Biomedical subjects

J Unützer

Publications and source records attributed to J Unützer.

42 records · Page 3Linked to original sources

PubMedDate not supplied

Effectiveness research and implications for study design: sample size and statistical power.

Most clinical trials have started to incorporate more broadly defined outcome measures, such as health-related quality of life, to complement clinical status measures as well as direct costs and cost-effectiveness analyses. Contrasting a broad range of outcome and cost measures, we analyze the implications for sample sizes and study design using data from prior mental health and primary care studies that span a wide range of practice settings, patient populations, and geographic areas. While meaningful clinical symptomatic differences are often detectable with sample sizes of well under 100 per cell, detecting even large changes in health-related quality of life generally requires several hundred observations per cell. Reasonable precision in cost estimates usually requires sample sizes in the thousands. Very few clinical trials or observational effectiveness studies that incorporate quality of life or cost measures have such sample sizes, resulting in many (unreported) null findings and, due to publication biases favoring significant results, scientific publications that exaggerate true effects. It raises issues for the general direction of clinical trials and effectiveness studies, as well as for how cost and health-related quality of life results based on small studies should be dealt with in publications.

Clinical Trials as Topic↗

PubMedDate not supplied

The use of administrative data to assess quality of care for bipolar disorder in a large staff model HMO.

We examined patterns of care for 1246 adults treated for bipolar disorder in a large health maintenance organization. Computerized pharmacy and visit data were used to identify patients treated for bipolar disorder. Automated medical records for the following year were used to assess continuity and dosing of treatment with mood stabilizers, laboratory monitoring for adverse effects and therapeutic serum levels, and frequency of follow-up visits. Of our 1246 subjects 83% filled a mood stabilizer prescription during the 1-year study period, and doses were within recommended ranges 80% of the time. Over 75% of the patients on mood stabilizers had at least one apparent interruption in medication use. Approximately half of the long-term users of mood stabilizers had at least one 7-month period without a recorded blood level and approximately half had a similar period without monitoring for adverse medication effects. Of the 116 subjects discharged from a psychiatric hospitalization 58% had a visit with a psychiatrist or a psychiatric nurse practitioner within 30 days. Of those discontinuing mood stabilizer treatment 68% made a mental health visit within 90 days. Our findings demonstrate the feasibility of using administrative data systems for population-based quality of care assessment and suggest opportunities for improving the care of bipolar patients.

Adolescent↗

PubMedDate not supplied

Evidence-based care for depression in managed primary care practices.

This paper evaluates whether externally designed, evidence-based interventions for improving care for depression can be locally implemented in managed care organizations. The interventions were carried out as part of a randomized trial involving forty-six practices within six diverse, nonacademic managed care plans. Based on evaluation of adherence to the intervention protocol, we determined that local practice leaders are able to implement predesigned interventions for improving depression care. Adherence rates for most key intervention activities were above 70 percent, and many were near 100 percent. Three intervention activities fell short of the goal of 70 percent implementation and should be targets for future improvement.

Depressive Disorder↗

PubMedDate not supplied

Understanding and caring for the distressed patient with multiple medically unexplained symptoms.

BACKGROUND: Although physicians commonly encounter patients with complicated medical problems, some have a mix of unexplained medical symptoms and distress that can seem overwhelming to patient and physician alike. METHODS: We describe a model for thinking about and helping these complex patients. The model was developed from our personal clinical experience as primary care psychiatric consultants, as well as from a review of the literature using such key words as "difficult," "frustrating," and "somatization." RESULTS: The model involves understanding predisposing factors that render the patient vulnerable to the development of a disabling condition, precipitating factors that initiate an episode of illness, and perpetuating factors that maintain maladaptive illness behaviors with time. CONCLUSIONS: Awareness of these factors allows the clinician not only to tolerate and gradually unravel the complicated interactions that create and sustain distress in patients with multiple medically unexplained symptoms, but also devise practical and effective management strategies for these complex patients.

Adult↗

PubMedDate not supplied

Detection and treatment of depressive syndromes in a rural island clinic.

BACKGROUND: Major depression is a serious and often persistent problem for 5 to 10 percent of patients in primary care. The detection and treatment of depression can be a particular challenge in rural settings. This study describes patterns of care for depression at a rural primary care clinic on an island off the coast of Washington State. METHODS: For a period of 2 months, 226 primary care patients were evaluated for depression using a two-stage screening method. Structured chart abstraction was conducted for patients meeting criteria for major depression or dysthymia. RESULTS: Ten percent of the study sample met Diagnostic and Statistical Manual of Medical Disorders, fourth edition, criteria for major depression, 4 percent met criteria for dysthymia, and 8 percent met criteria for major depression and dysthymia. Of the patients who had a diagnosis of major depression or dysthymia by the PRIME-MD, approximately 50 percent had their condition detected by their primary care provider, and approximately 50 percent received guideline level antidepressant treatment. Less than 40 percent of patients whose depression was treated with antidepressants made more than two visits during the 8 weeks after the initial prescription. CONCLUSIONS: These findings are consistent with those from other primary care settings and suggest that there are many opportunities for improving the quality of care for depressed patients in rural primary care settings.

Adult↗

PubMedDate not supplied

State legislation and the use of complementary and alternative medicine.

There are increasing attempts at the federal and state levels to change regulations for complementary and alternative medicine (CAM). We use data from a new survey of about 10,000 individuals to examine CAM use and insurance coverage and their relationship to state regulations. We find that insurance mandates to cover CAM providers are significantly associated with increased coverage of CAM, but not with increased use of CAM providers. Liberalization of physician licensure to practice CAM is associated with significantly increased CAM use, as are practice laws authorizing nonphysician CAM providers. In states with multiple CAM practice laws, insurance coverage for CAM visits among users is significantly lower than in states without CAM practice laws.

Adult↗