Improving the Management of Late-Life Depression in Primary Care: Barriers and Facilitators

The objectives of this study were to elicit Canadian health professionals' views on the barriers to identifying and treating late-life depression in primary care settings and on the solutions felt to be most important and feasible to implement. A consensus development process was used to generate, rank, and discuss solutions. Twenty-three health professionals participated in the consensus process. Results were analysed using quantitative and qualitative methods. Participants generated 12 solutions. One solution, developing mechanisms to increase family physicians' awareness of resources, was highly ranked for importance and feasibility by most participants. Another solution, providing family physicians with direct mental health support, was highly ranked as important but not as feasible by most participants. Deliberations emphasized the importance of case specific, as needed support based on the principles of shared care. The results suggest that practitioners highly value collaborative care but question the feasibility of implementing these principles in current Canadian primary care contexts

Hepatic steatosis progresses faster in HIV mono-infected than HIV/HCV co-infected patients and is associated with liver fibrosis

Background & Aims Hepatic steatosis (HS) seems common in patients infected with human immunodeficiency virus (HIV). However, the relative effect of HIV, as well as hepatitis C virus (HCV) in those co-infected, and the influence of HS on liver fibrosis progression are unclear. Methods The LIVEr disease in HIV (LIVEHIV) is a Canadian prospective Cohort using transient elastography and associated controlled attenuation parameter (CAP) to screen for HS and liver fibrosis in unselected HIV-infected adults. HS progression was defined as development of any grade HS (CAP ≥248 dB/m), or transition to severe HS (CAP ≥292 dB/m) for those with any grade HS at baseline. Fibrosis progression was defined as development of significant liver fibrosis (liver stiffness measurement [LSM] ≥7.1kPa), or transition to cirrhosis (LSM ≥12.5kPa) for those with significant liver fibrosis at baseline. Cox regression analysis was used to assess predictors of HS and fibrosis progression. Results A prospective cohort study was conducted, which included 726 HIV-infected patients (22.7% HCV co-infected). Prevalence of any grade HS did not differ between HIV mono-infected and HIV/HCV co-infected patients (36.1% vs 38.6%, respectively). 313 patients were followed for a median of 15.4 (interquartile range 8.5-23.0) months. The rate of HS progression was 37.8 (95% confidence interval [CI] 29.2-49.0) and 21.9 (95% CI 15.6-30.7) per 100 person-years in HIV mono-infection and HIV/HCV co-infection, respectively. HCV co-infection was an independent negative predictor of HS progression (adjusted hazard ratio [aHR] 0.50, 95% CI 0.28-0.89). HS predicted liver fibrosis progression in HIV mono-infection (aHR 4.18, 95% CI 1.21-14.5), but not in HIV/HCV co-infection. Conclusion HS progresses faster and is associated with liver fibrosis progression in HIV mono-infection but not in HIV/HCV co-infection

Helping family doctors detect vulnerable caregivers after an emergency department visit for an elderly relative: results of a longitudinal study

BACKGROUND: Family doctors have been ascribed a role in monitoring patients and their informal caregivers. Little is known about the factors that might alert physicians to changing circumstances or needs of the caregivers. The study objective was to examine changes in family caregivers' quality of life following an emergency department (ED) visit by an older community-dwelling relative that might cue doctors to subsequent caregiver distress. METHODS: A longitudinal study with follow-up at 1- and 4-months was conducted in the EDs of 4 hospitals in Montreal, Canada. Caregivers reported on demographics and quality of life (SF-36). Patients reported on demographics and functional disability. Multiple linear regression for repeated measures was used to evaluate changes in caregiver quality of life and factors related to these changes. RESULTS: 159 caregivers (60.5 yrs ± 15.8%; 73.0% female), including 68 (42.8%) spouses, 60 (37.7%) adult children, and 31 (19.5%) other relatives participated. Following an initial ED visit by older relatives, caregiver general health and physical functioning declined over time, while mental health status improved. Compared to the other relative caregiver group, spouses were at increased risk for decline in general health, mental health, and physical functioning at 1 month, while adult children were at increased risk for decline in physical health at 1 month. CONCLUSION: Spouses were most at risk for decline in quality of life. Primary care physicians who become aware of an ED visit by an elderly person may be alerted to possible subsequent deterioration in family caregivers, especially spouses

Adherence to colorectal cancer screening guidelines in Canada

<p>Abstract</p> <p>Background</p> <p>To identify correlates of adherence to colorectal cancer (CRC) screening guidelines in average-risk Canadians.</p> <p>Methods</p> <p>2003 Canadian Community Health Survey Cycle 2.1 respondents who were at least 50 years old, without past or present CRC and living in Ontario, Newfoundland, Saskatchewan, and British Columbia were included. Outcomes, defined according to current CRC screening guidelines, included adherence to: i) fecal occult blood test (FOBT) (in prior 2 years), ii) endoscopy (colonoscopy/sigmoidoscopy) (prior 10 years), and iii) adherence to CRC screening guidelines, defined as either (i) or (ii). Generalized estimating equations regression was employed to identify correlates of the study outcomes.</p> <p>Results</p> <p>Of the 17,498 respondents, 70% were non-adherent CRC screening to guidelines. Specifically, 85% and 79% were non-adherent to FOBT and endoscopy, respectively. Correlates for all outcomes were: having a regular physician (OR = (i) 2.68; (ii) 1.91; (iii) 2.39), getting a flu shot (OR = (i) 1.59; (ii) 1.51; (iii) 1.55), and having a chronic condition (OR = (i) 1.32; (ii) 1.48; (iii) 1.43). Greater physical activity, higher consumption of fruits and vegetables and smoking cessation were each associated with at least 1 outcome. Self-perceived stress was modestly associated with increased odds of adherence to endoscopy and to CRC screening guidelines (OR = (ii) 1.07; (iii) 1.06, respectively).</p> <p>Conclusion</p> <p>Healthy lifestyle behaviors and factors that motivate people to seek health care were associated with adherence, implying that invitations for CRC screening should come from sources that are independent of physicians, such as the government, in order to reduce disparities in CRC screening.</p

Recognition of Depression in Older Medical Inpatients

BACKGROUND: Studies of recognition of depression in older (aged 65 or more) medical inpatients show low rates of recognition of depression by attending physicians. However, few studies have compared different measures of recognition of depression. OBJECTIVES: (1) To compare the validity of four indicators of recognition of depression and a global measure of recognition against a diagnosis of depression and (2) to explore the effect of patient characteristics on recognition of depression. METHODS: In a cohort of 264 medical inpatients 65 years and older (115 with major or minor depression, 78 with no depression), sensitivities, specificities, and diagnostic odds ratios (DOR) of 4 indicators of recognition (symptoms, diagnosis, treatment, and referral) and a global measure of recognition (any of the 4 indicators) were calculated. The associations between patient characteristics (age, sex, history of depression, antidepressant use before admission, severity of depression, comorbidity, duration of hospitalization, disability, and hospital of admission) and recognition were explored using multiple logistic regression. RESULTS: Less than half of the depressed patients were recognized. The indicator with the highest sensitivity was treatment (27.8%, 95% confidence interval [CI] 20.0–37.0), whereas the indicator with the best specificity was diagnosis (96.6%, 95% CI 91.9–98.7). The unadjusted DOR of global recognition was 2.6 (95% CI 1.5, 4.4). Less comorbidity, more severe depression symptoms, a history of depression, longer hospital stay, and antidepressant use before admission were significantly associated with better global recognition. CONCLUSION: Recognition of depression in elderly medical inpatients depends upon the indicator of recognition used

Effect of discordant physician-patient perceptions on patient adherence in inflammatory bowel disease

Background. Discordant physician-patient perceptions on health-related information have been related to less favourable health outcomes and increased use of health services.Objectives. To develop a psychometrically-sound measure of physician-patient discordance that could be used by clinicians and researchers working with patients with various chronic diseases. To investigate the relationship between physician-patient discordance and patient adherence to self-care in inflammatory bowel disease.Study design and population. A prospective cohort study with follow-ups at 2-weeks and 4-months was conducted between February and November 1999 at three gastroenterology clinics affiliated with the McGill University Health Centre. Ten physicians and 200 patients with inflammatory bowel disease participated in the study.Methods. A 10-item visual analog scale questionnaire was developed which assessed perceptions of the patient's health status and of the clinical visit. Questionnaires were completed independently by physicians and patients following the index clinical visit. Discordance was calculated within physician-patient pairs. Demographic, clinical and psychosocial data were obtained prior to the visit. Patient adherence data were obtained at 2-weeks using a telephone interview and mail-back survey. General adherence was assessed with a visual analog scale; medication adherence was determined with a validated questionnaire. Medication data were obtained by chart review at 4-months. Multivariable generalized estimating equations models and mixed models for unbalanced repeated measures analysis of variance were used to determine associations between discordance and patient adherence.Results. Satisfactory psychometric properties were obtained for discordance scores. Higher psychological distress was the most important determinant of higher discordance. Higher distress was correlated with active disease, less time since diagnosis, greater number and impact of negative life events. Higher satisfaction with social support reduced psychological distress by buffering the negative impact of perceived stress. Higher discordance on symptoms and treatment increased the risk of general nonadherence in patients with higher social support satisfaction. Medication adherence was associated with active disease, greater disease duration and scheduling another appointment. Higher discordance on well-being decreased the probability of medication adherence in non-distressed patients.Conclusion. Preliminary evidence has been provided to support the validity of the new measure of physician-patient discordance. Higher discordance was associated with an increased risk of nonadherence in patients with healthy psychosocial characteristics

Does psychological status influence recovery in workers compensated for acute low back pain?

The influence of psychological status on recovery from a first lifetime episode of acute low-back pain was assessed in compensated workers seen in a physiatry clinic. One hundred thirty-four participants of a back school intervention trial were selected and followed for 1 year. The objectives were to determine the evolution of psychological distress, well-being, pain, self-reported disability and spinal flexibility, and to determine the psychological factors associated with return to work and recurrence. Improvement occurred post-treatment in all measures except well-being which did not fluctuate over the year. Additional improvement in functional disability occurred at 6 and 12 months. Using multiple logistic regression, low baseline psychological distress predicted late return to work and high baseline well-being predicted recurrence. A second model for recurrence that was constructed with post-treatment scores on the longitudinal measures had greater predictive power than the model using baseline scores. These results have implications for the management of return to work

Adherence to self-care interventions for depression or anxiety: A systematic review

The objective of this study was to synthesise and describe adherence to intervention in published studies of supported self-care for depression or anxiety, and to identify participant characteristics associated with higher adherence. We identified 40 studies of supported self-care interventions for depression and anxiety, of which 22 (55%) reported any measure of adherence to the intervention. Among these 22 studies, 18 (82%) reported the percentage of participants completing the entire self-care tool (20%–93%; Mean = 66%, SD 17), 13 studies reported the amount of self-care tools completed by the average participant (50.6%–96.4%; Mean = 80%, SD 11.6). Four studies (18%) reported the frequency of contacts with the self-care guide. Three (14%) studies reported participant characteristics associated with adherence. Overall, reported adherence levels to supported self-care interventions for depression and anxiety indicate a significant amount of patient involvement in these interventions. Routine reporting of adherence will improve our understanding of adherence to supported self-care interventions, and will allow researchers to link adherence with intervention outcome

Patient satisfaction with colonoscopy: A literature review and pilot study

BACKGROUND: Current guidelines recommend that colonoscopic colorectal cancer screening be undertaken every 10 years after the age of 50 years. However, because the procedure does not meet criteria that promote screening uptake, patient satisfaction with colonoscopy may encourage repeat screening