Tolerance for Uncertainty and Professional Development: a Normative Analysis.

Scholars from a range of disciplines including medicine, sociology, psychology, and philosophy have addressed the concepts of ambiguity and uncertainty in medical practice and training. Most of this scholarship has been descriptive, focusing on defining and measuring ambiguity and uncertainty tolerance or tracking clinicians' responses to ambiguous and uncertain situations. Meanwhile, scholars have neglected some fundamental normative questions: Is tolerance of uncertainty good; if so, to what extent? Using a philosophical approach to these questions, we show that neither tolerance nor intolerance of uncertainty is necessarily a good or bad trait. Rather, both tolerance and intolerance of uncertainty can give physicians advantages while at the same time exposing them to pitfalls in clinical practice. After making this case, we argue that cultivating certain virtues-like courage, diligence, and curiosity-could help clinicians avoid the dangers of excessive tolerance and intolerance of uncertainty. Finally, we suggest that medical educators develop curricula and career counseling beginning with matriculation and proceeding through specialty choice and residency training that explicitly address trainees' responses to clinical uncertainty. These programs should encourage trainees, students and residents, to be mindful of their reactions to uncertainty and help them develop virtues that will allow them to avoid the hazards of extreme tolerance or intolerance of uncertainty.

Strategies for Discussing Firearms Storage Safety in Primary Care: Veteran Perspectives.

BACKGROUND: Two-thirds of veteran suicides are attributable to firearm injury. Although half of veterans who die by suicide are seen in primary care settings in the month prior to death, little is known about how to promote firearm safety within primary care. OBJECTIVE: Describe veterans' perspectives on discussing firearms storage safety (FSS) during primary care visits, and identify key strategies for primary care teams to use in discussing FSS with veterans at elevated risk for suicide. DESIGN: Qualitative analysis of transcripts and notes from four veteran focus groups and from individual semi-structured interviews with six veterans. PARTICIPANTS: Altogether, 68 veterans participated. Three of the groups were associated with one Veterans Health Administration facility. Groups were diverse in age, service era, and gender. APPROACH: The goals of the focus groups and interviews were to assess acceptance of FSS discussions during primary care visits, identify facilitators and barriers to conducting FSS discussions, and identify strategies for primary care teams to use to effectively conduct FSS discussions. Transcripts and meeting notes were analyzed using a grounded theory approach. KEY RESULTS: There was general acceptance of having FSS discussions in primary care. Yet, most veterans did not support direct questioning about firearm ownership, which may trigger fears of having firearms taken away or limit access to firearms. Participants recommended primary care teams provide rationale for FSS discussions and be prepared to provide information on legal consequences of disclosing firearm ownership. Strategies suggested for primary care staff also included using a personalized, caring, and conversational approach rather than highly scripted or checklist approach, engaging veterans in a non-judgmental manner, and conveying respect for veterans' knowledge of firearms. CONCLUSIONS: Discussing FSS with veterans in primary care settings is a promising upstream approach that can complement other suicide prevention efforts, but must be conducted in a veteran-centric manner.

Making Narrative Statements to Describe Treatment Effects.

Accurately describing treatment effects using plain language and narrative statements is a critical step in communicating research findings to end users. However, the process of developing these narratives has not been historically guided by a specific framework. The Agency for Healthcare Research and Quality Evidence-based Practice Center Program developed guidance for narrative summaries of treatment effects that identifies five constructs. We explicitly identify these constructs to facilitate developing narrative statements: (1) direction of effect, (2) size of effect, (3) clinical importance, (4) statistical significance, and (5) strength or certainty of evidence. These constructs clearly overlap. It may not always be feasible to address all five constructs. Based on context and intended audience, investigators can determine which constructs will be most important to address in narrative statements.

The Association of Patient Factors, Digital Access, and Online Behavior on Sustained Patient Portal Use: A Prospective Cohort of Enrolled Users.

BACKGROUND: As electronic health records and computerized workflows expand, there are unprecedented opportunities to digitally connect with patients using secure portals. To realize the value of patient portals, initial reach across populations will need to be demonstrated, as well as sustained usage over time. OBJECTIVE: The study aim was to identify patient factors associated with short-term and long-term portal usage after patients registered to access all portal functions. METHODS: We prospectively followed a cohort of patients at a large Department of Veterans Affairs (VA) health care facility who recently completed identity proofing to use the VA patient portal. Information collected at baseline encompassed patient factors potentially associated with portal usage, including: demographics, Internet access and use, health literacy, patient activation, and self-reported health conditions. The primary outcome was the frequency of portal log-ins during 6-month and 18-month time intervals after study enrollment. RESULTS: A total of 270 study participants were followed prospectively. Almost all participants (260/268, 97.0%) reported going online, typically at home (248/268, 92.5%). At 6 months, 84.1% (227/270) of participants had visited the portal, with some variation in usage across demographic and health-related subgroups. There were no significant differences in portal log-ins by age, gender, education, marital status, race/ethnicity, distance to a VA facility, or patient activation measure. Significantly higher portal usage was seen among participants using high-speed broadband at home, greater self-reported ability using the Internet, and routinely going online. By 18 months, 91% participants had logged in to the portal, and no significant associations were found between usage and demographics, health status, or patient activation. When examining portal activity between 6 and 18 months, patients who were infrequent or high portal users remained in those categories, respectively. CONCLUSIONS: Short-term and long-term portal usage was associated with having broadband at home, high self-rated ability when using the Internet, and overall online behavior. Digital inclusion, or ready access to the Internet and digital skills, appears to be a social determinant in patient exposure to portal services.

The Development and Evaluation of an Online Healthcare Toolkit for Autistic Adults and their Primary Care Providers.

BACKGROUND: The healthcare system is ill-equipped to meet the needs of adults on the autism spectrum. OBJECTIVE: Our goal was to use a community-based participatory research (CBPR) approach to develop and evaluate tools to facilitate the primary healthcare of autistic adults. DESIGN: Toolkit development included cognitive interviewing and test-retest reliability studies. Evaluation consisted of a mixed-methods, single-arm pre/post-intervention comparison. PARTICIPANTS: A total of 259 autistic adults and 51 primary care providers (PCPs) residing in the United States. INTERVENTIONS: The AASPIRE Healthcare toolkit includes the Autism Healthcare Accommodations Tool (AHAT)-a tool that allows patients to create a personalized accommodations report for their PCP-and general healthcare- and autism-related information, worksheets, checklists, and resources for patients and healthcare providers. MAIN MEASURES: Satisfaction with patient-provider communication, healthcare self-efficacy, barriers to healthcare, and satisfaction with the toolkit's usability and utility; responses to open-ended questions. KEY RESULTS: Preliminary testing of the AHAT demonstrated strong content validity and adequate test-retest stability. Almost all patient participants (>94 %) felt that the AHAT and the toolkit were easy to use, important, and useful. In pre/post-intervention comparisons, the mean number of barriers decreased (from 4.07 to 2.82, p < 0.0001), healthcare self-efficacy increased (from 37.9 to 39.4, p = 0.02), and satisfaction with PCP communication improved (from 30.9 to 32.6, p = 0.03). Patients stated that the toolkit helped clarify their needs, enabled them to self-advocate and prepare for visits more effectively, and positively influenced provider behavior. Most of the PCPs surveyed read the AHAT (97 %), rated it as moderately or very useful (82 %), and would recommend it to other patients (87 %). CONCLUSIONS: The CBPR process resulted in a reliable healthcare accommodation tool and a highly accessible healthcare toolkit. Patients and providers indicated that the tools positively impacted healthcare interactions. The toolkit has the potential to reduce barriers to healthcare and improve healthcare self-efficacy and patient-provider communication.

Angina symptom burden associated with depression status among veterans with ischemic heart disease.

BACKGROUND: Angina and depression are common in ischemic heart disease (IHD), but their association remains understudied. PURPOSE: This study was conducted in order to evaluate the association of 1 year change in depression with change in patient-reported outcomes of stable angina. METHODS: Five hundred sixty-nine stable angina patients completed the Seattle Angina Questionnaire and Patient Health Questionnaire (PHQ) at baseline and 1 year. Participants were divided into four groups: not depressed, new onset of depression at 1 year, remitted at 1 year, and persistently depressed. Associations between depression and angina symptoms were evaluated using regression models. RESULTS: Compared to those not depressed, newly depressed participants reported more angina (ß = -11.7, p < 0.001) and physical limitations (ß = -11.8, p < 0.001) and lower treatment satisfaction (ß = -15.03, p < 0.001) and quality of life (ß = -15.4, p < 0.001). Persistently depressed participants reported physical limitations (ß = -7.4, p < 0.05), lower treatment satisfaction (ß = -10.1, p < 0.001), and poorer quality of life (ß = -10.03, p < 0.001). CONCLUSIONS: Changes in depression scores and angina outcomes were significantly associated.

Development and Preliminary Evaluation of an Education Program for Primary Care Teams on Discussing Firearms Storage Safety with Veterans.

BACKGROUND: Reducing access to lethal means is one of the few empirically supported approaches for lowering suicide rates, and safe firearms storage practices have been associated with reduced risk of death by suicide. Although there is substantial opportunity for primary care to assist in addressing lethal means with veterans, approaches to intervention and educating staff are not well documented. We sought to 1) describe development of an education program for primary care teams to help them discuss firearms storage safety (FSS) with veterans during primary care visits; and 2) conduct a preliminary evaluation of the pilot education program. METHODS: We used an iterative process involving veterans and primary care staff stakeholders to develop program content, format, and supplemental materials. A grounded theory approach was used to analyze data from focus groups and individual interviews. Following piloting of the program with 71 staff members in two primary care clinics, we analyzed pre- and post-training participant surveys of program satisfaction and attitudes comfort related to firearms safety discussions. RESULTS: During the development phase, 68 veterans and 107 staff members participated in four veteran focus groups and four primary care focus groups, respectively, and/or individual interviews. The program that was developed, "'Just in Case': Discussing means safety with veterans at elevated risk for suicide," addresses knowledge and skills learning objectives, and includes video demonstrations and skills practice. Survey data obtained just prior to the pilot training sessions showed low self-reported rates of discussing firearms safety with veterans who may be at elevated risk for suicide. Immediate post-training data showed generally high satisfaction with the program and significant improvements in participant self-reported ratings of the importance of, and comfort with FSS. CONCLUSIONS: This interactive knowledge and skill-based means safety curriculum shows promise as a means for educating primary care staff to deliver messaging about firearms safety to veterans. Additional research is needed to refine and evaluate impacts of this or similar training programs on clinician and veteran behaviors over time.

Development and preliminary psychometric testing of the centrality of pain scale.

OBJECTIVE: The objective of the study was to develop and begin to evaluate a new measure of the centrality of pain in patients' lives. DESIGN: The study was designed as a cross-sectional survey and cognitive interviews. SETTING: The study was set in an academic general internal medicine clinic. PATIENTS: Sixty-five adult internal medicine patients with chronic nonmalignant pain (CNMP) participated in the study. OUTCOME MEASURES: We assessed content validity and clarity of the 10-item Centrality of Pain Scale (COPS) by soliciting feedback from chronic pain experts and by conducting cognitive interviews with patients with CNMP. We assessed internal consistency reliability using Cronbach's alpha. We assessed construct validity by comparing the COPS with other measures of chronic pain morbidity including pain severity, depression, anxiety, physical and mental health function, posttraumatic stress disorder, quality of life, and provider assessment. RESULTS: Health care providers felt the COPS had excellent face validity. Cognitive interviews revealed that patients' understanding of the items matched the intended construct, the scale measured an important concept, and items were easy to understand. The COPS had excellent internal consistency (alpha = 0.9). It was negatively associated with age (r = -0.29; P = 0.02), but not with other demographic characteristics. Higher COPS scores were associated with poorer physical (r = -0.48; P < 0.001) and mental (r = -0.39; P = 0.002) health function, quality of life (r = -0.36; P = 0.004), and provider assessment of stability (r = -0.38; P = 0.004) as well as with greater pain grade (r = 0.55; P < 0.001), and depression (r = 0.63; P < 0.001). In multivariate analyses, age, physical and mental health function, and depression were independently associated with COPS. CONCLUSIONS: The COPS has excellent internal consistency and construct validity. Additional studies are needed to further validate the scale.

Primary care clinician adherence to guidelines for the management of chronic musculoskeletal pain: results from the study of the effectiveness of a collaborative approach to pain.

OBJECTIVE: We assessed primary care clinician-provided guideline-concordant care as documented in patients' medical records, predictors of documented guideline-concordant care, and its association with pain-related functioning. Patients were participants in a randomized trial of collaborative care for chronic musculoskeletal pain. The intervention featured patient and primary care clinician education, symptom monitoring and feedback to clinicians by the intervention team. METHODS: To assess concordance with the evidence-based treatment guidelines upon which our intervention was based, we developed an 8-item chart review tool, the Pain Process Checklist (PPC). We then reviewed electronic medical records for 365 veteran patients treated by 42 primary care clinicians over 12 months. Intervention status, demographic, and clinical variables were tested as predictors of PPC scores using generalized estimating equations (GEE). GEE was also used to test whether PPC scores predicted treatment response (≥30% decrease in Roland-Morris Disability Questionnaire score). RESULTS: Rates of documented guideline-concordant care varied widely among PPC items, from 94% of patients having pain addressed to 17% of patients on opioids having side effects addressed. Intervention status was unrelated to item scores, and PPC-7 totals did not differ significantly between intervention and treatment-as-usual patients (61.2%, standard error [SE] = 3.3% vs 55.2%, SE = 2.6%, P = 0.15). In a multivariate model, higher PPC-7 scores were associated with receiving a prescription for opioids (odds ratio [OR] = 1.07, P = 0.007) and lower PPC-7 scores with patient age (10-year difference OR = 0.97, P = 0.004). Finally, intervention patients who received quantitative pain and depression assessments were less likely to respond to treatment (assessed vs not: 18% vs 33%, P = 0.008, and 13% vs 28%, P = 0.001, respectively). CONCLUSIONS: As measured by medical record review, additional training and clinician feedback did not increase provision of documented guideline-concordant pain care, and adherence to guidelines by primary care clinicians did not improve clinical outcomes for patients with chronic musculoskeletal pain.

Firearms storage safety discussions in VA primary care: Staff perspectives.

OBJECTIVE: To describe VHA primary care clinician and staff perspectives on conducting firearms storage safety (FSS) discussions in primary care, and to identify key approaches for primary care teams to facilitate FSS conversations. METHOD: Qualitative analysis of transcripts and notes from focus groups with VA primary care staff and individual semi-structured interviews with primary care clinicians. One hundred-seven VHA primary care team members participated in one of four focus groups or individual semi-structured interviews (n = 5). RESULTS: FSS discussions are perceived as within the purview of primary care. Primary care staff also outlined five tools and processes needed to meaningfully implement FSS discussions in primary care: training on firearms and firearms culture; examining personal attitudes toward firearms; developing supplemental materials to normalize and support FSS discussions; increasing knowledge of firearms laws and regulations; and providing scripts to facilitate conversations. CONCLUSIONS: Conducting FSS discussions in primary care settings is perceived as an acceptable practice, yet care teams identified barriers and suggestions for overcoming implementation challenges.

Veterans Are Agreeable to Discussions About Firearms Safety in Primary Care.

BACKGROUND: Discussing safe storage of firearms, including access, during times of crisis with veterans in primary care settings may enhance suicide prevention efforts. However, veteran attitudes toward such discussions are not well understood. The goal of this study is to understand the perspectives of veterans on discussing firearms storage safety with staff during primary care visits. METHODS: Individual semistructured interviews with veterans were conducted by telephone, qualitatively coded, and analyzed for themes. The sample was composed of veterans (n = 27) who had positive depression or post-traumatic stress disorder screens and who received care from Veterans Health Administration primary care team members trained to discuss firearms storage safety with patients. RESULTS: Citing the urgent need to prevent veteran suicide, most veterans felt discussing firearms safety was acceptable and needed, even if discussions felt uncomfortable or they had concerns. Veterans identified the need for providers to be transparent in their purposes for asking about firearms and to respect veterans' unique relationships with firearms. DISCUSSION: Conducting firearms safety discussions in a primary care setting with veterans who are at elevated risk for suicide is acceptable to veterans when a respectful, veteran-centered, and transparent approach is used.

VA healthcare costs of a collaborative intervention for chronic pain in primary care.

BACKGROUND: Chronic pain is costly to individuals and the healthcare system, and is often undertreated. Collaborative care models show promise for improving treatment of patients with chronic pain. The objectives of this article are to report the incremental benefit and incremental health services costs of a collaborative intervention for chronic pain from a veterans affairs (VA) healthcare perspective. METHODS: Data on VA treatment costs incurred by participants were obtained from the VA's Decision Support System for all utilization except certain intervention activities which were tracked in a separate database. Outcome data were from a cluster-randomized trial of a collaborative intervention for chronic pain among 401 primary care patients at a VA medical center. Intervention group participants received assessments and care management; stepped-care components were offered to patients requiring more specialized care. The main outcome measure was pain disability-free days (PDFDs), calculated from Roland-Morris Disability Questionnaire scores. RESULTS: Participants in the intervention group experienced an average of 16 additional PDFDs over the 12-month follow-up window as compared with usual care participants; this came at an adjusted incremental cost of $364 per PDFD for a typical participant. Important predictors of costs were baseline medical comorbidities, depression severity, and prior year's treatment costs. CONCLUSIONS: This collaborative intervention resulted in more pain disability-free days and was more expensive than usual care. Further research is necessary to identify if the intervention is more cost-effective for some patient subgroups and to learn whether pain improvements and higher costs persist after the intervention has ended.

Differences in physical and mental health symptoms and mental health utilization associated with intimate-partner violence versus childhood abuse.

BACKGROUND: There is ample evidence that both intimate-partner violence (IPV) and childhood abuse adversely affect the physical and mental health of adult women over the long term. OBJECTIVE: The authors assessed the associations between abuse, symptoms, and mental health utilization. METHOD: The authors performed a cross-sectional survey of 380 adult female, internal-medicine patients. RESULTS: Although both IPV and childhood abuse were associated with depressive and physical symptoms, IPV was independently associated with physical symptoms, and childhood abuse was independently associated with depression. Women with a history of childhood abuse had higher odds, whereas women with IPV had lower odds, of receiving care from mental health providers. CONCLUSION: IPV and childhood abuse may have different effects on women's symptoms and mental health utilization.

Collaborative care for chronic pain in primary care: a cluster randomized trial.

CONTEXT: Chronic pain is common in primary care patients and is associated with distress, disability, and increased health care use. OBJECTIVE: To assess whether a collaborative intervention can improve chronic pain-related outcomes, including comorbid depression severity, in a Department of Veterans Affairs primary care setting. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized controlled trial of a collaborative care assistance with pain treatment intervention vs treatment as usual at 5 primary care clinics of 1 Department of Veterans Affairs Medical Center. Forty-two primary care clinicians were randomized to the assistance with pain treatment intervention group or the treatment as usual group. The 401 patients had musculoskeletal pain diagnoses, moderate or greater pain intensity, and disability lasting 12 weeks or longer and were assigned to the same treatment groups as their clinicians. Recruitment occurred from January 2006 to January 2007 and follow-up concluded in January 2008. INTERVENTION: Assistance with pain treatment included a 2-session clinician education program, patient assessment, education and activation, symptom monitoring, feedback and recommendations to clinicians, and facilitation of specialty care. MAIN OUTCOME MEASURES: Changes over 12 months in pain-related disability (Roland-Morris Disability Questionnaire, range of 0-24), pain intensity (Chronic Pain Grade [CPG] Pain Intensity subscale, range of 0-100), and depression (Patient Health Questionnaire 9 [PHQ-9], range of 0-27), measured as beta coefficients (difference in slopes in points per month). RESULTS: Intervention patients had a mean (SD) of 10.6 (4.5) contacts with the assistance with pain treatment team. Compared with the patients receiving treatment as usual, intervention patients showed greater improvements in pain-related disability (Roland-Morris Disability Questionnaire beta, -0.101 [95% confidence interval {CI}, -0.163 to -0.040]; P = .004 and CPG Pain Intensity subscale beta, -0.270 [95% CI, -0.480 to -0.061]; P = .01). Among patients with baseline depression (PHQ-9 score > or = 10), there was greater improvement in depression severity in patients receiving the intervention compared with patients receiving treatment as usual (PHQ-9 beta, -0.177 [95% CI, -0.295 to -0.060]; P = .003). The differences in scores between baseline and 12 months for the assistance with pain treatment intervention group and the treatment as usual group, respectively, were -1.4 vs -0.2 for the Roland-Morris Disability Questionnaire, -4.7 vs -0.6 for the CPG Pain Intensity subscale, and -3.7 vs -1.2 for PHQ-9. CONCLUSION: The assistance with pain treatment collaborative intervention resulted in modest but statistically significant improvement in a variety of outcome measures. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00129480.

"You always end up feeling like you're some hypochondriac": intimate partner violence survivors' experiences addressing depression and pain.

OBJECTIVE: Little is known regarding how providers should use information about intimate partner violence (IPV) to care for depressed patients. Our objective was to explore what depressed IPV survivors believe about the relationship between abuse, mental health, and physical symptoms and to elicit their recommendations for addressing depression. DESIGN: Focus group study. PATIENTS/PARTICIPANTS: Adult, English-speaking, female, Internal Medicine clinic patients with depressive symptoms and a history of IPV. INTERVENTIONS: Thematic analysis using an inductive approach (consistent with grounded theory), at a semantic level, with an essentialist paradigm. MEASUREMENTS AND MAIN RESULTS: Twenty three women participated in 5 focus groups. Although selected because of their depression, participants often felt their greatest concerns were physical. They acknowledged that their abuse history, depression, and physical complaints compound each other. They appreciated the need for health care workers to know about their depression and IPV history to get a "full picture" of their health, but they were often hesitant to discuss such issues with providers because of their fear that such information would make providers think their symptoms were "all in their head" or would encourage providers to discount their pain. Participants discussed difficulties related to trust and control in relationships with providers and gave recommendations as to how providers can earn their trust. CONCLUSIONS: Understanding a patient's IPV history may allow providers to develop a better therapeutic relationship. To treat depression adequately, it is important for providers to reassure patients that they believe their physical symptoms; to communicate respect for patients' intelligence, experience, and complexity; and to share control.

Proposed standards for medical education submissions to the Journal of General Internal Medicine.

To help authors design rigorous studies and prepare clear and informative manuscripts, improve the transparency of editorial decisions, and raise the bar on educational scholarship, the Deputy Editors of the Journal of General Internal Medicine articulate standards for medical education submissions to the Journal. General standards include: (1) quality questions, (2) quality methods to match the questions, (3) insightful interpretation of findings, (4) transparent, unbiased reporting, and (5) attention to human subjects' protection and ethical research conduct. Additional standards for specific study types are described. We hope these proposed standards will generate discussion that will foster their continued evolution.

Veterans affairs primary care clinicians' attitudes toward chronic pain and correlates of opioid prescribing rates.

OBJECTIVES: The primary objective of this study was to identify veterans affairs (VA) primary care clinicians' attitudes regarding chronic pain treatment. A secondary objective was to explore relationships between clinician and practice characteristics and an objective measure of opioid prescribing rates. DESIGN: Cross-sectional study of clinician survey and pharmacy data. PARTICIPANTS: Forty-five VA clinicians from five primary care clinics of one VA medical center. MEASURES: Survey of pain-related attitudes and behaviors, satisfaction with treatment resources, and job satisfaction; percentage of patients in clinicians' panels prescribed opioids (PCPO). RESULTS: Seventy-one percent of clinicians felt moderately or strongly confident in their ability to treat chronic pain, and 77% moderately or strongly agreed that skilled pain management is a high priority. However, 73% moderately or strongly agreed that patients with chronic pain are a major source of frustration and 38% reported moderate or greater dissatisfaction with their ability to provide optimal pain treatment. Fifty-two percent moderately or strongly agreed that their management is influenced by previous experiences with patients addicted to drugs. The mean PCPO was 16.5% (SD = 6.7). In bivariate comparisons, clinician panel size, job and resource satisfaction, and professional training were associated with opioid prescribing rates. CONCLUSION: High clinician confidence and interest in treating chronic pain concurrent with low satisfaction with ability to provide optimal treatment suggests a need for more system support. VA primary care clinicians are frequently influenced by fears of contributing to dependence or addiction. The relationships among panel size, job satisfaction, and opioid prescribing rates merit additional investigation.

Rationale, design, and baseline findings from a randomized trial of collaborative care for chronic musculoskeletal pain in primary care.

OBJECTIVE: This article describes the rationale, design, and baseline findings from an ongoing study of collaborative care for chronic musculoskeletal pain and comorbid depression. DESIGN: Cluster randomized clinical trial. PARTICIPANTS AND SETTING: Forty-two clinicians and 401 patients from five Veterans Affairs primary care clinics. INTERVENTION: The intervention was based on the chronic care model, and included patient and provider activation and education, patient assessment, outcomes monitoring, and feedback to providers over 12 months. The intervention team consisted of a full-time psychologist care manager and a part-time physician internist. Approaches included goal setting emphasizing function, patient activation and educating about fear avoidance, and care management. OUTCOME MEASURES: Main outcomes are Roland-Morris Disability Questionnaire (RMDQ) score, depression severity (Patient Health Questionnaire-9), and pain severity (Chronic Pain Grade Severity subscale) at 6 and 12 months. BASELINE RESULTS: Fifteen percent of primary care patients mailed a study advertisement letter requested screening for the study. The mean age of enrolled patients was 62. Back and neck or joint pain diagnoses were present in 67% and 65% of patients, respectively. Mean pain duration was 15 years, and mean RMDQ score (range 0-24) was 14.7 (standard deviation = 4.4). Sixty-five percent of patients were receiving disability. Eighteen percent of patients met criteria for major depression, 17% for posttraumatic stress disorder, and 9% for alcohol misuse. Thirty-nine percent of patients felt strongly that experiencing pain was a sign of damage, and 60% reported strong avoidance of painful activities. CONCLUSIONS: These baseline data support the rationale to develop a multifaceted approach to treat chronic pain in primary care that includes detection and treatment of psychiatric comorbidity.

Screening for posttraumatic stress disorder in VA primary care patients with depression symptoms.

BACKGROUND: Unrecognized posttraumatic stress disorder (PTSD) is common and may be an important factor in treatment-resistant depression. Brief screens for PTSD have not been evaluated for patients with depression. OBJECTIVE: The objective was to evaluate a 4-item screen for PTSD in patients with depression. DESIGN: Baseline data from a depression study were used to evaluate sensitivity, specificity, and likelihood ratios (LRs) using the PTSD checklist (PCL-17) as the reference standard. SUBJECTS: Subjects are 398 depressed patients seen in Veterans Affairs (VA) primary care clinics. MEASURES: The Patient Health Questionnaire (PHQ) for depression, PCL-17, and 4-item screen for PTSD were used. RESULTS: Patients had a mean PHQ score of 14.8 (SD 3.7). Using a conservative PCL-17 cut point "(>50)", the prevalence of PTSD was 37%. PCL-17 scores were strongly associated with PHQ scores (r = 0.59, P < 0.001). Among the 342 (86%) patients endorsing trauma, a score of 0 on the remaining 3 symptom items had a LR = 0.21, score of 1 a LR = .62, score of 2 a LR = 1.36, and score of 3 a LR = 4.38. CONCLUSIONS: Most depressed VA primary care patients report a history of trauma, and one third may have comorbid PTSD. Our 4-item screen has useful LRs for scores of 0 and 3. Modifying item rating options may improve screening characteristics.

Reactions to uncertainty and the accuracy of diagnostic mammography.

BACKGROUND: Reactions to uncertainty in clinical medicine can affect decision making. OBJECTIVE: To assess the extent to which radiologists' reactions to uncertainty influence diagnostic mammography interpretation. DESIGN: Cross-sectional responses to a mailed survey assessed reactions to uncertainty using a well-validated instrument. Responses were linked to radiologists' diagnostic mammography interpretive performance obtained from three regional mammography registries. PARTICIPANTS: One hundred thirty-two radiologists from New Hampshire, Colorado, and Washington. MEASUREMENT: Mean scores and either standard errors or confidence intervals were used to assess physicians' reactions to uncertainty. Multivariable logistic regression models were fit via generalized estimating equations to assess the impact of uncertainty on diagnostic mammography interpretive performance while adjusting for potential confounders. RESULTS: When examining radiologists' interpretation of additional diagnostic mammograms (those after screening mammograms that detected abnormalities), a 5-point increase in the reactions to uncertainty score was associated with a 17% higher odds of having a positive mammogram given cancer was diagnosed during follow-up (sensitivity), a 6% lower odds of a negative mammogram given no cancer (specificity), a 4% lower odds (not significant) of a cancer diagnosis given a positive mammogram (positive predictive value [PPV]), and a 5% higher odds of having a positive mammogram (abnormal interpretation). CONCLUSION: Mammograms interpreted by radiologists who have more discomfort with uncertainty have higher likelihood of being recalled.