Health state preferences of persons with anxiety.

We compared patient ratings of the desirability of anxiety health states with measures of psychological distress and functional status and investigated how these ratings predicted treatment by primary care and mental health clinicians. As expected, associations between desirability ratings and psychological and physical health status were low to moderate. Persons who rated their current anxiety health state as more desirable received fewer mental health referrals and were statistically more likely to receive a prescription for psychotropic medication. Simple ratings of health state desirability may help clinicians evaluate patients' views of their health status and discuss potential treatment options.

The functioning and well-being of patients with unrecognized anxiety disorders and major depressive disorder.

This study examines the degree to which untreated anxiety disorders and major depressive disorder, occurring either singly or in combination, reduce functioning and well-being among primary care patients. Adult patients were screened using the SCL-52 to identify those with clinically significant anxiety symptoms. They also completed the Rand Short-Form (SF-36) to measure self-reported patient functioning and well-being. Patients with untreated disorders were identified using the Q-DIS-III-R to diagnose six DIS-anxiety disorders (generalized anxiety disorder, post-traumatic stress disorder (PTSD), simple phobia, social phobia, panic/agoraphobia, obsessive/compulsive disorder) and major depression. Of 319 patients identified, 137 (43%) had a single disorder and 182 (57%) had multiple disorders. Regression models estimated the relative effects of these disorders on health status (SF-36) by comparing patients with the disorders to patients screened as being not-anxious. Estimates of these effects were consistent with available national norms. The estimated effect of each single disorder on all subscales for physical, social and emotional functioning was negative, often as much as a 20-30 point reduction on this 100-point scale. Major depression had the greatest negative impact, followed by PTSD and panic/ agoraphobia. For patients with multiple disorders, the presence of major depression was associated with the greatest reduction in functioning status. The impact of untreated anxiety disorders and major depressive disorder on functioning was comparable to, or greater than, the effects of medical conditions such as low back pain, arthritis, diabetes and heart disease.

The mental health patient profile: does it change primary care physicians' practice patterns?

BACKGROUND: We conducted a prospective trial randomizing 75 physicians to either a control or intervention arm to evaluate the impact of providing patient-reported information on anxiety and other mental health symptoms and disorders to primary care physicians. METHODS: Five hundred seventy-three patients of the study physicians who met entry criteria were randomized to either usual care or usual care supplemented with feedback of patient-reported mental health information to physicians. This mental health information was derived from initial patient-reported questionnaires completed in waiting rooms of physicians contracted to a mixed-model health maintenance organization in Colorado. Main outcome measures included impact of intervention on rates of (1) chart notation of anxiety, depression, or other mental health diagnoses or symptoms; (2) referral to mental health specialists; (3) prescription of psychotropic medications; (4) hospitalization; and (5) office visits during a 5-month observation period. RESULTS: Physicians receiving feedback on previously unrecognized and untreated anxiety patients were more likely to make chart notations (adjusted odds ratio [AOR] = 2.51, 95 percent confidence interval [CI] = 1.62-3.87), to make referrals to mental health specialists (AOR = 3.86, 95 percent CI = 1.63-9.16), and to see patients for more frequent outpatient visits (AOR = 1.73, 95 percent CI = 1.11-2.70). Use of psychotropic medications and rate of hospitalizations did not differ significantly. CONCLUSIONS: Providing patient-reported mental health information to primary care physicians resulted in increased recognition and referral rates for previously unrecognized and untreated anxiety patients, plus an increase in primary care visits, without concomitant increases in the use of psychotropic medications or rate of hospitalizations.

Sleep problems and their correlates in a working population.

OBJECTIVE: To measure the prevalence of sleep problems in a working population and examine their association with health problems, health-related quality-of-life measures, work-related problems, and medical expenditures. Also, to explore the usefulness of a sleep-problems screen for mental health conditions and underlying sleep disorders. DESIGN: Cross-sectional survey administered via voice mail and telephone interview. SETTING: A San Francisco Bay Area telecommunications firm. PARTICIPANTS: Volunteer sample of 588 employees who worked for a minimum of six months at the company and were enrolled in its fee-for-service health plan. MEASUREMENTS AND MAIN RESULTS: Thirty percent of respondents reported currently experiencing sleep problems and were found to have worse functioning and well-being (general health, cognitive functioning, energy), more work-related problems (decreased job performance and lower satisfaction, increased absenteeism), and a greater likelihood of comorbid physical and mental health conditions than were the respondents who did not have sleep problems. They also demonstrated a trend toward higher medical expenditures. CONCLUSIONS: Self-perceived sleep problems were common among the respondents and were associated with poorer health and health-related quality of life. A single question about sleep problems may serve as an effective screen for identifying primary care patients with mental health problems, as well as underlying sleep disorders.

Rapid translation of quality of life measures for international clinical trials: avoiding errors in the minimalist approach.

There is a growing demand for tools to assess outcomes multinationally for use in international clinical trials. This has been accompanied by the need to produce valid and reliable questionnaires in a multiplicity of languages within a short time frame. We present an eight-step protocol for rapidly translating a quality of life (QOL) questionnaire into multiple languages, and demonstrate the protocol's utility and effectiveness by evaluating the translations for reliability and validity. The rapid translation protocol represents a minimalist approach to QOL questionnaire translation. Although this minimalist approach is not considered a recommended methodology, it may represent a feasible mechanism for questionnaire translation under certain circumstances. Most of the steps were completed in the USA, including a translation and back-translation by bilingual translators who were native speakers in the target-language, a test-retest of the translated instrument on five bilingual respondents to establish language and cultural equivalence and review of the translation by and editorial review board. The translated instrument was performance tested in the target language country on a pilot population of patients to determine its reliability and validity. Based on the findings, the instrument was further refined for use in the clinical trial.

Necessary but not sufficient: the effect of screening and feedback on outcomes of primary care patients with untreated anxiety.

OBJECTIVE: To consider the impact on primary care patient outcomes of using both a screener to determine elevated anxiety levels among patients with previously undetected anxiety and a physician intervention to inform physicians of their patients' conditions. DESIGN: Participating physicians were randomized to either the demonstration or the control arm, and patients were assigned to a study arm based on the randomization of their physicians. The patients were followed for change in outcome measures during the five-month study period. SETTING: A mixed-model health maintenance organization serving approximately 110,000 enrollees in central Colorado. PATIENTS/PARTICIPANTS: 573 patients who had unrecognized and untreated anxiety identified from the approximately 8,000 patients who completed the waiting room screening questionnaire. INTERVENTIONS: A physician intervention served the dual function of 1) providing an educational demonstration of anxiety in the primary care setting and 2) providing a reporting system for summarizing the anxiety symptom levels and functioning status of the patients enrolled in the study. MEASUREMENTS AND MAIN RESULTS: Patient outcomes were measured as changes in global anxiety scores, functioning and well-being, and patients' reports of global improvements. CONCLUSIONS: The findings indicate that this method of reporting symptoms and functioning status to primary care physicians did not significantly change patient outcomes. Improvement in outcomes appeared to be more closely associated with the patient's severity of psychological distress.

Untreated anxiety among adult primary care patients in a Health Maintenance Organization.

BACKGROUND: Untreated anxiety may be particularly difficult for primary care physicians to recognize and diagnose because there are no reliable demographic or medical profiles for patients with this condition and because these patients present with a high rate of comorbid psychological conditions that complicate selection of treatment. METHOD: A prospective assessment of untreated anxiety symptoms and disorders among primary care patients. RESULTS: Approximately 10% of eligible patients screened in clinic waiting rooms of a mixed-model health maintenance organization reported elevated symptoms and/or disorders of anxiety that were unrecognized and untreated. These patients with untreated anxiety reported significantly worse functioning on both physical and emotional measures than "not anxious" comparison patients; in fact these patients reported reduced functioning levels within ranges that would be expected for patients with chronic physical diseases, such as diabetes and congestive heart failure. The most severe reductions in functioning were reported by untreated patients whose anxiety was mixed with depression symptoms or disorders. CONCLUSION: Primary care physicians may benefit from screening tools and consultations by mental health specialists to assist in recognition and diagnosis of anxiety symptoms and disorders alone and mixed with depression.

Quality of life of persons with onychomycosis.

Onychomycosis is a fungal infection of the nails which, although unsightly in appearance, is often considered to be a cosmetic problem. This research reports on the development and performance of a quality-of-life instrument to measure the impact of this disease on the patients' mental and general health, social functioning, pain, and self-confidence. In telephone interviews, 680 members of a health maintenance organization (299 with onychomycosis and 381 without) were asked a battery of items regarding quality of life (mental and social functioning, self-esteem, pain) and specific problems and symptoms related with one's nails. Persons with onychomycosis had significantly poorer ratings compared with the healthy persons with respect to general health (p = 0.02) and bodily pain p < 0.001). Persons with onychomycosis also had significantly (p < 0.05) poorer ratings for mental health, social functioning, health concern, physical appearance, and functional limitations associated with activities involving standing on one's feet or working with one's fingers. This study is the first to document the impact of onychomycosis on an individual's quality of life. Persons with onychomycosis may adapt to this condition, but they continue to experience embarrassment and discomfort that reduces their quality of life.

Quality of life and health service use among HIV-infected patients with chronic diarrhea.

Health-related quality of life and the utilization of health resources are important components of the evaluation of patient outcome in HIV infection because medical problems are often progressive and debilitating, and treatment is palliative. We evaluated quality-of-life measures and resource utilization of patients with AIDS and/or CD4 lymphocytes < 200 who had symptoms of chronic diarrhea and compared them with similar patients with AIDS and/or CD4 lymphocytes < 200 without diarrheal symptoms. Annual charges were 50% higher for patients with chronic diarrhea ($24,567 versus $14,471 for the comparison group, p < 0.01). Higher charges for the patients with diarrhea were a result of more physician visits and diagnostic testing. Quality-of-life scores were poor for all patients, but deterioration over the year in role functioning (social activity, daily living, energy, cognition) and general health was clearly evident (p < 0.01) for the patients with chronic diarrhea. These patients also suffered significant work loss and reported greater need for assistance in the home. These data suggest that HIV-infected patients with diarrhea experience marked decreases in quality of life and that care for patients with chronic diarrhea is costly. Relatively little attention has been paid to this debilitating syndrome, and current treatment options rarely provide permanent relief. Research and innovation in this area are needed; an estimated 25-50% of HIV-positive individuals suffer from this symptom complex.

Gemfibrozil cost-benefit study. Targeting subgroups for effective hyperlipidaemia drug therapy.

This cost-benefit analysis attempts to translate the clinical findings of the Helsinki Heart Study (HHS) and published results regarding additional cardiovascular conditions into economic terms meaningful to US managed care providers. The study has the following 3 key objectives: to define the cost effectiveness of gemfibrozil in the prevention of coronary heart disease (CHD); to assess the net impact of gemfibrozil on total treatment costs for CHD; and to identify those patient groups for whom gemfibrozil therapy is most cost effective. In order to reach these findings a cost-effectiveness model was constructed based on original clinical data provided by the HHS, published findings for CHD risk and cost of treatment in the US, expert opinion and extension of HHS to other cardiovascular conditions, and documented costs and treatment protocols of US Medicaid and privately managed health care programmes. The model was applied to the California Medicaid (Medi-Cal) programme to estimate costs of hyperlipidaemia therapy using gemfibrozil. In parallel, savings to Medi-Cal from averted coronary events were estimated. From these data, the net expected savings to Medi-Cal were calculated. The probability of experiencing CHD varies with cholesterol level, age, sex and risk factors such as smoking, hypertension and diabetes. Therefore, it is possible to use risk-factor profiles to define groups of individuals with low, moderate or high risk of experiencing acute myocardial infarction (AMI) or sudden cardiac death. The probability of a cardiac event within 5 years ranges from 1.1% in a 45-year-old low risk male to over 36% in a 55-year-old high risk male. The average total cost of CHD care was found to be US$22,271 within 5 years. Using the probability of a CHD event to calculate the expected 5-year cost of CHD care produces a range from US$242 in the 45-year-old low risk male to US$8084 in the 55-year-old high risk male. Treatment with gemfibrozil reduces the probability of AMI and sudden cardiac death events by 34%, as demonstrated in the HHS. Therefore, the corresponding probability ranges are reduced to 0.7% in the 45-year-old low risk male and 27.3% in the 55-year-old high risk male after treatment with gemfibrozil. The expected cost of a coronary event is reduced by US$82 and US$1997, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)