Robert G. Badgett

Case-finding for depression in primary care: a randomized trial∗ ∗

PURPOSE Depression is a highly prevalent, morbid, and costly illness that is often unrecognized and inadequately treated. Because depression questionnaires have the potential to improve recognition, we evaluated the accuracy and effects on primary care of two case-finding instruments compared to usual care. SUBJECTS AND METHODS The study was conducted at three university-affiliated and one community-based medical clinics. Consecutive patients were randomly assigned to be asked a single question about mood, to fill out the 20-item Center for Epidemiologic Studies Depression Screen, or to usual care. Within 72 hours, patients were assessed for Diagnostic and Statistical Manual of Mental Disorders Third Revised Edition (DSM-III-R) disorders by an assessor blinded to the screening results. Process of care was assessed using chart audit and administrative databases; patient and physician satisfaction was assessed using Likert scales. At 3 months, depressed patients and a random sample of nondepressed patients were re-assessed for DSM-III-R disorders and symptom counts. RESULTS We approached 1,083 patients, of whom 969 consented to screening and were assigned to the single question (n = 330), 20-item questionnaire (n = 323), or usual care (n = 316). The interview for DSM-III-R diagnosis was completed in 863 (89%) patients; major depression, dysthymia, or minor depression was present in 13%. Both instruments were sensitive, but the 20-item questionnaire was more specific than the single question (75% vs 66%, P = 0.03). The 20-item questionnaire was less likely to be self-administered (54% vs 90%) and took significantly more time to complete (15 vs 248 seconds). Case-finding with the 20-item questionnaire or single question modestly increased depression recognition, 30/77 (39%) compared with 11/38 (29%) in usual care (P = 0.31) but did not affect treatment (45% vs 43%, P = 0.88). Effects on DSM-III-R symptoms were mixed. Recovery from depression was more likely in the case-finding than usual care groups, 32/67 (48%) versus 8/30 (27%, P = 0.03), but the mean improvement in depression symptoms did not differ significantly (1.6 vs 1.5 symptoms, P = 0.21). CONCLUSIONS A simple question about depression has similar performance characteristics as a longer 20-item questionnaire and is more feasible because of its brevity. Case-finding leads to a modest increase in recognition rates, but does not have consistently positive effects on patient outcomes.

Evaluating the teaching of evidence based medicine: conceptual framework

Although evidence for the effectiveness of evidence based medicine has accumulated, there is still little evidence on what are the most effective methods of teaching it.

How well can the chest radiograph diagnose left ventricular dysfunction

OBJECTIVES: To review the diagnostic utility of the chest radiograph for left ventricular dysfunction.DATA SOURCES: Structured MEDLINE searches, citation reviews of relevant primary research, review articles, and textbooks, personal files, and data from experts.STUDY SELECTION: Studies of patients without valvular disease that allowed calculation of the sensitivity and specificity of selected radiographic signs compared with a criterion standard of increased left ventricular preload or reduced ejection fraction.DATA EXTRACTION: Two independent readers reviewed 29 studies. Studies were pooled after stratification by radiographic finding, criterion standard, and clinical setting.MAIN RESULTS: Redistribution best diagnosed increased preload with a sensitivity of 65% (95% confidence interval [CI] 55%, 75%) and specificity 67% (95% CI 53%, 79%). Cardiomegaly best diagnosed decreased ejection fraction with a sensitivity of 51% (95% CI 43%, 60%) and specificity of 79% (95% CI 71%, 85%). Interrater reliability was fair to moderate for redistribution and moderate for cardiomegaly. The clinical setting affected results by decreasing the specificity of cardiomegaly to 8% in detecting increased preload in patients with severe systolic dysfunction. The absence of redistribution could only exclude increased preload in situations in which the suspicion (pretest probability) of disease was less than 9%, whereas redistribution could confirm increased preload when the pretest probability was greater than 91%. The absence of cardiomegaly could only exclude a reduced ejection fraction if the pretest probability was less than 8%, whereas cardiomegaly could confirm a reduced ejection fraction if the pretest probability was greater than 87%.CONCLUSIONS: Redistribution and cardiomegaly are the best chest radiographic findings for diagnosing increased preload and reduced ejection fraction, respectively. Unfortunately, neither finding alone can adequately exclude or confirm left ventricular dysfunction in usual clinical settings. Redistribution is not always reliably interpreted.

Variations in Pharmacology of β-Blockers May Contribute to Heterogeneous Results in Trials of Perioperative β-Blockade

Background:Randomized controlled trials and meta-analyses provide conflicting guidance on the role of &bgr;-adrenergic receptor blockers (&bgr;-blockers) in reducing perioperative complications. We hypothesize that variability in trial results may be due in part to heterogeneous properties of &bgr;-blockers. First, we propose that the extent of &bgr;-blocker metabolism by cytochrome P-450 and the time available to titrate the dosage before surgery (titration time) may interact; dependence on P-450 may be most harmful when titration time is short. Second, &bgr;-blockers vary in their selectivity for the &bgr;-1 receptor and reduced selectivity may contribute to cerebral ischemia. Methods:We used meta-analysis and meta-regression of existing trials to explore the role of these pharmacological properties. Results:We found that both of these pharmacological factors are significantly associated with reduced efficacy of &bgr;-blockers. Conclusions:Pharmacological properties of &bgr;-blockers may contribute to heterogeneous trial results. Many trials have used metoprolol, which is extensively metabolized by cytochrome P450 and is less selective for the &bgr;-1 receptor. For these two reasons, the efficacy of metoprolol to prevent perioperative cardiac complications should be compared with the efficacy of other &bgr;-blockers.

Safety Belt Nonuse by Internal Medicine Patients: A Missed Opportunity in Clinical Preventive Medicine

BACKGROUND The United States Preventive Services Task Force recommends that physicians routinely counsel all patients to wear safety belts. We undertook this study to determine the prevalence of the nonuse of safety belts among internal medicine patients, to measure the association of nonuse with other health risk factors, and to ascertain the safety belt counseling practices of physicians. PATIENTS AND METHODS A total of 492 consecutive patients attending a university-based general medicine clinic were given a validated, self-administered questionnaire, and 94% responded. A medical chart review was performed in a blinded fashion on 94% of the eligible charts. RESULTS Of the 454 patients who provided safety belt information, 243 (54%) did not wear safety belts. Nonusers were more likely to be problem drinkers, inactive, obese, and to have a low income (adjusted odds ratios 1.8 to 2.0). Of patients with all four of these characteristics, 91% did not use safety belts. The leading reasons for safety belt nonuse were discomfort (35%), short driving distances (24%), and forgetfulness (13%). Obese patients were more likely to report discomfort as their reason for nonuse (odds ratio 2.4; 95% confidence limit 1.4 to 4.3). Eighteen patients (3.9%) reported that a physician had ever counseled them about safety belt use. Only two of 314 medical records (0.6%) noted physician questioning or counseling about safety belt use. CONCLUSIONS The majority of patients attending an internal medicine clinic do not wear safety belts. Nonusers are more likely to be problem drinkers, inactive, obese, and to have a low income. Patients with multiple health risk factors are at significant risk of nonuse. The most common reason for nonuse is physical discomfort, especially among obese patients. Finally, physicians rarely counsel patients to use safety belts.

A Living Systematic Review of Nebulized Hypertonic Saline for Acute Bronchiolitis in Infants

Results | The LTL (expressed in the telomere repeat copy number to the single gene copy number ratio) remained unchanged during and after the OC intake. In contrast, the LTL doubled while taking PioFluMet and returned to baseline after the PioFluMet intake was stopped (Figure). The LTL changes across treatment groups during 18 months related inversely to fasting insulinemia, body fat fraction by dual energy x-ray absorptiometry, and visceral and hepatic adiposity by magnetic resonance imaging (all r values were between −0.53 and −0.57; all P values were between 0.002 and 0.007). The ratio of circulating neutrophils to lymphocytes was first similar in treatment groups and remained similar in and between groups across 24 months. Noteworthy adverse effects were not encountered in either treatment group.4

Teaching clinical informatics to third-year medical students: negative results from two controlled trials

BackgroundPrior educational interventions to increase seeking evidence by medical students have been unsuccessful.MethodsWe report two quasirandomized controlled trials to increase seeking of medical evidence by third-year medical students. In the first trial (1997–1998), we placed computers in clinical locations and taught their use in a 6-hour course. Based on negative results, we created SUMSearch(TM), an Internet site that automates searching for medical evidence by simultaneous meta-searching of MEDLINE and other sites. In the second trial (1999–2000), we taught SUMSearchs use in a 5½-hour course. Both courses were taught during the medicine clerkship. For each trial, we surveyed the entire third-year class at 6 months, after half of the students had taken the course (intervention group). The students who had not received the intervention were the control group. We measured self-report of search frequency and satisfaction with search quality and speed.ResultsThe proportion of all students who reported searching at least weekly for medical evidence significantly increased from 19% (1997–1998) to 42% (1999–2000). The proportion of all students who were satisfied with their search results increased significantly between study years. However, in neither study year did the interventions increase searching or satisfaction with results. Satisfaction with the speed of searching was 27% in 1999–2000. This did not increase between studies years and was not changed by the interventions.ConclusionNone of our interventions affected searching habits. Even with automated searching, students report low satisfaction with search speed. We are concerned that students using current strategies for seeking medical evidence will be less likely to seek and appraise original studies when they enter medical practice and have less time.

Detection of injury-prone behaviors among internal medicine patients

Objectives:1) To describe the prevalence of eight injuryprone behaviors (IPBs) and the associations of these behaviors with ten standard chronic disease and sociodemographic risk factors (CDSRFs) among internal medicine patients and 2) to identify a subset of patients with multiple IPBs who might be at particularly high risk of injury.Design:Cross-sectional survey.Setting:The University of Colorado Health Sciences Center general internal medicine clinic.Patients:Four bundred ninety-two consecutive continuity care patients were eligible. The response rate was 94.3% (464/492).Instrument:A validated, self-administered questionnaire.Main results:Thirty-four percent of patients did not wear safety belts regularly and 32% had no smoke detector in their bomes. Nearly 26% of patients had firearms at home and 6% had a loaded and unlocked gun at home. Fourteen percent of patients had seriously throught about suicide and 6% had attempted suicide. In the prior month, 10% had ridden with a drunk driver, and 4% had driven after drinking too much. Of patients aged 65 years or older, 50% had had recent falls. After adjustment for other CDSRFs, problem drinking was the CDSRF most frequently associated with IPBs. Among men, problem drinking was significantly associated with drinking and driving (OR=35.3), safety belt non-use (OR=4.3), and previous thoughts of or attempts at suicide (OR=6.2). Among women, problem drinking was significantly associated with drinking and driving (OR=8.7). Among men, being unmarried was the demographic risk factor associated with the most IPBs. Of all IPBs, safety belt non-use was most frequently associated with CDSRFs (ORs ranged from 2.8 to 4.4). Men with three or more IPBs were more likely to be problem drinkers (OR=9.6), smokers (OR=15.8), obese (OR=6.3), and unmarried (OR=67.1).Conclusions:1) Injury-prone behaviors are common among patients attending a university-based internal medicine clinic; 2) men and women have substantially different patterns of risk factor associations; 3) CDSRFs, such as problem drinking, smoking, and being unmarried, are associated with many IPBs; 4) safety belt non-use is the IPB associated with the most CDSRFs; and 5) CDSRFs appear to cluster in men with multiple IPBs, suggesting that screening for high-risk individuals may be feasible in clinical practice.

A comparison of primary care information content in UpToDate and the National Guideline Clearinghouse.

OBJECTIVES The study sought to determine if two major resources for primary care questions have significant differences in information content and whether the number of documents found differs by disease category, patient age, or patient gender. METHODS Seven hundred fifty-two questions were randomly selected from the Clinical Questions Collection of the National Library of Medicine. UpToDate and the National Guidelines Clearinghouse (NGC) were searched utilizing keywords from the questions. The number of documents retrieved for each question in the resources was recorded. Chi-squared analysis was used to compare differences in retrieval between the resources. Logistic regression was used to evaluate the effect of patient age, patient gender, or disease category on the ability to find content. RESULTS UpToDate returned 1 or more documents for 580 questions, while NGC returned at least 1 document for 493 questions (77.1% versus 65.5% of question sampled, P = 0.001). In combination, the 2 resources returned content for 91% of searches (n = 685). NGC retrieved a mean of 16.3 documents per question versus 8.7 documents from UpToDate. Disease category was the only variable having a significant impact on the presence of online resource content. CONCLUSIONS UpToDate had greater breadth of content than NGC, while neither resource provided complete coverage. Current practice guidelines, as reflected by those in the NGC, addressed at most two-thirds of the selected clinical questions.

Clinical and sociocultural determinants of gallstone treatment

Cholecystectomy remains the principal treatment for gallstones. Many gallstone patients do not undergo surgery within 6 months of diagnosis. To determine factors associated with cholecystectomy, treated and untreated patients were compared with respect to clinical and sociodemographic factors. The study population was comprised of outpatients of a public system evaluated in an emergency room or at a community health center. All were interviewed in English or Spanish before completing imaging studies. Of 121 found to have gallstones, 75 underwent early cholecystectomy. Patients reporting episodes of prolonged abdominal pain more often had surgery (p < 0.003). Patients evaluated in the emergency room underwent surgery more often than those from the community health center (p < 0.04). Patient ethnicity was unrelated to treatment, but Mexican Americans who requested interviews in Spanish were less likely to undergo cholecystectomy (p < 0.05). After logistic regression, prolonged abdominal pain was the only significant predictor of surgical management, although relationships with language use and site of diagnosis persisted. It was concluded that clinical presentation largely determines surgical treatment for gallstones but site of diagnosis is also a factor. Patients with poor English language skills undergo cholecystectomy less often. This may be due to poor doctor-patient communication, or it may be a reflection of cultural factors linked to language use.