Table of Contents

The Issue in Brief

Jan/Feb 2012

Treatment Adjustment and Medication Adherence for Complex Patients With Diabetes, Heart Disease, and Depression: A Randomized Controlled Trial

Elizabeth H. B. Lin, and colleagues

Background Patients with multiple chronic diseases have unfavorable health outcomes and present challenges to both patient care and medical costs. This study examines the effect of a team-based care management intervention on the initiation and adjustment of drug therapy for patients with uncontrolled diabetes and/or coronary heart disease and depression.

What This Study Found The randomized controlled trial of 214 patients with poorly controlled diabetes or coronary heart disease and coexisting depression found that patients in the intervention group (1) increased self-monitoring of key disease parameters relative to usual care patients and (2) had higher pharmacotherapy adjustment rates compared with usual care patients. At 12 months, the average rate of blood pressure monitoring was more than 3 times higher in the intervention group compared with the usual care group, and the average blood glucose monitoring rate was 4.9 days per week vs 3.8 days per week, respectively. Pharmacotherapy initiation and adjustment rates were 6 times higher for antidepressants, 3 times higher for insulin therapy, and nearly 2 times higher for antihypertensive medications among patients in the intervention group relative to usual care. There was no difference in medication adherence rates.

Implications

• Results of this trial suggest that improving specific patient and clinician behaviors (close monitoring of disease control parameters and timely treatment adjustments to achieve individualized goals) can improve disease control and quality of life among multicondition patients with complex health care needs.

Integrated Management of Type 2 Diabetes Mellitus and Depression Treatment to Improve Medication Adherence: A Randomized Controlled Trial

Hillary R. Bogner, and colleagues

Background Depression is common in patients with diabetes and contributes to poor adherence to medication and dietary regimens, physical inactivity, poor glycemic control, reduced quality of life, disability, and increased health care costs. This study tests the effectiveness of integrated care management of type 2 diabetes and depression compared with usual care services in primary care.

What This Study Found A simple, brief treatment intervention using integration care managers is successful in improving medication adherence and disease outcomes for patients with both depression and type 2 diabetes, a group known to have poor treatment adherence. The intervention integrated depression treatment with type 2 diabetes management and provided an individualized program that recognized the patients' social and cultural context to improve adherence to antidepressants and oral hypoglycemic agents. Patients receiving the integrated care intervention had higher rates of adherence to oral hypoglycemic and antidepressant agents, greater glucose control, and fewer depressive symptoms compared with usual care patients. Specifically, patients receiving the integrated care intervention were more likely to achieve glycated hemoglobin levels of less than 7% and remission of depression when compared with patients in the usual care group.

Implications

• The authors call for an integrated approach to depression and type 2 diabetes treatment.
• This intervention, which has a total contact time of 2 hours, may offer a sustainable solution that can be implemented in primary care for patients managing multiple medical comorbidities with varying degrees of complexity in pharmacotherapy regimens.

Depression Treatment in Patients With General Medical Conditions: Results From the CO-MED Trial

David W. Morris, and colleagues

Background Major depressive disorder is commonly found in patients with a wide range of general medical conditions, and it may have a major impact on patient functioning. This study looks at the effect of antidepressant treatment combinations in depressed patients with single and multiple general medical conditions.

What This Study Found Though past studies have suggested that patients with general medical conditions are less responsive to antidepressant therapy, this study of the effectiveness and side effects of 3 different antidepressant regimens on patients with multiple medical conditions found only minimal differences in treatment response between groups. Analyzing data on 665 depressed patients with none, 1, 2, or 3 or more treated medical conditions, researchers found almost no statistical difference in efficacy and tolerability. Moreover, there were no differences in outcomes between antidepressant monotherapy and antidepressant combination therapies, regardless of the number of medical conditions the patient had.

Implications

• According to the authors, these findings suggest that depressed patients with or without comorbid conditions can receive safe and effective depression treatment without the risk of adverse effects or antidepressant tolerability.
• The authors report no additional benefit for combination antidepressant therapy versus monotherapy with selective serotonin reuptake inhibitors.

Primary Care Attributes and Mortality: A National Person-Level Study

Anthony Jerant, and colleagues

Background Are attributes of primary care related to patient mortality? This study examines whether patient-reported access to the primary care attributes of comprehensiveness, patient-centeredness, and enhanced access to care is associated with lower individual mortality risk.

What This Study Found Patients who report greater access to comprehensiveness, patient-centeredness, and enhanced access to care have lower mortality, a finding which strongly supports the ongoing patient-centered medical home health care redesign efforts in the United States. Based on nationally representative data on 52,241 patients aged 18 to 90 years, patients' primary care attribute scores (which measure the degree to which patients' usual source of care have the 3 primary care attributes) were inversely associated with mortality.

Implications

• Ongoing health care and primary care practice redesign efforts in the United States may have the potential to reduce preventable deaths, according to the study's findings.
• These findings complement and expand upon those of prior studies, which found lower mortality rates in geographical areas with more primary care clinicians. By comparison, this study suggests a mortality benefit for individual patients resulting from greater access to particular primary care attributes.

Reimbursement Restriction and Moderate Decrease in Benzodiazepine Use in General Practice

Joëlle M. Hoebert, and colleagues

Background In 2009, the Netherlands began limiting reimbursement for benzodiazepines to limit misuse and reduce costs. (Benzodiazepines are widely used to treat anxiety, panic disorders and insomnia, as well as in neurologic and rheumatologic conditions.) This study aimes to assess the impact of this reimbursement restriction on benzodiazepine use in patients newly diagnosed with anxiety or sleeping disorders in general practice.

What This Study Found The policy change restricting benzodiazepine reimbursement led to a moderate decrease in the number of new diagnoses of anxiety and sleeping disorder and a reduction in benzodiazepine prescriptions among patients with newly diagnosed disorders. Analyzing data on 13,596 patients with an incident diagnosis of anxiety or sleeping disorder, researchers found a significantly lower incidence of sleeping disorder diagnoses and anxiety diagnoses after the restriction went into effect. Moreover, the proportion of patients being prescribed a benzodiazepine after a diagnosis was lower in 2009 than in 2008 for both anxiety and sleeping disorder, as was the proportion of patients with more than one benzodiazepine prescription for both anxiety and sleeping disorder. In fact, researchers note, benzodiazepines disappeared from the Netherlands' top 10 most prescribed medications and were among the top 10 medications with the steepest decrease in number of prescriptions. Notably, the authors found no increase in the use of alternative treatment for anxiety using selective serotonin reuptake inhibitors.

Implications

• A policy measure can affect drug prescribing.
• The authors conclude that physicians have room to reduce benzodiazepine prescribing.

Chlamydia trachomatis Testing Sensitivity in Midstream Compared With First-Void Urine Specimens

Derelie Mangin, and colleagues

Background First-void urine specimens are used to test for Chlamydia trachomatis, the most common sexually transmitted bacterial infection, whereas midstream urine specimens are recommended for microscopy and culture of presumptive bacterial urinary tract infections. The ability to test for both C trachomatis and urinary tract infection on a single midstream urine specimen would greatly aid primary care practice. This pilot study set out to determine how many positive results obtained on first-void specimens would be missed if a midstream specimen were used.

What This Study Found First-void and midstream urine sampling had similar diagnostic accuracy for C trachomatis testing. Of 100 patients with a first-void specimen positive for C trachomatis, 96 also had a positive midstream specimen.

Implications

• Timing of urine specimen collection may not be as important in testing for C trachomatis as previously thought. If the results of this pilot study are confirmed, midstream urine specimens may be sufficiently equivalent to testing on first-void urine specimens for use in clinical practice as a case finding tool.

Envisioning a Learning Health Care System: The Electronic Primary Care Research Network, a Case Study

Brendan C. Delaney, and colleagues

Background Highlighting both the challenges and opportunities for using existing electronic clinical data from dispersed primary care practices for large-scale clinical research, the authors examine options and evaluate a functional software prototype for facilitating research in community practice settings. The electronic Primary Care Research Network (ePRN) project was one of 12 funded by the National Institutes of Health with the aim of developing clinical research.

What This Study Found This study identifies requirements for delivering clinical studies via a distributed electronic network linked to electronic health records. The study finds that electronic health record systems must use more sophisticated tools to capture and preserve rich clinical context in coded data. The authors also identify barriers to adopting prototype software in practice-based research networks, and describe an international consortium and model for sharing further developments across ongoing projects in the United States and Europe.

Implications

• To fully realize the vision of a true learning health care system, the authors call for the creation of an open market for e-health applications. Such a system, they assert, can be achieved only through open collaboration between the various stakeholders — from clinicians to vendors — with the goal of creating a single shared architecture.

Organizing Care for Complex Patients in the Patient-Centered Medical Home

Eugene C. Rich, and colleagues

Background The Agency for Healthcare Research & Quality and Mathematica Policy Research offer a summary report of strategies to help smaller primary care practices transform into medical homes that effectively serve patients with complex needs, particularly the frail elderly and working- age adults with disabilities.

What This Study Found Drawing on case studies of 5 programs around the United States that use a variety of approaches for supporting and collaborating with smaller, independent primary care practices in caring for patients with complex needs, the summary concludes that small practices require support and resources beyond those needed to meet current medical home standards. The two most critical supports are additional practice reimbursement for time spent coordinating care and the integration of care coordinators within primary care teams. The summary includes a link to a longer policy brief published simultaneously on the AHRQ website.

Implications

• Patients with complex health care needs represent the greatest challenge to transforming small primary care practices into high-functioning medical homes. They also present a great opportunity to improve such outcomes as lower costs, higher quality, and better care experiences for patients and clinicians.

Systematic Review and Meta-Analysis of Practice Facilitation Within Primary Care Settings

N. Bruce Baskerville, and colleagues

Background Practice facilitation is a multifaceted approach in which skilled individuals help others address the challenges in implementing evidence-based care guidelines in the primary care setting. As the United States attempts to redesign medical practice, practice facilitation increasingly is used to assist with needed practice changes. This study, a systematic review of the existing literature, examines the overall effect of practice facilitation.

What This Study Found Practice facilitation has a robust effect on the adoption of evidence-based guidelines in primary care. The systematic review, which includes 23 studies representing nearly 1,400 primary care practices, finds that practices are 2.76 times more likely to adopt evidence-based guidelines with practice facilitation than without. Tailoring the intensity of the intervention to the needs of the practice and the number of practices per facilitator has an impact on the effectiveness of the facilitation.

Implications

• The authors call for large-scale collaborative, practice-based evaluation research to understand the impact of facilitation on the adoption of guidelines, the relationship between context and the components of facilitation, sustainability, and costs to the health system.

Indication

Ronald E. Pust

Background In this essay, a family physician recounts the death of a newborn following an obstructed labor in a hospital in rural Kenya. The author seeks to learn from the patient, the hospital's director, and the consultant obstetrician, while contemplating the role of evidence-based medicine, issues in cross-cultural practice, and the nature of science.