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Biomedical subjects

D E Ford

Publications and source records attributed to D E Ford.

At least 55 records · Page 3Linked to original sources
PubMed1994

The effect of psychiatric symptoms on the recognition of alcohol disorders in primary care patients.

OBJECTIVE: To determine factors related to physician recognition of alcohol abuse in a primary clinic, specifically factors associated with psychiatric illness. METHOD: Using a cross-sectional study design, we conducted a comprehensive chart review of an existing study sample. A total of 321 systematically sampled patients completed a patient interview. One-hundred-and-one patients scored one or more on the CAGE screening questionnaire for alcohol abuse and were eligible for the medical chart review, which assessed sociodemographic variables, psychiatric and medical diagnoses, alcohol and other substance use, laboratory tests results, and number of patient contacts. RESULTS: 35 percent of the CAGE positive sample had a history of a psychiatric disorder documented in the chart, and an additional 17 percent had symptoms consistent with possible underlying psychopathology. Using multiple logistic regression analysis, the presence of documented psychiatric disorders was not found to be significantly associated with physician recognition (odds ratio = 1.7, 95% confidence interval, 0.5-5.8), relative to patients without these disorders. However, patients who reported psychiatric complaints were significantly more likely to have been recognized by their physicians as having a probable alcohol disorder (odds ratio = 4.4, 95% confidence interval, 1.2-16.2), relative to those without such complaints. Other factors found to be associated with recognition are discussed. CONCLUSIONS: The evidence indicates that a large proportion of alcohol disorders go unrecognized by physicians, however it does not appear that this is due to the misclassification of alcoholism as other psychiatric disorders or symptoms. Additional studies with objective assessment of psychiatric status will be helpful in further investigating this question.

Adult↗
PubMed1994

Home is not where the heart is: looming problems of the home care industry.

This analysis shows a definite trend of fiscal and social retrenchment policy by the government concerning in-home care service delivery (Tables 1 and 2). Ruggie (1990:164) notes that such shifts and changes in Medicare reimbursement patterns may be efforts of the government to realign itself to become the pivotal force in the provision or delivery of in-home care. Cost-containment pressures, although most needed in the health care industry, are the primary driving force behind retrenchment and the subsequent realignment of government. Such forces tend to impede the development of a comprehensive system for the provision of long-term care services. As noted, the movements and shifts in reimbursement patterns documented by this analysis can lead one to conclude that the same old features will continue to prevail instead of new and innovative delivery structures or public-private partnerships. In other words, the in-home care industry will become more like the nursing home industry--highly regulated and perpetually plagued by questions concerning quality of care. Although government is attempting to diminish its task as the prime provider of health services (i.e., through fiscal retrenchment) and the public's role as the dominant delivery system (i.e., social retrenchment), nevertheless the government has been unable to retrench politically in spite of its present direction of cost containment and fiscal restraint. Consequently, Ruggie (1990:147) notes that "the social welfare functions may continue to be performed" in spite of cost restraint policies. As a result, another "no care zone" is created and policy-makers will continue to develop "crisis policy" such as intense demands to hold unit costs low. The home care system has expanded many of the long-term care options and has emerged as a salient segment of our health and social service system (Applebaum and Phillips, 1990). Yet, policy-makers have not developed a comprehensive long-term care system, particularly one that defines a common policy for home care benefits and engenders the right kind of public-private partnership for the delivery of quality home care.

Aged↗
PubMed1994

Physician knowledge of the CAGE alcohol screening questions and its impact on practice.

A cross-sectional survey of physicians (n = 301) and patients (n = 321) at a university-based department of medicine was completed to determine physician's ability to list CAGE alcohol screening questions and how this knowledge is associated with practice patterns. Forty-five percent of the physicians had heard of the CAGE, but only 14% could list all four of the questions correctly. Physicians who knew the CAGE were more likely to report counseling and referral of their patients who abuse alcohol. However, as assessed by patient interview and chart review, patients with an alcohol abuse problem were no more likely to have been recognized by or to have received more aggressive care from residents who knew the CAGE than patients cared for by residents who did not know the CAGE. Knowledge of an alcohol screening test is not sufficient to change physician practice related to care of patients with an alcohol abuse problem. More attention must be directed towards the development of effective strategies which integrate into clinical practice screening and initial treatment of patients who abuse alcohol.

Adult↗
PubMed1993

Serum cholesterol in young men and subsequent cardiovascular disease.

BACKGROUND: The increased risk of cardiovascular disease associated with higher serum cholesterol levels in middle-aged persons has been clearly established, but there have been few opportunities to examine a potential link between serum cholesterol levels measured in young men and clinically evident premature cardiovascular disease later in life. METHODS: We performed a prospective study of 1017 young men (mean age, 22 years) followed for 27 to 42 years to quantify the risk of cardiovascular disease and total mortality associated with serum cholesterol levels during early adult life. The mean serum cholesterol level at entry was 192 mg per deciliter (5.0 mmol per liter). RESULTS: During a median follow-up of 30.5 years, there were 125 cardiovascular-disease events, 97 of which were due to coronary heart disease. The serum cholesterol level at base line was strongly associated with the incidence of events related to coronary heart disease and cardiovascular disease, as well as to total mortality and mortality due to cardiovascular disease. The risks were similar whether the events occurred before or after the age of 50. In a proportional-hazards analysis adjusted for age, body-mass index (the weight in kilograms divided by the square of the height in meters), the level of physical activity, coffee intake, change in smoking status, and the incidence of diabetes and hypertension during follow-up, a difference in the serum cholesterol level at base line of 36 mg per deciliter (0.9 mmol per liter)--the difference between the 25th and 75th percentiles of cholesterol level in the study population at base line--was associated with an increased risk of cardiovascular disease (relative risk, 1.72; 95 percent confidence interval, 1.39 to 2.14), coronary heart disease (relative risk, 2.01; 95 percent confidence interval, 1.59 to 2.53), and mortality due to cardiovascular disease (relative risk, 2.02; 95 percent confidence interval, 1.23 to 3.32). A difference in the base-line serum cholesterol level of 36 mg per deciliter was significantly associated with an increased risk of death before the age of 50 (relative risk, 1.64; 95 percent confidence interval, 1.03 to 2.61), but not with the overall risk of death (relative risk, 1.21; 95 percent confidence interval, 0.93 to 1.58). CONCLUSIONS: These findings indicate a strong association between the serum cholesterol level measured early in adult life in men and cardiovascular disease in midlife.

Adult↗
PubMed1993

Validity of physicians' self-reports of cardiovascular disease risk factors.

To determine the accuracy of self-reported risk factors in 78 physicians, self-reported information was compared to findings on a standardized examination. Measured weight (r = 0.98), height (r = 0.95), body mass index (r = 0.96), systolic blood pressure (SBP) (r = 0.72), and diastolic blood pressure (DBP) (r = 0.60) were highly correlated with self-reported values (all P < 0.0001). Mean self-reported SBP and DBP did not differ from measured values; measured weight was 1.5 kg greater and measured height 1.4 cm less than self-reported values (both p < 0.0001). Regression of measured on self-reported values indicated excellent agreement except for DBP and heart rate. Differences between measured and self-reported values were not associated with a variety of variables except for a greater difference in SBP at higher levels of SBP. None of the 60 self-reported nonsmokers had expired carbon monoxide levels greater than 10 ppm. These results indicate that physicians' self-reports of height, body mass index, SBP, and smoking are extremely accurate and suitable for research purposes.

Aged↗
PubMed1992

Can patients use an automated questionnaire to define their current health status?

Patient management decisions rarely incorporate standardized health status assessments, since accurate and reliable measures are difficult and expensive to obtain. In prior research with various methods for obtaining health data from patients, it was found that physicians' acceptance of a method was improved if it provided an individualized printout. It was also determined that patients will readily complete a health status questionnaire on a computer when the computer does not look like a computer. Patients' acceptance was greatest when they were presented with a single line of large, pressure-sensitive buttons with which they could respond to questions about their health histories. Using such an instrument, the HealthQuiz, the current study found the same discrepancy rate (3%) between patients' responses to health questions presented on HealthQuiz and during interview as between their responses to questions asked during two separate interviews. Further, to ascertain health status, rules determined by an expert panel were applied to patients' responses to health questions presented on the HealthQuiz screen. It was found that the numerical health status derived from answers to the automated presentation of questions was similar to numerical health status derived by a physician after a patient-physician interview.

Aged↗
PubMed1991

Preventive care guidelines: 1991. American College of Physicians. Canadian Task Force on the Periodic Health Examination. United States Preventive Services Task Force.

Clinicians increasingly are urged to integrate preventive services into their clinical practices. To facilitate this process, several groups have developed practice guidelines for preventing disease in asymptomatic patients. In this paper, we compare and contrast preventive guidelines from the American College of Physicians (ACP), the Canadian Task Force on the Periodic Health Examination (CTF), the United States Preventive Services Task Force (USPSTF), and other well-known authorities. We chose these groups because they based their recommendations on explicit methods that include critical appraisal of the pertinent literature. Recommendations from these authorities usually are consistent with each other. Moreover, the ACP, CTF, and USPSTF all favor a shift away from the relatively simple classification of patients by age and sex for general preventive interventions to the more complex stratification of patients by additional risk factors and the formulation of a selective prevention strategy that is specific to each risk profile. Some guidelines, particularly the criteria used to define patients who are at increased risk for preventable disease and who should have more intensive surveillance, are difficult to interpret. Further research is needed to address some areas of disagreement and ambiguity. In addition, new tools must be developed to help physicians apply preventive guidelines, particularly those that require noting many patient-specific characteristics.

Canada↗
PubMed1989

Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention?

As part of the National Institute of Mental Health Epidemiologic Catchment Area study, 7954 respondents were questioned at baseline and 1 year later about sleep complaints and psychiatric symptoms using the Diagnostic Interview Schedule. Of this community sample, 10.2% and 3.2% noted insomnia and hypersomnia, respectively, at the first interview. Forty percent of those with insomnia and 46.5% of those with hypersomnia had a psychiatric disorder compared with 16.4% of those with no sleep complaints. The risk of developing new major depression was much higher in those who had insomnia at both interviews compared with those without insomnia (odds ratio, 39.8; 95% confidence interval, 19.8 to 80.0). The risk of developing new major depression was much less for those who had insomnia that had resolved by the second visit (odds ratio, 1.6; 95% confidence interval, 0.5 to 5.3). Further research is needed to determine if early recognition and treatment of sleep disturbances can prevent future psychiatric disorders.

Adolescent↗
PubMed1989

The General Health Questionnaire by interview. Performance in relation to recent use of health services.

The General Health Questionnaire (GHQ) is a widely used method of assessing psychiatric distress in clinical settings and in the community. The authors administered a 20-item interview version of the GHQ and a battery of survey items on use of ambulatory health care services to 3,389 respondents in eastern Baltimore as part of the Epidemiologic Catchment Area survey. In addition, a subsample of these respondents (n = 810) was examined by research psychiatrists who provided a reference mental disorder diagnosis for comparison with GHQ results. Psychiatrists determined that 102 respondents had American Psychiatric Association's Diagnostic and Statistical Manual, third edition, (DSM-III) disorders suitable for detection by the GHQ. These respondents were categorized by the health service use they reported over the previous 6 months. A comparison indicated that 82% of the diagnosed cases with recent specialty care also had elevated GHQ scores. Among cases with recent general medical care, 52% had elevated GHQ scores. Among diagnosed cases reporting no recent ambulatory health care, only 38% had elevated GHQ scores. Receiver operating characteristic analysis demonstrated a similar trend. Cases of depression were separated into less severe cases (adjustment disorder with depressed mood) and more severe cases (major depression). There were relatively more cases of severe depression than cases of mild depression in those respondents reporting recent health service use compared with those respondents reporting no recent service use. This may account for the higher sensitivity of the GHQ in detecting psychiatric disorders for those persons utilizing health services compared with individuals using no health services.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory Care↗
PubMed1988

Principles of screening applied to psychiatric disorders.

The morbidity and mortality caused by psychiatric illness is a significant public health problem. The use of a psychiatric screening questionnaire has been one strategy to improve the recognition and treatment of psychiatric disorders in general medical settings. This paper discusses how well psychiatric screening procedures fulfill criteria outlined by the World Health Organization for evaluating the utility of general medical screening efforts. Current research on the utility of screening for psychiatric disorders is reviewed, and the lack of data on the treatment of psychiatric disorders is identified in the general medical sector is emphasized. The randomized clinical trial is offered as the best method to test the efficacy of screening by eliminating various biases outlined in the paper. Quantitative concepts such as positive predictive value and receiver operator characteristic analysis are discussed. The need for more research on the efficacy of early treatment of psychiatric disorders is emphasized.

Feedback↗
PubMedDate not supplied

Attitudes, knowledge, and behavior of family physicians regarding depression in late life.

OBJECTIVES: To assess self-reported knowledge, attitudes, and behaviors of practicing community family physicians regarding identification and management of depression in late life. DESIGN: We sent a 3-page "fax-back" survey to 768 active physician members of the Maryland Academy of Family Physicians, Baltimore. MEASUREMENTS: We asked physicians to rate how confident they felt in evaluating several common medical conditions of late life, including depression. The questionnaire included items related to knowledge and treatment practices for depression in older adults. RESULTS: Two hundred fifteen usable surveys were returned. In general, physicians took responsibility for diagnosing and treating depression. Few physicians reported that they routinely referred the older patient to a psychiatrist to treat depression, and only half thought that consultation was helpful. Physicians responding to the survey were generally aware of alternative presentations of depression in elderly persons, and were well informed about the duration of treatment with medications for depression. Most were using selective serotonin reuptake inhibitors as first-line agents to treat depression. Physicians though that medications for depression were as effective for older patients as for younger patients, but were less optimistic about the effectiveness of psychotherapy. The barriers to identifying and treating depression in older patients most often mentioned by physicians were related to the atypical presentation of depression in older adults. More than half of the physicians rated themselves as "very confident" in evaluating depression. There were few differences in the responses of physicians with and those without a Certificate of Added Qualifications in geriatrics. CONCLUSIONS: Depression in late life remains a difficult clinical challenge for primary care physicians. These findings are particularly relevant in the face of recent efforts to increase collaboration between primary care physicians and mental health professionals.

Adult↗
PubMedDate not supplied

Who talks to physicians about mental health and substance abuse problems?

This is an analysis of data from the NIMH-sponsored Epidemiologic Catchment Area community-based study, investigating who reported discussing mental health or substance abuse problems with nonpsychiatric physicians. Data were from 7,092 respondents in four sites, all of whom had received care only in the nonpsychiatric sector in the previous six months. A multiple logistic model found that those individuals who had psychiatric disorders, and female, middle-aged, and Hispanic respondents, were more likely to have discussed emotional or mental health problems with their physicians. Respondents with alcohol abuse and substance abuse disorders did not report any more discussion of mental health problems than did respondents without alcohol or substance abuse disorders. Only 36% of the respondents who said they had discussed mental health problems were found to have psychiatric disorders by the Diagnostic Interview Survey (DIS), but many of those without disorders reported more anxiety symptoms. An analysis was done to predict which respondents with DIS-defined psychiatric disorders did not report discussing mental health problems with their nonpsychiatric physicians. Those less than 35 years of age, those older than 65 years of age, males, and those with only one recent visit to a provider were statistically at high risk for not discussing their psychiatric problems.

Catchment Area, Health↗
PubMedDate not supplied

Patient characteristics related to intensity of weight reduction care in a university medical clinic.

OBJECTIVE: To identify patient characteristics related to intensity of weight reduction care provided in a primary care practice. DESIGN: Cross-sectional study linking data from a patient survey and data from medical records. SETTING: Internal medicine housestaff clinic in an urban university hospital. PARTICIPANTS: 321 outpatients who represented a systematic sample of all outpatients who had visited the clinic over one year. MEASUREMENTS AND MAIN RESULTS: The patient population was largely black (86%) and female (65%). Most patients (54%) were overweight [body-mass index (BMI) > 85th percentile for the United States by gender]. Intensity of care was defined by a composite scale: points were awarded for actions documented in the medical chart or recalled by the patient. Factors independently associated with a higher intensity of care among the 161 overweight patients were: BMI [odds ratio (OR) = 1.13 per kg/m2; 95% confidence interval (95% CI) = 1.04, 122; p = 0.002], the patient's self-perception of being overweight (OR = 5.37; 95% CI = 1.99, 14.46; p = 0.001), and age of 64 years or younger (OR = 2.48; 95% CI = 1.12, 5.48; p = 0.02). Race, gender, and presence of hypertension or hypercholesterolemia were not associated with greater intensity of care. CONCLUSIONS: Patients with hypertension and hypercholesterolemia may be receiving suboptimal weight reduction care. Heightened awareness of being overweight may enhance the provision of weight reduction care. Prospective studies are required to confirm these findings.

Adult↗
PubMedDate not supplied

Screening for psychiatric and substance abuse disorders in clinical practice.

Psychiatric disorders, particularly depression and alcohol abuse, represent a large burden of illness to the society. Many individuals with these disorders receive all of their care from health care providers who are not mental health specialists. There is evidence that non-psychiatric physicians frequently do not recognize these disorders in their patients. Screening questionnaires have been introduced to improve detection of these patients. Several studies have found that these screening questionnaires can increase detection rates, but no important impact on patient outcomes has been demonstrated. This review article outlines several reasons why it has been difficult to discern improvement in patient outcomes: inadequate study design, insufficient physician education, interdependence of psychiatric and medical conditions, and vague treatment guidelines. Practical use of the current psychiatric screening questionnaires and key areas for further investigation are considered.

Alcoholism↗
PubMedDate not supplied

Primary care patients' opinions regarding the importance of various aspects of care for depression.

The objectives of this study were to 1) ascertain the importance of various aspects of depression care from the patient's perspective and 2) select items and scales for inclusion in a new instrument to measure primary care patients' attitudes toward and ratings of depression care. We used a cross-sectional survey at a university-based urban primary care clinic; the subjects were adult patients being recruited for a study of minor depression. To help prioritize attitudinal domains, including 126 items identified previously in focus groups, we asked patients to rate the importance of each aspect of depression care on a five-point scale. Items were ranked according to mean scores and the percentage of patients ranking the items as extremely important. The items were selected for inclusion in an instrument to measure patients' attitudes toward depression care based on their importance ratings. We performed reliability and validity testing of scales comprising the 30 most important items and a shortened version that includes 16 items. The sample included 76 patients (mean age 34.8 years; mean CES-D score, 22.2; 72% women; 36% African-American; 32% college graduates). Forty-six percent had visited a mental health professional in the past. The top 30 items for the overall sample came from the following domains: 1) health care providers' interpersonal skills, 2) primary care provider recognition of depression, 3) treatment effectiveness, 4) treatment problems, 5) patient understanding about treatment, 6) intrinsic spirituality, and 7) financial access to services. Scales comprising items from these domains show adequate internal consistency (Cronbach's alpha >0.70) as well as convergent and discriminant validity. We have designed a brief patient-centered instrument for measuring attitudes toward depression care that has evidence for internal item consistency reliability and discriminant validity.

Adult↗
PubMedDate not supplied

The Quality Improvement for Depression collaboration: general analytic strategies for a coordinated study of quality improvement in depression care.

It is difficult to evaluate the promise of primary care quality-improvement interventions for depression because published studies have evaluated diverse interventions by using different research designs in dissimilar populations. Preplanned meta-analysis provides an alternative to derive more precise and generalizable estimates of intervention effects; however, this approach requires the resolution of analytic challenges resulting from design differences that threaten internal and external validity. This paper describes the four-project Quality Improvement for Depression (QID) collaboration specifically designed for preplanned meta-analysis of intervention effects on outcomes. This paper summarizes the interventions the four projects tested, characterizes commonalities and heterogeneity in the research designs used to evaluate these interventions, and discusses the implications of this heterogeneity for preplanned meta-analysis.

Adult↗