Steven J. Borowsky

Who Is at Risk of Nondetection of Mental Health Problems in Primary Care

AbstractOBJECTIVE: To determine patient and provider characteristics associated with increased risk of nondetection of mental health problems by primary care physicians. DESIGN: Cross-sectional patient and physician surveys conducted as part of the Medical Outcomes Study. PARTICIPANTS: We studied 19,309 patients and 349 internists and family physicians. MEASUREMENTS AND MAIN RESULTS: We counted “detection” of a mental health problem whenever physicians reported, in a postvisit survey, that they thought the patient had a mental health problem or that they had counseled or referred the patient for mental health. Key independent variables included patient self-reported demographic characteristics, health-related quality of life (HRQOL), depression diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, and physician demographics and proclivity to provide counseling for depression. Logistic regression analysis, adjusted for HRQOL, revealed physicians were less likely to detect mental health problems in African Americans (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.46 to 0.86), men (OR, 0.64; 95% CI, 0.54 to 0.75), and patients younger than 35 years (OR, 0.61; 95% CI, 0.44 to 0.84), and more likely to detect them in patients with diabetes (OR, 1.4; 95% CI, 1.0 to 1.8) or hypertension (OR, 1.3; 95% CI, 1.1 to 1.6). In a model that included DSM-III diagnoses, odds of detection remained reduced for African Americans as well as for Hispanics (OR, 0.29; 95% CI, 0.11 to 0.71), and patients with more-severe DSM-III diagnoses were more likely to be detected. Physician proclivity toward providing counseling for depression influenced the likelihood of detection. CONCLUSIONS: Patients’ race, gender, and coexisting medical conditions affected physician awareness of mental health problems. Strategies to improve detection of mental health problems among African Americans, Hispanics, and men should be explored and evaluated.

Dual use of VA and non-VA primary care

OBJECTIVE: To determine how frequently veterans use non-Department of Veterans Affairs (VA) sources of care in addition to primary care provided by the VA and to assess the association of this pattern of “dual use” to patient characteristics and satisfaction with VA care. DESIGN: Cross-sectional telephone survey of randomly selected patients from four VA medical centers. PARTICIPANTS: Of 1,240 eligible veterans, 830 (67%) participated in the survey. MEASUREMENTS AND MAIN RESULTS: Survey data were used to assess whether a veteran reported receiving primary care from both VA and non-VA sources of care, as well as the proportion of all primary care visits made to non-VA providers. Of 577 veterans who reported VA primary care visits, 159 (28%) also reported non-VA primary care visits. Among these dual users the mean proportion of non-VA primary care visits was 0.50. Multivariate analysis revealed that the odds of dual use were reduced for those without insurance (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.18, 0.66) and with less education (OR 0.60; 95% CI 0.38, 0.92), while increased for those not satisfied with VA care (OR 2.40; 95% CI 1.40, 4.13). Among primary care dual users, the proportion of primary care visits made to non-VA providers was decreased for patients with heart disease (p<.05) and patients with alcohol or drug dependence (p<.05). CONCLUSIONS: Primary care dual use was common among these veterans. Those with more education, those with any type of insurance, and those not satisfied with VA care were more likely to be dual users. Non-VA care accounted for approximately half of dual users’ total primary care visits.

Health‐Related Quality of Life, Functional Impairment, and Healthcare Utilization by Veterans: Veterans' Quality of Life Study

Objectives: To describe the health status of veterans receiving care in a veterans integrated service network (VISN).

Evaluation of the Department of Veterans Affairs community-based outpatient clinics.

Objective. This paper describes the history of the Department of Veterans Affairs (VA) Community-Based Outpatient Clinics (CBOCs), CBOC Performance Evaluation Project, and characteristics of CBOCs within the VA, and summarizes the findings and implications of the CBOC Performance Evaluation Project. Subjects. There were 139 CBOCs in operation at the end of fiscal year 1998. Ninety-eight percent of CBOCs offered primary health care, and 28% offered primary health care and primary mental health care. The average CBOC was 70.7 miles from its parent VAMC. Sixty-one percent of the CBOCs were located in urban areas and 39% were in rural areas. Sixty-four percent of the CBOCs were VA-staff and 36% were contract. Results. The details of the project’s findings are reported in four companion papers that describe, respectively, health care access and utilization, cost of care, patient perceptions of care, and quality of care in VA CBOCs. For most measures, CBOC performance was equivalent to their parent VAMCs. However, there were a few areas of potential concern: CBOCs had fewer patients that reported having one provider or team in charge of care; CBOC patients had fewer specialty visits; and CBOCs served a smaller percent of women and black persons. Conclusion. CBOCs appear to be performing comparably to their parent medical centers but will benefit from ongoing monitoring.

An evaluation of radical prostatectomy at Veterans Affairs Medical Centers: Time trends and geographic variation in utilization and outcomes

OBJECTIVE To examine temporal trends and geographic variation in utilization of radical prostatectomy (RP) as well as 30-day mortality and complication rates. DESIGN Administrative data-base study of radical prostatectomy (RP) using the Department of Veterans Affairs Patient Treatment File and Outpatient Clinic File between 1986 to 1996. Logistic regression was used to estimate temporal and geographic effects on the use of RP. SETTING All Departments of Veterans Affairs Medical Centers (VAMC) in the contiguous United States. PATIENTS Men aged 45 to 84 years who underwent RP at a VAMC (n = 13,398). MAIN OUTCOME MEASURES Number and utilization of RP, rate of 30-day mortality, major cardiopulmonary or vascular complications, and colorectal injuries requiring surgical repair within 30 days of RP. RESULTS From 1986 to 1996, the annual number of RP at VAMCs (range, 695-1,545 RP) more than doubled, and the rate of RP at VAMCs per male VA user increased by 40% (range, 48/100,000-66/100,000). After controlling for age and year, the utilization of RP in West North Central, Mountain, West South Central, and Pacific census divisions was 70%, 14%, 10%, and 8% higher, respectively, whereas the utilization of RP in New England, East North Central, and Mid-Atlantic divisions was 38%, 31%, and 25% lower, respectively, than the rest of the nation (P<0.001). Geographic variation in utilization decreased during the period between 1986 and 1996, but a twofold difference in RP utilization in 1996 remained between high- and low-utilization divisions. Major cardiopulmonary complications, vascular complications, and colorectal injuries occurred in 1.7%, 0.2%, and 1.8% of men, respectively. Thirty-day mortality was 0.73%, declined from 1986 to 1996, and was associated with a history of diabetes and congestive heart failure. CONCLUSION Utilization of RP at VAMCs increased over time and varied across geographic areas. Thirty-day mortality was less than 1% and decreased with time. Differences in utilization may be caused by uncertainty regarding the effectiveness of early detection and treatment of prostate cancer.

VA community-based outpatient clinics: performance measures based on patient perceptions of care.

Background. The Department of Veterans Affairs (VA) recently initiated a system of Community- Based Outpatient Clinics (CBOCs) to enhance delivery of primary care to veterans. Objective. The objective of this study was to determine the effect of CBOCs on patients’ perceptions of care. Research Design. The study design is a cross-sectional survey. Subjects. This study compares 4,980 patients from 44 geographically diverse CBOCs to 4,159 patients from 36 parent VA Medical Center primary care clinics administratively and geographically associated with the CBOCs studied. Measures. Survey data were obtained from the 1998 VA National Outpatient Customer Satisfaction Survey which assesses eight multiitem scales addressing access and timeliness of care, education/information, patient preferences, emotional support, coordination of care, courtesy, and specialty care access. Each scale was evaluated based upon item responses that indicate a problem with care. The survey also contained SF-12 health status measures used for case-mix adjustment. Results. Multivariate logistic regression controlling for patient health status measures revealed that CBOC patients reported fewer problems with care than VA-based patients on 7 of 8 scales though the absolute differences were small for most of the scales. The largest difference was observed for the access/timeliness scale. Significant differences between VA-staff and contract CBOCs were not observed. Conclusions. These results suggest that veterans participating in VA’s initiative to provide primary care in community-based settings report no more than, and in some dimensions fewer problems with care compared with veterans who receive care in VAMC clinics.

Effect of physician specialty on use of necessary coronary angiography

OBJECTIVES This study sought to determine whether having a cardiologist as a regular source of care influences likelihood of undergoing necessary coronary angiography. BACKGROUND An important element of the current health policy debate is the respective roles of primary care and specialist physicians. However, there are few data on interspecialty differences in quality of care for patients with ischemic heart disease. METHODS We contacted 243 patients by telephone (response rate 72%) who had positive (or very positive) exercise stress test results and met additional clinical criteria for necessary coronary angiography. Study patients were randomly sampled from those undergoing exercise stress testing at one university and three public hospitals in Los Angeles between January 1, 1990 and June 30, 1991. Patients were asked whether they had a regular source of care during the time after their exercise stress test and, if so, whether that provider was a cardiologist or cardiology clinic. RESULTS Among survey responders, 47% underwent necessary coronary angiography within 3 months of exercise testing and 61% within 12 months. After adjustment for sociodemographics and clinical presentation, patients with a cardiologist as a regular source of care were more likely than all other patients to have undergone necessary angiography within 3 months (52% vs. 38%, p = 0.05) and within 12 months (74% vs. 44%, p = 0.0001) of the exercise test. At 3 months, there was a trend toward a more pronounced effect of ongoing cardiologic care within the public hospitals compared with the private hospital (p = 0.09 for interaction between hospital types). CONCLUSIONS Patients with a cardiologist as a regular source of care were more likely than all other patients to undergo clinically necessary coronary angiography within both 3 and 12 months of exercise stress testing.

VA community-based outpatient clinics

Objectives. The purpose of this study was to compare access and utilization performance measures between Community-Based Outpatient Clinics (CBOC) and primary care clinics at parent VA Medical Centers (VAMC) and between VA-staff CBOCs and contract CBOCs. Methods. The study design was cross-sectional and retrospective. Performance measures were based on data routinely collected for administrative and research purposes by the VA. The sample included all primary care patients (n = 37,084) treated at the 38 CBOCs opened before 4/1/98 (30 VA-staff and 8 contract) and all primary care patients (n = 318,369) treated at the 32 parent VAMCs. Six months of service use data were used to derive the access and utilization performance measures. Multivariate regression analyses were used to control for observable casemix differences. Results. CBOCs are attracting new high priority patients to the VA health care system. CBOC patients had more primary care encounters and fewer specialty encounters than patients in the primary care clinics of the parent VAMCs. VA-staffed CBOC patients had more primary care encounters and fewer specialty encounters than contract CBOC patients. Conclusions. CBOCs are helping the VA achieve its goals of attracting new patients and shifting the focus of care from the specialty to the primary care setting.

Effect of Written and Computerized Decision Support Aids for the U.S. Agency for Health Care Policy and Research Depression Guidelines on the Evaluation of Hypothetical Clinical Scenarios

Objective. The objective of this study was to compare the effects of written and computerized decision support aids (DSAs) based on U.S. Agency for Health Care Policy and Research depression guidelines. Methods. Fifty-six internal medicine residents were randomized to evaluate clinical scenarios using either a written or a computerized DSA after first assessing scenarios without a DSA. The paired difference between aided and unaided scores was determined for diagnostic accuracy, treatment selection, severity and subtype classification, antipsychotic use, and mental health consultations. Results. Diagnostic accuracy with the written DSA increased from 64% to 73%, and with the computerized DSA decreased from 67% to 64% (P = 0.0065). Residents using the computerized DSA (vs. no DSA) requested fewer consultations (65% vs. 52%, P = 0.028). In post hoc analysis, the written DSA increased sensitivity (66% to 89%, P < 0.001) and the computerized DSA improved specificity (66% to 86%, P = 0.0020) but reduced sensitivity (67% to 49%, P = 0.011). Conclusions. A written DSA improved diagnostic accuracy, whereas a computerized DSA did not. However, the computerized DSA improved specificity and reduced mental health consultations.

Measuring the Physician Perspective on Quality of Care in Health Plans

Physicians provide one source of information about the quality of care in health plans, but concerns exist that physicians cannot distinguish quality from financial considerations or other underlying attitudes. We examined whether physicians can (a) distinguish different domains of health plan quality and (b) distinguish health plan quality from their under-lying attitudes. We analyzed data on 419 generalist physicians from four health plans. Three scales assessed physicians’ perceptions of facilitators and barriers to high-quality care in the plans and the clinical capabilities of plan physicians. Structural equation modeling indicated that physicians could distinguish domains of health plan quality. Physicians could also distinguish plan quality from their attitudes toward the plan, but plan quality was more highly correlated with general managed care attitudes than expected. These data suggest that physicians can provide information about health plan quality, but it will be important to validate these measures against patient outcomes.