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Objective: This study was conducted to determine whether patients with serious mental illness receiving care in Veterans Affairs (VA) mental health programs with colocated general medical clinics were more likely to receive adequate medical care than patients in programs without colocated clinics based on a nationally representative sample.Methods: The study included all VA patients with diagnoses of serious mental illness in fiscal year (FY) 2006-2007 who were also part of the VA's External Peer Review Program (EPRP) FY 2007 random sample and who received care from VA facilities (N=107 facilities) with organizational data from the VA Mental Health Program Survey (N=7,514). EPRP included patient-level chart review quality indicators for common processes of care (foot and retinal examinations for diabetes complications; screens for colorectal health, breast cancer, and alcohol misuse; and tobacco counseling) and outcomes (hypertension, diabetes blood sugar, and lipid control).Results: Ten out of 107 (10%) mental health programs had colocated medical clinics. After adjustment for organizational and patient-level factors, analyses showed that patients from colocated clinics compared with those without colocation were more likely to receive foot exams (OR=1.87, p<.05), colorectal cancer screenings (OR=1.54, p<.01), and alcohol misuse screenings (OR=2.92, p<.01). They were also more likely to have good blood pressure control (<140/90 mmHg; OR=1.32, p<.05) but less likely to have glycosylated hemoglobin <9% (OR=.69, p<.05).Conclusions: Colocation of medical care was associated with better quality of care for four of nine indicators. Additional strategies, particularly those focused on improving diabetes control and other chronic medical outcomes, might be warranted for patients with serious mental illness. [ABSTRACT FROM AUTHOR]

Objective: This study examined whether veterans with serious mental illness in mental health settings with colocated general medical care had fewer hospitalizations for ambulatory care-sensitive conditions than veterans in other settings.Methods: Using 2007 data, the study examined hospitalizations for ambulatory care-sensitive conditions with zero-inflated negative binomial regression controlling for demographic, clinical, and facility characteristics.Results: Of 92,268 veterans with serious mental illness, 9,662 (10.5%) received care at ten sites with colocated care and 82,604 (89.5%) at 98 sites without it. At sites without colocation, 5.1% had a hospitalization for an ambulatory care-sensitive condition, compared with 4.3% at sites with colocation. Attendance at sites with colocated care was associated with an adjusted count of hospitalizations of .76 compared with attendance at sites with no colocation (β=-.28, 95% confidence interval=.47 to -.09, p=.004).Conclusions: Colocation of general medical services in the mental health setting was associated with significantly fewer preventable hospitalizations. [ABSTRACT FROM AUTHOR]

To examine the role of psychological distress in accessing routine periodic health examinations among U.S. women of reproductive age, we examined data on 9,166 women aged 18-49 years from the 1998 National Health Interview Survey. In multivariate regression, women with psychological distress were more likely than non-distressed women to report delayed routine care, not having insurance, and lack of a usual source of care. Among women without a usual source of care, distressed women were more than six and one-half times more likely to delay care compared with non-distressed women. Women with psychological distress report delays in receiving routine care. EDITORS' STRATEGIC IMPLICATIONS: The findings suggest that, for distressed women in particular, continuity of care is vital in accessing routine care and obtaining timely and effective preventive services. [ABSTRACT FROM AUTHOR]

Abstract Background Participant attrition in longitudinal studies can introduce systematic bias, favoring participants who return for follow-up, and increase the likelihood that those with complications will be underestimated. Our aim was to examine the effectiveness of home follow-up (Home F/U) to complete the final study evaluation on potentially “lost” participants by: 1) evaluating the impact of including and excluding potentially “lost” participants (e.g., those who required Home F/U to complete the final evaluation) on the rates of study complications; 2) examining the relationship between timing and number of complications on the requirement for subsequent Home F/U; and 3) determining predictors of those who required Home F/U. Methods We used data from a randomized controlled trial (RCT) conducted from 1991–1994 among coronary artery bypass graft surgery patients that investigated the effect of High mean arterial pressure (MAP) (intervention) vs. Low MAP (control) during cardiopulmonary bypass on 5 complications: cardiac morbidity/mortality, neurologic morbidity/mortality, all-cause mortality, neurocognitive dysfunction and functional decline. We enhanced completion of the final 6-month evaluation using Home F/U. Results Among 248 participants, 61 (25%) required Home F/U and the remaining 187 (75%) received Routine F/U. By employing Home F/U, we detected 11 additional complications at 6 months: 1 major neurologic complication, 6 cases of neurocognitive dysfunction and 4 cases of functional decline. Follow-up of 61 additional Home F/U participants enabled us to reach statistical significance on our main trial outcome. Specifically, the High MAP group had a significantly lower rate of the Combined Trial Outcome compared to the Low MAP group, 16.1% vs. 27.4% (p=0.032). In multivariate analysis, participants who were ≥ 75 years (OR=3.23, 95% CI 1.52-6.88, p=0.002) or on baseline diuretic therapy (OR=2.44, 95% CI 1.14-5.21, p=0.02) were more likely to require Home F/U. In addition, those in the Home F/U group were more likely to have sustained 2 or more complications (p=0.05). Conclusions Home visits are an effective approach to reduce attrition and improve accuracy of study outcome reporting. Trial results may be influenced by this method of reducing attrition. Older participants, those with greater medical burden and those who sustain multiple complications are at higher risk for attrition.

Abstract Background The Computer Adaptive Test version of the Community Reintegration of Injured Service Members measure (CRIS-CAT) consists of three scales measuring Extent of, Perceived Limitations in, and Satisfaction with community integration. The CRIS-CAT was developed using item response theory methods. The purposes of this study were to assess the reliability, concurrent, known group and predictive validity and respondent burden of the CRIS-CAT. The CRIS-CAT was developed using item response theory methods. The purposes of this study were to assess the reliability, concurrent, known group and predictive validity and respondent burden of the CRIS-CAT. Methods This was a three-part study that included a 1) a cross-sectional field study of 517 homeless, employed, and Operation Enduring Freedom / Operation Iraqi Freedom (OEF/OIF) Veterans; who completed all items in the CRIS item set, 2) a cohort study with one year follow-up study of 135 OEF/OIF Veterans, and 3) a 50-person study of CRIS-CAT administration. Conditional reliability of simulated CAT scores was calculated from the field study data, and concurrent validity and known group validity were examined using Pearson product correlations and ANOVAs. Data from the cohort were used to examine the ability of the CRIS-CAT to predict key one year outcomes. Data from the CRIS-CAT administration study were used to calculate ICC (2,1) minimum detectable change (MDC), and average number of items used during CAT administration. Results Reliability scores for all scales were above 0.75, but decreased at both ends of the score continuum. CRIS-CAT scores were correlated with concurrent validity indicators and differed significantly between the three Veteran groups (P 0.9. MDCs were 5.9, 6.2, and 3.6, respectively for Extent, Perceived and Satisfaction subscales. Number of items (mn, SD) administered at Visit 1 were 14.6 (3.8) 10.9 (2.7) and 10.4 (1.7) respectively for Extent, Perceived and Satisfaction subscales. Conclusion The CRIS-CAT demonstrated sound measurement properties including reliability, construct, known group and predictive validity, and it was administered with minimal respondent burden. These findings support the use of this measure in assessing community reintegration.

Background: Community health centers grapple with high no-show rates, posing challenges to patient access and primary care provider (PCP) utilization., Aim: To address these challenges, we implemented a virtual waiting room (VWR) program in April 2023 to enhance patient access and boost PCP utilization., Setting: Academic community health center in a small urban city in Massachusetts., Participants: Community health patients (n = 8706) and PCP (n = 14)., Program Description: The VWR program, initiated in April 2023, involved nurse triage of same-day visit requests for telehealth appropriateness, then placing patients in a standby pool to fill in as a telehealth visit for no-shows or last-minute cancellations in PCP schedules., Program Evaluation: Post-implementation, clinic utilization rates between July and September improved from 75.2% in 2022 to 81.2% in 2023 (p < 0.01). PCP feedback was universally positive. Patients experienced a mean wait time of 1.9 h, offering a timely and convenient alternative to urgent care or the ER., Discussion: The VWR is aligned with the quadruple aim of improving patient experience, population health, cost-effectiveness, and PCP satisfaction through improving same-day access and improving PCP schedule utilization. This innovative and reproducible approach in outpatient offices utilizing telehealth holds the potential for enhancing timely access across various medical disciplines., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Introduction: The aim of this study was to determine whether a pharmacist-led telehealth disease management program is superior to usual care of nurse-led telehealth in improving diabetes medication adherence, haemoglobin A1C (A1C), and depression scores in patients with concomitant diabetes and depression., Methods: Patients with diabetes and depression were randomized to pharmacist-led or nurse-led telehealth. Veterans with type 1 or type 2 diabetes, an A1C ≥ 7.5%, diagnosis of depression, and access to a landline phone were invited to participate. Patients were randomized to usual care of nurse-led telehealth or pharmacist-led telehealth. Patients were shown how to use the telehealth equipment by the nurse or pharmacist. In the pharmacist-led group, the patients received an in-depth medication review in addition to the instruction on the telehealth equipment., Results: After six months, the pharmacist-led telehealth arm showed significant improvements for cardiovascular medication adherence (14.0; 95% confidence interval (CI) 0.4 to 27.6), antidepressant medication adherence (26.0; 95% CI 0.9 to 51.2), and overall medication adherence combined (13.9; 95% CI 6.6 to 21.2) from baseline to six-month follow-up. There was a significant difference in A1C between each group at the six-month follow-up in the nurse-led telehealth group (6.9 ± 0.9) as compared to the pharmacist-led telehealth group (8.8 ± 2.0). There was no significance in the change in patient health questionnaire-9 (PHQ-9) and Center for Epidemiologic Studies Depression Scale (CES-D) from baseline to follow-up in both groups., Discussion: Pharmacist-led telehealth was efficacious in improving medication adherence for cardiovascular, antidepressants, and overall medications over a six-month period as compared to nurse-led telehealth. There was no significant improvement in overall depression scores.

Background: The Centers for Medicare and Medicaid Services has emphasized patient satisfaction as a means by which hospitals should be compared and as a component of financial reimbursement. We sought to identify whether resource utilization is associated with patient satisfaction ratings., Design: This was a retrospective, cohort study over a 27-month period from January 2012 to April 2014 of adult respondents (n = 10,007) to the Hospital Consumer Assessment of Healthcare Providers and Systems survey at a tertiary care medical center. For each returned survey, we developed a resource intensity score related to the corresponding hospitalization. We calculated a raw satisfaction rating (RSR) for each returned survey. Multivariable logistic regression was used to determine the association between resource intensity and top decile RSRs, using those with the lowest resource intensity as the reference group., Results: Adjusting for age, gender, insurance payer, severity of illness, and clinical service, patients in higher resource intensity groups were more likely to assign top decile RSRs than the lowest resource intensity group ("moderate" [adjusted odds ratio {aOR}: 1.42, 95% confidence interval {CI}: 1.11-1.83], "major" [aOR: 1.56, 95% CI: 1.22-2.01], and "extreme" [aOR: 2.29, 95% CI: 1.8-2.92])., Conclusions: Resource utilization may be positively associated with patient satisfaction. These data suggest that hospitals with higher per-patient expenditures may receive higher ratings, which could result in hospitals with higher per-patient resource utilization appearing more attractive to healthcare consumers. Journal of Hospital Medicine 2016;11:785-791. © 2016 Society of Hospital Medicine., (© 2016 Society of Hospital Medicine.)

Background: Although depression screening occurs annually in the Department of Veterans Affairs (VA) primary care, many veterans may not be receiving guideline-concordant depression treatment., Objectives: To determine whether veterans' illness perceptions of depression may be serving as barriers to guideline-concordant treatment., Research Design: We used a prospective, observational design involving a mailed questionnaire and chart review data collection to assess depression treatment utilization and concordance with Healthcare Effectiveness Data and Information Set guidelines adopted by the VA. The Self-Regulation Model of Illness Behavior guided the study., Subjects: Veterans who screened positive for a new episode of depression at 3 VA primary care clinics in the US northeast., Measures: The Illness Perceptions Questionnaire-Revised, measuring patients' perceptions of their symptoms, cause, timeline, consequences, cure or controllability, and coherence of depression and its symptoms, was our primary measure to calculate veterans' illness perceptions. Treatment utilization was assessed 3 months after the positive depression screen through chart review. Healthcare Effectiveness Data and Information Set (HEDIS) guideline-concordant treatment was determined according to a checklist created for the study., Results: A total of 839 veterans screened positive for a new episode of depression from May 2009-June 2011; 275 (32.8%) completed the survey. Ninety-two (33.9%) received HEDIS guideline-concordant depression treatment. Veterans' illness perceptions of their symptoms, cause, timeline, and controllability of depression predicted receiving guideline-concordant treatment., Conclusions: Many veterans are not receiving guideline-concordant treatment for depression. HEDIS guideline measures may not be assessing all aspects of quality depression care. Conversations about veterans' illness perceptions and their specific needs are encouraged to ensure that appropriate treatment is achieved.

Objective: To determine whether specific depression symptoms are associated with glycemic control independent of potential demographic and clinical covariates among primary care patients with comorbid type 2 diabetes and provisional threshold or subthreshold depression., Method: We examined a convenience sample of patients diagnosed with type 2 diabetes and provisional threshold or subthreshold depression (N = 82) at 2 family health centers. Cases were identified using a population-based registry of patients diagnosed with type 2 diabetes (ICD-9 codes 250.00 for controlled type 2 diabetes and 250.02 for uncontrolled type 2 diabetes). Data from patients with a primary care provider appointment from the beginning of April 2011 through the end of June 2012 and with at least one 9-item Patient Health Questionnaire (PHQ-9) depression screener and a glycated hemoglobin A1c (HbA1c) laboratory test between 2 weeks before and 10 weeks after PHQ-9 screening were eligible for inclusion. We defined provisional threshold or subthreshold depression using PHQ-9 scoring criteria, which were designed to yield provisional diagnostic information about major depressive disorder based on DSM-5 diagnostic criteria., Results: Patients reporting higher severity of sleep problems on the PHQ-9 had significantly higher HbA1c levels (mean = 8.48, SD = 2.17) compared to patients reporting lower severity or absence of this symptom (mean = 7.19, SD = 1.34, t 48.88 = -3.13, P = .003). Problems with sleep contributed unique variance on glycemic control (β = 0.27, P = .02) when controlling for potential clinical and demographic covariates, with those reporting more sleep difficulties having higher HbA1c levels., Conclusions: For patients with type 2 diabetes and provisional threshold or subthreshold depression, it may be prudent to aggressively address sleep problems as a potential mechanism toward improving diabetes control.

Background: Depression is associated with cognitive impairment and dementia, but whether treatment for depression with antidepressants reduces the risk for cognitive decline is unclear. We assessed the association between antidepressant use and cognitive decline over 6 years., Methods: Participants were 3714 adults aged 50 years or more who were enrolled in the nationally representative Health and Retirement Study and had self-reported antidepressant use. Depressive symptoms were assessed using the 8-item Center for Epidemiologic Studies Depression Scale. Cognitive function was assessed at 4 time points (2004, 2006, 2008, 2010) using a validated 27-point scale. Change in cognitive function over the 6-year follow-up period was examined using linear growth models, adjusted for demographics, depressive symptoms, comorbidities, functional limitations, and antidepressant anticholinergic activity load., Results: At baseline, cognitive function did not differ significantly between the 445 (12.1%) participants taking antidepressants and those not taking antidepressants (mean, 14.9%; 95% confidence interval, 14.3-15.4 vs mean, 15.1%; 95% confidence interval, 14.9-15.3). During the 6-year follow up period, cognition declined in both users and nonusers of antidepressants, ranging from -1.4 change in mean score in those with high depressive symptoms and taking antidepressants to -0.5 change in mean score in those with high depressive symptoms and not taking antidepressants. In adjusted models, cognition declined in people taking antidepressants at the same rate as those not taking antidepressants. Results remained consistent across different levels of baseline cognitive function, age, and duration of antidepressant use (prolonged vs short-term)., Conclusions: Antidepressant use did not modify the course of 6-year cognitive change in this nationally representative sample., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Context: Diagnosis and treatment of depression has increased over the past decade in the United States. Whether self-reported depressive symptoms among older adults have concomitantly declined is unknown., Objective: To examine trends in depressive symptoms among older adults in the US between 1998 and 2008., Design: Serial cross-sectional analysis of six biennial assessments., Setting: Health and Retirement Study (HRS), a nationally-representative survey. PATIENTS OR OTHER PARTICIPANTS Adults aged 55 and older (N = 16,184 in 1998)., Main Outcome Measure: The eight-item Center for Epidemiologic Studies Depression scale (CES-D8) assessed three levels of depressive symptoms (none = 0, elevated = 4+, severe = 6+), adjusting for demographic and clinical characteristics., Results: Having no depressive symptoms increased over the 10-year period from 40.9 % to 47.4 % (prevalence ratio [PR]: 1.16, 95 % CI: 1.13-1.19), with significant increases in those aged ≥ 60 relative to those aged 55-59. There was a 7 % prevalence reduction of elevated symptoms from 15.5 % to 14.2 % (PR: 0.93, 95 % CI: 0.88-0.98), which was most pronounced among those aged 80-84 in whom the prevalence of elevated symptoms declined from 14.3 % to 9.6 %. Prevalence of having severe depressive symptoms increased from 5.8 % to 6.8 % (PR: 1.17, 95 % CI: 1.06-1.28); however, this increase was limited to those aged 55-59, with the probability of severe symptoms increasing from 8.7 % to 11.8 %. No significant changes in severe symptoms were observed for those aged ≥ 60., Conclusions: Overall late-life depressive symptom burden declined significantly from 1998 to 2008. This decrease appeared to be driven primarily by greater reductions in depressive symptoms in the oldest-old, and by an increase in those with no depressive symptoms. These changes in symptom burden were robust to physical, functional, demographic, and economic factors. Future research should examine whether this decrease in depressive symptoms is associated with improved treatment outcomes, and if there have been changes in the treatment received for the various age cohorts.

We conducted focus groups with Latinos enrolled in a Medicaid health plan in order to ask about the barriers to and facilitators of depression treatment in general as well as barriers to participation in depression telephone care management. Telephone care management has been designed for and tested in primary care settings as a way of assisting physicians with caring for their depressed patients. It consists of regular brief contacts between the care manager and the patient; the care manager educates, tracks, and monitors patients with depression, coordinates care between the patient and primary care physician, and may provide short-term psychotherapy. We conducted qualitative analyses of four focus groups (n = 30 participants) composed of Latinos who endorsed having been depressed themselves or having had a close friend or family member with depression, stress, nervios, or worries. Within the area of barriers and facilitators of receiving care for depression, we identified the following themes: vulnerability, social connection and engagement, language, culture, insurance/money, stigma, disengagement, information, and family. Participants discussed attitudes toward: importance of seeking help for depression, specific types of treatments, healthcare providers, continuity and coordination of care, and phone calls. Improved understanding of barriers and facilitators of depression treatment in general and depression care management in particular for Latinos enrolled in Medicaid should lead to interventions better able to meet the needs of this particular group.

Purpose: To assess whether VA MEDIC-E (Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction[EM DASH] Extended for 6 months), a pharmacist-led shared medical appointments program, could improve attainment of target goals for hypertension, hyperglycemia, hyperlipidemia, and tobacco use in patients with type 2 diabetes compared to standard primary care after 6 months of intervention., Methods: A randomized, controlled trial of VA MEDIC-E (n = 50) versus standard primary care (n = 49) in veterans with type 2 diabetes, hemoglobin A1c (A1C) > 7%, blood pressure (BP) > 130/80 mmHg, and low density lipoprotein cholesterol (LDL-C) > 100mg/dl (2.59 mmol/l) in the previous 6 months was conducted. The VA MEDIC-E intervention consisted of 4 weekly group sessions followed by 5 monthly booster group sessions. Each 2-hour session included 1 hour of multidisciplinary diabetes specific healthy lifestyle education and 1 hour of pharmacotherapeutic interventions performed by a clinical pharmacist. Evaluation measures included lab values of A1C, LDL cholesterol, BP, and goal attainment of these values, and diabetes self-care behavior questionnaires at 6 months., Results: The randomization groups were similar at baseline in all cardiovascular risk factors except for LDL, which was significantly lower in the MEDIC-E arm. At 6 months, significant improvements from baseline were found in the intervention arm for exercise, foot care, and goal attainment of A1C, LDL-C, and BP but not in the control arm., Conclusions: The results of this study demonstrate that the pharmacist-led group intervention program for 6 months was an efficacious and sustainable collaborative care approach to managing diabetes and reducing associated cardiovascular risk.

Background: For many high-risk patients, accessing primary care is challenged by competing needs and priorities, socioeconomics, and other circumstances. The resulting lack of treatment engagement makes these vulnerable patient populations susceptible to poor health outcomes and an over-reliance on emergency department-based care., Methods: We describe a quasi-experimental pre-post study examining a vulnerable population-based application of the patient-centered medical home applied to four high-risk groups: homeless veterans, cognitively impaired elderly, women veterans and patients with serious mental illness. We measured 6-month primary care, emergency department and inpatient care use and chronic disease management when care was based in a general internal medicine clinic (2006) and in a population-specific medical home (2008)., Results: Overall 457 patients were studied, assessing care use and outcomes for the last 6 months in each study year. Compared with 2006, in 2008 there was a significant increase in primary care use (p < 0.001) and improvement in chronic disease monitoring and diabetes control (2006 HBA1C: 8.5 vs. 2008 HBA1C 6.9) in all four groups. However, there was also an increase in both emergency department use and hospitalizations, albeit with shorter lengths of stay in 2008 compared with 2006. Most of the increased utilization was driven by a small proportion of patients in each group., Conclusion: Tailoring the medical home model to the specific needs and challenges facing high-risk populations can increase primary care utilization and improve chronic disease monitoring and diabetes management. More work is needed in directing this care model to reducing emergency department and inpatient use.

Objective: Pulmonary rehabilitation (PR) has emerged over the last decade as an essential component of an integrated approach to managing patients with chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD). We sought to examine how depression and anxiety symptom changes relate to disease-specific quality of life outcomes following PR., Methods: We performed a cohort study of 81 patients with COPD who completed PR at a Veterans Administration Medical Center. Pulmonary rehabilitation consisted of supervised exercise training and education twice weekly for 8 weeks. Beck Depression and Anxiety Inventories (BDI and BAI) assessed symptom burden at baseline and completion of PR. We measured change in disease-specific quality of life using the dyspnea, mastery, emotion and fatigue domains of the Chronic Respiratory Questionnaire Self-Reported (CRQ-SR) from baseline to completion of PR., Results: Participants were 69.8±9.1 years old and all male. Forced expiratory volume in 1 s (FEV1) was 1.23±0.39 L. The CRQ-SR scores improved significantly: dyspnea (P<.0001), mastery (P=.015) and fatigue (P=.017). The BDI scores improved significantly (13.1±10.5 to 10.8±9.9, P=.003; BAI: 13.1±10.1 to 12.1±11.7). Multivariate regression models controlling for age, FEV1, depression treatment and anxiety treatment showed that improvement in depressive symptoms were associated with improvement in fatigue (P=.003), emotion (P=.003) and mastery (P=.01). Anxiety symptom change was not significantly associated with change in disease-specific quality of life domains., Conclusion: Addressing anxiety symptoms in PR patients may be indicated because disease-specific quality of life improvement appears to be associated with mood., (Published by Elsevier Inc.)

Objectives: To determine whether trends in psychological distress exist in the United States and whether trends in healthcare expenditures and outpatient visits were associated with psychological distress., Study Design: Sequential cross-sectional study of nationally representative data., Methods: We examined data from the National Health Interview Survey (NHIS) from 1997 to 2004 linked to 2 years of subsequent Medical Expenditure Panel Survey (MEPS) data. Psychological distress was measured in the NHIS using the K6, a 6-item scale of the Kessler Psychological Distress Scale, which we classified as no/low, mild-moderate, or severe. We examined subsequent annualized total, outpatient, and office-based expenditures, and outpatient and office-based visits from MEPS., Results: Psychological distress remained stable from 1997 to 2004. There were upward trends in overall healthcare expenditures (P <.001) and outpatient expenditures (P <.001), but not outpatient visits. Overall healthcare expenditures, outpatient expenditures, and outpatient visits significantly increased as psychological distress increased from no/low to mild-moderate to severe. The interaction between psychological distress strata and year was not significant for expenditures or for visits., Conclusions: The upward trend in total and outpatient healthcare expenditures in the United States appears unrelated to psychological distress, although healthcare expenditures are consistently higher among those with greater psychological distress. Future work will explore the impact of treatment on costs and stability of the nation's mental health over time.

Dementia is a complicated disease requiring medical, psychological, and social services. Services to address these needs include medical care (outpatient physician/specialist, inpatient, emergency) and community care (home health, day care, meal preparation, transportation, counseling, support groups, respite care, physical therapy). This systematic review of articles published in English from 1991 to the present examines studies of ambulatory, community-dwelling dementia patients with established dementia diagnoses. Searches of the Medline database using 13 combinations of search terms, plus searches of Embase and PsycINFO databases using 3 combinations of terms and examination of reference lists of related articles, resulted in identification of 15 studies dealing with healthcare utilization among community-dwelling dementia patients in both medical and community care settings. Patients with dementia frequently use the full spectrum of medical services. Community resources are used less frequently. Community healthcare services may be a valuable resource in alleviating some burden of dementia care for physicians.

Background: Diabetes and hypertension can be challenging to manage in patients with mental health conditions. While the effectiveness of a cardiovascular risk reduction clinic (CRRC) has been shown not to differ between those with and without mental health conditions, it is unknown whether patients with mental health conditions would differ in durability of success following discharge from the CRRC., Objective: To determine the effect of mental health conditions on the maintenance of glycemic control and blood pressure control in patients with diabetes following successful completion of a CRRC program., Methods: Patients were discharged from the CRRC when therapeutic goals of hemoglobin A(1c) (A1C) <7% and blood pressure <130/80 mm Hg were achieved. We performed a retrospective chart review of a cohort of 231 patients by quarterly intervals for A1C and systolic blood pressure (SBP), providing up to 3 years of data following discharge from the CRRC. We assessed the time to failure to maintain goal A1C and SBP following CRRC discharge for patients with diagnosed mental health conditions versus patients without mental health conditions., Results: For patients with and without mental health conditions, 50% of those who had been discharged from the CRRC with an SBP goal of <130 mm Hg failed to maintain SBP by 1 quarter. The hazard ratio for failure to maintain SBP, with those without mental health conditions as the reference group, was 0.96 (95% CI 0.68 to 1.35). Overall, for patients with an A1C goal of <7%, the combined median time to failure was 3 quarters. Among patients without mental health conditions, 25% failed in 3 quarters, and of those with mental health conditions, 25% failed in 4 quarters (HR 0.91; 95% CI 0.50 to 1.66)., Conclusions: There was no significant difference between diabetic patients with and without mental health conditions in maintenance of A1C and SBP after discharge from a CRRC. This provides further evidence that a CRRC is a viable approach to cardiovascular risk reduction in individuals with mental health conditions.

Objective: To document values, attitudes, and beliefs that influence behavior change among a diverse group of patients post-angioplasty., Methods: Purposive and maximum-variation sampling were used to assemble a demographically diverse patient cohort (N=61) who had been successful or unsuccessful at post-angioplasty multibehavior change. Semistructured interviews and grounded theory methods were used to collect and analyze qualitative data., Results: Themes showed the following: a) Patients reported surviving a life-threatening event and feared disease recurrence and death; b) the perception of a turning point and self-determination facilitated behavior change; c) social support and spiritual beliefs promoted coping with the uncertainty of living with heart disease; and d) unsuccessful behavior change was related to physical limitations, a sense that "nothing helps," and the belief that angioplasty "cures" heart disease., Conclusion: Lifestyle interventions should be culturally relevant and adapted to physical abilities. Fostering self-determination and social support may promote successful behavior change., (Copyright 2010 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to assess whether the VA-MEDIC (Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction), a pharmacist-led group medical visit program, could improve achievement of target goals in hypertension, hyperglycemia, hyperlipidemia, and tobacco use in patients with type 2 diabetes compared to usual care., Methods: This was a randomized controlled trial of VA-MEDIC intervention in addition to usual care versus usual care alone in diabetic patients to reduce cardiac risk factors. VA-MEDIC consisted of a 40- to 60-minute educational component by nurse, nutritionist, physical therapist, or pharmacist followed by pharmacist-led behavioral and pharmacological interventions over 4 weekly sessions. Measures The attainment of target goals in hemoglobin A1C (A1C), blood pressure, fasting lipids, and tobacco use recommended by the American Diabetes Association., Results: Of 118 participants, 109 completed the study. VA-MEDIC (n = 58) participants were younger and had greater tobacco use at baseline than usual care but were similar in other cardiovascular risk factors. After 4 months, a greater proportion of VA-MEDIC participants versus controls achieved an A1C of less than 7% and a systolic blood pressure less than 130 mm Hg. No significant change was found in lipid control or tobacco use between the 2 study arms., Conclusion: Pharmacist-led group medical visits are feasible and efficacious for improving cardiac risk factors.

The authors evaluated maintenance of achieved cardiovascular risk control after discharge from a pharmacist-coordinated cardiovascular risk reduction clinic. Using data from 2001 to 2004 divided by financial quarters (ie, 3-month periods), the authors performed survival analysis of diabetic patients who had attained at least one cardiovascular risk goal in the clinic. Mean times to failure were 7.1 +/- 0.21 quarters for hemoglobin A1c, 7.6 +/- 0.29 quarters for low-density lipoprotein cholesterol (LDL-C), and 2.5 +/- 0.24 quarters for systolic blood pressure (SBP). Body mass index predicted glycemic control failure (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.01-1.15; P = .02), insulin use predicted LDL-C control failure (HR, 3.08; 95% CI, 1.15-8.22; P = .03), and baseline SBP predicted SBP control failure (HR, 1.02; 95% CI, 1.01-1.03; P = .0003). The authors found good durability of effect for most cardiovascular risk targets. Worse control at entry predicted failure after successful attainment of a cardiovascular goal. More sustained attention or booster interventions for patients with worse control at entry may be necessary.

Background: Several studies suggest that medical comorbidity is associated with worse clinical status in bipolar disorder. It is unclear which aspect of medical comorbidity is responsible: simple disease count, risk for future morbidity, or current physical burden., Methods: We analyzed three years of prospective data from a randomized clinical trial of collaborative care in 306 bipolar veterans. We examined the association of clinical outcome with baseline medical comorbidity defined as: (1) simple active disease count, (2) diseases with risk for future morbidity measured with the Charlson Comorbidity Index, and (3) current physical burden measured with the SF-36 Physical Component Summary score (PCS). Bipolar outcomes were weeks in episode, mean depression score, and change in mental health burden measured by the SF-36 Mental Component Summary score (MCS)., Results: The three medical comorbidity measures were not highly correlated, indicating that each conveyed novel information. Controlling for potential confounders, worse baseline PCS predicted significantly higher mean depression scores (p=0.011) and less improvement in MCS scores (p=0.0099) over three years. Simple disease count and risk for future risk did not predict worse bipolar outcomes., Limitations: Some potential limitations include not accounting for all confounding factors, selection bias for participants, increased the likelihood of Type I error due to multiple comparisons and having a predominantly male population., Conclusions: This long-term prospective study extends cross-sectional and retrospective research on the link between medical illness and bipolar outcomes. It is the current experience of burden of physical illness, rather than an unweighted or weighted disease count, that leads to worse bipolar outcomes.

Background: Although depression among COPD patients is a common problem with important consequences for the management of COPD and overall outcomes, the proportion of those who receive guideline-concordant depression care is low. Guideline-concordant depression care is associated with fewer depressive symptoms and lower risk for psychiatric hospitalization; however, it is unknown whether guideline-concordant depression care favorably impacts COPD-related outcomes for patients with both conditions., Methods: This retrospective cohort study investigated 5,517 veterans with COPD who experienced a new treatment episode for depression. Guideline-concordant depression care was defined as having an adequate supply of antidepressant medication and sufficient follow-up care. Multivariate methods were used to examine the relationship between the receipt of guideline-concordant depression care and (1) COPD-related hospitalization and (2) all-cause mortality 2 years after the depression episode, while controlling for care setting and other covariates., Results: There was no association between the receipt of guideline-concordant depression care and COPD-related hospitalization (odds ratio [OR], 0.98) or all-cause mortality (OR, 0.95). However, patients seen in mental health settings during their depressive episode had 30% lower odds of 2-year mortality than patients seen in primary care., Conclusions: For patients with COPD and depression, interacting with a mental health professional may be an important intervention. However, receiving guideline-concordant depression care, as outlined in common quality monitors, was not significantly associated with decreased hospitalization or mortality. These findings suggest that more referrals to specialty care or better care coordination with mental health specialty care may lead to a significant reduction in mortality risk for these patients.

Background: The effectiveness of bipolar collaborative chronic care models (B-CCMs) among those with co-occurring substance use, psychiatric, and/or medical conditions has not specifically been assessed. We assessed whether B-CCM effects are equivalent comparing those with and without co-occurring conditions., Methods: We reanalyzed data from the VA Cooperative Study #430 (n=290), an 11-site randomized controlled trial of the B-CCM compared to usual care. Moderators included common co-occurring conditions observed in patients with bipolar disorder, including substance use disorders (SUD), anxiety, psychosis; medical comorbidities (total number), and cardiovascular disease-related conditions (CVD). Mixed-effects regression models were used to determine interactive effects between moderators and 3-year primary outcomes., Results: Treatment effects were comparable for those with and without co-occurring substance use and psychiatric conditions, although possibly less effective in improving physical quality of life in those with CVD-related conditions (Beta=-6.11;p=0.04)., Limitations: Limitations included multiple comparisons and underpowered analyses of moderator effects., Conclusions: B-CCM effects were comparable in patients with co-occurring conditions, indicating that the intervention may be generally applied. Specific attention to physical quality of life in those with CVD maybe warranted.

Introduction: Depression may attenuate the effects of diabetes interventions. Our ongoing Cardiovascular Risk Reduction Clinic simultaneously addresses hyperglycemia, hypertension, smoking, and hyperlipidemia. We examined the relationship between depression diagnosis and responsiveness to the Cardiovascular Risk Reduction Clinic., Methods: We studied Cardiovascular Risk Reduction Clinic participants with diabetes who had a depression diagnosis and those with no mental health diagnosis. Our outcome measure was change in 20-year cardiovascular mortality risk according to the United Kingdom Prospective Diabetes Study (UKPDS) score., Results: Of 231 participants, 36 (15.6%) had a depression diagnosis. Participants with a depression diagnosis had a higher baseline UKPDS score (56.8 [SD 21.3]) than participants with no mental health diagnosis (49.5 [SD 18.7], P = .04). After Cardiovascular Risk Reduction Clinic participation, mean UKPDS scores did not differ significantly (37.8 [SD 15.9] for no mental health diagnosis and 39.4 [SD 18.6] for depression diagnosis). Mean UKPDS score reduction was 11.6 [SD 15.6] for no mental health diagnosis compared with 18.4 [SD 15.9] for depression diagnosis (P = .03). Multivariable linear regression that controlled for baseline creatinine, number of Cardiovascular Risk Reduction Clinic visits, sex, and history of congestive heart failure showed significantly greater improvement in UKPDS score among participants with a depression diagnosis (beta = 6.0, P = .04) and those with more Cardiovascular Risk Reduction Clinic visits (beta = 2.1, P < .001)., Conclusion: The Cardiovascular Risk Reduction Clinic program reduced cardiovascular disease risk among patients with diabetes and a diagnosis of depression. Further work should examine how depressive symptom burden and treatment modify the effect of this collaborative multifactorial program and should attempt to determine the durability of the effect.

Coexisting mental health conditions (MHCs) attenuate treatment effects in diabetes. A retrospective analysis was performed of a pharmacist-led cardiovascular risk reduction clinic (CRRC) targeting hypertension, diabetes, hyperlipidemia, and tobacco use in patients with at least one CRRC visit between January 2001 and January 2002. The United Kingdom Prospective Diabetes Study (UKPDS) risk change (after/before CRRC) for those with and without MHCs was compared. Of the 297 with diabetes and complete UKPDS data, 40.7% had at least 1 MHC (22.3% had a severe MHC). Patients with MHCs had a similar number of CRRC visits (4.7+/-2.6 vs 4.4+/-2.6) but had a lower baseline UKPDS score (0.31+/-0.18 vs 0.40+/-0.20; P=.001) compared with non-MHC patients. The risk change after CRRC was similar for those with and without MHCs (0.10+/-0.13 vs 0.10+/-0.14; P=.82), but patients with MHCs had a longer CRRC enrollment (245+/-152 vs 205+/-161 days; P<.03). The efficacy of the CRRC model to reduce cardiovascular risk is not attenuated by a concomitant MHC., (2008 Le Jacq.)

Background and Aim of the Study: The objective of this randomized trial was to compare the efficacy of two strategies of hemodynamic management during cardiopulmonary bypass (CPB) on morbidity, mortality, cognitive complications and deterioration in functional status., Methods: Patients scheduled to undergo primary elective CABG were eligible. In one group, mean arterial pressure target during CPB was 80 mmHg ("high" MAP group); in the other group, MAP target was determined by patients' pre-bypass MAP ("custom" MAP group). The principal outcomes were mortality, major neurologic or cardiac complications, cognitive complications or deterioration in functional status., Results: Of 412 enrolled patients, 36% were women, with overall mean age of 64.7 +/- 12.3 years. Duration of bypass was identical for the two randomization groups. Overall complication rates were similar: 16.5% of the high group and 14.6% of the custom group experienced one or more neurologic, cardiac or cognitive complications. When only cardiac and neurologic morbidity and mortality were considered, the rates were 11.7% and 12.6%, in the high and custom groups, respectively. The aggregate outcome rate, including functional deterioration, was 31.6% in the high group and 29.6% in the custom group., Conclusions: There were no statistically significant differences between the high MAP group and the custom MAP group for the combined outcome of mortality cardiac, neurologic or cognitive complications, and deterioration in the quality of life.

Depression is a severe medical illness that can interfere with an individual's self-care behaviors. Depression is prevalent [1], burdensome [2], treatable [3], and costly [4]. Recognizing depression in diabetic individuals is critical because depression may play a role in worse control of diabetes and worse diabetes outcomes [5-10]. Depression also appears to increase the costs associated with treating diabetes [11]. A number of clinical trials have recently focused on whether treatment of depression can lead to improved diabetes outcomes [12-15]. In this review, we examine the present state of knowledge on the interaction of depression and diabetes, discuss the epidemiologic and physiologic evidence for the co-occurrence of these conditions, and describe the ways in which diabetes control is worsened by depression, how depression interferes with diabetes care, and how depression acts to increase costs in diabetics. We focus specifically on interventions to treat depression in patients with diabetes and suggest areas of future research and practice with respect to improving care and outcomes those suffering in the intersection of these diseases.

Objective: To determine the relative contribution of maternal psychological distress, maternal restraint use, and sociodemographic characteristics to the likelihood that a child would not be restrained in a motor vehicle., Methods: We examined data on 6251 children aged 0-17 years from the 1998 National Health Interview Survey. The level of children's motor vehicle restraint use (low vs high) was examined by maternal psychological distress and motor vehicle restraint use. Multivariate regression analyses were used to model the odds of children's low use of motor vehicle restraints, controlling for potential confounders., Results: According to maternal reports, more than 10% of children and nearly 13% of mothers reported low use of motor vehicle restraints. Multivariate analyses revealed that maternal use of restraints and psychological distress were both independently related to children's use of restraints, with maternal low use as the stronger correlate. Older children were more likely than younger children to be low users of motor vehicle restraints if the mother reported that she was a low user of restraints. Families with male children, black and Hispanic mothers, and 4 or more members reported lower use of restraints for their children., Conclusions: Children's low use of motor vehicle restraints was associated with low levels of maternal motor vehicle restraint use and maternal psychological distress. Moreover, maternal motor vehicle restraint practices become increasingly important as children age. Health care providers should consider maternal motor vehicle restraint use, maternal psychological distress, and child age in addition to sociodemographics when assessing children's motor vehicle safety.

Objective: Depression is common among patients with chronic obstructive pulmonary disease (COPD). Patients with COPD may be more likely to have inadequate treatment with antidepressant medications. We tested the hypothesis that depressed patients with COPD have lower odds of adequate duration of antidepressant therapy in the first 3 months of treatment compared to those without COPD., Method: Using administrative and centralized pharmacy data from 14 northeastern Veterans Affairs Medical Centers, we identified 778 veterans with depression (ICD-9-CM codes 296.2x, 296.3x, and 311.xx) who were in the acute phase of antidepressant treatment from June 1, 1999, through August 31, 1999. Within this group, we identified those patients with COPD (23%). An adequate duration of antidepressant treatment was defined as ≥ 80% of days on an antidepressant. We used multivariable logistic regression models to determine the adjusted odds of adequate acute phase antidepressant treatment duration., Results: Those patients with COPD had markedly lower odds of adequate acute phase treatment duration (odds ratio = 0.67, 95% CI = 0.47 to 0.96); this was not observed with other medical diagnoses such as coronary heart disease, diabetes mellitus, or osteoarthritis., Conclusions: The first few months of treatment appears to be a critical period for depressed patients with COPD who are started on antidepressants. The causes for early antidepressant treatment inadequacy among patients with COPD require further investigation. More intensive efforts may be necessary early in the course of treatment to assure high-quality pharmacologic therapy of depressed patients with COPD.

Background: Few studies have examined the factors associated with depression in informal caregivers of HIV-infected persons., Objective: To investigate the relationship between depression and caregiver burden among informal caregivers of HIV-infected individuals., Design: Cross-sectional study using baseline data from an ongoing randomized trial of a supportive telephone intervention., Participants: One hundred seventy-six dyads of HIV patients and their informal caregiver., Measurements: Depression was defined as a Beck Depression Inventory >10. A Caregiver Strain Index >6 identified informal caregivers with a high caregiver burden. We used logistic regression to identify characteristics that were associated with depression in the informal caregiver., Results: Informal caregivers were 42 years old (SD, 13), 53% female, 59% nonwhite, and 30% had education beyond high school. Forty-seven percent of informal caregivers were the patient's partner, 18% a friend, and 35% a family member. Twenty-seven percent of informal caregivers had a high caregiver burden, and 50% were depressed. We found significantly greater odds of informal caregiver depression with high caregiver burden (OR, 6.08; 95% CI, 2.40 to 15.4), informal caregiver medical comorbidity besides HIV (OR, 2.32; 95% CI, 1.09 to 4.92), spending all day together (OR, 3.92; 95% CI, 1.59 to 9.69), having to help others besides the HIV patient (OR, 2.55; 95% CI, 1.14 to 5.74), and duration of the HIV patient's diagnosis (OR, 1.01 per month; 95% CI, 1.00 to 1.01)., Conclusions: High caregiver burden was strongly associated with depression among HIV-infected individuals' informal caregivers, who themselves had difficult life circumstances. Informal caregivers of HIV patients may be in need of both mental health services and assistance in caregiving.

Objective: Depression is common, costly, treatable, and a major influence on quality of life. Cost-utility analysis combines costs with quantity and quality of life into a metric that is meaningful for studies of interventions or care strategies and is directly comparable to measures in other such studies. The objectives of this study were to identify published cost-utility analyses of depression screening, pharmacologic treatment, nonpharmacologic therapy, and care management; to summarize the results of these studies in an accessible format; to examine the analytic methods employed; and to identify areas in the depression literature that merit cost-utility analysis., Method: The authors selected articles regarding cost-utility analysis of depression management from the Harvard Center for Risk Analysis Cost-Effectiveness Registry. Characteristics of the publications, including study methods and analysis, were examined. Cost-utility ratios for interventions were arranged in a league table., Results: Of the 539 cost-utility analyses in the registry, nine (1.7%) were of depression management. Methods for determining utilities and the source of the data varied. Markov models or cohort simulations were the most common analytic techniques. Pharmacologic interventions generally had lower costs per quality-adjusted life year than nonpharmacologic interventions. Psychotherapy alone, care management alone, and psychotherapy plus care management all had lower costs per quality-adjusted life year than usual care. Depression screening and treatment appeared to fall within the cost-utility ranges accepted for common nonpsychiatric medical conditions., Conclusions: There is a paucity of literature on cost-utility analysis of depression management. High-quality cost-utility analysis should be considered for further research in depression management.

Background: Depression has been associated with lower cancer screening rates in some studies. We examined whether a higher depressive symptom burden presented a barrier to subsequent mammography and Papanicolaou (Pap) smear testing., Methods: Study of Women's Health Across the Nation (SWAN) is a cohort study of 3302 community-dwelling women. At baseline, participants were 42-52 years old, had no surgical removal of the uterus or both ovaries, no current use of hormones that affect the ovaries, and at least one menses in the previous 3 months. SWAN data spanned 4 years. Repeated measures logistic models determined odds of mammography and of Pap screening in the year following depressive symptom burden, as determined by Center for Epidemiological Studies Depression score (CES-D). The models controlled for age, race/ethnicity, health insurance, medical history and use, smoking, obesity, and socioeconomic status., Results: At baseline, 75.6% (2493 of 3297) had a low depressive symptom burden (CES-D score < 16, referent), 9.5% (312 of 3297) had a moderate burden (CES-D 16-20), and 14.9% (492/3297) had a high burden (CES-D > or = 21). Women with a high depressive symptom burden had, in the subsequent year, significantly lower odds of mammography (OR 0.84, 95% CI 0.73-0.97) but not Pap smear (OR 0.88, 95% CI 0.76-1.03). There was not a significant dose-response relationship between depressive symptom burden and screening., Conclusions: The presence of a high depressive symptom burden is a modest independent risk factor for lack of subsequent mammography. Ensuring that depressed patients receive regular cancer screening services is important.

Background: During the decade from 1991 to 2000, the standard of care for diabetes mellitus evolved to require more intensive management of glycemia, blood pressure, and cholesterol levels., Methods: To assess changes in the complexity of outpatient management of diabetes, we used nationally representative data from the National Ambulatory Medical Care Survey. For 4708 primary care visits by patients with diabetes from 1991 to 2000, we characterized trends in the number of prescribed medicines, management of hyperglycemia, hypertension, and hyperlipidemia, provision of diabetes-related ambulatory services, and visit length., Results: From 1991 to 2000, the annual proportion of primary care visits listing at least 5 prescription medicines increased from 18.2% to 29.9% (P<.001). We found increases in visits listing oral medications for control of glucose levels (37.2% to 50.5%; P<.001), antihypertensive agents (35.9% to 42.3%; P<.001), and medications for lowering of lipid levels (4.1% to 17.3%; P<.001), whereas visits listing insulin treatment decreased from 25.3% in 1991 to 15.3% in 2000 (P<.001). Provision of diabetes-related ambulatory services remained stable (blood pressure measurement, cholesterol level testing, and dietary and smoking cessation counseling) or increased (exercise counseling; P =.01). The proportion of visits longer than 20 minutes increased from 17.8% in 1991 to 20.9% in 2000 (P =.02 for trend)., Conclusions: Office-based management of diabetes has changed significantly during the study decade. We found a marked increase in medical regimen complexity, a modest increase in visit length, and stable or increased provision of diabetes-related screening and counseling services. The increasing complexity of medical care combined with limited time during clinic visits may represent a barrier to achieving evidence-based goals of diabetes care.

BACKGROUND: The introduction of selective serotonin reuptake inhibitors (SSRIs) represented a breakthrough in depression treatment due to their safety and ease of use. The purpose of this study was to extend previous work on trends in antidepressant use to include recent data and to provide more detailed analysis of prescribing trends for SSRIs and newer non-SSRI antidepressants, specifically in adult primary care practice. METHOD: Adult primary care visits from the National Ambulatory Medical Care Survey (NAMCS) between 1989 and 2000 were analyzed. Chi-square tests for trend and multivariable logistic regression models were utilized to examine patterns of antidepressant use over time. SSRIs (citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) and newer non-SSRI antidepressants (bupropion, mirtazapine, nefazodone, venlafaxine) were classified as newer agents. RESULTS: 89,424 adult primary care visits were recorded in the NAMCS during the period studied. Antidepressant use increased in primary care from 2.6% ( approximately 6 million visits) in 1989 to 7.1% ( approximately 20.5 million) in 2000 (p <.001). SSRI and newer non-SSRI use increased linearly from 1989 to 2000 (p <.001), with an adjusted odds ratio for use of 1.27 per year (95% confidence interval = 1.25 to 1.29). The increase in antidepressant use was due to these newer agents (13.5% of all antidepressant use in 1989 to 82.3% in 2000) with each new agent adding to a stable base of previously introduced newer antidepressant agents. CONCLUSIONS: The prevalence of antidepressant use in adult primary care has risen dramatically since 1989, largely reflecting use of newer agents. The detailed pattern of increased use of these medications is striking, with each new agent adding to aggregate use without concomitant decrease in previously introduced newer agents. Such trends reflect more widespread pharmacologic treatment of depressed primary care patients.

Purpose: Coronary artery bypass graft (CABG) surgery generally decreases symptoms and improves quality of life, but for those patients without angina, prolongation of life takes precedence. We used the SF-36 to assess changes in health-related quality of life (HRQOL) among patients who were angina free prior to CABG compared to those reporting angina., Methods: We combined data from two randomized trials of hemodynamic management during surgery. Prior to CABG, demographic, clinical and SF-36 data were obtained. Patients were reevaluated at a 6-month follow-up. Patients with a decline of > or =15 points from baseline to follow-up for individual SF-36 domains and >5 points for summary components were classified as having a decline. We used logistic regression models that controlled for baseline SF-36 score and other baseline characteristics to assess HRQOL decline with respect to angina status., Results: Of 590 patients, 28% were angina free at baseline. A third of the patients angina free at baseline had a postoperative decline in physical function. Patients who were angina free at baseline were three times more likely to suffer a decline in physical function than those with angina (odds ratio 3.29, 95% confidence interval 1.86-5.82). This finding remained after addition of adverse outcomes to the model. Baseline angina status was not related to any other SF-36 domain or to physical or mental summary component scores. Major adverse outcomes did not differ between angina-free patients and those with angina., Conclusions: The incidence of patients reporting a decline in physical function after CABG was greater in patients without angina preoperatively, even when adjusting for baseline score. Given the substantial risk of decreased physical functioning, employing interventions to maintain HRQOL in this population should be considered., (Copyright 2003 S. Karger AG, Basel)

The authors evaluated the impact of an increase in depressive symptoms at 6 months after elective coronary artery bypass graft surgery on long-term cardiac morbidity and mortality between 6 and 36 months postoperatively. Patients who had low scores for depressive symptomatology pre-operatively and who completed follow-up at 6 months were contacted again 36 months after surgery to assess cardiac and neurologic morbidity and mortality. At 36 months after surgery, an interval history was completed, and baseline questionnaires were readministered. Follow-up was obtained on 123/124 patients (99%). The rate of combined new cardiac morbidity/mortality between 6 and 36 months was 13.6% among those with newly increased depressive symptoms at 6 months vs. 3.0% in the patients without new depressive symptoms at 6 months. Only an increase in depressive symptoms at 6 months was related to the occurrence of subsequent cardiac complications between 6 and 36 months. In this small sample of patients, increased depressive symptoms at 6 months after surgery appear to be associated with the occurrence of subsequent major cardiac morbidity/ mortality.

Depression is commonly reported in coronary artery bypass graft (CABG) surgery patients. This study assesses the relationship of preoperative characteristics, life stressors, social support, major cardiac and neurologic outcomes and other complications to depressive symptomatology. Demographic and clinical data, CES-D score and information on life stressors and social support were collected from 237 patients; 92% completed 6-month follow-up. CES-D score > or = 16 was defined as significant depressive symptomatology. Significant depressive symptomatology was found in 43% of patients preoperatively and 23% postoperatively. In multivariate models, low social support (p = 0.008), presence of at least one life stressor within a year of surgery (p = 0.006), moderate to severe dyspnea (p = 0.003), little to no available help (p = 0.05) and less education (p = 0.05) were associated with higher preoperative CES-D score, while longer intensive care unit (ICU) stay (p = 0.0001) and little or no available help (p = 0.0008) predicted higher postoperative CES-D scores when controlling for preoperative CES-D scores. Neither pre- nor postoperative depressive symptomatology was related to major outcomes or other complications. A high rate of significant depressive symptomatology exists in CABG patients preoperatively, and it decreases significantly postoperatively. Patients with the above preoperative characteristics as well as those who stay in the ICU postoperatively for more than 2 days might benefit from psychosocial interventions.

A recent randomized trial of higher versus lower mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) showed that higher MAP on CPB was associated with a lower incidence of overall cardiac and neurologic morbidity and mortality in coronary artery bypass graft surgery (CABG) patients. Cardiopulmonary bypass MAP was controlled pharmacologically while CPB flow was held constant for any given period. The objective of the present study was to assess the efficacy and safety of this pharmacologic protocol. Two hundred forty-eight patients participated in the study; the mean age was 65.8 +/- 9.4 years, 20% were women, and the mean preoperative ejection fraction was 48%. The low-flow corrected CPB MAP attained for the low and high MAP groups was 56.7 +/- 5.0 mmHg and 77.7 +/- 7.1 mmHg, respectively (p = 0.0001). Major cardiac and neurologic outcomes, postoperative blood loss, renal dysfunction, intensive care unit (ICU) stay, and duration of intubation were not found to be significantly associated with any drug in the pharmacologic protocol. These findings support that the pharmacologic protocol used to maintain CABG patients at higher MAP on CPB is both efficacious and safe.

Objective: To investigate variability between hand-written and computerized anesthesia records and evaluate any associated bias., Design and Measurements: A computer system that was used to collect intraoperative data for a study of hemodynamic management during coronary artery bypass graft surgery is described. The system collected and recorded hemodynamic data automatically downloaded from the anesthesia monitor as well as surgical events and drug administration data entered through menu options. The system then combined, summarized, and graphed the data as well as formatted it for export to a commercially available database program. In a sample of 14 patients, blood pressure data collected by the computer system was compared with the blood pressure data charted in the hand-written anesthesia record., Main Results: Although general linear models controlling for within-patient variation and randomization assignment for mean arterial pressure range on cardiopulmonary bypass showed a significant relationship; low R2 values indicated that much of the variability could not be explained and that there was, therefore, poor agreement between the two records. Furthermore, a systematic bias in the hand-written anesthesia record was found when the computer system record was compared with the hand-written record and to the difference of the two records, so that extremes seen in the computer system record tended to be minimized in the hand-written anesthesia record., Conclusions: Because of the lack of explained variability between the computer system and hand-written anesthesia records and the bias in the hand-written anesthesia record, the hand-written anesthesia record should not be relied on as a source of accurate data for research purposes.

Background: The objective of this randomized clinical trial of elective coronary artery bypass grafting was to investigate whether intraoperative mean arterial pressure below autoregulatory limits of the coronary and cerebral circulations was a principal determinant of postoperative complications. The trial compared the impact of two strategies of hemodynamic management during cardiopulmonary bypass on outcome. Patients were randomized to a low mean arterial pressure of 50 to 60 mm Hg or a high mean arterial pressure of 80 to 100 mm Hg during cardiopulmonary bypass., Methods: A total of 248 patients undergoing primary, nonemergency coronary bypass were randomized to either low (n = 124) or high (n = 124) mean arterial pressure during cardiopulmonary bypass. The impact of the mean arterial pressure strategies on the following outcomes was assessed: mortality, cardiac morbidity, neurologic morbidity, cognitive deterioration, and changes in quality of life. All patients were observed prospectively to 6 months after the operation., Results: The overall incidence of combined cardiac and neurologic complications was significantly lower in the high pressure group at 4.8% than in the low pressure group at 12.9% (p = 0.026). For each of the individual outcomes, the trend favored the high pressure group. At 6 months after coronary bypass for the high and low pressure groups, respectively, total mortality rate was 1.6% versus 4.0%, stroke rate 2.4% versus 7.2%, and cardiac complication rate 2.4% versus 4.8%. Cognitive and functional status outcomes did not differ between the groups., Conclusion: Higher mean arterial pressures during cardiopulmonary bypass can be achieved in a technically safe manner and effectively improve outcomes after coronary bypass.