Motivational interviewing improves depression outcome in primary care: A cluster randomized trial.

OBJECTIVE: To examine the effects of Motivational Interviewing (MI) conducted by primary care providers on rates of improvement over time for depressive symptoms and remission among low-income patients with newly diagnosed Major Depressive Disorder. METHOD: Ten care teams were randomized to MI with standard management of depression (MI-SMD; 4 teams, 10 providers, 88 patients) or SMD alone (6 teams, 16 providers, 80 patients). Patients were assessed at 6, 12 and 36 weeks with the Patient Health Questionnaire-9 (PHQ-9). Treatment receipt was ascertained through patient inquiry and electronic records. Audio-recorded index encounters were evaluated for mediators of improved depressive symptoms (providers' MI ability and patient language favoring participating in treatment or other depression related mood-improving behaviors). RESULTS: In Intention-To-Treat analyses, MI-SMD was associated with a more favorable trajectory of PHQ-9 depressive symptom scores than SMD alone (randomization group × time interaction estimate = 0.13, p = .018). At 36 weeks, MI-SMD was associated with improved depressive symptoms (Cohen's d = 0.41, 95% CI [0.11, 0.72]) and remission rate (Success Rate Difference = 14.53 [1.79, 27.26]) relative to SMD alone. MI-SMD was not associated with a significant group x time interaction for remission, or with increased receipt of antidepressant medication or specialty mental health counseling. The providers' ability to direct clinical discussions toward treating depression, and the patients' language favoring engagement in mood-improving behaviors, mediated the effects of MI-SMD on depressive symptoms (ps < .05). DISCUSSION: Training providers to frame discussions about depression using MI may improve upon standard management for depression. (PsycINFO Database Record

Positive Predictive Value of a Single Assessment of Estimated GFR in the Diagnosis of Chronic Kidney Disease.

OBJECTIVES: The positive predictive value (PPV) of a single assessment of estimated glomerular filtration rate (eGFR) in the diagnosis of chronic kidney disease (CKD) is not known. Our objective was to determine the PPV of a single assessment of eGFR among adults with at least one eGFR <60 mL/min in their lifetime, using the Distributed Area Research and Therapeutics Network CKD natural history dataset. METHODS: In all, 47,104 adults who were cared for by 113 practices in the United States were included. Proportions of patients in eGFR categories at baseline were calculated using the following categories: <15 mL/min, 15 to 29.99 mL/min, 30 to 44.99 mL/min, and 45 to 59.99 mL/min. Comparisons were then made between the baseline and the endpoint to identify patients who had a follow-up eGFR that remained at <60 mL/min. The proportions of patients in each eGFR category were compared baseline to endpoint using cross-tabulations. To test the proposed cutpoint, the proportions of patients who had an eGFR that remained at <60 mL/min were measured, using the cutpoints that included the highest cumulative proportion of patients. The sensitivity and specificity of that cutpoint were calculated. RESULTS: A cutpoint of <45 mL/min was identified, yielding a PPV of 93% with a sensitivity of 28% and a specificity of 94%. CONCLUSIONS: A valid cutpoint to screen for CKD was identified. This cutpoint may prove important to early screening for CKD while reducing the burden on the healthcare system and patients suspected of having CKD.

Pragmatic Cluster Randomized Trials Using Covariate Constrained Randomization: A Method for Practice-based Research Networks (PBRNs).

BACKGROUND: Cluster randomized trials (CRTs) are useful in practice-based research network translational research. However, simple or stratified randomization often yields study groups that differ on key baseline variables when the number of clusters is small. Unbalanced study arms constitute a potentially serious methodological problem for CRTs. METHODS: Covariate constrained randomization with data on relevant variables before randomization was used to achieve balanced study arms in 2 pragmatic CRTs. In study 1, 16 counties in Colorado were randomized to practice-based or population-based reminder recall for vaccinating children ages 19 to 35 months. In study 2, 18 primary care practices were randomized to computer decision support plus practice facilitation versus computer decision support alone to improve care for patients with stage 3 and 4 chronic kidney disease. For each study, a set of optimal randomizations, which minimized differences of key variables between study arms, was identified from the set of all possible randomizations. RESULTS: Differences between study arms were smaller in the optimal versus remaining randomizations. Even for the randomization in the optimal set with the largest difference between groups, study arms did not differ significantly on any variable for either study (P > .05). CONCLUSIONS: Covariate constrained randomization, which restricts the full randomization set to a subset in which differences between study arms are minimized, is a useful tool for achieving balanced study arms in CRTs. Because of the increasing recognition of the risk of imbalance in CRTs and implications for interpreting study findings, procedures of this type should be considered in designing practice-based or community-based trials.

What Peer Mentoring Adds to Already Good Patient Care: Implementing the Carpeta Roja Peer Mentoring Program in a Well-Resourced Health Care System.

PURPOSE: The purpose of this study was to evaluate the impact of a peer support program on the health outcomes of patients already receiving well-organized, comprehensive diabetes care. METHODS: We used a mixed-methods, nonrandomized, control-group design to evaluate the impact of a peer-mentoring program on the health outcomes and self-management behaviors of adults with type 2 diabetes in 15 primary care practices in San Antonio. Propensity score analysis, t-tests, and multivariable repeated analyses were used to evaluate impact. Qualitative interviews were conducted with 15 participants in the intervention group and analyzed using a grounded theory approach. RESULTS: Both intervention and control groups showed significant improvement on all health indicators from baseline to 6-month follow-up (P<.001). Hemoglobin A1c (HbA1c) decreased slightly faster for patients in the intervention group (P=.04). Self-management behaviors improved significantly from baseline to 6-month follow-up for the intervention group. Interviewed participants also reported reductions in social isolation and extension of impact of health behavior changes to multiple generations of family members. CONCLUSIONS: The addition of peer mentoring to already well-organized comprehensive diabetes care does not improve outcomes. However, findings suggest that the impact of the program extends to members of the participants' families, which is an intriguing finding that deserves further study.

Prioritization of patients for comprehensive medication review by a clinical pharmacist in family medicine.

BACKGROUND: This pilot study describes and evaluates the clinical pharmacy priority (CP2) score. We hypothesize that patients with high CP2 scores are more likely to receive a medication recommendation after comprehensive medication review (CMR) than patients with lower scores. Prioritization of patients for CMR by a clinical pharmacist in family medicine could enhance the provision of interprofessional care within the patient-centered medical home. METHODS: The CP2 score was developed collaboratively by the research team and is derived from 11 patient-specific factors extracted from the electronic health record. To evaluate the utility of the score, CMR was performed prospectively by a clinical pharmacist for patients with appointments between October 1 and December 31, 2012, at 2 University of Colorado family medicine clinics. RESULTS: CMR was performed for 1107 patient appointments. Of these, 101 were identified as having received a medication recommendation from the clinical pharmacist. For patients with a CP2 score of 0 to 2, 2 of 588 charts (0.3%) reviewed received a recommendation (level 1). The proportion increased to 37 of 358 (10.3%) for scores of 3 to 7 (level 2), 40 of 119 (33.6%) for scores of 8 to 10 (level 3), and 22 of 42 (52.4%) for scores of ≥11 (level 4). Compared with CP2 scores in level 1, patient appointments were more likely to receive a medication recommendation after CMR in level 2 (relative risk [RR], 30.4; 95% confidence interval [CI], 7.4-125.3), in level 3 (RR, 98.8; 95% CI, 24.2-403.3), and in level 4 (RR, 154; 95% CI, 37.5-632.8). CONCLUSIONS: Patients with higher CP2 scores were more likely to receive a medication recommendation after CMR by a clinical pharmacist than patients with lower scores. The CP2 score could be used by clinical pharmacists in family medicine to enhance the efficient and effective delivery of interprofessional care.

Training to use motivational interviewing techniques for depression: a cluster randomized trial.

OBJECTIVE: The goal of this study was to assess the effects of training primary care providers (PCPs) to use Motivational Interviewing (MI) when treating depressed patients on providers' MI performance and patients' expressions of interest in depression treatment ("change talk") and short-term treatment adherence. METHODS: This was a cluster randomized trial in urban primary care clinics (3 intervention, 4 control). We recruited 21 PCPs (10 intervention, 11 control) and 171 English-speaking patients with newly diagnosed depression (85 intervention, 86 control). MI training included a baseline and up to 2 refresher classroom trainings, along with feedback on audiotaped patient encounters. We report summary measures of technical (rate of MI-consistent statements per 10 minutes during encounters) and relational (global rating of "MI Spirit") MI performance, the association between MI performance and number of MI trainings attended (0, 1, 2, or 3), and rates of patient change talk regarding depression treatments (physical activity, antidepressant medication). We report PCP use of physical activity recommendations and antidepressant prescriptions and patients' short-term physical activity level and prescription fill rates. RESULTS: Use of MI-consistent statements was 26% higher for MI-trained versus control PCPs (P = .005). PCPs attending all 3 MI trainings (n = 6) had 38% higher use of MI-consistent statements (P < .001) and were over 5 times more likely to show beginning proficiency in MI Spirit (P = .036) relative to control PCPs. Although PCPs' use of physical activity recommendations and antidepressant prescriptions was not significantly different by randomization arm, patients seen by MI-trained PCPs had more frequent change talk (P = .001). Patients of MI-trained PCPs also expressed change talk about physical activity 3 times more frequently (P = .01) and reported more physical activity (3.05 vs 1.84 days in the week after the visit; P = .007) than their counterparts visiting untrained PCPs. Change talk about antidepressant medication and fill rates were similar by randomization arm (P > .05 for both). CONCLUSIONS: MI training resulted in improved MI performance, more depression-related patient change talk, and better short-term adherence.

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.

Outcomes of biomarker feedback on physical activity, eating habits, and emotional health: from the Americans in Motion-Healthy Intervention (AIM-HI) study.

PURPOSE: The purpose of this article was to test whether physical activity, healthy eating, and emotional well-being would improve if patients received feedback about biomarkers that have been shown to be responsive to changes in weight and fitness. METHODS: Patients were randomized to limited feedback (weight, body mass index [BMI], and blood pressure at 4 and 10 months) or enhanced feedback (weight, BMI, blood pressure, homeostatic insulin resistance, and nuclear magnetic resonance lipoprotein profiles at 2, 4, 7, and 10 months). Repeated measures mixed effects multivariate regression models were used to determine whether BMI, fitness, diet, and quality of life changed over time. RESULTS: Major parameters were similar in both groups at baseline. BMI, measures of fitness, healthy eating, quality of life, and health state improved in both patient groups, but there was no difference between patient groups at 4 or 10 months. Systolic blood pressure improved in the enhanced feedback group, and there was a difference between the enhanced and limited feedback groups at 10 months (95% confidence interval, -6.011 to -0.5113). CONCLUSIONS: Providing patients with enhanced feedback did not dramatically change outcomes. However, across groups, many patients maintained or lost weight, suggesting the need for more study of nondiet interventions.

Testing to prevent colon cancer: results from a rural community intervention.

PURPOSE: Colon cancer is the second leading cause of cancer death in the United States. Despite tests that can detect and enable removal of precancerous polyps, effectively preventing this disease, screening for colon cancer lags behind other cancer screening. The purpose of this study was to develop and test a community-based participatory approach to increase colon cancer screening. METHODS: Using a community-based participatory research approach, the High Plains Research Network and their Community Advisory Council developed a multicomponent intervention-Testing to Prevent Colon Cancer-to increase colon cancer screening. A controlled trial compared 9 intervention counties in northeast Colorado with 7 control counties in southeast Colorado. We performed a baseline and postintervention random digit-dial telephone survey and conducted both intent-to-treat and on-treatment analyses. RESULTS: In all, 1,050 community members completed a preintervention questionnaire and 1,048 completed a postintervention questionnaire. During the study period, there was a 5% absolute increase in the proportion of respondents who reported ever having had any test in the intervention region (from 76% to 81%) compared with no increase in the control region (77% at both time points) (P = .22). No significant differences between these groups were found in terms of being up to date generally or on specific tests. The extent of exposure to intervention materials was associated with a significant and cumulative increase in screening. CONCLUSIONS: This community-based multicomponent intervention engaged hundreds of community members in wide dissemination aimed at increasing colorectal cancer screening. Although we did not find any statistically significant differences, the findings are consistent with an intervention-related increase in screening and provide preliminary evidence on the effectiveness of such interventions to improve colon cancer screening.

Aspects of patient and clinician language predict adherence to antidepressant medication.

OBJECTIVE: High-quality patient-clinician communication is associated with better medication adherence, but the specific language components associated with adherence are poorly understood. We examined how patient and clinician language may influence adherence. METHODS: We audio-recorded primary care encounters from 63 patients newly diagnosed with depression and prescribed an antidepressant medication. We rated clinicians' language (motivational interviewing-adherent statements [MIAs], reflections, and global ratings of empathy and "motivational interviewing spirit") along with patients' "change talk" (CT) demonstrating motivation to take medication. Filling a first prescription and an estimate of overall adherence, the proportion of >180 days covered (PDC) (primary outcome), were measured based on pharmacy records. RESULTS: Fifty-six patients (88.8%) filled an initial prescription, and mean (standard deviation) PDC across all subjects was 45.2% (33.6%). MIAs, complex reflections, and empathy were associated with more CT (for all: rs ≥0.27; P < .05). Two or more and 0 or 1 CT statements were associated with 63.0% and 36.6% PDC, respectively. Empathy, motivational interviewing spirit, and CT were associated with filling the first prescription (for all: rs ≥0.25; P < .05). In an adjusted analysis, empathy (t = 2.3; P = .027) and ≥2 CT statements (t = 2.3; P = .024) were associated with higher PDC. CONCLUSIONS: Clinician empathy, reflections, and MIAs may elicit patient CT, whereas empathy and CT seem to enhance filling an initial prescription and PDC.

Effectiveness of 2 methods of promoting physical activity, healthy eating, and emotional well-being with the americans in motion--healthy interventions approach.

PURPOSE: An increasing number of Americans are putting their health at risk from being overweight. We undertook a study to compare patient-level outcomes of 2 methods of implementing the Americans In Motion-Healthy Interventions (AIM-HI) approach to promoting physical activity, healthy eating, and emotional well-being. METHODS: We conducted a randomized trial in which 24 family medicine practices were randomized to (1) an enhanced practice approach in which clinicians and office staff used AIM-HI tools to make personal changes and created a healthy environment, or (2) a traditional practice approach in which physicians and staff were trained and asked to use the tools with patients. Of the 610 patients enrolled, 331 were in healthy practices, and 279 were in traditional practices. At 0, 4, and 10 months we assessed blood pressure, body mass index, fasting blood glucose and insulin levels, nuclear magnetic resonance lipoprotein profiles, fitness, dietary intake, physical activity, and emotional well-being. Outcome data were analyzed using linear, mixed-effects multivariate models, adjusting for practices as a random effect. RESULTS: Regardless of patient group, 16.2% of patients who completed a 10-month visit (n = 378 patients, 62% of enrollees) and 10% of all patients enrolled lost 5% or more of their body weight; 16.7% of patients who completed a 10-month visit (10.3% of all enrollees) had a 2-point or greater increase in their fitness level; and 29.2% of 10-month completers (18.0% of all enrollees) lost 5% or more of their body weight and/or increased their fitness level by 2 or more points. There were no significant differences in these outcomes between groups. CONCLUSIONS: There was no difference between the 2 groups in the primary and most secondary outcomes. Both patient groups were able to show significant before-after improvements in selected patient-level outcomes.

Use of the Americans in Motion-Healthy Intervention (AIM-HI) to create a culture of fitness in family practice.

BACKGROUND: Americans in Motion-Healthy Interventions (AIM-HI) is an initiative designed to assist family physicians with positioning fitness (physical activity, nutrition, and emotional well-being) as the treatment of choice for prevention and management of chronic disease. We investigated whether the concept of a culture of fitness would benefit office personnel and carry over to patient care. METHODS: This randomized, controlled trial provided an intervention based on the AIM-HI curriculum to 12 enhanced offices with support for office activities, while 12 traditional offices received only AIM-HI tools with encouragement for use with patients. Before intervention, at 4 months, and at 14 months, we measured the practice personnel's dietary behavior (PrimeScreen), physical activity (International Physical Activity Questionnaire), self-determined (intrinsic) motivation (Treatment Self-Regulation Questionnaire [TSRQ]), perceived ability to carry out health behaviors (Perceived Competence Scale), and readiness to improve and/or maintain health behaviors (Stages of Change). RESULTS: From 24 practices we enrolled 470 subjects; 21 practices completed the study, and data from 341 patients were analyzed. Differential change from baseline between the enhanced and traditional offices was not evident for behavior changes. An overall decrease from baseline in self-reported total physical activity measured as metabolic equivalent-minutes for all surveyed groups occurred over the study time period (4-month ß = -11.97; 14-month ß = -9.01; P = .003). A statistically significant increase occurred at 4 months among participants from the enhanced practices for the TSRQ outcomes of Healthy Eating (baseline, 3.00 ± 0.12; 4 months, 3.26 ± 0.13; P = .013). Among clinicians, TSRQ Healthy Eating scores increased from 3.19 ± 0.13 at baseline to 3.52 ± 0.14 at 4 months (P = .005). However, increases in TSRQ Eating scores were not sustained by 14 months. Stages of Change scores decreased from baseline to 4 months in enhanced group offices. There was also a decrease in Stages of Change scores among staff from baseline to 14 months. CONCLUSIONS: Primary care clinicians and office staff are resistant to health behavior change. External motivation did not seem to help them change. The effect of this intervention on patient care is not yet known.

Regional variations in physicians' attitudes and recommendations surrounding implantable cardioverter-defibrillators.

INTRODUCTION: This study was designed to determine if physicians' attitudes and recommendations surrounding implantable cardioverter-defibrillators (ICDs) are regionally associated with ICD use. METHODS AND RESULTS: A national sample of 9969 members of the American College of Cardiology was surveyed electronically. Responses were merged with rates of ICD implantation from the National Cardiovascular Data Registry. Multivariable regression was used to assess trends between regional use and responses. We received 1210 responses (12%) and used 1124 after exclusions. Across regions, physicians were equally likely to recommend ICDs to males or females with ischemic (∼99% for both; P = NS) or nonischemic cardiomyopathy (85 vs. 88% P = 0.85). Significant increasing trends in the probability recommending ICD therapy were found when the patient was "frail" (21% to 32%; P = .03) or had a life expectancy <1 year (5% to 10%; P = .05). These differences were not associated with attitudes toward ICDs. CONCLUSIONS: Independent of variations in physicians' attitudes towards ICDs, physicians in regions of low ICD use are not less likely to recommend ICDs in situations clearly supported by guidelines while those in regions of high ICD use are more likely to recommend ICDs to patients who might have limited benefit.

Women with type 2 diabetes perceive harder effort during exercise than nondiabetic women.

Regular exercise is a cornerstone of diabetes treatment; however, people with type 2 diabetes (T2D) are commonly sedentary. It is possible that a harder rate of perceived exertion (RPE) during exercise for those with T2D as compared with nondiabetics may be a barrier to physical activity. This study examined RPE (Borg scale, ordinal range 6-20) during submaximal exercise at identical absolute work rates to test the hypothesis that women with T2D demonstrate harder RPE during exercise than nondiabetic controls. In a prespecified analysis of existing data from equivalently sedentary women, RPE during submaximal exercise was compared among women with uncomplicated T2D (n = 13, mean body mass index (BMI) 34.2, mean hemoglobin A1c 9%), overweight controls (OC, n = 13, mean BMI 30.7), and normal-weight controls (NWC, n = 13, mean BMI 23.1). Subjects performed three 7 min, constant-load exercise tests at 20 W and 30 W. Mixed-effects general linear modeling was used to test for differences in mean RPE estimates among groups with and without adjustment for relative work intensity, age, habitual physical activity, or BMI. Subjects with T2D perceived harder effort during bicycling exercise than controls, as measured by RPE at 20 W and 30 W (p < 0.05 for T2D vs. OC and for T2D vs. NWC). Adjusting for relative work intensity eliminated significant group RPE differences at 30 W, but group RPE differences at 20 W remained significant. Harder perceived effort during exercise may be a barrier to physical activity for those with T2D.

Increasing colon cancer testing in rural Colorado: evaluation of the exposure to a community-based awareness campaign.

BACKGROUND: Despite effective prevention and early detection screening methods, colorectal cancer is the second leading cause of cancer death in the United States. Colorectal cancer screening community-based interventions are rare, and the literature lacks information about community-based intervention processes. Using participatory research methods, the High Plains Research Network developed a community-based awareness and educational intervention to increase colorectal cancer screening rates in rural northeastern Colorado. This study describes the program components and implementation and explores whether the target population was exposed to the intervention, the reach of the individual intervention components, and the effect on screening intentions. METHODS: A random digit dial survey was conducted of residents age 40 and older in the first 3 communities to receive the intervention to estimate exposure to the intervention and its effect on colorectal cancer screening intentions. RESULTS: Exposure to at least intervention component was reported by 68% of respondents (n = 460). As the level of exposure increased, intentions to talk to a doctor about colorectal cancer screening increased significantly more in respondents who had not been tested in the past 5 years than those who had (p = .025). Intentions to get tested increased significantly in both groups at the same rate as level of exposure increased (p < .001). CONCLUSION: Using local community members led to the successful implementation of the intervention. Program materials and messages reached a high percentage of the target population and increased colorectal cancer screening intentions.

Use of colon cancer testing in rural Colorado primary care practices.

BACKGROUND: People living in rural areas may be less likely to be up to date (UTD) with screening guidelines for colorectal cancer (CRC). OBJECTIVES: To determine (1) rates of being UTD with screening or ever having had a test for CRC and (2) correlates for testing among patients living in a rural area who visit a provider. DESIGN: Cross-sectional survey. PARTICIPANTS: Five hundred seventy patients aged 50 years and older who visited their health-care provider in High Plains Research Network (HPRN) practices. MEASUREMENTS: (1) Ever having had a CRC screening test, (2) being UTD with CRC screening, and (3) intention to get tested. RESULTS: The survey completion rate was 65%; 71% of patients had ever had any CRC screening test, while 52% of patients were UTD. Correlates of intending to get tested included having a family history of CRC, having a doctor recommend a test, knowing somebody who got tested, and believing that testing for CRC gives one a feeling of being in control of their health. Of those who had never had a CRC screening test, 12% planned on getting tested in the future, while 55% of those who were already up to date intended to be tested again (p < 0.001). CONCLUSIONS: Prevalence of being UTD with CRC testing in the HPRN was on par with statewide CRC testing rates, but over three quarters of patients who had not yet been screened had no intention of getting tested for CRC, despite having a medical home.

Effectiveness of hydralazine/isosorbide dinitrate in racial/ethnic subgroups with heart failure.

BACKGROUND: The addition of hydralazine/isosorbide dinitrate (H-ISDN) to a standard heart failure treatment regimen in the African-American Heart Failure Trial was associated with a 43% reduction in mortality. However, the effectiveness of H-ISDN in a community sample of African-American patients and other racial/ethnic groups is unknown. OBJECTIVE: The aim of this study was to assess the associations between treatment with H-ISDN and mortality or hospitalization for heart failure in veterans with the disease. METHODS: For this retrospective cohort study, electronic data on outpatient prescriptions, comorbidity, and other heart failure risk factors were analyzed in veterans with heart failure. Patients were classified based on whether they were prescribed H-ISDN and subclassified based on race/ethnicity (African American, Hispanic, or white). Patients who were prescribed H-ISDN were subclassified based on time of initiation of H-ISDN treatment (0-121, 122-365, or >365 days after diagnosis). Data were analyzed using propensity-adjusted Cox regression analyses, with exposure to H-ISDN modeled as a time-varying covariate. RESULTS: Data from 76,828 veterans were analyzed (98% men, 2% women). H-ISDN prescription was not associated with the risk of death in 5 of the 9 subgroups predefined by race/ethnicity or time of initiation of H-ISDN; however, H-ISDN was associated with an increased risk of death in the 4 subgroups with longer times to initiation. H-ISDN was associated with a significantly increased risk of heart failure hospitalization in all but 1 of the 9 subgroups. The risk of both mortality and hospitalization associated with H-ISDN was significantly lower in African-American patients than in those who were Hispanic or white. Concurrent prescription of other, evidence-based heart failure therapies (eg, angiotensin-converting enzyme inhibitors, beta-blockers, and combinations) had strong, statistically significant associations with reduced mortality. CONCLUSIONS: In this population of veterans with heart failure, H-ISDN prescription was not associated with significant reductions in mortality or hospitalization in any of the subgroups defined by race/ethnicity and time of initiation of H-ISDN analyzed compared with the group that did not receive H-ISDN. It is possible, or even likely, that unmeasured differences in important risk factors-particularly heart failure severity and left ventricular dysfunction-between the group that received H-ISDN and the one that did not masked a beneficial effect of H-ISDN. Therefore, our conclusions must be regarded as hypothesis generating and need to be tested in subsequent randomized trial(s).

Lack of impact of direct-to-consumer advertising on the physician-patient encounter in primary care: a SNOCAP report.

PURPOSE: Direct-to-consumer advertising (DTCA) has increased tremendously during the past decade. Recent changes in the DTCA environment may have affected its impact on clinical encounters. Our objective was to determine the rate of patient medication inquiries and their influence on clinical encounters in primary care. METHODS: Our methods consisted of a cross-sectional survey in the State Networks of Colorado Ambulatory Practices and Partners, a collaboration of 3 practice-based research networks. Clinicians completed a short patient encounter form after consecutive patient encounter for one-half or 1 full day. The main outcomes were the rate of inquiries, independent predictors of inquiries, and overall impact on clinical encounters. RESULTS: One hundred sixty-eight clinicians in 22 practices completed forms after 1,647 patient encounters. In 58 encounters (3.5%), the patient inquired about a specific new prescription medication. Community health center patients made fewer inquiries than private practice patients (1.7% vs 7.2%, P<.001). Predictors of inquiries included taking 3 or more chronic medications and the clinician being female. Most clinicians reported the requested medication was not their first choice for treatment (62%), but it was prescribed in 53% of the cases. Physicians interpreted the overall impact on the visit as positive in 24% of visits, neutral in 66%, and negative in 10%. CONCLUSIONS: Patient requests for prescription medication were uncommon overall, and even more so among patients in lower income groups. These requests were rarely perceived by clinicians as having a negative impact on the encounter. Future mixed methods studies should explore specific socioeconomic groups and reasons for clinicians' willingness to prescribe these medications.

Latino families report lower child injury rates than white families.

Latino children have lower visit rates to emergency departments and primary care physicians than white children in the USA. Using a nationally representative household survey, this study asked whether parental report of injury was also lower for Latino children, after adjusting for demographic, socioeconomic, health status and health care access factors. Data were obtained on injuries for which medical advice or treatment was received from the National Health Interview Survey (NHIS) from 1997 to 2003. Using the multistage probability design of NHIS, annual rates and adjusted odds of childhood injury report by race and ethnicity were calculated. Respondents reported lower rates of injury for Latino children (6.0 (95% CI 5.3-6.8)/100 person-years) than white children (13.4 (12.7-14.2)/100 person-years). Lower injury rates were mainly due to lower rates of sports injuries and accidental falls. Latino children had lower odds of reported injury than white children, even after adjusting for multiple factors (odds ratio 0.7; 95% CI 0.6-0.8). Lower odds of injury report among Latino children are independent of direct measures of demographic, socioeconomic, health status and health care access factors and indirect measures of acculturation including respondent language and country of origin. Potential explanations include lower exposure to risk, greater child supervision, reporting bias, differences in cultural attitudes toward seeking of health care and reduced health care access that cannot be explored in NHIS due to the form of the current questions. Further research is needed to investigate cultural differences in risk exposure, child supervision and seeking of injury care.

Clinician burden and depression treatment: disentangling patient- and clinician-level effects of medical comorbidity.

BACKGROUND: Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment. OBJECTIVE: To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects. DESIGN: Secondary analysis from the Quality Improvement in Depression Study dataset. PARTICIPANTS: The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study. MEASUREMENTS: Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden. RESULTS: Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45). CONCLUSIONS: Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.