W. Perry Dickinson

Use of Chronic Care Model Elements Is Associated With Higher-Quality Care for Diabetes

PURPOSE In 30 small, independent primary care practices, we examined the association between clinician-reported use of elements of the Chronic Care Model (CCM) and diabetic patients’ hemoglobin A1c (HbA1c) and lipid levels and self-reported receipt of care. METHODS Ninety clinicians (60 physicians, 17 nurse-practitioners, and 13 physician’s assistants) completed a questionnaire assessing their use of elements of the CCM on a 5-point scale (never, rarely, occasionally, usually, and always). A total of 886 diabetic patients reported their receipt of various diabetes care services. We computed a clinical care composite score that included patient-reported assessments of blood pressure, lipids, microalbumin, and HbA1c; foot examinations; and dilated retinal examinations. We computed a behavioral care composite score from patient-reported support from their clinician in setting self-management goals, obtaining nutrition education or therapy, and receiving encouragement to self-monitor their glucose. HbA1c values and lipid profiles were obtained by independent laboratory assay. We used multilevel regression models for analyses to account for the hierarchical nature of the data. RESULTS Clinician-reported use of elements of CCM was significantly associated with lower HbA1c values (P = .002) and ratios of total cholesterol to high-density lipoprotein cholesterol (P = .02). For every unit increase in clinician-reported CCM use (eg, from “rarely” to “occasionally”), there was an associated 0.30% reduction in HbA1c value and 0.17 reduction in the lipid ratio. Clinician use of the CCM elements was also significantly associated with the behavioral composite score (P = .001) and was marginally associated with the clinical care composite score (P = .07). CONCLUSIONS Clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care.

A randomized clinical trial of a care recommendation letter intervention for somatization in primary care

PURPOSE This paper describes the impact of a care recommendation (CR) letter intervention on patients with multisomatoform disorder (MSD) and analysis of patient factors that affect the response to the intervention. METHODS One hundred eighty-eight patients from 3 family practices, identified through screening of 2,902 consecutive patients, were classified using somatization diagnoses based on the number of unexplained physical symptoms from a standardized mental health interview. In a controlled, single-crossover trial, patients were randomized to have their primary care physician receive the CR letter either immediately following enrollment or 12 months after enrollment. The CR letter notified the physician of the patient’s somatization status and provided recommendations for the patient’s care. Patients were followed for 24 months with assessments of functional status at baseline, 12, and 24 months. RESULTS Longitudinal analysis revealed a 12-month intervention effect for patients with multisomatoform disorder (MSD) of 5.5 points (P < .001) on the physical functioning (PCS) scale of the SF-36. Analysis of scores on the MCS scale of the SF-36 found no significant effect on mental functioning. The intervention was more effective for patients with 1 or more comorbid chronic physical diseases (P = .01). CONCLUSIONS The CR letter has a favorable impact on physical impairment of primary care patients with MSD, especially for patients with comorbid chronic physical disease. Multisomatoform disorder appears to be a useful diagnostic classification for managing and studying somatization in primary care patients.

Care Management for Depression in Primary Care Practice: Findings From the RESPECT-Depression Trial

PURPOSE This qualitative study examined the barriers to adopting depression care management among 42 primary care clinicians in 30 practices. METHODS The RESPECT-Depression trial worked collaboratively with 5 large health care organizations (and 60 primary care practices) to implement and disseminate an evidence-based intervention. This study used semistructured interviews with 42 primary care clinicians from 30 practice sites, 18 care managers, and 7 mental health professionals to explore experience and perceptions with depression care management for patients. Subject selection in 4 waves of interviews was driven by themes emerging from ongoing data analysis. RESULTS Primary care clinicians reported broad appreciation of the benefits of depression care management for their patients. Lack of reimbursement and the competing demands of primary care were often cited as barriers. These clinicians at many levels of initial enthusiasm for care management increased their enthusiasm after experiencing care management through the project. Psychiatric oversight of the care manager with suggestions for the clinicians was widely seen as important and appropriate by clinicians, care managers, and psychiatrists. Clinicians and care managers emphasized the importance of establishing effective communication among themselves, as well as maintaining a consistent and continuous relationship with the patients. The clinicians were selective in which patients they referred for care management, and there was wide variation in opinion about which patients were optimal candidates. Care managers were able to operate both from within a practice and more centrally when specific attention was given to negotiating communication strategies with a clinician. CONCLUSIONS Care management for depression is an attractive option for most primary care clinicians. Lack of reimbursement remains the single greatest obstacle to more widespread adoption.

The somatization in primary care study: a tale of three diagnoses

Somatization is a common phenomenon that has been defined in many ways. The two most widely used diagnoses, Somatization Disorder (SD) and Abridged Somatization Disorder (ASD), are based on lifetime unexplained symptoms. However, reports indicate instability in lifetime symptom recall among somatizing patients. Multisomatoform disorder (MSD) is a new diagnosis based on current unexplained symptoms. To understand how knowledge about SD and ASD translates to MSD, we examined the diagnostic concordance, impairment and health care utilization of these groups in a sample from the Somatization in Primary Care Study. The diagnostic concordance was high between MSD and SD, but lower between MSD and ASD. All three groups reported considerable physical impairment (measured using the PCS subscale of the SF-36). The mental health (MCS) scores for the three groups were only slightly lower than those of the general population. Over the course of one year, physical functioning fell significantly for all three groups. Mental functioning did not change significantly for any of the three groups over this period. Utilization patterns were very similar for the three groups. The high prevalence, serious impairment, and worsening physical functioning over the course of one year suggest the importance of developing interventions in primary care to alleviate the impaired physical functioning and reduce utilization in somatizing patients. MSD should be a useful diagnosis for targeting these interventions because it identifies a sizable cohort of somatizing patients reporting impairment of comparable severity to full SD, using a more efficient diagnostic algorithm based on current symptoms.

AAFP Guideline for the Detection and Management of Post-Myocardial Infarction Depression

EVIDENCE-BASED RECOMMENDATIONS The American Academy of Family Physicians (AAFP) Commission on Science convened a panel to review the evidence on the effect of depression on persons after myocardial infarction. The evidence report on this topic was published in May 2005 by the Agency for Healthcare Research and Quality (AHRQ) and is used as the basis for this review.1 The AAFP Post–Myocardial Infarction Depression Clinical Practice Guideline Panel (Post-MI Guideline Panel) was charged with examining the evidence and developing an evidence-based clinical practice guideline for the detection and management of persons with postmyocardial infarction (post-MI) depression. The following recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they refl ect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations.

Comprehensiveness and Continuity of Care and the Inseparability of Mental and Behavioral Health From the Patient-Centered Medical Home

Comprehensiveness and continuity of care are key elements of primary care system redesign. Comprehensiveness encompasses evaluating the whole person and dealing with the full range of physical, mental, and behavioral healthcare issues; and continuity is based on building healing relationships over time. This article suggests that a focus on comprehensiveness and continuity implies that responding to mental health, behavioral health, and substance use must be core elements of the patient-centered medical home. A list of necessary next steps toward achieving comprehensive and integrated care is recommended.

Implementing a Depression Improvement Intervention in Five Health Care Organizations: Experience from the RESPECT-Depression Trial

A growing body of research provides strong evidence for the effectiveness of programs to improve the primary care of depression based on the chronic care model. At the same time these changes are difficult to sustain in their original research settings and more difficult to widely disseminate in primary care practice. The RESPECT-Depression trial tested an implementation and dissemination strategy by working through five community-based health care organizations (HCOs) to implement the Three Component Model (TCM) for improving depression care. This report describes the results of extensive interviews of project principals, health care program managers, depression care managers, and practicing primary care clinicians to understand the characteristics of organizations and the intervention components that were associated with implementation and dissemination of the TCM. In two of the organizations all 29 participating practices continued the TCM, while all 31 practices from the other three organizations did not. Successful continuation and dissemination appeared to be related to a broadly shared vision and commitment among all levels of the organization, clearly articulated by clinical leadership, for pursuing a systematic change strategy to improve chronic care that included, but extended beyond, depression, independent of clear evidence for cost-effectiveness of expanding depression management. Factors associated with inability to sustain the TCM included lack of a shared change strategy throughout the organization and inability to rationalize an economic model of depression care.

Does a Depression Intervention Result in Improved Outcomes for Patients Presenting with Physical Symptoms

OBJECTIVE: To investigate the effects of exclusively physical presentation of depression on 1) depression management and outcomes under usual care conditions, and 2) the impact of an intervention to improve management and outcomes.DESIGN AND SETTING: Secondary analysis of a depression intervention trial in 12 community-based primary care practices.PARTICIPANTS: Two hundred adults beginning a new treatment episode for depression.MEASUREMENTS: Presenting complaint and physician depression query at index visit; antidepressant use, completion of adequate antidepressant trial, change in depressive symptoms, and physical and emotional role functioning at 6 months.MAIN RESULTS: Sixty-six percent of depressed patients presented exclusively with physical symptoms. Under usual care conditions, psychological presenters were more likely than physicial presenters to complete an adequate trial of anti-depressant treatment but experienced equivalent improvements in depressive severity and role functioning. In patients presenting exclusively with physicial symptoms, the intervention significantly improved physician query (40.8% vs 18.0%; P=.06), receipt of any antidepressant (63.0% vs 20.1%; P=.001), and an adequate antidepressant trial (34.9% vs 5.9%; P=.004), but did not significantly improve depression severity or role functioning. In patients presenting with psychological symptoms, the intervention significantly improved receipt of any antidepressant (79.9% vs 38.0%; P=.01) and an adequate antidepressant trial (46.0% vs 23.8%; P=.004), and also improved depression severity and physical and emotional role functioning.CONCLUSIONS: Our results suggest that there is a differential intervention effect by presentation style at the index visit. Thus, current interventions should be targeted at psychological presenters and new approaches should be developed for physical presenters.

Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial

PURPOSE We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation. METHODS We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys. RESULTS Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices. CONCLUSIONS Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.

Patient-Centered Medical Home: How It Affects Psychosocial Outcomes for Diabetes

Fragmentation of the current U.S. health care system and the increased prevalence of chronic diseases in the U.S. have led to the recognition that new models of care are needed. Chronic disease management, including diabetes, is often accompanied by a myriad of associated psychosocial issues that need to be addressed as part of a comprehensive treatment plan. Diabetes care should be aligned with comprehensive whole-person health care. The patient-centered medical home (PCMH) has emerged as a model for enhanced primary care that focuses on comprehensive integrated care. PCMH demonstration projects have shown improvements in quality of care, patient experience, care coordination, access to care, and quality measures for diabetes. Key PCMH transformative features associated with psychosocial issues related to diabetes reviewed in this article include integration of mental and behavioral health, care management/coordination, payment reform, advanced access, and putting the patient at the center of health care. This article also reviews the evidence supporting comprehensive and integrated care for addressing psychosocial issues associated with diabetes in the medical home.