Five-Year Outcomes of a Melanoma Screening Initiative in a Large Health Care System.

Importance: Population-based skin cancer screening is currently not recommended owing to lack of data to quantify the balance of benefits and harms. Objective: To compare thickness-specific incidence of melanoma in screened vs unscreened patients following the initiation of a primary care-based skin cancer screening initiative. Design, Setting, and Participants: This observational study of a quality improvement initiative was conducted from January 1, 2014, through December 31, 2018, among patients 35 years and older presenting for a primary care visit at primary care practices within an academic and community-based health care system during the study period. Data analysis was performed January 2020 to January 2022. Interventions: Primary care clinicians were offered training in melanoma identification through skin examination and encouraged to offer annual screening to patients 35 years and older. Main Outcomes and Measures: Thickness of melanomas diagnosed in screened and unscreened patients. Results: Among 595 799 analyzed screen-eligible patients, 144 851 (24.3%) were screened at least once. Screened patients were older (median [IQR] age, 59 [49-67] vs 55 [45-66] years) and more likely to be female (82 244 [56.8%] vs 250 806 [55.6%]; P < .001) and non-Hispanic White (124 747 [86.1%] vs 375 890 [83.4%]; P < .001) than unscreened patients. After adjusting for age, sex, and race, screened patients were more likely than unscreened patients to be diagnosed with in situ (incidence, 30.4 vs 14.4; hazard ratio [HR], 2.6; 95% CI, 2.1-3.1; P < .001) or thin invasive (≤1 mm) melanoma (incidence, 24.5 vs 16.1; HR, 1.8; 95% CI, 1.5-2.2; P < .001). Screened patients were also more likely than unscreened patients to be diagnosed with in situ (incidence, 26.7 vs 12.9; HR, 2.1; 95% CI, 1.7-2.6; P < .001) or thin invasive (≤1 mm) interval melanomas (melanoma diagnosed at least 60 days after initial screening examination) (incidence, 18.5 vs 14.4; HR, 1.3; 95% CI, 1.0-1.7; P = .03). Incidence of melanoma thicker than 4 mm in unscreened and screened patients, respectively, was 3.3 and 2.7 (HR, 0.8; 95% CI, 0.4-1.4; P = .38) for all melanomas and 2.7 and 1.5 (HR, 0.6; 95% CI, 0.2-1.2; P = .15) for interval melanomas. Conclusions and Relevance: In this quality improvement study, primary care-based melanoma screening was associated with increased detection of thin melanoma, raising concern about overdiagnosis. Further studies with longer follow-up are needed to determine the influence of screening on the incidence of thick melanoma and outcomes associated with high costs and poor outcomes, such as metastasis.

Effect of a Primary Care-Based Diabetes Education Model on Provider Referrals and Patient Participation.

PURPOSE: The purpose of this study was to evaluate the impact of a primary care (PC)-based delivery model on diabetes self-management education and support (DSMES) referrals and participation. Despite evidence that DSMES is a critical component of diabetes care, referrals and participation remain low. METHODS: PC practices were assigned to the intervention (n = 6) or usual care (n = 6). Intervention practices had direct access to a diabetes educator (DE) and applied patient-centered medical home elements to DSMES delivery. Usual care practices referred patients to traditional hospital-based outpatient DSMES programs. DSMES referrals and participation were examined for patients with diabetes, 18 to 75 years old, presenting to PC over 18 months (n = 4,894) and compared between groups. RESULTS: Compared to the usual care group, a higher percentage of patients in the intervention practices were referred to DSMES (18.4% vs 13.4%; P < .0001), and of those referred, a higher percentage of patients in the intervention practices participated in DSMES (34.9% vs 26.1%; P = .02). Patient-level factors predicting referrals were obesity (odds ratio [OR] = 1.6), higher A1C (OR = 1.4), female (OR = 1.3), and younger age (OR = 0.98). The only patient-level factor that predicted DSMES participation was lower A1C (OR = 0.9). CONCLUSIONS: This study demonstrates the positive influence of a PC-based intervention on DSMES referral and participation. However, modest improvements in DSMES rates, even with targeted efforts to address reported barriers, raise questions as to what is truly needed to drive meaningful change.

Guided Digital Cognitive Behavioral Program for Anxiety in Primary Care: Propensity-Matched Controlled Trial.

BACKGROUND: Cognitive behavioral therapy (CBT) is the gold standard treatment for adult anxiety disorders but is often not readily available in a scalable manner in many clinical settings. OBJECTIVE: This study examines the feasibility, acceptability, and effectiveness of a coach-facilitated digital cognitive behavioral program for anxious adults in primary care. METHODS: In an open trial, patients who screened positive for anxiety (General Anxiety Disorder-7 [GAD7] score ≥5) were offered the digital cognitive behavioral program (active group, n=593). Primary outcomes included anxiety, quality of life (QoL), and ambulatory medical use over 6 months. Intent-to-treat (ITT) and modified intent-to-treat (mITT) analyses were completed. Subsequently, we compared the outcomes of participants with those of a matched control group receiving primary care as usual (CAU; n=316). RESULTS: More than half of the patients downloaded the cognitive behavioral mobile app program and about 60% of these were considered engaged, which was defined as completion of ≥3 techniques. The active group demonstrated medium size effects on reducing anxiety symptoms (effect size d=0.44; P<.001) and improving mental health QoL (d=0.49; P<.001) and showed significantly improved physical health QoL (d=0.39; P=.002) and a decreased likelihood of high utilization of outpatient medical care (odds ratio=0.49; P<.001). The active group did not significantly outperform the CAU group in anxiety reduction or QoL improvement (d=0.20; P=.07). However, intent-to-treat analysis showed that the active group had a significantly lower likelihood of high utilization of outpatient medical care than the enhanced CAU group (P<.0001; odds ratio=0.09). CONCLUSIONS: A coach-facilitated digital cognitive behavioral program prescribed in primary care is feasible and acceptable. Primary care patients prescribed a digital cognitive behavioral program for anxiety experienced significant improvements in anxiety symptoms, QoL, and reduced medical utilization. This effect was observed even among patients with chronic medical conditions and behavioral health comorbidities. Although the primary outcomes in the active group did not improve significantly more than the CAU group, health care utilization declined, and some secondary outcomes improved in participants who engaged in the program compared to the CAU group. TRIAL REGISTRATION: ClinicalTrials.gov NCT03186872; https://clinicaltrials.gov/ct2/show/NCT03186872.

Psychosocial consequences of skin cancer screening.

Screening for melanoma may save lives, but may also cause patient distress. One key reason that preventative visual skin examinations for skin cancer are not currently recommended is the inadequate available evidence to assess potential harm to psychosocial wellbeing. We investigated potential psychological harms and benefits of skin examinations by conducting telephone surveys in 2015 of 187 screened participants; all were ≥35 years old. Participants had their skin examined by practitioners who had completed INFORMED, a validated web-based training for detection of skin cancers, particularly melanoma. Participants underwent the Spielberger State-Trait Anxiety Inventory (STAI), Psychological Consequences of Screening (PCQ), Hospital Anxiety and Depression (HAD) scale, and the 12-Item Short Form Health Survey (SF-12). Analyses were conducted in 2017. Of the entire study sample, 40% were thoroughly screened as determined by patient-reported level of undress and skin areas examined. Participants who were thoroughly screened: did not differ on negative psychosocial measures; scored higher on measures of positive psychosocial wellbeing (PCQ); and were more motivated to conduct monthly self-examinations and seek annual clinician skin examinations, compared to other participants (p < 0.05). Importantly, thoroughly screened patients were more likely to report skin prevention practices (skin self-examinations to identify a concerning lesion, practitioner provided skin exam), recommend skin examinations to peers, and feel satisfied with their skin cancer education than less thoroughly screened individuals (p < 0.01). Our results suggest that visual screening for skin cancer does not worsen patient psychosocial wellbeing and may be associated with improved skin cancer-related practices and attitudes.

Implementation of a Guided, Digital Cognitive Behavioral Program for Anxiety in Primary Care: Preliminary Findings of Engagement and Effectiveness.

BACKGROUND: Implementation of digital behavioral health programs in primary care (PC) can improve access to care for patients in need. INTRODUCTION: This study provides preliminary data on user engagement and anxiety symptom change among patients referred by their PC provider to a guided, mobile cognitive behavioral program, Lantern. MATERIALS AND METHODS: Adults aged 20-65 years with at least mild anxiety (GAD-7 ≥ 5) during routine clinical screening in two PC practices were offered Lantern. The primary outcome was self-reported anxiety collected at baseline and 2 months. Linear mixed effects modeling was used to examine anxiety symptom reduction from baseline to 2 months. Post hoc analyses evaluated how number of units completed, number of techniques practiced, and days of usage impacted symptom change. RESULTS: Sixty-three participants signed up for Lantern and had both baseline and 2- month GAD-7. A mixed effects model adjusted for age, gender, medical complexity score, and physical health found a significant effect of time on GAD-7 (ß = -2.08, standard error = 0.77, t(62) = -2.71, p = 0.009). Post hoc analyses indicated that mean number of units, techniques, and usage days did not significantly impact GAD-7 change over 2 months. However, there was significantly greater improvement in anxiety in participants who completed at least three techniques. DISCUSSION: Results benchmark to previous studies that have found statistically significant symptom change among participants after 4-9 weeks of face-to-face or Internet-based cognitive behavioral therapy (CBT). CONCLUSIONS: This study suggests that use of Lantern is associated with anxiety reduction and provides proof-of-concept for the dissemination and implementation of guided, CBT-based mobile behavioral health interventions in PC settings.

A study protocol for a non-randomised comparison trial evaluating the feasibility and effectiveness of a mobile cognitive-behavioural programme with integrated coaching for anxious adults in primary care.

INTRODUCTION: Generalised anxiety disorder (GAD) and subclinical GAD are highly prevalent in primary care. Unmanaged anxiety worsens quality of life in patients seen in primary care practices and leads to increased medical utilisation and costs. Programmes that teach patients cognitive-behavioural therapy (CBT) techniques have been shown to improve anxiety and to prevent the evolution of anxiety symptoms to disorders, but access and engagement have hampered integration of CBT into medical settings. METHODS AND ANALYSIS: This pragmatic study takes place in University of Pittsburgh Medical Center primary care practices to evaluate a coach-supported mobile cognitive- behavioural programme (Lantern) on anxiety symptoms and quality of life. Clinics were non-randomly assigned to either enhanced treatment as usual or Lantern. All clinics provide electronic screening for anxiety and, within clinics assigned to Lantern, patients meeting a threshold level of mild anxiety (ie, >5 on Generalised Anxiety Disorder 7-Item Questionnaire (GAD-7)) are referred to Lantern. The first study phase is aimed at establishing feasibility, acceptability and effectiveness. The second phase focuses on long-term impact on psychosocial outcomes, healthcare utilisation and clinic/provider adoption/sustainable implementation using a propensity score matched parallel group study design. Primary outcomes are changes in anxiety symptoms (GAD-7) and quality of life (Short-Form Health Survey) between baseline and 6-month follow-ups, comparing control and intervention. Secondary outcomes include provider and patient satisfaction, patient engagement, durability of changes in anxiety symptoms and quality of life over 12 months and the impact of Lantern on healthcare utilisation over 12 months. Patients from control sites will be matched to the patients who use the mobile app. ETHICS AND DISSEMINATION: Ethics and human subject research approval were obtained. A data safety monitoring board is overseeing trial data and ethics. Results will be communicated to participating primary care practices, published and presented at clinical and scientific conferences. TRIAL REGISTRATION NUMBER: NCT03035019.

Effectiveness of certified diabetes educators following pre-approved protocols to redesign diabetes care delivery in primary care: Results of the REMEDIES 4D trial.

OBJECTIVE: To evaluate changes in HbA1c, blood pressure, and LDLc levels in participants from practices where certified diabetes educators (CDEs) implemented standardized protocols to intensify treatment compared with those receiving usual care. RESEARCH DESIGN AND METHODS: This clustered, randomized, clinical trial was implemented in community-based primary care practices. Fifteen primary care practices and 240 patients with type 2 diabetes were randomized to the intervention (n=175) or usual care (n=65). Participants had uncontrolled HbA1c, blood pressure, or LDLc. The one-year intervention included CDEs implementing pre-approved protocols to intensify treatment. Diabetes self-management education was also provided in both study groups. RESULTS: The population was 50.8% male with a mean age of 61years. The HbA1c in the intervention group decreased from 8.8% to 7.8%, (p=0.001) while the HbA1c in the usual care group increased slightly from 8.2% to 8.3%. There was also a significant difference in HbA1c between the two groups (p=0.004). There was not a significant difference between groups for systolic blood pressure (SBP) or LDLc at the end of the intervention. Those in the intervention group were more likely to have glucose-lowering medications intensified and were more likely to have their HbA1c (35% vs 15%), SBP (80% vs 77%) and HbA1c, SBP, and LDLc at goal (11% vs 1.5%) compared with the usual care group. There was no significant difference in intensification of blood pressure or cholesterol medication. CONCLUSIONS: Findings suggest that CDEs following standardized protocols in primary care is feasible and can effectively intensify treatment and improve glycemic control.

A Large Skin Cancer Screening Quality Initiative: Description and First-Year Outcomes.

IMPORTANCE: The lack of prospective randomized clinical trials demonstrating that full-body skin examination (FBSE) reduces melanoma morbidity or mortality has prompted an "I" rating from the United States Preventive Services Task Force for population-based skin cancer screening. More data on these screening programs are needed. OBJECTIVES: To describe a skin cancer screening quality initiative in a large health care system and to determine if the intervention was associated with screening of a demographically higher-risk population than previous screening programs and if melanoma incidence and thickness differed in screened vs unscreened patients. DESIGN, SETTING, AND PARTICIPANTS: This observational evaluation of a prospectively implemented quality initiative was conducted in a large health care system in western Pennsylvania (University of Pittsburgh Medical Center, UPMC) among adults seen in an office visit by a UPMC-employed primary care physician (PCP) in 2014. INTERVENTIONS: Implementation of a campaign promoting annual skin cancer screening by FBSE, including training of PCPs, promotion of the initiative to physicians and patients, and modification of the electronic health record (EHR) to include FBSE as a recommended preventive service for patients 35 years or older. MAIN OUTCOMES AND MEASURES: Characteristics of screened and unscreened patients and melanomas detected among them. RESULTS: Of 333 735 adult patients seen in an office visit by PCPs in 2014, 53 196 patients (15.9% of the screen-eligible population) received an FBSE, and 280 539 did not. Screened patients were slightly older (median age, 60 vs 57 years; P < .001) but did not differ significantly by sex (43.2% vs 43.1% men; P = .49) from the unscreened population. Fifty melanomas were diagnosed in screened patients and 104 melanomas were diagnosed in unscreened patients. Screened patients were more likely than unscreened patients to be diagnosed with melanoma (adjusted risk ratio [RR], 2.4; 95% CI, 1.7-3.4; P < .001) and to have a thinner invasive melanoma (median thickness, 0.37 mm vs 0.65 mm; P < .001). The incidence of melanoma lesions 1 mm or thicker was similar in screened vs unscreened patients (adjusted RR, 0.7; 95% CI, 02.-2.2; P = .52). CONCLUSIONS AND RELEVANCE: Large-scale screening for melanoma within a United States health care system is feasible and can result in increased detection of thinner melanomas. This intervention also resulted in screening of a higher proportion of men and an older patient population than previous screening interventions in which younger individuals and women predominated.

Downstream consequences of melanoma screening in a community practice setting: First results.

BACKGROUND: Population-based screening for the early detection of melanoma holds great promise for reducing melanoma mortality, but evidence is needed to determine whether benefits outweigh risks. Skin surgeries and dermatology visits after screening were assessed to indicate potential physical, psychological, and financial consequences. METHODS: Targeted primary care providers (PCPs) at the University of Pittsburgh Medical Center were trained to detect early melanoma using the INFORMED (INternet course FOR Melanoma Early Detection) program. The authors analyzed aggregated administrative data describing 3 groups of patients aged ≥35 years who had received an annual physical examination by PCPs: group A1 included patients of PCPs from the group with the highest percentage of INFORMED-trained providers, group A2 included patients of PCPs from the group with a lower percentage of INFORMED-trained providers, and group B included patients of PCPs without INFORMED training. RESULTS: INFORMED-trained PCPs screened 1572 of 16,472 patients in groups A1 or A2 and none of the 56,261 patients in group B. In group A1, there was a 79% increase (95% confidence interval, 15%-138%) in melanoma diagnoses noted; no increase was observed for the other groups, and no substantial increase in skin surgeries or dermatology visits occurred in any group. CONCLUSIONS: A large-scale melanoma screening using the INFORMED program was conducted in Pennsylvania. To the best of the authors' knowledge, the current study is the first analysis of downstream results and the findings indicate increased melanoma diagnoses but little impact on skin surgeries or dermatology visits. This result provides some reassurance that such efforts can be conducted without major adverse consequences, at least as measured by these parameters, and therefore should be considered for more widespread use. Cancer 2016;122:3152-6. © 2016 American Cancer Society.

Rationale, design, and implementation of a cluster randomized trial using certified diabetes educators to intensify treatment for glycemia, blood pressure and lipid control: REMEDIES 4D.

BACKGROUND: Evidence supports that adequate treatment of hyperglycemia, hypercholesterolemia, and hypertension can reduce morbidity and mortality in people with diabetes, however achieving treatment goals remains elusive. The majority of diabetes care occurs in the primary care setting; however there are often missed opportunities for timely intervention during office visits. This paper describes a systematic redesign of current diabetes treatment in primary care by implementing evidence-based protocols. MATERIALS/METHODS: This is a cluster randomized controlled trial using certified diabetes educators (CDEs) to intensify therapeutic management. Fifteen primary care practices from the University of Pittsburgh Medical Center were recruited. Practices were randomized to intervention (implementation of diabetes management protocols) or usual care. Eligibility criteria included diagnosis of type 2 diabetes at least one year prior to baseline and an A1C ≥ 7%, LDLc ≥ 100 mg/dl or blood pressure ≥ 130/80 mmHg which were the goal levels established by the American Diabetes Association at study inception. Treatment was intensified according to preapproved protocols. Participants also received diabetes education during their visits. Research assessments were done at baseline, three, six and twelve months. Clinical visits were scheduled between research visits, as needed, to adjust medications. Primary outcomes were achievement of glycemic, blood pressure, or lipid control goals. Secondary outcomes included quality of life, medication and diabetes care satisfaction, medication adherence, and cost-effectiveness. CONCLUSIONS: Results from this study will provide the evidence to support expanded roles for CDEs in primary care. Using this model to deliver diabetes care may offer a more cost-effective approach for diabetes management.

Translating the Diabetes Prevention Program: a comprehensive model for prevention training and program delivery.

BACKGROUND: The Diabetes Prevention Program (DPP) demonstrated that lifestyle intervention reduces risk for type 2 diabetes and the metabolic syndrome. A universal framework for translation of multiple aspects of the DPP intervention, including training, support, and evaluation is needed to enhance treatment fidelity in a variety of settings. PURPOSE: This study aims to develop a comprehensive model for diabetes prevention translation using a modified DPP lifestyle intervention. METHODS: The DPP lifestyle intervention was adapted to a 12-session group-based program called Group Lifestyle Balance for implementation in the community setting. A model for training and support mirroring that of the DPP was developed for prevention professionals administering the program. The process of training/support and program implementation was evaluated for feasibility and effectiveness using a nonrandomized prospective design in two phases (N=51, Phase 1: 2005-2006; N=42, Phase 2: 2007-2009; data analysis completed 2008-2009). A total of 93 nondiabetic individuals with BMI >or=25 kg/m(2) and the metabolic syndrome or prediabetes participated. Measures were collected at baseline and post-intervention for all and 6 and 12 months post-intervention for Phase 2. RESULTS: Significant decreases in weight, waist circumference, and BMI were noted in both phases from baseline. Participants in Phase 2 also demonstrated decreases in total cholesterol, non-HDL cholesterol, and systolic and diastolic blood pressure that were maintained at 12 months. Average combined weight loss for both groups over the course of the 3-month intervention was 7.4 pounds (3.5% relative loss, p<0.001); 23.8% and 52.2% of those who completed the program reached 7% and 5% weight loss, respectively. More than 80% of those achieving 7% weight loss in the Phase-2 group maintained their weight loss at 6 months. CONCLUSIONS: A comprehensive diabetes prevention model for training, intervention delivery, and support was shown to be successful and was effective in reducing diabetes and cardiovascular disease risk factors in this group of high-risk individuals.

Physicians encouraging colorectal screening: a randomized controlled trial of enhanced office and patient management on compliance with colorectal cancer screening.

BACKGROUND: Colorectal cancer screening is underused. Our objective was to evaluate methods for promoting colorectal cancer screening in primary care practice. METHODS: A 2 x 2 factorial randomized clinical trial measured the effects of a tailored vs nontailored physician recommendation letter and an enhanced vs nonenhanced physician office and patient management intervention on colorectal cancer screening adherence. The enhanced and nonenhanced physician office and patient management interventions varied the amount of external support to help physician offices develop and implement colorectal cancer screening programs. The study included 10 primary care physician office practices and 599 screen-eligible patients aged 50 to 79 years. The primary end point was medical-record-verified flexible sigmoidoscopy or colonoscopy. Statistical end-point analysis (according to randomization intent) used generalized estimating equations to account for correlated outcomes according to physician group. RESULTS: During a 1-year period, endoscopy in the lower gastrointestinal tract (lower endoscopy) occurred in 289 of 599 patients (48.2%). This finding included the following rates of lower endoscopy: 81 of 152 patients (53.3%) in the group that received the tailored letter and enhanced management; 103 of 190 (54.2%) in the group that received the nontailored letter and enhanced management; 58 of 133 (43.6%) in the group that received the tailored letter and nonenhanced management; and 47 of 124 (37.9%) in the group that received the nontailored letter and nonenhanced management. Enhanced office and patient management increased the odds of completing a colonoscopy or flexible sigmoidoscopy by 1.63-fold (95% confidence interval, 1.11-2.41; P = .01). However, the tailored letter increased the odds of completion by only 1.08-fold (95% confidence interval, 0.72-1.62; P = .71). CONCLUSIONS: Approximately one-half of the screen-eligible primary medical care patients aged 50 to 79 years obtained lower endoscopic colorectal cancer screening within 1 year of recommendation. An enhanced office and patient management system significantly improved colorectal cancer screening adherence. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00327457.

Organizational factors and depression management in community-based primary care settings.

BACKGROUND: Evidence-based quality improvement models for depression have not been fully implemented in routine primary care settings. To date, few studies have examined the organizational factors associated with depression management in real-world primary care practice. To successfully implement quality improvement models for depression, there must be a better understanding of the relevant organizational structure and processes of the primary care setting. The objective of this study is to describe these organizational features of routine primary care practice, and the organization of depression care, using survey questions derived from an evidence-based framework. METHODS: We used this framework to implement a survey of 27 practices comprised of 49 unique offices within a large primary care practice network in western Pennsylvania. Survey questions addressed practice structure (e.g., human resources, leadership, information technology (IT) infrastructure, and external incentives) and process features (e.g., staff performance, degree of integrated depression care, and IT performance). RESULTS: The results of our survey demonstrated substantial variation across the practice network of organizational factors pertinent to implementation of evidence-based depression management. Notably, quality improvement capability and IT infrastructure were widespread, but specific application to depression care differed between practices, as did coordination and communication tasks surrounding depression treatment. CONCLUSIONS: The primary care practices in the network that we surveyed are at differing stages in their organization and implementation of evidence-based depression management. Practical surveys such as this may serve to better direct implementation of these quality improvement strategies for depression by improving understanding of the organizational barriers and facilitators that exist within both practices and practice networks. In addition, survey information can inform efforts of individual primary care practices in customizing intervention strategies to improve depression management.

Bilateral cytomegalovirus (CMV) oophoritis mimicking widely metastatic carcinoma: a case report and review of the literature.

Ovarian cytomegalovirus (CMV) infection is a rare finding reported in autopsy studies of immunocompromised patients. We report the first case of bilateral CMV oophoritis diagnosed in surgical resection specimens from a 63-year-old woman with metastatic brain lesions undergoing whole brain radiation and steroid treatment. The ovarian involvement of CMV infection was an incidental finding during the colectomy and bilateral salpingo-oophorectomy procedure for gastrointestinal bleeding and presumed ovarian metastases. In contrast to the prevailing dogma, a review of the literature found similar prevalence of pre-menopausal and post-menopausal cases. While age related vasculopathy was thought to be the prevailing mechanism for CMV oophoritis, the observation of an inflammation mediated microthrombosis in our case provides a plausible age independent mechanism suggesting that both restrictive and obstructive vascular changes can be involved in the pathogenesis of CMV oophoritis. To avoid misdiagnosis, both pathologists and clinicians should recognize ovarian involvement by CMV as a possibility in the immunocompromised patient.

Deploying the chronic care model to implement and sustain diabetes self-management training programs.

PURPOSE: The purpose of this project was to evaluate the utility of using the 6 elements of the chronic care model (CCM; health system, community, decision support, self-management support, clinical information systems, and delivery system design) to implement and financially sustain an effective diabetes self-management training (DSMT) program. METHODS: The University of Pittsburgh Medical Center (UPMC) uses all elements of the CCM. Partnerships were formed between UPMC and western Pennsylvanian community hospitals and practices; the American Diabetes Association DSMT recognition program provided decision support. A clinical data repository and reorganization of primary care practices aided in supporting DSMT. The following process and patient outcomes were measured: number of recognized programs, reimbursement, patient hemoglobin A1C levels, and the proportion of patients who received DSMT in primary care practices versus hospital-based programs. RESULTS: Using elements of the CCM, the researchers were able to gain administrative support; expand the number of recognized programs from 3 to 21; cover costs through increased reimbursement; reduce hemoglobin A1C levels (P < .0001), and increase the proportion of patients receiving DSMT through delivery in primary care (26.4% suburban; 19.8% urban) versus hospital-based practices (8.3%; P < .0001). CONCLUSIONS: The CCM serves as an effective model for implementing and sustaining DSMT programs.

Predictors of adequacy of depression management in the primary care setting.

OBJECTIVES: Depression is most commonly treated in the primary care setting. However, most studies have shown that depression care in this setting is often inadequate. This study examined the adequacy of antidepressant treatment and overall depression management by primary care physicians and identified patient characteristics related to inadequate care. METHODS: Adequacy of depression care among patients with depression who presented to a primary care office was evaluated by using physicians' self-reports and medication prescription data. Adequacy of depression care was measured in two ways: adequacy of the current medication trial was measured by using the Antidepressant Treatment and History Form (ATHF), and adequacy of overall management by the physician was measured by using an algorithm developed for this study. The association was examined between patient characteristics and adequacy of the medication trial or depression management. RESULTS: Data were gathered for 389 patients with depression. Overall, 71 percent of patients had adequate ATHF scores, and 75 percent were judged to receive adequate depression management. No significant differences in adequacy were seen on the basis of race, age, or gender. When depressive symptoms were almost absent or extremely severe, 91 percent of patients were adequately managed; in contrast, when symptoms were mild, mild to moderate, or moderate 69 percent of patients were adequately managed. Additionally, specific medications, such as sertraline and fluoxetine, were associated with a lower likelihood of an adequate ATHF score. CONCLUSIONS: A majority of these primary care patients were adequately treated for depression, with no detectable disparity related to race or age. However, mild to moderate depressive symptoms (as opposed to remitted or severe symptoms) and specific medications were associated with a lower rate of adequacy. These findings have implications for ways that primary care physicians could be trained to more adequately manage the spectrum of severity of depression.

Response speed and rate of remission in primary and specialty care of elderly patients with depression.

OBJECTIVE: Depression treatment in primary care elderly patients has been inadequate, resulting in low rates of response and remission. The authors compared treatment remission rates and time-to-remission of elderly subjects enrolled in two ongoing depression treatment studies, one in primary care practices ("PROSPECT") and the other in an academic tertiary mental health care center ("MTLD-2"), in order to assess the value of standardizing and intensifying depression treatment in primary care elderly patients. METHODS: Authors compared remission rates and time to criterion endpoints via survival analysis. The 126 PROSPECT subjects (mean age 71) included primary care patients with either current episodes of major depression or minor depression. The 129 MTLD-2 subjects (mean age 77) had single or recurrent unipolar major depression. PROSPECT subjects received a variety of open treatments, including the drug citalopram and/or interpersonal psychotherapy (IPT). Both patient and provider preferences influenced treatment selected. MTLD-2 subjects received more structured, open paroxetine treatment and IPT. RESULTS: The remission rates of PROSPECT and MTLD-2 were 86.5% and 88.4%, respectively. Median time-to-remission in PROSPECT was significantly longer than in MTLD-2 (12 weeks versus 8.7 weeks). Limiting the survival analysis to subjects with major depression produced faster attainment of remission criteria. CONCLUSION: Notwithstanding these differences in speed and rate of symptom resolution, good treatment can work well in geriatric depression in the primary care sector.