Veterans Are Agreeable to Discussions About Firearms Safety in Primary Care.

BACKGROUND: Discussing safe storage of firearms, including access, during times of crisis with veterans in primary care settings may enhance suicide prevention efforts. However, veteran attitudes toward such discussions are not well understood. The goal of this study is to understand the perspectives of veterans on discussing firearms storage safety with staff during primary care visits. METHODS: Individual semistructured interviews with veterans were conducted by telephone, qualitatively coded, and analyzed for themes. The sample was composed of veterans (n = 27) who had positive depression or post-traumatic stress disorder screens and who received care from Veterans Health Administration primary care team members trained to discuss firearms storage safety with patients. RESULTS: Citing the urgent need to prevent veteran suicide, most veterans felt discussing firearms safety was acceptable and needed, even if discussions felt uncomfortable or they had concerns. Veterans identified the need for providers to be transparent in their purposes for asking about firearms and to respect veterans' unique relationships with firearms. DISCUSSION: Conducting firearms safety discussions in a primary care setting with veterans who are at elevated risk for suicide is acceptable to veterans when a respectful, veteran-centered, and transparent approach is used.

Tolerance for Uncertainty and Professional Development: a Normative Analysis.

Scholars from a range of disciplines including medicine, sociology, psychology, and philosophy have addressed the concepts of ambiguity and uncertainty in medical practice and training. Most of this scholarship has been descriptive, focusing on defining and measuring ambiguity and uncertainty tolerance or tracking clinicians' responses to ambiguous and uncertain situations. Meanwhile, scholars have neglected some fundamental normative questions: Is tolerance of uncertainty good; if so, to what extent? Using a philosophical approach to these questions, we show that neither tolerance nor intolerance of uncertainty is necessarily a good or bad trait. Rather, both tolerance and intolerance of uncertainty can give physicians advantages while at the same time exposing them to pitfalls in clinical practice. After making this case, we argue that cultivating certain virtues-like courage, diligence, and curiosity-could help clinicians avoid the dangers of excessive tolerance and intolerance of uncertainty. Finally, we suggest that medical educators develop curricula and career counseling beginning with matriculation and proceeding through specialty choice and residency training that explicitly address trainees' responses to clinical uncertainty. These programs should encourage trainees, students and residents, to be mindful of their reactions to uncertainty and help them develop virtues that will allow them to avoid the hazards of extreme tolerance or intolerance of uncertainty.

Primary care clinician adherence to guidelines for the management of chronic musculoskeletal pain: results from the study of the effectiveness of a collaborative approach to pain.

OBJECTIVE: We assessed primary care clinician-provided guideline-concordant care as documented in patients' medical records, predictors of documented guideline-concordant care, and its association with pain-related functioning. Patients were participants in a randomized trial of collaborative care for chronic musculoskeletal pain. The intervention featured patient and primary care clinician education, symptom monitoring and feedback to clinicians by the intervention team. METHODS: To assess concordance with the evidence-based treatment guidelines upon which our intervention was based, we developed an 8-item chart review tool, the Pain Process Checklist (PPC). We then reviewed electronic medical records for 365 veteran patients treated by 42 primary care clinicians over 12 months. Intervention status, demographic, and clinical variables were tested as predictors of PPC scores using generalized estimating equations (GEE). GEE was also used to test whether PPC scores predicted treatment response (≥30% decrease in Roland-Morris Disability Questionnaire score). RESULTS: Rates of documented guideline-concordant care varied widely among PPC items, from 94% of patients having pain addressed to 17% of patients on opioids having side effects addressed. Intervention status was unrelated to item scores, and PPC-7 totals did not differ significantly between intervention and treatment-as-usual patients (61.2%, standard error [SE] = 3.3% vs 55.2%, SE = 2.6%, P = 0.15). In a multivariate model, higher PPC-7 scores were associated with receiving a prescription for opioids (odds ratio [OR] = 1.07, P = 0.007) and lower PPC-7 scores with patient age (10-year difference OR = 0.97, P = 0.004). Finally, intervention patients who received quantitative pain and depression assessments were less likely to respond to treatment (assessed vs not: 18% vs 33%, P = 0.008, and 13% vs 28%, P = 0.001, respectively). CONCLUSIONS: As measured by medical record review, additional training and clinician feedback did not increase provision of documented guideline-concordant pain care, and adherence to guidelines by primary care clinicians did not improve clinical outcomes for patients with chronic musculoskeletal pain.

VA healthcare costs of a collaborative intervention for chronic pain in primary care.

BACKGROUND: Chronic pain is costly to individuals and the healthcare system, and is often undertreated. Collaborative care models show promise for improving treatment of patients with chronic pain. The objectives of this article are to report the incremental benefit and incremental health services costs of a collaborative intervention for chronic pain from a veterans affairs (VA) healthcare perspective. METHODS: Data on VA treatment costs incurred by participants were obtained from the VA's Decision Support System for all utilization except certain intervention activities which were tracked in a separate database. Outcome data were from a cluster-randomized trial of a collaborative intervention for chronic pain among 401 primary care patients at a VA medical center. Intervention group participants received assessments and care management; stepped-care components were offered to patients requiring more specialized care. The main outcome measure was pain disability-free days (PDFDs), calculated from Roland-Morris Disability Questionnaire scores. RESULTS: Participants in the intervention group experienced an average of 16 additional PDFDs over the 12-month follow-up window as compared with usual care participants; this came at an adjusted incremental cost of $364 per PDFD for a typical participant. Important predictors of costs were baseline medical comorbidities, depression severity, and prior year's treatment costs. CONCLUSIONS: This collaborative intervention resulted in more pain disability-free days and was more expensive than usual care. Further research is necessary to identify if the intervention is more cost-effective for some patient subgroups and to learn whether pain improvements and higher costs persist after the intervention has ended.

Collaborative care for chronic pain in primary care: a cluster randomized trial.

CONTEXT: Chronic pain is common in primary care patients and is associated with distress, disability, and increased health care use. OBJECTIVE: To assess whether a collaborative intervention can improve chronic pain-related outcomes, including comorbid depression severity, in a Department of Veterans Affairs primary care setting. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized controlled trial of a collaborative care assistance with pain treatment intervention vs treatment as usual at 5 primary care clinics of 1 Department of Veterans Affairs Medical Center. Forty-two primary care clinicians were randomized to the assistance with pain treatment intervention group or the treatment as usual group. The 401 patients had musculoskeletal pain diagnoses, moderate or greater pain intensity, and disability lasting 12 weeks or longer and were assigned to the same treatment groups as their clinicians. Recruitment occurred from January 2006 to January 2007 and follow-up concluded in January 2008. INTERVENTION: Assistance with pain treatment included a 2-session clinician education program, patient assessment, education and activation, symptom monitoring, feedback and recommendations to clinicians, and facilitation of specialty care. MAIN OUTCOME MEASURES: Changes over 12 months in pain-related disability (Roland-Morris Disability Questionnaire, range of 0-24), pain intensity (Chronic Pain Grade [CPG] Pain Intensity subscale, range of 0-100), and depression (Patient Health Questionnaire 9 [PHQ-9], range of 0-27), measured as beta coefficients (difference in slopes in points per month). RESULTS: Intervention patients had a mean (SD) of 10.6 (4.5) contacts with the assistance with pain treatment team. Compared with the patients receiving treatment as usual, intervention patients showed greater improvements in pain-related disability (Roland-Morris Disability Questionnaire beta, -0.101 [95% confidence interval {CI}, -0.163 to -0.040]; P = .004 and CPG Pain Intensity subscale beta, -0.270 [95% CI, -0.480 to -0.061]; P = .01). Among patients with baseline depression (PHQ-9 score > or = 10), there was greater improvement in depression severity in patients receiving the intervention compared with patients receiving treatment as usual (PHQ-9 beta, -0.177 [95% CI, -0.295 to -0.060]; P = .003). The differences in scores between baseline and 12 months for the assistance with pain treatment intervention group and the treatment as usual group, respectively, were -1.4 vs -0.2 for the Roland-Morris Disability Questionnaire, -4.7 vs -0.6 for the CPG Pain Intensity subscale, and -3.7 vs -1.2 for PHQ-9. CONCLUSION: The assistance with pain treatment collaborative intervention resulted in modest but statistically significant improvement in a variety of outcome measures. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00129480.

Veterans affairs primary care clinicians' attitudes toward chronic pain and correlates of opioid prescribing rates.

OBJECTIVES: The primary objective of this study was to identify veterans affairs (VA) primary care clinicians' attitudes regarding chronic pain treatment. A secondary objective was to explore relationships between clinician and practice characteristics and an objective measure of opioid prescribing rates. DESIGN: Cross-sectional study of clinician survey and pharmacy data. PARTICIPANTS: Forty-five VA clinicians from five primary care clinics of one VA medical center. MEASURES: Survey of pain-related attitudes and behaviors, satisfaction with treatment resources, and job satisfaction; percentage of patients in clinicians' panels prescribed opioids (PCPO). RESULTS: Seventy-one percent of clinicians felt moderately or strongly confident in their ability to treat chronic pain, and 77% moderately or strongly agreed that skilled pain management is a high priority. However, 73% moderately or strongly agreed that patients with chronic pain are a major source of frustration and 38% reported moderate or greater dissatisfaction with their ability to provide optimal pain treatment. Fifty-two percent moderately or strongly agreed that their management is influenced by previous experiences with patients addicted to drugs. The mean PCPO was 16.5% (SD = 6.7). In bivariate comparisons, clinician panel size, job and resource satisfaction, and professional training were associated with opioid prescribing rates. CONCLUSION: High clinician confidence and interest in treating chronic pain concurrent with low satisfaction with ability to provide optimal treatment suggests a need for more system support. VA primary care clinicians are frequently influenced by fears of contributing to dependence or addiction. The relationships among panel size, job satisfaction, and opioid prescribing rates merit additional investigation.

Proposed standards for medical education submissions to the Journal of General Internal Medicine.

To help authors design rigorous studies and prepare clear and informative manuscripts, improve the transparency of editorial decisions, and raise the bar on educational scholarship, the Deputy Editors of the Journal of General Internal Medicine articulate standards for medical education submissions to the Journal. General standards include: (1) quality questions, (2) quality methods to match the questions, (3) insightful interpretation of findings, (4) transparent, unbiased reporting, and (5) attention to human subjects' protection and ethical research conduct. Additional standards for specific study types are described. We hope these proposed standards will generate discussion that will foster their continued evolution.

Rationale, design, and baseline findings from a randomized trial of collaborative care for chronic musculoskeletal pain in primary care.

OBJECTIVE: This article describes the rationale, design, and baseline findings from an ongoing study of collaborative care for chronic musculoskeletal pain and comorbid depression. DESIGN: Cluster randomized clinical trial. PARTICIPANTS AND SETTING: Forty-two clinicians and 401 patients from five Veterans Affairs primary care clinics. INTERVENTION: The intervention was based on the chronic care model, and included patient and provider activation and education, patient assessment, outcomes monitoring, and feedback to providers over 12 months. The intervention team consisted of a full-time psychologist care manager and a part-time physician internist. Approaches included goal setting emphasizing function, patient activation and educating about fear avoidance, and care management. OUTCOME MEASURES: Main outcomes are Roland-Morris Disability Questionnaire (RMDQ) score, depression severity (Patient Health Questionnaire-9), and pain severity (Chronic Pain Grade Severity subscale) at 6 and 12 months. BASELINE RESULTS: Fifteen percent of primary care patients mailed a study advertisement letter requested screening for the study. The mean age of enrolled patients was 62. Back and neck or joint pain diagnoses were present in 67% and 65% of patients, respectively. Mean pain duration was 15 years, and mean RMDQ score (range 0-24) was 14.7 (standard deviation = 4.4). Sixty-five percent of patients were receiving disability. Eighteen percent of patients met criteria for major depression, 17% for posttraumatic stress disorder, and 9% for alcohol misuse. Thirty-nine percent of patients felt strongly that experiencing pain was a sign of damage, and 60% reported strong avoidance of painful activities. CONCLUSIONS: These baseline data support the rationale to develop a multifaceted approach to treat chronic pain in primary care that includes detection and treatment of psychiatric comorbidity.

Depression treatment preferences of VA primary care patients.

The authors identified veterans' depression treatment preferences and explored relationships between preferences, process of care, and clinical outcomes. Patients entering a collaborative depression intervention trial in primary care completed an assessment of treatment preferences. Medical record review was used to identify treatments offered and received over a 12-month period. Of 314 patients, 32% preferred antidepressants; 19%, individual counseling; 18%, anti-depressants plus counseling; 7%, group counseling; and 25%, "watchful waiting." Although the treatment that was offered was associated with treatment preferences, being offered preferred treatment was not associated with receiving treatment or with changes in depression severity or satisfaction over time.

Screening for posttraumatic stress disorder in VA primary care patients with depression symptoms.

BACKGROUND: Unrecognized posttraumatic stress disorder (PTSD) is common and may be an important factor in treatment-resistant depression. Brief screens for PTSD have not been evaluated for patients with depression. OBJECTIVE: The objective was to evaluate a 4-item screen for PTSD in patients with depression. DESIGN: Baseline data from a depression study were used to evaluate sensitivity, specificity, and likelihood ratios (LRs) using the PTSD checklist (PCL-17) as the reference standard. SUBJECTS: Subjects are 398 depressed patients seen in Veterans Affairs (VA) primary care clinics. MEASURES: The Patient Health Questionnaire (PHQ) for depression, PCL-17, and 4-item screen for PTSD were used. RESULTS: Patients had a mean PHQ score of 14.8 (SD 3.7). Using a conservative PCL-17 cut point "(>50)", the prevalence of PTSD was 37%. PCL-17 scores were strongly associated with PHQ scores (r = 0.59, P < 0.001). Among the 342 (86%) patients endorsing trauma, a score of 0 on the remaining 3 symptom items had a LR = 0.21, score of 1 a LR = .62, score of 2 a LR = 1.36, and score of 3 a LR = 4.38. CONCLUSIONS: Most depressed VA primary care patients report a history of trauma, and one third may have comorbid PTSD. Our 4-item screen has useful LRs for scores of 0 and 3. Modifying item rating options may improve screening characteristics.

Primary care provider preferences for working with a collaborative support team.

BACKGROUND: Clinical interventions based on collaborative models require effective communication between primary care providers (PCPs) and collaborative support teams. Despite growing interest in collaborative care, we have identified no published studies describing how PCPs prefer to communicate and interact with collaborative support teams. This manuscript examines the communication and interaction preferences of PCPs participating in an ongoing randomized clinical trial of a collaborative intervention for chronic pain and depression. METHODS: The trial is being conducted in five primary care clinics of a Veterans Affairs Medical Center. Twenty-one PCPs randomized to the study intervention completed a survey regarding preferences for interacting with the collaborative support team. RESULTS: A majority of PCPs identified email (95%) and telephone calls (68%) as preferred modes for communicating with members of the support team. In contrast, only 29% identified in-person communications as preferred. Most PCPs preferred that the care manager and physician pain specialist assess patients (76%) and make initial treatment changes (71%) without first conferring with the PCP. One-half wanted to be designated cosigners of all support team notes in the electronic medical record, one-half wanted to receive brief and focused information rather than in-depth information about their patients, and one-half wanted their practice nurses automatically included in communications. Panel size was strongly associated (p < 0.001) with preference for brief, to-the-point discussions about patients. CONCLUSION: The substantial variation in PCP communication preferences suggests the need for knowledge of these preferences when designing and implementing collaborative interventions. Additional research is needed to understand relationships between clinician and practice characteristics and interaction preferences.

Reactions to uncertainty and the accuracy of diagnostic mammography.

BACKGROUND: Reactions to uncertainty in clinical medicine can affect decision making. OBJECTIVE: To assess the extent to which radiologists' reactions to uncertainty influence diagnostic mammography interpretation. DESIGN: Cross-sectional responses to a mailed survey assessed reactions to uncertainty using a well-validated instrument. Responses were linked to radiologists' diagnostic mammography interpretive performance obtained from three regional mammography registries. PARTICIPANTS: One hundred thirty-two radiologists from New Hampshire, Colorado, and Washington. MEASUREMENT: Mean scores and either standard errors or confidence intervals were used to assess physicians' reactions to uncertainty. Multivariable logistic regression models were fit via generalized estimating equations to assess the impact of uncertainty on diagnostic mammography interpretive performance while adjusting for potential confounders. RESULTS: When examining radiologists' interpretation of additional diagnostic mammograms (those after screening mammograms that detected abnormalities), a 5-point increase in the reactions to uncertainty score was associated with a 17% higher odds of having a positive mammogram given cancer was diagnosed during follow-up (sensitivity), a 6% lower odds of a negative mammogram given no cancer (specificity), a 4% lower odds (not significant) of a cancer diagnosis given a positive mammogram (positive predictive value [PPV]), and a 5% higher odds of having a positive mammogram (abnormal interpretation). CONCLUSION: Mammograms interpreted by radiologists who have more discomfort with uncertainty have higher likelihood of being recalled.

Depression decision support in primary care: a cluster randomized trial.

BACKGROUND: Intensive collaborative interventions improve depression outcomes, but the benefit of less intensive interventions is not clear. OBJECTIVE: To determine whether decision support improves outcomes for patients with depression. DESIGN: Clinician-level, cluster randomized, controlled trial. SETTING: 5 primary care clinics of 1 Veterans Affairs medical center. PARTICIPANTS: 41 primary care clinicians, and 375 patients with depression (Patient Health Questionnaire [PHQ-9] depression scores of 10 to 25 or Hopkins Symptom Checklist-20 [SCL-20] scores > or = 1.0). MEASUREMENTS: The primary outcome was change in depression score (SCL-20) at 6 and 12 months. Secondary outcomes were health-related quality-of-life (36-item Short Form for Veterans [SF-36V] score), patient satisfaction, antidepressant use, and health care utilization. INTERVENTION: Clinicians received depression education and were randomly assigned to depression decision support or usual care. The depression decision support team, which consisted of a psychiatrist and nurse, provided 1 early patient educational contact and depression monitoring with feedback to clinicians over 12 months. RESULTS: Although SCL-20 depression scores improved in both groups, the intervention had no effect compared with usual care. The difference in slopes comparing intervention and control over 12 months was 0.20 (95% CI, -0.37 to 0.78; P = 0.49), which was neither clinically nor statistically significant. Changes in SF-36V scores also did not differ between groups. At 12 months, intervention patients reported greater satisfaction (P = 0.002) and were more likely to have had at least 1 mental health specialty appointment (41.1% vs. 27.2%; P = 0.025), to have received any antidepressant (79.3% vs. 69.3%; P = 0.041), and to have received antidepressants for 90 days or more (76.2% vs. 61.6%; P = 0.008). LIMITATIONS: Usual care clinicians received depression education and had on-site mental health support, which may have mitigated intervention effectiveness. CONCLUSIONS: Decision support improved processes of care but not depression outcomes. More intensive care management or specialty treatment may be needed to improve depression outcomes.

Measuring depression and pain with home health monitors.

The objective of this pilot study was to test the feasibility of using home health monitors to administer standardized measures for depression and pain in a Veterans Affairs (VA) patient population. Five patients were recruited from a larger study of collaborative depression care, and were asked to use Viterion 100 Telehealth monitors to transmit depression (Patient Health Questionnaire-9) and pain severity (SF36-V bodily pain items) scores on a weekly basis for 24 weeks. Information was received and reviewed by a nurse care manager, who recommended treatment changes as appropriate. The care manager occasionally followed up reports of changes in symptom severity with phone calls; in one case, she called to inquire why a patient was not submitting data. Overall, four patients were able to use the monitors successfully and frequently. Patient satisfaction was high: 5 of 5 reported that they would use monitors again, and 3 of 5 preferred monitors to phone or mail for completing questionnaires. Patients expressed no concerns about privacy. The data allowed tracking of the longitudinal interrelationship between depression and pain severity. However, the monitors were limited in their ability to display questionnaire items, and the system could neither directly compute measure scores nor transfer data to patient medical records. These results suggest that with modifications, home health monitoring shows promise for monitoring symptom severity for a variety of medical and mental health conditions, for either clinical or research purposes.

Use of videoconferencing for depression research: enrollment, retention, and patient satisfaction.

The goal of this study was to describe the effects of using videoconferencing on participant enrollment, research measure administration and responses, study retention, and satisfaction. We recruited 400 patients from the Portland Veterans Affairs Primary Care Clinics for a randomized clinical trial of a care management intervention for depression. Patients recruited from distant clinic sites had the option of traveling to Portland, Oregon, for initial interviews or being interviewed using videoconferencing. Interviews included obtaining informed consent and administration of research measures. Remote participants were subsequently asked to complete a 12-item mail survey regarding the interview. There were no significant problems with the process of interviewing and obtaining informed consent by videoconferencing, as reported by patients and clinic staff. Twenty of the 31 participants interviewed by videoconferencing returned the satisfaction questionnaire. Participants indicated a high degree of satisfaction with these interviews, and expressed willingness to recommend videoconferencing to others. No differences were observed between the Patient Health Questionnaire depression scores of videoconferencing and in-person participants, and there was no significant difference in the 6-month rate of loss to follow-up in the randomized trial. Videoconferencing allows patients in rural and remote locations to participate in psychiatric research and expands sources of recruitment for research projects.

Screening for depression and suicidality in a VA primary care setting: 2 items are better than 1 item.

OBJECTIVE: To evaluate the psychometric properties of a single-item depression screen against validated scoring algorithms for the Patient Health Questionnaire (PHQ) and the utility of these algorithms in screening for depression and suicidality in a Department of Veterans Affairs (VA) primary care setting. STUDY DESIGN: Recruitment phase of a randomized trial. METHODS: A total of 1211 Portland VA patients with upcoming primary care clinic appointments were administered by telephone a single item assessing depressed mood over the past year and the PHQ. The PHQ-9 (9 items) encompasses DSM-IV criteria for major depression, the PHQ-8 (8 items) excludes the thoughts of death or suicide item, and the PHQ-2 (2 items) assesses depressed mood and anhedonia. Patients whose responses suggested potential suicidality were administered 2 additional items assessing suicidal ideation. Patients receiving mental health specialty care were excluded. RESULTS: Using the PHQ-9 algorithm for major depression as the reference standard, the VA single-item screen was specific (88%) but less sensitive (78%). A PHQ-2 score of > or =3 demonstrated similar specificity (91%) with high sensitivity (97%). For case finding, the PHQ-8 was similar to the PHQ-9. Approximately 20% of patients screened positive for moderate depression, 7% reported thoughts of death or suicide, 2% reported thoughts of harming themselves, and 1% had specific plans. CONCLUSIONS: The PHQ-2 offers brevity and better psychometric properties for depression screening than the single-item screen. The PHQ-9 item assessing thoughts of death or suicide does not improve depression case finding; however, one third of patients endorsing this item reported recent active suicidal ideation.

Radiologist uncertainty and the interpretation of screening.

OBJECTIVE: To determine radiologists' reactions to uncertainty when interpreting mammography and the extent to which radiologist uncertainty explains variability in interpretive performance. METHODS: The authors used a mailed survey to assess demographic and clinical characteristics of radiologists and reactions to uncertainty associated with practice. Responses were linked to radiologists' actual interpretive performance data obtained from 3 regionally located mammography registries. RESULTS: More than 180 radiologists were eligible to participate, and 139 consented for a response rate of 76.8%. Radiologist gender, more years interpreting, and higher volume were associated with lower uncertainty scores. Positive predictive value, recall rates, and specificity were more affected by reactions to uncertainty than sensitivity or negative predictive value; however, none of these relationships was statistically significant. CONCLUSION: Certain practice factors, such as gender and years of interpretive experience, affect uncertainty scores. Radiologists' reactions to uncertainty do not appear to affect interpretive performance.