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Biomedical subjects

K Rost

Publications and source records attributed to K Rost.

At least 37 records · Page 2Linked to original sources
PubMed1995

The process and outcomes of care for major depression in rural family practice settings.

Although primary care physicians provide the majority of care for rural residents with major depression, little is known about the quality of the care they provide. The aim of this study was to characterize the process and outcomes of care for rural patients with major depression, and to examine the relationship between the process and outcomes of care in this population. Six hundred and thirty-one patients in 21 primary care practices in small towns were screened; 47 patients (7.4% of patients screened) meeting DSM-III-R criteria for current major depression were recruited into the study, and 38 (81.0% of patients recruited) were followed an average of five months later using the Depression Outcomes Module (Rost, Smith, Burnam, & Burns, 1992). While 24 (63.1%) of the 38 depressed subjects received a prescription for one or more antidepressants between the index visit and follow-up, only 11 (28.9%) received pharmacologic treatment in concordance with the new Agency for Health Care Policy and Research (AHCPR) guidelines; 26 (68.4%) of 38 depressed patients continued to meet criteria for major depression at five months. Those who received pharmacologic treatment concordant with AHCPR guidelines showed more improvement at follow-up. The findings suggest that outcomes for major depression may be worse in rural family practice settings than in urban settings. The study also demonstrates that AHCPR guidelines define effective treatment for major depression in the study sample. The Depression Outcomes Module appears to be a reliable and valid instrument for monitoring the outcomes of care for major depression in family practice settings.

Arkansas↗
PubMed1994

The deliberate misdiagnosis of major depression in primary care.

OBJECTIVE: Because the correct diagnosis of a psychiatric condition can jeopardize reimbursement and other benefits, physicians deliberately substitute alternative diagnoses. We estimated the prevalence of alternative coding for major depression by primary care physicians and the reasons for its occurrence. DESIGN: Cross-sectional mail survey with telephone follow-up of nonresponders. SETTING: Primary care practices in communities across the nation. PARTICIPANTS: Physicians were eligible to participate if they were randomly selected from membership lists of two professional organizations of primary care clinicians. Four hundred forty-four physicians (70.0% of eligible physicians and 89.5% of eligible physicians we could locate) completed the survey by mail or telephone. MAIN OUTCOME MEASURE: Substitution of an alternative code for major depression within a 2-week period. RESULTS: Of our respondents, 50.3% (SE, +/- 2.5%) reported that they had substituted another diagnostic code during a 2-week period for one or more patients whom they recognized met the criteria for major depression in the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. Thirty-one percent of depressed patients received alternative codes. The most common reasons for these substitutions involved physician uncertainty about the diagnosis and problems with reimbursement for services if a diagnosis of major depression was coded. CONCLUSION: The practice of deliberately substituting another diagnostic code for major depression is widespread among primary care providers. Physicians who employ deliberate misdiagnosis circumvent inequitable policies for particular patients, but the impact of substitution on the health care system as a whole deserves more careful consideration.

Adult↗
PubMed1994

Physician management preferences and barriers to care for rural patients with depression.

OBJECTIVE: To describe rural primary care physicians' current preferences in treating depression and the barriers they face in providing effective care for this condition. DESIGN: Cross-sectional survey of randomly selected practicing primary care physicians registered in Arkansas. SETTING: Primary care practices in nonmetropolitan counties. PARTICIPANTS: Forty of 50 eligible physicians completed a face-to-face interview; one physician, an interview by telephone; and two physicians, an interview in questionnaire form. Total response rate was 86%. MAIN OUTCOME MEASURES: Physician preferences for and barriers to the effective management of depression. RESULTS: An estimated 44% of rural physicians consider medication alone to be the best initial approach to treating depression; 30% prefer to prescribe medication and refer patients to mental health care professionals for counseling; and 26% prefer to prescribe medication and conduct counseling themselves. The greatest barriers to treatment were the physician's lack of time and the patient's failure to recognize depression. Most physicians had recently referred one or more depressed patients to specialty care and had encountered few referral sources, long waiting lists, and inadequate follow-up. CONCLUSIONS: The majority of rural primary care physicians prefer to treat depressed patients in their practices themselves. Except for the limited availability of specialty services, most of the barriers to the provision of effective care for depression perceived by rural physicians do not appear to be unique to rural practices.

Adult↗
PubMed1994

Effectiveness of psychiatric intervention with somatization disorder patients: improved outcomes at reduced costs.

In order to determine the health effects of an intervention that reduces the cost of care for somatization disorder (SD) patients, 59 primary care physicians were randomized to receive a psychiatric consultation letter providing treatment recommendations for 73 patients either at baseline or the end of the year-long study. Seventy of these patients (96%) were followed every 4 months for 1 year by a research assistant blind to randomization. A year following the intervention, patients of experimental physicians reported greater physical capacity than patients of control physicians (mean difference = 17.9, 95% CI 1.0-34.9) with a $466 reduction (95% CI $132-$699) in health care charges. In addition to a net 21% reduction in health care charges for the typical SD patient, the consultation letter improved physical functioning in a group of highly impaired subjects.

Adult↗
PubMed1993

Development of screeners for depressive disorders and substance disorder history.

If screeners are going to be widely incorporated in clinical care to increase the detection of common psychiatric disorders, they need to be brief, easy to score, and sensitive across diverse patient populations. Few screeners exist that meet these criteria. This problem is addressed in this study by identifying a subset of questions from the Diagnostic Interview Schedule (DIS), which predicted simultaneously obtained DIS diagnoses. A two-item screener to detect depression or dysthymia within the last year and three-item screeners for lifetime drug disorders and alcohol disorders were tested in community residents, medical, and mental health patients. The sensitivity of the depression screener ranged between 83% and 94%. The sensitivity of the drug screener ranged between 91% and 94%, excluding one site with an extremely low prevalence of drug problems. The sensitivity of the alcohol screener ranged between 87% and 92%. Specificity for all three screeners exceeded 90% in community and medical samples, while being somewhat lower among mental health patients. These findings indicate that these brief screeners may be useful in a variety of epidemiologic studies to provide estimates of common psychiatric disorders when complete diagnostic interviews are not feasible. If further validation studies support these sensitivity and specificity estimates, these new instruments may also be valuable as initial brief screeners in a two-stage screening process to improve clinicians' recognition of common mental health problems that complicate case management and impair patient functioning.

Adult↗
PubMed1993

Rural-urban differences in stigma and the use of care for depressive disorders.

Stigma may be a particularly important barrier to mental health care in rural communities where lack of anonymity increases the probability that someone who seeks care will be labeled "crazy." This study examined rural-urban differences in the stigma associated with depressive symptoms and the stigma associated with seeking treatment for depressive disorders. In addition, the study compared how the stigma associated with seeking treatment predicted use of care in rural and urban residents with a history of depressive symptoms. Two hundred subjects from metropolitan and adjacent non-metropolitan counties rated one of four randomly selected vignettes using 14-point semantic differential scales. The findings indicated that rural residents with a history of depressive symptoms labeled people who sought professional help for the disorder somewhat more negatively than their urban counterparts. Logistic models controlling for sociodemographic characteristics demonstrated that the more negative the labeling, the less likely depressed rural residents were to have sought professional help. Labeling was not associated with use of care among urban people with depressive symptoms. We concluded that prospective studies are warranted to inform the development of interventions to decrease the stigma associated with seeking treatment for depressive disorders in rural communities.

Data Collection↗
PubMed1993

The introduction of the older patient's problems in the medical visit.

In this study of 100 diabetes patients 60 years old or older making return medical visits, 56% of patients reported one or more important medical problems that were never raised with their doctor. Sixty percent of patients reported important psychosocial problems that were never raised. One quarter of all patients were not able to raise even modest agendas of medical problems during the visit. These gaps in doctor-patient communication potentially reduce the effectiveness of medical care by failing to address symptoms of treatable conditions that impact functional status and quality of life.

Aged↗
PubMed1993

Clinician assessment of psychiatric comorbidity and alcoholism severity in adult alcoholic inpatients.

Although psychiatric comorbidity and alcoholism severity are risk factors for poor outcomes in treating alcoholism, little is known about whether clinicians assess these conditions accurately. In this study we evaluated four clinicians' assessments of two indicators of alcoholism severity and three psychiatric co-morbidities in 78 inpatients in their third to seventh day of hospitalization in alcohol treatment programs. Clinicians overestimated the number of days drinking in 28% of subjects, and the number of drinks per drinking day in 37% of subjects. Clinicians underestimated alcohol consumption for patients with higher incomes. Clinicians correctly diagnosed 67% of 18 subjects with antisocial personality disorder, 65% of 26 with major depression, and 89% of 28 with drug abuse. These preliminary results need to be replicated in larger samples of clinicians to determine whether interventions are needed to improve the recognition of important prognostic factors in the treatment of alcoholic patients.

Adult↗
PubMed1992

Measuring the outcomes of care for mental health problems. The case of depressive disorders.

To conduct effectiveness research in mental health, many nontrivial problems need to be addressed. A multidisciplinary expert panel designed an outcomes module for major depression and dysthymia to measure disease-specific outcomes, treatments routinely provided, and patient characteristics that influence treatment or its outcomes. The outcomes module was pilot-tested to evaluate its ability to identify a diagnostically homogeneous group of patients, to establish its reliability and validity, and to assess the feasibility of administering the module in a mental health setting. In a cohort of 40 patients, the module identified all 31 patients who had a research diagnosis of major depression or dysthymia (100% sensitivity), and 2 of 9 patients who did not have this diagnosis (77.8% specificity). The outcomes module measured key constructs accurately enough to discriminate between groups of depressed patients expected to differ, indicating positive construct validity. High rates of instrument completion supported the feasibility of using the module in specialty settings. Extensive efforts locating patients for follow-up will be needed to draw valid conclusions about treatment effectiveness.

Adult↗
PubMed1992

Family psychiatric history of patients with somatization disorder.

We estimated the prevalence of psychiatric disability and disorders (depression, mania, schizophrenia, alcohol disorder, drug disorder, antisocial personality, and somatization) in the parents, siblings, and children of three groups of index cases: primary care patients with somatization disorder (n = 70), primary care patients who approached, but did not reach, DSM-III-R criteria for somatization disorder (n = 29), and randomly-selected community residents with no psychiatric disorder (n = 1633). Nearly all psychiatric disorders were more common in relatives of both patient samples than in relatives of community residents, and the patient samples rarely differed from each other. In the patient samples, the 22.9% rate of patients with multiple unexplained medical problems is substantially higher than previous investigations of somatization would predict. The most common disorders in patients' relatives were depression and alcohol disorder. There was little difference in the rates of depression in relatives of somatization patients who were or were not themselves depressed. A similar pattern occurred for alcohol disorder. There was a high risk for antisocial personality disorder in parents of patients meeting DSM-III-R criteria for somatization disorder, but this increase was not found for other relatives.

Adult↗
PubMed1992

An analysis of panel data. The impact of a psychiatric consultation letter on the expenditures and outcomes of care for patients with somatization disorder.

In this study, the cost and health outcomes of a psychiatric consultation letter to primary care physicians caring for a sample of patients diagnosed with somatization disorder, a psychiatric condition associated with multiple, unexplained medical complaints, was assessed. To accommodate the small sample size of 73 patients, outcome effects were calculated using panel analysis. Study patients were randomized to a consultation or noconsultation group, and were repeatedly assessed at equal time intervals. Data were analyzed using parsimonious regression models derived from economic theory. During the 1-year follow-up period, a psychiatric consultation letter was associated with a 12% reduction in health care costs ($455 per patient within first year), with no evidence of deterioration in physical, mental, or general health. Less powerful t-test comparisons between treated and control groups lead to different conclusions. Reasons for these differences are discussed.

Adult↗
PubMed1992

Return to work after an initial myocardial infarction and subsequent emotional distress.

We examined how return to work predicted subsequent change in emotional distress in 143 patients who had been employed at the time of initial myocardial infarction. Ninety patients (63%) returned to work by 4 months and remained employed at 12 months. There were no differences in mental health at baseline between those who returned to work and those who did not, but emotional distress decreased significantly between 4 and 12 months only in the group who returned to work. Emotional distress declined after resuming work even when employees returned to jobs with which they reported dissatisfaction at the time of the myocardial infarction. The relationship between return to work and decreasing emotional distress remained after controlling for initial physical and psychological adjustment as well as sociodemographic and social support characteristics. The improvements in mental health associated with return to work should reassure clinicians who emphasize the emotional as well as economic value of work after an initial myocardial infarction.

Employment↗
PubMed1991

Measuring physical activity with a single question.

Using 1,004 subjects enrolled in a worksite health promotion program, this report evaluated the validity of a single question about participation in regular exercise. Measured at baseline, this one question had a significant age-adjusted association with body mass index (p less than 0.0001 in women and p = 0.001 in men), HDL cholesterol (p less than 0.0001 in women), and oxygen capacity (p = 0.0007 in women and p = 0.002 in men). Thus, one self-reported question can provide useful information about who is and who is not participating in regular exercise. The potential validity of a single exercise question is particularly relevant in complex epidemiologic studies where lengthy questionnaires highlight the importance of brief instruments.

Adult↗
PubMed1990

Capacity to remember prescription drug changes: deficits associated with diabetes. Collaborative Study Group of the Task Force on the Medical Interview.

This study compared the capacity of 44 diabetes patients and 131 non-diabetic patients to remember prescription medication recommendations made during return visits to primary care clinics. Diabetes patients were 1.6-times less likely to remember all medication recommendations immediately after the visit than non-diabetic patients, a discrepancy which remained significant after controlling for sociodemographic, health status and treatment differences between the two groups. The results suggest that the cognitive deficits that diabetes patients demonstrate in laboratory testing may be severe enough to diminish their ability to learn treatment recommendations made in primary care settings. Further research is needed to determine whether recall is problematic for diabetes patients in general, or primarily for those in poor metabolic control. Clinicians who treat diabetes patients need to incorporate readily implemented strategies to promote patient recall for substantial numbers of diabetes patients to benefit from pharmacological treatment.

Aged↗
PubMed1990

Predictors of employee involvement in a worksite health promotion program.

Although worksite health promotion programs have proliferated, little is known about the population they reach. This study of employees of a large utility company compared whether the same characteristics which predict recruitment also predict extended participation. The study also prospectively assessed how risk factors are related to employees' on-going extended participation. The findings demonstrate that sociodemographic predictors of recruitment are almost mirror images of the predictors of extended participation. Over time employees who are at higher risk for cardiovascular disease participated in on-going sessions less frequently. Data suggest that referral to targeted sessions does not result in higher rates of attendance by employees with a particular risk factor, although there is no evidence of selective avoidance. Organizational influences on participation evident from the beginning are sustained through four sessions. Programs targeting higher risk employees nested within worksite-wide programs may be useful to increase the extended participation of individuals at elevated risk for heart disease.

Adult↗
PubMed1989

Introduction of information during the initial medical visit: consequences for patient follow-through with physician recommendations for medication.

While negotiation of treatment decisions in the medical visit has long been recognized as an important interviewing skill, limited work has been done to investigate how doctors and patients negotiate what information is relevant in understanding the patient's problem. In this research we tested how the introduction of information reflecting both the patient's and physician's perspective is related to the patient's adherence to physician recommendations for medication. Introduction of information was defined as bi-directional if patients independently offered information or behavior as frequently as they provided the information or exhibited behavior that physicians requested. Thirty random samples of audiotaped dialogue were used to construct estimates of introduction of information during the history, examination, and consultation phases of initial ambulatory care visits of 45 older male patients. The data demonstrate that bi-directional introduction of information during the examination segment explains more than half of the variance in patient adherence to physician recommendations for new medication. These findings support the idea that physician willingness to allow patients to contribute input may contribute to the partnership's arrival at treatment decisions that have meaning for both.

Adult↗