Margary Kurland

TRIPPD: A Practice-Based Network Effectiveness Study of Postpartum Depression Screening and Management

PURPOSE Postpartum depression is common but inadequately recognized and undertreated. Continuing depressive symptoms are associated with adverse outcomes for the woman, her infant, and family. We wanted to determine the effect of a practice-based training program for screening, diagnosis, and management of depression in postpartum mothers. METHODS In this practice-based effectiveness study, 28 practices were randomized to usual care (n = 14) or intervention (n = 14), and 2,343 women were enrolled between 5 and 12 weeks’ postpartum. The intervention sites received education and tools for postpartum depression screening, diagnosis, initiation of therapy, and follow-up within their practices. Usual-care practices received a 30-minute presentation about postpartum depression. Screening information for the usual care was obtained from baseline surveys sent directly to the central site but was not available for patient care. Outcomes were based on patient-reported outcomes (level of depressive symptoms) from surveys at 6 and 12 months, plus medical record review (diagnosis and therapy initiation). RESULTS Among the 2,343 women enrolled, 1,897 (80.1%) provided outcome information, and were included in the analysis. Overall, 654 (34.5% of 1,897) women had elevated screening scores indicative of depression, with comparable rates in the intervention and usual-care groups. Among the 654 women with elevated postpartum depression screening scores, those in the intervention practices were more likely to receive a diagnosis (P = .0006) and therapy for postpartum depression (P = .002). They also had lower depressive symptom levels at 6 (P = .07) and 12 months’ (P=.001) postpartum. CONCLUSIONS Primary care–based screening, diagnosis, and management improved mother’s depression outcomes at 12 months. This practical approach could be implemented widely with modest resources.

Concordance of Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9) to Assess Increased Risk of Depression among Postpartum Women

Objectives: To compare the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9) as screening tools for postpartum depression. Methods: This study population included the first 500 women to enroll and return their packets during an ongoing study of postpartum depression. Results: The primary outcome of this study was to find rates of concordance and discordance in the EPDS and PHQ-9 categories of “normal” and “increased risk for major depressive disorder.” Overall, 97% of eligible women enrolled and 70% returned the packets that included the EPDS and PHQ-9. Four hundred eighty-one of the first 500 packets had complete data, with elevated EPDS or PHQ-9 scores in 138 and 132 women, respectively. Concordance of the EPDS and PHQ-9 were present in 399 women (83%): 326 (67.8%) had “normal” score on both, and 73 (15.2%) had elevated scores for both. Discordant scores in 82 women included 17 with elevated PHQ-9 scores but normal EPDS scores and 65 with elevated EPDS scores and PHQ-9 scores <10. In multivariate logistic regression modeling, only age >30 and low education level were predictive of discordant scores, using EPDS and PHQ-9 scores of ≥10 as elevated (odds ratio, 1.9 and P = .02; and odds ratio, 2.3 and P = .01, respectively). PHQ-9 scores of 5 to 9 have been referred to as consistent with “mild depressive symptoms” and appropriate for “watchful waiting” and repeat PHQ-9 at follow-up. Using this follow-up approach would require re-evaluation of 120 (25%) of the women screened. Conclusions: Postpartum depression screening is feasible in primary care practices, and for most women the EPDS and PHQ-9 scores were concordant. Further work is required to identify reasons for the 17% discordant scores as well as to provide definitive recommendations for PHQ-9 scores of 5 to 9.

Outcome results of a school-based screening program for undertreated asthma

BACKGROUND Undertreatment of asthma is associated with significant potentially preventable morbidity, including frequent school absences. Guideline dissemination and clinician education have met with variable success. School-based identification of children with potentially undertreated asthma may provide an alternative strategy for improving asthma management in children. OBJECTIVE To evaluate the effectiveness of school-based identification of potentially undertreated asthma. METHODS A controlled trial of school-based identification of children with known but symptomatic asthma using mailed parent surveys, letters recommending medical follow-up, and medical record review to evaluate changes in asthma treatment after referral. RESULTS Most parents (79.9%, n = 5,116 respondents) responded to the survey and 19.4% (n = 994) of children were reported to have a physician diagnosis of asthma or reactive airway disease. Letters of referral were sent to 489 children with parent-reported asthma who were identified as having potentially undertreated asthma. Approximately one-third (31.2%, n = 153) of these children had physician visits, and 92 (18.8% of all referred) had documented medication changes. In addition, there were 20 new physician diagnoses in this group of children. In the control group of 604 children with asthma, there were significantly fewer children with asthma-related visits (131, 21.7%, P = 0.0004) and children with medication changes (74, 12.3%, P = 0.002) in a comparable 6-month window. CONCLUSIONS School-based screening or case identification increased the number of physician asthma-related visits and changes in asthma therapy.

Do published guidelines for evaluation of Irritable Bowel Syndrome reflect practice

BackgroundThe only US guidelines listed in the National Guideline Warehouse for the diagnosis of Irritable Bowel Syndrome (IBS) are the expert opinion guidelines published by The American Gastroenterology Association. Although the listed target audience of these guidelines includes family physicians and general internists, the care recommended in the guidelines has not been compared to actual primary care practice. This study was designed to compare expert opinion guidelines with the actual primary care provided and to assess outcomes in the 3 years following the IBS diagnosis.MethodsThis is a retrospective medical record review study using a random sample of incident IBS cases from all Olmsted County, Minnesota providers diagnosed between January 1, 1993 and December 31, 1995. Data was collected on all care and testing provided to the subjects as well as 3-year outcomes related to the IBS diagnosis.ResultsOf the 149 IBS patients, 99 were women and the mean age was 47.6 years. No patient had all of the diagnostic tests recommended in the guidelines. 42% had the basic blood tests of CBC and a chemistry panel. Sedimentation rate (2%) and serum thyroxine level (3%) were uncommon. Colon imaging studies were done in 41% including 74% of those over the age of 50. In the 3 years following the diagnosis, only one person had a change in diagnosis and no diagnoses of gastro-intestinal malignancies were made in the cohort.ConclusionsPrimary care practice based diagnostic evaluations for IBS differ significantly from the specialty expert opinion-based guidelines. Implementation of the specialty guidelines in primary care practice would increase utilization with apparent limited improvement in diagnostic outcomes.

Practice Benefit from Participating in a Practice-based Research Network Study of Postpartum Depression: A National Research Network (NRN) Report

Background: At the midpoint of a large clinical trial taking place in a practice-based research network (PBRN), we asked leaders of the enrolled practices about the impact of participating in a PBRN study. Methods: Using semistructured interviews, the lead study nurse and physician from each site were queried about the impact of study participation on issues related to the study topic of postpartum depression (PPD) as well as any other impacts on the practice not directly related to PPD. From the results, initial themes were identified by 3 of the investigators (BPY, SB, MK) and confirmed by all the authors. Interviewee responses were grouped by theme. Results: Forty-eight study leaders from 28 solo, moderately sized group and residency practices were interviewed during a period of 60 days. Practices were located in 20 different states, and 54% were in rural communities. Six major themes emerged. Study participation led to: (1) the recognition of the need for systematic approaches; (2) more effective teamwork and communication within the practice; (3) adaptation and extension of the PPD study tools and a systematic approach to the care of other chronic conditions; (4) increased professional self-worth and community recognition; (5) opportunity and support for staff members to “stretch” into new roles; and (6) increased research literacy within the practice. Conclusions: Participating in a PBRN research study can provide advantages to practices that extend beyond the studys specific purpose and content. These results provide further support for the value of PBRN research funding.

Lessons learned from the conduct of a multisite cluster randomized practical trial of decision aids in rural and suburban primary care practices

BackgroundThe decision aids for diabetes (DAD) trial explored the feasibility of testing the effectiveness of decision aids (DAs) about coronary prevention and diabetes medications in community-based primary care practices, including rural clinics that care for patients with type 2 diabetes.MethodsAs originally designed, we invited clinicians in eight practices to participate in the trial, reviewed the patient panel of clinicians who accepted our invitation for potentially eligible patients, and contacted these patients by phone, enrolling those who accepted our invitation. As enrollment failed to meet targets, we recruited four new practices. After discussing the study with the clinicians and receiving their support, we reviewed all clinic panels for potentially eligible patients. Clinicians were approached to confirm participation and patient eligibility, and patients were approached before their visit to provide written informed consent. This in-clinic approach required study coordinators to travel and stay longer at the clinics as well as to screen more patient records for eligibility. The in-clinic approach was associated with better recruitment rates, lower patient retention and outcome completion rates, and a better intervention effect.ResultsWe drew four lessons: 1) difficulties identifying potentially eligible patients threaten the viability of practical trials of DAs; 2) to improve the recruitment yield, recruit clinicians and patients for the study at the clinic, just before their visit; 3) approaches that improve recruitment may be associated with reduced retention and survey response; and 4) procedures that involve working closely with the practice may improve recruitment and may also affect the quality of the implementation of the interventions.ConclusionSuccess in practice-based trials in usual primary care including rural clinics may require the smallest possible research footprint on the practice while implementing a streamlined protocol favoring in-clinic, in-person interactions with clinicians and patients.Trial registrationClinicalTrials.gov NCT01029288

Protocol for the asthma tools study: a pragmatic practice-based research network trial

Background Asthma is common among children, adolescents, and adults. However, management of asthma often fails to follow evidence-based guidelines. Control assessments have been developed, validated against expert opinion, and disseminated. However, in primary care, assessment of control is only one step in asthma management. To facilitate integration of the evidence-based guidelines into practice, tools should also guide the next steps in care. The Asthma APGAR tools do just that, incorporating a control assessment as well as assessment of the most common reasons for inadequate and poor control. The Asthma APGAR tool is also linked to a care algorithm based on the 2007 National Heart, Lung, and Blood Institute asthma guidelines. The objective of this study is to assess the impact of implementation of the Asthma APGAR on patient asthma outcomes in primary care practices. Methods A total of 1400 patients aged 5–60 years with physician-diagnosed asthma are enrolled in 20 practice-based research network (PBRN) practices randomized to intervention or usual care. The primary outcomes are changes in patient self-reported asthma control, asthma-related quality of life, and rates of exacerbations documented in medical records over the 18–24 months of enrollment. Process measures related to implementation of the Asthma APGAR system into daily care will also be assessed using review of medical records. Qualitative assessments will be used to explore barriers to and facilitators for integrating the Asthma APGAR tools into daily practice in primary care. Discussion Data from this pivotal pragmatic study are intended to demonstrate the importance of linking assessment of asthma and management tools to improve asthma-related patient outcomes. The study is an effectiveness trial done in real-world PBRN practices using patient-oriented outcome measures, making it generalizable to the largest possible group of asthma care providers and primary care clinics.

Automated patient and medication payment method for clinical trials

Barbara P Yawn1 Suzanne Madison1 Susan Bertram1 Wilson D Pace2 Anne Fuhlbrigge3 Elliot Israel3 Dawn Littlefield1 Margary Kurland1 Michael E Wechsler4 1Olmsted Medical Center, Department of Research, Rochester, MN, 2UCDHSC, Department of Family Medicine, University of Colorado Health Science Centre, Aurora, CO, 3Brigham and Women’s Hospital, Pulmonary and Critical Care Division, Boston, MA, 4National Jewish Medical Center, Division of Pulmonology, Denver, CO, USA

Depressive Symptoms and Access to Mental Health Care in Women Screened for Postpartum Depression Who Lose Health Insurance Coverage After Delivery: Findings From the Translating Research Into Practice for Postpartum Depression (TRIPPD) Effectiveness Study

OBJECTIVE To determine the impact of losing health insurance coverage on perceived need for and access to mental health care in women screened for postpartum depression (PPD) in primary care settings. PATIENTS AND METHODS The study sample included 2343 women enrolled in a 12-month, multisite, randomized trial that compared clinical outcomes of a comprehensive PPD screening and management program with usual care (March 1, 2006, through August 31, 2010). Screening for PPD occurred at the first postpartum visit (5-12 weeks) using the Edinburgh Postnatal Depression Scale followed by the 9-item Patient Health Questionnaire. Insurance status during the prenatal period, at delivery, and during the first postpartum year and perceived need for and access to mental health care during the first postpartum year were assessed via questionnaires completed by individual patients and participating practices. RESULTS Rates of uninsured increased from 3.8% during pregnancy and delivery (n=87 of 2317) to 10.8% at the first postpartum visit (n=253 of 2343) and 13.7% at any subsequent visit to the practice after 2 months post partum (n=226 of 1646) (P<.001, both comparisons vs baseline). For patients with data on insurance type during follow-up, insurance loss occurred primarily in Medicaid beneficiaries. Nine-item Patient Health Questionnaire scores and self-reported need for mental health care did not differ significantly between patients who remained insured and those who lost insurance during the first postpartum year. However, of patients who reported the need for mental health care, 61.1% of the uninsured (n=66 of 108) vs 27.1% of the insured (n=49 of 181) reported an inability to obtain mental health care (P<.001). CONCLUSION Loss of insurance during the first postpartum year did not significantly affect depressive symptoms or perceived need for mental health care but did adversely affect self-reported ability to obtain mental health care.