Do physicians communicate the adverse effects of medications that older patients want to hear?

BACKGROUND AND OBJECTIVES: Physicians routinely discuss adverse effects of medications, but whether discussions match older patients' desire for information is unexplored. This study compares patient preferences for adverse effect discussions with reported physician practice. METHODS: Cross-sectional survey of a convenience sample of 100 practicing primary care physicians from 9 medical groups and 178 patients recruited from 11 senior centers in the Los Angeles metropolitan area. Physicians listed the adverse effects they typically discuss when prescribing an ACE inhibitor. Patients were given a hypothetical scenario about a new medication prescription, and were asked to circle the three adverse effects they most wanted to hear about from a list. RESULTS: More than 90 % of patients wanted a physician to discuss medication adverse effects: they wanted information about both dangerous (75 % of patients) and common (66 % of patients) adverse effects. However, patients most commonly chose to hear about adverse effects occurring for < 1 % of patients and selected a wide range of adverse effects for discussion. Physicians reported most frequently educating patients about more common and life-threatening adverse effects. Patients who wanted to discuss more adverse effects were more worried about adverse effects than those wishing to hear fewer (4.0 vs. 3.4 on a 5-point Likert scale; p = 0.02). CONCLUSIONS: For the studied medication, there was little concordance between the medication adverse effects physicians say they discuss and what patients want to hear. Physicians cannot practically verbally satisfy patients' information desires about the adverse effects of new medications during time-compressed office visits. Innovative solutions are needed.

Avoidance of Total Knee Replacement in a Population Health Setting: Introducing a Noninvasive Biomechanical Intervention for Patients with Knee Osteoarthritis.

The observed increase in osteoarthritis (OA) of the knee as a result of an aging population and the obesity epidemic has led to a concomitant increase in the rates of total knee replacement (TKR), placing an additional financial and social burden on the ability of health care systems to control medical costs. Our study shows how a home-based, noninvasive biomechanical intervention reduced the rate of progression to surgery for a cohort of 237 patients with knee OA deemed eligible for TKR based on pre-established clinical selection criteria. Over the 24-month study period, 204 patients (86%) avoided surgery, with only 33 patients (14%, 95% confidence interval 82%-91%) progressing to a TKR with an average length of time to TKR of 324 days (ranging from 31 to 671 days). The application of this intervention provides health plans and provider networks managing patient care under financial risk arrangements an opportunity to realize significant cost savings without compromising quality of care or clinical outcomes.

Do health educator telephone calls reduce at-risk drinking among older adults in primary care?

BACKGROUND: Alcohol screening and brief intervention for unhealthy alcohol use has not been consistently delivered in primary care as part of preventive healthcare. OBJECTIVE: To explore whether telephone-based intervention delivered by a health educator is efficacious in reducing at-risk drinking among older adults in primary care settings. DESIGN: Secondary analyses of data from a randomized controlled trial. PARTICIPANTS: Subjects randomized to the intervention arm of the trial (n = 310). INTERVENTIONS: Personalized risk reports, advice from physicians, booklet about alcohol and aging, and up to three telephone calls from a health educator. All interventions were completed before the three-month follow-up. MEASUREMENTS: Risk outcomes (at-risk or not at-risk) at 3 and 12 months after enrollment. MAIN RESULTS: In univariate analyses, compared to those who remained at risk, those who achieved not at-risk outcome at 3 months were more likely to be women, Hispanic or non-white, have lower levels of education, consume less alcohol, drink less frequently, and have lower baseline number of risks. In mixed-effects logistic regression models, completing all three health educator calls increased the odds of achieving not at-risk outcome compared to not completing any calls at 3 months (OR 5.31; 95% CI 1.92-14.7; p = 0.001), but not at 12 months (OR 2.01; 95% CI 0.71-5.67; p = 0.18). CONCLUSIONS: Telephone-based intervention delivered by a health educator was moderately efficacious in reducing at-risk drinking at 3 months after enrollment among older adults receiving a multi-faceted intervention in primary care settings; however, the effect was not sustained at 12 months.

Physicians' satisfaction with a collaborative disease management program for late-life depression in primary care.

OBJECTIVE: This study describes physicians' satisfaction with care for patients with depression before and after the implementation of a primary care-based collaborative care program. METHOD: Project Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) is a multisite, randomized controlled trial comparing a primary care-based collaborative disease management program for late-life depression with care as usual. A total of 450 primary care physicians at 18 participating clinics participated in a satisfaction survey before and 12 months after IMPACT initiation. The preintervention survey focused on physicians' satisfaction with current mental health resources and ability to provide depression care. The postintervention survey repeated these and added questions about physician's experience with the IMPACT collaborative care model. RESULTS: Before intervention, about half (54%) of the participating physicians were satisfied with resources to treat patients with depression. After intervention, more than 90% reported the intervention as helpful in treating patients with depression and 82% felt that the intervention improved patients' clinical outcomes. Participating physicians identified proactive patient follow-up and patient education as the most helpful components of the IMPACT model. CONCLUSIONS: Physicians perceived a substantial need for improving depression treatment in primary care. They were very satisfied with the IMPACT collaborative care model for treating depressed older adults and felt that similar care management models would also be helpful for treating other chronic medical illnesses.

Depression treatment in a sample of 1,801 depressed older adults in primary care.

OBJECTIVES: To examine rates and predictors of lifetime and recent depression treatment in a sample of 1,801 depressed older primary care patients DESIGN: Cross sectional survey data collected from 1999 to 2001 as part of a treatment effectiveness trial. SETTING: Eighteen primary care clinics belonging to eight organizations in five states. PARTICIPANTS: One thousand eight hundred one clinic users aged 60 and older who met diagnostic criteria for major depression or dysthymia. MEASUREMENTS: Lifetime depression treatment was defined as ever having received a prescription medication, counseling, or psychotherapy for depression. Potentially effective recent depression treatment was defined as 2 or more months of antidepressant medications or four or more sessions of counseling or psychotherapy for depression in the past 3 months. RESULTS: The mean age +/- standard deviation was 71.2 +/- 7.5; 65% of subjects were women. Twenty-three percent of the sample came from ethnic minority groups (12% were African American, 8% were Latino, and 3% belonged to other ethnic minorities). The median household income was $23,000. Most study participants (83%) reported depressive symptoms for 2 or more years, and most (71%) reported two or more prior depressive episodes. About 65% reported any lifetime depression treatment, and 46% reported some depression treatment in the past 3 months, although only 29% reported potentially effective recent depression treatment. Most of the treatment provided consisted of antidepressant medications, with newer antidepressants such as selective serotonin reuptake inhibitors constituting the majority (78%) of antidepressants used. Most participants indicated a preference for counseling or psychotherapy over antidepressant medications, but only 8% had received such treatment in the past 3 months, and only 1% reported four or more sessions of counseling. Men, African Americans, Latinos, those without two or more prior episodes of depression, and those who preferred counseling to antidepressant medications reported significantly lower rates of depression care. CONCLUSION: The findings suggest that there is considerable opportunity to improve care for older adults with depression. Particular efforts should be focused on improving access to depression care for older men, African Americans, Latinos, and patients who prefer treatments other than antidepressants.

Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial.

CONTEXT: Depression and arthritis are disabling and common health problems in late life. Depression is also a risk factor for poor health outcomes among arthritis patients. OBJECTIVE: To determine whether enhancing care for depression improves pain and functional outcomes in older adults with depression and arthritis. DESIGN, SETTING, AND PARTICIPANTS: Preplanned subgroup analyses of Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), a randomized controlled trial of 1801 depressed older adults (> or =60 years), which was performed at 18 primary care clinics from 8 health care organizations in 5 states across the United States from July 1999 to August 2001. A total of 1001 (56%) reported coexisting arthritis at baseline. INTERVENTION: Antidepressant medications and/or 6 to 8 sessions of psychotherapy (Problem-Solving Treatment in Primary Care). MAIN OUTCOME MEASURES: Depression, pain intensity (scale of 0 to 10), interference with daily activities due to arthritis (scale of 0 to 10), general health status, and overall quality-of-life outcomes assessed at baseline, 3, 6, and 12 months. RESULTS: In addition to reduction in depressive symptoms, the intervention group compared with the usual care group at 12 months had lower mean (SE) scores for pain intensity (5.62 [0.16] vs 6.15 [0.16]; between-group difference, -0.53; 95% confidence interval [CI], -0.92 to -0.14; P =.009), interference with daily activities due to arthritis (4.40 [0.18] vs 4.99 [0.17]; between-group difference, -0.59; 95% CI, -1.00 to -0.19; P =.004), and interference with daily activities due to pain (2.92 [0.07] vs 3.17 [0.07]; between-group difference, -0.26; 95% CI, -0.41 to -0.10; P =.002). Overall health and quality of life were also enhanced among intervention patients relative to control patients at 12 months. CONCLUSIONS: In a large and diverse population of older adults with arthritis (mostly osteoarthritis) and comorbid depression, benefits of improved depression care extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status and quality of life.

Why do older unhealthy drinkers decide to make changes or not in their alcohol consumption? Data from the Healthy Living as You Age study.

OBJECTIVES: To understand characteristics of older at-risk drinkers and reasons why they decide to change or maintain their alcohol consumption. DESIGN: Secondary analysis of data from a randomized controlled trial to reduce drinking in at-risk drinkers. SETTING: Three primary care sites in southern California. PARTICIPANTS: Six hundred thirty-one adults aged 55 and older who were at-risk drinkers at baseline, 521 of whom who completed a 12-month assessment. MEASUREMENTS: Sociodemographic and alcohol-related characteristics of 12-month assessment completers and noncompleters and among those completing the 12-month assessment by telephone or mail were compared using descriptive statistics. Reasons why respondents maintained or changed average alcohol consumption were asked of those who completed a 12-month assessment by telephone. Factors that might motivate at-risk drinkers to reduce drinking were asked about, and frequencies were calculated for these responses. RESULTS: Participants were primarily male, white, highly educated, and in good health. Those who responded to the 12-month assessment by mail were more likely to be working, to be in the intervention arm, and to drink more. Most who reduced alcohol consumption and heavy drinking did so because they thought it would benefit them. Those who did not thought that drinking was not a problem for them. Both groups cited their environment and circumstances as influencing their drinking. Remaining at-risk drinkers reported that medical evidence that alcohol was harming them would motivate them to reduce drinking. CONCLUSION: Older adults report that they reduce their drinking when they recognize that their drinking habits may be causing them harm; one's environment can hinder or help one to reduce drinking.

Primary care-based intervention to reduce at-risk drinking in older adults: a randomized controlled trial.

AIMS: To examine whether a multi-faceted intervention among older at-risk drinking primary care patients reduced at-risk drinking and alcohol consumption at 3 and 12 months. DESIGN: Randomized controlled trial. SETTING: Three primary care sites in southern California. PARTICIPANTS: Six hundred and thirty-one adults aged ≥ 55 years who were at-risk drinkers identified by the Comorbidity Alcohol Risk Evaluation Tool (CARET) were assigned randomly between October 2004 and April 2007 during an office visit to receive a booklet on healthy behaviors or an intervention including a personalized report, booklet on alcohol and aging, drinking diary, advice from the primary care provider and telephone counseling from a health educator at 2, 4 and 8 weeks. MEASUREMENTS: The primary outcome was the proportion of participants meeting at-risk criteria, and secondary outcomes were number of drinks in past 7 days, heavy drinking (four or more drinks in a day) in the past 7 days and risk score. FINDINGS: At 3 months, relative to controls, fewer intervention group participants were at-risk drinkers [odds ratio (OR) 0.41; 95% confidence interval (CI) 0.22-0.75]; they reported drinking fewer drinks in the past 7 days [rate ratio (RR) 0.79; 95% CI 0.70-0.90], less heavy drinking (OR 0.46; 95% CI 0.22-0.99) and had lower risk scores (RR 0.77 95% CI 0.63-0.94). At 12 months, only the difference in number of drinks remained statistically significant (RR 0.87; 95% CI 0.76-0.99). CONCLUSIONS: A multi-faceted intervention among older at-risk drinkers in primary care does not reduce the proportions of at-risk or heavy drinkers, but does reduce amount of drinking at 12 months.

A practice-based intervention to improve primary care for falls, urinary incontinence, and dementia.

OBJECTIVES: To determine whether a practice-based intervention can improve care for falls, urinary incontinence, and cognitive impairment. DESIGN: Controlled trial. SETTING: Two community medical groups. PARTICIPANTS: Community-dwelling patients (357 at intervention sites and 287 at control sites) aged 75 and older identified as having difficulty with falls, incontinence, or cognitive impairment. INTERVENTION: Intervention and control practices received condition case-finding, but only intervention practices received a multicomponent practice-change intervention. MEASUREMENTS: Percentage of quality indicators satisfied measured using a 13-month medical record abstraction. RESULTS: Before the intervention, the quality of care was the same in intervention and control groups. Screening tripled the number of patients identified as needing care for falls, incontinence, or cognitive impairment. During the intervention, overall care for the three conditions was better in the intervention than the control group (41%, 95% confidence interval (CI)=35-46% vs 25%, 95% CI=20-30%, P<.001). Intervention group patients received better care for falls (44% vs 23%, P<.001) and incontinence (37% vs 22%, P<.001) but not for cognitive impairment (44% vs 41%, P=.67) than control group patients. The intervention was more effective for conditions identified by screening than for conditions identified through usual care. CONCLUSION: A practice-based intervention integrated into usual clinical care can improve primary care for falls and urinary incontinence, although even with the intervention, less than half of the recommended care for these conditions was provided. More-intensive interventions, such as embedding intervention components into an electronic medical record, will be needed to adequately improve care for falls and incontinence.

Impacting late life depression: integrating a depression intervention into primary care.

groups and semi-structured individual interviews with all Depression Clinical Specialists (DCSs) working with Project IMPACT (Improving Mood: Promoting Access to Collaborative Treatment), a study testing a collaborative care intervention for late life depression, to examine integration of the intervention model into primary care. DCSs described key intervention components, including supervision from a psychiatrist and a liaison primary care provider, weekly team meetings, computerized patient tracking, and outcomes assessment tools as effective in supporting patient care. DCSs discussed details of protocols, training, environmental set-up, and interpersonal factors that seemed to facilitate integration. DCSs also identified research-related factors that may need to be preserved in the real world. Basic elements of the IMPACT model seem to support integration of late life depression care into primary care. Research-related components may need modification for dissemination.

Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial.

CONTEXT: Few depressed older adults receive effective treatment in primary care settings. OBJECTIVE: To determine the effectiveness of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. DESIGN: Randomized controlled trial with recruitment from July 1999 to August 2001. SETTING: Eighteen primary care clinics from 8 health care organizations in 5 states. PARTICIPANTS: A total of 1801 patients aged 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). INTERVENTION: Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual care (n = 895). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert and who offered education, care management, and support of antidepressant management by the patient's primary care physician or a brief psychotherapy for depression, Problem Solving Treatment in Primary Care. MAIN OUTCOME MEASURES: Assessments at baseline and at 3, 6, and 12 months for depression, depression treatments, satisfaction with care, functional impairment, and quality of life. RESULTS: At 12 months, 45% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001), more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group difference, -0.4; 95% CI, -0.46 to -0.33; P<.001), less functional impairment (range, 0-10; between-group difference, -0.91; 95% CI, -1.19 to -0.64; P<.001), and greater quality of life (range, 0-10; between-group difference, 0.56; 95% CI, 0.32-0.79; P<.001) than participants assigned to the usual care group. CONCLUSION: The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.