Correlates of depression outcomes in collaborative care for HIV.

BACKGROUND: Collaborative care can treat depression in HIV but existing studies have been limited by excluding patients with acute or severe depression. The purpose of this analysis is to determine if real-world implementation of collaborative care in HIV is associated with improvement in depression, and to identify correlates of depression outcomes. METHODS: Collaborative care was implemented as part of a large practice transformation initiative. Change in depression, measured by PHQ-9 score, at baseline compared to 12 months post-enrollment was the outcome, which was operationalized as remission, response, and neither response nor remission. Bivariate and multivariate associations were assessed between several variables at baseline and the outcome. RESULTS: Out of 416, 99 (23.79%) patients remitted and 89 (21.39%) responded (without remission). In the bivariate analysis having a documented psychiatric comorbidity was associated with low remission [31 (16.58%)]; p = 0.008. Having generalized anxiety disorder was associated with low remission [18 (15.00%)] and response rates [26 (21.67%)]; p = 0.022. Having a substance use disorder (alcohol, cocaine, or amphetamine) - was associated with poor remission [29 (16.67%)] and response [33 (18.97%)]; p = 0.004. Social isolation was correlated with lower response and remission rates (p = 0.0022). In the multivariate analysis older age was associated with higher remission rates (OR: 1.10; 95% CI: 1.005-1.194) whereas being a Medicaid beneficiary (OR: 0.652; 95% CI: 1.123-2.797), having comorbid generalized anxiety disorder (OR: 0.267; 95% CI: 0.122-0.584) or a stimulant use disorder (cocaine [OR: 0.413; 95% CI: 0.222-0.926] or amphetamines [OR: 0.185; 95% CI: 0.037-0.766]), was associated with lower remission rates. CONCLUSION: We found that depression improved in our study subjects. We identified several modifiable correlates of depression outcomes.

Balancing the risk of postoperative surgical infections: a multivariate analysis of factors associated with laparoscopic appendectomy from the NSQIP database.

OBJECTIVE: To establish the relationship between operative approach (laparoscopic or open) and subsequent surgical infection (both incisional and organ space infection) postappendectomy, independent of potential confounding factors. BACKGROUND: Although laparoscopic appendectomy has been associated with lower rates of incisional infections than an open approach, the relationship between laparoscopy and organ space infection (OSI) is not as clearly established. METHODS: Cases of appendectomy were retrieved from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for 2005 to 2008. Patient factors, operative variables, and the primary outcomes of incisional infections and OSIs were recorded. Factors associated with surgical infections were identified using logistic regression models. These models were then used to calculate probabilities of OSI in clinical vignettes demonstrating varying levels of infectious risk. RESULTS: A total of 39,950 appendectomy cases were included of which 30,575 (77%) were performed laparoscopically. On multivariate analysis, laparoscopy was associated with a lower risk of incisional infection [odds ratio (OR) 0.37, 95% confidence interval (CI) 0.32-0.43] but with an increased risk of OSI after adjustment for confounding factors (OR 1.44, 95% CI 1.21-1.73). For a low-risk patient, probability of OSI was calculated to be 0.3% and 0.4%, respectively, for open versus laparoscopic appendectomy, whereas for a high-risk patient, probabilities were estimated at 8.9% and 12.3%, respectively. CONCLUSION: Laparoscopy was associated with a decreased risk of incisional infection but with an increased risk of OSI. The degree of this increased risk varies depending on the clinical profile of a surgical patient. Recognition of these differences in risk may aid clinicians in the choice of operative approach for appendectomy.