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2.  Community-Partnered Evaluation of Depression Services for Clients of Community-Based Agencies in Under-Resourced Communities in Los Angeles 
Journal of General Internal Medicine  2013;28(10):1279-1287.
As medical homes are developing under health reform, little is known regarding depression services need and use by diverse safety-net populations in under-resourced communities. For chronic conditions like depression, primary care services may face new opportunities to partner with diverse community service providers, such as those in social service and substance abuse centers, to support a collaborative care model of treating depression.
To understand the distribution of need and current burden of services for depression in under-resourced, diverse communities in Los Angeles.
Baseline phase of a participatory trial to improve depression services with data from client screening and follow-up surveys.
Of 4,440 clients screened from 93 programs (primary care, mental health, substance abuse, homeless, social and other community services) in 50 agencies, 1,322 were depressed according to an eight-item Patient Health Questionnaire (PHQ-8) and gave contact information; 1,246 enrolled and 981 completed surveys. Ninety-three programs, including 17 primary care/public health, 18 mental health, 20 substance abuse, ten homeless services, and 28 social/other community services, participated.
Comparisons by setting in 6-month retrospective recall of depression services use.
Depression prevalence ranged from 51.9 % in mental health to 17.2 % in social-community programs. Depressed clients used two settings on average to receive depression services; 82 % used any setting. More clients preferred counseling over medication for depression treatment.
Need for depression care was high, and a broad range of agencies provide depression care. Although most participants had contact with primary care, most depression services occurred outside of primary care settings, emphasizing the need to coordinate and support the quality of community-based services across diverse community settings.
PMCID: PMC3785668  PMID: 23670566
depression services; community-partnered;  participatory research; CPPR; CBPR; community-based; under-resourced
3.  A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better Effectiveness After Transition - Heart Failure (BEAT-HF) randomized controlled trial 
Trials  2014;15:124.
Heart failure is a prevalent health problem associated with costly hospital readmissions. Transitional care programs have been shown to reduce readmissions but are costly to implement. Evidence regarding the effectiveness of telemonitoring in managing the care of this chronic condition is mixed. The objective of this randomized controlled comparative effectiveness study is to evaluate the effectiveness of a care transition intervention that includes pre-discharge education about heart failure and post-discharge telephone nurse coaching combined with home telemonitoring of weight, blood pressure, heart rate, and symptoms in reducing all-cause 180-day hospital readmissions for older adults hospitalized with heart failure.
A multi-center, randomized controlled trial is being conducted at six academic health systems in California. A total of 1,500 patients aged 50 years and older will be enrolled during a hospitalization for treatment of heart failure. Patients in the intervention group will receive intensive patient education using the ‘teach-back’ method and receive instruction in using the telemonitoring equipment. Following hospital discharge, they will receive a series of nine scheduled health coaching telephone calls over 6 months from nurses located in a centralized call center. The nurses also will call patients and patients’ physicians in response to alerts generated by the telemonitoring system, based on predetermined parameters. The primary outcome is readmission for any cause within 180 days. Secondary outcomes include 30-day readmission, mortality, hospital days, emergency department (ED) visits, hospital cost, and health-related quality of life.
BEAT-HF is one of the largest randomized controlled trials of telemonitoring in patients with heart failure, and the first explicitly to adapt the care transition approach and combine it with remote telemonitoring. The study population also includes patients with a wide range of demographic and socioeconomic characteristics. Once completed, the study will be a rich resource of information on how best to use remote technology in the care management of patients with chronic heart failure.
Trial registration # NCT01360203.
PMCID: PMC3990010  PMID: 24725308
Heart failure; Telemonitoring; Nurse coaching; Readmission; Care coordination; Self-care
4.  Who purchases cigarettes from cheaper sources in China? Findings from the ITC China Survey 
Tobacco control  2013;23(0 1):i97-i101.
The availability of cigarettes from cheaper sources constitutes a major challenge to public health throughout the world, including China, because it may counteract price-based tobacco control policies. The goal of this study was to identify factors associated with purchasing cigarettes from cheaper sources among adult smokers in China.
Data were analyzed from Waves 1–3 of the International Tobacco Control China Survey, conducted in 2006–2009 among adult smokers in six cities in China (N=7,980). One survey question asked, “In the last six months, have you purchased cheaper cigarettes than you can get from local stores for economic reasons?” We examined whether sociodemographic factors and smoking intensity were associated with purchasing cigarettes from cheaper sources using the general estimating equations (GEE) model. Sociodemographic factors considered were gender, age, marital status, monthly household income, education, employment status, and city of residence.
15.6% of smokers reported purchasing cigarettes from cheaper sources. After controlling for other covariates, the associations of the behavior of purchasing cigarettes from cheaper sources with age (AOR=1.49, 95% CI=1.17–3.92 for age 18–24 compared to age 55+) and with income (AOR=2.93, 95%CI=2.27–3.79 for low income compared to high income) were statistically significant, but there was no statistically significant relationship with smoking intensity.
Our findings indicate that young and low income smokers are more likely than older and high income smokers to purchase cigarettes from cheaper sources in China. Tobacco control policies that reduce the availability of cigarettes from cheaper sources could have an impact on reducing cigarette consumption among young and low income smokers in China.
PMCID: PMC3931911  PMID: 24078076
Cheaper sources; Smoking; China; Taxation; Income
5.  Wrist Arthroscopy under Portal Site Local Anesthesia (PSLA) without Tourniquet 
Journal of Wrist Surgery  2012;1(2):149-152.
Purpose wrist arthroscopy is typically performed under general or regional anesthesia with the aid of a tourniquet to maintain a bloodless field. We have been using portal site local anesthesia (PSLA) for wrist arthroscopy without a tourniquet since 1998. The aim of the study was to assess the efficacy, safety, and complications of PSLA and whether this can be recommended for routine wrist arthroscopy.
Method We conducted a retrospective study, identifying 111 consecutive cases of wrist arthroscopies performed from January 2007 to December 2009. All cases were performed under PSLA. The effectiveness of PSLA was assessed by analyzing whether the procedure required adjuvant forms of anesthesia. The subjective effectiveness was assessed via phone questionnaires.
Results Sixty-eight male and 43 female patients were identified. The average age was 43.2 (range 16–77). The indications included chronic wrist pain of unknown origin (30), posttraumatic arthritis (27), rheumatoid arthritis (5), ganglion (30), triangular fibrocartilage complex (TFCC) injury (14), infectious (1), and carpal instability (4). The average duration of the procedures was 73 minutes (range 20–255 minutes). Therapeutic procedures were performed in all 111 cases in addition to a routine diagnostic assessment. These included arthroscopic debridement (82) synovectomy (6), ganglionectomy (30), TFCC repair (3), TFCC debridement (11), radial styloidectomy (2), wafer procedure (4), thermal shrinkage (2), distal scaphoidectomy (1), and synovial biopsy (4). All procedures could be completed uneventfully. Most patients tolerated the procedure well throughout the operation, and the satisfaction level was high. No complication was encountered.
Discussions We concluded that PSLA technique is a feasible mode of anesthesia in selected patients. Level of evidence: Level IV
PMCID: PMC3658691  PMID: 24179719
wrist; arthroscopy; portal site; local anesthesia
6.  The Association of General Medical and Psychiatric Comorbidities with Receipt of Guideline-Concordant Care for Depression 
The objective is to describe the effect of medical and psychiatric comorbidities on receipt of guideline-concordant depression care.
2003-6 pharmacy, medical and behavioral claims and enrollment data from OptumHealth were linked for 1,835 adults with a new depression diagnosis or antidepressant fill. Multiple logistic regression was used to estimate the association of comorbidities with receipt of guideline-concordant pharmacotherapy, psychotherapy, and any therapy.
Respectively 11%, 23% and 33% of study patients received guideline-concordant psychotherapy, pharmacotherapy and any therapy. Having a psychiatric but no medical comorbidity was associated with higher rates of guideline-concordant psychotherapy and overall guideline concordance; the converse was true for having a medical but no psychiatric comorbidity. Associations of comorbidities were with the probability of receiving any therapy, not improved guideline-concordance among patients already receiving therapy.
Patients with medical comorbidities may not receive psychotherapy referrals, perhaps due to well-established relationships with their primary care providers.
PMCID: PMC3776027  PMID: 21123412
depression; quality of care; medical morbidity and mortality in psychiatric patients; psychotherapy; psychopharmacology/general
7.  Validity Study of the K6 Scale as a Measure of Moderate Mental Distress based on Mental Health Treatment Need and Utilization 
The widely-used Kessler K6 nonspecific distress scale screens for severe mental illness defined as a K6 score ≥ 13, estimated to afflict about 6% of US adults. The K6, as currently used, fails to capture individuals struggling with more moderate mental distress that nonetheless warrants mental health intervention. The current study determined a cutoff criterion on the K6 scale indicative of moderate mental distress based on mental health treatment need and assessed the validity of this criterion by comparing participants with identified moderate and severe mental distress on relevant clinical, impairment, and risk behavior measures. Data were analyzed from 50,880 adult participants in the 2007 California Health Interview Survey. Receiver operating characteristic curve analysis identified K6≥5 as the optimal lower threshold cut-point indicative of moderate mental distress. Based on the K6, 8.6% of California adults had serious mental distress and another 27.9% had moderate mental distress. Correlates of moderate and serious mental distress were similar. Respondents with moderate mental distress had rates of mental health care utilization, impairment, substance use and other risks lower than respondents with serious mental distress and greater than respondents with none/low mental distress. The findings support expanded use and analysis of the K6 scale in quantifying and examining correlates of mental distress at a moderate, yet still clinically relevant, level.
PMCID: PMC3370145  PMID: 22351472
mental distress; mental health; psychiatric scale; Kessler
8.  Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities 
Journal of General Internal Medicine  2013;28(10):1268-1278.
Depression contributes to disability and there are ethnic/racial disparities in access and outcomes of care. Quality improvement (QI) programs for depression in primary care improve outcomes relative to usual care, but health, social and other community-based service sectors also support clients in under-resourced communities. Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors.
To compare the effectiveness of Community Engagement and Planning (CEP) and Resources for Services (RS) to implement depression QI on clients’ mental health-related quality of life (HRQL) and services use.
Matched programs from health, social and other service sectors were randomized to community engagement and planning (promoting inter-agency collaboration) or resources for services (individual program technical assistance plus outreach) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles.
From 93 randomized programs, 4,440 clients were screened and of 1,322 depressed by the 8-item Patient Health Questionnaire (PHQ-8) and providing contact information, 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up.
Self-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.
CEP was more effective than RS at improving mental HRQL, increasing physical activity and reducing homelessness risk factors, rate of behavioral health hospitalization and medication visits among specialty care users (i.e. psychiatrists, mental health providers) while increasing depression visits among users of primary care/public health for depression and users of faith-based and park programs (each p < 0.05). Employment, use of antidepressants, and total contacts were not significantly affected (each p > 0.05).
Community engagement to build a collaborative approach to implementing depression QI across diverse programs was more effective than resources for services for individual programs in improving mental HRQL, physical activity and homelessness risk factors, and shifted utilization away from hospitalizations and specialty medication visits toward primary care and other sectors, offering an expanded health-home model to address multiple disparities for depressed safety-net clients.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2484-3) contains supplementary material, which is available to authorized users.
PMCID: PMC3785665  PMID: 23649787
depression; community partnered participatory research; CPPR; community-based participatory research; CBPR
9.  Cigarette Smoking and Serious Psychological Distress: A Population-Based Study of California Adults 
Nicotine & Tobacco Research  2011;13(12):1183-1192.
This study examines differences in smoking behaviors between adults with and without serious psychological distress (SPD) in California, which has the longest running comprehensive tobacco control program in the world.
Cross-sectional data from the 2007 California Health Interview Survey on 50,880 noninstitutionalized adults were used to analyze smoking prevalence, cigarette consumption, and quit ratio. Persons with SPD were identified using the K6 scale, a clinically validated psychological screening instrument.
About 3.8% of California adults screened positive for SPD in the past 30 days (acute SPD) and an additional 4.8% screened positive for SPD in the past 2–12 months (recent SPD). Persons with SPD were more likely to be current smokers than those without SPD (adjusted odds ratios [AOR] = 2.54, 95% CI = 2.02−3.19 for acute SPD and AOR = 2.20, 95% CI = 1.79−2.71 for recent SPD). Current smokers with acute SPD were more likely to smoke ≥20 cigarettes daily than those without SPD (AOR = 1.59, 95% CI = 1.06−2.39). The quit rate was lower among ever-smokers with acute (AOR = 0.46, 95% CI = 0.35−0.62) or recent SPD (AOR = 0.55, 95% CI = 0.42−0.71) than those without SPD. While persons with acute or recent SPD comprised 8.6% of adults, they consumed 19.2% of all cigarettes in California.
In California, adults with SPD were more likely to be current smokers and to smoke heavily and less likely to quit than those without SPD. The findings underscore the need for effective smoking cessation strategies targeting this group.
PMCID: PMC3223579  PMID: 21849411
10.  Primary Care Providers Advising Smokers to Quit: Comparing Effectiveness Between Those With and Without Alcohol, Drug, or Mental Disorders 
Nicotine & Tobacco Research  2011;13(12):1193-1201.
Individuals with alcohol, drug, or mental (ADM) disorders combined make up over 40% of all smokers in the U.S. Primary care providers (PCPs) play an important role in smoking cessation counseling, but their effectiveness with this population is unclear. This study evaluated the effectiveness of PCP smoking cessation counseling for smokers with ADM disorders.
Probit regressions conducted in 2009–2010 examined the relationship between past year PCP smoking cessation counseling and successful quitting among 1,356 adults who reported smoking in the 1998–1999 Community Tracking Study survey and who reported seeing a PCP in the past year in the follow-up 2000–2001 Healthcare for Communities Survey. Past year PCP exercise counseling was used as an instrumental variable for past year PCP smoking cessation counseling to account for potential hidden bias between smoking status and receipt of smoking cessation counseling.
Smokers with and without ADM disorders were equally likely to receive smoking cessation counseling (72.9% vs. 69.9%). Using the instrumental variable approach, smoking cessation counseling by PCPs was significantly associated (p < .01) with quitting among both groups. Predicted probabilities of quitting without smoking cessation counseling were 6.0% for smokers with ADM disorders and 10.5% for smokers without ADM disorders. Predicted probabilities of quitting with smoking cessation counseling were 31.3% for smokers with ADM disorders and 34.9% for smokers without ADM disorders.
This study shows that PCPs can help smokers with ADM disorders successfully quit. These smokers should be targeted for smoking cessation counseling to reduce the health burden of tobacco.
PMCID: PMC3254155  PMID: 21859810
11.  Using a knowledge translation framework to implement asthma clinical practice guidelines in primary care 
Quality problem
International guidelines establish evidence-based standards for asthma care; however, recommendations are often not implemented and many patients do not meet control targets.
Initial assessment
Regional pilot data demonstrated a knowledge-to-practice gap.
Choice of solutions
We engineered health system change in a multi-step approach described by the Canadian Institutes of Health Research knowledge translation framework.
Knowledge translation occurred at multiple levels: patient, practice and local health system. A regional administrative infrastructure and inter-disciplinary care teams were developed. The key project deliverable was a guideline-based interdisciplinary asthma management program. Six community organizations, 33 primary care physicians and 519 patients participated. The program operating cost was $290/patient.
Six guideline-based care elements were implemented, including spirometry measurement, asthma controller therapy, a written self-management action plan and general asthma education, including the inhaler device technique, role of medications and environmental control strategies in 93, 95, 86, 100, 97 and 87% of patients, respectively. Of the total patients 66% were adults, 61% were female, the mean age was 35.7 (SD = ±24.2) years. At baseline 42% had two or more symptoms beyond acceptable limits vs. 17% (P< 0.001) post-intervention; 71% reported urgent/emergent healthcare visits at baseline (2.94 visits/year) vs. 45% (1.45 visits/year) (P< 0.001); 39% reported absenteeism (5.0 days/year) vs. 19% (3.0 days/year) (P< 0.001). The mean follow-up interval was 22 (SD = ±7) months.
Lessons learned
A knowledge-translation framework can guide multi-level organizational change, facilitate asthma guideline implementation, and improve health outcomes in community primary care practices. Program costs are similar to those of diabetes programs. Program savings offset costs in a ratio of 2.1:1
PMCID: PMC3441097  PMID: 22893665
asthma; guideline adherence; implementation; knowledge translation; patient education as topic; primary care
12.  Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients with Heart Failure 
Recent studies have found substantial variation in hospital resource utilization by expired Medicare beneficiaries with chronic illnesses. By analyzing only expired patients, these studies cannot identify differences across hospitals in health outcomes like mortality. This study examines the association between mortality and resource utilization at the hospital level, when all Medicare beneficiaries hospitalized for heart failure are examined.
Methods and Results
3,999 individuals hospitalized with a principal diagnosis of heart failure at six California teaching hospitals between January 1, 2001 and June 30, 2005 were analyzed with multivariate risk-adjustment models for total hospital days, total hospital direct costs, and mortality within 180-days after initial admission (“Looking Forward”). A subset of 1,639 individuals who died during the study period were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180-days prior to death (“Looking Back”). “Looking Forward” risk-adjusted hospital means ranged from 17.0% to 26.0% for mortality, 7.8 to 14.9 days for total hospital days, and 0.66 to 1.30 times the mean value for indexed total direct costs. Spearman rank correlation coefficients were −0.68 between mortality and hospital days, and −0.93 between mortality and indexed total direct costs. “Looking Back” risk-adjusted hospital means ranged from 9.1 to 21.7 days for total hospital days and 0.91 to 1.79 times the mean value for indexed total direct costs. Variation in resource utilization site ranks between expired and all individuals were due to insignificant differences.
California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource utilization and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences.
PMCID: PMC2951887  PMID: 20031892
heart failure; delivery of health care; outcome assessment; healthcare costs; healthcare economics; organizations
13.  Chinese Physicians and Their Smoking Knowledge, Attitudes, and Practices 
China has the most smokers in the world. Physicians play a key role in smoking cessation but little is known about Chinese physicians and smoking.
This 2004 clustered randomized survey of 3552 hospital-based physicians from six Chinese cities measured smoking attitudes, knowledge, personal behavior, and cessation practices for patients. Descriptive statistics and multivariate analysis of factors associated with asking about or advising against smoking were conducted in 2005 and 2006.
Smoking prevalence was 23% among all Chinese physicians, 41% for men and 1% for women. Only 30% report good implementation of smoke-free workplace policies and 37% of current smokers have smoked in front of their patients. Although 64% usually advise smokers to quit, only 48% usually ask about smoking status and 29% believe most smokers will follow their cessation advice. Less than 7% set quit dates or use pharmacotherapy when helping smokers quit. Although 95% and 89% respectively know active or passive smoking causes lung cancer, only 66% and 53% respectively know active or passive smoking causes heart disease. Physicians were significantly more likely to ask about or advise against smoking if they believed that counseling about health harms help smokers quit and that most smokers would follow smoking cessation advice.
Physician smoking cessation, smoke-free workplaces, and education on smoking cessation techniques need to be increased among Chinese physicians. Strengthening counseling skills may result in more Chinese physicians helping smoking patients to quit. These improvements can help reduce the Chinese and worldwide health burden from smoking.
PMCID: PMC2800817  PMID: 17572306

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