Problems In Primary Care Settings Research Articles

Using digital assessment technology to detect neuropsychological problems in primary care settings.

Screening for neurocognitive impairment and psychological distress in ambulatory primary and specialty care medical settings is an increasing necessity. The Core Cognitive Evaluation™ (CCE) is administered/scored using an iPad, requires approximately 8 min, assesses 3- word free recall and clock drawing to command and copy, asks questions about lifestyle and health, and queries for psychological distress. This information is linked with patients' self- reported concerns about memory and their cardiovascular risks. A total of 199 ambulatory patients were screened with the CCE as part of their routine medical care. The CCE provides several summary indices, and scores on 44 individual digital clock variables across command and copy tests conditions. Subjective memory concerns were endorsed by 41% of participants. Approximately 31% of participants reported psychological distress involving loneliness, anxiety, or depression. Patients with self-reported memory concerns scored lower on a combined delay 3- word/ clock drawing index (p < 0.016), the total summary clock drawing command/ copy score (p < 0.050), and clock drawing to command Drawing Efficiency (p < 0.036) and Simple and Complex Motor (p < 0.029) indices. Patients treated for diabetes and atherosclerotic cardiovascular disease (ASCVD) scored lower on selected CCE outcome measures (p < 0.035). Factor analyses suggest that approximately 10 underlying variables can explain digital clock drawing performance. The CCE is a powerful neurocognitive assessment tool that is sensitive to patient's subjective concerns about possible decline in memory, mood symptoms, possible cognitive impairment, and cardiovascular risk. iPad administration ensures total reliability for test administration and scoring. The CCE is easily deployable in outpatient ambulatory primary care settings.

Design and evaluation of a team-based interprofessional practice placement: A design-based research approach

Introduction Team-based Interprofessional Practice Placements (TIPPs) are innovative training practices. Evidence to substantiate the design of TIPPs is limited. This study explores the design and evaluation of TIPPs to support undergraduate students in gaining a better understanding of the complexity of patient problems in primary care settings and of collaboration within interprofessional teams. Method We implemented TIPPs at a University of Applied Sciences, Belgium based on three principles: (1) authentic tasks with real clients, (2) students collaborated in small interprofessional teams, and (3) students were supported by teachers. TIPPs were evaluated using focus groups (N = 5) that explored teachers’ (N = 13) and students’ (N = 22) experiences. Data were analysed thematically. Results Three themes were constructed. First, TIPPs enhance students’ understanding of the complexity of clients’ problems and what matters to the client. Second, TIPPs support students to value the expertise of interprofessional team members. Finally, to enhance students’ learning, TIPPs must strike an appropriate balance between teacher support and student autonomy. Conclusion The three design principles used to underpin the TIPPs were viable. Although students reported to receive sufficient support, they also felt this support should have been gradually withdrawn to offer more opportunities for autonomous learning. Teachers reported difficulties in balancing their support.

Health of undocumented migrants in primary care in Switzerland.

BackgroundUndocumented migrants endure adverse living conditions while facing barriers to access healthcare. Evidence is lacking regarding their healthcare needs, notably in regards to chronic diseases. Our goal was to investigate health conditions in undocumented migrants attended in primary care setting.MethodsThis study was conducted at the primary care outpatient clinic, Geneva University Hospitals, Switzerland. We retrospectively recorded and coded all medical conditions of a random sample of 731 undocumented migrants using the International Classification of Primary Care, 2nd version (ICPC-2). We dichotomized conditions as chronic or non-chronic and considered multimorbidity in the presence of three or more chronic conditions.ResultsParticipants originated from 72 countries and were mainly female (65.5%) with a mean age of 42.4 (standard deviation [SD]: 11.4) years. They presented a mean of 2.9 (SD: 2.1; range: 1–17) health conditions. In multivariable analysis, the number of conditions was associated with female gender (p = 0.011) and older age (p <0.001), but not with origin (p = 0.373). The body systems most frequently affected were endocrine, metabolic and nutritional (n = 386; 18.4%), musculoskeletal (n = 308, 14.7%) and digestive (n = 266, 12.8%). Hypertension (17.9%; 95% CI: 15.2%, 29.9%), obesity or overweight (16%; 95% CI: 13.4%, 18.9%) and gastric problems (14.1%; 95% CI: 11.6%, 16.8%) were most prevalent. Overall, 71.8% (95% CI: 68.5%, 75%) participants had at least one chronic condition while 20% (95% CI: 17.2%, 23.1%) had three or more. In multivariable analysis, age (p <0.001) was the only predictor of presenting at least one or three or more chronic conditions.ConclusionsUndocumented migrants present multiple health problems in primary care settings and bear an important burden of chronic diseases. The extent of multimorbidity highlights the need to provide and facilitate the access to comprehensive and long-term primary healthcare services.

Collaborative Care model in mental health. Scope and experiences after three years of activity in Mexico City.

For many years, different ways to address mental health problems in primary care settings have been evaluated. However, there is still debate over how to treat psychiatric conditions in such a context. A cross-sectional design was used. The study was conducted in two consecutive studies in six PCC that serve marginalized population in Mexico City. In the first study, cases were interviewed, diagnosed, and treated by a psychiatrist. In the second study, Collaborative Care model was used and GPs were trained; psychiatrists diagnosed and treated patients but GPs discussed the symptoms and treatment of the patients with the psychiatrist. Findings First study: 18 patients with depressive and/or anxiety disorders were interviewed; these cases were not discussed between the GPs and the psychiatrist. Second study: psychiatrists and GPs conducted joint interviews and cases were discussed. From the 399 evaluated individuals, 38.94% were diagnosed with a depressive disorder. After the Collaborative Care model was applied, GPs were more aware about mental health problems and they were more interested in the identification of these conditions in PCC. Replication studies will help confirm the effectiveness of this model.

Classification of acute phase febrile upper respiratory tract infection: Retrospective chart review

ABSTRACTAimAcute upper respiratory tract infections (URI) are a common problem in primary care settings. In traditional East Asian medicine, URI are categorized into three major disorders: influenza‐like; common cold; and warmth disorders. The categorization of acute febrile URI, however, is yet to be ascertained. Here, we conducted a single‐center retrospective chart review and classification of the various symptoms of acute phase febrile URI.MethodsA retrospective chart review between December 2013 and May 2015 was performed. We included febrile (≥38°C) patients with upper respiratory symptoms within 48 h from the onset of fever. Patient profile and symptoms were investigated at the first consultation and clusters were constructed based on symptoms.ResultsThe study included 135 patients. Patients were divided into two groups, day 1 and day 2, according to the time from fever onset. The incidence rate of symptoms, such as general fatigue and muscle pain, were higher in day 1 visitors. Local symptoms, including cough, sore throat, and nasal symptoms, were more frequent in day 2 visitors. Three clusters were observed: chills without sweating (60.0%); chills with sweating (23.0%); and without chills (17.0%).ConclusionSymptoms in acute fever vary. The present three clusters observed suggest that the classical classification of febrile disease is still true. Further studies are necessary to confirm the course of febrile URI described in classical textbooks.

Accuracy of a Pediatric Behavioral Health Screener to Detect Untreated Behavioral Health Problems in Primary Care Settings.

An estimated 10% to 20% of youth in primary care exhibit behavioral symptoms and may go underdetected. Most screeners identify risk base of symptoms alone, irrespective of functional impairment. To address this issue, the Pediatric Symptom Checklist-17 (PSC-17), a widely used symptom screener, was combined with functional impairment and current behavioral services enrollment items to form the Pediatric Behavioral Health Screen (PBHS) and assessed compared to the full Child Behavior Checklist (CBCL). A total of 267 youth between 6 and 16 years of age were administered the screener and the CBCL. Areas under the receiver operating curves approached or exceeded 0.90 in all analyses, reflecting excellent classification accuracy. Almost no false negatives were observed among currently untreated cases with functional impairment. No differential item functioning was found. Performance of the PSC-17 as a pediatric primary care behavioral health screener supported previous research, and additional functional impairment items to form the PBHS appeared useful, particularly for interpreting borderline range scores.

Screening instruments for depression in primary care: a concise review for clinicians

Depression is prevalent across the life span worldwide. It is a common problem encountered in primary care settings. The World Health Organization recommends the integration of mental health into general health care in order to seal the existing gap between the number of patients who need mental health care and those who actually receive it. Addressing the burden of mental health problems in primary care settings has its limitations, particularly because of the time constraints in busy primary care clinics as well as the inadequate training of staff and physicians in mental health disorders. That is why reliable, brief, and easy to administer depression screening instruments are important in helping physicians identify patients at risk. The 2-item Patient Health Questionnaire (PHQ-2) is a suitable primary screening tool for depression. If positive, other tools should be administered, such as the PHQ-9 in adults, the PHQ-9 or Geriatric Depression Scale-15 in older adults, or the Arroll’s help question or the Edinburgh Postnatal Depression Scale in ante- or postpartum women. Patients with positive scores ought to be interviewed more thoroughly. Computerized depression screening instruments that are interfaced or integrated into electronic health records seem to be promising steps toward optimizing diagnosis, treatment, and follow-up. The availability of adequate management and follow-up are ethical requirements for the utilization of any screening instrument for depression.

Psychometric Properties of the Primary Care Behavioral Health Screen

The Primary Care Behavioral Health Screen (PCBHS) is a self-report instrument developed to screen for behavioral health problems in primary care settings. The present paper describes development of the PCBHS and reports findings from item analyses and studies examining the instrument's convergent validity and test-retest reliability. Results suggest the PCBHS is a useful and valid method for screening a variety of behavioral health problems in a busy primary care practice. Recommendations for further research on the PCBHS are provided.

The CORE‐10: A short measure of psychological distress for routine use in the psychological therapies

AbstractBackground: There is a need for a generic, short, and easy‐to‐use assessment measure for common presentations of psychological distress in UK primary care mental health settings. This paper sets out the development of the CORE‐10 in response to this need. Method: Items were drawn from the CORE‐OM and 10 items were selected according to a combination of usefulness, coverage of item clusters, and statistical procedures. Three CORE‐OM datasets were employed in the development phase: (1) a primary care sample, (2) a sample from an MRC platform trial of enhanced collaborative care of depression in primary care, and (3) a general population sample derived from the Office of National Statistics Psychiatric Morbidity Follow‐up survey. A fourth dataset comprising a sample from an occupational health setting was used to evaluate the CORE‐10 in its standalone format. Results: The internal reliability (alpha) of the CORE‐10 was .90 and the score for the CORE‐10 correlated with the CORE‐OM at .94 in a clinical sample and .92 in a non‐clinical sample. The clinical cut‐off score for general psychological distress was 11.0 with a reliable change index (90% CI) of 6. For depression, the cut‐off score for the CORE‐10 was 13 and yielded sensitivity and specificity values of .92 (CI=.83–1.0) and 0.72 (CI=.60–.83) respectively. Conclusion: The CORE‐10 is an acceptable and feasible instrument that has good psychometric properties and is practical to use with people presenting with common mental health problems in primary care settings.

Case-finding for mental distress in primary health care: An evaluation of the performance of a five-item screening instrument

Background: There is an increased interest in developing better and more accurate methods to recognize and manage mental health problems in primary care settings. Abbreviated screening instruments for mental distress are useful tools for research and clinical practice. The present study seeks to investigate whether only a few questionnaire items from the Self-Reporting- Questionnaire-10 (SRQ-10) can be a robust method in the screening for Mental Distress in Primary Health care. Methods: We compared the screening accuracy of a short, five-item (SRQ-5) version of the SRQ-10 with that of the SRQ-20, General Health Questionnaire 12 (GHQ-12) using the DSM-IV axis as a gold standard and analyzed its performance in different diagnostic entities. We also assessed the correlation, sensitivity and specificity between the 4 instruments. All the instruments were administered to 400 primary health care attendees. Results: The estimated prevalence of mental distress was 13.6% in the study sample (Depression 11%, anxiety disorders 1.8%). The SRQ-5 was highly correlated to SRQ-10 (0.923, p Conclusion: This validation showed that in moving from SRQ with 10 or 20 items to one with merely 5 items, we do not seem to lose the screening prowess of the instrument. The SRQ-5 represents a simplified and less time-consuming screening instrument with strong performance characteristics. We therefore recommend it for inclusion into existing patient assessment protocols, thus enhancing case finding at primary health care level.

Paternal depression and the family context

This invited commentary highlights how this special issue provides multiple perspectives from which to understand the nature and consequences of paternal depression. Articles herein examine paternal depression in the context of the family environment and identify specific mechanisms that link paternal depression and child well-being. This commentary identifies limitations of the knowledge base, specifically, little research on depression and psychosocial functioning among nonresidential fathers. One promising avenue for intervention is screening fathers for depression and other mental health problems in primary care settings.

Psychometric evaluation of the Turkish version of the Pediatric Symptom Checklist‐17 for detecting psychosocial problems in low‐income children

To evaluate the usefulness of Pediatric Symptom Checklist-17 in identifying psychosocial problems in low-income, Turkish children. Epidemiological data indicate that 10-20% of children in primary care settings exhibit significant psychosocial problems. Early detection and treatment of these problems may lead to considerable health benefits. However, the brief and valid screening tool for children with psychosocial problems is not available in Turkey. Survey. A sample of 306 parents with children between 6-16 years of age who were attending primary schools in Istanbul was included. The psychometric properties of the scale were established by examining the content, convergent, discriminant, construct validity and internal consistency and stability. Receiver operating characteristic analysis was conducted to estimate the optimal cut-off score of scale using the Child Behaviour Checklist as the criterion standard. Convergent validity was supported, and discriminant validity suggested that the scale successfully discriminated among the normal, borderline and clinical range groups. Although, exploratory factor analysis extracted three factors, confirmatory factor analysis did not meet the criteria for good model fit. Internal consistency was found to be 0·81; test-retest reliability was found to be 0·72. The area under curve was found to be 0·91 and optimal cut-off score was found to be 12 (sensitivity: 0·81; specificity: 0·86) for clinical range psychopathology. The results provided an empirical support for extending the use of the Pediatric Symptom Checklist-17 in the primary care settings. The Turkish version of the Pediatric Symptom Checklist-17 showed an adequate reliability and validity for its use in low-income, Turkish children. Primary care providers can use the Pediatric Symptom Checklist-17 for early identification of childhood psychosocial problems in primary care settings. This easy-to-use tool can provide guidance to care providers for further assessment of children.

Identification of Families At Risk for Behavior Problems in Primary Care Settings

Parenting practices and cognitions are associated with child externalizing behavior problems. Parenting programs targeting these areas are effective in improving child behavior but are limited to the extent to which they reach at-risk families. This study compared the parenting practices and cognitions of parents with high and low tolerance for misbehavior to parents of children with clinically significant behavior problems to evaluate the utility of assessing parental tolerance for identifying children at risk for externalizing behavior problems. Participants were 1014 parents of children between the ages of 2 and 16 years presenting for primary care. Parents completed the Eyberg Child Behavior Inventory, Parenting Scale, and Parenting Sense of Competence Scale. Parents with high and low tolerance resembled the clinically significant problem groups in both parental behaviors and cognitions. Differences regarding parental cognitions were consistent across all age groups assessed. This study demonstrated the clinical utility of interpreting caregiver responses to questions about the intensity of their child's behavior problems and parental tolerance for these problems separately. Results indicated that parents with high or low tolerance for their child's behavior are at risk of having children with clinically significant behavior problems. Parents who are concerned about their child's behavior, even if their child does not currently exhibit clinically significant behavior problems, are likely to profit from early intervention for behavior problems.

Psychosocial Problems in Primary Care: Patient and Provider Perceptions

Primary care physicians and clinics have become the frontline of health care for most Americans—they are the first point of contact and the source of both treatment and referrals. Psychosocial problems, such as difficulty with finances, family, housing, and work, are associated with a high demand for medical care in primary care practice, yet little is known about the prevalence of psychosocial problems in primary care settings. The purpose of this study is to assess the type and level of psychosocial problems in primary care patients by examining patient and provider perceptions at the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS). A purposive sample of 684 veterans and a convenience sample of 59 providers anonymously completed the Social Needs Checklist. Patients reported an average of five psychosocial problems, with finances, personal stress, transportation, employment, and legal issues being the most prevalent. Thirty-two percent of patients indicated a desire to see a social worker. Provider and patient differences were compared. Provider estimates of patients' problems were consistently lower than patient estimates in all psychosocial problem areas except need for nursing home placement and problem drinking or drug use. Implications for social work in primary care are discussed.

Race-Ethnicity as a Predictor of Attitudes Toward Mental Health Treatment Seeking

Race-Ethnicity as a Predictor of Attitudes Toward Mental Health Treatment Seeking

Race-Ethnicity as a Predictor of Attitudes Toward Mental Health Treatment Seeking

Previous research on mental health disparities shows that persons from racial-ethnic minority groups have less access to mental health care, engage in less treatment, and receive poorer-quality treatment than non-Hispanic whites. Attitudes and beliefs about mental health treatment were examined to determine whether they contribute to these disparities. Data from the National Comorbidity Survey Replication (NCS-R) were analyzed to determine attitudes toward treatment-seeking behavior among people of non-Hispanic white, African-American, and Hispanic or Latino race-ethnicity. Additional sociodemographic variables were examined in relation to attitudes and beliefs toward treatment. African-American race-ethnicity was a significant independent predictor of greater reported willingness to seek treatment and lesser reported embarrassment if others found out about being in treatment. These findings persisted when analyses adjusted for socioeconomic variables. Hispanic or Latino race-ethnicity also was associated with an increased likelihood of willingness to seek professional help and lesser embarrassment if others found out, but these differences did not persist after adjustment for the effects of socioeconomic variables. Contrary to the initial hypothesis, African Americans and Hispanics or Latinos may have more positive attitudes toward mental health treatment seeking than non-Hispanic whites. To improve access to mental health services among racial-ethnic minority groups, it is crucial to better understand a broader array of individual-, provider-, and system-level factors that may create barriers to care.

Addressing alcohol problems in primary care settings: A study of general medical practitioners in Cape Town, South Africa

To explore alcohol-related practices among general practitioners (GPs) in the Cape Town metropole and to examine barriers to addressing risky drinking among patients. A cross-sectional survey of 50 GPs was conducted between November 2004 and April 2005. A questionnaire assessing GPs' alcohol-related practices and barriers to alcohol-related interventions was administered to participating GPs. In the past 12 months, most GPs reported seeing only 11-30 patients for alcohol problems specifically. While only 12% thought that they could effectively help patients reduce their alcohol consumption, 78% of GPs indicated that, given adequate training and support, they could become more effective. Among the barriers that hindered their ability to intervene in patients' alcohol-related problems were difficulties in getting reimbursed for treating patients with alcohol problems, insufficient training, lack of materials with which to do screening and counselling, perceptions of ineffectiveness, and time constraints. GPs are willing to conduct interventions for risky drinking but require additional training in these interventions as well as appropriate support and intervention tools.

Behavioral Health Screening in Urban Primary Care Settings: Construct Validity of the PSC-17

The Pediatric Symptom Checklist-17 (PSC-17) is a brief form of the Pediatric Symptom Checklist that is designed to screen for behavioral health problems in primary care settings. It has been proposed to have three subscales: externalizing, internalizing, and attention problems. In the context of developing a behavioral health screening program in an inner-city primary care practice, we evaluated the construct validity of the PSC-17. A total of 331 families with children between 4 and 12 years of age who were seen for well-child care during the study were invited to complete the PSC-17 and 320 families (96.5%) did so. A confirmatory factor analysis was performed and the Comparative Fit Index and root mean square error of approximation fit statistics were calculated to determine whether the data fit the proposed three-factor model. We found that although the PSC-17 contained three subscales, several items did not load predominantly on the subscale that they were proposed to measure. Specifically, although the five items on the internalizing subscale loaded only on this subscale, only four of the seven externalizing items loaded exclusively on the externalizing subscale, and only two of the five attention items loaded exclusively on the attention problems subscale. Clinicians using the PSC-17 in urban low-income communities should recognize that the externalizing and attention problems subscales of the PSC-17 may not be valid measures of these dimensions of child behavior in this population.

Identification of Youth Psychosocial Problems During Pediatric Primary Care Visits

This investigation applied the Gateway Provider Model (GPM) of child mental health services to investigate whether characteristics of the child, family, visit, and provider were related to the identification of youth psychosocial problems during primary care visits. Data were gathered during 774 visits to 54 primary care providers (PCPs) at 13 clinics. Similar to previous investigations in primary care settings, 42% of youth demonstrated at least a sub-threshold clinical mental health problem. Most PCPs reported high job satisfaction and control, but reported varying access to mental health specialists. PCPs generally had positive attitudes and beliefs about treating psychosocial problems but many reported that doing so was burdensome. Identification was more likely when the visit was for a mental health problem, when issues related to psychosocial problems were discussed during the visit, when the youth demonstrated mental health symptoms, impairment, or burden to the family, and when the youth was older, uninsured, or received Medicaid. Identification was less likely when the PCP reported greater burden associated with treating psychosocial problems and when the PCP reported greater accessibility to mental health specialists. These results suggest that identification is associated with the interaction of multilevel factors and that the GPM is a useful model to investigate points of intervention for improving the identification of children's mental health problems in primary care settings.

Five-year trajectories of health care utilization and cost in a drug and alcohol treatment sample

Background: The study examined the effect of individual characteristics on longitudinal patterns of health care utilization and cost among individuals entering chemical dependency (CD) treatment. Method: Structured interviews and computerized administrative databases were linked to obtain severity, utilization and cost data. Total medical costs and their components were examined for the 6 months prior to intake through 5 years post-intake. Statistical analyses were conducted using the hierarchical linear modeling framework. Results: Age was positively correlated with total medical costs. Women had higher inpatient utilization and higher inpatient, primary care and total cost at baseline ( p < .05). However, they had steeper decline in primary care costs. While age was not related to inpatient and ER use at baseline (after controlling for psychiatric and medical severity), older individuals had smaller declines in hospital days and inpatient cost over time. Individuals with high medical and psychiatric severity had higher utilization and costs ( p < .01). Those who were abstinent had higher costs. Conclusions: There are important differences in patient characteristics and treatment outcomes that influence utilization and cost trajectories. The relationship between medical severity at intake and primary care cost pre-intake among patients with drug and alcohol problems suggests an opportunity to identify and treat drug and alcohol problems in primary care settings. It also suggests that medical evaluations and treatment should not be overlooked during CD treatment. The positive association between abstinence and trajectories of primary care and total medical costs suggests that maintaining abstinence over a long term requires some kind of continuing care either in primary care settings or via additional contacts with specialty CD departments.