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Dunivan G.C.,University of North Carolina at Chapel Hill | Heymen S.,University of North Carolina at Chapel Hill | Palsson O.S.,University of North Carolina at Chapel Hill | von Korff M.,Center for Health Studies | And 3 more authors.
American Journal of Obstetrics and Gynecology | Year: 2010

Objective: We sought to estimate the frequency of self-reported fecal incontinence (FI), identify what proportion of these patients have a diagnosis of FI in their medical record, and compare health care costs and utilization in patients with different severities of FI to those without FI. Study Design: Patients in a health maintenance organization were eligible and 1707 completed a survey. Patients with self-reported FI were assessed for a diagnosis of FI in their medical record for the last 5 years. Health care costs and utilization were obtained from claims data. Results: FI was reported by 36.2% of primary care patients, but only 2.7% of patients with FI had a medical diagnosis. FI adversely affected quality of life and severe FI was associated with 55% higher health care costs (including 77% higher gastrointestinal-related health care costs) compared to continent patients. Conclusion: Increased screening of FI is needed. © 2010 Mosby, Inc. All rights reserved. Source

Leveille S.G.,Beth Israel Deaconess Medical Center | Leveille S.G.,University of Massachusetts Boston | Walker J.,Beth Israel Deaconess Medical Center | Ralston J.D.,Center for Health Studies | And 3 more authors.
BMC Medical Informatics and Decision Making | Year: 2012

Background: Providers and policymakers are pursuing strategies to increase patient engagement in health care. Increasingly, online sections of medical records are viewable by patients though seldom are clinicians' visit notes included. We designed a one-year multi-site trial of online patient accessible office visit notes, OpenNotes. We hypothesized that patients and primary care physicians (PCPs) would want it to continue and that OpenNotes would not lead to significant disruptions to doctors' practices. Methods/Design. Using a mixed methods approach, we designed a quasi-experimental study in 3 diverse healthcare systems in Boston, Pennsylvania, and Seattle. Two sites had existing patient internet portals; the third used an experimental portal. We targeted 3 key areas where we hypothesized the greatest impacts: beliefs and attitudes about OpenNotes, use of the patient internet portals, and patient-doctor communication. PCPs in the 3 sites were invited to participate in the intervention. Patients who were registered portal users of participating PCPs were given access to their PCPs' visit notes for one year. PCPs who declined participation in the intervention and their patients served as the comparison groups for the study. We applied the RE-AIM framework to our design in order to capture as comprehensive a picture as possible of the impact of OpenNotes. We developed pre- and post-intervention surveys for online administration addressing attitudes and experiences based on interviews and focus groups with patients and doctors. In addition, we tracked use of the internet portals before and during the intervention. Results: PCP participation varied from 19% to 87% across the 3 sites; a total of 114 PCPs enrolled in the intervention with their 22,000 patients who were registered portal users. Approximately 40% of intervention and non-intervention patients at the 3 sites responded to the online survey, yielding a total of approximately 38,000 patient surveys. Discussion. Many primary care physicians were willing to participate in this "real world" experiment testing the impact of OpenNotes on their patients and their practices. Results from this trial will inform providers, policy makers, and patients who contemplate such changes at a time of exploding interest in transparency, patient safety, and improving the quality of care. © 2012 Leveille et al; licensee BioMed Central Ltd. Source

Simon G.E.,Center for Health Studies | Imel Z.E.,University of Utah | Ludman E.J.,Group Health Research Institute | Steinfeld B.J.,Behavioral Health Services
Psychiatric Services | Year: 2012

Objective: The authors compared outcomes reported by patients who did or did not return for treatment after an initial psychotherapy visit. Methods: Members of a group health plan were surveyed about initial psychotherapy visits occurring between March and September 2010. The survey assessed satisfaction with care and therapeutic alliance during the visit and later clinical improvement. Results: Of the 2,666 members who returned surveys, 906 (34%) did not return for a second visit within 45 days. The distribution of satisfaction, therapeutic alliance, and self-rated improvement scores between patients who did and did not return differed significantly (p<.001). Patients who did not return were more likely to report the most favorable and the least favorable outcomes. Conclusions: Failure to return after an initial psychotherapy visit can represent successful and satisfying treatment. Systematic outreach and outcome assessment are necessary to identify the patients who drop out of therapy after unsuccessful and unsatisfying treatment. Source

Ogale S.S.,University of Washington | Ogale S.S.,Genentech | Lee T.A.,Hines Veterans Administration Hospital | Lee T.A.,University of Illinois at Chicago | And 3 more authors.
Chest | Year: 2010

Background: Studies have suggested an increased risk of cardiovascular morbidity and mortality associated with the use of ipratropium bromide. We sought to examine the association between ipratropium bromide use and the risk of cardiovascular events (CVEs). Methods: We performed a cohort study of 82,717 US veterans with a new diagnosis of COPD between 1999 and 2002. Subjects were followed until they had their first hospitalization for a CVE (acute coronary syndrome, heart failure, or cardiac dysrhythmia), they died, or the end of the study period (September 30, 2004). Cumulative anticholinergic exposure was calculated as the number of 30-day equivalents (ipratropium bromide) within the past year. We used Cox regression models with time-dependent covariates to estimate the risk of CVE associated with anticholinergic exposure and to adjust for potential confounders, including markers of COPD severity and cardiovascular risk. Results: We identified 6,234 CVEs (44% heart failure, 28% acute coronary syndrome, 28% dysrhythmia). Compared with subjects not exposed to anticholinergics within the past year, any exposure to anticholinergics within the past 6 months was associated with an increased risk of CVE (hazard ratio [95% CI] for ≤ four and > four 30-day equivalents: 1.40 [1.30-1.51] and 1.23 [1.13-1.36], respectively). Among subjects who received anticholinergics more than 6 months prior, there did not appear to be elevated risk of a CVE. Conclusions: We found an increased risk of CVEs associated with the use of ipratropium bromide within the past 6 months. These findings are consistent with previous concerns raised about the cardiovascular safety of ipratropium bromide. © 2010 American College of Chest Physicians. Source

Patel V.,London School of Hygiene and Tropical Medicine | Patel V.,Sangath Center | Weiss H.A.,Medical Research Council Tropical Epidemiology Group | Chowdhary N.,Sangath Center | And 10 more authors.
The Lancet | Year: 2010

Background Depression and anxiety disorders are common mental disorders worldwide. The MANAS trial aimed to test the eff ectiveness of an intervention led by lay health counsellors in primary care settings to improve outcomes of people with these disorders. Methods In this cluster randomised trial, primary care facilities in Goa, India, were assigned (1:1) by computergenerated randomised sequence to intervention or control (enhanced usual care) groups. All adults who screened positive for common mental disorders were eligible. The collaborative stepped-care intervention off ered case management and psychosocial interventions, provided by a trained lay health counsellor, supplemented by antidepressant drugs by the primary care physician and supervision by a mental health specialist. The research assessor was masked. The primary outcome was recovery from common mental disorders as defi ned by the International Statistical Classifi cation of Diseases and Related Health Problems-10th revision (ICD-10) at 6 months. This study is registered with ClinicalTrials.gov, number NCT00446407. Findings 24 study clusters, with an equal proportion of public and private facilities, were randomised equally between groups. 1160 of 1360 (85%) patients in the intervention group and 1269 of 1436 (88%) in the control group completed the outcome assessment. Patients with ICD-10-confi rmed common mental disorders in the intervention group were more likely to have recovered at 6 months than were those in the control group (n=620 [65•0%] vs 553 [52•9%]; risk ratio 1•22, 95% CI 1•00-1•47; risk diff erence=12•1%, 95% CI 1•6%-22•5%). The intervention had strong evidence of an eff ect in public facility attenders (369 [65•9%] vs 267 [42•5%], risk ratio 1•55, 95% CI 1•02-2•35) but no evidence for an eff ect in private facility attenders (251 [64•1%] vs 286 [65•9%], risk ratio 0•95, 0•74-1•22). There were three deaths and four suicide attempts in the collaborative stepped-care group and six deaths and six suicide attempts in the enhanced usual care group. None of the deaths were from suicide. Interpretation A trained lay counsellor-led collaborative care intervention can lead to an improvement in recovery from CMD among patients attending public primary care facilities. Funding The Wellcome Trust. © 2010 Elsevier Ltd. Source

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