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Depression and coexisting illnesses should be treated
together to reduce costs and improve outcomes
Older primary care patients who are depressed incur greater average charges for diagnostic tests
than patients who are not depressed. These higher charges are not due to depression, per se, but
instead can be attributed to the greater burden of coexisting medical illnesses borne by depressed
patients compared with patients who are not depressed, according to Christopher M. Callahan,
M.D., of the Regenstrief Institute for Health Care, lead author of a recent study.
Older persons, in particular, are more apt to suffer from coexisting illness, to be functionally
impaired, or to receive medication that can lead to symptoms of depression or mask existing
depression, according to the study, which was supported in part by the Agency for Health Care
Policy and Research (HS07632 and HS07763). Thus, improved treatment of mental illness is not
the answer to reducing excess use of medical services by patients with mental disorders. Instead,
primary care physicians and mental health specialists need to address organic and psychiatric
illnesses simultaneously, notes Dr. Callahan.
Dr. Callahan and his colleagues compared the amount and charges for inpatient and outpatient
diagnostic testing for 3,767 patients 60 years of age and older who completed testing on the
Centers for Epidemiologic Studies Depression Scale (CES-D) during routine office visits at a
primary care group practice from 1991 to 1993.
The researchers found that depressed patients were more apt than nondepressed patients to have
nonpsychiatric medical problems and more visits to the outpatient care center (nine visits vs. eight
visits, respectively), to use the emergency department (52 percent vs. 40 percent), and to be
hospitalized (22 percent vs. 17 percent). These patients also incurred $200 more in diagnostic test
charges for a 1-year period ($583 vs. $387) than nondepressed patients—a large sum if
for an entire population of older adults over several years. The 54 percent difference in charges,
mostly for clinical pathology (for example, routine blood and urine tests), persisted into the
See "Association of symptoms of depression with diagnostic test charges among older adults," by
Dr. Callahan, Joseph G. Kesterson, M.A., and William M. Tierney, M.D., in the March 15, 1997,
issue of Annals of Internal Medicine 126, pp. 426-432.
Primary care physicians are more likely to recognize
depression in women and more educated patients
Primary care physicians often fail to recognize depression when it is present in their patients, yet
they are less likely to miss it in women and more educated patients than in men and less educated
patients, according to a study supported by the Agency for Health Care Policy and Research
(HS08029 and HS06167). The study shows that depressed women are twice as apt to be
diagnosed as such than depressed men and that for each additional year of education, the odds
increase by 24 percent that a patient will be correctly diagnosed as depressed.
Health status measures, such as level of energy and physical and social functioning, declined
among patients in this study as their depression symptoms increased. Therefore, Edward J.
Callahan, Ph.D., and Klea K. Bertakis, M.D., M.P.H., of the University of California, Davis, and
their colleagues suggest that clinicians incorporate health status measures when assessing primary
care patients. When a patient demonstrates an unexpectedly sudden decline or progressive
deterioration in health status scores that is not accounted for by a physical illness or other medical
problem, the clinician should suspect a mental disorder. The clinician can then use other
diagnostic techniques and instruments such as the Beck Depression Inventory (BDI) to aid in the
The researchers gathered data from 1990 to 1993 on 508 consecutive new patients who were
randomly assigned to 105 family practice and general internal medicine residents. Each physician
saw an average of five patients. The patients completed the BDI, which measures the presence
and severity of 13 symptoms of depression, and the SF-36 health status questionnaire. The
researchers compared the test results, which were not revealed to the physicians, with the
presence or absence of depression diagnosis on the patients medical charts.
Physicians made a chart notation of depression for only 28 percent of the 130 moderately or
severely depressed patients (BDI score of 9 or more). The physicians were more apt to correctly
diagnose depressed women and more educated patients, even after adjusting for differences in
health status, BDI scores, and other factors. Age and race did not influence recognition of
depression by the primary care physicians.
Details are in "Depression in primary care: Patient factors that influence recognition," by Drs.
Callahan and Bertakis, Rahman Azari, Ph.D., and others, in the March 1997 issue of Family
Medicine 29(3), pp. 172-176.
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Primary care physicians fail to identify half of patients
at risk for HIV infection
Primary care physicians do not routinely assess patients for HIV risk, even when the patients have
obvious risk behaviors for HIV, such as multiple sex partners or intravenous drug use. In fact,
they fail to identify risk behaviors for HIV infection or include HIV in the diagnosis of more than
half of the patients in whom active HIV infection should be considered, according to a study
supported by the Agency for Health Care Policy and Research (HS06454).
Paul G. Ramsey, M.D., principal investigator, and other researchers randomly selected 134
primary care physicians to examine standardized patients (SPs, individuals trained to enact
specific case presentations) to assess overall clinical skills, as well as the physicians skill at
identifying and managing HIV infection. In a day of testing, physicians saw 13 to 16 SPs with
diverse case presentations. Nine SPs were at high risk for HIV infections with unidentified risk
behaviors for HIV, which they offered if asked. However, only 12 percent of at-risk SPs were
asked about their history of sexually transmitted disease, which increases the risk of HIV
infection; 49 percent were asked if they were sexually active; 15 percent were asked about the
number of sexual partners they had; 39 percent were asked about injection drug use; and 50
percent of at-risk male SPs were asked about sex with other men.
Individual physicians initiated screening in at least one of the five risk assessment categories with
an average of 60 percent of at-risk SPs they saw. General internists initiated screening for a higher
percentage of SPs than family practitioners (67 percent vs. 55 percent of SPs seen), and
physicians with the most HIV experience initiated screening more often than physicians with the
least experience (69 percent vs. 55 percent of SPs seen).
Primary care physicians are inconsistent and sporadic in screening for and identifying HIV risk
factors, concludes Marjorie D. Wenrich, M.P.H., of the University of Washington, Seattle, the
lead author of a recent paper describing these findings. She points out that standardized screening
techniques are needed to identify persons at risk for HIV. One approach would be the inclusion of
specific questions about HIV risk behaviors in standard medical intake forms.
Details are in "HIV risk screening in the primary care setting," by Ms. Wenrich, J. Randall Curtis,
M.D., M.P.H., Jan D. Carline, Ph.D., and others, in the February 1997 Journal of General
Internal Medicine 12, pp. 107-113.
Many health care providers do not test TB patients for
HIV infection as recommended
Nearly half of urban tuberculosis (TB) patients in the United States are also infected with the
human immunodeficiency virus, or HIV. But despite recommendations to test all TB patients for
HIV, many health care providers choose to test only those they perceive to be at risk of HIV
infection, according to a study supported in part by the Agency for Health Care Policy and
Research (National Research Service Award training grant T32 HS00046). It shows that
one-third of TB patients in AIDS-dense areas of Los Angeles were not tested for HIV, and that
provider choice not to test, rather than patient refusal to be tested for HIV, was the critical
Physicians tested mostly persons with HIV risk factors, but at least 2 to 7 percent of low-risk
patients were infected with HIV. Thus, the opportunity to diagnose and treat HIV coinfection
may be missed in a substantial number of TB patients, conclude the California researchers. They
reviewed the medical charts of 500 patients at 20 health centers, who were listed in the Los
Angeles County tuberculosis registry in 1993, to document whether or not the patients had been
tested for HIV infection.
The researchers found that females were 42 percent less likely to have been tested compared with
males, and persons aged 20 to 49 years were more apt to be tested than younger and older
persons. Patients with HIV risk factors were nearly nine times more likely to be tested for HIV
than patients without risk factors. Overall, physicians tested only 63 percent of TB patients for
HIV infection. Patients of private practitioners were 68 percent less likely to have been tested
than were patients treated by public health authorities. This may be because public health
providers are better educated about the relationship between TB and HIV or that they have a
stronger commitment to infectious disease control, suggest the researchers. They conclude that
further education of health care providers is essential to achieve universal HIV testing among TB
For more information, see "Testing for human immunodeficiency virus infection among
tuberculosis patients in Los Angeles," by Steven M. Asch, M.D., Andrew S. London, Ph.D., Peter
F. Barnes, M.D., and Lillian Gelberg, M.D., M.S.P.H., in the American Journal of Respiratory
and Critical Care Medicine 155, pp. 378-381, 1997.
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Homeless individuals living in congested urban areas
are at high risk for TB infection
Homeless persons living in crowded shelters are vulnerable to infection with tuberculosis (TB).
They come into contact with former prison inmates, substance abusers, and others who are at high
risk of already being infected, and their often crowded quarters make it easier for the TB bacteria
to pass into their lungs via air droplets when infected persons cough or sneeze. As a result, about
one-third of the homeless persons in Los Angeles and San Francisco are infected with TB; this
translates to a prevalence rate that is three to six times greater than the 5 to 10 percent prevalence
of TB skin test positivity in the general adult population.
A recent study, supported in part by the Agency for Health Care Policy and Research (HS06696),
examined factors that increase the risk of homeless persons becoming infected with TB. It found
that 40 percent of homeless persons in the urban Skid Row area of Los Angeles had positive TB
skin tests compared with 14 percent of homeless persons in the suburban Westside area (an
overall 32 percent prevalence). This was probably due to the crowded conditions in the urban
area, explains lead investigator Lillian Gelberg, M.D., M.S.P.H., of the University of California,
Los Angeles, School of Medicine.
The researchers performed TB skin tests on 260 homeless adults in shelters, soup lines, and
outdoor locations in two areas of L.A. Compared with persons living in traditional housing (hotel,
apartment, or house), persons living in a shelter or institution were four times more likely to have
a positive TB test. Individuals living in limited shelters—such as an abandoned building, car,
all-night theater—were 3.5 times more apt to test positive, and those living on the streets
times as likely to test positive.
The likelihood of skin test positivity increased dramatically after an individual had been homeless
for 10 years (quadrupling the risk) but was relatively constant up to that point. Older homeless
persons were more apt to test positive, with persons aged 18 to 30 years showing a prevalence of
19 percent; those 31 to 40, 27 percent; and those over 40, 44 percent. Although alcohol and drug
abuse and prison history have been shown to be predictors of TB in the general population, they
were not important predictors of TB test positivity in this study.
Details are in "Tuberculosis skin testing among homeless adults," by Dr. Gelberg, Christopher J.
Panarites, Ph.D., Hal Morgenstern, Ph.D., and others, in the January 1997 Journal of General
Internal Medicine 12, pp. 2-33.
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AHCPR News and Notes
From the Administrator
I would like to take this opportunity to introduce myself, and tell you how pleased I am to be
working with you as Administrator of the Agency for Health Care Policy and Research. During
my years as a health services researcher, I was impressed with the high caliber of the research
supported by AHCPR and conducted by researchers on its staff. This continues to be true as I
learn more about the Agency from the inside.
AHCPR is the nation's lead Agency in ensuring that there is a scholarly and scientific foundation
for a rapidly changing health care system. However, we cannot succeed without your expertise
and dedication to excellence in research. Our shared goal is to enhance the way health care
services are organized, financed, and provided. We want to improve the care patients receive and
help them take responsibility for their own health and health care.
My agenda is still evolving, but one of my priorities is to ensure that AHCPR continues to
enhance the quality of health care and its value by meeting the needs of the health services
research community. One of the most critical needs is to ensure that we continue to build capacity
for health services research. We already are expanding our efforts to nurture the careers of new
investigators beyond our dissertation grants program and our National Research Service Awards.
I also plan to work with you to create centers of excellence where teams of established
researchers can do state-of-the-art work, and where young researchers can be trained. We already
have excellent examples in our Patient Outcomes Research Teams (PORTs), upcoming
Evidence-based Practice Centers, and MEDTEP Minority Research Centers.
We also will continue to play a critical role in fostering innovation among researchers in our field.
To that end, AHCPR is carefully weighing the balance between the funding of
investigator-initiated research and targeted research. We are reviewing the criteria we use in
targeting funds to particular areas and will be seeking funding partners for targeted research
projects. In addition, AHCPR will be working with you to translate health services research
findings into a language that can be used by decisionmakers at all levels, from patients, clinicians,
and health systems to the Federal and State governments. I firmly believe that we must
disseminate our findings and do everything we can to ensure that they are applied or at least
considered so that the public may benefit from the work we do.
I encourage you to let us know how we can do a better job of communicating and working with
you and of providing the basic tools and leadership needed to ensure that health services research
can meet the challenges that lie ahead. Please send your comments and suggestions to the
Managing Editor, Research Activities. We will let
you know in an upcoming issue of Research Activities about the comments and recommendations we receive and how we plan to address them.
AHCPR to collaborate with AMA and AAHP to
develop a National Guideline Clearinghouse™
Department of Health and Human Services (HHS) Secretary Donna E. Shalala recently
announced that the Agency for Health Care Policy and Research—a HHS
collaborate with two private-sector organizations to develop a comprehensive Internet-based
source for clinical practice guidelines. The new National Guideline Clearinghouse™ (NGC) will
make available a full range of current guidance on treatments for specific medical conditions.
Under the plan, AHCPR, the American Association of Health Plans, and the American Medical
Association will work jointly to develop the new guideline clearinghouse. It is anticipated that
AHCPR will award a contract later this year for the technical work to establish the NGC. The
target date for launching the new Internet clearinghouse site is fall 1998.
Internet technology makes it possible to provide rapid access to the latest information on medical
treatments. According to AHCPR Administrator John M. Eisenberg, M.D., the NGC will provide
access to the widest selection of guidelines available from public and private organizations by
establishing an independent, interactive Web site, accessible by using any standard Web browser
or through the Web sites of the three collaborating organizations.
The development and use of clinical practice guidelines have grown markedly in the past 5 years.
However, many existing and potential guideline users have difficulty gaining access to and
keeping abreast of the many clinical practice guidelines currently in use. In addition, existing
guidelines often differ in their development and content, further complicating their use. To help
address these issues, the NGC Web site will:
- Contain standardized information for thousands of guidelines such as title, sponsoring
organization, author(s), and methodology used.
- Provide guideline abstracts and where possible the full text of guidelines.
- Compare and contrast the recommendations of guidelines on similar topics, and provide
summaries covering major areas of agreement and disagreement.
- Have topic-specific electronic mailing lists to enable registered users to communicate with
another on guideline development, dissemination, implementation, and use.
AHCPR updates CONQUEST database
The Agency for Health Care Policy and Research has released an update to the clinical
performance measures database first released last year. CONQUEST 1.1, the Computerized
Needs-Oriented Quality Measurement Evaluation System, has been changed to make it more
user-friendly and compatible with a variety of operating systems.
CONQUEST is a quality improvement software tool that helps users identify, understand,
evaluate and select measures to assess and improve clinical performance. It summarizes
information on approximately 1,200 clinical performance measures developed by public- and
private-sector organizations to examine the quality of clinical care. CONQUEST describes
measures using a common language and provides a research short-cut by identifying specific types
of measures that may be modifiable or adaptable for a users own unique needs. If modified, the
measures should be retested for validity and reliability.
Organized in an easy-to-use format, CONQUEST consists of two interlocking databases—a
Condition Database and a Measure Database—that allow users to target specific conditions
measures. The Condition Database includes information on 52 clinical conditions; the Measure
Database contains information on the 1,200 measures contained in 53 measure sets. Users can
produce preprogrammed or custom reports and add measures and conditions to the database.
The 1.1 version functions as a run-time program in Windows® 3.1 and higher, including Windows®
95. Microsoft®'s Access® 2.0 is no longer required but still may be used to complete keyword
searches or add to the database. The User's Guide has been updated with clearer instructions and
CONQUEST may be downloaded from AHCPR's Web site. The diskettes (AHCPR Publication No.
97-DP01) and the User's Guide (AHCPR Publication No. 97-R001) also are available free from
the AHCPR Publications Clearinghouse.
CONQUEST users can obtain free technical assistance through AHCPR's Quality Measurement
Network (QMNet) contractor by calling (800) 865-5380.
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