Methodological approaches to situational analysis in global mental health: a scoping review.

Global inequity in access to and availability of essential mental health services is well recognized. The mental health treatment gap is approximately 50% in all countries, with up to 90% of people in the lowest-income countries lacking access to required mental health services. Increased investment in global mental health (GMH) has increased innovation in mental health service delivery in LMICs. Situational analyses in areas where mental health services and systems are poorly developed and resourced are essential when planning for research and implementation, however, little guidance is available to inform methodological approaches to conducting these types of studies. This scoping review provides an analysis of methodological approaches to situational analysis in GMH, including an assessment of the extent to which situational analyses include equity in study designs. It is intended as a resource that identifies current gaps and areas for future development in GMH. Formative research, including situational analysis, is an essential first step in conducting robust implementation research, an essential area of study in GMH that will help to promote improved availability of, access to and reach of mental health services for people living with mental illness in low- and middle-income countries (LMICs). While strong leadership in this field exists, there remain significant opportunities for enhanced research representing different LMICs and regions.

Excessive sleepiness: under-recognized and essential marker for sleep/wake disorder management.

BACKGROUND: Research during the past few decades has provided substantial evidence indicating that excessive sleepiness (ES) and associated sleep/wake disorders can result in significant morbidity and mortality. However, symptomatology (e.g., ES) and the relationships among common morbidities (e.g., cardiovascular disease, metabolic disorders, mood impairment) and sleep/wake disorders remain under-recognized in clinical practice, particularly in primary care. Yet assessment of sleep/wakefulness and associated symptoms can often be easily conducted in the primary care setting, providing valuable information to facilitate the diagnosis and management of sleep/wake disorders. OBJECTIVE: To provide a conceptual and educational framework that helps primary care physicians comprehensively assess, differentially diagnosis, and appropriately manage patients presenting with ES or ES-related sleep/wake disorders. METHODS: Comprised of six sleep specialists and six primary care physicians, the Sleep/Wake Disorders Working Group (SWG) used a modified, two-round Delphi approach to create and harmonize consensus recommendations for the assessment, diagnosis, treatment, and ongoing management of patients with common sleep/wake disorders related to ES. RESULTS: After a review of the relevant literature, the SWG arrived at consensus on a number of clinical recommendations for the assessment and management ES and some of the most commonly associated sleep/wake disorders. Ten consensus statements ­ five each for assessment/diagnosis and treatment/ongoing care ­ were created for ES, insomnia, obstructive sleep apnea, circadian rhythm disorders, restless legs syndrome, and narcolepsy. CONCLUSION: ES and ES-related sleep/wake disorders are commonly encountered in the primary care setting. By providing an educational framework for primary care physicians, the SWG hopes to improve patient outcomes by emphasizing recognition, prompt diagnosis, and appropriate ongoing management of ES and associated sleep/wake disorders.

An ideal trial to test differential onset of antidepressant effect.

Although various published clinical studies have suggested that some antidepressants may have a more rapid onset of therapeutic effect than others, none of these trials was adequately designed to measure differential time to onset of effect. Thus, existing data do not support claims that one drug reduces the symptoms of depression faster than another. In this article, we propose a study that would be ideal for measuring comparative onset of antidepressant effect. The key features of this ideal trial include (1) a prospective definition of early onset of action, (2) increased frequency of assessment, (3) a data-analytic approach capable of capturing the dynamic nature of symptomatic change, and (4) various strategies to minimize bias and heterogeneity of response.

Early onset of antidepressant action: impact on primary care.

Although the prevalence of depression among patients in primary care is high, the primary care system is inefficient at recognizing and managing this disorder. The delayed onset of antidepressant effect contributes to this problem, since patients and physicians may prematurely discontinue a medication that is not perceived as effective. The undertreatment of depression has profound effects on patients, the health care system, and society. The development of antidepressants with a faster onset of action would improve the pharmacologic management of depression and have wide-ranging benefits for the health care system.

A cross-national study of acute otitis media: risk factors, severity, and treatment at initial visit. Report from the International Primary Care Network (IPCN) and the Ambulatory Sentinel Practice Network (ASPN).

BACKGROUND: Treatment of acute otitis media (AOM) differs worldwide. The Dutch avoid antimicrobials unless fever and pain persist; the British use them for 5 to 7 days, and Americans use them for 10 days. If effects of therapies are to be compared, it is necessary to evaluate rates of risk factors, severity of attacks, and their influence on treatment decisions. We wanted to compare the prevalence of risk factors for AOM and evaluate their association with severity of attacks and of severity with antimicrobial treatment. METHODS: We undertook a prospective cohort study of 2,165 patients with AOM enrolled by primary care physicians; 895 were enrolled from North America, 571 were enrolled from the United Kingdom, and 699 were enrolled from The Netherlands. The literature was searched using the key words "acute otitis media," "severity," and "international comparisons." RESULTS: The prevalence of several AOM risk factors differs significantly among patients from the three country networks; these factors include race, parent smoking habits, previous episodes, previous episodes without a physician visit, tonsillectomy or adenoidectomy, frequency of upper respiratory tract infections, day care, and recumbent bottle-feeding. Dutch children have the most severe attacks as defined by fever, ear discharge, decreased hearing during the previous week, and moderate or severe ear pain. In country-adjusted univariate analyses, increasing age, exposure to tobacco smoke, day care, previous attacks of AOM, previous attacks without physician care, past prophylactic antimicrobials, ear tubes, adenoidectomy, and tonsillectomy all contribute to severity. Only country network, age, history of AOM, previous episode without physician care, and history of adenoidectomy and tympanostomy tubes are independently related to increased severity, while current breast-feeding is protective. Severity of attacks influences treatment decisions. Dutch children are least likely to receive antimicrobials, and even for severe attacks the British and Dutch physicians usually use amoxicillin or trimethoprim-sulfa; North American children with severe attacks are more likely to receive a broad-spectrum second-line antimicrobial. CONCLUSION: Dutch children have the highest ratings in all severity measures, possibly reflecting parental decisions about care seeking for earaches. When comparing groups of patients with AOM, it is necessary to adjust for baseline characteristics. Severity of episode affects physician treatment decisions. Adoption of Dutch guidelines restricting use of antimicrobials for AOM in the United States could result in annual savings of about $185 million.

Tympanometry interpretation by primary care physicians. A report from the International Primary Care Network (IPCN) and the Ambulatory Sentinel Practice Network (ASPN).

BACKGROUND: The accuracy of data gathered by primary care clinicians in practice-based research networks (PBRNs) has been questioned. Tympanometry, recently recommended as a means of improving accuracy of diagnosing acute otitis media, was included as an objective diagnostic measure in an international PBRN study. We report the level of agreement of interpretations of tympanograms between primary care physicians in PBRNs and experts. METHODS: Primary care physicians in PBRNs in the Netherlands, United Kingdom, United States, and Canada enrolled 1773 children aged 6 to 180 months who contributed 6358 tympanograms during 3179 visits. The physicians were trained in the use and interpretation of tympanometry using the Modified Jerger Classification. We determined the level of agreement between physicians and experts for interpretation of tympanograms. One comparison used the 6358 individual ear tracings. A second comparison used the 3179 office visits by children as the unit of analysis. RESULTS: The distribution of expert interpretation of all tympanograms was: 35.8% A, 30% B, 15.5% C1, 12% C2, and 6.8% uninterpretable; for visits, 37.8% were normal (A or C1), 55.6% abnormal (B or C2), and 6.6% could not be classified. There was a high degree of agreement in the interpretation of tympanograms between experts and primary care physicians across networks (kappa=0.70-0.77), age groups of children (kappa=0.69-0.73), and types of visits (kappa=0.66-0.77). This high degree of agreement was also found when children were used as a unit of analysis. CONCLUSIONS: Interpretations of tympanograms by primary care physicians using the Modified Jerger Classification can be used with confidence. These results provide further evidence that practicing primary care physicians can provide high-quality data for research purposes.

The duration of ambulatory visits to physicians.

BACKGROUND: The objective of our study was to determine the typical length of ambulatory visits to a nationally representative sample of primary care physicians, and the patient, physician, practice, and visit characteristics affecting duration of visit. METHODS: We used an analysis of cross-sectional survey data to determine duration of visit and the characteristics associated with it. The data sources were a random sample of the 19,192 visits by adults to 686 primary care physicians contained in the 1991-1992 National Ambulatory Medical Care Survey, and the results of the Physician Induction Interview conducted by the National Center for Health Statistics. Duration of visit was defined as the total time spent in face-to-face contact with the physician. RESULTS: Mean duration of visit was 16.3 minutes (standard deviation = 9.7). Multivariate analysis allowed the calculation of the independent effect on visit length of a variety of characteristics of patients, physicians, organizational/practice setting, geographic location, and visit content. Certain patient characteristics (increasing age and the presence of psychosocial problems) were associated with increased duration of visit. Visit content was also associated with increased duration, including ordering or performing 4 or more diagnostic tests (71% increase), Papanicolaou smears (34%), ambulatory surgical procedures (34%), patient admission to the hospital (32%), and 3 preventive screening tests (25%). Reduced duration of visit was associated with availability of non-physician support personnel and health maintenance organization and Medicaid insurance. CONCLUSIONS: Multiple factors affect duration of visit. Clinicians, policymakers, and health system managers should take these considerations into account in managing physician resources during daily ambulatory practice.

Trends in adult visits to primary care physicians in the United States.

BACKGROUND: Although numerous changes are apparent in the US health care system, little is known about how these changes have altered the work of primary care physicians. METHODS: We analyzed a nationally representative sample of 136,233 adult office visits to general internists, general practitioners, and family physicians contained in the 1978 through 1981, 1985, and 1989 through 1994 National Ambulatory Medical Care Surveys. Annual sample sizes varied between 5662 and 19,977 visits. Measures included the characteristics of patients presenting to primary care physicians, physician activities during these visits, and the disposition of the visits to primary care physicians. RESULTS: Visits to primary care physicians have diminished as a proportion of all adult visits from 52% in 1978 to 41% in 1994. Dramatic trends in adult primary care included the growing racial or ethnic diversity of patients, the doubling (since 1985) of health maintenance organization coverage, increased provision of prevention services, changes in the most common medications, and an 18% increase in the duration of adult visits to primary care physicians. CONCLUSIONS: Trends in primary care practice reflect changes in society and in the US health care system, including demographic changes, an emphasis on prevention, and the growth of managed care. The increasing role of managed care, with its emphasis on increased productivity, appears at odds with primary care physicians' increasing responsibility for prevention and the associated increase in the duration of primary care visits.

Addressing preconception risks identified at the time of a negative pregnancy test. A randomized trial.

BACKGROUND: A preconception care program has the potential to assist women who want to become pregnant by advising these women about risk factors, healthy lifestyles, and assessing readiness for pregnancy. We conducted a randomized controlled trial to determine whether comprehensive preconception risk assessment at the time of a negative pregnancy test followed by referral to primary care services is effective in initiating treatment for women with preconception risk factors. METHODS: One hundred seventy women were offered preconception risk assessment following a negative pregnancy test. Women were assigned randomly either to a usual care group or an intervention group. Women in the latter group were informed about the risks identified and received an appointment with a primary care clinician who was also informed. Women in the usual care group and their clinicians received no feedback. All charts were reviewed and the women were contacted by telephone to determine if interventions to reduce risk were offered by clinicians during the year following the assessment. RESULTS: An average of 8.96 risks were identified per woman. The proportion of women having risks in each of 12 risk categories studied ranged from 19% to 71%. One hundred women (59%) made at least one visit during the subsequent year, thus allowing the opportunity for preconception care. The proportion of these women who had a risk addressed ranged from 18% for psychosocial risks to 48% for those with fetal exposures (smoking, alcohol, and drug use). There was no difference between groups in the percentage of risks addressed. CONCLUSIONS: The notification of women and their clinicians of identified preconception risks did not improve intervention rates. A more organized intervention system including office-based protocols is needed.

Changes in the daily practice of primary care for children.

BACKGROUND: The environment in which medicine is practiced has changed in the past 2 decades, but little information has been available on how the day-to-day practice of primary care for children has changed during this period. OBJECTIVE: To identify aspects of primary care practices for children that are undergoing substantial changes. DESIGN: Analysis of National Ambulatory Medical Care Surveys from 1979 to 1981, 1985, and 1989 to 1994. PARTICIPANTS: Primary care practitioners recorded data on 58,488 child visits. MAIN OUT COME MEASURES: Characteristics and insurance status of children, physician activities during visits, and disposition after visit. RESULTS: Child visits to primary care physicians increased by 22% between 1979 and 1994. The mean age of children visiting primary care physicians decreased from 6.7 years in 1979 to 5.7 years in 1994 (P for trend, < .001). The ethnic diversity of child visits increased primarily as a result of an increasing proportion of visits by Hispanic (6.0% in 1979 to 12.6% in 1994, P for trend, < .001) and Asian patients (1.6% in 1979 to 4.1% in 1994, P for trend, < .001). Medicaid and managed care increased dramatically as sources of payment. Changes in physician activities included an increase in some preventive services, changes in the most commonly encountered medications, and an increased mean duration of patient visits (11.8 minutes in 1979 to 14.2 minutes in 1994, P for trend, < .001). CONCLUSIONS: These data may assist in the development of educational and research initiatives for physicians caring for children. The declining proportion of adolescent visits may present physicians with challenges in the care of adolescents. Physician prescribing practices showed changes without evidence of a benefit to child health. The increased ethnic diversity and provision of preventive services were associated with an increased mean duration of primary care visits. The increased duration of child visits may conflict with the managed care emphasis on physician productivity.

Guidelines for international collaborative research.

OBJECTIVE: As the global village becomes a reality, there is an increasing need to conduct international collaborative studies in family practice. A workshop at the WONCA meeting in Hong Kong used international attendees to produce a set of guidelines for international research. METHODS: At the workshop four completed international projects, each using a different strategy, were presented so that common themes might become apparent. The themes were then discussed and guidelines emerged from the process. RESULTS: Seven guidelines emerged for consideration before embarking on an international collaborative research project in family medicine. The guidelines deal with the characteristics of the research question and the importance of communication. The need for simple, brief methods of data collection, funding and pilot testing were identified. CONCLUSION: The question must be relevant to all participants to maintain interest and measurement tools must be validated to understand the impact of cultural differences in understanding.