While evidence exists regarding the effectiveness of many health education interventions, few of these evidence-based programs have been systematically or widely disseminated. This paper reports on ...the dissemination of one such intervention, the 6-week peer-led Chronic Disease Self-Management Program, throughout a large health-care system, Kaiser Permanente. We describe the dissemination process and, using qualitative analysis of interviews and surveys, discuss the factors that aided and hindered this process and make recommendations for similar dissemination projects. Six years after the beginning of the dissemination process, the program is integrated in most of the Kaiser Permanente regions and is being offered to several thousand people a year.
Objective: The objective of this study was to examine primary care physicians' propensity to assess their elderly patients for depression using data from videotapes and patient and physician surveys. ...Study Design: An observational study was informed by surveys of 389 patients and 33 physicians, and 389 videotapes of their clinical interactions. Secondary quantitative analyses used video data scored by the Assessment of Doctor-Elderly Patient Transactions system regarding depression assessment. A random-effects logit model was used to analyze the effects of patient health, competing demands, and racial and gender concordance on physicians' propensity to assess elderly patients for depression. Results: Physicians assessed depression in only 14% of the visits. The use of formal depression assessment tools occurred only 3 times. White patients were almost 7 times more likely than nonwhite patients to be assessed for depression (odds ratio OR, 6.9; P < 0.01). Depression assessment was less likely if the patient functioned better emotionally (OR, 0.95; P < 0.01). The propensity of depression assessment was higher in visits that covered multiple topics (OR, 1.3; P < 0.01) contrary to the notion of competing demands crowding out mental health services. Unexpectedly, depression assessment was less likely to occur in gender and racially concordant patient-physician dyads. Conclusions: Primary care physicians assessed their elderly patients for depression infrequently. Reducing the number of topics covered in visits and matching patients and physicians based on race and gender may be counterproductive to depression detection. Informed by videotapes and surveys, our findings offer new insights on the actual care process and present conclusions that are different from studies based on administrative or survey data alone.
Age differences on the 20-item Center for Epidemiological Studies Depression Scale (CES-D) were examined for 4 age-cohort groups: 20-39 years
(
n
= 548)
, 40-54 years
(
n
= 218)
, 55-69 years
(
n
= ...352)
, and 70-98 years
(
n
= 212)
. On total CES-D, there was a significant age effect and quadratic trend, with means for the middle aged least and those for the oldest most elevated. On 4 CES-D subscales-Depressed Mood, Psychomotor Retardation, Lack of Well-being (i.e., reverse-scored items), and Interpersonal Difficulties-the oldest group scored highest only on lack of well-being. Somatic symptoms of depression were not elevated. Young adults scored highest on depressed mood. Adults who are now old were not generally characterized by elevated self-reports of depressive symptoms; however, on items asking whether the respondent has a hopeful outlook, those aged 70 and older were more likely to endorse a lack of such positive feelings.
This paper reports ethnographic and statistical data on the indigenous Chinese concept of constitution (ti-zhi) and its association with health status. The data were obtained through in-depth ...interviews with 203 Chinese elderly residing in Taipei and Los Angeles. The informants used several dimensions to characterize their constitutions. They also described how their constitutions originated and were expressed over the lifecourse. The association between these characterizations of constitution and reported number of symptoms/diseases, self-rated health status and satisfaction with health were examined statistically. These analyses indicate that characterizations of constitution as strong/weak or as hot/cold, have significant but moderate associations with the indicators of health status.
This research identified characteristics of persons and their illness episodes that predict appropriate and inappropriate decisions to seek medical care.
This study analyzes 1,292 health care ...decisions of 885 elderly members of an HMO in Los Angeles. Illness episodes are divided into three categories based on the expertise of a panel of 22 geriatricians, using a formal mathematical analysis derived from anthropological consensus theory. These categories are physician visit not recommended, physician visit recommended, and physician visit mandatory. Physician contact is regressed on a list of variables derived from Andersen's behavioral model separately for each group of episodes.
Although the variables indicating perceived seriousness and duration of the episode consistently predict the decision to contact a physician, regardless of whether that contact is considered appropriate by the geriatrician panel, the variables indicating other illness responses and predisposing personal attributes have less consistent patterns of significance.
The category of episodes (visit recommended) for which predisposing personal attributes figure most strongly in the treatment decision is the one for which there are no clear cultural directives to action. Implications for health education and policy are drawn from the findings.
Data collected from 288 patients with rheumatoid arthritis (RA) indicated that 54% of respondents also reported other chronic conditions, and that 20% rated at least one of these other conditions as ...severe. Both the frequency and severity of these comorbidities affected scores on measures of depressive symptoms, social connectedness and on the Arthritis Impact Measurement Scales. These findings suggest that the absence of controls for comorbidity may bias measures of functional status among patients with RA.
To evaluate the Stress Process Model proposed by Pearlin and colleagues by examining the role of personal and social resources in mediating the relationship between the rheumatoid arthritis (RA) ...related stressors of functional disability, pain, and flares, and the outcome of depressive symptoms.
Data are from 285 patients who participated in a study of the natural history of RA, comorbidity and depression. Measures include the Center for Epidemiologic Studies-Depression (CES-D) scale, the Arthritis Impact Measurement Scale Functioning and Pain scales, the Lubben Social Network scale, and items indicating sociodemographic status, health status and personal resources. A series of hierarchical regression analyses with multiplicative interaction terms were conducted.
Substantial consistency between the Stress Process Model and relationships observed in the data was demonstrated.
Although no claim is made to having demonstrated that the observed relationships are causal, the fact that the data are consistent with the model invites a prospective analysis in which the ordering of the variables over time can be established unambiguously. Because of the implications of the Stress Process Model for the design of psychosocial interventions, such a test is especially important.
Although considerable research has been done on patient-physician interaction, few studies have examined discrepancies between patients and physicians in their assessments of the patient's physical ...functioning. One recent study reports such discrepancies between rheumatologists and 41% of their rheumatoid arthritis patients. This article reports data replicating that study and examining the relationships between such discrepancies and a number of other variables.
This is a longitudinal study of 158 patients with rheumatoid arthritis who were interviewed 4 times over a 2-year period and who reported their levels of physical functioning on the Arthritis Impact Measurement Scales. At the time of the fourth interview, the rheumatologists rated each patient's physical functioning on the revised criteria published by the American College of Rheumatology.
Rheumatologists' assessments of their patients' physical functioning were discrepant with the patient's assessment for 35% of these patients. Twenty-seven patients were rated as worse than they rated themselves and 28 were rated as better. There were no differences between the concordant and the two discrepant groups in demographic or health status characteristics.
Medicare beneficiaries who enroll in "risk contract" Health Maintenance Organizations (HMOs) are covered for services only if they are provided or approved by the HMO. Thus, their enrollment ...decisions involve selecting a health care delivery system and may be influenced by whether the HMO has contracts with particular providers. Disenrollment decisions, in turn, may be influenced by breaks in contracts between the HMO and its medical groups. This study examines decisions made by Medicare HMO enrollees when their HMO terminated its relationship with a major medical group; the group then signed a contract with a competing HMO. Beneficiaries were forced to choose between remaining with their HMO and switching to another provider, and switching to the competing HMO where they could keep their provider. Beneficiaries demonstrated considerable loyalty to their providers; nearly 60% switched to the competing HMO. Previous research on health care coverage decisions has been based on models which did not address consumers' knowledge, options, and information sources. In this decision context, we found that knowledge and information sources were the most important determinants of beneficiary decisions.
Using theory and methods from cognitive anthropology, this article examines, in a two-step analysis, the degree to which health care decisions made by elderly Medicare recipients coincide with the ...norms of physicians. First, consensus theory (Romney et al. 1986) was used to establish that physicians specializing in geriatrics agreed which among many symptoms experienced by elderly patients should receive medical attention. By asking 22 physicians to rate the medical necessity of physician visits for 106 symptoms, a key was developed to assess which patient treatment decisions were deemed "biomedically appropriate" by physicians. Second, a comparison was made between the treatment decisions deemed biomedically appropriate by physicians and 2,091 actual decisions reported by 885 elderly study participants. This comparison showed, in the aggregate, that the treatment decisions made by the elderly study participants are congruent with the norms of the physicians. Rationales given by the elders for their treatment decisions are discussed using an ethnographic decision modeling framework in an effort to understand the patterning of criteria they used to arrive at biomedically appropriate and inappropriate decisions.
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