Depression complexity prevalence and outcomes among veterans affairs patients in integrated primary care.

INTRODUCTION: The Veterans Health Administration (VA) Primary Care-Mental Health Integration (PC-MHI) initiative targets depression (MDD), anxiety/posttraumatic stress disorder (PTSD) and alcohol misuse (AM) for care improvement. In primary care, case finding often relies on depression screening. Whereas clinical practice guidelines solely inform management of depression, minimal information exists to guide treatment when psychiatric symptom clusters coexist. We provide descriptive clinical information for care planners about VA PC patients with depression alone, depression plus alcohol misuse, and depression with complex psychiatric comorbidities (PTSD and/or probable bipolar disorder). METHOD: We examined data from a VA study that used a visit-based sampling procedure to screen 10,929 VA PC patients for depression; 761 patients with probable major depression completed baseline measures of health and care engagement. Follow-up assessments were completed at 7 months. RESULTS: At baseline, 53% of patients evidenced mental health conditions in addition to depression; 10% had concurrent AM, and 43% had psychiatrically complex depression (either with or without AM). Compared with patients with depression alone or depression with AM, those with psychiatrically complex depression evinced longer standing and more severe mood disturbance, higher likelihood of suicidal ideation, higher unemployment, and higher levels of polypharmacy. Baseline depression complexity predicted worse mental health status and functioning at follow-up. DISCUSSION: A substantial proportion of VA primary care patients with depression presented with high medical multimorbidity and elevated safety concerns. Psychiatrically complex depression predicted lower treatment effectiveness, suggesting that PC-MHI interventions should co-ordinate and individualize care for these patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Challenges in referral communication between VHA primary care and specialty care.

BACKGROUND: Poor communication between primary care providers (PCPs) and specialists is a significant problem and a detriment to effective care coordination. Inconsistency in the quality of primary-specialty communication persists even in environments with integrated delivery systems and electronic medical records (EMRs), such as the Veterans Health Administration (VHA). OBJECTIVE: The purpose of this study was to measure ease of communication and to characterize communication challenges perceived by PCPs and primary care personnel in the VHA, with a particular focus on challenges associated with referral communication. DESIGN: The study utilized a convergent mixed-methods design: online cross-sectional survey measuring PCP-reported ease of communication with specialists, and semi-structured interviews characterizing primary-specialty communication challenges. PARTICIPANTS: 191 VHA PCPs from one regional network were surveyed (54% response rate), and 41 VHA PCPs and primary care staff were interviewed. MAIN MEASURES/APPROACH: PCP-reported ease of communication mean score (survey) and recurring themes in participant descriptions of primary-specialty referral communication (interviews) were analyzed. KEY RESULTS: Among PCPs, ease-of-communication ratings were highest for women's health and mental health (mean score of 2.3 on a scale of 1-3 in both), and lowest for cardiothoracic surgery and neurology (mean scores of 1.3 and 1.6, respectively). Primary care personnel experienced challenges communicating with specialists via the EMR system, including difficulty in communicating special requests for appointments within a certain time frame and frequent rejection of referral requests due to rigid informational requirements. When faced with these challenges, PCPs reported using strategies such as telephone and e-mail contact with specialists with whom they had established relationships, as well as the use of an EMR-based referral innovation called "eConsults" as an alternative to a traditional referral. CONCLUSIONS: Primary-specialty communication is a continuing challenge that varies by specialty and may be associated with the likelihood of an established connection already in place between specialty and primary care. Improvement in EMR systems is needed, with more flexibility for the communication of special requests. Building relationships between PCPs and specialists may also facilitate referral communication.

Challenges facing primary care practices aiming to implement patient-centered medical homes.

BACKGROUND: While the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality. OBJECTIVE: Prior to the design and implementation of the Veterans Health Administration's (VA) national PCMH model--Patient Aligned Care Teams (PACT)--we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges. DESIGN AND PARTICIPANTS: A national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sample n = 229 sites). MAIN MEASURES: PC directors were asked to rate the degree to which they faced 48 management challenges in eight PCMH-related domains (access, preventive care, chronic diseases requiring care in PC, challenging medical conditions, mental health/substance abuse, special populations, PC coordination of care, and clinical informatics). Responses were dichotomized as moderately-to-extremely challenging versus somewhat-slightly-not at all challenging. Items were rank ordered; chi square or regression techniques were used to examine variations in facility size, type, urban/rural location, and region. KEY RESULTS: On average, VA PC directors reported 16 moderate-to-extreme challenges, and the top 20 challenges spanned all eight PCMH domains. Four of the top 20 challenges, including the top two challenges, were from the clinical informatics domain. Management of chronic non-malignant pain requiring opiate therapy was the third most reported challenge nationwide. Significant organizational and area level variations in reported challenges were found especially for care coordination. CONCLUSIONS: Better understanding of PC challenges ahead of PCMH implementation provides important context for strategic planning and redesign efforts. As a national healthcare system, the VA provides a unique opportunity to examine organizational and area determinants relevant to other PCMH models.

Prevalence and correlates of smoking status among veterans affairs primary care patients with probable major depressive disorder.

In an attempt to guide planning and optimize outcomes for population-specific smoking cessation efforts, the present study examined smoking prevalence and the demographic, clinical and psychosocial characteristics associated with smoking among a sample of Veterans Affairs primary care patients with probable major depression. Survey data were collected between 2003 and 2004 from 761 patients with probable major depression who attended one of 10 geographically dispersed VA primary care clinics. Current smoking prevalence was 39.8%. Relative to nonsmokers with probable major depression, bivariate comparisons revealed that current smokers had higher depression severity, drank more heavily, and were more likely to have comorbid PTSD. Smokers with probable major depression were also more likely than nonsmokers with probable major depression to have missed a health care appointment and to have missed medication doses in the previous 5months. Smokers were more amenable than non-smokers to depression treatment and diagnosis, and they reported more frequent visits to a mental health specialist and less social support. Alcohol abuse and low levels of social support were significant concurrent predictors of smoking status in controlled multivariable logistic regression. In conclusion, smoking prevalence was high among primary care patients with probable major depression, and these smokers reported a range of psychiatric and psychosocial characteristics with potential to complicate systems-level smoking cessation interventions.

Implementation and spread of interventions into the multilevel context of routine practice and policy: implications for the cancer care continuum.

The promise of widespread implementation of efficacious interventions across the cancer continuum into routine practice and policy has yet to be realized. Multilevel influences, such as communities and families surrounding patients or health-care policies and organizations surrounding provider teams, may determine whether effective interventions are successfully implemented. Greater recognition of the importance of these influences in advancing (or hindering) the impact of single-level interventions has motivated the design and testing of multilevel interventions designed to address them. However, implementing research evidence from single- or multilevel interventions into sustainable routine practice and policy presents substantive challenges. Furthermore, relatively few multilevel interventions have been conducted along the cancer care continuum, and fewer still have been implemented, disseminated, or sustained in practice. The purpose of this chapter is, therefore, to illustrate and examine the concepts underlying the implementation and spread of multilevel interventions into routine practice and policy. We accomplish this goal by using a series of cancer and noncancer examples that have been successfully implemented and, in some cases, spread widely. Key concepts across these examples include the importance of phased implementation, recognizing the need for pilot testing, explicit engagement of key stakeholders within and between each intervention level; visible and consistent leadership and organizational support, including financial and human resources; better understanding of the policy context, fiscal climate, and incentives underlying implementation; explication of handoffs from researchers to accountable individuals within and across levels; ample integration of multilevel theories guiding implementation and evaluation; and strategies for long-term monitoring and sustainability.

Yield of practice-based depression screening in VA primary care settings.

BACKGROUND: Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis. OBJECTIVE: We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression. DESIGN: Baseline enrollees in a group randomized trial of implementation of collaborative care for depression. PARTICIPANTS: Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states. MEASUREMENTS: PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions. RESULTS: Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months). CONCLUSIONS: Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.

Factors associated with clinician intention to address diverse aspects of pain in seriously ill outpatients.

BACKGROUND: Pain is a common, often undertreated problem among patients with palliative needs. OBJECTIVES: To evaluate clinician factors associated with intention to address diverse aspects of pain. DESIGN: Clinicians reviewed a clinical vignette describing a frail elderly patient with advanced hormone-refractory metastatic prostate cancer, depression, and pain not on analgesic therapy. Clinicians were surveyed about their intentions for treatment. PARTICIPANTS: All 280 primary care and specialist clinicians working in 19 hospital and community-based primary care, oncology, and cardiology clinics at eight geographically dispersed sites in two large VA hospital systems. MAIN MEASURES: Endpoints were clinician intention to deliver guideline-concordant care: prescribe opioids/antidepressants, assess existential wellbeing, and offer mental health referral. Demographic and behavioral measures were evaluated in association with endpoints. KEY RESULTS: Of 208 (74%) responding practitioners, 189 were responsible for prescribing decisions. Of those, 86, 77, 75, and 69 were "very"/"somewhat likely" to prescribe opioids, antidepressants, refer to a mental health specialist, or assess existential wellbeing, respectively. Factors associated with greater intent to prescribe an opioid or antidepressant included female gender, being an attending physician, being a primary care clinician, and greater confidence in pain management skills. Greater trust in the validity of pain ratings was associated with intent to prescribe an antidepressant and assess existential wellbeing. Prescribing opioids was less likely if perceived as an administrative burden. Assessing existential wellbeing was less likely if time constraints were perceived a barrier to evaluating pain. Female gender was the only factor associated with intent to refer to a mental health specialist. CONCLUSIONS: Our findings suggest useful targets for improving pain management include bolstering clinician confidence in pain management and their trust in pain ratings.

Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists.

BACKGROUND: Whether collaborative care models that enable interactive communication (timely, 2-way exchange of pertinent clinical information directly between primary care and specialist physicians) improve patient outcomes is uncertain. PURPOSE: To assess the effects of interactive communication between collaborating primary care physicians and key specialists on outcomes for patients receiving ambulatory care. DATA SOURCES: PubMed, PsycInfo, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Web of Science through June 2008 and secondary references, with no language restriction. STUDY SELECTION: Studies that evaluated the effects of interactive communication between collaborating primary care physicians and specialists on outcomes for patients with diabetes, psychiatric conditions, or cancer. DATA EXTRACTION: Contextual, intervention, and outcome data from 23 studies were extracted by one reviewer and checked by another. Study quality was assessed with a 13-item checklist. Disagreement was resolved by consensus. Main outcomes for analysis were selected by reviewers who were blinded to study results. DATA SYNTHESIS: Meta-analysis indicated consistent effects across 11 randomized mental health studies (pooled effect size, -0.41 [95% CI, -0.73 to -0.10]), 7 nonrandomized mental health studies (pooled effect size, -0.47 [CI, -0.84 to -0.09]), and 5 nonrandomized diabetes studies (pooled effect size, -0.64 [CI, -0.93 to -0.34]). These findings remained robust to sensitivity analyses. Meta-regression indicated studies that included interventions to enhance the quality of information exchange had larger effects on patient outcomes than those that did not (-0.84 vs. -0.27; P = 0.002). LIMITATIONS: Because collaborative interventions were inherently multifaceted, the efficacy of interactive communication by itself cannot be established. Inclusion of study designs with lower internal validity increased risk for bias. No studies involved oncologists. CONCLUSION: Consistent and clinically important effects suggest a potential role of interactive communication for improving the effectiveness of primary care-specialist collaboration. PRIMARY FUNDING SOURCE: RAND Health's Comprehensive Assessment of Reform Options Initiative, the Veterans Affairs Center for the Study of Provider Behavior, The Commonwealth Fund, and the Health Foundation.

Targeting primary care referrals to smoking cessation clinics does not improve quit rates: implementing evidence-based interventions into practice.

OBJECTIVE: To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice. DATA SOURCES/STUDY SETTING: We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states. STUDY DESIGN: In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care. DATA COLLECTION: To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns. PRINCIPAL FINDINGS: Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation. CONCLUSIONS: EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

Variations in practice guideline adherence for abnormal cervical cytology in a county healthcare system.

BACKGROUND: Reduction in cervical cancer incidence and mortality is not only dependant on promoting cervical cancer screening but also on providing appropriate follow-up and treatment of abnormal cervical cytology. OBJECTIVES: The objective of this study was to determine variations in guideline adherence for women requiring abnormal cervical cytology follow-up. SUBJECTS: Subjects of the study are women 18 years or older with an abnormal Pap test in 2000 within a large county healthcare system (n = 8,571). MEASUREMENTS: Guideline adherence was determined by the presence or absence of the appropriate follow-up procedure within an acceptable time interval for each degree of cytological abnormality. Patients with no follow-up studies were deemed to be lost to follow-up. RESULTS: Of study subjects, 18.5% were lost to follow-up care. Of the remaining 6,987 women, 60.3% received optimal care, 9.4% received suboptimal care, and 30.3% received poor care. Follow-up rates were higher for patients with higher degree of cytological abnormality (OR, 1.29, 95% CI, 1.17-1.42), older patients (OR, 1.03, 95% CI, 1.02-1.030) and those receiving the index Pap test at a larger healthcare facility (OR, 1.13; 95% CI, 1.01-1.27). Receiving optimal care was positively correlated with higher degree of cytological abnormality (p < .0001) and larger facility size (p = .002). Regional variations in care demonstrated the largest cluster having the lowest lost to follow-up rate and the most optimal care. CONCLUSIONS: A significant number of women with abnormal cervical cytology are receiving less than optimal care. Further studies are required to determine the specific healthcare delivery practices that need to be targeted to improve guideline adherence for follow-up of abnormal cytology.

Measuring the quality of colorectal cancer screening: the importance of follow-up.

PURPOSE: As evidence mounts for effectiveness, an increasing proportion of the United States population undergoes colorectal cancer screening. However, relatively little is known about rates of follow-up after abnormal results from initial screening tests. This study examines patterns of colorectal cancer screening and follow-up within the nation's largest integrated health care system: the Veterans Health Administration. METHODS: We obtained information about patients who received colorectal cancer screening in the Veterans Health Administration from an existing quality improvement program and from the Veterans Health Administration's electronic medical record. Linking these data, we analyzed receipt of screening and follow-up testing after a positive fecal occult blood test. RESULTS: A total of 39,870 patients met criteria for colorectal cancer screening; of these 61 percent were screened. Screening was more likely in patients aged 70 to 80 years than in those younger or older. Female gender (relative risk, 0.92; 95 percent confidence interval, 0.9-0.95), Black race (relative risk, 0.92; 95 percent confidence interval, 0.89-0.96), lower income, and infrequent primary care visits were associated with lower likelihood of screening. Of those patients with a positive fecal occult blood test (n = 313), 59 percent received a follow-up barium enema or colonoscopy. Patient-level factors did not predict receipt of a follow-up test. CONCLUSIONS: The Veterans Health Administration rates for colorectal cancer screening are significantly higher than the national average. However, 41 percent of patients with positive fecal occult blood tests failed to receive follow-up testing. Efforts to measure the quality of colorectal cancer screening programs should focus on the entire diagnostic process.

Assessing the institutional approach to implementing smoking cessation practice guidelines in veterans health administration facilities.

National smoking cessation guidelines include recommended strategies for providers and health care organizations, but they offer little guidance on how to structure care. We conducted a cross-sectional survey at 40 Veterans Health Administration facilities, to describe the structure of smoking cessation care, to assess adherence to national guidelines, and to assess facilities' preferred approach to providing smoking cessation treatment. We categorized sites as those using a primary care approach (most smokers treated by the primary care provider) versus a specialty approach (medication restricted to smoking cessation clinics, to which most patients were referred). Nearly all sites reported systematic screening for smoking and counseling of smokers, usually by both nursing staff members and the primary care provider. Most sites used a specialty approach, restricting medication access to smokers attending a cessation program. Future research should evaluate whether this approach provides adequate access and responsiveness to patient preferences for the full population of smokers in primary care.

Smokers' interest in quitting and services received: using practice information to plan quality improvement and policy for smoking cessation.

Given the prevalence of smoking, its impact, and the benefits of cessation, helping smokers quit should be a top priority for health care organizations. To restructure health care delivery and guide future policy, the authors used baseline survey data from an 18-site Veterans Health Administration group randomized trial to assess the level of interest in quitting smoking for a practice population and determine what smoking cessation services they reported receiving. Among 1941 current smokers, 55% did not intend to quit in the next 6 months, and the remainder intended to quit in the next month (13%) to 6 months (32%). Forty-five percent reported a quit attempt in the prior year. While nearly two thirds of smokers reported being counseled about cessation within the past year, only 29% were referred to a cessation program, and 25% received a prescription for nicotine patches. Tobacco control efforts within this population should focus on increasing the rate of assisting patients with quitting.

Geographic variation across veterans affairs medical centers in the treatment of early stage prostate cancer.

PURPOSE: We investigated geographic variation in the treatment of early stage prostate cancer in a national sample of veterans after widespread adoption of the prostate specific antigen test. MATERIALS AND METHODS: Our sample consisted of 16,352 cases from the Veterans Affairs Central Cancer Registry that were diagnosed between January 1997 and December 1999 with stage I or II prostate cancer. We used a 2-stage nested logit model to compare surgery, radiation therapy and noncurative treatment among 4 geographic regions of the United States. RESULTS: Multivariate analysis showed that patients in the West (referent group) had a higher OR of undergoing surgery than radiation compared with the Northeast, South or Midwest (OR 0.77, 95% CI 0.67 to 0.87, OR 0.86, 95% CI 0.76 to 0.98 and OR 0.75, 95% CI 0.64 to 0.87, respectively. Black men, men with lower grade and higher stage tumors, and unmarried men were less likely to undergo curative treatment and less likely to undergo surgery than radiation. CONCLUSIONS: Geographic variation persists in patterns of care in men with early stage prostate cancer. However, this variation is limited to the choice between surgery and radiation rather than to the choice between curative and noncurative treatment.

Lipid screening in HIV-infected veterans.

BACKGROUND: Lipid screening is recommended for patients taking protease inhibitors (PIs). METHODS: We examined data from the Veterans Administration Immunology Case Registry to assess lipid screening among HIV-infected veterans who received PIs for at least 6 consecutive months during 1999 and 2001. We estimated crude and adjusted associations between lipid screening and patient characteristics (age, gender, HIV exposure, and race/ethnicity), comorbidities (AIDS, cardiovascular disease, diabetes, hypertension, smoking, and hyperlipidemia), and facility characteristics (urban location, case management, guidelines, and quality improvement programs). RESULTS: Among 4065 patients on PIs, clinicians screened 2395 (59%) for lipids within 6 months of initiating treatment. Adjusting for patient characteristics, comorbidities, facility traits, and clustering, lipid screening was more common among patients who were cared for in urban areas (relative risk [RR] = 1.3, confidence limits: 1.0-1.5), diabetic (RR = 1.2, confidence limits: 1.1-1.3), or previously hyperlipidemic (RR = 1.4, confidence limits: 1.3-1.5) and less common among patients with a history of intravenous drug use (IVDU) (RR = 0.90, confidence limits: 0.79-1.0) or unknown HIV risk (RR = 0.85, confidence limits: 0.75-0.95). CONCLUSIONS: Six in 10 patients taking PIs receive lipid screening within 6 months of PI use. Systemic interventions to improve overall HIV quality of care should also address lipid screening, particularly among patients with unknown or IVDU HIV risk and those cared for in nonurban areas.

Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial.

BACKGROUND: Quality improvement (QI) programs for depressed primary care patients can improve health outcomes for 6 to 28 months; effects for longer than 28 months are unknown. OBJECTIVE: To assess how QI for depression affects health outcomes, quality of care, and health outcome disparities at 57-month follow-up. DESIGN: A group-level randomized controlled trial. SETTING: Forty-six primary care practices in 6 managed care organizations. PATIENTS: Of 1356 primary care patients who screened positive for depression and enrolled in the trial, 991 (73%, including 451 Latinos and African Americans) completed 57-month telephone follow-up. INTERVENTIONS: Clinics were randomly assigned to usual care or to 1 of 2 QI programs supporting QI teams, provider training, nurse assessment, and patient education, plus resources to support medication management (QI-meds) or psychotherapy (QI-therapy) for 6 to 12 months. MAIN OUTCOME MEASURES: Probable depressive disorder in the previous 6 months, mental health-related quality of life in the previous 30 days, primary care or mental health specialty visits, counseling or antidepressant medications in the previous 6 months, and unmet need, defined as depressed but not receiving appropriate care. RESULTS: Combined QI-meds and QI-therapy, relative to usual care, reduced the percentage of participants with probable disorder at 5 years by 6.6 percentage points (P =.04). QI-therapy improved health outcomes and reduced unmet need for appropriate care among Latinos and African Americans combined but provided few long-term benefits among whites, reducing outcome disparities related to usual care (P =.04 for QI-ethnicity interaction for probable depressive disorder). CONCLUSIONS: Programs for QI for depressed primary care patients implemented by managed care practices can improve health outcomes 5 years after implementation and reduce health outcome disparities by markedly improving health outcomes and unmet need for appropriate care among Latinos and African Americans relative to whites; thus, equity was improved in the long run.

What patient population does visit-based sampling in primary care settings represent?

BACKGROUND: Evaluations of outpatient interventions often rely on consecutive sampling of clinic visitors, and assume that study results generalize to the population of patients cared for. OBJECTIVE: The representativeness of such visit-based sampling compared with the population of patients seen during the same year, in terms of sociodemographic and clinical characteristics of the user groups that visit-based sampling yielded were assessed. METHODS: One thousand five hundred forty-six continuing patients visiting the primary care firms in an urban VA medical center were consecutively sampled, and visit frequencies were compared for these patients with subsets of the patient population. Administrative and survey data was then used to describe the types of patients visit-based sampling most represented compared with the types of patients sampled less frequently. RESULTS: The average sampled patient visited the firms significantly more often than patients in the reference population (18.7 vs. 9.5). Sampled patients were significantly older (>55 years), in poorer health (higher prevalence of cancer, stroke, hypertension), less likely to smoke, and more likely to be single than the average patient visiting the firms (P<0.05). Adjusting for age and sickness, frequent visitors were more apt to have experienced continuity of care during the prior year, to prefer VA care, and to be unemployed. CONCLUSIONS: Consecutive visit-based sampling actually selected patients with a visit pattern more typical of the patient population visiting four or more times a year. Studies using sampling of consecutive visitors will typically under-represent low users of care and should account for the degree to which results may not generalize to the broader practice population.

Interventions that increase use of adult immunization and cancer screening services: a meta-analysis.

PURPOSE: The relative effectiveness of the diverse approaches used to promote preventive care activities, such as cancer screening and adult immunization, is unknown. Despite many high-quality published studies, practices and policymakers attempting to improve preventive care have little definitive information on which to base decisions. Thus, we quantitatively assessed the relative effectiveness of previously studied approaches for improving adherence to adult immunization and cancer screening guidelines. DATA SOURCES: MEDLINE, the Cochrane Effective Practice and Organization of Care Review Group register, previous systematic reviews, and the Medicare Health Care Quality Improvement Project database. STUDY SELECTION: Controlled clinical trials that assessed interventions to increase use of immunizations for influenza and pneumococcal pneumonia and screening for colon, breast, and cervical cancer in adults. DATA EXTRACTION: Two reviewers independently extracted data on characteristics and outcomes from unmasked articles. Intervention components to increase use of services were classified as reminder, feedback, education, financial incentive, legislative action, organizational change, or mass media campaign. DATA SYNTHESIS: Of 552 abstracts and articles, 108 met the inclusion criteria. To assess the effect of intervention components, meta-regression models were developed for immunizations and each cancer screening service by using 81 studies with a usual care or control group. The most potent intervention types involved organizational change (the adjusted odds ratios for increased use of services from organizational change ranged from 2.47 to 17.6). Organizational change interventions included the use of separate clinics devoted to prevention, use of a planned care visit for prevention, or designation of nonphysician staff to do specific prevention activities. The next most effective intervention components were patient financial incentives (adjusted odds ratios, 1.82 to 3.42) and patient reminders (adjusted odds ratios, 1.74 to 2.75); the adjusted odds ratios ranged from 1.29 to 1.53 for patient education and from 1.10 to 1.76 for feedback. CONCLUSIONS: Rates of adult immunization and cancer screening are most likely to improve when a health care organization supports performance of these activities through organizational changes in staffing and clinical procedures. Involving patients in self-management through patient financial incentives and reminders is also likely to positively affect performance.