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Biomedical subjects

L Miriam Dickinson

Publications and source records attributed to L Miriam Dickinson.

At least 19 recordsLinked to original sources
PubMed2007

Will pediatricians adopt the new rotavirus vaccine?

OBJECTIVES: Our objective was to determine the following among US pediatricians: (1) perceptions regarding burden of rotavirus disease and need for a vaccine; (2) intentions for recommending a newly licensed rotavirus vaccine; (3) perceived barriers to implementation; and (4) factors associated with plans for vaccine adoption. PATIENTS AND METHODS: A network of 431 pediatricians was recruited from a random sample of American Academy of Pediatrics' members. The network was designed to be representative of the American Academy of Pediatrics with respect to region of the country, practice type, and practice setting. During January and February 2006, physicians were surveyed by Internet or mail. The survey contained a paragraph summarizing results of the new rotavirus vaccine trial. Respondents were asked about intentions to use the vaccine and anticipated barriers. RESULTS: The survey response rate was 71%. Of the respondents, 52% strongly agreed and 37% somewhat agreed with the need for a rotavirus vaccine. If recommended for routine use, 50% would strongly recommend and 34% would recommend but not strongly; 52% would begin to use within 6 months and 27% from 6 months to 1 year. The top 3 "definite" barriers to implementation included concerns about uniform coverage of vaccine by insurers, lack of adequate reimbursement, and parental reluctance because of withdrawal of previous rotavirus vaccine. In multivariate analysis, factors associated with very likely adoption of the vaccine included perception of a high burden of rotavirus disease and a high level of confidence in prelicensure studies of vaccine safety. The presence of physician concerns about safety of the new vaccine and the perception of parental concerns about vaccine safety in general were negatively associated with adoption. CONCLUSIONS: The majority of pediatricians reported willingness to implement the new rotavirus vaccine, most within 6 months. Major barriers to optimal implementation included provider concerns about reimbursement issues and parental acceptance of the vaccine.

Attitude of Health Personnel↗
PubMed2006

Multisomatoform disorder: agreement between patient and physician report of criterion symptom explanation.

OBJECTIVE: To determine the level of agreement between patients and expert physicians in whether criterion multisomatoform (MSD) symptoms are explained. METHODS: We systematically collected reports from 280 primary care patients about whether they had suffered from any of 15 criterion MSD symptoms in the past month and whether they had received a medical explanation from a physician for positive criterion symptoms. The research team compared MSD symptom diagnoses derived from patient report with MSD symptom diagnoses derived from an expert physician report. RESULTS: MSD symptom diagnoses derived from patient report had 98.7% sensitivity, 97.9% specificity, 89.3% positive predictive value, and 99.7% negative predictive value compared with MSD symptom diagnoses derived from an expert physician report. Analysis demonstrated that 15.0% of patients met symptom criteria for MSD, according to patient and physician report; 83.0% failed to meet symptom criteria for MSD, according to patient and physician report; 1.8% of patients met symptom criteria for MSD, according to patient report but not physician report, while 0.2% met symptom criteria for MSD according to physician report but not by patient report. CONCLUSION: Patients demonstrated high agreement with a physician expert in somatization about whether criterion MSD symptoms are explained, suggesting revised screeners may accurately identify somatizing patients.

Adolescent↗
PubMed2006

How safe is triage by an after-hours telephone call center?

OBJECTIVES: Our goals were to assess (1) compliance with nurse disposition recommendations, (2) frequency of death or potential underreferral associated with hospitalization within 24 hours after a call, and (3) factors associated with potential underreferral, for children receiving care within an integrated health care delivery organization who were triaged by a pediatric after-hours call center. METHODS: The study population included all pediatric patients enrolled in Kaiser Permanente Colorado whose families called the Children's Hospital after-hours call center in Denver, Colorado, during the period between October 1, 1999, and March 31, 2003. Postcall disposition recommendations were categorized as urgent (visit within 4 hours), next day (visit in > 4 hours but within 24 hours), later visit (visit in > 24 hours), or home care (care at home without a visit). Compliance with the nurses' triage disposition recommendations was calculated as the proportion of cases for which utilization data matched the disposition recommendations. RESULTS: Of the 32,968 eligible calls during the study period, 21% received urgent, 27% next day, 4% later visit, and 48% home care disposition recommendations. Rates of compliance with both urgent and home care disposition recommendations were 74%, and the rate of compliance with next day recommendations was 44%. No deaths occurred within < 1 week after the after-hours calls. The rate of potential underreferral with subsequent hospitalization was 0.2%, or 1 case per 599 triaged calls. In multivariate modeling, age of < 6 weeks or > 12 years and being triaged after 11 pm were associated with higher rates of potential under-referral. CONCLUSIONS: Approximately three fourths of families complied with recommendations for their child to be evaluated urgently or to be treated at home, with much lower rates of compliance with intermediate dispositions. The rate of potential underreferral with hospitalization was low, and age and time of call triage were associated with this outcome.

Adolescent↗
PubMed2006

A national survey of pediatrician knowledge and attitudes regarding human papillomavirus vaccination.

OBJECTIVE: A human papillomavirus vaccine was licensed in June 2006. The vaccine is quadrivalent, protecting against 2 human papillomavirus strains that cause cervical cancer and 2 that cause genital warts. The objective of this study was to determine physician characteristics, knowledge, and attitudes associated with an intention to recommend human papillomavirus vaccination. METHODS: Between August and October 2005, a cross-sectional survey was administered to a national network of 431 pediatricians. The network was developed from a random sample of American Academy of Pediatrics members and was designed to be representative of the organization's membership with respect to urban/rural location, practice type, and region. The survey was conducted before human papillomavirus vaccine licensure and therefore focused on a candidate quadrivalent human papillomavirus vaccine and a range of potential vaccination recommendations. The main outcome measure was intention to recommend a quadrivalent human papillomavirus vaccine to young adolescent (10- to 12-year-old) females. RESULTS: Survey response rate was 68%. If endorsed by national health organizations, 46% of respondents would recommend vaccination for 10- to 12-year-old females, 77% for 13- to 15-year-old females, and 89% for 16- to 18-year-old females. Corresponding rates for males were 37%, 67%, and 82%, respectively. Whereas 60% of respondents thought that parents would be concerned that human papillomavirus vaccination may encourage risky sexual behaviors, 11% reported that they themselves had this concern. Respondents who believed that other new adolescent immunization recommendations (eg, meningococcal, pertussis) would facilitate human papillomavirus vaccine implementation were more likely to intend to recommend vaccination. CONCLUSIONS: Although a national sample of pediatricians expressed a high level of acceptance of human papillomavirus vaccination in older adolescent females, fewer than one half anticipated giving human papillomavirus vaccine to younger female patients. Provider concerns about parental vaccine acceptance will need to be addressed to optimize human papillomavirus vaccination implementation.

Attitude of Health Personnel↗
PubMed2006

Action or inaction? Decision making in patients with diabetes and elevated blood pressure in primary care.

OBJECTIVE: Hypertension increases micro- and macrovascular complications of diabetes. The goal for blood pressure is <130/80 mmHg. In primary care, however, blood pressure in many patients exceeds this goal. In this study, we evaluated the clinical decision-making process when a patient with diabetes presents with elevated blood pressure. RESEARCH DESIGN AND METHODS: Twenty-six primary care practices in two practice-based research networks in Colorado participated. Questionnaires were completed after each encounter with an adult with type 2 diabetes. Data obtained from the survey included 1) demographic information, 2) blood pressure results, 3) action taken, 4) type of action if action was taken, and 5) reasons for inaction if action was not taken. Bivariate and multivariate analyses were performed to identify predictors of action. RESULTS: Completed surveys totaled 778. Blood pressure was 130/74 +/- 18.8/12.0 mmHg (mean +/- SD). Sixty-two percent of patients exceeded goals. Action was taken to lower blood pressure in 34.9% of those. Predictors of action were 1) blood pressure level, 2) total number of medicines the patient was taking, and 3) patient already taking medicines for blood pressure. As blood pressure rose, providers attributed inaction more often to "competing demands" and reasons other than "blood pressure being at or near goal." CONCLUSIONS: No evidence was found for patterns of poor care among primary care physicians. Providers balance the clinical circumstances, including how elevated the blood pressure is, and issues of polypharmacy, medication side effects, and costs when determining the best course of action. Knowledge deficit is not a common cause of inaction.

Diabetic Angiopathies↗
PubMed2005

Missing clinical information during primary care visits.

CONTEXT: The coordinating function of primary care is information-intensive and may be impeded by missing clinical information. However, missing clinical information has not been explicitly investigated in the primary care setting. OBJECTIVE: To describe primary care clinicians' reports of missing clinical information. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey conducted in 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing. Clinician characteristics were also recorded. MAIN OUTCOME MEASURES: Reports of missing clinical information frequency, type, and presumed location; perceived likelihood of adverse effects, delays in care, and additional services; and time spent looking for missing information. Multivariate analysis was conducted to assess the relationship of missing information to patient, visit, or clinician characteristics, adjusting for potential confounders and effects of clustering. RESULTS: Clinicians reported missing clinical information in 13.6% of visits; missing information included laboratory results (6.1% of all visits), letters/dictation (5.4%), radiology results (3.8%), history and physical examination (3.7%), and medications (3.2%). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3%), to be at least somewhat likely to adversely affect patients (44%), and to potentially result in delayed care or additional services (59.5%). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6%; >10 minutes, 10.4%). After adjustment, reported missing clinical information was more likely when patients were recent immigrants (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.06-2.99), new patients (OR, 2.39; 95% CI, 1.70-3.35), or had multiple medical problems compared with no problems (1 problem: OR, 1.09; 95% CI, 0.69-1.73; 2-5 problems: OR, 1.87; 95% CI, 1.21-2.89; >5 problems: OR, 2.78; 95% CI, 1.61-4.80). Missing clinical information was less likely in rural practices (OR, 0.52; 95% CI, 0.29-0.92) and when individual clinicians reported having full electronic records (OR, 0.40; 95% CI, 0.17-0.94). CONCLUSIONS: Primary care clinicians report that missing clinical information is common, multifaceted, likely to consume time and other resources, and may adversely affect patients. Additional research on missing information is needed to focus on validating clinicians' perceptions and on conducting prospective studies of its causes and sequelae.

Communication↗
PubMed2005

Stress, coping, and health: a comparison of Mexican immigrants, Mexican-Americans, and non-Hispanic whites.

Mexican immigrants, Mexican-Americans, and non-Hispanic white Americans all face different stressors. Stress-coping strategies may vary for each group as well. We compared relationships among perceived stress, stress-coping strategies, and health-related quality of life (HRQL) in a rural sample of Mexican citizens living in the United States, Mexican-Americans, and non-Hispanic whites. Health-related quality of life and stress-coping styles varied among the three groups. Mexican citizens reported significantly better physical functioning than did non-Hispanic whites or Mexican-Americans. Mexican-Americans reported significantly better mental health functioning than did non-Hispanic whites or Mexican citizens. Mexican citizens were more likely to use positive reframing, denial, and religion, and less likely to use substance abuse and self-distraction, as stress-coping strategies. Stress-coping style may be a potentially modifiable predictor of physical and mental HRQL, and may account for part of the Hispanic health paradox.

Adaptation, Psychological↗
PubMed2005

Clinical improvement associated with conformance to HEDIS-based depression care.

BACKGROUND: Employers recently requested a valid metric of depression treatment quality. Such an indicator needs to measure the proportion of the population in need who receive high-quality care, and to predict clinical improvement. METHODS: We constructed an administrative database indicator derived from HEDIS criteria for antidepressant medication management, and tested it in 230 employed patients in five health plans. RESULTS: Indicator rates were 7.0% in the population in need. Conformance to indicator criteria in this population was associated with 23.0% improvement in depression severity over 1 year (p = .02). CONCLUSIONS: Administrative database indicators that predict clinical improvement are a very rare accomplishment. Existing depression indicators may need to be calculated for the population in need to provide a valid metric for employer purchasers.

Adult↗
PubMed2005

Student drivers: a study of fatal motor vehicle crashes involving 16-year-old drivers.

STUDY OBJECTIVE: Motor vehicle crashes are the leading cause of death for US teenagers, accounting for 40% of fatalities. The purpose of this study was to compare novice (aged 16 years) and experienced (aged 25 to 49 years) drivers involved in fatal motor vehicle crashes with respect to crash characteristics and driver behaviors. METHODS: This cross-sectional study of fatal motor vehicle crashes in Colorado used data from the Fatality Analysis Reporting System (1995 to 2001). Driver and crash variables were compared in the 2 age groups using separate logistic regression models, adjusted for sex, geographic locale, and year. RESULTS: Two thousand four hundred twenty fatal motor vehicle crashes were included; 158 fatalities (6.5%) were novice drivers. Novice drivers were more likely to have been speeding (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.34 to 3.08); driving recklessly (OR 4.78, 95% CI 3.31 to 6.92); charged with a traffic violation (OR 3.08, 95% CI 2.20 to 4.31); in a single-vehicle (OR 1.84, 95% CI 1.32 to 2.57), rollover (OR 1.36, 95% CI 0.97 to 1.91) or run-off-the-road (OR 1.54, 95% CI 1.03 to 2.30) crash; and carrying 2 (OR 4.52, 95% CI 2.75 to 7.41) or more (OR 4.07, 95% CI 2.49 to 6.55) passengers. Safety belt nonuse was high for novice (48%) and experienced (42%) drivers (OR 1.19, 95% CI 0.86 to 1.67). Novice drivers had older cars (mean difference 1.5 years, 95% CI 0.37 to 2.57 years). Novice drivers were less likely to be involved in crashes caused by alcohol (OR 0.24, 95% CI 0.14 to 0.41) or adverse weather (OR 0.37, 95% CI 0.19 to 0.75) and to be driving a sport utility vehicle (OR 0.62, 95% CI 0.39 to 0.97). CONCLUSION: Fatal motor vehicle crashes involving novice drivers are characterized by speeding, recklessness, single-vehicle and rollover crashes, and traffic law violations, suggesting that novice drivers bear considerable responsibility for their fatal crashes. Moreover, almost half of 16-year-old drivers involved in fatal motor vehicle crashes were not wearing their safety belts. These data may prove useful in strengthening graduated licensing laws and in improving drivers' education courses and public safety campaigns.

Accidents, Traffic↗
PubMed2004

Does a depression intervention result in improved outcomes for patients presenting with physical symptoms?

OBJECTIVE: To investigate the effects of exclusively physical presentation of depression on 1). depression management and outcomes under usual care conditions, and 2). the impact of an intervention to improve management and outcomes. DESIGN AND SETTING: Secondary analysis of a depression intervention trial in 12 community-based primary care practices. PARTICIPANTS: Two hundred adults beginning a new treatment episode for depression. MEASUREMENTS: Presenting complaint and physician depression query at index visit; antidepressant use, completion of adequate antidepressant trial, change in depressive symptoms, and physical and emotional role functioning at 6 months. MAIN RESULTS: Sixty-six percent of depressed patients presented exclusively with physical symptoms. Under usual care conditions, psychological presenters were more likely than physical presenters to complete an adequate trial of antidepressant treatment but experienced equivalent improvements in depressive severity and role functioning. In patients presenting exclusively with physical symptoms, the intervention significantly improved physician query (40.8% vs 18.0%; P =.06), receipt of any antidepressant (63.0% vs 20.1%; P =.001), and an adequate antidepressant trial (34.9% vs 5.9%; P =.004), but did not significantly improve depression severity or role functioning. In patients presenting with psychological symptoms, the intervention significantly improved receipt of any antidepressant (79.9% vs 38.0%; P =.01) and an adequate antidepressant trial (46.0% vs 23.8%; P =.004), and also improved depression severity and physical and emotional role functioning. CONCLUSIONS: Our results suggest that there is a differential intervention effect by presentation style at the index visit. Thus, current interventions should be targeted at psychological presenters and new approaches should be developed for physical presenters.

Adult↗
PubMed2004

Clinical decisions regarding HbA1c results in primary care: a report from CaReNet and HPRN.

OBJECTIVE: To describe decisions made by primary care providers on elevated HbA(1c) results and their reasons for not intensifying therapy. RESEARCH DESIGN AND METHODS: In this cross-sectional study, a provider survey was administered in two practice-based research networks when HbA(1c) results were reviewed on all nonpregnant patients >18 years old with type 2 diabetes. Univariate and Mantel-Hantel analyses assessed associations between patient characteristics and clinical decisions. RESULTS: A total of 483 surveys were completed by at least 88 providers at 19 clinics. Most patients were female (62.5%), mean age was 60 years, and 28.6% were Hispanic. The overall action rate on HbA(1c) results >/=7% (n = 294) was 70.7%. Patients who were black or had Medicare without medication insurance had lower rates of action on HbA(1c) >/=7 and >/=8%, respectively (P < 0.05). The most common reasons providers reported for inaction were "patient improving/doing well," "competing demands," and "hypoglycemic risk." CONCLUSIONS: Primary care providers generally adhere to national glycemic control guidelines, although there may be disparities in black patients and patients without medication insurance coverage. A variety of reasons were given when control was not intensified.

Adult↗
PubMed2002

Impact of ongoing primary care intervention on long term outcomes in uninsured and insured patients with depression.

BACKGROUND AND OBJECTIVES: To assess the differential impact of an ongoing primary care depression intervention on uninsured and insured patients' outcomes 12, 18, and 24 months following baseline. RESEARCH DESIGN: Quasi-experimental longitudinal study of insured and uninsured patients with depression receiving treatment from 12 practices randomized to enhanced (intervention) and usual care study conditions. SUBJECTS: In 1996 to 1997, 383 nonelderly patients with depression (290 insured, 93 uninsured) were enrolled and followed for 24 months. MEASURES: Mental-health-related-quality-of-life (MHQOL) was assessed at each follow-up using the SF-36 Mental Component Summary scale. Presence of major depressive episode was assessed at 24-month follow-up with the Composite International Diagnostic Interview. RESULTS: Uninsured enhanced-care patients had significantly better MHQOL outcomes at 24 months than uninsured usual care patients (40.6 vs. 32.7, respectively; P = 0.01). The intervention had no significant impact on insured patients' MHQOL outcomes at any follow-up interval. Among patients receiving usual care, the uninsured compared with the insured had significantly poorer MHQOL outcomes (32.7 vs. 40.7, respectively; P = 0.002) and significantly increased probability of experiencing a major depressive episode (40.6% vs. 19.8%, respectively; P = 0.04) at 24 months. No such disparities were observed between uninsured and insured patients receiving enhanced care. CONCLUSIONS: The ongoing intervention significantly improved quality-of-life outcomes in uninsured patients at 24 months. If the intervention's impact on MHQOL can be confirmed and proved cost-effective in larger uninsured patient populations, clinicians serving the uninsured may want to consider implementing the study's intervention.

Adult↗
PubMedDate not supplied

Less anticipatory guidance is associated with more subsequent injury visits among infants.

OBJECTIVE: To describe clinician delivery of injury prevention anticipatory guidance and injury visits in a birth cohort, and to describe the association of injury prevention anticipatory guidance with subsequent injury visits. METHODS: We performed a prospective cohort study of 2610 infants born from July 1, 1998 to June 30, 1999, at an urban safety-net hospital and seen subsequently for well child care (WCC, visits = 10558) and/or injury by 16 months of age. Injury guidance was defined as the proportion of recommended injury prevention anticipatory guidance items delivered to those expected, given the WCC visits the child attended. The outcome was a first injury visit to a clinic, emergency department, or hospital. RESULTS: The injury prevention items most discussed were car seats (84%-95% of all WCC visits) and rolling over at the 2-month WCC visit (80%). Other items were addressed at 36%-69% of visits. A total of 1931 (74%) of children received > or = 50% expected injury guidance. A total of 277 children (11%) had an injury visit, primarily for minor injuries. In unadjusted analysis, children receiving < 25% expected injury guidance were more likely to have a subsequent injury visit (unadjusted odds ratio 6.2; 95% confidence interval [95% CI] 3.2-9.7). In adjusted analysis, children who received < 25% and 25%-49% expected injury guidance were more likely to have a subsequent injury visits (adjusted odds ratio [AOR] 6.6; 95% CI 3.8-11.2; and AOR 2.9, 95% CI 2.0-4.3, respectively). CONCLUSIONS: Disadvantaged children whose families received less injury guidance than other children in their cohort were more likely to have a subsequent injury visit. Further studies are needed to determine whether increased injury prevention counseling reduces injury visits.

Accident Prevention↗
PubMedDate not supplied

The somatization in primary care study: a tale of three diagnoses.

Somatization is a common phenomenon that has been defined in many ways. The two most widely used diagnoses, Somatization Disorder (SD) and Abridged Somatization Disorder (ASD), are based on lifetime unexplained symptoms. However, reports indicate instability in lifetime symptom recall among somatizing patients. Multisomatoform disorder (MSD) is a new diagnosis based on current unexplained symptoms. To understand how knowledge about SD and ASD translates to MSD, we examined the diagnostic concordance, impairment and health care utilization of these groups in a sample from the Somatization in Primary Care Study. The diagnostic concordance was high between MSD and SD, but lower between MSD and ASD. All three groups reported considerable physical impairment (measured using the PCS subscale of the SF-36). The mental health (MCS) scores for the three groups were only slightly lower than those of the general population. Over the course of one year, physical functioning fell significantly for all three groups. Mental functioning did not change significantly for any of the three groups over this period. Utilization patterns were very similar for the three groups. The high prevalence, serious impairment, and worsening physical functioning over the course of one year suggest the importance of developing interventions in primary care to alleviate the impaired physical functioning and reduce utilization in somatizing patients. MSD should be a useful diagnosis for targeting these interventions because it identifies a sizable cohort of somatizing patients reporting impairment of comparable severity to full SD, using a more efficient diagnostic algorithm based on current symptoms.

Female↗
PubMedDate not supplied

RCT of a care manager intervention for major depression in primary care: 2-year costs for patients with physical vs psychological complaints.

PURPOSE: Depression care management for primary care patients results in sustained improvement in clinical outcomes with diminishing costs over time. Clinical benefits, however, are concentrated primarily in patients who report to their primary care clinicians psychological rather than exclusively physical symptoms. This study proposes to determine whether the intervention affects outpatient costs differentially when comparing patients who have psychological with patients who have physical complaints. METHODS: We undertook a group-randomized controlled trial (RCT) of depression comparing intervention with usual care in 12 primary care practices. Intervention practices encouraged depressed patients to engage in active treatment, using nurses to provide regularly scheduled care management for 24 months. The study sample included 200 adults beginning a new depression treatment episode where patient presentation style could be identified. Outpatient costs were defined as intervention plus outpatient treatment costs for the 2 years. Cost-offset analysis used general linear mixed models, 2-part models, and bootstrapping to test hypotheses regarding a differential intervention effect by patients' style, and to obtain 95% confidence intervals for costs. RESULTS: Intervention effects on outpatient costs over time differed by patient style (P <.05), resulting in a $980 cost decrease for depressed patients who complain of psychological symptoms and a 1,378 dollars cost increase for depressed patients who complain of physical symptoms only. CONCLUSIONS: Depression intervention for a 2-year period produced observable clinical benefit with decreased outpatient costs for depressed patients who complain of psychological symptoms. It produced limited clinical benefit with increased costs, however, for depressed patients who complain exclusively of physical symptoms, suggesting the need for developing new intervention approaches for this group.

Adult↗
PubMedDate not supplied

Cost-effectiveness of enhancing primary care depression management on an ongoing basis.

PURPOSE: Although potentially costly, enhancing primary care depression management on an ongoing basis results in substantial long-term treatment effectiveness. The purpose of this article is to compare the cost-effectiveness of this approach with that of usual care. METHODS: The study was conducted in 12 community primary care practices randomized to enhanced or usual care after stratification by baseline practice patterns. Practices assigned to enhanced care encouraged depressed patients to engage in active treatment, using practice nurses to provide regularly scheduled care management during the course of 24 months. We analyze outcomes for 211 adults (73.4% of potential eligible patients) beginning a new treatment episode for major depression determined by previsit screening. Outcomes included blinded estimates of days free of depression impairment as well as health care costs for 2 years. RESULTS: Enhanced care significantly increased the number of days free of depression impairment for 2 years when compared with usual care (647.6 days vs 588.2 days, P <.01). The incremental cost-effectiveness ratio for enhanced care ranged from 9,592 dollars to 14,306 dollars per quality-adjusted life-year (QALY). The number of incremental days free of depression impairment increased between the first year and the second year (23.0 vs 36.4, respectively, P <.001) while incremental health plan costs decreased significantly (568 dollars vs -12 dollars, P <.001). CONCLUSIONS: Enhancing primary care depression management on an ongoing basis should be considered for adoption by policy and health plan leaders.

Adult↗
PubMedDate not supplied

Multilevel modeling and practice-based research.

PURPOSE: The health care system in the United States is inherently hierarchical. Patients are "nested" within physicians who in turn are "nested" within practices. Much of the research data gathered in practice-based research networks (PBRNs) also have similar patterns of nesting (clustering). When research data are nested, statistical approaches to the data must account for the multilevel nature of the data or risk errors in interpretation. We illustrate the concept of multilevel structure and provide examples with implications for practice-based research. METHODS: We present a selection of multilevel (hierarchical) models and contrast them with traditional linear regression models, using an example of a simulated observational study to illustrate increasingly complex statistical approaches, as well as to explore the consequences of ignoring clustering in data. Additionally, we discuss other types of outcome data and designs, and the effects of clustering on sample size and power. RESULTS: Multilevel models demonstrate that the effects of physician-level activities may differ from clinic to clinic as well as between rural and urban settings; this variability would be undetected in traditional linear regression approaches. Study conclusions differed when the data were analyzed with multilevel methods compared with traditional linear regression methods. Clustered data also affected sample size; as the intraclass correlation increased and the patients per cluster increased, the required number of patients increased dramatically. CONCLUSIONS: Recognizing and accounting for multilevel structure when analyzing data from PBRN studies can lead to more accurate conclusions, as well as offer opportunities to explore contextual effects and differences across sites. Accommodating multilevel structure in planning research studies can result in more appropriate estimation of required sample size.

Biomedical Research↗