Abstract Purpose Depression is associated with lowered work functioning, including absences, impaired productivity, and decreased job retention. Few studies have examined depression symptoms across a ...continuum of severity in relationship to the magnitude of work impairment in a large and heterogeneous patient population, however. We assessed the relationship between depression symptom severity and productivity loss among patients initiating treatment for depression. Methods Data were obtained from patients participating in the DIAMOND (Depression Improvement Across Minnesota: Offering a New Direction) initiative, a statewide quality improvement collaborative to provide enhanced depression care. Patients newly started on antidepressants were surveyed with the Patient Health Questionnaire 9-item screen (PHQ-9), a measure of depression symptom severity; the Work Productivity and Activity Impairment (WPAI) questionnaire, a measure of loss in productivity; and items on health status and demographics. Results We analyzed data from the 771 patients who reported being currently employed. General linear models adjusting for demographics and health status showed a significant linear, monotonic relationship between depression symptom severity and productivity loss: with every 1-point increase in PHQ-9 score, patients experienced an additional mean productivity loss of 1.65% ( P <.001). Even minor levels of depression symptoms were associated with decrements in work function. Full-time vs part-time employment status and self-reported fair or poor health vs excellent, very good, or good health were also associated with a loss of productivity ( P <.001 and P = .045, respectively). Conclusions This study shows a relationship between the severity of depression symptoms and work function, and suggests that even minor levels of depression are associated with a loss of productivity. Employers may find it beneficial to invest in effective treatments for depressed employees across the continuum of depression severity.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Summary
Background
Psoriasis vulgaris is a chronic, inflammatory skin disease characterized by a dysregulated immune response and it is associated with substantial systemic comorbidities. Biological ...drugs such as tumour necrosis factor (TNF)‐α inhibitors can ameliorate the disease but are expensive. Biosimilar drugs have the same amino‐acid sequence as the originator, but differences in manufacturing can affect biological activity, efficacy and tolerability.
Objectives
To explore potential differences in intracellular phosphorylation of signalling molecules in peripheral blood cells from patients with psoriasis treated with the TNF‐α inhibitor infliximab compared with healthy controls, and to investigate if the phosphorylation pattern was influenced by switching from the originator infliximab to the biosimilar CT‐P13.
Methods
By flow cytometry, we measured phosphorylation of nuclear factor kappa B, extracellular signal‐regulated kinase 1/2, p38 mitogen‐activated protein kinase and signal transducer and activator of transcription 3, before and after TNF‐α stimulation in monocytes and T, B, natural killer and CD3+ CD56+ cells from 25 patients with psoriasis treated with infliximab and 19 healthy controls.
Results
At inclusion, phosphorylation levels of peripheral blood mononuclear cells (PBMCs) were increased in patients with psoriasis compared with healthy controls, even though clinical remission had already been achieved. Phosphorylation levels declined in patients on both originator infliximab and biosimilar during continued treatment. No significant differences were detected between the two medications after 12 months.
Conclusions
Patients with psoriasis on infliximab have higher activation levels of PBMCs than do healthy controls, possibly reflecting systemic inflammation. Switching from the originator infliximab to biosimilar CT‐P13 did not affect phosphorylation levels or clinical parameters, suggesting that CT‐P13 is a noninferior treatment alternative to the originator infliximab.
What's already known about this topic?
The pathogenesis of psoriasis encompasses interactions between dendritic cells, T cells, keratinocytes and neutrophils. Certain cytokines, including tumour necrosis factor (TNF)‐α, from these cells activate intracellular signalling cascades, which can be measured using phospho flow cytometry.
Infliximab and the biosimilar CT‐P13, both effective in psoriasis, act by binding TNF‐α.
What does this study add?
Peripheral blood mononuclear cells (PBMCs) from patients with psoriasis are more activated with higher intracellular signalling activity than PBMCs from healthy controls.
This elevated activation level declines during infliximab treatment with no significant differences between originator and biosimilar infliximab.
What is the translational message?
Higher activation levels of PBMCs implies an ongoing systemic inflammation, possibly related to cardiovascular disease and obesity associated with psoriasis.
Long‐term infliximab treatment may be beneficial in preventing such comorbidities.
Switching from originator to biosimilar infliximab does not seem to influence intracellular signalling activity of PBMCs.
Linked Comment: Gjersvik. Br J Dermatol 2018; 179:247–248.
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Shared decision making (SDM) is an important component of patient-centered care, but there is little information about its use in the primary care of depression, so we sought to study its frequency ...in usual care as reported by patients.
Telephone interview of 1168 depressed patients taking antidepressants in 88 Minnesota primary care clinics who were identified from pharmacy claims data soon after a prescription for an antidepressant. We measured depression severity with the 9-item Patient Health Questionnaire and used a composite measure of SDM that reflected patient involvement in treatment decisions.
These patients reported an average score for SDM of 50.7 (standard deviation, 32.8) on a scale of 0 to 100, where higher scores equate with greater SDM. In univariate analyses, the largest differences among scores were for age (scores of 58, 53, 45, and 33 for those aged 18-34, 35-49, 50-64, and >64 years, respectively; P < .0001); duration of treatment (a score of 56.6 on treatment <6 weeks vs 45.5 if longer; P < .001); and other treatments in the past 6 months (60.5 if yes vs. 46.0 if no; P = .001). SDM was not associated with any clinic characteristics, but it was correlated with patient-reported quality of care (r = 0.48; P < .001). Multivariate analyses confirmed some of these findings while showing a more complex set of relationships.
Older patients with depression and those who have been in treatment longer report much less SDM in their care. Improving SDM, especially for these groups, may be an important target for improving patient experience and perceived quality.
Research connecting patient-centered medical homes (PCMHs) with improved quality and reduced utilization is inconsistent, possibly because individual domains of change, and the stage of change, are ...not incorporated in the research design. The objective of this study was to examine the association between stage and domain of change and patterns of health care utilization.
This was a cross-sectional observational study that including 87 Minnesota clinics certified as medical homes. Patients included those receiving management for diabetes or cardiovascular disease with insurance coverage by payers participating in the study. PCMH transformation stage was defined by practice systems in place, with measurements summarized in 5 domains. Health care utilization was measured by total utilization, frequency of outpatient visits and prescriptions, and occurrence of inpatient and emergency department visits.
PCMH transformation was associated with few changes in utilization, but there were important differences by the underlying domains of change. We demonstrate meaningful differences in the impact of PCMH transformation by diagnosis cohort and comorbidity status of the patient.
Because the association of health care utilization with PCMH transformation varied by transformation domain and patient diagnosis, practice leaders need to be supported by research incorporating detailed measures of PCMH transformation.
Immunogenicity is a frequent cause of secondary non‐response to tumour necrosis factor (TNF) inhibitors. Drug level measurement and detection of antidrug antibodies have been shown to be cost ...effective and clinically relevant, and a large number of assays are available for these purposes. It is, however, difficult to compare assays and translate results into clinical meaningful information due to different methodological approaches and a lack of assay standardization. We have analysed infliximab drug levels and antidrug antibodies in 107 patient samples using enzyme‐linked immunoassays (ELISA), immunofluorometric assays (IFMA) and reporter‐gene assays (RGA). The RGA gave the lowest results for drug levels, whereas the IFMA detected the highest number of antidrug antibody positive sera. Applying individualized therapeutic ranges to each assay resulted in agreement among all three assays in 74% of samples for drug levels and 98% of samples for antidrug antibodies. We found that TNF inhibitor monitoring assays measure on different scales and that the agreement between quantitative results is limited. However, interassay differences can partially be overcome by assay‐individualized translations of quantities into categories, which also is necessary for a meaningful clinical application. Our data demonstrate that assays should not be used interchangeably and that direct comparison of quantitative drug levels obtained with different assays should be avoided.
Abstract Purpose We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. Methods ...Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. Results The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. Conclusions These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
The purpose of this article is to produce a relatively simple conceptual framework for guiding and studying practice improvement.
I summarize the lessons from my experience with a variety of quality ...improvement research studies during the last 30 years, supplemented with relevant literature from both medicine and other industries about the issues associated with successful quality improvement.
My experience suggests that organizational leadership with an urgent vision for change, ability to manage the change process, and selection of systematic changes capable of fulfilling the vision are each critical for successful quality improvement. Published literature from other industries emphasizes the importance of a goal-directed change process managed by leaders who recognize the need to engage their employees and other leaders in a disciplined but flexible way that accommodates external and internal factors and uses teams and group learning. It also suggests the importance of organizational context and the level of external and internal barriers and facilitators for change. The resulting model proposes that priority, change process, and care process content are necessary for measurable improvements in quality of care and patient outcomes, although internal and external barriers must also be attended to and addressed.
This framework may provide a guide to those in the front lines of care who would like to make the care transformations that are needed to greatly improve care. It may also be helpful to those who are developing or testing interventions and recruiting medical practices for such change efforts.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Objectives: To determine whether depression is treated differently in older and younger patients in primary care clinics.
Design: Administrative data were used to identify patients with a depression ...diagnosis code. The sources of data were baseline and 3‐month follow‐up surveys, the health plan electronic database, and chart audits.
Setting: Nine primary care clinics owned by a health maintenance organization in the Midwest.
Participants: The study sample (N=1,023) consisted of adult patients, aged 19 to 93, and was divided into six age groups, from young adult, under age 35, to old old, 75 or older.
Measurements: Independent variables were a series of dummy variables: age groups, baseline depression severity, sex, and incident depression. Outcomes were defined as care processes (assessment, resources) and improvement in depression symptoms (Center for Epidemiologic Studies—Depression scale short form). Univariate and multivariate logistic regression analyses were used to analyze patient characteristics, depression symptoms, and care process variables. Significance level was reported based on the chi‐square test of probability, P≤.05.
Results: The adjusted response rates to the baseline and follow‐up surveys were 69% and 82%. Elderly depressed patients were more likely than younger depressed patients to be widowed, have low levels of education, have fair or poor health, and have three or more comorbid health problems. There were no differences, by age, in number of depressive symptoms, antidepressant treatment, or recommendation for a follow‐up appointment. Younger patients were more likely than older patients to have a new diagnosis of depression and to report being depressed most of the past year. Providers were only 6% as likely to ask old‐old depressed patients about suicide risk, about one‐fourth as likely to referral them to a mental health therapist, about one‐fifth as likely to ask if they felt depressed, and one‐twentieth as likely to ask about a problem with alcohol as they were with young‐adult depressed patients. The old‐old were about one‐third as likely to report improvement in depression symptoms after 3 months as the young‐adult patients.
Conclusion: This study suggests a possible pattern of underattention to the oldest depressed patients. Failure to ask about suicide risk is especially of concern because of the high suicide rate of depressed geriatric patients. The finding that physicians are less likely to focus on depression with old‐old patients may be explained, in part, by the concept of invisibility of the ordinary.
Adolescent Primary Care Visit Patterns Nordin, James D., MD, MPH; Solberg, Leif I., MD; Parker, Emily D., MPH, PhD
Annals of family medicine,
11/2010, Letnik:
8, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Abstract Purpose Many clinical preventive care services are recommended for adolescents. Little is known about whether most adolescents have a sufficient number of preventive care services visits ...over time to receive those services. We wanted to measure how frequently adolescents who are insured either through private insurance or government programs have preventive vs nonpreventive care visits. Methods We conducted a retrospective descriptive analysis based on claims data from a large health plan in Minnesota with about 700,000 members. All study patients were aged 11 to 18 years between January 1, 1998, and December 31, 2007. Our outcome measure was rates of preventive and nonpreventive care visits. Results One-third of adolescents with 4 or more years of continuous enrollment had no preventive care visits from age 13 through 17 years, and another 40% had only a single such visit. Nonpreventive care visits were more frequent in all age-groups, averaging about 1 per year at age 11 years, climbing to about 1.5 per year at age 17 years. Differences in rates between government insurance and commercial insurance were small. In older adolescence, girls had more preventive care visits and more nonpreventive care visits than did boys. Conclusions Most adolescents come in infrequently for preventive care visits but more often for nonpreventive care visits. We recommend using the same approach in adolescence for preventive care that is being used in adults: the no-missed-opportunities paradigm. All visits by adolescents should be viewed as an opportunity to provide preventive care services, and systems should be set up to make that possible, even in busy practices with short encounters with a clinician.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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