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Biomedical subjects

Kurt Kroenke

Publications and source records attributed to Kurt Kroenke.

At least 37 records · Page 2Linked to original sources
PubMed2005

Access to communication technologies in a sample of cancer patients: an urban and rural survey.

BACKGROUND: There is a growing awareness among providers of the symptom burden experienced by cancer patients. Systematic symptom screening is difficult. Our plan was to evaluate a technology-based symptom screening process using touch-tone telephone and Internet in our rural outreach cancer program in Indiana. Would rural patients have adequate access to technologies for home-based symptom reporting? OBJECTIVES: 1) To determine access to touch-tone telephone service and Internet for patients in urban and rural clinics; 2) to determine barriers to access; 3) to determine willingness to use technology for home-based symptom reporting. METHODS: Patients from representative clinics (seven rural and three urban) in our network were surveyed. Inclusion criteria were age greater than 18, able to read, and diagnosis of malignancy. RESULTS: The response rate was 97%. Of 416 patients completing the survey (230 rural, 186 urban), 95% had access to touch-tone telephone service, while 46% had Internet access (56% of urban patients, 38% of rural patients). Higher rates of Internet access were related to younger patient age, current employment, and higher education and income. The primary barrier to Internet access was lack of interest. Use of the Internet for health related activities was less than 50%. The preferred means of symptom reporting in patients with internet access were the touch-tone telephone (70%), compared to reporting by the Internet (28%). CONCLUSION: Access to communication technologies appears adequate for home-based symptom reporting. The use of touch-tone telephone and Internet reporting, based upon patient preference, has the potential of enhancing symptom detection among cancer patients that is not dependent solely upon clinic visits and clinician inquiry.

Community-Institutional Relations↗
PubMed2005

Performance of the PHQ-9 as a screening tool for depression after stroke.

BACKGROUND AND PURPOSE: The purpose of this study was to examine the performance of the Patient Health Questionnaire (PHQ)-9, a 9-item depression scale, as a screening and diagnostic instrument for assessing depression in stroke survivors. METHODS: As part of a randomized treatment trial for poststroke depression (PSD), subjects with and without PSD completed the PHQ-9, a 9-item summed scale, with scores ranging from 0 (no depressive symptoms) to 27 (all symptoms occurring daily). Subjects endorsing 2 or more symptoms of depression were administered the criterion standard Structured Clinical Interview for Depression (SCID). Receiver operating characteristic analysis was used to examine the sensitivity and specificity of the PHQ-9 RESULTS: Of 316 subjects enrolled, 145 met SCID criteria for major depression or other depressive disorder, and 171 were not depressed. PHQ-9 scores discriminated well between subjects with any versus no depressive disorder, with an area under the curve (AUC) of 0.96, as well as between subjects with and without major depression (AUC=0.96). The AUC was similar regardless of patient age, gender, or ethnicity. A PHQ-9 score > or =10 had 91% sensitivity and 89% specificity for major depression, and 78% sensitivity and 96% specificity for any depression diagnosis. CONCLUSIONS: The PHQ-9 performs well as a brief screener for PSD with operating characteristics similar or superior to other depression measures and similar to its characteristics in a primary care population. Moreover, PHQ-9 scores discriminate equally well between those with and without PSD regardless of age, gender, or ethnicity.

Depression↗
PubMed2005

Physical symptoms as a predictor of health care use and mortality among older adults.

PURPOSE: To describe the patterns of physical symptoms in older adults and to examine the validity of symptoms in predicting hospitalization and mortality. SUBJECTS AND METHODS: Adults aged 60 years and older (N=3498) who completed screening for self-reported symptoms at routine primary care visits. Self-reported symptoms were collected using an abbreviated PRIME-MD screening instrument. Clinical characteristics, hospitalization, and mortality in the year following screening were measured using data taken from a comprehensive electronic medical record. RESULTS: The mean patient age was 69 years, 69% were women, and 56% were African-American. A majority (51%) of respondents characterized their health as fair or poor. The most commonly reported symptoms were musculoskeletal pain (65%), fatigue (55%), back pain (45%), shortness of breath (41%), and difficulty sleeping (38%). A summary score of physical symptoms (range 0-12) was a significant independent predictor of future hospitalization and death even when controlling for clinical characteristics, chronic medical conditions, self-rated health, and affective symptoms. Disease-specific symptoms were more common among patients diagnosed with the specific condition but there was also a substantial background prevalence of these symptoms. CONCLUSION: Physical symptoms are highly prevalent in older primary care patients and predict hospitalization and mortality at one year. Future work is needed to determine how to target symptoms as a potential mechanism to reduce health care use and mortality.

Aged↗
PubMed2005

Detecting and monitoring depression with a two-item questionnaire (PHQ-2).

OBJECTIVE: This study evaluates the two-item Patient Health Questionnaire (PHQ-2) as a measure for diagnosing and monitoring depression. METHODS: We assessed construct validity in a cross-sectional sample of 1619 medical outpatients (mean age 43+/-14 years, 64% female) by comparing the PHQ-2 to four longer self-report questionnaires. Criterion validity was established in a subsample of 520 participants with reference to the Structured Clinical Interview for DSM-IV (SCID). Sensitivity to change was investigated in a prospective study of 167 patients who completed the SCID both at baseline and the 1-year follow-up. RESULTS: With reference to the SCID, the PHQ-2 had a sensitivity of 87% and a specificity of 78% for major depressive disorder and a sensitivity of 79% and a specificity of 86% for any depressive disorder. Its diagnostic performance was comparable with that of longer depression scales. PHQ-2 change scores accurately reflected improved, unchanged, and deteriorated depression outcomes. CONCLUSION: The PHQ-2 performed favorably with respect to a standard diagnostic interview, as well as established depression scales and proved sensitive to change. Thus, the PHQ-2 appears promising as a brief multipurpose measure for detecting depression, grading its severity, and monitoring outcomes over time.

Adult↗
PubMed2005

A comparison of clinically important differences in health-related quality of life for patients with chronic lung disease, asthma, or heart disease.

OBJECTIVE: On the eight scales of the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), Version 2, we compared the clinically important difference (CID) thresholds for change over time developed by three separate expert panels of physicians with experience in quality of life assessment among patients with chronic obstructive pulmonary disease (COPD), asthma, and heart disease. STUDY DESIGN: We used a modified Delphi technique combined with a face-to-face panel meeting within each disease to organize and conduct the consensus process among the expert panelists, who were familiar with the assessment and evaluations of health-related quality of life (HRQL) measures among patients with the panel-specific disease. PRINCIPAL FINDINGS: Each of the expert panels first determined the magnitude of the smallest numerically possible change on each SF-36 scale, referred to as a state change, and then built their CIDs from this metric. All three panels attained consensus on the scale changes that constituted small, moderate, and large clinically important SF-36 change scores. The CIDs established by the heart disease panel were generally greater than the CIDs agreed on by the asthma and COPD panels. CONCLUSIONS: These panel-derived thresholds reflect possible differences in disease management among the represented panel-specific diseases, and are all greater than the minimal CID thresholds previously developed for the SF-36 scales among patients with arthritis. If confirmed among patients with the relevant diseases and those patients' physicians, these disease-specific CIDs could assist both researchers and practicing clinicians in the use and interpretation of HRQL changes over time.

Asthma↗
PubMed2005

Symptomatic severity of PRIME-MD diagnosed episodes of panic and generalized anxiety disorder in primary care.

BACKGROUND: Panic disorder (PD) and generalized anxiety disorder (GAD) are often unrecognized by primary care physicians (PCPs). The Primary Care Evaluation of Mental Disorders (PRIME-MD) has been used as a case-finding instrument for depression. Yet, little is known on its usefulness as a case-finding tool for anxiety disorders within the context of a clinical trial. OBJECTIVE: To examine the: (1) completion rate of the PRIME-MD by patients approached to enroll in a treatment study for PD and GAD; (2) distribution of anxiety diagnoses generated; (3) severity of PD and GAD episodes thus identified; and (4) level of PCPs' agreement with these diagnoses. DESIGN: Cross-sectional interview. PATIENTS: Individuals aged 18 to 64 who presented for care at 4 primary care practices. MEASUREMENTS: The PRIME-MD, Structured Interview Guide for the Hamilton Anxiety Rating Scale (SIGH-A), and the Panic Disorder Severity Scale (PDSS). RESULTS: Of the 6,700 patients who completed the PRIME-MD Patient Questionnaire (PQ), 2,926 (44%) screened positive for an anxiety disorder, and 1,216 (42%) met preliminary study eligibility and consented to the PRIME-MD Anxiety Module. Of these, 619 (51%) had either GAD (308), PD (94), or both (217) disorders. Later, 329 completed a telephone interview. Of these, 59% with GAD and 68% with PD reported moderate or greater levels of anxiety symptoms on the SIGH-A and PDSS, respectively, and PCPs agreed with the PRIME-MD diagnosis for 98% of these patients. CONCLUSIONS: The PRIME-MD can efficiently screen patients for PD and GAD. Although patients thus identified endorse a wide range of anxiety symptoms, PCPs often agree with the diagnosis.

Adult↗
PubMed2005

Treatment of depression improves physical functioning in older adults.

OBJECTIVES: To determine the effect of collaborative care management for depression on physical functioning in older adults. DESIGN: Multisite randomized clinical trial. SETTING: Eighteen primary care clinics from eight healthcare organizations. PARTICIPANTS: One thousand eight hundred one patients aged 60 and older with major depressive disorder. INTERVENTION: Patients were randomized to the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) intervention (n=906) or to a control group receiving usual care (n=895). Control patients had access to all health services available as part of usual care. Intervention patients had access for 12 months to a depression clinical specialist who coordinated depression care with their primary care physician. MEASUREMENTS: The 12-item short form Physical Component Summary (PCS) score (range 0-100) and instrumental activities of daily living (IADLs) (range 0-7). RESULTS: The mean patient age was 71.2, 65% were women, and 77% were white. At baseline, the mean PCS was 40.2, and the mean number of IADL dependencies was 0.7; 45% of participants rated their health as fair or poor. Intervention patients experienced significantly better physical functioning at 1 year than usual-care patients as measured using between-group differences on the PCS of 1.71 (95% confidence interval (CI)=0.96-2.46) and IADLs of -0.15 (95% CI=-0.29 to -0.01). Intervention patients were also less likely to rate their health as fair or poor (37.3% vs 52.4%, P<.001). Combining both study groups, patients whose depression improved were more likely to experience improvement in physical functioning. CONCLUSION: The IMPACT collaborative care model for late-life depression improves physical function more than usual care.

Activities of Daily Living↗
PubMed2005

Somatoform disorders: time for a new approach in DSM-V.

OBJECTIVE: DSM-III introduced somatoform disorders as a speculative diagnostic category for somatic symptoms "not explained by a general medical condition." Although retained and enlarged in DSM-IV, somatoform disorders have been the subject of continuing criticism by both professionals and patients. The extended period of preparation for DSM-V offers an important opportunity to reconsider the category of somatoform disorders. METHOD: Exploration of the diverse aims of a diagnostic classification indicates that the authors must not only address the conceptual and practical problems associated with this category but also reconcile it with the parallel medical descriptive classification of functional symptoms and syndromes. RESULTS: The existing somatoform disorders categories require modification. The authors favor the radical option of the abolition of the categories. Diagnoses currently within somatoform disorders could be redistributed into other groupings, and the disorders currently defined solely by somatic symptoms could be placed on axis III as "functional somatic symptoms and syndromes." Greater use could be made of "psychological factors affecting medical condition" on axis I. The authors suggest supplementing the diagnosis of functional somatic symptoms with a multiaxial formulation. CONCLUSIONS: The authors promote a classification of somatic symptoms in DSM-V that is compatible with that used in general medicine and offers new opportunities both for research into the etiology and treatment of symptoms and for the greater integration of psychiatry into general medical practice.

Attitude of Health Personnel↗
PubMed2005

Comorbid depression is an independent risk factor for mortality in patients with rheumatoid arthritis.

OBJECTIVE: Whether comorbid depression increases mortality in patients with rheumatoid arthritis (RA) is unknown. Our objective was to determine whether the presence of depression predicted mortality in patients with RA. METHODS: We followed 1290 consecutive outpatients with RA who met our stringent inclusion criteria during an 18-year observation period. Since 1981, demographic, clinic, and self-report data were collected and entered into a computer database at the time of each clinic visit. The comorbidity data were consistently recorded beginning in 1991. Our primary independent variable was the mean of the Arthritis Impact Measurement Scales (AIMS) depression scores during the first 4 years of entry into the clinic cohort (average 4-year depression). Data were analyzed using Cox proportional hazard models. RESULTS: After adjusting for covariates, the hazard ratio (HR) for each unit increase in the average 4-year depression score on mortality was 1.14 (p < 0.0001). Using only the data obtained from 1991 to 2003, the mortality risk was slightly increased (HR 1.35, p < 0.0001). To reduce residual confounding due to RA disease activity and/or comorbid medical conditions, we then excluded deaths during the first 2 years after study onset. With this method, the HR for the average 4-year depression remained significant (HR 1.35, p < 0.0001). Because an AIMS depression score > or = 4 is consistent with clinical depression, we analyzed the dataset using the average 4-year depression score as a dichotomous variable (score < 4 or > or = 4). The HR of clinical depression on mortality was 2.2 (95% CI 1.2- 3.9, p = 0.01). CONCLUSION: Depression increases the risk of mortality in RA. Our study highlights the importance of comorbid depression in patients with RA.

Arthritis, Rheumatoid↗
PubMed2004

Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial.

OBJECTIVE: To test the effectiveness of an evidence based model for management of depression in primary care with support from quality improvement resources. DESIGN: Cluster randomised controlled trial. SETTING: Five healthcare organisations in the United States and 60 affiliated practices. PATIENTS: 405 patients, aged > or = 18 years, starting or changing treatment for depression. INTERVENTION: Care provided by clinicians, with staff providing telephone support under supervision from a psychiatrist. MAIN OUTCOME MEASURES: Severity of depression at three and six months (Hopkins symptom checklist-20): response to treatment (> or = 50% decrease in scores) and remission (score of < 0.5). RESULTS: At six months, 60% (106 of 177) of patients in intervention practices had responded to treatment compared with 47% (68 of 146) of patients in usual care practices (P = 0.02). At six months, 37% of intervention patients showed remission compared with 27% for usual care patients (P = 0.014). 90% of intervention patients rated their depression care as good or excellent at six months compared with 75% of usual care patients (P = 0.0003). CONCLUSION: Resources such as quality improvement programmes can be used effectively in primary care to implement evidence based management of depression and improve outcomes for patients with depression.

Adult↗
PubMed2004

Predicting reports of unmet expectations among rheumatology patients.

OBJECTIVE: Approximately 25% of patients report unmet expectations after their doctor visits. In a longitudinal study of rheumatology patients, we examined whether changes in health status could predict unmet expectations. METHODS: Arthritis patients (n = 177) responded to 2 surveys (baseline and 6-month followup). Both surveys contained questions on health status (functional status, pain, helplessness, psychological status) and visit duration. The followup survey contained questions on postvisit unmet expectations. Factors associated with unmet expectations were determined. RESULTS: Fifty-eight patients (33%) reported unmet expectations, most often for information (47%) and new medications (31%). Unmet expectations were more common among patients with greater baseline helplessness (odds ratio [OR] 1.9, 95% confidence interval [95% CI] 1.0-3.6) and short doctor visits at followup (OR 5.6, 95% CI 2.4-13.1). Unmet expectations were less common among those experiencing a decline in pain (OR 0.3, 95% CI 0.1-0.9). CONCLUSION: Attention to the patient's level of pain and helplessness and duration of the visit may limit reports of unmet expectations.

Adult↗
PubMed2004

Clinically important differences in health status for patients with heart disease: an expert consensus panel report.

BACKGROUND: The purpose of the study was to develop clinically important difference (CID) standards for patients with coronary artery disease and congestive heart failure that identify small, moderate, and large intraindividual changes with time in a modified version of the Chronic Heart Failure Questionnaire (CHQ) and the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36, version 2). Prior work in ascertaining important difference standards for the CHQ have centered on patient-perceived changes. No important difference standards for the SF-36 have been published for patients with heart disease. This development of CIDs would facilitate the use of health status measures in daily clinical decision-making. METHODS: We used a modification of the RAND Appropriateness Method to assemble and guide a 9-member consensus panel of physicians with substantial experience in using the CHQ or the SF-36 among patients with heart disease. RESULTS: On the basis of their own experience using these measures and an extensive review of articles describing the development and use of these instruments, the expert panel achieved consensus on small, medium, and large clinically relevant changes in scores for the CHQ and SF-36. The CID standards established by this panel were slightly higher than the minimal important difference standards previously established for the CHQ using patient-perceived changes. CONCLUSIONS: The CID standards established by this expert panel provide an important and useful tool for determining whether routine clinical health status assessments will benefit patients and enhance physicians' decision-making capacity in clinical settings.

Chronic Disease↗
PubMed2004

Common comorbidity scales were similar in their ability to predict health care costs and mortality.

OBJECTIVE: To compare the ability of commonly used measures of medical comorbidity (ambulatory care groups [ACGs], Charlson comorbidity index, chronic disease score, number of prescribed medications, and number of chronic diseases) to predict mortality and health care costs over 1 year. STUDY DESIGN AND SETTING: A prospective cohort study of community-dwelling older adults (n=3,496) attending a large primary care practice. RESULTS: For predicting health care charges, the number of medications had the highest predictive validity (R(2)=13.6%) after adjusting for demographics. ACGs (R(2)=16.4%) and the number of medications (15.0%) had the highest predictive validity for predicting ambulatory visits. ACGs and the Charlson comorbidity index (area under the receiver operator characteristic [ROC] curve=0.695-0.767) performed better than medication-based measures (area under the ROC curve=0.662-0.679) for predicting mortality. There is relatively little difference, however, in the predictive validity across these scales. CONCLUSION: In an outpatient setting, a simple count of medications may be the most efficient comorbidity measure for predicting utilization and health-care charges over the ensuing year. In contrast, diagnosis-based measures have greater predictive validity for 1-year mortality. Current comorbidity measures, however, have only poor to moderate predictive validity for costs or mortality over 1 year.

Black or African American↗
PubMed2004

Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians' diagnoses.

BACKGROUND: The aim of this study was to compare the validity of the Hospital Anxiety and Depression Scale (HADS), the WHO (five) Well Being Index (WBI-5), the Patient Health Questionnaire (PHQ), and physicians' recognition of depressive disorders, and to recommend specific cut-off points for clinical decision making. METHODS: A total of 501 outpatients completed each of the three depression screening questionnaires and received the Structured Clinical Interview for DSM-IV (SCID) as the criterion standard. In addition, treating physicians were asked to give their psychiatric diagnoses. Criterion validity and Receiver Operating Characteristics (ROC) were determined. Areas under the curves (AUCs) were compared statistically. RESULTS: All depression scales showed excellent internal consistencies (Cronbach's alpha: 0.85-0.90). For 'major depressive disorder', the operating characteristics of the PHQ were significantly superior to both the HADS and the WBI-5. For 'any depressive disorder', the PHQ showed again the best operating characteristics but the overall difference did not reach statistical significance at the 5% level. Cut-off points that can be recommended for the screening of 'major depressive disorder' had sensitivities of 98% (PHQ), 94% (WBI-5), and 85% (HADS). Corresponding specificities were 80% (PHQ), 78% (WBI-5), and 76% (HADS). In contrast, physicians' recognition of 'major depressive disorder' was poor (sensitivity, 40%; specificity, 87%). LIMITATIONS: Our sample may not be representative of medical outpatients, but sensitivity and specificity are independent of disorder prevalence. CONCLUSIONS: All three questionnaires performed well in depression screening, but significant differences in criterion validity existed. These results may be helpful in the selection of questionnaires and cut-off points.

Adolescent↗
PubMed2004

Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9).

BACKGROUND: The nine-item depression module from the Patient Health Questionnaire (PHQ-9) is well validated and widely used as a brief diagnostic and severity measure, but its validity as an outcome measure for depression has not yet been established. Therefore, we investigated the sensitivity to change of the PHQ-9 in three groups of patients whose depression status either improved, remained unchanged, or deteriorated over time. METHODS: From three cohorts of medical outpatients, with an equal distribution of major depressive disorder, other depressive disorders, or no depressive disorder, 167 patients (82.7%) were followed up after a mean of 12.3 +/- 3.0 months. The PHQ-9 and the Structured Clinical Interview for DSM-IV (SCID) were completed at both baseline and follow-up. Depression diagnoses from the SCID were used as the criterion standard to divide patients into subgroups with (a) improved depression status, (b) unchanged depression status, and (c) deteriorated depression status. RESULTS: Effect sizes (ES) of PHQ-9 change scores were ES = -1.33 for the improved depression status subgroup (n = 52), ES = -0.21 for the unchanged status subgroup (n = 91), and ES = 0.47 for the deteriorated status subgroup (n = 24). PHQ-9 change scores differed significantly between the three depression outcome groups. LIMITATIONS: The PHQ-9 and the SCID were completed in person at baseline, whereas they were completed in a telephone interview at follow-up. CONCLUSIONS: This study demonstrates the ability of the PHQ-9 to detect depression outcome and changes over time. Data from treatment trials will help further establish the sensitivity to change of the PHQ-9 in comparison to other depression severity measures.

Adult↗
PubMed2004

Monitoring depression treatment outcomes with the patient health questionnaire-9.

BACKGROUND: Although effective treatment of depressed patients requires regular follow-up contacts and symptom monitoring, an efficient method for assessing treatment outcome is lacking. We investigated responsiveness to treatment, reproducibility, and minimal clinically important difference of the Patient Health Questionnaire-9 (PHQ-9), a standard instrument for diagnosing depression in primary care. METHODS: This study included 434 intervention subjects from the IMPACT study, a multisite treatment trial of late-life depression (63% female, mean age 71 years). Changes in PHQ-9 scores over the course of time were evaluated with respect to change scores of the SCL-20 depression scale as well as 2 independent structured diagnostic interviews for depression during a 6-month period. Test-retest reliability and minimal clinically important difference were assessed in 2 subgroups of patients who completed the PHQ-9 twice exactly 7 days apart. RESULTS: The PHQ-9 responsiveness as measured by effect size was significantly greater than the SCL-20 at 3 months (-1.3 versus -0.9) and equivalent at 6 months (-1.3 versus -1.2). With respect to structured diagnostic interviews, both the PHQ-9 and the SCL-20 change scores accurately discriminated patients with persistent major depression, partial remission, and full remission. Test-retest reliability of the PHQ-9 was excellent, and its minimal clinically important difference for individual change, estimated as 2 standard errors of measurement, was 5 points on the 0 to 27 point PHQ-9 scale. CONCLUSIONS: Well-validated as a diagnostic measure, the PHQ-9 has now proven to be a responsive and reliable measure of depression treatment outcomes. Its responsiveness to treatment coupled with its brevity makes the PHQ-9 an attractive tool for gauging response to treatment in individual patient care as well as in clinical research.

Aged↗