Sarah Hudson Scholle

Screening for Depression in the Postpartum Period: A Comparison of Three Instruments

OBJECTIVES Postpartum depression, the most prevalent complication of childbirth, is often unrecognized. Our objective was to compare the effectiveness of three screening instruments--Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire (PHQ-9), and the 7-item screen of the Postpartum Depression Screening Scale (PDSS)--for identifying women with postpartum depression in the first 6 months after delivery. METHODS We administered the three instruments via telephone to women who were > or =18 years and had delivered infants 6-8 weeks earlier. We arranged home interviews to confirm DSM-IV criteria current major depressive disorder (MDD) in women who had an above-threshold score on any of the instruments. For women who screened negative on the 6-8 week call, we repeated the screening at 3 months and 6 months to identify emergent symptoms. The primary outcome measures were the screening scores and DSM-IV diagnoses. RESULTS Of 135 women reached, 123 (91%) were screened, 29 (24%) had home visits, and 13 (11%) had an MDD within 6 months of delivery. Analyses of the scores at 6-8 weeks postpartum and the DSM-IV diagnoses indicated the EPDS at a cutoff point of > or =10 identified 8 (62%) of cases, the PHQ-9 at a cutoff point of > or =10 identified 4 (31%), and the PDSS 7-item Short Form (PDSS_SF) at a cutoff point of > or =14 identified 12 (92%). However, 15 of 16 (94%) women without current MDD screened positive on the PDSS_SF. The EPDS was significantly more accurate (p = 0.01) than the PDSS_SF and PHQ-9 with the cutoff points used. After correcting for verification bias, we found the EPDS and the PDSS_SF were significantly more accurate than the PHQ-9 (p < 0.03). CONCLUSIONS Administering the EPDS by phone at 6-8 weeks postpartum is an efficient and accurate way to identify women at high risk for postpartum depression within the first 6 months after delivery.

Barriers to screening sexually active adolescent women for chlamydia: a survey of primary care physicians

PURPOSE To determine the proportion of primary care physicians who screen sexually active teenage women for chlamydia and to determine demographic factors, practice characteristics, and attitudes associated with chlamydia screening. METHODS We obtained a random sample of 1600 Pennsylvania physicians from the American Medical Association masterfile, stratified to include at least 40% women and equal numbers of family physicians, internists, obstetricians/gynecologists, and pediatricians. In January 1998, physicians received mailed questionnaires; nonrespondents received two follow-up mailings. Physician characteristics associated with chlamydia screening were determined using bivariate and logistic regression analyses. RESULTS Only one-third of physicians responded that they would screen asymptomatic, sexually active teenage women for chlamydia during a routine gynecologic examination. In multivariate analysis, physicians were significantly (p <.05) more likely to screen if they were female (43% vs. 24%), worked in a clinic versus solo practice (60% vs. 18%), worked in a metropolitan location (46% vs. 26%), or had a patient population > or = 20% African-American (54% vs. 25%). Attitudes associated with screening included the belief that most 18-year-old women in their practice were sexually active (36% vs. 12%), feeling responsible for providing information about the prevention of sexually transmitted diseases to their patients (42% vs. 21%), or knowing that screening for chlamydia prevents pelvic inflammatory disease (37% vs. 13%). Physicians were less likely to screen if they believed that the prevalence of chlamydia was low (10% vs. 41%). CONCLUSIONS A majority of physicians do not adhere to recommended chlamydia screening practices for teenage women. Interventions to improve chlamydia screening might target physicians who are male, in private practice, or who practice in rural areas, and should focus on increasing awareness of the prevalence of chlamydia and benefits of screening.

Understanding Turning Points in Intimate Partner Violence: Factors and Circumstances Leading Women Victims Toward Change

OBJECTIVE When counseling women experiencing intimate partner violence (IPV), healthcare providers can benefit from understanding the factors contributing to a womens motivation to change her situation. We wished to examine the various factors and situations associated with turning points and change seeking in the IPV situation. METHODS We performed qualitative analysis on data from 7 focus groups and 20 individual interviews with women (61 participants) with past and/or current histories of IPV. RESULTS The turning points women identified fell into 5 major themes: (1) protecting others from the abuse/abuser; (2) increased severity/humiliation with abuse; (3) increased awareness of options/access to support and resources; (4) fatigue/recognition that the abuser was not going to change; and (5) partner betrayal/infidelity. CONCLUSIONS Women experiencing IPV can identify specific factors and events constituting turning points or catalyst to change in their IPV situation. These turning points are dramatic shifts in beliefs and perceptions of themselves, their partners, and/or their situation that alter the womens willingness to tolerate the situation and motivate them to consider change. When counseling women experiencing IPV, health providers can incorporate understanding of turning points to motivate women to move forward in their process of changing their IPV situation.

Context Matters: The Experience of 14 Research Teams in Systematically Reporting Contextual Factors Important for Practice Change

PURPOSE We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. METHODS Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. RESULTS The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. CONCLUSIONS These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

Addressing depression in obstetrics/gynecology practice ☆

Efforts to improve the care of depression in primary care patients have largely ignored the potential of obstetrics/gynecology (OB/GYN) practices. We describe feasibility studies of a depression screening and care management intervention in three diverse OB/GYN practices. Patients were screened using the Patient Health Questionnaire. A depression care manager offered education and referral assistance to women who screened positive for depression. The prevalence of depression was higher in the hospital clinic (20.2%, 47/233) than the suburban clinic (10.7%, 8/75) or the office practice (8.2%, 48/583). Seventy-two women participated in the care management intervention. Patient satisfaction with the intervention was high and at 1-month follow-up, 31.9% of patients had kept or scheduled a new mental health appointment. Depression interventions developed in primary care can be successfully adapted for use with patients in OB/GYN practices. Additional modifications, particularly efforts to improve coordination of care with both general medical and mental health providers, are needed.

Trends in women's health services by type of physician seen: data from the 1985 and 1997-98 NAMCS.

As managed care enrollment has increased, controversy has arisen about the role of internists (IM), family physicians (FP), and obstetrician/gynecologists (ob/gyns) in the provision of womens health care. Efforts to improve training in womens health needs have also increased. Yet it is unclear how these trends have affected practice. We used the National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based medical visits, to examine by physician specialty a) trends in the proportion of visits for womens health care and b) the content of nonillness care. Between 1985 and 1997-98, market share of reproductive health services increased for IMs (e.g., from 3.7% to 10.5% of contraceptive visits, p <.05) and decreased for FPs (from 30.5% to 20.5% for contraceptive visits, p <.05). Ob/Gyns increased their share of womens health care visits, with reproductive health visits increasing from 56.2% to 65.9% (p <.0001). The trend in hormone replacement therapy visits differed, with nonsignificant gains in market share for IMs and decreases for ob/gyns. Nonillness care (1997-98 data only) differed predictably by specialty, with IMs and FPs more often providing cholesterol screening while ob/gyns more often provided reproductive health services. Compared with IMs and FPs, ob/gyns were more likely to counsel women on reproductive health topics and equally likely to counsel on general health topics, but additional time spent in counseling was lower. Specialty differences in the provision of womens health services continue, though the scope of care provided by IMs has broadened. Still, women are unlikely to obtain a full range of preventive services in a single nonillness visit. Ensuring adequate coordination among physicians providing primary care to women continues to be a critical concern.

Physical abuse among depressed women

AbstractOBJECTIVE: To provide estimates of physical abuse and use of health services among depressed women in order to inform efforts to increase detection and treatment of physical abuse. DESIGN: Retrospective assessment of abuse and health services use over 1 year in a cohort of depressed women. SETTING: Statewide community sample from Arkansas. PARTICIPANTS: We recruited 303 depressed women through random-digit-dial screening. MEASUREMENTS AND MAIN RESULTS: Exposure to physical abuse based on the Conflict Tactics Scale, multi-informant estimate of health and mental health services. Over half of the depressed women (55.2%) reported experiencing physical abuse as adults, with 14.5% reporting abuse during the study year. Women abused as adults had significantly more severe depressive symptoms, more psychiatric comorbidity, and more physical illnesses than nonabused women. After controlling for sociodemographic and severity-of-illness factors, recently abused, depressed women were much less likely to receive outpatient care for mental health problems as compared to other depressed women (odds ratio [OR] 0.3; p=.013), though they were more likely to receive health care for physical problems (OR 5.7, p=.021). CONCLUSIONS: Because nearly all depressed women experiencing abuse sought general medical rather than mental health care during the year of the study, primary care screening for physical abuse appears to be a critical link to professional help for abused, depressed women. Research is needed to inform primary care guidelines about methods for detecting abuse in depressed women.

Primary Care Physician Attitudes Regarding Sexually Transmitted Diseases

Background Primary care physicians see the majority of patients with sexually transmitted diseases (STDs), but little is known about their attitudes regarding STD-related issues. Goal The study goal was to determine the attitudes of primary care physicians toward STD-related issues, to determine physicians’ characteristics associated with attitudes, and to examine the relationship of attitudes to STD counseling practices. Study Design A cross-sectional survey was mailed to randomly selected primary care physicians in Pennsylvania. Results Of 1054 eligible physicians, 541 (51%) responded. Although most physicians were comfortable discussing sex-related issues with their patients (89%), many believed their STD counseling was ineffective (70%), their medical school STD training was inadequate (48%), or that they were not responsible for STD preventive services for their patients (43%). Overall, STD-related attitudes were more positive among physicians who were female, worked in clinic settings, and received adequate training in STDs. More positive attitude scores were significantly associated with performance of six specific risk-assessment and counseling behaviors. Conclusions Many physicians reported low confidence, limited responsibility, and time barriers that may affect their STD-prevention practices. Interventions that influence STD-related attitudes may improve STD-prevention practices by primary care physicians.

Pediatric mood and anxiety syndromes in primary care: who gets identified?.

Objective: To seek clues to the enhancement of primary care management by (i) Determining how often and in whom primary care clinicians in the United States, Puerto Rico, and Canada identify pediatric mood or anxiety syndromes; (ii) Determining which clinical and demographic features predict higher rates of identification; (iii) Describing assessment methods used. Methods: This report uses the database of the multi-site Child Behavior Study. This cross-sectional study involved 206 primary care practices in the United States, Puerto Rico, and Canada; 395 clinicians and 20,861 primary care attenders aged 4–15 years. Clinicians completed a visit questionnaire addressing presence and type of psychosocial problems and how assessed. Parents completed a questionnaire addressing family demographics, child symptoms (Pediatric Symptom Checklist) and functioning, and child service use. Results: Clinicians identified psychosocial problems on 17.9% of visits, but mood or anxiety syndromes on only 3.3%, most commonly in children judged to have co-morbid behavioral syndromes, of whom the majority (66.7%) already had contact with specialized mental health. Neither parental concerns about mood and anxiety symptoms nor clinician familiarity with the patient were major predictors of identification. When making a diagnosis of a pure internalizing syndrome (i.e., without a co-morbid behavioral syndrome) clinicians rarely used standardized tools or school reports. Conclusions: Neither screening for nor diagnosis of mood and anxiety syndromes is a routine part of primary care of children and adolescents. Efforts to improve care must include practical, validated screening procedures to enhance assessment for mood and anxiety syndromes, particularly among children in whom primary care clinicians identify psychosocial problems.

A Comparison of Ambulatory Medicaid Claims to Medical Records: A Reliabiligy Assessment

This study compares the documentation of ambulatory care visits and diagnoses in Medicaid paid claims and in medical records. Data were obtained from Maryland Medicaids 1988 paid claims files for 2407 individuals who were continuously enrolled for the fiscal year, had at least one billed visit for one of six indicator conditions, and had received the majority of their care from one provider. The patients sampled were also stratified on the basis of the case-mix adjusted cost of their usual source of care. The medical records for these individuals as maintained by their usual source of care were abstracted by trained nurse reviewers to compare claims and record information. Linked claim and medical record data for sampled patients were used to calculate: (i) the percent of billed visits doc umented in the record, (ii) the percent of medical record visits where both the date and the diagnosis agreed with the claims data, and (iii) the ratio of medical record vis its to visits from billed claims. Included in the analysis were independent variables specifying place of residence, type and costliness of usual care source, level of patient utilization, and indicator condition on which patient was sampled. Ninety percent of the visits chronicled in the paid claims were documented in the medical record with 82% agreeing on both date and diagnosis. Compared to the med ical records kept by private physicians and community health centers, a significantly lower percent of hospital medical records agreed with the claims data. Total volume of visits was 2.6% higher in the medical records than in the claims. Claims data substantially understated visits in the medical record by 25% for low cost providers and by 41% for patients with low use rates (based on claims in formation). Conversely, medical records substantially un derstated billed visits by 19% for rural patients and by 10% for persons with high visit rates. Although Medicaid claims are relatively accurate and useful for examining av erage ambulatory use patterns, they are subject to signif icant biases when comparing subgroups of providers classified by case-mix adjusted cost and patients classi fied by utilization rates. Medicaid programs are using claims data for profiling and performance assessment need to un derstand the limitations of administrative data.