Primary Care Clinic Setting Research Articles

Development of an instrument to identify symptoms potentially indicative of ovarian cancer in a primary care clinic setting

Background: Several recently published studies suggest that screening for symptoms could improve the early diagnosis of ovarian cancer. This report describes the development of a simple and reliable method of collecting symptom information in a primary care clinic. Methods: 1200 women, ages 40 - 87, completed several versions of a draft symptom index (SI) assessment form during their visits to a primary care clinic. Factors associated with a positive SI result were examined. Providers were surveyed about acceptability of the symptom screening procedures. Findings: Variation in the instructions provided to women influenced the rate at which women indicated having symptoms indicative of a positive SI, 5% had positive results when written instructions emphasized listing only current symptoms. Women coming to the clinic because of a current medical concern or problem did have higher rates of positive SI results, as did non-white women (p < 0.05). Acceptability by providers was high. Patients could independently complete the SI in under 5 minutes. One patient with a positive SI was diagnosed with ovarian cancer and none with a negative SI developed cancer. Interpretation: A quick paper and pencil form can be used to identify women with symptoms potentially indicative of ovarian cancer. Use of such a form for ovarian cancer screening purposes is acceptable to most women and providers in a primary care clinic setting.

Helicobacter pylori management in primary care

Helicobacter pylori is a Gram-negative bacterium that chronically infects the stomach of more than 50% of the human population, and represents the major cause of gastric cancer, gastric lymphoma, gastric autoimmunity and peptic ulcer diseases [1–4]. The International Agency for Research on Cancer classifies H. pylori as a human carcinogen for distal gastric cancer. Eradicating the bacterium, in high-risk populations, reduces the incidence of gastric cancer [5]. Likewise, antibiotic treatment leads to the regression of gastric MALT lymphoma [2]. H. pylori also contributes to other conditions, such as vitamin B12 and iron deficiencies, idiopathic thrombocytic purpura, and growth retardation in children [6]. Current guidelines indicate that the eradication of H. pylori infection is considered mandatory in patients with peptic ulcer and gastric malignancies, such as gastric adenocarcinoma and MALT lymphoma [6, 7]. Furthermore, it is recommended in patients with non-ulcer dyspepsia, especially in those with the evidence of macroscopic or microscopic mucosal abnormalities (erosions, intestinal metaplasia, atrophy), naive non-steroidal anti-inflammatory drugs (NSAIDs) users, chronic NSAIDs users, first-degree relatives of gastric cancer patients as well as in unexplained iron deficiency anaemia, and idiopathic thrombocytopenic purpura. Low-dose aspirin (ASA) therapy is widely used in primary care because of the proved efficacy in both primary and secondary prevention of cardiovascular events [8]. A synergistic interaction between H. pylori infection and NSAIDs has been extensively documented although the benefits of H. pylori eradication in NSAIDs users are conflicting [6, 9–11]. H. pylori has been shown to increase, by almost seven times, the risk of upper gastrointestinal complications in chronic NSAIDs users [12, 13]. The relationship between H. pylori infection and NSAIDs in gastroduodenal pathology is complex. Since both NSAIDs and H. pylori can cause peptic ulcers, H. pylori eradication can only be expected to prevent the recurrence of H. pylori ulcers, and while it may also reduce the incidence of ulcers among those with both H. pylori and NSAID use, the effects will vary depending on the proportion with real H. pylori ulcers in the population studied [6]. Zullo et al. [14] designed a very interesting study (reported in the current issue) to assess the management of H. pylori infection in a very large cohort of chronic NSAID users in primary care clinical settings. H. pylori was being used only in a minority (less than 20%) of primary care patients receiving chronic NSAID therapy. H. pylori was eventually cured in two-third of the infected cases. The low alertness towards such H. pylori infection in these patients suggests a need for prompt implementation of current guidelines. Furthermore, the results obtained by Zullo et al. [14], other large meta-analysis studies, strongly support the concept that patients requiring long-term NSAIDs/ASA therapy should be tested and cured of the infection [9, 14, 15] because the cure of H. pylori infection contributes to the reduction of potential life-threatening gastrointestinal critical events (such as gastroduodenal bleeding) in primary care unstable patients. M. M. D’Elios E. Silvestri G. Emmi D. Prisco PatologiaMedica, AOU Careggi, Largo Brambilla 3, 50134 Florence, Italy

Inappropriate Use of Fibrate Therapy in a University-Based Primary Care Clinic Setting*

and 4) revealed that only age had a significant inverse association with a providers’ ability to calculate non-HDL-C (odds ratio 0.45, 95% confidence interval 0.24–0.85). Type of provider (physician vs nonphysician), specialists versus nonspecialist provider, academic versus non-academic practice setting, years since completing training, percentage of patients with dyslipidemia in a provider’s panel, and provider’s use of specialized lipid testing were not associated with providers’ ability to calculate non-HDL-C levels or knowledge regarding non-HDL-C treatment goals. Conclusions: Major gaps remain in providers’ awareness regarding non-HDL-C treatment goals and their ability to calculate non-HDL-C levels. These gaps are systemic and not restricted to specialists or non-specialists. Therefore, there is a need to implement system level interventions across specialties to address these gaps.

Quality of and patient satisfaction with primary health care for anxiety disorders.

Most patients with anxiety disorders receive their care from primary care practitioners (PCPs). The purpose of this study was to evaluate quality of and patient satisfaction with primary health care for anxiety disorders. A survey was performed among 1,004 outpatients with anxiety disorders (diagnosed according to DSM-IV) referred by their PCPs from 17 primary care clinical settings (3 of which were university-affiliated) in 4 regions of the United States for participation in the Coordinated Anxiety Learning and Management (CALM) study, a therapeutic trial. Participating research institutions were the University of Washington at Seattle, the University of California at San Diego and Los Angeles, and the University of Arkansas for Medical Sciences at Little Rock. Enrollment took place between June 2006 and April 2008. Patients were contacted by telephone after enrollment to provide information about previous care received (during the 6 months prior to referral) and satisfaction with that care. Quality-of-care indicators were self-reported type, dose, and duration of antianxiety medication treatment and self-reported psychotherapy with cognitive-behavioral therapy (CBT) elements. A total of 576 patients (57.4%) had received an appropriate antianxiety medication in the previous 6 months, but only 289 patients (29.4% of 983 who answered this question) had received the medication at adequate dose for at least 2 months. A total of 465 patients (46.3%) had received some counseling with at least 1 element of CBT, but only 213 patients (21.2%) had received counseling with a strong (3+ elements) CBT focus. Overall, 416 patients (41.4%) had received quality pharmacotherapy or psychotherapy, and 81 patients (8.1%) had received both. Only 432 patients (44.8% of 964 who answered this question) were at least somewhat satisfied with their mental health care. Receipt of quality psychotherapy was the sole positive predictor (adjusted odds ratio = 2.71; 95% CI, 1.94-3.80; P < .0005) of satisfaction with mental health care for anxiety. Moreover, there was a dose-response relationship between the number of CBT elements consistently delivered and satisfaction with care (test for trend, z = 4.06, P < .0005). Despite recognition of these patients' anxiety disorders and referral by their PCPs to an anxiety treatment study, fewer than half of the patients had in the prior 6 months received quality pharmacologic and/or psychosocial mental health care. Receipt of CBT-oriented, quality psychosocial (but not pharmacologic) care showed a strong dose-response relationship with satisfaction with mental health care.

Harnessing Geographic Information Systems (GIS) to Enable Community-Oriented Primary Care

Background: Despite growing acceptance and implementation of geographic information systems (GIS) in the public health arena, its utility for clinical population management and coordination by leaders in a primary care clinical health setting has been neither fully realized nor evaluated. Methods: In a primary care network of clinics charged with caring for vulnerable urban communities, we used GIS to (1) integrate and analyze clinical (practice management) data and population (census) data and (2) generate distribution, service area, and population penetration maps of those clinics. We then conducted qualitative evaluations of the responses of primary care clinic leaders, administrators, and community board members to analytic mapping of their clinic and regional population data. Results: Practice management data were extracted, geocoded, and mapped to reveal variation between actual clinical service areas and the medically underserved areas for which these clinics received funding, which was surprising to center leaders. In addition, population penetration analyses were performed to depict patterns of utilization. Qualitative assessments of staff response to the process of mapping clinical and population data revealed enthusiastic engagement in the process, which led to enhanced community comprehension, new ideas about data use, and an array of applications to improve their clinical revenue. However, they also revealed barriers to further adoption, including time, expense, and technical expertise, which could limit the use of GIS and mapping unless economies of scale across clinics, the use of web technology, and the availability of dynamic mapping tools could be realized. Conclusions: Analytic mapping was enthusiastically received and practically applied in the primary care setting, and was readily comprehended by clinic leaders for innovative purposes. This is a tool of particular relevance amid primary care safety-net expansion and increased funding of health information technology diffusion in these settings, particularly if the hurdles of cost and technological expertise are overcome by harnessing new advances in web-based mapping technology.

Warnings That Signal Serious Illness in Children

INFECTION IS AN important source of mortality in children in developed countries. In children aged 1–4 years, infections account for 20% of childhood deaths (Confidential Enquiry into Maternal and Child Health, 2008). In developed countries, every child will come to his or her health care provider, on average, more than once a year with the symptoms of an infection (Van den Bruel, Haj-Hassen, Thompson, Buntinx, & Mant, 2010). Clinicians in primary care settings are often faced with the challenge of recognizing serious illness in children.

Red Flags That Signal Serious Illness in Children

Clinicians in primary care settings occasionally are faced with the challenge of recognizing and identifying serious illness in children. To examine

The effect of time spent in treatment and dropout status on rates of convictions, cautions and imprisonment over 5 years in a primary care‐led methadone maintenance service

Methadone maintenance treatment (MMT) in primary care settings is used increasingly as a standard method of delivering treatment for heroin users. It has been shown to reduce criminal activity and incarceration over periods of periods of 12 months or less; however, little is known about the effect of this treatment over longer durations. To examine the association between treatment status and rates of convictions and cautions (judicial disposals) over a 5-year period in a cohort of heroin users treated in a general practitioner (GP)-led MMT service. Cohort study. The primary care clinic for drug dependence, Sheffield, 1999-2005. The cohort comprised 108 consecutive patients who were eligible and entered treatment. Ninety were followed-up for the full 5 years. The intervention consisted of MMT provided by GPs in a primary care clinic setting. Criminal conviction and caution rates and time spent in prison, derived from Police National Computer (PNC) criminal records. The overall reduction in the number of convictions and cautions expected for patients entering MMT in similar primary care settings is 10% for each 6 months retained in treatment. Patients in continuous treatment had the greatest reduction in judicial disposal rates, similar to those who were discharged for positive reasons (e.g. drug free). Patients who had more than one treatment episode over the observation period did no better than those who dropped out of treatment. MMT delivered in a primary care clinic setting is effective in reducing convictions and cautions and incarceration over an extended period. Continuous treatment is associated with the greatest reductions.

Harnessing Geographic Information Systems (GIS) to Enable Community-Oriented Primary Care

Despite growing acceptance and implementation of geographic information systems (GIS) in the public health arena, its utility for clinical population management and coordination by leaders in a primary care clinical health setting has been neither fully realized nor evaluated. In a primary care network of clinics charged with caring for vulnerable urban communities, we used GIS to (1) integrate and analyze clinical (practice management) data and population (census) data and (2) generate distribution, service area, and population penetration maps of those clinics. We then conducted qualitative evaluation of the responses of primary care clinic leaders, administrators, and community board members to analytic mapping of their clinic and regional population data. Practice management data were extracted, geocoded, and mapped to reveal variation between actual clinical service areas and the medically underserved areas for which these clinics received funding, which was surprising to center leaders. In addition, population penetration analyses were performed to depict patterns of utilization. Qualitative assessments of staff response to the process of mapping clinical and population data revealed enthusiastic engagement in the process, which led to enhanced community comprehension, new ideas about data use, and an array of applications to improve their clinical revenue. However, they also revealed barriers to further adoption, including time, expense, and technical expertise, which could limit the use of GIS and mapping unless economies of scale across clinics, the use of web technology, and the availability of dynamic mapping tools could be realized. Analytic mapping was enthusiastically received and practically applied in the primary care setting, and was readily comprehended by clinic leaders for innovative purposes. This is a tool of particular relevance amid primary care safety-net expansion and increased funding of health information technology diffusion in these settings, particularly if the hurdles of cost and technological expertise are overcome by harnessing new advances in web-based mapping technology.

Understanding Nicotine and Depression

It is likely that nurse practitioners (NPs) will see patients who are chronic smokers and also depressed. Nicotine-dependent smokers are twice as likely to experience major depression compared to nondependent smokers and non-smokers. Biological and cognitive learning models provide an understanding of the relationship between the 2 conditions. Clinicians in primary care settings can select strategies of assessment, treatment, and education to care for patients presenting with these co-occurring conditions.

Are Elements of the Chronic Care Model Associated with Cardiovascular Risk Factor Control in Type 2 Diabetes?

Control of modifiable risk factors for cardiovascular (CV) disease, the most common cause of morbidity and mortality among people with Type 2 diabetes is dependent on both patient self-care behaviors and the characteristics of the clinic in which care is delivered. The relationship between control of CV risk factors, patient self-care behaviors, and the presence of CCM (Chronic Care Model) components across multiple primary care clinic settings was examined. Thirty consecutive patients presenting with Type 2 diabetes were enrolled from each of 20 primary care clinics from across South Texas. Patients were asked about their stage of change for four self-care behaviors: diet, exercise, glucose monitoring, and medication adherence. CV risk factors included the most recent values of glycosolated hemoglobin (A1C), blood pressure, and (low-density lipoprotein) cholesterol. Clinicians in each clinic completed the Assessment of Chronic Illness Care (ACIC) survey, a validated measure of the CCM components. Hierarchical logistic regression models were used. Only 25 (13%) of the 618 patients had good control of all three CV risk factors. Good control of these risk factors was positively associated with community linkages and delivery system design but was inversely associated with clinical information systems. Patients who were in the maintenance stage of change for all four self-care behaviors were more likely to have all three risk factors well controlled. Risk factors for CV disease among patients with diabetes are associated with the structure and design of the clinical microsystem where care is delivered. In addition to focusing on clinician knowledge, future interventions should address the clinical microsystem's structure and design to reduce the burden of CV disease among patients with Type 2 diabetes.

Exercise (Carefully) to Boost Quality of Life

Adhering to an “exercise prescription” can result in a higher level of physical activity, but whether this outcome is sustained beyond 1 year of follow-up (and what its effects are on health-risk factors) is unknown. In a New Zealand study in the primary care clinic setting, investigators randomized 1089 physically inactive women (age range, 40–74) to exercise prescriptions (intervention group) or usual care (control group). For the intervention group, clinicians prescribed physical activity with the goal of 150 minutes of moderate exercise (such …

Sexually Transmitted Infection/HIV Risk Reduction Interventions in Clinical Practice Settings

African American women, particularly those who live in inner-city areas, experience disproportionately high rates of sexually transmitted infections including HIV. As there are currently no preventive vaccines for HIV and most sexually transmitted infections, prevention efforts must focus on behavioral risk reduction. Thus, culturally tailored interventions for African American women are needed to reduce their incidence of sexually transmitted infections including HIV. One place to intervene with inner-city African American women is in primary care settings. Primary care settings have the potential to reach a wide range of women, including those who may not proactively seek sexually transmitted infection/HIV prevention services. However, in order to be feasible for use in clinical settings, sexually transmitted infection/HIV risk reduction interventions must be brief and easily adapted for use with diverse clients in varied practice environments. To date, few brief sexually transmitted infection/HIV prevention interventions have been designed for use with African American women in primary care settings. Only one of these, the "Sister to Sister: Respect Yourself! Protect Yourself! Because You Are Worth It!" intervention, has demonstrated effectiveness in reducing sexual risk behaviors and sexually transmitted infection incidence. This article describes this 20-minute, one-on-one nurse-led intervention for African American women and discusses considerations for its implementation in primary care and other clinical settings.

Understanding ethnic disparities in the use of total joint arthroplasty: Application of the health belief model

The Health Belief Model holds promise in understanding patient-related factors that may explain disparities in the use of total joint arthroplasty (TJA). We examined whether patients' health beliefs differ between African Americans and whites. In a primary care clinic setting, 691 African Americans and whites with at least a moderately severe degree of osteoarthritis (OA) completed the Arthritis-related Health Belief Instrument. The instrument has 4 scales: perceived benefits of TJA, perceived barriers to obtaining TJA, perceived severity of arthritis, and perceived susceptibility of arthritis to worsen. The sample (40% women) consisted of 263 (38%) African Americans and 428 (62%) whites who were similar with respect to education, amount of insurance coverage, number of comorbidities, and self-report OA severity score. The African American group was younger, had less men, had more participants who reported an annual income<$15,000, and had a higher body mass index than whites. After controlling for confounders, African Americans were almost 50% (odds ratio [OR] 0.60, 95% confidence interval [95% CI] 0.42-0.86, P=0.005) as likely as whites to perceive that TJA is beneficial or helpful for their arthritis. Furthermore, African Americans were 70% (OR 1.7, 95% CI 1.18-2.44, P=0.004) more likely than whites to recognize barriers (e.g., risky, etc.) to TJA. Race was not associated with either the perceived severity or the perceived susceptibility of arthritis to worsen. Among patients with at least moderately severe OA, African Americans were significantly less likely than whites to perceive the benefits of TJA and more likely to recognize barriers to TJA.

Factorial invariance found in survey instrument measuring arthritis-related health beliefs among African-Americans and Whites

Objective Reliable and valid instruments for measuring health beliefs related to arthritis and total joint arthroplasty (TJA) are lacking. The present study examined the factorial invariance of an Arthritis-related Health Belief Instrument (AHBI) that measures four constructs: severity of arthritis, susceptibility of arthritis to get worse, and perceived benefits and barriers of TJA. Study Design and Setting In an urban primary care clinic setting, African-American (AA) and White (W) patients ( n = 664) with at least a moderately severe degree of osteoarthritis completed the AHBI. For the cross-sectional data on the first 120 enrolled participants, exploratory factor analysis was performed to derive the initial factor structures. For the remaining 544 participants, single-group and multi-group confirmatory factor analyses (CFA) were performed to assess factorial invariance. Results The CFA analyses revealed that a four-factor model was invariant across race. Conclusion The findings of invariance across race support the use of the AHBI to measure ethnic group differences in health beliefs as they relate to arthritis and TJA. Future analyses should continue to assess other aspects of reliability and validity of the AHBI.

Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation

To assess the clinical effectiveness and cost-effectiveness of buprenorphine maintenance therapy (BMT) and methadone maintenance therapy (MMT) for the management of opioid-dependent individuals. Major electronic databases were searched from inception to August 2005. Industry submissions to the National Institute for Health and Clinical Excellence were accessed. The assessment of clinical effectiveness was based on a review of existing reviews plus an updated search for randomised controlled trials (RCTs). A decision tree with Monte Carlo simulation model was developed to assess the cost-effectiveness of BMT and MMT. Retention in treatment and opiate abuse parameters were sourced from the meta-analysis of RCTs directly comparing flexible MMT with flexible dose BMT. Utilities were derived from a panel representing a societal perspective. Most of the included systematic reviews and RCTs were of moderate to good quality, and focused on short-term (up to 1-year follow-up) outcomes of retention in treatment and the level of opiate use (self-report or urinalysis). Most studies employed a trial design that compared a fixed-dose strategy (i.e. all individuals received a standard dose) of MMT or BMT and were conducted in predominantly young men who fulfilled criteria as opiate-dependent or heroin-dependent users, without significant co-morbidities. RCT meta-analyses have shown that a fixed dose of MMT or BMT has superior levels of retention in treatment and opiate use than placebo or no treatment, with higher fixed doses being more effective than lower fixed doses. There was evidence, primarily from non-randomised observational studies, that fixed-dose MMT reduces mortality, HIV risk behaviour and levels of crime compared with no therapy and one small RCT has shown the level of mortality with fixed-dose BMT to be significantly less than with placebo. Flexible dosing (i.e. individualised doses) of MMT and BMT is more reflective of real-world practice. Retention in treatment was superior for flexible MMT than flexible BMT dosing but there was no significant difference in opiate use. Indirect comparison of data from population cross-sectional studies suggests that mortality with BMT may be lower than that with MMT. A pooled RCT analysis showed no significant difference in serious adverse events with MMT compared with BMT. Although treatment modifier evidence was limited, adjunct psychosocial and contingency interventions (e.g. financial incentives for opiate-free urine samples) appeared to enhance the effects of both MMT and BMT. Also, MMT and BMT appear to be similarly effective whether delivered in a primary care or outpatient clinic setting. Although most of the included economic evaluations were considered to be of high quality, none used all of the appropriate parameters, effectiveness data, perspective and comparators required to make their results generalisable to the NHS context. One company (Schering-Plough) submitted cost-effectiveness evidence based on an economic model that had a 1-year time horizon and sourced data from a single RCT of flexible-dose MMT compared with flexible-dose BMT and utility values obtained from the literature; the results showed that for MMT vs no drug therapy, the incremental cost-effectiveness ratio (ICER) was pound 12,584/quality-adjusted life-year (QALY), for BMT versus no drug therapy, the ICER was pound 30,048/QALY and in a direct comparison, MMT was found to be slightly more effective and less costly than BMT. The assessment group model found for MMT versus no drug therapy that the ICER was pound 13,697/QALY, for BMT versus no drug therapy that the ICER was pound 26,429/QALY and, as with the industry model, in direct comparison, MMT was slightly more effective and less costly than BMT. When considering social costs, both MMT and BMT gave more health gain and were less costly than no drug treatment. These findings were robust to deterministic and probabilistic sensitivity analyses. Both flexible-dose MMT and BMT are more clinically effective and more cost-effective than no drug therapy in dependent opiate users. In direct comparison, a flexible dosing strategy with MMT was found be somewhat more effective in maintaining individuals in treatment than flexible-dose BMT and therefore associated with a slightly higher health gain and lower costs. However, this needs to be balanced by the more recent experience of clinicians in the use of buprenorphine, the possible risk of higher mortality of MMT and individual opiate-dependent users' preferences. Future research should be directed towards the safety and effectiveness of MMT and BMT; potential safety concerns regarding methadone and buprenorphine, specifically mortality and key drug interactions; efficacy of substitution medications (in particular patient subgroups, such as within the criminal justice system, or within young people); and uncertainties in cost-effectiveness identified by current economic models.

Impact of an Emergency Department Pain Management Protocol on the Pattern of Visits by Patients with Sickle Cell Disease

This study explores how implementation of pain management guidelines in concert with clinic case management affected emergency department (ED) utilization, clinic visits, and hospital admissions for patients with sickle cell disease. A pain management guideline that eliminated meperidine and encouraged timely use of morphine or hydromorphone for pain control in sickle cell crisis was introduced as a quality improvement project. This study is a retrospective review of ED visits, clinic visits, and admissions from 1 year before and 3 years after the guideline implementation. Working with the ED, the Hematology Clinic began to proactively seek the return of their patients for clinic follow-up. A formal case management program for sickle cell patients was initiated in June 2003. A total of 1584 visits by 223 patients were collected, 1097 to the ED and 487 to the Hematology Clinic. Total hospital visits did not change significantly in any of the 4 years, p > 0.10 for each comparison. Total ED visits decreased significantly over the 4-year study period ( p < 0.001), whereas clinic visits steadily increased ( p < 0.001). Return visits to the ED within 30 days also declined significantly, p < 0.001. Both the absolute number of admissions per year and the total admissions per hospital visit per year declined significantly over the study period, p = 0.001. Although total admissions per hospital visit did not change, the proportion of ED visits that resulted in admission in year 1 (29%) was significantly lower than the proportion admitted in year 2 (43%), p = 0.04. A pain protocol using morphine or hydromorphone coupled with increased access to outpatient clinics decreased ED visits, hospitalizations, and increased utilization of a more stable primary care clinic setting by patients with sickle cell disease.

DEPRESSION AMONG LOW-INCOME AFRICAN AMERICANS AND LATINOS: EXPLORING SYMPTOMS AND SEVERITY.

Purpose Depression is a leading cause of disability and premature mortality in the United States. Depression is also highly underdiagnosed and undertreated in African Americans and Latinos. More research is needed on the mental health and mental health needs of ethnic minority groups. This study examined the differences in symptomatology for major depression among African Americans and Latinos in a low-income, primary care clinic setting. Methods This is a cross-sectional study using data gathered from three county clinics in Los Angeles, CA. Subjects completed a survey that assessed sociodemographic characteristics and their level of depression using a Patient Health Questionnaire Depression Scale (PHQ-9). Logistic regression models were used to compare depressive symptoms between African Americans and Latinos. Results A total of 411 subjects were recruited, with an 83% response rate, of which 334 were African American or Latino. In general, the difference in depression symptoms, as characterized by items in the PHQ-9 scale, was not significant between the two groups. However, relative to Latinos, African Americans were more likely to be diagnosed with major depression (PHQ ≥ 10, p = 0.06, OR = 2.03) and suffer from changes to their appetite (p = .012, OR = 2.58). Conclusions We found that most depression symptoms were similar between African Americans and Latinos but differed with regard to changes in appetite. Results also suggest a higher prevalence of major depression among African Americans when compared with Latinos. More research is needed to see if these results are generalizable and to develop interventions that can successfully detect and treat depression among Latinos and African Americans attending public sector clinics.

Innovations in Disability Care Coordination Organizations

Specialized programs have emerged to coordinate care for Medicaid beneficiaries with disabilities who commonly have multiple, complex medical and psychosocial comorbidities. These specialized programs, disability care coordination organizations (DCCOs), center around nurse and social worker care managers who function largely in integrated or collaborative care management models. Two programs extended the traditional DCCO roles of care manager, colocating them in primary care and behavioral clinical settings with results beneficial to care managers, providers, and patients. These initiatives required overcoming the challenges found among differing specialty cultures, insufficient organizational supports, and consumer behaviors that commonly defeat their self-management of their health and life needs. The outcomes are encouraging to care management practice, to primary care and behavioral health providers, the systems in which they practice, and to DCCO beneficiaries. The nurse and social worker care managers and the providers in both systems built positive professional relationships, gained insights into the knowledge and practices of specialties different from their own, and leveraged each other's expertise to the benefit of patients. Organizational systems gained insights into the supports needed to achieve optimal integration and comprehensive care. Outcomes for patients were significant: enhanced abilities to manage their complex health and life situations and realize improved health states.

Gender and Peripheral Arterial Disease

The aim of this study is to determine gender differences in the risk factor profile and leg symptoms of peripheral arterial disease (PAD). We identified men and women with PAD from a cohort of patients within a primary care clinic setting. We screened patients 50 years of age and older. We diagnosed PAD based on an ankle-brachial index (ABI) level of less than 0.9; the ABI is the ratio of ankle and arm systolic blood pressure measurements. Patients completed 4 questionnaires, one of which was used to ascertain leg symptoms related to compromised blood flow, the San Diego Claudication Questionnaire (SDCQ). Additional questionnaires were used to determine the patient's medical history, walking impairment, and health-related quality of life. We enrolled 403 patients stratified by race and gender including 55 white women, 82 African American women, and 71 Hispanic women. There were no significant differences by gender in the prevalence of disease. The prevalence of PAD was 9.1% in white women, 21.9% in African American women, and 14.1% in Hispanic women (P = .11). Risk factors for PAD were the same for women and men (ie, diabetes mellitus, current smoking, and use of blood pressure medication). Walking impairment subscale scores were lower for women with PAD when compared with women without PAD and to men with disease. Scores for physical function and general health were lower for women versus men with PAD. The prevalence of PAD, a common disease within primary care clinics, does not vary by gender. Women with PAD are at greater risk for a compromise in daily function and quality of life. Future research is needed to prevent walking impairment and improve limb functioning in patients, particularly women, with PAD.