Matthew R. Meunier

Epidemiology of polypharmacy among family medicine patients at hospital discharge.

Background: Polypharmacy has been identified as a quality indicator, but no studies have been reported about the epidemiology of polypharmacy among hospital patients at discharge. Methods: Records of 142 family medicine patients aged ≥65 years who were discharged from the hospital during the period November 2008 to October 2009 were extracted. Forty-six of these patients were readmitted within 30 days and the remaining 96 not readmitted within 30 days. Polypharmacy was measured as >16 medications at dismissal. Independent variables related to person (use of medical care in the 12 months prior to hospitalization, number of high-risk diagnoses, and demographic characteristics), place (living situation at admission and disposition location), and time (month of admission). Chronic obstructive pulmonary disease, cancer, diabetes mellitus, congestive heart failure, and coronary artery disease were diagnoses determined to be high-risk. Results: Mean number of medications at dismissal was 13.5 and 23.2% of patients were prescribed more than 16 medications. No interactions were found between readmission status and any of the independent variables. Use of medical services in the previous year was not related to polypharmacy and no seasonal pattern was detected. Two or more high-risk diagnoses were independently related to polypharmacy (odds ratio [OR] = 4.75, confidence interval [CI] = 1.0-11.2, P = .00). Being discharged to a location with personal health services such as home care or a skilled nursing facility was also related to polypharmacy (OR = 3.07, CI = 1.3-7.2, P = .01). Conclusion: Drug reviews intended to reduce the rate of polypharmacy among discharged persons aged ≥65 years can be targeted at patients who have 2 or more high-risk diagnoses and at those discharged to receive personal health services either at home or in a convalescence facility.

Diabetes and Obesity Not Associated With 6-Month Remission Rates for Primary Care Patients With Depression

BACKGROUND Complex interrelationships appear to exist among depression, diabetes, and obesity, and it has been proposed that both diabetes and obesity have an association with depression. OBJECTIVE The purpose of our study was to explore the effect of obesity and diabetes on response to the treatment of depression. Our hypothesis was that obesity and the diagnosis of diabetes in primary care patients with depression would have no effects on depression remission rates 6 months after diagnosis. METHODS A retrospective chart review analysis of 1894 adult (age ≥18y) primary care patients diagnosed with major depressive disorder or dysthymia and a Patient Health Questionnaire-9 score ≥10 from January 1, 2008, through September 30, 2012. Multiple logistic regression modeling retaining all independent variables was performed for the outcome of remission (Patient Health Questionnaire-9 < 5) 6 months after diagnosis. RESULTS The presence of obesity (odds ratio = 0.937, 95% CI: 0.770-1.140, p = 0.514) or the diagnosis of diabetes (odds ratio = 0.740, 95% CI: 0.535-1.022, p = 0.068) did not affect the likelihood of remission, while controlling for the other independent variables. CONCLUSIONS In primary care patients treated for depression, the presence of diabetes or obesity at the time of diagnosis of depression does not appear to significantly affect remission of depressive symptoms 6 months after diagnosis.

Impact of symptom remission on outpatient visits in depressed primary care patients treated with collaborative care management and usual care.

Depression symptoms contribute to significant morbidity and health care utilization. The aim of this study was to determine the impact of symptom improvement (to remission) on outpatient clinical visits by depressed primary care patients. This study was a retrospective chart review analysis of 1733 primary care patients enrolled into collaborative care management (CCM) or usual care (UC) with 6-month follow-up data. Baseline data (including demographic information, clinical diagnosis, and depression severity) and 6-month follow-up data (Patient Health Questionnaire scores and the number of outpatient visits utilized) were included in the data set. To control for individual patient complexity and pattern of usage, the number of outpatient visits for 6 months prior to enrollment also was measured as was the presence of medical comorbidities. Multiple logistic regression analysis demonstrated that clinical remission at 6 months was an independent predictor of outpatient visit outlier status (>8 visits) (odds ratio [OR] 0.609, confidence interval (CI) 0.460-0.805, P<0.01) when controlling for all other independent variables including enrollment into CCM or UC. The OR of those patients not in remission at 6 months having outpatient visit outlier status was the inverse of this at 1.643 (CI 1.243-2.173). The most predictive variable for determining increased outpatient visit counts after diagnosis of depression was increased outpatient visits prior to diagnosis (OR 4.892, CI 3.655-6.548, P<0.01). In primary care patients treated for depression, successful treatment to remission at 6 months decreased the likelihood of the patient having more than 8 visits during the 6 months after diagnosis.

Timely response to secure messages from primary care patients.

Purpose: To assess delays in response to patient secure e-mail messages in primary care. Background: Secure electronic messages are initiated by primary care patients. Timely response is necessary for patient safety and quality. Data Source: A database of secure messages. Sample: A random sample of 353 secure electronic messages initiated by primary care patients treated in 4 clinics. Outcome Measures: Message not opened after 12 hours or messages not responded to after 36 hours. Results: A total of 8.5% of electronic messages were not opened within 12 hours, and 17.6% did not receive a response in 36 hours. Clinic location, being a clinic employee, and patient sex were not related to delays. Patients older than 50 years were more likely to receive a delayed response (25.7% delayed, P = .013). The risk of both kinds of delays was higher on weekends (P < .001 for both). Conclusion: The e-mail message system resulted in high rates of delayed response. Delays were concentrated on weekends (Friday-Sunday). Reducing delayed responses may require automatic rerouting of messages to message centers staffed 24–7 or other mechanisms to manage this after-hours work flow.

Plans to Accommodate Proposed Maternity Care Training Requirements: A National Survey of Family Medicine Directors of Obstetrics Curricula

Introduction: Proposed changes to family medicine maternity care training requirements, including a 2-tiered basic and advanced curriculum, have raised questions about their perceived feasibility and impact. The goal of this study was to elicit family medicine obstetrics faculty plans to adopt changes in their maternity care training of family physicians. Methods: We surveyed obstetrics curriculum directors at 423 family medicine residency programs, eliciting their plans to accommodate proposed maternity care training requirements. Results: Two hundred nine programs participated (49.4% response rate). Of the curriculum adoption plans reported by directors, 41.7% anticipated using both curriculum models, 19.6% anticipated using the advanced model, 3.9% anticipated using the basic model, and 23.5% had no changes planned for their obstetrics curricula. Conclusions: Most programs plan structured changes, but a significant minority of programs plan no change to their curriculum based on proposed maternity care requirements.

Diabetes and depression: does worsening control of diabetes lead to poorer depression outcomes?

RATIONALE, AIMS AND OBJECTIVES The relationship between diabetes and depression is complex. The aim of this study was to study the impact of diabetic control in depressed primary care patients with diabetes on clinical remission of their depression at 6 months. METHODS This study was a retrospective chart review analysis of 145 adult patients diagnosed with either major depressive disorder or dysthymia and had a score of 10 or greater on the PHQ-9. The dependent variable for this study was depression remission at 6 months. The independent variables for this study were age, gender, marital status, race, BMI and HbA1c level within 2 months prior to the time of depression diagnosis. RESULTS Multiple logistic regression modelling demonstrated that initial diabetic control or obesity were not independent predictors of depression remission at 6 months after index date. Also, the odds for the diabetes being in control (HbA1c <8.0%) after 6 months was only associated with being in control at baseline (OR 5.549, CI 2.364-13.024, P < 0.001). CONCLUSIONS Baseline diabetic control does not appear to be an independent predictor for depression outcomes at 6 months. The best predictor of diabetic control after the diagnosis of depression was previous control of diabetes.

Future Complexity of Care Tier Affected by Depression Outcomes

Background: The inclusion of mental health issues in the evaluation of multimorbidity generally has been as the presence or absence of the condition rather than severity, complexity, or stage. The hypothesis for this study was that clinical outcome of the depression 6 months after enrollment into collaborative care management would have a role in predicting future complexity of care tier. Methods: This study was a retrospective chart review of 1894 primary care patients who were diagnosed with major depressive disorder or dysthymia as of December 2012. Multiple logistic regression analysis was used to test the independent associations between each variable and the odds of being included in the higher tiers (HT) group. Results: Age (odds ratio [OR] = 1.022, confidence interval [CI] = 1.013-1.030, P < .001), female gender (OR = 1.380, CI = 1.020-1.868, P = .037), being married (OR = 0.730, CI = 0.563-0.947, P = .018), and the presence of comorbidities (1, OR = 1.986, CI = 1.485-2.656, P < .001; ≥2, OR = 4.678, CI = 3.242-6.750, P < .001) were independently associated with future HT levels. The presence of persistent depressive symptoms (PHQ-9 ≥10) at 6 months conferred 2.280 (CI = 1.673-3.107, P < .001) times likely odds of HT level compared with clinical remission at 6 months. Conclusion: Patients with the diagnosis of major depression or dysthymia had greater odds of complex tier levels in the future, if depression was not treated to remission by 6 months. This study demonstrated the importance of the goal of significant improvement (ie, remission) of depression symptoms by 6 months (especially those older patients with more comorbidity) from entering into the higher complexity tiers.

EPA-0017 – Remission decreased outpatient visit counts in depressed primary care patients treated with collaborative care management or usual care

Introduction Depression symptoms contribute to significant morbidity and health care utilization. Healthcare reform should consider improvements in clinical outcomes as well as decreased overall utilization as mechanisms to control health care costs. Objectives/Aims The aim of this study was to determine the impact of remission on outpatient clinical visits by depressed primary care patients in collaborative care management (CCM) or usual care (UC). The hypothesis was that depressed patients with worse outcomes at six months would have increased outpatient visit counts, regardless of treatment type. Methods The study was a retrospective, chart review analysis of 1,733 patients with six month follow-up data. The data set included baseline data (demographic information, diagnosis, medical comorbidity, prior outpatient visit counts and depression severity) and six month follow up data (PHQ-9 scores and number of outpatient visits utilized). Results Multiple logistic regression demonstrated that remission at six months was an independent predictor of outpatient visit outlier status (>8 visits) (OR 0.609 CI 0.460-0.805, p Conclusions In primary care patients treated for depression, successful treatment to remission at six months decreased the likelihood of the patient having more than 8 visits during the six months after diagnosis. This holds true even when controlling for the individual patients prior outpatient visit counts, health care comorbidities and enrollment into CCM vs. UC.