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PTSD in urban primary care: high prevalence and low physician recognition.

ABSTRACT: Posttraumatic stress disorder (PTSD) is associated with medical and psychological morbidity. The prevalence of PTSD in urban primary care has not been well described.To measure the prevalence of PTSD in primary care patients overall and among those with selected conditions (chronic pain, depression, anxiety, heavy drinking, substance dependence (SD), irritable bowel syndrome (IBS), and immigrant status).Cross-sectional study.English-speaking patients aged 18-65 years old, awaiting primary care appointments in an urban academic medical center, were eligible for enrollment to determine PTSD prevalence (N = 509). Additional eligible participants (n = 98) with IBS or SD were subsequently enrolled.PTSD (past year) and trauma exposure were measured with Composite International Diagnostic Interview. We calculated the prevalence of PTSD associated with depression, anxiety, heavy drinking, SD, IBS, and chronic pain. Only the analyses on heavy drinking, SD, and IBS used all 607 participants.Among the 509 adults in primary care, 23% (95% CI, 19-26%) had PTSD, of whom 11% had it noted in the medical record. The prevalence of PTSD, adjusted for age, gender, race, and marital and socioeconomic statuses, was higher in participants with, compared to those without, the following conditions: chronic pain (23 vs 12%, p = .003), major depression (35 vs 11%, p < .0001), anxiety disorders (42 vs 14%, p < .0001), and IBS (34 vs 18%, p = .01) and lower in immigrants (13 vs 21%, p = .05).The prevalence of PTSD in the urban primary care setting, and particularly among certain high-risk conditions, compels a critical examination of optimal approaches for screening, intervention, and referral to PTSD treatment.

SUBMITTER: Liebschutz J

PROVIDER: S-EPMC2219859 | biostudies-other | 2007 Jun

REPOSITORIES: biostudies-other

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Project description:ImportanceEfforts to reduce low-value tests and treatments in primary care are often ineffective. These efforts typically target physicians broadly, most of whom order low-value care infrequently.ObjectivesTo measure physician-level use rates of 4 low-value screening tests in primary care to investigate the presence and characteristics of primary care physicians who frequently order low-value care.Design, setting, and participantsA retrospective cohort study was conducted using administrative health care claims collected between April 1, 2012, and March 31, 2016, in Ontario, Canada. This study measured use of 4 low-value screening tests-repeated dual-energy x-ray absorptiometry (DXA) scans, electrocardiograms (ECGs), Papanicolaou (Pap) tests, and chest radiographs (CXRs)-among low-risk outpatients rostered to a common cohort of primary care physicians.ExposuresPhysician sex, years since medical school graduation, and primary care model.Main outcomes and measuresThis study measured the number of tests to which a given physician ranked in the top quintile by ordering rate. The resulting cross-test score (range, 0-4) reflects a physician's propensity to order low-value care across screening tests. Physicians were then dichotomized into infrequent or isolated frequent users (score, 0 or 1, respectively) or generalized frequent users for 2 or more tests (score, ≥2).ResultsThe final sample consisted of 2394 primary care physicians (mean [SD] age, 51.3 [10.0] years; 50.2% female), who were predominantly Canadian medical school graduates (1701 [71.1%]), far removed from medical school graduation (median, 25.3 years; interquartile range, 17.3-32.3 years), and reimbursed via fee-for-service in a family health group (1130 [47.2%]). They ordered 302 509 low-value screening tests (74 167 DXA scans, 179 855 ECGs, 19 906 Pap tests, and 28 581 CXRs) after 3 428 557 ordering opportunities. Within the cohort, generalized frequent users represented 18.4% (441 of 2394) of physicians but ordered 39.2% (118 665 of 302 509) of all low-value screening tests. Physicians who were male (odds ratio, 1.29; 95% CI, 1.01-1.64), further removed from medical school graduation (odds ratio, 1.03; 95% CI, 1.02-1.04), or in an enhanced fee-for-service payment model (family health group) vs a capitated payment model (family health team) (odds ratio, 2.04; 95% CI, 1.42-2.94) had increased odds of being generalized frequent users.Conclusions and relevanceThis study identified a group of primary care physicians who frequently ordered low-value screening tests. Tailoring future interventions to these generalized frequent users might be an effective approach to reducing low-value care.

Project description:Although previous studies suggest an association between provider burnout and suboptimal self-reported communication, no studies relate physician burnout to observed patient-physician communication behaviors.To investigate the relationship between physician burnout and observed patient-physician communication outcomes in patient-physician encounters.Longitudinal study of enrollment data from a trial of interventions to improve patient adherence to hypertension treatment.Fifteen urban community-based clinics in Baltimore, MD.Forty physicians and 235 of their adult hypertensive patients, with oversampling of ethnic minorities and poor persons. Fifty-three percent of physicians were women, and the average practice experience was 11.2 years. Among the 235 patients, 66% were women, 60% were African-American, and 90% were insured.Audiotape analysis of communication during outpatient encounters (one per patient) using the Roter Interaction Analysis System and patients' ratings of satisfaction with and trust and confidence in the physician.The median time between the physician burnout assessment and the patient encounter was 15.1 months (range 5.6-30). Multivariate analyses revealed no significant differences in physician communication based on physician burnout. However, compared with patients of low-burnout physicians, patients of high-burnout physicians gave twice as many negative rapport-building statements (incident risk ratio 2.06, 95% CI 1.58-2.86, p < 0.001). Physician burnout was not significantly associated with physician or patient affect, patient-centeredness, verbal dominance, or length of the encounter. Physician burnout was also not significantly associated with patients' ratings of their satisfaction, confidence, or trust.Physician burnout was not associated with physician communication behaviors nor with most measures of patient-centered communication. However, patients engaged in more rapport-building behaviors. These findings suggest a complex relationship between physician burnout and patient-physician communication, which should be investigated and linked to patient outcomes in future research.

Project description:BackgroundIn high-income countries with a low HIV prevalence, primary care doctors are likely the first point of medical contact for people at high risk of HIV. One of the key factors for successful implementation of preventive measures is the cooperation of primary healthcare providers. Hong Kong's population mostly seek primary care in the private sectors. Our study evaluated the involvement of private primary healthcare providers in HIV prevention and care.MethodsA cross-sectional postal structured questionnaire was administered to 1102 private primary care doctors in Hong Kong in December 2017. Responses were received via postal mail, fax or online. Non-respondents received a phone-call reminder to complete the survey. Descriptive analyses were performed for all the question items. Chi-square test was used to assess the association between participants' level of involvement in HIV prevention and care and their demographics and medical practice characteristics.ResultsThe response rate was 17.9% (197/1102). Most of the respondents were Chinese (95%) and have obtained their primary medical qualifications in Hong Kong (72%). More than half of the doctors have practiced in the private sector for more than 20 years (54%). Six aspects were used to evaluate practices or involvements in HIV prevention or care: Most of the responding doctors had offered advice (61%) and/or HIV test (76%) to patients with high-risk behaviors. However, fewer doctors had diagnosed HIV (27%), provided care for HIV positive patients (21%), reported HIV cases (19%) or prescribed antiretrovirals (4%). Nine (4.5%) did not answer all six questions on their practices or involvements in HIV prevention or care. The remaining respondents were then categorized into no/low involvement group and high involvement group. Overall,71% had no/low involvement (133/188) compared to 29% who had high involvement (55/188). Factors associated with high involvement included being in the 50-59 age group (OR: 2.48, 95% CI: 1.12-5.5), and belonging to a large practice (OR: 3.16, 95% CI: 1.4-7.12).ConclusionsOverall, most private primary care doctors in Hong Kong have no or low involvement in HIV prevention and care. However, most were willing and experienced in providing general preventive services, such as HIV testing and advice.

Project description:PurposeWe conducted a study to understand primary care physician (PCP) and urologist perspectives on determinants of active surveillance care delivery for men with low-risk prostate cancer.MethodsWe conducted in-depth, semistructured, virtual interviews with a purposive sample of 19 PCPs and 15 urologists between June 2020 and March 2021. We used the behavioral theory-informed Theoretical Domains Framework to understand barriers to and facilitators of active surveillance care delivery. Interviews were recorded, transcribed, and deductively coded into framework domains and constructs by 3 independent coders. Participant recruitment continued until data saturation by group.ResultsOur study included 19 PCPs (9 female; 4 in community practices, 15 in academic medical centers) and 15 urologists (3 female; 5 in private practice, 3 in academic medical centers). The most commonly reported Theoretical Domains Framework domains affecting active surveillance care were (1) knowledge and (2) environmental context and resources. Although urologists were knowledgeable about active surveillance, PCPs mentioned limitations in their understanding of active surveillance (eg, what follow-up entails). Both groups noted the importance of an informed patient, especially how a patient's understanding of active surveillance facilitates their receipt of recommended follow-up. Physicians viewed patient loss to follow-up as a barrier, but identified a favorable organizational culture/climate (eg, good communication between physicians) as a facilitator.ConclusionsWith patients increasingly involving their PCPs in their cancer care, our study presents factors both PCPs and urologists perceive (or identify) as affecting optimal active surveillance care delivery. We provide insights that can help inform multilevel supportive interventions for patients, physicians, and organizations to ensure the success of active surveillance as a management strategy for low-risk prostate cancer.

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PTSD in urban primary care: high prevalence and low physician recognition.

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