Mirrian Smolders

Which Physician and Practice Characteristics are Associated With Adherence to Evidence-Based Guidelines for Depressive and Anxiety Disorders?

Background:Research on quality of care for depressive and anxiety disorders has reported low rates of adherence to evidence-based depression and anxiety guidelines. To improve this care, we need a better understanding of the factors determining guideline adherence. Objective:To investigate how practice- and professional-related factors are associated with adherence to these guidelines. Design:Cross-sectional cohort study. Participants:A total of 665 patients with a composite interview diagnostic instrument diagnosis of depressive or anxiety disorders, and 62 general practitioners from 21 practices participated. Measures:Actual care data were derived from electronic medical record data. The measurement of guideline adherence was based on performance indicators derived from evidence-based guidelines. Practice-, professional-, and patient-related characteristics were measured with questionnaires. The characteristics associated with guideline adherence were assessed by multivariate multilevel regression analysis. Results:A number of practice and professional characteristics showed a significant univariate association with guideline adherence. The multivariate multilevel analyses revealed that, after controlling for patient characteristics, higher rates of guideline adherence were associated with stronger confidence in depression identification, less perceived time limitations, and less perceived barriers for guideline implementation. These professional-related determinants differed among the overall concept of guideline adherence and the various treatment options. Conclusions:This study showed that rates of adherence to guidelines on depressive and anxiety disorders were not associated with practice characteristics, but to some extent with physician characteristics. Although most of the identified professional-related determinants are very difficult to change, our results give some directions for improving depression and anxiety care.

Patient factors associated with guideline-concordant treatment of anxiety and depression in primary care

ObjectiveTo identify associations of patient characteristics (predisposing, enabling and need factors) with guideline-concordant care for anxiety and depression in primary care.DesignAnalysis of data from the Netherlands Study of Depression and Anxiety (NESDA).ParticipantsSeven hundred and twenty-one patients with a current anxiety or depressive disorder, recruited from 67 general practitioners (GPs), were included.MeasuresDiagnoses according to the Diagnostic and Statistic Manual of Mental Disorders, fourth edition (DSM-IV) were made using a structured and widely validated assessment. Socio-demographic and enabling characteristics, severity of symptoms, disability, (under treatment for) chronic somatic conditions, perceived need for care, beliefs and evaluations of care were measured by questionnaires. Actual care data were derived from electronic medical records. Criteria for guideline-concordant care were based on general practice guidelines, issued by the Dutch College of General Practitioners.ResultsTwo hundred and eighty-one (39%) patients received guideline-concordant care. High education level, accessibility of care, comorbidity of anxiety and depression, and severity and disability scores were positively associated with receiving guideline-concordant care in univariate analyses. In multivariate multi-level logistic regression models, significant associations with the clinical need factors disappeared. Positive evaluations of accessibility of care increased the chance (OR = 1.31; 95%−CI = 1.05–1.65; p = 0.02) of receiving guideline-concordant care, as well as perceiving any need for medication (OR = 2.99; 95%−CI = 1.84–4.85; p < 0.001), counseling (OR = 2.25; 95%−CI = 1.29–3.95; p = 0.005) or a referral (OR = 1.83; 95%−CI = 1.09–3.09; p = 0.02). A low educational level decreased the odds (OR = 0.33; 95%−CI = 0.11–0.98; p = 0.04) of receiving guideline-concordant care.ConclusionsThis study shows that education level, accessibility of care and patients’ perceived needs for care are more strongly associated with the delivery of guideline-concordant care for anxiety or depression than clinical need factors. Initiatives to improve GPs’ communication skills around mental health issues, and to improve recognition of people suffering from anxiety disorders, could increase the number of patients receiving treatment for depression and anxiety in primary care.

What determines the management of anxiety disorders and its improvement

INTRODUCTION Although anxiety disorders are highly prevalent, lack of correct diagnosis and related concerns about treatment are serious clinical problems. Several factors affect, positively or negatively, management of anxiety and its improvement. A literature review and thematic analysis was executed to obtain an overview of the types of determinants of anxiety care and its improvement. METHODS Literature was identified from electronic database searching (January 1995-March 2006), contact with authors of studies, and searching of websites of organizations concerned with mental health. By using a template analysis approach, a set of strong themes relating to determinants of anxiety care and its improvement was identified. RESULTS The 15 eligible studies identified 43 factors that impeded or facilitated optimal anxiety care and its improvement. Individual characteristics of both patients (n = 13) and professionals (n = 6) were most frequently reported as determinants of anxiety care and its improvement. A considerable number of factors were related to the organizational context (n = 12), such as practice type and location. Some factors related to the social context (n = 4), the economic context (n = 2), or to the innovation itself (n = 6) were identified. CONCLUSION The findings show that there is a multitude of barriers and facilitators to optimal anxiety care and its improvement. Some determinants are modifiable, and thus responsive to interventions. Examples are collaboration within and between organizations, financial resources and assignment of both an opinion leader and responsible staff. The quality of anxiety care can be improved by systematically designing innovation strategies which are tailored to a selection of the determinants identified in this study.

Depressed and a co-morbid condition: more psychotropics prescribed!

Background: Depression often occurs simultaneously with a variety of somatic, psychiatric, and social conditions. Knowledge about differences in the pharmacological treatment of depressed patients with and without co-morbidity is lacking. Objective: To compare GPs’ pharmacological treatment of depressed patients with and without co-morbidity. Methods: Data were extracted from the computerized medical records of 77 general practices participating in the Dutch National Information Network of General Practice (LINH). We used diagnosis and prescription data of newly diagnosed depressed patients aged 18–65 years (n=4372). A mixed-model technique was used for analyzing the medical data. Results: During the year after diagnosing depression, depressed patients who also suffered from chronic somatic or psychiatric morbidity were prescribed more psychotropics than patients with depression only. Prescription patterns of psychotropic drugs for depressed patients with and without co-morbid social problems differed only during the first 3 months after diagnosis. For the whole 1-year period after diagnosis, the pharmacological treatment of depression in patients with and without co-morbid social problems did not differ. Conclusion: Our results indicate that chronic somatic or psychiatric co-morbidity in depressed patients leads to higher GP prescription levels of psychotropics, whereas co-morbid social problems do not seem to influence GPs’ pharmacological treatment decisions for depression.

Comorbiditeit beïnvloedt het voorschrijfgedrag bij depressie.

SamenvattingDepressie gaat meestal gepaard met andere psychiatrische, somatische of sociale problematiek. Soms is dit toeval, maar vaak is er een verband. De NHG-Standaard Depressieve stoornis adviseert om het beleid bij een depressieve stoornis onder andere af te stemmen op eventuele comorbiditeit van de patiënt. Met betrekking tot vorm en intensiteit van de behandeling

P01-83 - Associations between guideline-concordant care and clinical outcomes for depression and anxiety

Aims To determine possible associations between guideline-concordant care and clinical outcome in general practice patients with anxiety and depression, and identification of patient characteristics associated with poor clinical outcome. Methods Data from the Netherlands Study of Anxiety and Depression (NESDA) was used. NESDA is a longitudinal cohort study to measure the long-term course and consequences of anxiety and depressive disorders. Adult patients were interviewed to measure DSM-IV diagnoses during the baseline assessment, and completed questionnaires measuring symptom severity, sociodemographic variables and social support at baseline and 12 months later. The definition of guideline adherence was based on an algorithm on care that was received. Results 721 patients with a current (6-month recency) anxiety or depressive disorder participated. While patients who received guideline-concordant care (N=281) suffered from more severe symptoms than patients who received non-guideline concordant care (N=440), both groups improved equally on their depressive or anxiety symptoms after 12 months. Patients who (still) had moderate or severe symptoms at follow-up, were more often unemployed, had smaller personal networks and more severe depressive symptoms at baseline than patients with low symptoms at follow-up. Conclusions The added value of guideline-concordant care could not be demonstrated in this study. While patients with comorbidity of both anxiety and depressive disorders, those with smaller social networks and the unemployed were more likely to suffer from moderate or severe symptoms after 12 months, severity of depressive symptoms at baseline was most strongly associated. Findings have practical implications as well as implication for future research.