Counseling for depression by primary care providers.

OBJECTIVE: Primary care providers (PCPs) deliver a significant amount of depression care, yet little is known about the content of clinical encounters with depressed patients. We describe the extent to which PCP's encounters with depressed and non-depressed patients involve psychotherapeutic counseling relative to other types of counseling during primary care visits. METHOD: Cross-sectional evaluation of audiotaped office visits between October 1997 and September 1998 with 154 patients of 27 PCPs at three Veterans' Health Administration clinics in California. Using the Roter Interaction Analysis System, we coded conversation into mutually exclusive talk categories and developed specific measures of depression counseling coded for sequences of depression talk. Analysis of variance and covariance was used to evaluate differences in counseling by depression type adjusted for encounter length, previous depression treatment, patient characteristics, and provider clustering. RESULTS: PCPs delivered significantly more depression care (assessed using coded audiotapes of patient visits) to their patients with major depression compared with patients who had no depression or symptoms but no disorder. However, counseling using psychotherapeutic techniques did not differ by depression level and was equivalent for patients with major depression and subthreshold relative to non-depressed. Encounters with patients who had major depression included more talk about depression, devoted more time to discussing depression, and included more depression talk per minute. PCP encounters with depressed patients also included less biomedical talk compared to other groups. CONCLUSIONS: Findings suggest that PCPs do provide depression counseling to their patients who need it the most. Whether counseling is associated with appropriate treatment and subsequent outcomes will require additional research.

Utilization of well-child care services for African-American infants in a low-income community: results of a randomized, controlled case management/home visitation intervention.

OBJECTIVE: To evaluate a case management/home visitation intervention to improve access to and utilization of well-child care (WCC) visits. STUDY DESIGN: Randomized, controlled trial with baseline and follow-up interview surveys. Mothers and infants in the intervention group were assigned to a case manager who made at least four home visits during the infant's first year of life. In addition, the case managers contacted clients by telephone and mail to see if they had kept their WCC appointments and to follow up on other issues. SAMPLE AND DATA COLLECTION: A population-based random sample of African-American mothers of newborns from South Central Los Angeles: 185 mothers in the intervention group and 180 in the control group completed both interview surveys. The principal outcome variable was number of WCC visits. Additional outcome variables included the child's type of insurance, the number of months with insurance coverage during the first year of life, age when first enrolled in Medi-Cal, age at the first WCC visit, usual source of WCC, travel time to the usual source of care, whether the child had a regular provider, and whether the child ever needed care but did not get it. RESULTS: There was little change in the overall distribution of number of WCC visits during the first year of life. Comparisons of the cumulative numbers of visits for each possible cutoff showed that children in the intervention group were more likely than children in the control group to have at least four visits (81% vs 70%). Because this split was identified empirically rather than through an antecedent hypothesis, we conducted a Smirnov test to account for multiple comparisons. This test showed a reduced level of significance. Other outcome variables did not show significant differences for the control and intervention groups. CONCLUSIONS: In light of the high expense of this intervention, our evaluation shows that our moderate-intensity case management and home visitation program is not an effective way to increase the number of WCC visits.

Increasing immunization rates among inner-city, African American children. A randomized trial of case management.

CONTEXT: Immunization rates in the inner city remain lower than in the general US population, but efforts to raise immunization levels in inner-city areas have been largely untested. OBJECTIVE: To assess the effectiveness of case management in raising immunization levels among infants of inner-city, African American families. DESIGN: Randomized controlled trial with follow-up through 1 year of life. SETTING: Low-income areas of inner-city Los Angeles, Calif. PATIENTS: A representative sample of 419 African American infants and their families. INTERVENTIONS: In-depth assessment by case managers before infants were 6 weeks of age, with home visits 2 weeks prior to when immunizations were scheduled and additional follow-up visits as needed. MAIN OUTCOME MEASURES: Percentage of children with up-to-date immunizations at age 1 year, characteristics associated with improved immunization rates, and cost-effectiveness of case management intervention. RESULTS: A total of 365 newborns were followed up to age 1 year. Overall, the immunization completion for the case management group was 13.2 percentage points higher than the control group (63.8% vs 50.6%; P=.01). In a logistic model, the case management effect was limited to the 25% of the sample who reported 3 or fewer well-child visits (odds ratio, 3.43; 95% confidence interval, 1.26-9.35); for them, immunization levels increased by 28 percentage points. Although for the case management group intervention was not cost-effective ($12022 per additional child immunized), it was better ($4546) for the 25% of the sample identified retrospectively to have inadequate utilization of preventive health visits. CONCLUSIONS: A case management intervention in the first year of life was effective but not cost-effective at raising immunization levels in inner-city, African American infants. The intervention was demonstrated to be particularly effective for subpopulations that do not access well-child care; however, currently there are no means to identify these groups prospectively. For case management to be a useful tool to raise immunizations levels among high-risk populations, better methods of tracking and targeting, such as immunization registries, need to be developed.

Counseling typically provided for depression. Role of clinician specialty and payment system.

BACKGROUND: To assess how current policy trends may affect the use of counseling for depression, we examined the variation in the use of counseling and usual clinician counseling style for depression across specialty sectors (psychiatry, psychology, and general medicine) and reimbursement type (fee-for-service or prepaid). METHODS: Three types of observational data from the RAND Medical Outcomes Study: (1) patient-reported demographics, depressive symptoms, clinical status, and perceptions about participation style; (2) clinician reports of counseling during specific patient encounters; and (3) clinician reports of the usual counseling and interpersonal style across patients who were seen in a practice. RESULTS: While almost all depressed patients who were being treated by mental health specialists received brief counseling for at least 3 minutes, less than half of the depressed patients in the general medical sector received such counseling--even for those patients with a current depressive disorder. Counseling rates were lower under prepaid than fee-for-service care in general medical practices. Psychiatrists relied more on psychodynamic approaches, and psychologists relied more on behavioral therapies relative to each other, but both specialty groups provided longer sessions and used more formal psychotherapeutic techniques (e.g., interpretation) than did general medical clinicians. Clinicians who were treating more patients who had prepaid plans reported a lower proclivity for face-to-face counseling, and they spent less time when they were counseling patients compared with clinician who were treating more patients who had fee-for-service plans; however, these differences were not large. CONCLUSION: The use of counseling in the usual care for depression varied by both specialty and payment system, while the usual clinician counseling style differed markedly by specialty, but only slightly by payment system.

Factors related to immunization status among inner-city Latino and African-American preschoolers.

OBJECTIVE: To identify factors associated with undervaccination at 3 months and 24 months among low-income, inner-city Latino and African-American preschool children. DESIGN: Interviews with a representative sample of inner-city families using a cross-sectional, multi-stage, cluster-sample design combined with a replicated quota sampling approach. SETTING: South Central and East Los Angeles areas in inner-city Los Angeles. POPULATION: Eight hundred seventeen Latino and 387 African-American families with children between 12 and 36 months of age. MAIN OUTCOME VARIABLES: Being fully immunized or up-to-date (UTD) at 3 months (1 diphtheria-tetanus-pertussis vaccine and 1 oral polio vaccine) and 24 months of age (4 diphtheria-tetanus-pertussis vaccines, 3 oral polio vaccines, and 1 measles-mumps-rubella vaccine). METHODS: Logistic regressions of UTD immunization status at 3 and 24 months by population and health care system factors. RESULTS: Seventy percent of Latino children and 53% of African-American children were UTD at 3 months of age. At 24 months of age, 42% of Latino children and 26% of African-American children were UTD on their immunizations. Receipt of the first immunizations by 3 months was associated with smaller family size, and evidence of connection to prenatal care. Latino children were less likely to be UTD at 24 months if they obtained well child care from private providers versus public clinics (odds ratio [OR] = 0.45, 95% confidence interval [CI] = 0.26, 0.79). There was also a trend for Latino children to be less well immunized if they were in health maintenance organizations versus public clinics (0.31, 0.05 < P < .1). African-American children were more likely to be UTD at 24 months if they were UTD at 3 months (OR = 5.56, 95% CI = 1.43, 21.6), had more health visits (OR = 1.13, 95% CI = 1.01, 1.27), and were less likely to be UTD at 24 months if they were on Medicaid versus private insurance (OR = 0.26, 95% CI = 0.08, 0.90). IMPLICATIONS: Both African-American and Latino children in inner-city Los Angeles have low immunization rates at 3 and 24 months. Prenatal care and family size are strongly associated with being UTD by 3 months; however, family and child characteristics are relatively unimportant predictors of being UTD at 24 months of age. Important risk factors for underimmunization at 2 years of age in the inner-city, low-income communities studied include type of health insurance and source of well child care, with the public sector having higher rates than private doctors' offices or health maintenance organization/managed care plans.

The impact of patient adherence on health outcomes for patients with chronic disease in the Medical Outcomes Study.

The association between adherence to medical recommendations and health outcomes (physical, role, and social functioning, energy/fatigue, pain, emotional well-being, general health perceptions, diastolic blood pressure, and glycohemoglobin) was examined in a 4-year longitudinal, observational study of 2125 adult patients with chronic medical conditions (hypertension, diabetes, recent myocardial infarction, congestive heart failure) and/or depression. Change score models were evaluated, controlling for disease and comorbidity. Patient adherence was associated minimally with improvement in health outcomes in this study. Only 11 of 132 comparisons showed statistically significant positive effects of adherence on health outcomes. We conclude that the relationship between adherence and health outcomes is much more complex than has often been assumed.

The RAND 36-Item Health Survey 1.0.

Recently, Ware and Sherbourne published a new short-form health survey, the MOS 36-Item Short-Form Health Survey (SF-36), consisting of 36 items included in long-form measures developed for the Medical Outcomes Study. The SF-36 taps eight health concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, general mental health, social functioning, energy/fatigue, and general health perceptions. It also includes a single item that provides an indication of perceived change in health. The SF-36 items and scoring rules are distributed by MOS Trust, Inc. Strict adherence to item wording and scoring recommendations is required in order to use the SF-36 trademark. The RAND 36-Item Health Survey 1.0 (distributed by RAND) includes the same items as those in the SF-36, but the recommended scoring algorithm is somewhat different from that of the SF-36. Scoring differences are discussed here and new T-scores are presented for the 8 multi-item scales and two factor analytically-derived physical and mental health composite scores.