L. Miriam Dickinson

The somatization in primary care study: a tale of three diagnoses

Somatization is a common phenomenon that has been defined in many ways. The two most widely used diagnoses, Somatization Disorder (SD) and Abridged Somatization Disorder (ASD), are based on lifetime unexplained symptoms. However, reports indicate instability in lifetime symptom recall among somatizing patients. Multisomatoform disorder (MSD) is a new diagnosis based on current unexplained symptoms. To understand how knowledge about SD and ASD translates to MSD, we examined the diagnostic concordance, impairment and health care utilization of these groups in a sample from the Somatization in Primary Care Study. The diagnostic concordance was high between MSD and SD, but lower between MSD and ASD. All three groups reported considerable physical impairment (measured using the PCS subscale of the SF-36). The mental health (MCS) scores for the three groups were only slightly lower than those of the general population. Over the course of one year, physical functioning fell significantly for all three groups. Mental functioning did not change significantly for any of the three groups over this period. Utilization patterns were very similar for the three groups. The high prevalence, serious impairment, and worsening physical functioning over the course of one year suggest the importance of developing interventions in primary care to alleviate the impaired physical functioning and reduce utilization in somatizing patients. MSD should be a useful diagnosis for targeting these interventions because it identifies a sizable cohort of somatizing patients reporting impairment of comparable severity to full SD, using a more efficient diagnostic algorithm based on current symptoms.

Does a Depression Intervention Result in Improved Outcomes for Patients Presenting with Physical Symptoms

OBJECTIVE: To investigate the effects of exclusively physical presentation of depression on 1) depression management and outcomes under usual care conditions, and 2) the impact of an intervention to improve management and outcomes.DESIGN AND SETTING: Secondary analysis of a depression intervention trial in 12 community-based primary care practices.PARTICIPANTS: Two hundred adults beginning a new treatment episode for depression.MEASUREMENTS: Presenting complaint and physician depression query at index visit; antidepressant use, completion of adequate antidepressant trial, change in depressive symptoms, and physical and emotional role functioning at 6 months.MAIN RESULTS: Sixty-six percent of depressed patients presented exclusively with physical symptoms. Under usual care conditions, psychological presenters were more likely than physicial presenters to complete an adequate trial of anti-depressant treatment but experienced equivalent improvements in depressive severity and role functioning. In patients presenting exclusively with physicial symptoms, the intervention significantly improved physician query (40.8% vs 18.0%; P=.06), receipt of any antidepressant (63.0% vs 20.1%; P=.001), and an adequate antidepressant trial (34.9% vs 5.9%; P=.004), but did not significantly improve depression severity or role functioning. In patients presenting with psychological symptoms, the intervention significantly improved receipt of any antidepressant (79.9% vs 38.0%; P=.01) and an adequate antidepressant trial (46.0% vs 23.8%; P=.004), and also improved depression severity and physical and emotional role functioning.CONCLUSIONS: Our results suggest that there is a differential intervention effect by presentation style at the index visit. Thus, current interventions should be targeted at psychological presenters and new approaches should be developed for physical presenters.

Complex posttraumatic stress disorder: evidence from the primary care setting

Sexual abuse is a common problem among female primary care medical patients. There is a wide spectrum of long-term sequelae, ranging from mild to the complex symptom profiles consistent with the theories of a posttraumatic sense of identity. Generally, the latter occurs in the context of severe, chronic abuse, beginning in childhood and often compounded by the presence of violence, criminal behavior, and substance abuse in the family of origin. In this study we search for empirical evidence for the existence of a complex posttraumatic stress syndrome in 99 women patients at 3 family practice outpatient clinics who report a history of sexual abuse. A structured interview was administered by trained female interviewers to gather data on family history and psychiatric symptoms and diagnoses. Empirical evidence from cluster analysis of the data supports the theory of a complex posttraumatic syndrome. The severity gradient based on symptoms roughly parallels the severity gradient based on childhood abuse and sociopathic behavior and violence in the family of origin, with the most severely abused subjects characterized by symptom patterns that fit the description of a complex posttraumatic stress syndrome.

Parental Views of School-Located Delivery of Adolescent Vaccines

PURPOSEnSchool-located immunization has the potential to increase adolescent vaccination rates. This study assessed parents attitudes toward administration of adolescent vaccines (tetanus, diphtheria, acellular pertussis [Tdap], meningococcal conjugate [MenACWY], human papillomavirus [HPV], and influenza) at school.nnnMETHODSnWe conducted a mailed survey of parents of sixth graders from July 2009 to September 2009 in three urban/suburban (Aurora, CO) middle schools assessing barriers and facilitators to school vaccination and willingness to consent for vaccines at school. Unadjusted and adjusted analyses examined the association of parent and student characteristics with parent willingness to consent to school-located vaccination.nnnRESULTSnThe response rate was 62% (500/806). Parents reported 82% of teens had a regular site of health care, and 17% were uninsured. Overall, 71% of parents would consent for vaccines at school; 72% for Tdap, 71% for MenACWY, 53% for HPV (parents of girls), and 67% for seasonal influenza. Among parents who answered it was important their child receives recommended vaccines, (88%) would consent for influenza vaccine at school, compared with Tdap (76%), MenACWY (74%), and HPV (72%). Multivariable logistic regression analysis demonstrated parents of uninsured teens (odds ratio [OR] 3.77, 95% confidence interval [CI]: 1.40, 12.23), who were unmarried (OR 1.90, 95% CI: 1.14, 3.25), or had a child attending the school with the highest percent eligibility for free/reduced lunch (OR 2.75, 95% CI: 1.36, 5.80) were significantly more willing to consent for vaccines at school.nnnCONCLUSIONSnThese data suggest parents are generally supportive of school-located vaccine delivery, particularly for annual influenza vaccination and for uninsured and low-income adolescents.

Adherence to Expanded Influenza Immunization Recommendations among Primary Care Providers

OBJECTIVEnTo assess practices regarding the expanded Advisory Committee on Immunization Practices (ACIP) recommendations for influenza vaccination in children among US pediatricians and family medicine physicians (FMs) and strategies to promote vaccination.nnnSTUDY DESIGNnWe administered a survey between July and October 2009 to 416 pediatricians and 424 FMs from nationally representative networks.nnnRESULTSnThe response rate was 75% (79% pediatricians, 70% FMs). FMs were less likely than pediatricians to report adherence to ACIP recommendations (35% vs 65%; adjusted risk ratio [RR], 0.60; 95% CI, 0.50-0.72). Most physicians (89% pediatricians and 89% FMs) reported using posters or pamphlets to encourage influenza vaccination, and 57% pediatricians and 41% FMs reported offering after hours dedicated influenza vaccination clinics. Only 23% pediatricians and 14% FMs reported providing written, telephone, or e-mail reminders to all children. Having dedicated influenza vaccination clinics after hours or weekends was associated with routine vaccination of all children (adjusted RR, 1.33; 95% CI, 1.15-1.57).nnnCONCLUSIONnIn the first year of the expanded ACIP recommendations to immunize all eligible children against influenza, two-thirds of pediatricians and one-half of FMs reported adherence, although less than one-quarter were actively engaging in reminder/recall efforts. Practices that adhered to the ACIP recommendations were more likely to put a substantial effort into promoting vaccination opportunities.

Centralized Reminder/Recall to Increase Immunization Rates in Young Children: How Much Bang for the Buck?

OBJECTIVEnWe compared the effectiveness and cost-effectiveness of: 1) centralized reminder/recall (C-R/R) using the Colorado Immunization Information System (CIIS) versus practice-based reminder/recall (PB-R/R) approaches to increase immunization rates; 2) different levels of C-R/R intensity; and 3) C-R/R with versus without the name of the childs provider.nnnMETHODSnWe conducted 3 sequential cluster-randomized trials involving children aged 19 to 25 months in 15 Colorado counties in March 2013 (trial 1), October 2013 (trial 2), and May 2014 (trial 3). In C-R/R counties, the intensity of the intervention decreased sequentially in trials 1 through 3, from 3 to 1 recall messages. In PB-R/R counties, practices were offered training using CIIS and financial support. The percentage of children with up-to-date (UTD) vaccinations was compared 6 months after recall. A mixed-effects model assessed the association between C-R/R versus PB-R/R and UTD rates.nnnRESULTSnC-R/R was more effective in trials 1 to 3 (relative riskxa0=xa01.11; 95% confidence interval 1.01-1.20; Pxa0=xa0.009). Effectiveness did not decrease with decreasing intervention intensity (Pxa0=xa0.59). Costs decreased with decreasing intensity in the C-R/R arm, from

Understanding adaptations to patient-centered medical home activities: The PCMH adaptations model

18.72 per child brought UTD in trial 1 to

Metabolic Testing for Adults in a State Medicaid Program Receiving Antipsychotics: Remaining Barriers to Achieving Population Health Prevention Goals

10.11 in trial 3. Costs were higher and more variable in the PB-R/R arm, ranging from

Stakeholder Benefit from Depression Disease Management: Differences by Rurality?

20.63 to

Provider Preferences and Experiences With a Countywide Centralized Collaborative Reminder/ Recall for Childhood Immunizations

237.81 per child brought UTD. C-R/R was significantly more effective if the childs practice name was included (Pxa0<xa0.0001).nnnCONCLUSIONSnC-R/R was more effective and cost-effective than PB-R/R for increasing UTD rates in young children and was most effective if messages included the childs provider name. Three reminders were not more effective than one, which may be explained by the increasing accuracy of contact information in CIIS over the course of the trials.