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Background: The effectiveness of collaborative care of mental health problems is clear for depression and growing but mixed for anxiety disorders, including posttraumatic stress disorder (PTSD). We know little about whether collaborative care can be effective in settings that serve low-income patients such as Federally Qualified Health Centers (FQHCs).Objective: We compared the effectiveness of minimally enhanced usual care (MEU) versus collaborative care for PTSD with a care manager (PCM).Design: This was a multi-site patient randomized controlled trial of PTSD care improvement over 1 year.Participants: We recruited and enrolled 404 patients in six FQHCs from June 2010 to October 2012. Patients were eligible if they had a primary care appointment, no obvious physical or cognitive obstacles to participation, were age 18-65 years, planned to continue care at the study location for 1 year, and met criteria for a past month diagnosis of PTSD.Main Measures: The main outcomes were PTSD diagnosis and symptom severity (range, 0-136) based on the Clinician-Administered PTSD Scale (CAPS). Secondary outcomes were medication and counseling for mental health problems, and health-related quality of life assessed at baseline, 6 months, and 12 months.Key Results: Patients in both conditions improved similarly over the 1-year evaluation period. At 12 months, PTSD diagnoses had an absolute decrease of 56.7% for PCM patients and 60.6% for MEU patients. PTSD symptoms decreased by 26.8 and 24.2 points, respectively. MEU and PCM patients also did not differ in process of care outcomes or health-related quality of life. Patients who actually engaged in care management had mental health care visits that were 14% higher (p < 0.01) and mental health medication prescription rates that were 15.2% higher (p < 0.01) than patients with no engagement.Conclusions: A minimally enhanced usual care intervention was similarly effective as collaborative care for patients in FQHCs. [ABSTRACT FROM AUTHOR]

Background: Effective collaboration and teamwork is essential in providing safe and effective hospital care. Prior research reveals deficiencies in collaboration on medical teaching units.Objective: The aim of this study was to assess the impact of an intervention, structured inter-disciplinary rounds (SIDR), on hospital care providers' ratings of collaboration and teamwork.Methods: The study was a controlled trial comparing an intervention medical teaching unit with a similar control unit. The intervention, SIDR, combined a structured format for communication with a forum for regular interdisciplinary meetings. We surveyed providers on each unit and asked them to rate the quality of communication and collaboration they had experienced with other disciplines using a five-point ordinal scale. We also assessed the teamwork and safety climate using a validated instrument. Multivariable regression analyses were used to assess the impact on length of stay (LOS) and cost.Results: One hundred forty-seven of 159 (92%) eligible providers completed the survey. Although resident physicians on each unit rated the quality of communication and collaboration with nurses similarly, a greater percentage of nurses gave high ratings to the quality of collaboration with resident physicians on the intervention unit as compared to the control unit (74% vs. 44%; p = 0.02). Providers on the intervention unit rated the teamwork climate significantly higher as compared to the control unit (82.4 +/- 11.7 vs. 77.3 +/- 12.3; p = 0.01). The difference was explained by higher teamwork climate ratings on the part of nurses on the intervention unit (83.5 +/- 14.7 vs. 74.2 +/- 14.1; p = 0.005). Ratings of the safety climate were not significantly different between units. Adjusted LOS and hospital costs were not significantly different between units.Conclusions: SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a medical teaching unit. Further study is required to assess the impact of SIDR on patient safety measures. [ABSTRACT FROM AUTHOR]

Background: Effective physician-nurse collaboration is an important, but incompletely understood determinant of patient and nurse satisfaction, and patient safety. Its impact on physicians has not been described. This study was undertaken to develop a fuller understanding of the collaboration experience and its outcomes.Methods: Twenty-five medical residents, 32 staff nurses, 5 physician and 5 nurse faculty wrote narratives about successful collaboration; the narratives were then qualitatively analyzed. Narrative analysis was the initial qualitative method iteratively employed to identify themes. A phenomenological approach was subsequently used to develop a framework for collaborative competence.Results: Collaboration triggers, facilitative behaviors, outcomes and collaborative competence were the themes identified. Affect was identified in the triggers leading to collaboration and in its outcomes. Practioners typically entered a care episode feeling worried, uncertain or inadequate and finished the interaction feeling satisfied, understood and grateful to their colleagues. The frequency of affective experience was not altered by gender, profession, or ethnicity. These experiences were particularly powerful for novice practioners of both disciplines and appear to have both formative and transformative potential. Collaborative competence was characterized by a series of graduated skills in clinical and relational domains. Many stories took place in the ICU and afterhours settings.Conclusions: Despite the prevailing wisdom that nursing and medicine are qualitatively different, the stories from this study illuminate surprising commonalities in the collaboration experience, regardless of gender, age, experience, or profession. Collaborative competence can be defined and its component skills identified. Contexts of care can be identified that offer particularly rich opportunities to foster interprofessional collaboration. [ABSTRACT FROM AUTHOR]

The author reflects on how the quality of hospital language services has been improved and measured. In relation to this, a program called Speaking Together: National Language Services Network has been launched by the Robert Wood Johnson Foundation. This is designed to improve the quality and availability of language services at hospitals in the U.S.

Background: There is a need to identify effective practical interventions to decrease cardiovascular disease risk in patients with diabetes.Objective: We examine the impact of participation in a collaborative implementing the chronic care model (CCM) on the reduction of cardiovascular disease risk in patients with diabetes.Design: Controlled pre- and postintervention study.Patients/participants: Persons with diabetes receiving care at 13 health care organizations exposed to the CCM collaborative and controls receiving care in nonexposed sites.Measurements and Main Results: Ten-year risk of cardiovascular disease; determined using a modified United Kingdom Prospective Diabetes Study risk engine score. A total number of 613 patients from CCM intervention sites and 557 patients from usual care control sites met the inclusion criteria. The baseline mean 10-year risk of cardiovascular disease was 31% for both the intervention group and the control group. Participants in both groups had improved blood pressure, lipid levels, and HbA1c levels during the observation period. Random intercept hierarchical regression models showed that the intervention group had a 2.1% (95% CI -3.7%, -0.5%) greater reduction in predicted risk for future cardiovascular events when compared to the control group. This would result in a reduced risk of one cardiovascular disease event for every 48 patients exposed to the intervention.Conclusions: Over a 1-year interval, this collaborative intervention using the CCM lowered the cardiovascular disease risk factors of patients with diabetes who were cared for in the participating organization's settings. Further work could enhance the impact of this promising multifactorial intervention on cardiovascular disease risk reduction. [ABSTRACT FROM AUTHOR]

Background: Depression is common in patients with diabetes, but it is often inadequately treated within primary care. Competing clinical demands and treatment resistance may make it especially difficult to improve depressive symptoms in patients with diabetes who have multiple complications.Objective: To determine whether a collaborative care intervention for depression would be as effective in patients with diabetes who had 2 or more complications as in patients with diabetes who had fewer complications.Design: The Pathways Study was a randomized control trial comparing collaborative care case management for depression and usual primary care. This secondary analysis compared outcomes in patients with 2 or more complications to patients with fewer complications.Patients: Three hundred and twenty-nine patients with diabetes and comorbid depression were recruited through primary care clinics of a large prepaid health plan.Measurements: Depression was assessed at baseline, 3, 6, and 12 months with the 20-item depression scale from the Hopkins Symptom Checklist. Diabetes complications were determined from automated patient records.Results: The Pathways collaborative care intervention was significantly more successful at reducing depressive symptoms than usual primary care in patients with diabetes who had 2 or more complications. Patients with fewer than 2 complications experienced similar reductions in depressive symptoms in both intervention and usual care.Conclusion: Patients with depression and diabetes who have multiple complications may benefit most from collaborative care for depression. These findings suggest that with appropriate intervention depression can be successfully treated in patients with diabetes who have the highest severity of medical problems. [ABSTRACT FROM AUTHOR]

Objectives: Effective communication is a critical component of quality health care, and to improve it we must understand its dynamics. This investigation examined the extent to which physicians' and patients' preferences for control in their relationship (e.g., shared control vs doctor control) were related to their communications styles and adaptations (i.e., how they responded to the communication of the other participant).Design: Stratified case-controlled study.Patients/participants: Twenty family medicine and internal medicine physicians and 135 patients.Measurements: Based on scores from the Patient-Practitioner Orientation Scale, 10 patient-centered physicians (5 male, 5 female) and 10 doctor-centered physicians (5 male, 5 female) each interacted with 5 to 8 patients, roughly half of whom preferred shared control and the other half of whom were oriented toward doctor control. Audiotapes of 135 consultations were coded for behaviors indicative of physician partnership building and active patient participation.Main Results: Patients who preferred shared control were more active participants (i.e., expressed more opinions, concerns, and questions) than were patients oriented toward doctor control. Physicians' beliefs about control were not related to their use of partnership building. However, physicians did use more partnership building with male patients. Not only were active patient participation and physician partnership building mutually predictive of each other, but also approximately 14% of patient participation was prompted by physician partnership building and 33% of physician partnership building was in response to active patient participation.Conclusions: Communication in medical encounters is influenced by the physician's and patient's beliefs about control in their relationship as well as by one another's behavior. The relationship between physicians' partnership building and active patient participation is one of mutual influence such that increases in one often lead to increases in the other. [ABSTRACT FROM AUTHOR]

Compliance with the consultant's recommendations is one measure of the effectiveness of a consultation. A previous study showed that compliance was better when fewer recommendations were made. In the subsequent year, consultants were encouraged to limit their recommendations to five or fewer. Despite a significant decrease in the number of recommendations, compliance rates remained essentially unchanged (72%). Multivariate analysis demonstrated that the clinical severity of the patient's disease and the number of associated problems, as well as the types of recommendations, were significant predictors of compliance. Compliance was best for recommendations involving medications (84%) and worst for recommendations involving diagnostic tests (62%). Compliance was also evaluated in the context of a surgeon's view of the appropriateness of the recommendations. For recommendations felt to be essential to patient care the compliance rate was 75%, but it was only 44% for recommendations judged nonessential (p less than 0.001). The consulting internist should be aware that the surgeon's view of the relevance of the recommendations to patient care needs may have an important effect on compliance. [ABSTRACT FROM AUTHOR]