Disease Management Update
Volume III, No. 36
December 28, 2006
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Table of Contents
- Requests for Antidepressants Influence Physician Evaluations of Depression
- Disease Management Q&A: Marketing e-Visits to Physicians
- HealthSounds Podcast: Primary Care Physicians and Disease Management
- Extended Hours for Residents Associated with Medical Errors, Patient Death
- Prescription for Primary Care: Initiatives for Change
1. Requests for Antidepressants Influence Physician Evaluations of Depression
Patients who initiate a general discussion about the need for antidepressant medication with their primary care physician (PCP) are more likely to be thoroughly evaluated for depression than those who make a brand-specific request or no request, according to a study appearing in the December issue of Medical Care.
The study was conducted with 18 "standardized patients" — actors who are specifically trained to portray patients in medical education settings. Each "patient" portrayed a role involving one of two clinical presentations: major depression accompanied by carpal tunnel syndrome or an adjustment disorder accompanied by lower-back pain. The standardized patients were also trained to request an antidepressant medication by brand name, request a general antidepressant, or not ask for medication.
Study findings showed that requests for general antidepressant medication were associated with an increase in depression-specific history-taking by physicians. On average, physicians asked 0.80 more questions than if no request was made, while brand-specific requests were only marginally associated with an increase in questions (0.45 more questions).
A greater amount of time spent by the physician in depression history-taking was also directly associated with both the likelihood of a diagnosis of depression being made in the patient's medical record and the provision of minimally acceptable initial depression care.
Findings also showed that physicians obtained more extensive depression-related history from patients who portrayed major depression with carpal tunnel syndrome compared to those who portrayed an adjustment disorder accompanied by lower-back pain (6.7 questions compared to 5.2 questions).
To learn more about the findings of this study, please visit:
2. Disease Management Q&A: Marketing e-Visits to Physicians
Each week, a healthcare professional responds to a reader's
query on an industry issue. This week's expert is Dr. Eric Liederman, medical director of clinical information systems for the University of California Davis Medical Center.
Question: How do you market e-visits within the physician group?
Response: For internal marketing, we employ all our physicians and staff, so we've implemented a system in all our clinics. Our goal was to improve access for patients, but that's quite different from getting somebody to like it. We've found that the volume of registered patients and received messages is most closely correlated with how well or poorly an individual physician likes the system, irrespective of nurse or medical assistant opinions.
The question is how to move through the adoption curve and get these laggard physicians, the ones who don't like the system for some reason, to decide differently. We've taken a two-pronged approach to that.
First, we use opinion leaders in various clinics to work with resistant doctors and assess reasons behind their hesitation. Many times these issues relate to feeling uncomfortable using the computer and not understanding the functionality well enough to make it easy. So far, that's been addressable through their peers.
We're also implementing changes to our compensation system to tie some compensation to a percentage of panel patients and messages, not just for the individual, but for the whole clinic. There's built-in peer pressure to the compensation structure.
For more details on establishing criteria for billable visits, allocating IT and directing costs, please visit:
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3. HealthSounds Podcast: Primary Care Physicians and Disease Management
In this week's Disease Management podcast, Peter Simpson, president of Segmedica Inc, defines the three types of physicians his organization has identified after years of psychological research. Additionally, Dr. Maureen Mangotich, medical director of provider and community outreach with McKesson Health Solutions, reviews some feedback McKesson has received after introducing new programs to primary care physicians.
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4. Extended Hours for Residents Associated with Medical Errors, Patient Death
Doctors-in-training, or interns, are four times more likely to make fatigue-related medical errors that contribute to the death of a patient after working five extra-long shifts per month, 24 or more hours without rest, compared to months when they do not work extended-duration shifts, according to the results of a study from the division of sleep medicine at Brigham and Women's Hospital (BWH).
Researchers conducted a Web-based survey across the United States in which 2,737 interns from diverse specialties completed 17,003 confidential monthly reports. Each intern acted as his or her own control. The researchers observed that compared to months in which no extended-duration shifts were worked, interns were 3.5 times more likely to report at least one fatigue-related significant medical error during months they worked one to four extended-duration shifts and were 7.5 times more likely to report at least one fatigue-related significant medical error during months they worked five or more extended-duration shifts.
They were also 8.7 times more likely to report at least one fatigue-related preventable adverse event that harmed the patient during months they worked one to four extended-duration shifts and were 7 times more likely to report at least one fatigue-related preventable adverse event that harmed the patient during months they worked five or more extended-duration shifts.
Interns were 4.1 times more likely to report at least one fatigue-related preventable adverse event that resulted in the death of the patient during months they worked five or more extended-duration shifts.
To see more of this survey's results, please visit:
5. Prescription for Primary Care: Initiatives for Change
There are rumblings at each step of the healthcare continuum: hospitals and health plans want PCPs to accept a larger role in disease management and care transitions, including patient education and follow-up. Meanwhile, PCPs struggle to provide quality care and devote adequate time to patients in the face of reduced reimbursements and increased reporting. It's a scenario that frustrates patients, who increasingly turn to emergency departments for primary care when the PCP is unavailable.
Given this climate, it's no wonder that more medical students choose specialty training over family medicine, leaving hospitals and practices poised for a staffing shortage. To reverse these trends, primary care is now a strategic focus for much of the industry. In its October 2006 online survey, the Healthcare Intelligence Network (HIN) asked healthcare organizations how they are affected by the state of primary care and how they are handling the deficiencies.
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