A pharmacist-guided protocol for improved monitoring of patients on antidepressants.

BACKGROUND: Local guidelines recommend that patients treated for depression receive 3 follow-ups within 12 weeks of antidepressant initiation; however, this is often not achieved in practice. METHODS: A monitoring protocol was implemented as a quality improvement project at Wingra Access Medical Center in which patients treated for anxiety or depression received a follow-up phone call 1 to 2 weeks after starting an antidepressant. RESULTS: A retrospective chart review demonstrated the percentage of patients achieving 3 follow-ups within 12 weeks significantly increased from 7% to 24% following implementation. CONCLUSION: Results suggest the protocol is a feasible method to improve antidepressant followup in primary care. Confounding factors including cohort dissimilarities and introduction of a behavioral health service should be considered.

Association Between Service Agreements and Frequency of Primary Care Visits in a Chinese Community Health Service Center.

BACKGROUND: To increase the utilization of Community Health Service (CHS) centers for primary care, the Central Government of China has promoted the use of contracts-known as "service agreements" (SAs)-between patients and primary care physicians. This study sought to identify factors that predict who signed SAs and the association between SAs and frequency of primary care visits in a CHS center in Beijing. METHODS: Four years of electronic health record (EHR) data (2015 to 2018) were analyzed. Multivariate logistic regression analysis was performed to examine the tendency of patients to establish a SA. The pattern of the primary care visits between the SA and the non-SA groups was compared using Gamma regression models, controlling for demographic and comorbidity conditions. Contrast analysis was performed to assess the odds ratios of signing SAs among levels of a specific patient characteristic. RESULTS: Data from 32,682 adult CHS patients were collected. Of those, 66.4% had signed a SA. Patients who were female, older, more educated, married, employed, insured, or had comorbid conditions were more likely to sign SAs. Overall, having a SA was associated with a higher frequency of primary care visits for women and older patients, but not for the young and educated patients. CONCLUSIONS: The evidence provides an important consideration for reducing gaps in the use of primary care services during the nationwide transition from the fee-for-service specialty care system to the patient-centered primary care-driven medical home model.

Mindfulness meditation for substance use disorders: a systematic review.

Relapse is common in substance use disorders (SUDs), even among treated individuals. The goal of this article was to systematically review the existing evidence on mindfulness meditation-based interventions (MM) for SUDs. The comprehensive search for and review of literature found over 2000 abstracts and resulted in 25 eligible manuscripts (22 published, 3 unpublished: 8 randomized controlled trials, 7 controlled nonrandomized, 6 noncontrolled prospective, and 2 qualitative studies, and 1 case report). When appropriate, methodological quality, absolute risk reduction, number needed to treat, and effect size were assessed. Overall, although preliminary evidence suggests MM efficacy and safety, conclusive data for MM as a treatment of SUDs are lacking. Significant methodological limitations exist in most studies. Further, it is unclear which persons with SUDs might benefit most from MM. Future trials must be of sufficient sample size to answer a specific clinical question and should target both assessment of effect size and mechanisms of action.

Correlation Between Climate Change and Dysphoria in Primary Care.

BACKGROUND: Concern about climate change may affect mental health. We evaluated the relationship between primary care patients' attitudes toward climate change and dysphoria. METHODS: In 2013, we surveyed 571 adult primary care patients in southern Wisconsin. Attitudes toward climate change were measured using a 46-point composite of 9 questions. Dysphoria was measured using a 13-point composite summing the Patient Health Questionnaire (PHQ-2) and the Generalized Anxiety Disorder scale (GAD-2). RESULTS: Patients frequently reported concern about climate change and 22.5% experienced dysphoria. A significant, positive correlation existed between the composite climate change score and the dysphoria score (rs=0.345; P<0.001). CONCLUSION: Primary care patients are concerned about climate change and this concern is positively related to dysphoria. The level to which dysphoria is due to climate change should be elucidated.

Does the Primary Care Behavioral Health Model Reduce Emergency Department Visits?

OBJECTIVE: To examine the impact of integrating behavioral health services using the primary care behavioral health (PCBH) model on emergency department (ED) utilization. DATA SOURCES: Utilization data from three Dane County, Wisconsin hospitals and four primary care clinics from 2003 to 2011. STUDY DESIGN: We used a retrospective, quasi-experimental, controlled, pre-post study design. Starting in 2007, two clinics began integrating behavioral health into their primary care practices with a third starting in 2010. A fourth, nonimplementing, community clinic served as control. Change in emergency department and primary care utilization (number of visits) for patients diagnosed with mood and anxiety disorders was the outcomes of interest. DATA COLLECTION: Retrospective data were obtained from electronic patient records from the three main area hospitals along with primary care data from participating clinics. PRINCIPAL FINDINGS: Following the introduction of the PCBH model, one clinic experienced a statistically significant (p < .01, 95 percent CI 6.3-16.3 percent), 11.3 percent decrease in the ratio of ED visits to primary care encounters, relative to a control site, but two other intervention clinics did not. CONCLUSIONS: The PCBH model may be associated with a reduction in ED utilization, but better-controlled studies are needed to confirm this result.

Primary care reform in the Peoples' Republic of China: implications for training family physicians for the world's largest country.

Just as China has struggled with bringing an expanding economy to a country with large areas of economic underdevelopment, the Chinese health care system is experiencing tension between tradition and modernization. Because of this tension, health care in the Peoples' Republic of China has been undergoing significant reform since the beginning of the 1980s. Experiments in market-based health systems have been unsuccessful and have exacerbated disparities. New reforms, announced in 2006, stress the role of family physicians in leading the health care system. This paper discusses the history of the developments that led up to the new reforms and the educational challenges of training sufficient numbers of family physicians to meet the requirements of the new system.

Initial examination of characteristics of patients who are high utilizers of an established primary care behavioral health consultation service.

Obective: Although much has been studied regarding high-utilizing patients of medical services, no studies have been published regarding high-utilizing patients of integrated primary care behavioral health (PCBH) services. The primary purpose of the current study was to examine characteristics of high-utilizing patients of PCBH services and model adherence. The secondary purpose was to describe the process of conducting this research by clinicians in integrated care. METHOD: Data were obtained from electronic health records retrospectively for the study's time period, 2007-2013, for the sample of all patients who met with the behavioral health consultation team during that time. Variables include demographics, diagnoses, involvement in additional services, and scores on a patient-complexity scale for a subset of patients. Chi-square analyses, t tests and logistic regression analyses were performed. RESULTS: The results demonstrate significant associations between key demographic characteristics, use of population-based augmentation services (i.e., consulting psychiatry, care management, substance-abuse consulting), and high-utilizing status. Model adherence was maintained over time. Logistic regression analysis, controlling for high-utilizing status and number of visits, demonstrated a significant relationship between more complex diagnostic categories and behavioral health issues. DISCUSSION: There are differences between high-utilizing patients and nonhigh-utilizing patients suggestive of increased clinical severity and appropriate use of services while maintaining PCBH model integrity. The use of the population-based augmentation services is associated with high-utilizer status, and reflects the ability of these services to target those patients who most need the clinical care. (PsycINFO Database Record

Exploring Residents' Interactions With Electronic Health Records in Primary Care Encounters.

OBJECTIVES: Our objective was to explore and compare residents' interaction with electronic health records during primary care encounters and whether those behaviors differ by residency year level. METHODS: A field study was conducted in which 38 patient visits with 12 family medicine resident physicians were observed and video recorded in two primary care clinics under the umbrella of a university-based department of family medicine. Videos were then coded for gaze behaviors in which patients' and physicians' gazes at electronic health records and at each other were coded using a pre-established objective coding scheme. RESULTS: Third-year residents spent the greatest percentage of visit time looking at EHR screens when compared to first- and second-year residents. Third-year residents also spent significantly more time typing or inputting information into the records during the clinical visit when compared to first- and second-year residents. CONCLUSIONS: This study illustrated that patterns for using the EHR and interacting with patients may change over time for residents. These changes may be due to increased EHR proficiency or increased workload that incentivizes using the EHR to retrieve information and to complete charting in front of the patient.

Death pronouncements: using the teachable moment in end-of-life care residency training.

INTRODUCTION: Performing death pronouncement and communicating effectively with gathered family is an important skill relevant to end-of-life care. Often it is a responsibility of first-year residents who lack proper training or emotional preparation for the task. Residents' tension about this task presents an opportunity to positively effect their emotions and build skills for providing end of life care in the future. This paper describes a death pronouncement workshop including its objectives specific to Accreditation Council on Graduate Medical Education (ACGME) competencies, its format and its evolution over 8 years. METHODS: Multiple media and methods are used in the 90-minute workshop for first-year family practice residents including poetry, prose, and narratives on doing death pronouncements by senior residents; reviews and discussion of protocols for death pronouncement, autopsy, and organ donation; and a role-play of a death pronouncement with the opportunity for reflection. RESULTS: Residents consistently provide high ratings for the overall value of workshop. CONCLUSIONS: The death pronouncement workshop serves to prepare residents emotionally to deal with dying patients and provides them the skills to effectively and compassionately communicate with those patients' families while addressing all six ACGME core competencies.

You cannot wash off blood with blood: entering the mind through the body.

The old Zen saying, "You cannot wash off blood with blood," refers to the conviction that it is difficult to control thoughts with other thoughts. This saying implies that the way to control the mind is through the body. In Zen meditation (zazen), this is accomplished through the regulation of breathing and posture. The purpose of this article is to examine the relationship between breathing, posture and concentration in one tradition of Zen. I will explore how this relationship may be relevant to the practice of psychotherapy and the healing arts, as well as its implications for future research in these fields.