Does engagement matter? The impact of patient and community engagement on implementation of cardiovascular health materials in primary care settings

BACKGROUND

Engaging patients and community members in healthcare implementation, research and evaluation has become more popular over the past two decades. Despite the growing interest in patient engagement, there is scant evidence of its impact and importance. Boot Camp Translation (BCT) is one evidence-based method of engaging communities in research. The purpose of this report is to describe the uptake by primary care practices of cardiovascular disease prevention materials produced through four different local community engagement efforts using BCT.

METHODS

EvidenceNOW Southwest (ENSW) was a randomized trial to increase cardiovascular disease (CVD) prevention in primary care practices. Because of its study design, Four BCTs were conducted, and the materials created were made available to participating practices in the "enhanced" study arm. As a result, ENSW offered one of the first opportunities to explore the impact of the BCT method by describing the uptake by primary care practices of health messages and materials created locally using the BCT process. Analysis compared uptake of locally translated BCT products vs. all other products among practices based on geography, type of practice, and local BCT.

RESULTS

Within the enhanced arm of the study that included BCT, 69 urban and 13 rural practices participated with 9 being federally qualified community health centers, 14 hospital owned and 59 clinician owned. Sixty-three practices had 5 or fewer clinicians. Two hundred and ten separate orders for materials were placed by 43 of the 82 practices. While practices ordered a wide variety of BCT products, they were more likely to order materials developed by their local BCT.

CONCLUSIONS

In this study, patients and community members generated common and unique messages and materials for cardiovascular disease prevention relevant to their regional and community culture. Primary care practices preferred the materials created in their region. The greater uptake of locally created materials over non-local materials supports the use of patient engagement methods such as BCT to increase the implementation and delivery of guideline-based care. Yes, patient and community engagement matters.

TRIAL REGISTRATION AND IRB

Trial registration was prospectively registered on July 31, 2015 at ClinicalTrials.gov (NCT02515578, protocol identifier 15-0403). The project was approved by the Colorado Multiple Institutional Review Board and the University of New Mexico Human Research Protections Office.

Postresidency Practice Setting and Clinical Care Features According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Pilot Study

BACKGROUND AND OBJECTIVES

Factors associated with physician practice choice include residency location, training experiences, and financial incentives. How length of training affects practice setting and clinical care features postgraduation is unknown.

METHODS

In this Length of Training Pilot (LoTP) study, we surveyed 366 graduates of 3-year (3YR) and 434 graduates of 4-year (4YR) programs 1 year after completion of training between 2013 and 2021. Variables assessed included reasons for practice setting choice, practice type, location, practice and community size, specialty mix, and clinical care delivery features (eg, integrated behavioral health, risk stratified care management). We compared different length of training models using χ2 or Fisher's exact tests for categorical variables and independent samples, and t test (unequal variances) for continuous variables.

RESULTS

Response rates ranged from 50% to 88% for 3YR graduates and 68% to 95% for 4YR graduates. Scope of practice was a predominant reason for graduates choosing their eventual practice, and salary was a less likely reason for those completing 4 years versus 3 years of training (scope, 72% vs 55%, P=.001; salary, 15% vs 22%, P=.028). Community size, practice size, practice type, specialty mix, and practice in a federally designated underserved site did not differ between the two groups. We found no differences in patient-centered medical home features when comparing the practices of 3YR to 4YR graduates.

CONCLUSIONS

Training length did not affect practice setting or practice features for graduates of LoTP programs. Future LoTP analyses will examine how length of training affects scope of practice and clinical preparedness, which may elucidate other elements associated with practice choice.

Behavioral health integration and specialty medical care: Opportunities for applying knowledge from primary care integration

While education and advocacy regarding behavioral health (BH) integration in primary care have been in full force at the state and national level for many years, specialty care BH integration has not received the same attention in terms of practice transformation, workforce development, and payment reform. Models of BH care have been tested in primary care and can be easily adapted to improve specialty patient care. There are many opportunities for using the knowledge base gained from integrated primary care to help move integration forward in the specialty medical setting. The timing for this is rife, as the benefits of integrated BH for patient health outcomes are well established. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Unique Model and Workforce to Address Health-Related Social Needs and Health Equity: Regional Health Connectors in Colorado

Unmet health-related social needs contribute to high morbidity and poor population health. Improving social conditions are likely to reduce health disparities and improve the health of the overall U.S. population. The primary objective of this article is to describe an innovative workforce model, called Regional Health Connectors (RHCs), and how they address health-related social needs in Colorado. This is a program evaluation that analyzed field notes and interview data from 2021-2022. We applied our findings to the framework developed by the National Academies of Sciences, Engineering, and Medicine's (NASEM's) report on strengthening social care integration into health care (2019). We found that RHCs address the following health-related social needs most commonly: food insecurity (n = 18 of 21 regions or 85% of all regions), housing (n = 17 or 81% of all regions), transportation (n = 11 or 52% of all regions), employment opportunities (n = 10 or 48% of all regions), and income/financial assistance (n = 11 or 52% of all regions). RHCs interacted across many sectors to address health-related social needs and provided multiple types of support to primary care practices at the organizational level. Examples of emerging impact of RHCs are described and mapped onto the NASEM framework. Findings from this program evaluation add to the growing landscape of knowledge and importance of detecting and addressing health-related social needs. We conclude that RHCs are a unique and emerging workforce that addresses multiple domains needed to integrate social care into health care.

Resident Visit Productivity and Attitudes About Continuity According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Study

BACKGROUND AND OBJECTIVES

Training models in the Length of Training Pilot (LOTP) vary. How innovations in training length affect patient visits and resident perceptions of continuity is unknown.

METHODS

We analyzed resident in-person patient encounters (2013-2014 through 2018-2019) for each postgraduate year (PGY) and total visits at graduation derived from the Accreditation Council for Graduate Medical Education reports for each LOTP program. We collected data on residents' perceptions of continuity from annual surveys (2015-2019). We analyzed continuous variables using independent samples t tests with unequal variance and categorical variables using χ2 tests in comparing 3-year (3YR) versus 4-year (4YR) programs.

RESULTS

PGY-1 and PGY-2 residents in 4YR programs saw statistically more patients than their counterparts in 3YR programs. In PGY3, 3YR program residents had statistically higher visit volume compared to 4YR program residents. Visits conducted in PGY4 ranged from 832 to 884. The additional year of training resulted in approximately 1,000 more total patient visits. Most residents in 3YR and 4YR programs rated their continuity clinic experience as somewhat or very adequate (range 86.3% to 93.7%), which did not statistically differ according to length of training.

CONCLUSIONS

Resident visits were significantly different at each PGY level when comparing 3YR and 4YR programs in the LOTP and the additional year of training resulted in about 1,000 more total visits. Resident perspectives on the adequacy of their continuity clinic experience appeared to not be affected by length of training. Future research should explore how the volume of patient visits performed in residency affects scope of practice and clinical preparedness.

Something Republicans and Democrats can agree on: Support for integrated behavioral health

Barriers to the spread of integrated behavioral health and primary care continue to limit progress on meeting critical needs for mental health and substance use disorder services. The recent Bipartisan Policy Center Report (2021) provides key policy recommendations to address these barriers and accelerate the adoption of integrated behavioral health in Medicaid and Medicare. Having bipartisan support presents a policy window of opportunity to advance integrated behavioral health through advocacy for implementation of these recommendations, parallel changes to occur in employer-based and other commercial insurance plans, and development of operationalized standards for core service delivery elements. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

An Exploratory Mixed Methods Study of Experiences of Interprofessional Teams Who Received Coaching to Simultaneously Redesign Primary Care Education and Clinical Practice

INTRODUCTION/OBJECTIVES

Coaching is emerging as a form of facilitation in health professions education. Most studies focus on one-on-one coaching rather than team coaching. We assessed the experiences of interprofessional teams coached to simultaneously improve primary care residency training and interprofessional practice.

METHODS

This three-year exploratory mixed methods study included transformational assistance from 9 interprofessional coaches, one assigned to each of 9 interprofessional primary care teams that included family medicine, internal medicine, pediatrics, nursing, pharmacy and behavioral health. Coaches interacted with teams during 2 in-person training sessions, an in-person site visit, and then as requested by their teams. Surveys administered at 1 year and end study assessed the coaching relationship and process.

RESULTS

The majority of participants (82% at end of Year 1 and 76.6% at end study) agreed or strongly agreed that their coach developed a positive working relationship with their team. Participants indicated coaches helped them: (1) develop as teams, (2) stay on task, and (3) respond to local context issues, with between 54.3% and 69.2% agreeing or strongly agreeing that their coaches were helpful in these areas. Cronbach's alpha for the 15 coaching survey items was 0.965. Challenges included aligning the coach's expertise with the team's needs.

CONCLUSIONS

While team coaching was well received by interprofessional teams of primary care professionals undertaking educational and clinical redesign, the 3 primary care disciplines have much to learn from each other regarding how to improve inter- and intra-professional collaborative practice among clinicians and staff as well as with interprofessional learners rotating through their outpatient clinics.

Exemplary Practices in Cardiovascular Care: Results on Clinical Quality Measures from the EvidenceNOW Southwest Cooperative

BACKGROUND

Identifying characteristics of primary care practices that perform well on cardiovascular clinical quality measures (CQMs) may point to important practice improvement strategies.

OBJECTIVE

To identify practice characteristics associated with high performance on four cardiovascular disease CQMs.

DESIGN

Longitudinal cohort study among 211 primary care practices in Colorado and New Mexico. Quarterly CQM reports were obtained from 178 (84.4%) practices. There was 100% response rate for baseline practice characteristics and implementation tracking surveys. Follow-up implementation tracking surveys were completed for 80.6% of practices.

PARTICIPANTS

Adult patients, staff, and clinicians in family medicine, general internal medicine, and mixed-specialty practices.

INTERVENTION

Practices received 9 months of practice facilitation and health information technology support, plus biannual collaborative learning sessions.

MAIN MEASURES

This study identified practice characteristics associated with overall highest performance using area under the curve (AUC) analysis on aspirin therapy, blood pressure management, and smoking cessation CQMs.

RESULTS

Among 178 practices, 39 were exemplars. Exemplars were more likely to be a Federally Qualified Health Center (69.2% vs 35.3%, p = 0.0006), have an underserved designation (69.2% vs 45.3%, p = 0.0083), and have higher percentage of patients with Medicaid (p < 0.0001). Exemplars reported greater use of cardiovascular disease registries (61.5% vs 29.5%,), standing orders (38.5 vs 22.3%) or electronic health record prompts (84.6% vs 49.6%) (all p < 0.05), were more likely to have medical home recognition (74.4% vs 43.2%, p = 0.0006), and reported greater implementation of building blocks of high-performing primary care: regular quality improvement team meetings (3.0 vs 2.2), patient experience survey (3.1 vs 2.2), and resources for patients to manage their health (3.0 vs 2.3). High improvers (n = 45) showed greater improvement implementing team-based care (32.8 vs 11.7, p = 0.0004) and population management (37.4 vs 20.5, p = 0.0057).

CONCLUSIONS

Multiple strategies-registries, prompts and protocols, patient self-management support, and patient-team partnership activities-were associated with delivering high-quality cardiovascular care over time, measured by CQMs.

TRIAL REGISTRATION

ClinicalTrials.gov registration: NCT02515578.

Practice Transformation Support and Patient Engagement to Improve Cardiovascular Care: From EvidenceNOW Southwest (ENSW)

PURPOSE

To improve cardiovascular care through supporting primary care practices' adoption of evidence-based guidelines.

STUDY DESIGN

A cluster randomized trial compared two approaches: (1) standard practice support (practice facilitation, practice assessment with feedback, health information technology assistance, and collaborative learning sessions) and (2) standard support plus patient engagement support.

METHODS

Primary outcomes were cardiovascular clinical quality measures (CQMs) collected at baseline, 9 months, and 15 months. Implementation of the first 6 "Building Blocks of High-Performing Primary Care" was assessed by practice facilitators at baseline and 3, 6, and 9 months. CQMs from practices not involved in the study served as an external comparison.

RESULTS

A total of 211 practices completed baseline surveys. There were no differences by study arm (odds ratio [95% confidence interval]) for aspirin use (1.03 [0.99, 1.06]), blood pressure (0.98 [0.95, 1.01]), cholesterol (0.96 [0.92, 1.00]), and smoking (1.01 [0.96, 1.07]); however, there were significant improvements over time in aspirin use (1.04 [1.01, 1.07]), cholesterol (1.05 [1.03, 1.08]), and smoking (1.03 [1.01, 1.06]), but not blood pressure (1.01 [0.998, 1.03]). Improvement in enrolled practices was greater than external comparison practices across all 4 measures (all P < .05). Implementation improved in both arms for Team-Based Care, Patient-Team Partnership, and Population Management, and improvement was greater in enhanced intervention practices (all P < .05). Leadership and Data-Driven Improvement (P < .05) improved significantly, with no difference by arm. A greater improvement in Building Block implementation was associated with a greater improvement in blood pressure measures (P < .05).

CONCLUSIONS

Practice transformation support can assist practices with improving quality of care. Patient engagement in practice transformation can further enhance practices' implementation of aspects of new models of care.

Self-management support for chronic disease in primary care: frequency of patient self-management problems and patient reported priorities, and alignment with ultimate behavior goal selection

Background

To enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients’ identified self-management problems (SM-Problems) and priorities (SM-Priorities), a practical, systematic method for assessing self-management needs and priorities is needed. In the current report, we present patient reported data generated from Connection to Health (CTH), to identify the frequency of patients’ reported SM-Problems and SM-Priorities; and examine the degree of alignment between patient SM-Priorities and the ultimate Patient-Healthcare team member selected Behavioral Goal.

Methods

CTH, an electronic self-management support system, was embedded into the flow of existing primary care visits in 25 primary care clinics and was used to assess patient-reported SM-Problems across 12 areas, patient identified SM-Priorities, and guide the selection of a Patient-Healthcare team member selected Behavioral Goal. SM-Problems included: BMI, diet (fruits and vegetables, salt, fat, sugar sweetened beverages), physical activity, missed medications, tobacco and alcohol use, health-related distress, general life stress, and depression symptoms. Descriptive analyses documented SM-Problems and SM-Priorities, and alignment between SM-Priorities and Goal Selection, followed by mixed models adjusting for clinic.

Results

446 participants with ≥ one chronic diseases (mean age 55.4 ± 12.6; 58.5% female) participated. On average, participants reported experiencing challenges in 7 out of the 12 SM-Problems areas; with the most frequent problems including: BMI, aspects of diet, and physical activity. Patient SM-Priorities were variable across the self-management areas. Patient- Healthcare team member Goal selection aligned well with patient SM-Priorities when patients prioritized weight loss or physical activity, but not in other self-management areas.

Conclusion

Participants reported experiencing multiple SM-Problems. While patients show great variability in their SM-Priorities, the resulting action plan goals that patients create with their healthcare team member show a lack of diversity, with a disproportionate focus on weight loss and physical activity with missed opportunities for using goal setting to create targeted patient-centered plans focused in other SM-Priority areas. Aggregated results can assist with the identification of high frequency patient SM-Problems and SM-Priority areas, and in turn inform resource allocation to meet patient needs.

Trial registration

ClinicalTrials.gov ID: NCT01945918.

The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons From 5 Case Studies

Passage of the Patient Protection and Affordable Care Act triggered 2 successive grant initiatives from the Agency for Healthcare Research and Quality, allowing for the evolution of health extension models among 20 states, not limited to support for in-clinic primary care practice transformation, but also including a broader concept incorporating technical assistance for practices and their communities to address social determinants of health. Five states stand out in stretching the boundaries of health extension: New Mexico, Oklahoma, Oregon, Colorado, and Washington. Their stories reveal lessons learned regarding the successes and challenges, including the importance of building sustained relationships with practices and community coalitions; of documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders; of understanding that health extension is a function that can be carried out by an individual or group depending on resources; and of being prepared for political struggles over "turf" and ownership of extension. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems.

Primary Care Practices' Ability to Report Electronic Clinical Quality Measures in the EvidenceNOW Southwest Initiative to Improve Heart Health

IMPORTANCE

The capability and capacity of primary care practices to report electronic clinical quality measures (eCQMs) are questionable.

OBJECTIVE

To determine how quickly primary care practices can report eCQMs and the practice characteristics associated with faster reporting.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study examined an initiative (EvidenceNOW Southwest) to enhance primary care practices' ability to adopt evidence-based cardiovascular care approaches: aspirin prescribing, blood pressure control, cholesterol management, and smoking cessation (ABCS). A total of 211 primary care practices in Colorado and New Mexico participating in EvidenceNOW Southwest between February 2015 and December 2017 were included.

INTERVENTIONS

Practices were instructed on eCQM specifications that could be produced by an electronic health record, a registry, or a third-party platform. Practices received 9 months of support from a practice facilitator, a clinical health information technology advisor, and the research team. Practices were instructed to report their baseline ABCS eCQMs as soon as possible.

MAIN OUTCOMES AND MEASURES

The main outcome was time to report the ABCS eCQMs. Cox proportional hazards models were used to examine practice characteristics associated with time to reporting.

RESULTS

Practices were predominantly clinician owned (48%) and in urban or suburban areas (71%). Practices required a median (interquartile range) of 8.2 (4.6-11.9) months to report any ABCS eCQM. Time to report differed by eCQM: practices reported blood pressure management the fastest (median [interquartile range], 7.8 [3.5-10.4] months) and cholesterol management the slowest (median [interquartile range], 10.5 [6.6 to >12] months) (log-rank P < .001). In multivariable models, the blood pressure eCQM was reported more quickly by practices that participated in accountable care organizations (hazard ratio [HR], 1.88; 95% CI, 1.40-2.53; P < .001) or participated in a quality demonstration program (HR, 1.58; 95% CI, 1.14-2.18; P = .006). The cholesterol eCQM was reported more quickly by practices that used clinical guidelines for cardiovascular disease management (HR, 1.35; 95% CI, 1.18-1.53; P < .001). Compared with Federally Qualified Health Centers, hospital-owned practices had greater ability to report blood pressure eCQMs (HR, 2.66; 95% CI, 95% CI, 1.73-4.09; P < .001), and clinician-owned practices had less ability to report cholesterol eCQMs (HR, 0.52; 95% CI, 0.35-0.76; P < .001).

CONCLUSIONS AND RELEVANCE

In this study, time to report eCQMs varied by measure and practice type, with very few practices reporting quickly. Practices took longer to report a new cholesterol measure than other measures. Programs that require eCQM reporting should consider the time and effort practices must exert to produce reports. Practices may benefit from additional support to succeed in new programs that require eCQM reporting.

Supporting Family Medicine Research Capacity: The Critical Role and Current Contributions of US Family Medicine Organizations

BACKGROUND AND OBJECTIVES

Family medicine is continuously advanced by a reinforcing research enterprise. In the United States, each national family medicine organization contributes to the discipline's research foundations. We sought to map the unique and interorganizational roles of the eight US family medicine professional organizations participating in Family Medicine for America's Health (FMAHealth) in supporting family medicine research.

METHODS

We interviewed leaders and reviewed supporting materials from organizations participating in FMAHealth. We explored existing activities, capacity, and collaboration. We identified areas of strength and opportunities for growth and synergy with respect to how the family of family medicine nurtures family medicine research.

RESULTS

The FMAHealth organizations support certain aspects of the family medicine research infrastructure. Six domains were identified through this work: showcasing scholarship, communication and dissemination, workforce development, data-driven initiatives, performing primary research, and advocacy for family medicine research. Each organization's areas of emphasis differ, but we found substantial collaboration on initiatives across organizations, possibly attributable to the fact that many members belong to more than one organization.

CONCLUSIONS

Deliberate contributions to each of the six domains identified herein will be important for the future success of family medicine research. Key opportunity areas described here include coordinated and strategic advocacy for increased funding for family medicine research, dedicated investment in training opportunities, protected effort to grow the next generation of family medicine researchers, pilot funding to build a research base for future high-impact research, and infrastructure to facilitate cross-institutional collaboration and data sharing.

Colorado Residency PCMH Project: Results From a 6-Year Transformation Effort

BACKGROUND AND OBJECTIVES

Our objective was to describe the results of a 6-year patient-centered medical home (PCMH) transformation program in 11 Colorado primary care residency practices.

METHODS

We used a parallel qualitative and quantitative evaluation including cross-sectional surveys of practice staff and clinicians, group and individual interviews, meeting notes, and longitudinal practice facilitator field notes. Survey analyses assessed change over time, adjusting for practice-level random effects. Qualitative data analysis used iterative template coding and matrix analyses to synthesize data over time and across cases.

RESULTS

There were significant improvements in clinicians' self-reported routine delivery of patient-centered care, team-based care, self-management support, and use of information systems (P&lt;.0001). Clinicians and staff reported significant gains in practice change culture (P=.001). Self-reported practice-level assessments pointed to additional significant improvements in quality improvement (QI) processes, continuity of care, self-management support/care coordination, and the use of data and population management (P≤.0215). Practices and their practice facilitators reported important changes in how practices operated, significantly improving their QI processes, shared leadership, change culture, and achieving Level III PCMH NCQA Recognition. Important barriers to further progress remain, including inadequate payment models, inflexible staff roles, and difficult access to clinical data.

CONCLUSIONS

The success of these 11 primary care residency practices in making significant improvements in their delivery of patient-centered care, team-based care, self-management support, and use of information systems took time, effort, and external support. Further practice redesign for advanced primary care models will take sustained sources of well-aligned support, flexibility, shared leadership, and partnerships across residency programs for collaborative learning to assist in their transformation efforts.

A protocol for a cluster randomized trial comparing strategies for translating self-management support into primary care practices

BACKGROUND

Advanced primary care models emphasize patient-centered care, including self-management support (SMS), but the effective use of SMS for patients with type 2 diabetes (T2DM) remains a challenge. Interactive behavior-change technology (IBCT) can facilitate the adoption of SMS interventions. To meet the need for effective SMS intervention, we have developed Connection to Health (CTH), a comprehensive, evidence-based SMS program that enhances interactions between primary care clinicians and patients to resolve self-management problems and improve outcomes. Uptake and maintenance of programs such as CTH in primary care have been limited by the inability of practices to adapt and implement program components into their culture, patient flow, and work processes. Practice facilitation has been shown to be effective in helping practices make the changes required for optimal program implementation. The proposed research is designed to promote the translation of SMS into primary care practices for patients with T2DM by combining two promising lines of research, specifically, (a) testing the effectiveness of CTH in diverse primary-care practices, and (b) evaluating the impact of practice facilitation to enhance implementation of the intervention.

METHODS

A three-arm, cluster-randomized trial will evaluate three discrete strategies for implementing SMS for patients with T2DM in diverse primary care practices. Practices will be randomly assigned to receive and implement the CTH program, the CTH program plus practice facilitation, or a SMS academic detailing educational intervention. Through this design, we will compare the effectiveness, adoption and implementation of these three SMS practice implementation strategies. Primary effectiveness outcomes including lab values and evidence of SMS will be abstracted from medical records covering baseline through 18 months post-baseline. Data from CTH assessments and action plans completed by patients enrolled in CTH will be used to evaluate practice implementation of CTH and the impact of CTH participation. Qualitative data including field notes from encounters with the practices and interviews of practice personnel will be analyzed to assess practice implementation of SMS.

DISCUSSION

This study will provide important information on the implementation of SMS in primary care, the effectiveness of an IBCT tool such as CTH, and the use of practice facilitation to assist implementation.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov - ClinicalTrials.gov ID: NCT01945918 , date 08/27/2013. Modifications have been updated.

A Community Engagement Method to Design Patient Engagement Materials for Cardiovascular Health

PURPOSE

EvidenceNOW Southwest is a cluster-randomized trial evaluating the differential impact on cardiovascular disease (CVD) care of engaging patients and communities in practice transformation in addition to standard practice facilitation support. The trial included development of locally tailored CVD patient engagement materials through Boot Camp Translation (BCT), a community engagement process that occurred before practice recruitment but after cluster randomization.

METHODS

We introduce a cluster randomization method performed before recruitment of small to medium-size primary care practices in Colorado and New Mexico, which allowed for balanced study arms while minimizing contamination. Engagement materials for the enhanced study arm were developed by means of BCT, which included community members, practice members, and public health professionals from (1) metropolitan Denver, (2) rural northeast Colorado, (3) Albuquerque, and (4) rural southeast New Mexico. Outcome measures were messages and materials from BCTs and population characteristics of study arms after using geographic-based covariate constrained randomization.

RESULTS

The 4 BCTs' messages and materials developed by the BCT groups uniquely reflected each community and ranged from family or spiritual values to early prevention or adding relevance to CVD risk. The geographic-based covariate of a cluster randomization method constrained randomization-assigned regions to study arms, allowing BCTs to precede practice recruitment, reduce contamination, and balance populations.

CONCLUSIONS

Cluster-randomized trials with community-based interventions present study design and implementation challenges. The BCTs elicited unique contextual messages and materials, suggesting that interventions designed to help primary care practices decrease CVD risk may not be one size fits all.

Practice Facilitation for PCMH Implementation in Residency Practices

BACKGROUND AND OBJECTIVES

Primary care residency programs continue to adapt and change to become high-performing training sites for advanced primary care. Practice facilitation is a key method to assist practices in implementing organizational changes. This evaluation described the unique nature and essential roles and qualities of practice facilitation for residency program patient-centered medical home (PCMH) transformation.

METHODS

Evaluation of the Colorado Residency PCMH Project from 2009 through 2014 included template and immersion-crystallization approaches to qualitative analysis of field notes, key informant interviews, and meeting documentation to identify themes related to external facilitation for practice transformation in 11 Colorado primary care residency practices.

RESULTS

Important practice facilitator roles in residency practice transformation included supporter of quality improvement and NCQA implementation, connector of practices, and leadership and engagement coach. Key qualities included the relationship development between practice members and facilitators over time, flexibility, consistent presence and communication, and an external nature that provided a valuable outside perspective.

CONCLUSIONS

Residency programs provide a unique environment that is particularly well-suited for transformation, though it also presents challenges. External practice facilitators that demonstrate key roles and qualities can support residency practices through this complex transformation process.

The Importance of and the Complexities Associated With Measuring Continuity of Care During Resident Training: Possible Solutions Do Exist

BACKGROUND AND OBJECTIVES

Evolutions in care delivery toward the patient-centered medical home have influenced important aspects of care continuity. Primary responsibility for a panel of continuity patients is a foundational requirement in family medicine residencies. In this paper we characterize challenges in measuring continuity of care in residency training in this new era of primary care.

METHODS

We synthesized the literature and analyzed information from key informant interviews and group discussions with residency faculty and staff to identify the challenges and possible solutions for measuring continuity of care during family medicine training. We specifically focused on measuring interpersonal continuity at the patient level, resident level, and health care team level.

RESULTS

Challenges identified in accurately measuring interpersonal continuity of care during residency training include: (1) variability in empanelment approaches for all patients, (2) scheduling complexity in different types of visits, (3) variability in ability to attain continuity counts at the level of the resident, and (4) shifting make-up of health care teams, especially in residency training. Possible solutions for each challenge are presented. Philosophical issues related to continuity are discussed, including whether true continuity can be achieved during residency training and whether qualitative rather than quantitative measures of continuity are better suited to residencies.

CONCLUSIONS

Measuring continuity of care in residency training is challenging but possible, though improvements in precision and assessment of the comprehensive nature of the relationships are needed. Definitions of continuity during training and the role continuity measurement plays in residency need further study.

Practice context affects efforts to improve diabetes care for primary care patients: a pragmatic cluster randomized trial

BACKGROUND

Efforts to improve primary care diabetes management have assessed strategies across heterogeneous groups of patients and practices. However, there is substantial variability in how well practices implement interventions and achieve desired outcomes.

OBJECTIVE

To examine practice contextual features that moderate intervention effectiveness.

DESIGN

Secondary analysis of data from a cluster randomized trial of three approaches for implementing the Chronic Care Model to improve diabetes care.

PARTICIPANTS

Forty small to mid-sized primary care practices participated, with 522 clinician and staff member surveys. Outcomes were assessed for 822 established patients with a diagnosis of type 2 diabetes who had at least one visit to the practice in the 18 months following enrollment.

MAIN MEASURES

The primary outcome was a composite measure of diabetes process of care, ascertained by chart audit, regarding nine quality measures from the American Diabetes Association Physician Recognition Program: HgA1c, foot exam, blood pressure, dilated eye exam, cholesterol, nephropathy screen, flu shot, nutrition counseling, and self-management support. Data from practices included structural and demographic characteristics and Practice Culture Assessment survey subscales (Change Culture, Work Culture, Chaos).

KEY RESULTS

Across the three implementation approaches, demographic/structural characteristics (rural vs. urban + .70(p = .006), +2.44(p < .001), -.75(p = .004)); Medicaid: < 20 % vs. ≥ 20 % (-.20(p = .48), +.75 (p = .08), +.60(p = .02)); practice size: < 4 clinicians vs. ≥ 4 clinicians (+.56(p = .02), +1.96(p < .001), +.02(p = .91)); practice Change Culture (high vs. low: -.86(p = .048), +1.71(p = .005), +.34(p = .22)), Work Culture (high vs. low: -.67(p = .18), +2.41(p < .001), +.67(p = .005)) and variability in practice Change Culture (high vs. low: -.24(p = .006), -.20(p = .0771), -.44(p = .0019) and Work Culture (high vs. low: +.56(p = .3160), -1.0(p = .008), -.25 (p = .0216) were associated with trajectories of change in diabetes process of care, either directly or differentially by study arm.

CONCLUSIONS

This study supports the need for broader use of methodological approaches to better examine contextual effects on implementation and effectiveness of quality improvement interventions in primary care settings.

Supporting primary care practices in building capacity to use health information data

Introduction:

Our objective was to describe essential support resources and strategies in order to advance the pace and scope of the use of health information technology (HIT) data.

Background and Context:

Primary data were collected between January 2011 and October 2012. The primary study population comprised 51 primary care practices enrolled in the Colorado Beacon Consortium in western Colorado.

Methods:

We used qualitative methods embedded in a mixed-method evaluation: monthly narrative reports from practices; interviews with providers and staff; and focused, group discussions with quality improvement (QI) advisors and staff from the Health Information Technology Regional Extension Center.

Findings:

Practices valued effective support strategies to assist with using HIT, including the following: translating rules and regulations into individual practice settings; facilitating peer-to-peer connections; providing processes and tools for practice improvement; maintaining accountability and momentum; and providing local electronic health record (EHR) technical expertise. Benefits of support included improved quality measures, operational improvements, increased provider and staff engagement, and deeper understanding of EHR data.

Discussion:

The findings affirm the utility of practice facilitation for HIT-focused aims with personalized attention and cross-fertilization among practices for improvements. Facilitation to sustain ongoing improvements and prepare for future HIT-intensive improvement activities was highly valued. In addition to the general practice facilitator, an EHR technical expert was critical to improving practice capacity to use electronic clinical data. Collaborative learning expands the pool of mentors and teachers, who can further translate their own lessons into practical advice for their peers, yielding the emergence of a stronger sense of community among the practices.

Conclusions:

Using HIT more effectively in primary care will require sustained, focused efforts by practices as regulations, incentives and HIT evolve. Ongoing support for community-based practice facilitators; collaborative learning; and local, personalized EHR advisors will help practices care for patients while more effectively deploying HIT to improve care.

Practice facilitation to improve diabetes care in primary care: a report from the EPIC randomized clinical trial

PURPOSE

We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation.

METHODS

We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys.

RESULTS

Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices.

CONCLUSIONS

Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.

Curriculum redesign for teaching the PCMH in Colorado Family Medicine Residency programs

BACKGROUND AND OBJECTIVES

The patient-centered medical home (PCMH) is a practice model that is intended to improve the quality of care by making it safer, more comprehensive, integrated, and personal. However, most family medicine residency programs are not fully prepared to train residents on this idealized model. The Colorado Family Medicine Residency PCMH Project's overall objective is to transform 10 residency practices into PCMHs through practice improvement and curriculum redesign. This paper focuses on the programs' implementation of key PCMH components into the residency curricula and the impact on resident self-perceived competence in and use of PCMH components.

METHODS

Mixed-method evaluation assessed PCMH curricular characteristics, routine use of PCMH components in patient care, and perceived resident competence after implementation of quality improvement coaching and PCMH curriculum tools. Baseline and follow-up PCMH semi-structured curriculum interviews assessed elements included in the residency programs' curricula. The PCMH Clinician Assessment (PCMH-CA) Survey assessed routine use of PCMH components in patient care. The PCMH Competency Self-Assessment Survey assessed residents' perceived competency in applying PCMH elements in patient care.

RESULTS

Qualitative data results demonstrated active efforts by the residency programs to implement key PCMH components. Survey results showed significant improvement from baseline to follow-up (12--36 months).

CONCLUSIONS

Implementation of the key components of PCMH into practice improvement efforts and residency curricula improved residents' routine use of PCMH in patient care and their perceived PCMH competence.

Patient-centered medical home: how it affects psychosocial outcomes for diabetes

Fragmentation of the current U.S. health care system and the increased prevalence of chronic diseases in the U.S. have led to the recognition that new models of care are needed. Chronic disease management, including diabetes, is often accompanied by a myriad of associated psychosocial issues that need to be addressed as part of a comprehensive treatment plan. Diabetes care should be aligned with comprehensive whole-person health care. The patient-centered medical home (PCMH) has emerged as a model for enhanced primary care that focuses on comprehensive integrated care. PCMH demonstration projects have shown improvements in quality of care, patient experience, care coordination, access to care, and quality measures for diabetes. Key PCMH transformative features associated with psychosocial issues related to diabetes reviewed in this article include integration of mental and behavioral health, care management/coordination, payment reform, advanced access, and putting the patient at the center of health care. This article also reviews the evidence supporting comprehensive and integrated care for addressing psychosocial issues associated with diabetes in the medical home.

Overcoming early barriers to PCMH practice improvement in family medicine residencies

BACKGROUND AND OBJECTIVES

Residency programs face inevitable challenges as they redesign their practices for higher quality care and resident training. Identifying and addressing early barriers can help align priorities and thereby augment the capacity to change.

METHODS

Evaluation of the Colorado Family Medicine Residency PCMH Project included iterative qualitative analysis of field notes, interviews, and documents to identify early barriers to change and strategies to overcome them.

RESULTS

Nine common but not universal barriers were identified: (1) a practice's history reflected some negative past experiences with quality improvement or routines incompatible with transformative change, (2) leadership gaps were evident in unprepared practice leaders or hierarchical leadership, (3) resistance and skepticism about change were expressed through cynicism aimed at change or ability to change, (4) unproductive team processes were reflected in patterns of canceled meetings, absentee leaders, or lack of accountability, (5) knowledge gaps about the Patient-centered Medical Home (PCMH) were apparent from incomplete dissemination about the project or planned changes, (6) EHR implementation distracted focus or stalled improvement activity, (7) sponsoring organizations' constraints emerged from staffing rules and differing priorities, (8) insufficient staff participation resulted from traditional role expectations and structures, and (9) communication was hampered by ineffective methods and part-time faculty and residents. Early barriers responded to varying degrees to specific interventions by practice coaches.

CONCLUSIONS

Some barriers that interfere with practices getting started with cultural and structural transformation can be addressed with persistent attention and reflection from on-site coaches and by realigning the talents, leaders, and priorities already in these residency programs.

Comprehensiveness and continuity of care and the inseparability of mental and behavioral health from the patient-centered medical home

Comprehensiveness and continuity of care are key elements of primary care system redesign. Comprehensiveness encompasses evaluating the whole person and dealing with the full range of physical, mental, and behavioral healthcare issues; and continuity is based on building healing relationships over time. This article suggests that a focus on comprehensiveness and continuity implies that responding to mental health, behavioral health, and substance use must be core elements of the patient-centered medical home. A list of necessary next steps toward achieving comprehensive and integrated care is recommended.

Clinician burden and depression treatment: disentangling patient- and clinician-level effects of medical comorbidity

BACKGROUND

Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.

OBJECTIVE

To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.

DESIGN

Secondary analysis from the Quality Improvement in Depression Study dataset.

PARTICIPANTS

The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study.

MEASUREMENTS

Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden.

RESULTS

Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45).

CONCLUSIONS

Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.

Correlates of household smoking bans in low-income families of children with and without asthma

Exposure to secondhand smoke (SHS) harms all children's health, especially children with asthma. Yet, children with asthma are as likely to live with smokers as healthy children. Household smoking bans are being advocated to reduce children's harm from SHS. To measure the effect of household smoking bans on child SHS exposure and to examine correlates of strict smoking bans in a low-income, diverse sample, 91 children with asthma were matched to 91 healthy children. All had at least one smoker living in their homes. Nicotine dosimeters, child cotinine assays, and maternal reports quantified child SHS exposures. Maternal reports of household smoking rules, behaviors, and beliefs, and other family characteristics were also gathered. The presence of a strict household smoking ban vastly reduced children's SHS exposures and was associated with fewer cigarettes smoked by the mother and by other family members, the belief that SHS was a personal health risk, having children with asthma, and living in a single-family home. Many children are exposed to high levels of SHS at home. Strict household smoking bans greatly decrease, but do not eliminate children's SHS exposure. Even in disadvantaged families, mutable factors were associated with strict smoking bans. Increased dissemination and use of established public health strategies are needed to reduce children's SHS exposures.

Care management for depression in primary care practice: findings from the RESPECT-Depression trial

PURPOSE

This qualitative study examined the barriers to adopting depression care management among 42 primary care clinicians in 30 practices.

METHODS

The RESPECT-Depression trial worked collaboratively with 5 large health care organizations (and 60 primary care practices) to implement and disseminate an evidence-based intervention. This study used semistructured interviews with 42 primary care clinicians from 30 practice sites, 18 care managers, and 7 mental health professionals to explore experience and perceptions with depression care management for patients. Subject selection in 4 waves of interviews was driven by themes emerging from ongoing data analysis.

RESULTS

Primary care clinicians reported broad appreciation of the benefits of depression care management for their patients. Lack of reimbursement and the competing demands of primary care were often cited as barriers. These clinicians at many levels of initial enthusiasm for care management increased their enthusiasm after experiencing care management through the project. Psychiatric oversight of the care manager with suggestions for the clinicians was widely seen as important and appropriate by clinicians, care managers, and psychiatrists. Clinicians and care managers emphasized the importance of establishing effective communication among themselves, as well as maintaining a consistent and continuous relationship with the patients. The clinicians were selective in which patients they referred for care management, and there was wide variation in opinion about which patients were optimal candidates. Care managers were able to operate both from within a practice and more centrally when specific attention was given to negotiating communication strategies with a clinician.

CONCLUSIONS

Care management for depression is an attractive option for most primary care clinicians. Lack of reimbursement remains the single greatest obstacle to more widespread adoption.

Measuring organizational attributes of primary care practices: development of a new instrument

OBJECTIVE

To develop an instrument to measure organizational attributes relevant for family practices using the perspectives of clinicians, nurses, and staff.

DATA SOURCES/STUDY SETTING

Clinicians, nurses, and office staff (n=640) from 51 community family medicine practices.

DESIGN

A survey, designed to measure a practices' internal resources for change, for use in family medicine practices was created by a multidisciplinary panel of experts in primary care research and health care organizational performance. This survey was administered in a cross-sectional study to a sample of diverse practices participating in an intervention trial. A factor analysis identified groups of questions relating to latent constructs of practices' internal resources for capacity to change. ANOVA methods were used to confirm that the factors differentiated practices.

DATA COLLECTION

The survey was administered to all staff from 51 practices.

PRINCIPAL FINDINGS

The factor analysis resulted in four stable and internally consistent factors. Three of these factors, "communication,""decision-making," and "stress/chaos," describe resources for change in primary care practices. One factor, labeled "history of change," may be useful in assessing the success of interventions.

CONCLUSIONS

A 21-item questionnaire can reliably measure four important organizational attributes relevant to family practices. These attributes can be used both as outcome measures as well as important features for targeting system interventions.

Use of chronic care model elements is associated with higher-quality care for diabetes

PURPOSE

In 30 small, independent primary care practices, we examined the association between clinician-reported use of elements of the Chronic Care Model (CCM) and diabetic patients' hemoglobin A(1c) (HbA(1c)) and lipid levels and self-reported receipt of care.

METHODS

Ninety clinicians (60 physicians, 17 nurse-practitioners, and 13 physician's assistants) completed a questionnaire assessing their use of elements of the CCM on a 5-point scale (never, rarely, occasionally, usually, and always). A total of 886 diabetic patients reported their receipt of various diabetes care services. We computed a clinical care composite score that included patient-reported assessments of blood pressure, lipids, microalbumin, and HbA(1c); foot examinations; and dilated retinal examinations. We computed a behavioral care composite score from patient-reported support from their clinician in setting self-management goals, obtaining nutrition education or therapy, and receiving encouragement to self-monitor their glucose. HbA(1c) values and lipid profiles were obtained by independent laboratory assay. We used multilevel regression models for analyses to account for the hierarchical nature of the data.

RESULTS

Clinician-reported use of elements of CCM was significantly associated with lower HbA(1c) values (P = .002) and ratios of total cholesterol to high-density lipoprotein cholesterol (P = .02). For every unit increase in clinician-reported CCM use (eg, from "rarely" to "occasionally"), there was an associated 0.30% reduction in HbA(1c) value and 0.17 reduction in the lipid ratio. Clinician use of the CCM elements was also significantly associated with the behavioral composite score (P = .001) and was marginally associated with the clinical care composite score (P = .07).

CONCLUSIONS

Clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care.

Family physicians and youth tobacco-free education: outcomes of the Colorado Tar Wars program

BACKGROUND

Tar Wars is a national school-based tobacco-free education program operated by the American Academy of Family Physicians. The Tar Wars lesson uses an interactive 45-min session taught by volunteer family physicians in 4th- and 5th-grade classrooms and focuses on the short-term image-based consequences of tobacco use. In this study, we evaluated the effectiveness of the Tar Wars program in Colorado with both quantitative and qualitative measures.

METHODS

Students participating in the quantitative evaluation were tested before and after a Tar Wars teaching session using a 14-question test covering the short-term and image-based consequences of tobacco use, cost of smoking, tobacco advertising, and social norms of tobacco use. Qualitative evaluation of the program included guided telephone interviews and focus groups with participating students, teachers, and presenters.

RESULTS

Quantitative evaluation showed statistically significant improvement in correct responses for the 14 questions measured with an average increase in correct responses from 8.95 to 10.23. Three areas recommended by the Centers for Disease Control (CDC) for youth tobacco prevention showed greater change in correct responses, including cost of smoking, truth of tobacco advertising, and peer norms of tobacco use. Qualitative evaluation found that the overall message of the session was well received, that previously known tobacco information was reinforced by its presentation in a novel format, and that new information learned included cost of smoking, truth of tobacco advertising, and peer norms of tobacco use.

CONCLUSIONS

The Tar Wars lesson plan is effective in increasing students' understanding about the short-term consequences of tobacco use, cost of tobacco use, truth of tobacco advertising, and peer norms. Tar Wars meets the CDC guidelines as one component of effective comprehensive youth tobacco prevention.

Implementing a depression improvement intervention in five health care organizations: experience from the RESPECT-Depression trial

A growing body of research provides strong evidence for the effectiveness of programs to improve the primary care of depression based on the chronic care model. At the same time these changes are difficult to sustain in their original research settings and more difficult to widely disseminate in primary care practice. The RESPECT-Depression trial tested an implementation and dissemination strategy by working through five community-based health care organizations (HCOs) to implement the Three Component Model (TCM) for improving depression care. This report describes the results of extensive interviews of project principals, health care program managers, depression care managers, and practicing primary care clinicians to understand the characteristics of organizations and the intervention components that were associated with implementation and dissemination of the TCM. In two of the organizations all 29 participating practices continued the TCM, while all 31 practices from the other three organizations did not. Successful continuation and dissemination appeared to be related to a broadly shared vision and commitment among all levels of the organization, clearly articulated by clinical leadership, for pursuing a systematic change strategy to improve chronic care that included, but extended beyond, depression, independent of clear evidence for cost-effectiveness of expanding depression management. Factors associated with inability to sustain the TCM included lack of a shared change strategy throughout the organization and inability to rationalize an economic model of depression care.

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.

The case for interdepartmental research in primary care

Research problems in human biology, clinical medicine, and health services delivery are complex, and increasingly require collaborative approaches. Despite the commitment of general internists, general pediatricians, and family physicians to comprehensive, coordinated, and longitudinal care, their substantial overlap in research topics, methods, and data sources, and their shared emphasis on research conducted in community-based settings, the three primary care disciplines rarely collaborate in research. The research enterprises of most primary care departments and divisions in the United States are small "cottage industries," while interdepartmental research units are rare. Interdepartmental research units can develop and maintain the critical mass of investigators, trainees, and staff that is necessary for an intellectually vibrant and financially sound primary care research enterprise. The University of Colorado Health Sciences Center School of Medicine has developed a successful interdepartmental research effort in primary care that includes joint fellowship training and faculty development programs and a Primary Care Research Unit that supports the analysis of secondary databases, practice-based research networks, and interdisciplinary research projects. Key elements of this collaboration include shared projects among faculty and trainees, proactive negotiation about resources, and shared research space, staff, and faculty. Such a collaboration provides the breadth of perspectives necessary to address complex health care problems, and the pragmatic infrastructure necessary to sustain research themes and careers.

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.