Ramona S. DeJesus

Missed appointments in resident continuity clinic: patient characteristics and health care outcomes.

BACKGROUND Frequent missed patient appointments in resident continuity clinic is a well-documented problem, but whether rates of missed appointments are disproportionate to standard academic practice, what patient factors contribute to these differences, and health care outcomes of patients who frequently miss appointments are unclear. METHODS The overall population for the study was composed of patients in an academic internal medicine continuity clinic with 5 or more office visits between January 2006 and December 2008. We randomly selected 325 patients seen by resident physicians and 325 patients cared for by faculty. Multivariate linear regression was used to examine the relationship between patient factors and missed appointments. Health outcomes were compared between patients with frequent missed appointments and the remainder of the study sample, using Cox regression analysis. RESULTS Resident patients demonstrated significantly higher rates of missed appointments than faculty patients, but this difference was explained by patient factors. Factors associated with more missed appointments included use of a medical interpreter, Medicaid insurance, more frequent emergency department visits, less time impanelled in the practice, and lower proportion of office visits with the primary care provider. Patients with frequent missed appointments were less likely to be up to date with preventive health services and more likely to have poorly controlled blood pressure and diabetes. CONCLUSIONS We found that the disproportionate frequency of missed appointments in resident continuity clinic is explained by patient factors and practice discontinuity, and that patients with frequent missed appointments demonstrated worse health care outcomes.

A System-Based Approach to Depression Management in Primary Care Using the Patient Health Questionnaire-9

Primary care physicians are more likely to see patients with depression than with any other disorder except hypertension, and its management poses a challenge to busy primary care practices. The Patient Health Questionnaire-9, a simple self-administered tool of proven validity and reliability, is a commonly used screening instrument for depression in primary care practice. This review article provides a system-based approach to depression management using the Patient Health Questionnaire-9 to guide clinicians in the identification and treatment of depression and its follow-up care.

Use of a clinical decision support system to increase osteoporosis screening.

Background In 2002, the US Preventive Services Task Force recommended routine osteoporosis screening for women aged 65 years or older. However, studies have indicated that osteoporosis remains underdiagnosed, and various methods such as the use of health information technology have been tried to increase screening rates. We investigated whether we could boost the low rates of bone mineral density testing with implementation of a point-of-care clinical decision support system in our primary care practice. Methods We retrospectively reviewed the medical records of female patients eligible for osteoporosis screening who had no prior bone mineral density test who were seen at our primary care practice sites in 2007 or 2008 (before and after implementation of a point-of-care clinical decision support system). Results Overall, screening rates were 80.1% in 2007 and 84.1% in 2008 (P < 0.001). Of patients who did not have osteoporosis screening before the visit, 5.87% completed the screening after the visit in 2007, compared with 9.79% in 2008 (when the clinical support system was implemented), a 66.7% improvement (P = 0.025). Conclusion Clinical decision support for primary care doctors significantly improved osteoporosis screening rates among eligible women. Carefully designed clinical decision support systems can optimize care delivery, ensuring that important preventive services such as osteoporosis screening for patients at risk for fracture are performed while unnecessary testing is avoided.

Supervised, vigorous intensity exercise intervention for depressed female smokers: A pilot study

Introduction: Few studies have evaluated exercise interventions for smokers with depression or other psychiatric comorbidities. This pilot study evaluated the potential role of supervised vigorous exercise as a smoking cessation intervention for depressed females. Methods: Thirty adult women with moderate–severe depressive symptoms were enrolled and randomly assigned to 12 weeks of thrice weekly, in person sessions of vigorous intensity supervised exercise at a YMCA setting (EX; n = 15) or health education (HE; n = 15). All participants received behavioral smoking cessation counseling and nicotine patch therapy. Assessments were done in person at baseline, at the end of 12 weeks of treatment, and at 6 months post-target quit date. Primary end points were exercise adherence (proportion of 36 sessions attended) and biochemically confirmed 7-day point prevalence abstinence at Week 12. Biomarkers of inflammation were explored for differences between treatment groups and between women who smoked and those abstinent at Week 12. Results: Treatment adherence was high for both groups (72% for EX and 66% for HE; p = .55). The Week 12 smoking abstinence rate was higher for EX than HE (11/15 [73%] vs. 5/15 [33%]; p = .028), but no significant differences emerged at 6-month follow-up. Interleukin-6 levels increased more for those smoking than women abstinent at Week 12 (p = .040). Conclusions: Vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. Innovative and cost-effective strategies to bolster long-term exercise adherence and smoking cessation need evaluation in this population. Inflammatory biomarkers could be examined in future research as mediators of treatment efficacy. Implications: This preliminary study found that vigorous intensity supervised exercise is feasible and enhances short-term smoking cessation among depressed female smokers. This research addressed an important gap in the field. Despite decades of research examining exercise interventions for smoking cessation, few studies were done among depressed smokers or those with comorbid psychiatric disorders. A novel finding was increases in levels of a pro-inflammatory biomarker observed among women who smoked at the end of the intervention compared to those who did not.

Initial implementation of a depression care manager model: an observational study of outpatient utilization in primary care clinics.

Many primary care physicians understand the challenges of taking care of patients with depression. Care management models for depression have been described as more effective than usual practice. The implementation of such a model requires a clinic manager to be able to predict how this new process might impact staffing and clinical demand. This study was designed to evaluate the initial impact of the implementation of a depression care manager (CM) model on the utilization of outpatient visits. The hypothesis is that the introduction of a CM model for depression in a primary care practice would be associated with an increased utilization of health care resources when compared to usual care (UC). There were 38 patients enrolled during the initial 2 months of implementation of the CM model. Using a retrospective medical record review, the CM population was compared to a similar group receiving UC (N = 49), and a significant increase in the percentage of patients who were seen for any reason in the CM population was found (65.8% vs. 36.7%, P = 0.01). The average CM patient had 1.24 outpatient visits for any reason vs. 0.69 for the UC group (P = 0.01). When specifically focusing on outpatient visits for depression, the CM group averaged 0.95 visits per patient as compared to the UC patients having 0.55 visits per patient (P = 0.04). This study suggests that the initial implementation of a CM model for treatment of depression will increase outpatient utilization. .

Primary care patient and provider preferences for diabetes care managers

Purpose: The collaborative care model, using care managers, has been shown to be effective in achieving sustained treatment outcomes in chronic disease management. Little effort has been made to find out patient preferences for chronic disease care, hence, we conducted a study aimed at identifying these. Methods: A 20-item questionnaire, asking for patients’ and providers’ preferences and perceptions, was mailed out to 1000 randomly selected patients in Olmsted County, Minnesota, identified through a diabetes registry to have type 2 diabetes mellitus, a prototypical prevalent chronic disease. Surveys were also sent to 42 primary care providers. Results: There were 254 (25.4%) patient responders and 28 (66%) provider responders. The majority of patients (>70%) and providers (89%) expressed willingness to have various aspects of diabetes care managed by a care manager. Although 75% of providers would be comfortable expanding the care manager role to other chronic diseases, only 39.5% of patient responders would be willing to see a care manager for other chronic problems. Longer length of time from initial diagnosis of diabetes was associated with decreased patient likelihood to work with a care manager. Conclusion: Despite study limitations, such as the lack of validated measures to assess perceptions related to care management, our results suggest that patients and providers are willing to collaborate with a care manager and that both groups have similar role expectations of a care manager.

Impact of collaborative care for depression on clinical, functional, and work outcomes: A practice-based evaluation

Background:The impact of collaborative care (CC) on depression and work productivity in routine, nonresearch primary care settings remains unclear due to limited evidence. Methods:This prospective study examined depression and work outcomes (eg, absenteeism, presenteeism) for 165 individuals in CC for depression versus 211 patients in practice as usual in a multisite primary care practice. Results:CC predicted greater adjusted 6-month improvements in treatment response, remission, and absenteeism versus practice as usual. Response/remission increased productivity overall. Conclusions:CC increased clinical and work improvements in a nonresearch care setting. Insurers and employers should consider CCs work benefits in developing payment structures.

Age of Depressed Patient does Not Affect Clinical Outcome in Collaborative Care Management

Abstract Clinical response and remission for the treatment of depression has been shown to be improved utilizing collaborative care management (CCM). Prior studies have indicated that the presence of mental health comorbidities noted by self-rated screening tools at the intake for CCM are associated with worsening outcomes; few have examined directly the impact of age on clinical response and remission. The hypothesis was that when controlling for other mental health and demographic variables, the age of the patient at implementation of CCM does not significantly impact clinical outcome, and that CCM shows consistent efficacy across the adult age spectrum. We performed a retrospective chart analysis of a cohort of 574 patients with a clinical diagnosis of major depression (not dysthymia) treated in CCM who had 6 months of follow-up data. Using the age group as a categorical variable in logistic regression models demonstrated that while maintaining control of all other variables, age grouping remained a nonsignificant predictor of clinical response (P ≥ 0.1842) and remission (P ≥ 0.1919) after 6 months of treatment. In both models, a lower Generalized Anxiety Disorder-7 score and a negative Mood Disorder Questionnaire score were predictive of clinical response and remission. However, the initial Patient Health Questionnaire-9 score was a statistically significant predictor only for clinical remission (P = 0.0094), not for response (P = 0.0645), at 6 months. In a subset (n = 295) of the study cohort, clinical remission at 12 months was also not associated with age grouping (P ≥ 0.3355). The variables that were predictive of remission at 12 months were the presence of clinical remission at 6 months (odds ratio [OR], 7.4820; confidence interval [CI], 3.9301-14.0389; P < 0.0001), clinical response (with persistent symptoms) (OR, 2.7722; CI, 1.1950-6.4313; P = 0.0176), and a lower initial Patient Health Questionnaire-9 score (OR, 0.9121; CI, 0.8475-0.9816; P = 0.0140). Our study suggests that using CCM for depression treatment may transcend age-related differences in depression and result in positive outcomes regardless of age.

Collaborative Care Management for Depression Comparison of Cost Metrics and Clinical Response to Usual Care

The collaborative care management (CCM) model has been demonstrated to be significantly more effective compared to usual care (UC) in depression management although an initial increase in cost measures was seen. In this paper, cost measures as well as clinical response were analyzed on patients with available follow-up data at six months. Records of 219 patients with follow-up data in CCM group and 119 in UC group were reviewed. At six months, there was a statistically significant clinical response rate among patients in CCM compared to UC group (P < 0.0001). Likewise, 65% in CCM group was “symptom-free” at 6 months vs. 31.9% in UC group (P < 0.0001). Among the responders in both groups, there was no statistical difference in cost measures. However, cost measures were significantly higher among non-responders compared to responders within CCM. Between the two models, the non-responders in UC had lower cost measures than the non-responders under CCM.

Effects of efforts to intensify management on blood pressure control among patients with type 2 diabetes mellitus and hypertension: A pilot study

There continues to be a need for improved medical management of diabetes patients with hypertension in primary care. While several care models have shown effectiveness in achieving various outcomes among these patients, it remains unclear what care model is most effective in improving blood pressure control in primary care. In this prospective study, 54 patients with type 2 diabetes mellitus and blood pressure of >140/90 identified through the registry, were randomized into three groups. Group A attended a nurse educator-conducted class on diabetes and hypertension, group B attended the same class and was asked to monitor their home blood pressure using provided device, and group C served as control (usual care). Of the 24 subjects who completed the study, only 20% achieved the target blood pressure of <130/80 and there was no statistical difference in mean systolic and diastolic blood pressures among the three groups (p > 0.05). Efforts to intensify management of hypertension among type 2 diabetes patients did not result in better blood pressure control compared to usual care. Studies looking into factors which limit patients’ participation in group classes and determining patients’ preferences in disease management would be helpful in ensuring success of any chronic disease management program.