Selecting trial centers using a standardized, automated site assessment survey instrument (SASI).

BACKGROUND: To improve the site selection process for clinical trials, we expanded a site survey to include standardized assessments of site commitment time, team experience, feasibility of tight timelines, and local medical community equipoise as factors that might better predict performance. We also collected contact information about institutional research services ahead of site onboarding. AIM: As a first step, we wanted to confirm that an expanded survey could be feasible and generalizable-that asking site teams for more details upfront was acceptable and that the survey could be completed in a reasonable amount of time, despite the assessment length. METHODS: A standardized, two-part Site Assessment Survey Instrument (SASI), examining qualitative components and with multiple contact list sections, was developed using a publicly accessible dashboard and later transferred to a REDCap platform. After multiple rounds of internal testing, the SASI was deployed 11 times for multicenter trials. Follow-up questionnaires were sent to site teams to confirm that an expanded survey instrument is acceptable to the research community and could be completed during a brief work shift. RESULTS: Respondents thought the SASI collected useful and relevant information about their sites (100%). Sites were "comfortable" (90%) supplying detailed information early in the site selection process and 57% completed the SASI in one to two hours. CONCLUSIONS: Coordinating centers and sites found the SASI tool to be acceptable and helpful when collecting data in consideration of multicenter trial site selection.

Association of sex, age and education level with patient reported outcomes in atrial fibrillation.

BACKGROUND: In atrial fibrillation (AF), there are known sex and sociodemographic disparities in clinical outcomes such as stroke. We investigate whether disparities also exist with respect to patient-reported outcomes. We explored the association of sex, age, and education level with patient-reported outcomes (AF-related quality of life, symptom severity, and emotional and functional status). METHODS: The PaTH AF cohort study recruited participants (N = 953) with an AF diagnosis and age ≥ 18 years across 4 academic medical centers. We performed longitudinal multiple regression with random effects to determine if individual characteristics were associated with patient-reported outcomes. RESULTS: Women reported poorer functional status (ß - 2.23, 95% CI: -3.52, - 0.94) and AF-related quality of life (ß - 4.12, 95% CI: -8.10, - 0.14), and higher symptoms of anxiety (ß 2.08, 95% CI: 0.76, 3.40), depression (ß 1.44, 95% CI: 0.25, 2.63), and AF (ß 0.29, 95% CI: 0.08, 0.50). Individuals < 60 years were significantly (p < 0.05) more likely to report higher symptoms of depression, anxiety, and AF, and poorer AF-related quality of life. Lack of college education was associated with reporting higher symptoms of AF (ß 0.42, 95% CI: 0.17, 0.68), anxiety (ß 1.86, 95% CI: 0.26, 3.45), and depression (ß 1.11, 95% CI: 0.15, 2.38), and lower AF-related quality of life (ß - 4.41, 95% CI: -8.25, - 0.57) and functional status. CONCLUSION: Women, younger adults, and individuals with lower levels of education reported comparatively poor patient-reported outcomes. These findings highlight the importance of understanding why individuals experience AF differently based on certain characteristics.

First, Do No Harm: Referring Primary Care Patients with Depression to an Internet Support Group.

BACKGROUND: Internet Support Groups (ISGs) offer people easy access to information regarding depression as well as support from others who are either currently suffering from depression or have previously suffered from depression. The safety and efficacy of ISGs for people with depression have not been thoroughly studied. INTRODUCTION: The safety and helpfulness of a depression ISG were assessed by analyzing pre- and postintervention depressive symptoms, other psychological outcomes, and participant ratings of helpfulness. MATERIALS AND METHODS: Participants were recruited through self-referral from six primary care offices. Participants were given access to a depression ISG and participated in an ISG for 6 weeks. RESULTS: Thirty-four (n = 34) participants enrolled in the study (mean age = 32.53, standard deviation [SD] = 16.10). Depressive symptoms approached significance for decreasing over time and self-efficacy increased over time. No self-harm occurred over the course of the study, but two participants developed self-harm ideation. Ratings of ISG helpfulness were mixed. DISCUSSION: Primary care patients participating in depression ISGs reported few adverse experiences directly related to the ISG. Depressive symptoms and self-efficacy have beneficial findings while ratings of helpfulness were mixed. CONCLUSIONS: Primary care patients can benefit from the use of an ISG. This could be particularly pertinent to people in rural settings where mental health resources are not as available. An ISG offers a low-cost and easily accessible resource for primary care patients with depression.

Patient, Provider, and System Factors Contributing to Patient Safety Events During Medical and Surgical Hospitalizations for Persons With Serious Mental Illness.

This study aimed to explore patient-, provider-, and system-level factors that may contribute to elevated risk of patient safety events among persons with serious mental illness (SMI). We conducted a medical record review of medical/surgical admissions in Maryland hospitals from 1994 to 2004 for a community-based sample of adults with SMI (N = 790 hospitalizations). We estimated the prevalence of multiple patient, provider, and system factors that could influence patient safety among persons with SMI. We conducted a case crossover analysis to examine the relationship between these factors and adverse patient safety events. Patients' mental status, level of consciousness, disease severity, and providers' lack of patient monitoring, delay/failure to seek consultation, lack of trainee supervision, and delays in care were positively associated with adverse patient safety events (p < 0.05). Efforts to reduce SMI-related patient safety risks will need to be multifaceted and address both patient- and provider-level factors.

Patient Safety Events and Harms During Medical and Surgical Hospitalizations for Persons With Serious Mental Illness.

OBJECTIVE: This study explored the risk of patient safety events and associated nonfatal physical harms and mortality in a cohort of persons with serious mental illness. This group experiences high rates of medical comorbidity and premature mortality and may be at high risk of adverse patient safety events. METHODS: Medical record review was conducted for medical-surgical hospitalizations occurring during 1994-2004 in a community-based cohort of Maryland adults with serious mental illness. Individuals were eligible if they died within 30 days of a medical-surgical hospitalization and if they also had at least one prior medical-surgical hospitalization within five years of death. All admissions took place at Maryland general hospitals. A case-crossover analysis examined the relationships among patient safety events, physical harms, and elevated likelihood of death within 30 days of hospitalization. RESULTS: A total of 790 hospitalizations among 253 adults were reviewed. The mean number of patient safety events per hospitalization was 5.8, and the rate of physical harms was 142 per 100 hospitalizations. The odds of physical harm were elevated in hospitalizations in which 22 of the 34 patient safety events occurred (p<.05), including medical events (odds ratio [OR]=1.5, 95% confidence interval [CI]=1.3-1.7) and procedure-related events (OR=1.6, CI=1.2-2.0). Adjusted odds of death within 30 days of hospitalization were elevated for individuals with any patient safety event, compared with those with no event (OR=3.7, CI=1.4-10.3). CONCLUSIONS: Patient safety events were positively associated with physical harm and 30-day mortality in nonpsychiatric hospitalizations for persons with serious mental illness.

Evaluating the QUIT-PRIMO clinical practice ePortal to increase smoker engagement with online cessation interventions: a national hybrid type 2 implementation study.

BACKGROUND: Effective web-assisted tobacco interventions (WATIs) have been underutilized by smokers; moreover, despite practice guideline recommendations, clinical teams do not routinely refer smokers to WATIs. Our goal was to test a clinical practice innovation, an ePortal designed to change practice and patient behavior. Our hypotheses were that the integrated system would result in increased smoker referrals, with an automated follow-up system resulting in more smoker registrations and finally augmentations of the WATI would result in more smokers quitting at 6 months. METHODS: Practice ePortal Implementation Trial: Practices (n = 174) were randomized to an online practice ePortal with an "e-referral tool" to the WATI (e-referred smokers received automated email reminders from the practice) and with practice feedback reports with patient tracking and practice-to-patient secure messaging versus comparison (a paper "referral prescription"). Implementation success was measured by the number of smokers referred and smokers registering. Clinical Effectiveness Trial: To estimate the effectiveness of the WATI components on 6-month smoking cessation, registered smokers were randomized into three groups: a state-of-the-art tailored WATI control [control], the WATI enhanced with proactive, pushed tailored email motivational messaging (messaging), and the WATI with messaging further enhanced with personal secure messaging with a tobacco treatment specialist and an online support group (personalized). RESULTS: Practice ePortal Trial results: A total of 4789 smokers were referred. The mean smokers referred per practice was not statistically different by group (ePortal 24.89 (SD 22.29) versus comparison 30.15 (SD 25.45), p = 0.15). The e-referral portal implementation program resulted in nearly triple the rate of smoker registration (31 % of all smokers referred registered online) versus comparison (11 %, p < 0.001). Clinical Effectiveness Trial results: Active smokers randomized to the personalized group had a 6-month cessation rate of 25.2 %, compared with the messaging group (26.7 %) and the control (17 %). Next, when using an inverse probability weighted selection model to account for attrition, those randomized to the two groups that received motivational messaging (messaging or personalized) were more likely to quit than those in the control (p = 0.04). CONCLUSIONS: Among all smokers referred, the e-referral resulted in nearly threefold greater registrants (31 %) than paper (11 %). The practice ePortal smokers received multiple reminders (increasing registration opportunities), and the practices could track patient progress. The result was more smokers registering and, thus, more cessation opportunities. Combining the proactive referral and the WATI resulted in higher rates of smoking cessation. TRIAL REGISTRATION: Web-delivered Provider Intervention for Tobacco Control (QUIT-PRIMO) - a randomized controlled trial: NCT00797628 .

Schizophrenia and potentially preventable hospitalizations in the United States: a retrospective cross-sectional study.

BACKGROUND: Persons with schizophrenia may face barriers to high quality primary care due to communication difficulties, cognitive impairment, lack of social support, and fragmentation of healthcare delivery services. As a result, this group may be at high risk for ambulatory care sensitive (ACS) hospitalizations, defined as hospitalizations potentially preventable by timely primary care. The goal of this study was to determine if schizophrenia is associated with overall, acute, and chronic ACS hospitalizations in the United States (US). METHODS: We conducted a retrospective cross-sectional study. Hospitalization data for the US were obtained from the Nationwide Inpatient Sample for years 2003-2008. We examined 15,275,337 medical and surgical discharges for adults aged 18-64, 182,423 of which had a secondary diagnosis of schizophrenia. ACS hospitalizations were measured using the Agency for Healthcare Research and Quality's Prevention Quality Indicators (PQIs). We developed logistic regression models to obtain nationally-weighted odds ratios (OR) for ACS hospitalizations, comparing those with and without a secondary diagnosis of schizophrenia after adjusting for patient, hospitalization, and hospital characteristics. RESULTS: Schizophrenia was associated with increased odds of hospitalization for acute ACS conditions (OR = 1.34; 95% CI: 1.31, 1.38), as well as for chronic ACS conditions characterized by short-term exacerbations. Schizophrenia was associated with decreased odds of hospitalization for diabetes mellitus long-term complications and diabetes-related lower extremity amputation, conditions characterized by long-term deterioration. CONCLUSIONS: Additional research is needed to determine which individual and health systems factors contribute to the increased odds of hospitalization for acute PQIs in schizophrenia.

Comparative effectiveness of standard versus patient-centered collaborative care interventions for depression among African Americans in primary care settings: the BRIDGE Study.

OBJECTIVE: To compare the effectiveness of standard and patient-centered, culturally tailored collaborative care (CC) interventions for African American patients with major depressive disorder (MDD) over 12 months of follow-up. DATA SOURCES/STUDY SETTING: Twenty-seven primary care clinicians and 132 African American patients with MDD in urban community-based practices in Maryland and Delaware. STUDY DESIGN: Cluster randomized trial with patient-level, intent-to-treat analyses. DATA COLLECTION/EXTRACTION METHODS: Patients completed screener and baseline, 6-, 12-, and 18-month interviews to assess depression severity, mental health functioning, health service utilization, and patient ratings of care. PRINCIPAL FINDINGS: Patients in both interventions showed statistically significant improvements over 12 months. Compared with standard, patient-centered CC patients had similar reductions in depression symptom levels (-2.41 points; 95 percent confidence interval (CI), -7.7, 2.9), improvement in mental health functioning scores (+3.0 points; 95 percent CI, -2.2, 8.3), and odds of rating their clinician as participatory (OR, 1.48, 95 percent CI, 0.53, 4.17). Treatment rates increased among standard (OR = 1.8, 95 percent CI 1.0, 3.2), but not patient-centered (OR = 1.0, 95 percent CI 0.6, 1.8) CC patients. However, patient-centered CC patients rated their care manager as more helpful at identifying their concerns (OR, 3.00; 95 percent CI, 1.23, 7.30) and helping them adhere to treatment (OR, 2.60; 95 percent CI, 1.11, 6.08). CONCLUSIONS: Patient-centered and standard CC approaches to depression care showed similar improvements in clinical outcomes for African Americans with depression; standard CC resulted in higher rates of treatment, and patient-centered CC resulted in better ratings of care.

Improving care for depression: performance measures, outcomes and insights from the Health Disparities Collaboratives.

This paper reports 10 measures, outcomes, and insights from HRSA Depression Health Disparities Collaboratives, representing attempts to accelerate evidence-based guidelines into practice. The authors analyze interviews with leadership of high-performing centers. Monthly data was submitted on 38,000 patients from 94 centers. Regression analyses were conducted to identify process measures predictive of better outcomes. Results indicated that these 10 measures of care were effective in guiding and quantifying improved outcomes. One measure, early and sustained response (ESR), proved particularly useful as it reflects long term outcomes. Regression analyses identified one process measure (Patient Health Questionnaire Reassessment) strongly associated with improved clinical outcomes (n=37, R2=44%). Interviews identified 18 process changes deemed pivotal for meaningful change. In sum, well-designed approaches utilizing proven improvement methodologies resulted in substantial enhancements in depression care. This approach and these measures, especially ESR and PHQ Reassessment, may improve depression care in other under-served settings.

Post-myocardial-infarction quality of care among disabled Medicaid beneficiaries with and without serious mental illness.

OBJECTIVE: The objective was to examine the association between serious mental illness and quality of care for myocardial infarction among disabled Maryland Medicaid beneficiaries. METHODS: We conducted a retrospective cohort study of disabled Maryland Medicaid beneficiaries with myocardial infarction from 1994 to 2004. Cardiac procedures and guideline-based medication use were compared for persons with and without serious mental illness. RESULTS: Of the 633 cohort members with myocardial infarction, 137 had serious mental illness. Serious mental illness was not associated with differences in receipt of cardiac procedures or guideline-based medications. Overall use of guideline-based medications was low; 30 days after the index hospitalization for myocardial infarction, 19%, 35% and 11% of cohort members with serious mental illness and 22%, 37% and 13% of cohort members without serious mental illness had any use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers and statins, respectively. Study participants with and without serious mental illness had similar rates of mortality. Overall, use of beta-blockers [hazard ratio 0.93, 95% confidence interval (CI) 0.90-0.97] and statins (hazard ratio 0.93, 95% CI 0.89-0.98) was associated with reduced risk of mortality. CONCLUSIONS: Quality improvement programs should consider how to increase adherence to medications of known benefit among disabled Medicaid beneficiaries with and without serious mental illness.

A novel evaluation of World No Tobacco day in Latin America.

BACKGROUND: World No Tobacco Day (WNTD), commemorated annually on May 31, aims to inform the public about tobacco harms. Because tobacco control surveillance is usually annualized, the effectiveness of WNTD remains unexplored into its 25th year. OBJECTIVE: To explore the potential of digital surveillance (infoveillance) to evaluate the impacts of WNTD on population awareness of and interest in cessation. METHODS: Health-related news stories and Internet search queries were aggregated to form a continuous and real-time data stream. We monitored daily news coverage of and Internet search queries for cessation in seven Latin American nations from 2006 to 2011. RESULTS: Cessation news coverage peaked around WNTD, typically increasing 71% (95% confidence interval [CI] 61-81), ranging from 61% in Mexico to 83% in Venezuela. Queries indicative of cessation interest peaked on WNTD, increasing 40% (95% CI 32-48), ranging from 24% in Colombia to 84% in Venezuela. A doubling in cessation news coverage was associated with approximately a 50% increase in cessation queries. To gain a practical perspective, we compared WNTD-related activity with New Year's Day and several cigarette excise tax increases in Mexico. Cessation queries around WNTD were typically greater than New Year's Day and approximated a 2.8% (95% CI -0.8 to 6.3) increase in cigarette excise taxes. CONCLUSIONS: This novel evaluation suggests WNTD had a significant impact on popular awareness (media trends) and individual interest (query trends) in smoking cessation. Because WNTD is constantly evolving, our work is also a model for real-time surveillance and potential improvement in WNTD and similar initiatives.

Needs of women with breast cancer as communicated to physicians on the Internet.

PURPOSE: With improved access to health information via the Internet, an increasing number of women with breast cancer are using this venue to obtain information about their illness and treatment from physicians. This study aims to identify the needs of women with breast cancer who communicate with physicians on the Internet. METHODS: From a total of 4,424 requests posted by Korean women with breast cancer to a physician run Internet Q&A board during 2003 to 2007, we sampled 1,355 representative requests according to different type of online user identification and analyzed these using a qualitative content analytic approach to identify the nature of the requests. RESULTS: The vast majority of women (93.5%) used the online Q&A board to seek informational support from physicians. They requested information across a broad range of topics, including treatment (38.4% of requests), physical condition (31.7%), and lifestyle/self-care (24%).Women at different disease stages made requests indifferent informational domains. Few (<5%) postings were direct requests for emotional support, but emotional requests were often embedded within informational requests. Over 63% of requests expressed concern and worry, and about 75% of the requests included at least one emotional expression. There was no difference by type of online user identification with respect to the subject and purpose of the requests. CONCLUSIONS: Korean women with breast cancer expressed diverse needs related to their physical and psychological conditions in their online requests to physicians via a Q&A board. While future research should establish and evaluate the role of internet communications for cancer management,we conclude that an online Q&A board can be a valuable tool in assisting breast cancer patients in managing their physical and psychosocial needs as well as communicating these needs to physicians.

Health insurance coverage among persons with schizophrenia in the United States.

OBJECTIVE: This study estimated the rates of health insurance coverage in the U.S. civilian noninstitutionalized population with schizophrenia and assessed whether basic access to health care varied across health insurance categories. METHODS: Data from the Medical Expenditures Panel Survey collected between 2002 and 2006 were used. RESULTS: The sample contained 328 records representing 493,006 noninstitutionalized civilian persons with schizophrenia. Eighty-seven percent had Medicaid or Medicare, 8% received care through the Veterans Health Administration, and 15% had private insurance for at least one day during the year. About 7% were uninsured all of the year. The uninsured tended to be male (92%), nonwhite (54%), and unmarried (97%), and 30% of the uninsured had not had a medical checkup in more than five years. CONCLUSIONS: Almost all U.S. adults with schizophrenia were found to receive government health insurance, yet a measurable minority remained uninsured. These national estimates highlight opportunities for improving health service delivery for this vulnerable population.

Quality of care for heart failure among disabled Medicaid recipients with and without severe mental illness.

OBJECTIVE: To examine the association between severe mental illness (SMI) and quality of care in heart failure. METHODS: We conducted a cohort study between 2001 and 2004 of disabled Maryland Medicaid participants with heart failure. Quality measures and clinical outcomes were compared for individuals with and without SMI. RESULTS: Of 1801 individuals identified with heart failure, 341 had comorbid SMI. SMI was not associated with differences in quality measures, including left ventricular assessment [adjusted relative risk (aRR) 0.99; 95% CI 0.91-1.07], utilization of angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) (aRR 1.04; 95% CI 0.92-1.17), or beta-blocker use (aRR 1.13; 95% CI 0.99-1.29). During the study period, 52.2% of individuals in the cohort filled a prescription for an ACE inhibitor or ARB and 45.5% filled a beta-blocker prescription. Individuals with and without SMI had similar rates of clinical outcomes, including hospitalizations, readmissions, and mortality. Both medication interventions were associated with improved mortality. CONCLUSIONS: In this sample of disabled Medicaid recipients with heart failure, persons with SMI received similar quality of care as those without SMI. Both groups had low rates of beneficial medical treatments. Quality improvement programs should consider how best to target these vulnerable populations.

A cluster randomized trial of standard quality improvement versus patient-centered interventions to enhance depression care for African Americans in the primary care setting: study protocol NCT00243425.

BACKGROUND: Several studies document disparities in access to care and quality of care for depression for African Americans. Research suggests that patient attitudes and clinician communication behaviors may contribute to these disparities. Evidence links patient-centered care to improvements in mental health outcomes; therefore, quality improvement interventions that enhance this dimension of care are promising strategies to improve treatment and outcomes of depression among African Americans. This paper describes the design of the BRIDGE (Blacks Receiving Interventions for Depression and Gaining Empowerment) Study. The goal of the study is to compare the effectiveness of two interventions for African-American patients with depression--a standard quality improvement program and a patient-centered quality improvement program. The main hypothesis is that patients in the patient-centered group will have a greater reduction in their depression symptoms, higher rates of depression remission, and greater improvements in mental health functioning at six, twelve, and eighteen months than patients in the standard group. The study also examines patient ratings of care and receipt of guideline-concordant treatment for depression. METHODS/DESIGN: A total of 36 primary care clinicians and 132 of their African-American patients with major depressive disorder were recruited into a cluster randomized trial. The study uses intent-to-treat analyses to compare the effectiveness of standard quality improvement interventions (academic detailing about depression guidelines for clinicians and disease-oriented care management for their patients) and patient-centered quality improvement interventions (communication skills training to enhance participatory decision-making for clinicians and care management focused on explanatory models, socio-cultural barriers, and treatment preferences for their patients) for improving outcomes over 12 months of follow-up. DISCUSSION: The BRIDGE Study includes clinicians and African-American patients in under-resourced community-based practices who have not been well-represented in clinical trials to improve depression care. The patient-centered and culturally targeted approach to depression care is a relatively new one that has not been tested in most previous studies. The study will provide evidence about whether patient-centered accommodations improve quality of care and outcomes to a greater extent than standard quality improvement strategies for African Americans with depression. TRIAL REGISTRATION: ClinicalTrials.gov NCT00243425.

Testing for statistical discrimination by race/ethnicity in panel data for depression treatment in primary care.

OBJECTIVE: To test for discrimination by race/ethnicity arising from clinical uncertainty in treatment for depression, also known as "statistical discrimination." DATA SOURCES: We used survey data from 1,321 African-American, Hispanic, and white adults identified with depression in primary care. Surveys were administered every six months for two years in the Quality Improvement for Depression (QID) studies. STUDY DESIGN: To examine whether and how change in depression severity affects change in treatment intensity by race/ethnicity, we used multivariate cross-sectional and change models that difference out unobserved time-invariant patient characteristics potentially correlated with race/ethnicity. DATA COLLECTION/EXTRACTION METHODS: Treatment intensity was operationalized as expenditures on drugs, primary care, and specialty services, weighted by national prices from the Medical Expenditure Panel Survey. Patient race/ethnicity was collected at baseline by self-report. PRINCIPAL FINDINGS: Change in depression severity is less associated with change in treatment intensity in minority patients than in whites, consistent with the hypothesis of statistical discrimination. The differential effect by racial/ethnic group was accounted for by use of mental health specialists. CONCLUSIONS: Enhanced physician-patient communication and use of standardized depression instruments may reduce statistical discrimination arising from clinical uncertainty and be useful in reducing racial/ethnic inequities in depression treatment.

Patient-physician communication in the primary care visits of African Americans and whites with depression.

BACKGROUND: Little research investigates the role of patient-physician communication in understanding racial disparities in depression treatment. OBJECTIVE: The objective of this study was to compare patient-physician communication patterns for African-American and white patients who have high levels of depressive symptoms. DESIGN, SETTING, AND PARTICIPANTS: This is a cross-sectional study of primary care visits of 108 adult patients (46 white, 62 African American) who had depressive symptoms measured by the Medical Outcomes Study-Short Form (SF-12) Mental Component Summary Score and were receiving care from one of 54 physicians in urban community-based practices. MAIN OUTCOMES: Communication behaviors, obtained from coding of audiotapes, and physician perceptions of patients' physical and emotional health status and stress levels were measured by post-visit surveys. RESULTS: African-American patients had fewer years of education and reported poorer physical health than whites. There were no racial differences in the level of depressive symptoms. Depression communication occurred in only 34% of visits. The average number of depression-related statements was much lower in the visits of African-American than white patients (10.8 vs. 38.4 statements, p = .02). African-American patients also experienced visits with less rapport building (20.7 vs. 29.7 statements, p = .009). Physicians rated a higher percentage of African-American than white patients as being in poor or fair physical health (69% vs. 40%, p = .006), and even in visits where depression communication occurred, a lower percentage of African-American than white patients were considered by their physicians to have significant emotional distress (67% vs. 93%, p = .07). CONCLUSIONS: This study reveals racial disparities in communication among primary care patients with high levels of depressive symptoms. Physician communication skills training programs that emphasize recognition and rapport building may help reduce racial disparities in depression care.