visit time, controlling for patient demographics and health status, physician specialty, visit type, and resident involvement in care. We also estimated the effect of LEP on cross-sectional utilization of health care resources and adherence to follow-up with referral and testing appointments. RESULTS The 3 language groups differed significantly by age, education, and reason for visit but not gender, number of active medical conditions, physical functioning, or mental health. Physician visit time averaged 38+/-20 minutes (mean+/-SD). Compared with English-speaking patients and after multivariate adjustment, Spanish and Russian speakers averaged 9.1 and 5.6 additional minutes of physician time, respectively (P <0.05). The language effect was confined largely to follow-up visits with resident physicians (house staff). Compared with English speakers, Russian speakers had more referrals (P = 0.003) and Spanish speakers were less likely to follow-up with recommended laboratory studies (P = 0.031). CONCLUSIONS In these academic primary care clinics, some groups of patients using interpreters required more physician time than those proficient in English Additional reimbursement may be needed to ensure continued access and high-quality care for this special population.

The influence of patient age on primary care resident physician-patient interaction.

OBJECTIVES: To explore resident physician‐patient interaction in primary care to address issues relevant to quality of care for older people.

Differences between family physicians' and general internists' medical charges.

OBJECTIVES Data from 509 primary care patients were analyzed to determine whether practice style differences between family physicians and general internists generate differential utilization of health care resources leading to differential medical charges. METHODS New adult patients were prospectively randomized to care by family physicians and general internists. Utilization of medical care services and associated charges then were monitored for 1 year of care. RESULTS Family practice patients had a significantly higher mean number of visits to their primary care clinic and significantly fewer emergency room visits than patients assigned to Internal Medicine. Mean charges for primary care and emergency department treatment were significantly lower for patients assigned to Family Practice than for those assigned to General Internal Medicine. There were no significant differences in charges for specialty clinic visits, hospitalizations, or diagnostic services. CONCLUSIONS Practice style differences between family physicians and general internists were associated with differential medical charges, with family physicians generating lower charges for some aspects of care.

Comparison of Primary Care Resident Physicians' Practice Styles During Initial and Return Patient Visits

New adult patients (n=212) were randomly assigned to 58 primary care resident physicians. Physician practice styles during initial and return visits were analyzed using the Davis Observation Code. Compared with initial patient visits, return visits were shorter, but more work-intensive, Return visits displayed significantly less technically oriented behavior (including history taking, physical examination, and treatment planning) and fewer discussions regarding use of addictive substances; however, there was more emphasis on health behaviors and active involvement of patients in their own care. These physicians’ practice style differences between initial and return patient visits suggest that physician-patient familiarity affects what happens during the medical interview.

Errors in the Numerical Assessment of the Benefits of Price Stabilization

This paper presents a simple computational procedure for determining a consumers willingness to pay to have a price stabilization policy implemented. Numerical simulations are then provided which demonstrate that the commonly used expected surplus measures (whether Hicksian or Marshallian) can in fact seriously misstate the true benefits of price stabilization. These simulations also illustrate the extent to which the results may be dependent upon the assumptions made—implicitly or explicitly—regarding the consumers attitudes toward risk, thereby underscoring the need to conduct sensitivity analyses to determine the robustness of cost-benefit assessments with respect to these assumptions.

Chemoprevention: drug pricing and mortality: the case of tamoxifen.

Tamoxifen is a prototypic cancer chemopreventive agent, yet clinical trials have not evaluated its effect on mortality or the impact of drug pricing on its cost‐effectiveness.

Surveillance After Treatment for Cervical Intraepithelial Neoplasia: Outcomes, Costs, and Cost-Effectiveness

OBJECTIVE: To estimate outcomes and costs of surveillance strategies after treatment for high-grade cervical intraepithelial neoplasia (CIN). METHODS: A hypothetical cohort of women was evaluated after treatment for CIN 2 or 3 using a Markov model incorporating data from a large study of women treated for CIN, systematic reviews of test accuracy, and individual preferences. Surveillance strategies included initial conventional or liquid-based cytology, human papillomavirus testing, or colposcopy 6 months after treatment, followed by annual or triennial cytology. Estimated outcomes included CIN, cervical cancer, cervical cancer deaths, life expectancy, costs, cost per life-year, and cost per quality-adjusted life-year. RESULTS: Conventional cytology at 6 and 12 months, followed by triennial cytology, was least costly. Compared with triennial cytology, annual cytology follow-up reduced expected cervical cancer deaths by 73% to 77% and had an average incremental cost per life-year gained of

Tamoxifen for breast cancer risk reduction: impact of alternative approaches to quality-of-life adjustment on cost-effectiveness analysis.

69,000 to

Comparing stochastic price regimes: The limitations of expected surplus measures

81,000. For colposcopy followed by annual cytology, the incremental cost per life-year gained ranged from