Number Of Primary Care Visits Research Articles

P211 Exacerbation frequency and maintenance treatment of COPD in UK clinical practice

Introduction and ObjectivesCOPD exacerbations are associated with high morbidity, mortality and costs. Prevention of exacerbations is recommended as a key goal of COPD management. Pharmacotherapy shown to reduce exacerbation frequency...

Diabetes Care Among Somali Immigrants and Refugees

The risk for development of diabetes and associated complications among immigrants increases in the years after arrival to the United States. Somali immigrants and refugees represent the largest subset of African immigrants to the United States, yet little is known about the quality of their diabetes care. Therefore, adherence with diabetes quality indicators (Hemoglobin A1C <7%, LDL cholesterol <100 mg/dl, blood pressure <130/80 mm Hg) were compared between Somali and non-Somali patients with diabetes at a large academic primary care practice in the United States in 2008. Demographic and health-seeking behavior variables were assessed for association with adherence among the Somali population. A total of 5,843 non-Somali and 81 Somali patients with diabetes were identified. Somali patients with diabetes were less likely to meet the criteria for optimal glycemic control than non-Somali patients (40.6% vs. 53.9%; P=0.02). There was a similar, though statistically non-significant, trend towards lower rates of lipid control among Somali patients. There was no difference in achievement of optimal blood pressure between the two groups. There was a strong association between number of primary care visits during the study interval and achievement of all three diabetes care quality goals. This study demonstrates disparities in achievement of diabetes management quality goals among Somali patients compared with non-Somali patients, highlighting the need for additional system and practice changes to target this particularly vulnerable population.

Patient-physician Language Concordance and Primary Care Screening Among Spanish-speaking Patients

Language discordance between patient and physician is associated with worse patient self-reported healthcare quality. As Hispanic patients have low rates of cardiovascular and cancer screening, we sought to determine whether patient-physician language concordance was associated with differences in rates of screening. We performed a retrospective medical record review of 101 Spanish-speaking patients cared for by 6 Spanish-speaking PCPs (language-concordant group) and 205 Spanish-speaking patients cared for by 44 non-Spanish-speaking PCPs (language-discordant group). Patients were included in the study if they were of age 35 to 75 years and had used interpreter services 2001 to 2006 in 2 Boston-based primary care clinics. Our outcomes included screening for hyperlipidemia, diabetes, cervical cancer, breast cancer, and colorectal cancer with age-appropriate and sex-appropriate subgroups. Our main predictor of interest was patient-physician language concordance. In multivariable modeling, we adjusted for age, sex, insurance status, number of primary care visits, and comorbidities. We adjusted for clustering of patients within individual physicians and clinic sites using generalized estimating equations. Patients in the language-discordant group tended to be female compared with patients in the language-concordant group. There were no significant differences in age, insurance status, number of primary care visits, or Charlson comorbidity index between the 2 groups. Rates of screening for hyperlipidemia, diabetes, cervical cancer, and breast cancer were similar for both language-concordant and language-discordant groups. However, patients in the language-concordant group were less likely to be screened for colorectal cancer compared with the language-discordant group risk ratio 0.78 (95% confidence interval, 0.61-0.99) after multivariable adjustment. This study finds that Spanish-speaking patients cared for by language-concordant PCPs were not more likely to receive recommended screening for cardiovascular risk factors and cancer. Furthermore, language concordance was associated with lower likelihood colorectal cancer screening. Further research is needed to examine which conditions are optimal to improve cardiovascular and cancer screening for Spanish-speaking patients, particularly for colorectal cancer, which has a low rate of screening.

Institutional, provider, and patient correlates of low-density lipoprotein and non–high-density lipoprotein cholesterol goal attainment according to the Adult Treatment Panel III guidelines

The aim of this analysis was to identify the proportion of coronary heart disease (CHD) patients achieving guideline-recommended low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) goals and to identify correlates of dual goal attainment. We analyzed patient, provider, and facility characteristics for 21,801 CHD patients in one Veterans Affairs Hospitals Network. Low-density lipoprotein cholesterol goal attainment was 80%, but optional LDL-C goal attainment was 41%. Of patients with triglycerides ≥200 mg/dL, 51% attained both LDL-C and non-HDL-C goals. Correlates of higher dual goal attainment included older age (65-74 years: odds ratio [OR] 1.47, 95% CI 1.28-1.69), diabetes (OR 1.33, 95% CI 1.16-1.53), obesity (OR 1.25, 95% CI 1.04-1.50), a higher number of primary care visits (OR 1.04, 95% CI 1.04-1.05), and mild increase in illness severity of patients in provider's panel (OR 1.20, 95% CI 1.0008-1.46), whereas African American patients were less likely to achieve dual lipid goals (OR 0.63, 95% CI 0.48-0.82). Receipt of care from physician (vs nonphysician) or specialist (vs primary care) provider, number of patients in provider's panel, and percentage of patients in provider's panel with diagnosis of hyperlipidemia were not associated with dual goal attainment. A large proportion of CHD patients attained LDL-C goal, but optional LDL-C goal attainment was low. Patients with elevated triglycerides had poor attainment of dual LDL-C and non-HDL-C goals, suggesting a treatment gap. Factors associated with dual goal attainment may identify interventions needed to improve future guideline adherence.

Screening prevalence and incidence of colorectal cancer among American Indian/Alaskan natives in the Indian Health Service.

BackgroundStudies on colorectal cancer (CRC) screening and incidence among American Indian/Alaska Natives (AI/AN) are few.AimsOur aim was to determine CRC screening prevalence and to calculate CRC incidence among AI/AN receiving care within the Indian Health Service (IHS).MethodsA retrospective cohort study of AI/AN who utilized IHS from 1996 to 2004. AI/AN who were average-risk for CRC and received primary care within IHS were identified by searching the IHS Resource Patient Management System for selected ICD-9/CPT codes (n = 142,051). CRC screening prevalence was calculated and predictors of screening were determined for this group. CRC incidence rates were ascertained for the entire AI/AN population ages 50–80 who received IHS medical care between 1996 and 2004 (n = 283,717).ResultsCRC screening was performed in 4.0% of average-risk AI/AN. CRC screening was more common among women than men (RR = 1.6, 95% CI 1.4–1.7) and among AI/AN living in the Alaska region compared to the Pacific Coast region (RR = 2.5, 95% CI 2.2–2.8) while patients living in the Northern Plains (RR = 0.4, 95% CI 0.3–0.4) were less likely to have been screened. CRC screening was less common among patients with a greater number of primary care visits. The age-adjusted CRC incidence among AI/AN ages 50–80 was 227 cancers per 100,000 person-years.ConclusionsCRC was common among AI/AN receiving medical care within IHS. However, CRC screening prevalence was far lower than has been reported for the U.S. population.

Colorectal Cancer Screening at the VA: How Well Are We Doing?

Purpose: Fecal occult blood testing (FOBT) is the primary screening modality for colorectal cancer in the VA healthcare system. The benefit of FOBT is reduced by inappropriate testing and lack of follow-up with a colonoscopy for positive results. We sought to determine factors associated with receipt of a complete colonoscopy after a positive FOBT, and rates of inappropriate FOBT use. Methods: We used all positive FOBT results at the Minneapolis VA between 2006-2007 to identify rates of inappropriate FOBT, and factors associated with receipt of colonoscopy after a positive FOBT. We used multivariate logistic regression for the final model. Results: There were 606 positive FOBT results, of which 583 (98%) were male and 385 (95%) were white. The average age at the time of FOBT was 66 years old (range 22-91 years old). Within 3 years of positive FOBT, colonoscopies were performed in 454 (76%) patients. In multivariable logistic regression, patients with primary care based at the Minneapolis VA were more likely to receive a colonoscopy after a positive FOBT than patients with community-based outreach clinic (CBOC) primary care [OR 2.46, 95% CI 1.64-3.66, p<0.01]. Age, race, gender, distance from patient's home to the Minneapolis VA, number of primary care visits and number of primary care visits to the same provider within the 12 months prior to the positive FOBT result were not associated with receipt of colonoscopy. Of the positive FOBTs, 233 (39%) were done in patients in whom FOBT was inappropriate for colorectal cancer screening (patient was <50 or ≥80 years old, had history of colon polyps or cancer, IBD, hematochezia, iron-deficiency anemia, or a normal colonoscopy within the past 10 years). Patients with CBOC-based primary care were more likely to be given a FOBT inappropriately than VA-based primary care patients (52% vs. 47%, p=0.005). Of those “inappropriates” with positive FOBT results, 64% received a colonoscopy. Of patients appropriately screened with FOBT, 84% received a colonoscopy. Conclusion: Rates of follow-up colonoscopy after positive FOBT at the VA are high. Patients with VA-based primary care were more likely to receive a colonoscopy after a positive FOBT. Interventions to limit use of FOBT for colorectal cancer screening to the appropriate population are needed.

Factors Associated with Detection and Receipt of Treatment for Youth with Depression and Anxiety Disorders

Anxiety and depression are common among youth and are associated with significant morbidity. Few youth with depression are diagnosed and receive treatment for these disorders. The purpose of this study was to examine the rate of recognition and management among an insured population and the factors associated with evidence of detection among youth. Structured mental health interviews assessing depression and anxiety diagnoses were completed with a random sample of 581 youth (age range 11-17 years) from an integrated health care system. Administrative data on medical and pharmacy services were used to examine any evidence of detection by the medical system in the prior 12 months. Fifty-one youth met criteria for an anxiety or depressive disorder. Twenty-two percent of these youth with an anxiety or depressive disorder as defined in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition had evidence of detection or treatment. Factors associated with detection and treatment included having diagnosis of a depressive disorder (with or without an anxiety disorder), more depressive symptoms, greater functional impairment, a higher number of primary care visits in the prior year, and higher parent-reported externalizing symptoms. On multivariate analysis, having more depressive symptoms and a higher number of primary care visits were significant predictors of detection and receipt of treatment. The rate of detection and treatment of anxiety and depressive disorders is very low in this age group and suggests a need for increased focus on detection, particularly in light of recent evidence suggesting decreases in diagnosis and treatment among youth following the black box warning regarding antidepressant medications.

Implementing Group Medical Visits for Older Adults at Group Health Cooperative

In a pair of randomized controlled trials in the Kaiser Permanente delivery system in Colorado in the 1990s, group visits for older adults (monthly non-disease-specific group medical appointments for a cohort of patients led by primary care teams) were proven to reduce costs, decrease hospitalizations, and improve patient and provider satisfaction. As part of a translational effort, this group visit intervention was replicated in a delivery system in Seattle, Washington, and the log of total healthcare costs was measured in the first year of the intervention. Utilization and patient and physician satisfaction were secondary outcomes. For the cost and utilization analysis, a retrospective case-control design compared 221 case patients aged 65 and older with high outpatient usage in the previous 18 months with 1,015 control patients selected randomly from clinics not participating in the intervention. Controls were matched to cases on the number of primary care visits in the prior 18 months. Total costs were not statistically different for intervention patients and controls ($8,845 vs $10,288, P=.11), nor were there statistically significant differences in utilization, including hospital admissions and outpatient visits, but patient and provider satisfaction with the intervention was high. This translational effort did not demonstrate the cost savings of the original efficacy trials. Possible explanations for these divergent results may have to do with differences between those who participated and differences between the two delivery systems.

A medication-estimated health status measure for predicting primary care visits: the Long-Term Therapeutic Groups Index

Managed care is one of the means advocated for health care reforms. The Malaysian government has proposed managed care for its citizens. In the Malaysian private health care sector, managed care is practised on a small scale with crude risk adjustment. The main determinant of an individual's health service utilization is their health status (HS). HS is used as a risk adjuster for capitation payment. Prescribed medications represent a useful source for HS estimation. We aimed to develop and validate a medication-based HS estimate and to incorporate it in the Andersen model of health service utilization. This is a preparatory step in studying the feasibility of developing a model for risk assessment in the Malaysian context. Data were collected retrospectively from an academic year from computerized databases in University Sains Malaysia (USM) about users of USM primary care services. A user is a USM health scheme beneficiary who made at least one visit in the academic year to USM-assigned primary care providers. Socio-demographic variables, enrolment period, medications prescribed and number of visits were also collected. Chronic illness medications and some non-chronic illness medications were used to calculate the Long-Term Therapeutic Groups Index (LTTGI) which is an estimate of the HS of users. Using a random 50% of users, weighted least square methods were used to develop a model that predicts a user's number of visits. The other 50% were used for validation. Socio-demographic variables explained 15% of variability in number of primary care visits among users. Adding the LTTGI improved the explanatory power of the model to 36% (P < 0.001). A similar contribution of the LTTGI was noted in the validation. The Long-Term Therapeutic Groups Index was successfully developed. Variability in number of primary care visits can be predicted by LTTGI-based models.

Does Diabetes Double the Risk of Depression?

In this study, we compared the rate of depression diagnoses in adults with and without diabetes mellitus, while carefully controlling for number of primary care visits. We matched adults with incident diabetes (n = 2,932) or prevalent diabetes (n = 14,144) to nondiabetic control patients based on (1) age and sex, or (2) age, sex, and number of outpatient primary care visits. Logistic regression analysis was used to assess the association between various predictors and a diagnosis of depression in each diabetes cohort relative to matched nondiabetic control patients. With matching for age and sex alone, patients with prevalent diabetes having few primary care visits were significantly more likely to have a new depression diagnosis than matched control patients (odds ratio [OR] = 1.46, 95% confidence interval [CI], 1.19-1.80), but this relationship diminished when patients made more than 10 primary care visits (OR = 0.95, 95% CI, 0.77-1.17). With additional matching for number of primary care visits, patients with prevalent diabetes mellitus with few primary care visits were more likely to have a new diagnosis of depression than those in control group (OR = 1.32, 95% CI, 1.07-1.63), but this relationship diminished and reversed when patients made more than 4 primary care visits (OR = 0.99, 95% CI, 0.80-1.23). Similar results were observed in the subset of patients with incident diabetes and their matched control patients. Patients with diabetes have little or no increase in the risk of a new diagnosis of depression relative to nondiabetic patients when analyses carefully control for the number of outpatient visits. Studies showing such an association may have inadequately adjusted for comorbidity or for exposure to the medical care system.

Potentially inappropriate medication prescribing in outpatient practices: Prevalence and patient characteristics based on electronic health records

Background: Some older adults receive potentially inappropriate medications (PIMs), increasing their risk for adverse events. A literature search did not find any US multicenter studies that measured the prevalence of PIMs in outpatient practices based on data from electronic health records (EHRs), using both the Beers and Zhan criteria. Objectives: The aims of the present study were to compare the prevalence of PIMs using standard drug terminologies at 2 disparate institutions using EHRs and to identify characteristics of elderly patients who have a PIM on their active-medication lists. Methods: This cross-sectional study of outpatients' active-medication lists from April 1, 2006, was conducted using data from 2 outpatient primary care settings: Intermountain Healthcare, Salt Lake City, Utah (center 1), and the Cleveland Clinic, Cleveland, Ohio (center 2). Data were included from patients who were aged ≥65 years at the time of the last office visit and had ≥2 documented clinic visits within the previous 2 years. The primary end point was prevalence of PIMs, measured according to the 2002 Beers criteria or the 2001 Zhan criteria. Results: Data from 61,251 patients were included (36,663 women, 24,588 men; center 1: 37,247 patients; center 2: 24,004). A total of 8693 (23.3%) and 5528 (23.0%) patients at centers 1 and 2, respectively, were documented as receiving a PIM as per the Beers criteria; this difference was not statistically significant. Per the Zhan criteria ( P < 0.001), these values were 6036 (16.2%) and 4160 (17.3%). Eight of the most common PIMs were the same at both institutions, with propoxyphene and fluoxetine (once daily) being the most prescribed. Female sex, polypharmacy (≥6 medications), and multiple primary care visits were significantly associated with PIM prescribing. Conclusions: In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations. Female sex, polypharmacy, and number of primary care visits were significantly associated with PIM prescribing. In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations.

Patient-Physician Language Concordance and Lifestyle Counseling Among Spanish-Speaking Patients

Patient-physician language discordance is associated with worse quality of healthcare for patients with limited English proficiency. Patients with language-discordant physicians have more problems understanding medical situations. The impact of patient-physician language concordance on lifestyle counseling among Spanish-speaking patients is not known. We performed a retrospective medical record review and identified 306 Spanish-speaking patients who used interpreter services between June 2001 and June 2006 in two Boston-based primary care practices. Our primary outcome was counseling on exercise, diet, and smoking. Our main predictor of interest was patient-physician language concordance. Patients with language-concordant physicians were more likely to be counseled on diet and physical activity compared to patients with language-discordant physicians. After adjustment for age, sex, insurance status, number of primary care visits, and comorbidity score, these differences in counseling persisted for diet [odds ratio (OR) = 2.2, CI 1.3-3.7] and physical activity (OR = 2.3, CI 1.4-3.8). There was no significant difference with regard to discussion of smoking (OR = 1.3, CI 0.8-2.1). Spanish-speaking patients are more likely to discuss diet and exercise modification if they have a Spanish-speaking physician compared to those having a non-Spanish-speaking physician. Further research is needed to explore whether matching Spanish-speaking patients with Spanish-speaking providers may improve lifestyle counseling.

Delivery of the paediatric curriculum of the Royal College of Paediatrics and Child Health (RCPCH)

<h3>AIM</h3> To determine the frequency of use of complementary treatment and measure its impact on clinical outcomes in a hospitalised general paediatric population. <h3>METHODS</h3> A population based random sample of...

Impact of Primary Care Patient Visits on Racial and Ethnic Disparities in Preventive Care in the United States

The causes of racial and ethnic disparities in preventive care are not fully understood. We examined the hypothesis that fewer primary care visits by minority patients contribute to these disparities. We analyzed claims for Medicare beneficiaries 65 and older who participated in the Medicare Current Beneficiary Survey, 1998 to 2002. Five preventive services were included: colorectal cancer testing, influenza vaccination, lipid screening, mammography, and Papanicolaou smear screening. In separate multivariate analyses, we examined the effect of minority status (self-report of African American race or Hispanic ethnicity) on having a claim in the past 12 months for each preventive service after successive control for number of primary care visits and other patient characteristics. The final sample included 15,962 subjects. In age-adjusted analyses, minorities had statistically lower rates of claims for each of the 5 procedures. After controlling for number of primary care visits, the effect of minority status was slightly attenuated but remained statistically significant for receipt of each procedure. After adding low income, low educational level and supplementary insurance, health status, and year, minority status was significantly associated only with colorectal cancer screening (odds ratio [OR] 0.79; 95% confidence interval [CI] 0.67 to 0.94) and influenza vaccinations (OR 0.56; 95% CI 0.49 to 0.64). The frequency of primary care visits seems to contribute minimally to racial and ethnic disparities in preventive services. Other patient characteristics, particularly those associated with poverty, explain much of these disparities.

Primary Medical Care and Reductions in HIV Risk Behaviors in Adults with Addictions

Human immunodeficiency virus (HIV) risk behaviors are prevalent in persons with addictions. Objectives: To assess whether exposure to primary medical care is associated with decreases in HIV risk behaviors. Design: Prospective 2-year cohort of 298 adults with addictions. Outcomes: Sex and drug-related HIV risk behaviors, measured by the Risk Assessment Battery. Predictors: Cumulative number of primary care visits (0, 1, p ⩽ 2). Associations were tested using regression models for correlated data. Results: In women, receipt of primary care was associated with less sex risk behavior (mean decrease 2.1, p ⩽0.1). Among women and men, ⩾2 primary care visits was associated with lower odds of any drug risk behavior (OR = 0.37, p = 0.03). Conclusions: Exposure to primary care can impact HIV risk behavior favorably among adults with addictions.

Clinical Characteristics and Health Service Use of Veterans With Comorbid Bipolar Disorder and PTSD

Clinical Characteristics and Health Service Use of Veterans With Comorbid Bipolar Disorder and PTSD

Quality of Mental Health Care for Youth With Asthma and Comorbid Anxiety and Depression

Youth with asthma have a high rate of anxiety and depressive disorders, and these comorbid disorders are associated with increased asthma symptom burden and functional impairment. This study examined the rates and predictors of recognition of anxiety and depressive disorders among youth (ages 11 to 17) with asthma who are seen in primary care settings as well as the quality of mental health care provided to those with comorbid anxiety and depression over a 12-month period. This study used automated utilization and pharmacy data from a health maintenance organization to describe the rate of recognition of Diagnostic and Statistical Manual of Mental Disorders, edition IV, anxiety and depressive disorders and the quality of mental health care provided for the 17% of youth with asthma and comorbid anxiety and/or depression during the 12-month period prior to diagnosis. Psychiatric diagnoses were based on a telephone version of the Computerized Diagnostic Interview Schedule for Children (Version 4.0). Approximately 35% of youth with 1 or more anxiety and depressive disorders and 43% of those with major depression were recognized by the medical system during a 12-month period. Greater functional impairment (odds ratio [OR] 3.32, 95% confidence interval [CI] 1.25-8.79), higher severity on parent-rated anxiety and depressive symptoms (OR 2.49, 95% CI 1.04-6.00), and a greater number of primary care visits (OR 1.26, 95% CI 1.10-1.44) were associated with significantly higher recognition rates while having Medicaid or Washington state medical insurance was associated with lower rates of recognition (OR 0.27, 95% CI 0.08-0.92). Only approximately 1 in 5 youths with comorbid major depression received an adequate dosage and duration of antidepressant medication, and only 1 in 6 received a minimally adequate number of psychotherapy sessions (> or =4 visits). Rates of recognition of comorbid anxiety and depressive disorders are low in youth with asthma and few youth with asthma and comorbid anxiety and depression receive guideline-level mental health treatment.

Distinctive Patterns of Medical Care Utilization in Patients Who Somatize

Somatizing patients have maladaptive and increased rates of medical care utilization. If there were a way of routinely identifying such patients, one that did not require intensive, case-by-case review, they could be targeted for specific interventions to improve their use of medical care. We sought to identify patterns of medical care utilization that would distinguish somatizing and nonsomatizing medical outpatients with acceptable sensitivity and specificity. Subjects completed questionnaires assessing somatization and sociodemographic characteristics. Their medical care utilization was obtained for the 12 months preceding the index visit. We then used multivariable logistic regression and recursive partitioning to identify patients with a provisional diagnosis of somatoform disorder. These exploratory models used various patterns of medical care utilization and sociodemographic characteristics as the independent variables. We studied consecutive adults attending 2 primary care practices on randomly chosen days. The provisional diagnosis of a somatoform disorder was assessed with a 15-item self-report questionnaire. The number of primary care visits, specialty visits, mental health visits, emergency visits, and inpatient and outpatient costs were obtained for the 12 months preceding the index visit from our hospital's automated medical records, which also provided a rating of aggregate medical morbidity. Self-reported utilization outside our hospital system was obtained from a subsample of patients. Complete data were obtained on 1440 patients. Somatizing patients had more specialty care than primary care visits, higher outpatient than inpatient costs, and more emergency visits than nonsomatizing patients. A regression model containing 7 measures of utilization and 4 sociodemographic characteristics distinguished somatizing and nonsomatizing patients with a c-statistic = 0.73. Recursive partitioning identified 10 terminal nodes with a very high specificity (99%) but a very low sensitivity (15%). We identified 7 discrete patterns of medical care utilization that distinguished somatizing and nonsomatizing patients. However, they did so with only modest specificity and sensitivity. This algorithm might be used effectively as the first step in a 2-step screening procedure whose second step would entail more intensive screening or individual, case-by-case review to identify somatizing patients in primary care practice.

Volume Matters: Physician Practice Characteristics and Immunization Coverage Among Young Children Insured Through a Universal Health Plan

We studied the association between immunization coverage for a cohort of 2-year-old children covered by a universal health insurance plan and pediatric provider and other health services characteristics. We assembled a cohort of 101,570 infants born in urban areas in Ontario, Canada, between July 1, 1997, and June 31, 1998. Children were considered to have up-to-date (UTD) immunization coverage if they had > or =5 immunizations by 2 years of age, ie, the recommended 3 doses and 1 booster of diphtheria-polio-tetanus-pertussis/Haemophilus influenzae type b vaccine and 1 dose of measles-mumps-rubella vaccine. Provider practice characteristics were derived from outpatient billing records, and 1996 census data were used to derive neighborhood income quintiles. The association between UTD immunization status and provider characteristics was assessed with multilevel regression models, controlling for patient characteristics. Overall, the rate of complete UTD immunization coverage was low (66.3%) despite a large number of primary care visits (median: 19 visits). Children whose usual provider had a low volume of pediatric primary care were less than one half as likely to be UTD. Other factors associated with not being UTD included very low continuity of care, low continuity of care, and usual provider in practice for <5 years. With adjustment for patient and provider characteristics, there was no difference in immunization coverage for general practitioners versus pediatricians. Children from low-income neighborhoods were less likely to be UTD. Despite universal access to primary care services, rates of complete immunization coverage among 2-year-old children in Ontario are low. Because visit rates are high, primary care reform should include interventions directed at provider immunization practices to reduce missed opportunities.

Datapoints: detecting depression in VA primary care clinics.

Back to table of contents Previous article Next article ColumnsFull AccessDatapoints: Detecting Depression in VA Primary Care ClinicsJoAnn E. Kirchner, M.D., Geoffrey M. Curran, Ph.D., and James Aikens, M.S.JoAnn E. KirchnerSearch for more papers by this author, M.D., Geoffrey M. CurranSearch for more papers by this author, Ph.D., and James AikensSearch for more papers by this author, M.S.Published Online:1 Apr 2004https://doi.org/10.1176/appi.ps.55.4.350AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The treatment of depression largely falls to providers in primary care settings, which have been identified as the de facto mental health delivery system (1). Systemwide programs to improve depression care have been initiated in the Department of Veterans Affairs (VA) and in other health care organizations (2,3). One such VA initiative is screening for depression as part of the Prevention Index, which was mandated in 1998 as an annual screening tool for all primary care patients. Our study investigated diagnosis patterns of depressive disorders in VA primary care clinics over a five-year period. Specifically, we wanted to determine whether primary care service use data indicated that implementing and monitoring the mandated depression screening affected depression diagnosis rates.Data on all primary care visits were gathered from the VA's national outpatient service use database for fiscal years 1997 to 2001. In the database, all primary care visits carry a primary diagnosis that indicates the main reason for and the presenting problem at the visit as well as up to ten secondary diagnoses.Overall, the frequency with which depression was diagnosed, as well as the percentage of the primary care population who received a diagnosis of depression, increased across the study years. As can be seen in Figure 1, the rates of primary diagnosis of depression remained unchanged in our study.Despite the overall increase in the diagnosis of depression in the primary care setting, it is important to note that among veterans with a primary care diagnosis of depression, the average number of primary care visits for which a primary diagnosis of depression was noted did not vary across the study period (1.4 or 1.3 visits) and falls well below guideline recommendations for the treatment of depression in this population (4).AcknowledgmentsThis work was supported by grant NMH98-001 from the Department of Veterans Affairs Mental Health Quality Enhancement Research Initiative and by grant IIR-98086-3 from the Department of Veterans Affairs Health Services Research and Development Service.Dr. Kirchner and Dr. Curran are affiliated with the Department of Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, 2200 Fort Roots Drive, Building 58, North Little Rock, Arkansas 72114 (e-mail, [email protected]). All of the authors are with the Department of Veterans Affairs Mental Health Quality Enhancement Research Initiative. Harold Alan Pincus, M.D., and Terri L. Tanielian, M.A., are editors of this column.Figure 1. Patients with a diagnosis of depressive disorder among veterans in Department ofVeterans Affairs (VA) primary care clinics, from the VA national outpatient serviceuse database for fiscal years 1997 to 2001aa Yearly changes significant at p<.001