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Article ; Online: Pre-Anesthetic Medical Evaluations

Kushal D. Khera / Joseph D. Blessman / Mark E. Deyo-Svendsen / Nathaniel E. Miller / Kurt B. Angstman

Health Services Research & Managerial Epidemiology, Vol

Criteria Considerations for Telemedicine Alternatives to Face to Face Visits

2022 Volume 9

Abstract: Background The number of pre-anesthetic medical evaluations (PAMEs) being conducted in primary care is increasing. Due to the COVID-19 pandemic, the use of telemedicine has surged, providing a feasible way to conduct some of these visits. This study ... ...

Abstract	Background The number of pre-anesthetic medical evaluations (PAMEs) being conducted in primary care is increasing. Due to the COVID-19 pandemic, the use of telemedicine has surged, providing a feasible way to conduct some of these visits. This study aimed to identify patient-related factors where a face to face (FTF) evaluation is indicated, measured by the need for pre-operative testing. Methods A retrospective chart review was conducted on patients age ≥ 18 years who had a PAME between January 2019–June 2020 at a rural primary care clinic in Southeast Minnesota. Data collected included age, gender, Charlson Comorbidity Index Score, medications, revised cardiac risk index (RCRI), smoking status, exercise capacity, body mass index, and pre-operative testing. Logistical regression modeling for odds ratios of outcomes was performed. Results 254 patients were included, with an average age of 64.1 years; 43.7% were female. Most were obese (mean BMI 31.6), non-smoking (93.7%) with excellent functional capacity (87.8% ≥ 5 METs). 76.8% of the planned surgeries were intermediate or high risk. 35.0% ( n = 89) of visits resulted in medication adjustments and 76.7% ( n = 195) in pre-operative testing. Age ≥ 65 years, ≥7 current medications, and diabetes all significantly increased the odds of requiring pre-operative testing ( P < .05). Conclusions This study was able to identify patient-related factors that increased the likelihood of requiring pre-operative testing. Patients who are age ≥ 65 years, ≥7 current medications, and those with diabetes could be scheduled for a FTF evaluation. Others could be scheduled for a telemedicine visit to minimize health-care exposures.
Keywords	Medicine (General) ; R5-920 ; Public aspects of medicine ; RA1-1270
Subject code	170
Language	English
Publishing date	2022-01-01T00:00:00Z
Publisher	SAGE Publishing
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Impact of rural address and distance from clinic on depression outcomes within a primary care medical home practice

Hailon Wong / Kyle Moore / Kurt B. Angstman / Gregory M. Garrison

BMC Family Practice, Vol 20, Iss 1, Pp 1-

2019 Volume 8

Abstract: Abstract Background Depression is the second leading cause of death among young adults and a major cause of disability worldwide. Some studies suggest a disparity between rural and urban outcomes for depression. Collaborative Care Management (CCM) is ... ...

Abstract	Abstract Background Depression is the second leading cause of death among young adults and a major cause of disability worldwide. Some studies suggest a disparity between rural and urban outcomes for depression. Collaborative Care Management (CCM) is effective in improving recovery from depression, but its effect within rural and urban populations has not been studied. Methods A retrospective cohort study of 3870 patients diagnosed with depression in a multi-site primary care practice that provided optional, free CCM was conducted. US Census data classified patients as living in an Urban Area, Urban Cluster, or Rural area and the distance they resided from their primary care clinic was calculated. Baseline demographics, clinical data, and standardized psychiatric assessments were collected. Six month Patient Health Questionnaire (PHQ 9) scores were used to judge remission (PHQ9 < 5) or Persistent Depressive Symptoms (PDS) (PHQ9 ≥ 10) in a multivariate model with interaction terms. Results Rural patients had improved adjusted odds of remission (AOR = 2.8) and PDS (AOR = 0.36) compared to urban area patients. The natural logarithm transformed distance to primary care clinic was significant for rural patients resulting in a lower odds of remission and increased odds of PDS with increasing distance from clinic. The marginal probability of remission or PDS for rural patients equaled that of urban area patients at a distance of 34 or 40 km respectively. Distance did not have an effect for urban cluster or urban area patients nor did distance interact with CCM. Conclusion Residing in a rural area had a beneficial effect on the recovery from depression. However this effect declined with increasing distance from the primary care clinic perhaps related to greater social isolation or difficulty accessing care. This distance effect was not seen for urban area or urban cluster patients. CCM was universally beneficial and did not interact with distance.
Keywords	Depression ; Primary care ; Rural-urban disparity ; Collaborative care management ; Medicine (General) ; R5-920
Subject code	310
Language	English
Publishing date	2019-09-01T00:00:00Z
Publisher	BMC
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Individualized Health Care

Kurt B. Angstman MD

Inquiry: The Journal of Health Care Organization, Provision, and Financing, Vol

2014 Volume 51

Keywords	Public aspects of medicine ; RA1-1270
Language	English
Publishing date	2014-11-01T00:00:00Z
Publisher	SAGE Publishing
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Depression Outcomes in Smokers and Nonsmokers

Joseph A. Akambase / Nathaniel E. Miller / Gregory M. Garrison / Paul Stadem MD / Heather Talley / Kurt B. Angstman

Journal of Primary Care & Community Health, Vol

Comparison of Collaborative Care Management Versus Usual Care

2019 Volume 10

Abstract: Background: Depression is common in the primary care setting and tobacco use is more prevalent among individuals with depression. Recent research has linked smoking to poorer outcomes of depression treatment. We hypothesized that in adult primary care ... ...

Abstract	Background: Depression is common in the primary care setting and tobacco use is more prevalent among individuals with depression. Recent research has linked smoking to poorer outcomes of depression treatment. We hypothesized that in adult primary care patients with the diagnosis of depression, current smoking would have a negative impact on clinical outcomes, regardless of treatment type (usual primary care [UC] vs collaborative care management [CCM]). Methods: A retrospective chart review study of 5155 adult primary care patients with depression in a primary care practice in southeast Minnesota was completed. Variables obtained included age, gender, marital status, race, smoking status, initial Patient Health Questionnaire–9 (PHQ-9), and 6-month PHQ-9. Clinical remission (CR) was defined as 6-month PHQ-9 <5. Persistent depressive symptoms (PDS) were defined as PHQ-9 ≥10 at 6 months. Treatment in both CCM and UC were compared. Results: Using intention to treat analysis, depressed smokers treated with CCM were 4.60 times as likely (95% CI 3.24-6.52, P < .001) to reach CR and were significantly less likely to have PDS at 6 months (adjusted odds ratio [AOR] 0.19, 95% CI 0.14-0.25, P < .001) compared with smokers in UC. After a 6-month follow-up, depressed smokers treated with CCM were 1.75 times as likely (95% CI 1.18-2.59, P = .006) to reach CR and were significantly less likely to have PDS (AOR 0.45, 95% CI 0.31-0.64, P < .001) compared with smokers in UC. Conclusions: CCM significantly improved depression outcomes for smokers at 6 months compared with UC. However, in the UC group, smoking outcomes were not statistically different at 6 months for either remission or PDS. Also, nonsmokers in CCM had the best clinical outcomes at 6 months in both achieving clinical remission and reduction of PDS when compared with smokers in UC as the reference group.
Keywords	Computer applications to medicine. Medical informatics ; R858-859.7 ; Public aspects of medicine ; RA1-1270
Subject code	616 ; 610
Language	English
Publishing date	2019-07-01T00:00:00Z
Publisher	SAGE Publishing
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Impact of Personality Disorder Cluster on Depression Outcomes Within Collaborative Care Management Model of Care

Merit P. George / Gregory M. Garrison / Zachary Merten / Dagoberto Heredia / Cesar Gonzales / Kurt B. Angstman

Journal of Primary Care & Community Health, Vol

2018 Volume 9

Abstract: Background: Previous studies have suggested that having a comorbid personality disorder (PD) along with major depression is associated with poorer depression outcomes relative to those without comorbid PD. However, few studies have examined the influence ...

Abstract	Background: Previous studies have suggested that having a comorbid personality disorder (PD) along with major depression is associated with poorer depression outcomes relative to those without comorbid PD. However, few studies have examined the influence of specific PD cluster types. The purpose of the current study is to compare depression outcomes between cluster A, cluster B, and cluster C PD patients treated within a collaborative care management (CCM), relative to CCM patients without a PD diagnosis. The overarching goal was to identify cluster types that might confer a worse clinical prognosis. Methods: This retrospective chart review study examined 2826 adult patients with depression enrolled in CCM. The cohort was divided into 4 groups based on the presence of a comorbid PD diagnosis (cluster A/nonspecified, cluster B, cluster C, or no PD). Baseline clinical and demographic variables, along with 6-month follow-up Patient Health Questionnaire–9 (PHQ-9) scores were obtained for all groups. Depression remission was defined as a PHQ-9 score <5 at 6 months, and persistent depressive symptoms (PDS) was defined as a PHQ-9 score ≥10 at 6 months. Adjusted odds ratios (AORs) were determined for both remission and PDS using logistic regression modeling for the 6-month PHQ-9 outcome, while retaining all study variables. Results: A total of 59 patients (2.1%) had a cluster A or nonspecified PD diagnosis, 122 patients (4.3%) had a cluster B diagnosis, 35 patients (1.2%) had a cluster C diagnosis, and 2610 patients (92.4%) did not have any PD diagnosis. The presence of a cluster A/nonspecified PD diagnosis was associated with a 62% lower likelihood of remission at 6 months (AOR = 0.38; 95% CI 0.20-0.70). The presence of a cluster B PD diagnosis was associated with a 71% lower likelihood of remission at 6 months (AOR = 0.29; 95% CI 0.18-0.47). Conversely, having a cluster C diagnosis was not associated with a significantly lower likelihood of remission at 6 months (AOR = 0.83; 95% CI 0.42-1.65). Increased odds of ...
Keywords	Computer applications to medicine. Medical informatics ; R858-859.7 ; Public aspects of medicine ; RA1-1270
Language	English
Publishing date	2018-05-01T00:00:00Z
Publisher	SAGE Publishing
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Collaborative Care Management Associated With Improved Depression Outcomes in Patients With Personality Disorders, Compared to Usual Primary Care

Jeremy J. Solberg / Mark E. Deyo-Svendsen / Kelsey R. Nylander / Elliot J. Bruhl / Dagoberto Heredia / Kurt B. Angstman

Journal of Primary Care & Community Health, Vol

2018 Volume 9

Abstract: Background: The use of a collaborative care management (CCM) model can dramatically improve short- and long-term treatment outcomes for patients with major depressive disorder (MDD). Patients with comorbid personality disorder (PD) may experience poorer ... ...

Abstract	Background: The use of a collaborative care management (CCM) model can dramatically improve short- and long-term treatment outcomes for patients with major depressive disorder (MDD). Patients with comorbid personality disorder (PD) may experience poorer treatment outcomes for MDD. Our study seeks to examine the differences in MDD treatment outcomes for patients with comorbid PD when using a CCM approach rather than usual care (UC). Methods: In our retrospective cohort study, we reviewed the records of 9614 adult patients enrolled in our depression registry with the clinical diagnosis MDD and the diagnosis of PD (Yes/No). Clinical outcomes for depression were measured with Patient Health Questionnaire–9 (PHQ-9) scores at 6 months. Results: In our study cohort, 59.4% of patients (7.1% of which had comorbid PD) were treated with CCM, as compared with 40.6% (6.8% with PD) treated with UC. We found that the presence of a PD adversely affected clinical outcomes of remission within both groups, however, at 6 months patients with PD had significantly lower MDD remission rates when treated with UC as compared with those treated with CCM (11.5% vs 25.2%, P = .002). Patients with PD in the UC group were also noted to have an increased rate of persistent depressive symptoms (PHQ-9 score ≥10) at 6 months as compared with those in the CCM group (67.7% vs 51.7%, P = .004). Conclusions: In patients with comorbid MDD and PD, clinical outcomes at 6 months were significantly improved when treated with CCM compared with UC. This finding is encouraging and supports the idea that CCM is an effective model for caring for patients with behavioral concerns, and it may be of even greater benefit for those patients being treated for comorbid behavioral health conditions.
Keywords	Computer applications to medicine. Medical informatics ; R858-859.7 ; Public aspects of medicine ; RA1-1270
Subject code	616
Language	English
Publishing date	2018-05-01T00:00:00Z
Publisher	SAGE Publishing
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Cellulitis in Obesity

Meghan Theofiles / Julie Maxson / Lori Herges / Alberto Marcelin / Kurt B. Angstman

Journal of Primary Care & Community Health, Vol

2015 Volume 6

Abstract: Purpose: Cellulitis in obese patients is associated with increased rates of treatment failure compared to those with normal body mass index (BMI); however, patients have not been extensively studied in the outpatient environment or stratified based on ... ...

Abstract	Purpose: Cellulitis in obese patients is associated with increased rates of treatment failure compared to those with normal body mass index (BMI); however, patients have not been extensively studied in the outpatient environment or stratified based on range of obesity and associated risk factors. This study looked at antibiotic dosing and treatment failure in the obese population from the primary care perspective and accounts for BMI range, weight, comorbid diabetes, and tobacco use. Methods: This study was a retrospective chart review of 637 adult primary care patients designed to evaluate rates of treatment failure of outpatient cellulitis among patients of varying BMI. Treatment failure was defined as ( a ) hospital admission for intravenous antibiotics, ( b ) prolonged antibiotic course, or ( c ) requiring a different antibiotic after initial course. Results: Adverse outcomes were not statistically significant between normal BMI and those with BMI ≥40 kg/m 2 . A subset of patients with a BMI ≥50 kg/m 2 was noted to have approximately twice the rate of adverse outcomes as the normal BMI group. While controlling for age, gender, race, diagnosis of diabetes mellitus, and tobacco use, a BMI of ≥50 kg/m 2 and a weight ≥120 kg was associated with adverse outcomes with an odds ratio of 2.440 (95% CI, 1.260-4.724; P = .008) and 2.246 (95% CI, 1.154-4.369; P = .017), respectively. Conclusions: Patients with cellulitis weighing >120kg or with a BMI ≥50 kg/m 2 were at greatest risk for treatment failure in the outpatient setting, even when controlling for comorbid diabetes and tobacco use. As morbid obesity continues to become more prevalent, it becomes imperative that primary care physicians have better antibiotic dosing guidelines to account for the physiologic effects of obesity to minimize the risk of increased morbidity, health care costs, and antibiotic resistance.
Keywords	Computer applications to medicine. Medical informatics ; R858-859.7 ; Public aspects of medicine ; RA1-1270
Subject code	610 ; 616
Language	English
Publishing date	2015-10-01T00:00:00Z
Publisher	SAGE Publishing
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Personality Disorders in Primary Care

Kurt B. Angstman / Ashok Seshadri / Alberto Marcelin / Cesar A. Gonzalez / Gregory M. Garrison / Jay-Sheree Allen

Journal of Primary Care & Community Health, Vol

Impact on Depression Outcomes Within Collaborative Care

2017 Volume 8

Abstract: Background: Individuals with personality disorders (PDs) are high utilizers of primary care and mental health services; however, they struggle to utilize the care effectively and studies have shown a strong association between having a PD and higher ... ...

Abstract	Background: Individuals with personality disorders (PDs) are high utilizers of primary care and mental health services; however, they struggle to utilize the care effectively and studies have shown a strong association between having a PD and higher impairment in social role functioning. This is especially important because PDs are highly comorbid with a wide range of other mental health disorders. The collaborative care model (CCM) for depression was developed with an emphasis on patient engagement and aimed to reduce health care utilization, while improving treatment outcomes in primary care. We hypothesized that the diagnosis of a personality disorder in primary care patients will negatively affect 6-month depression outcomes after enrollment into a CCM. Methods: This retrospective chart review study was conducted on patients enrolled into CCM over a period of 7 years with collection of 6-month follow-up data. A total of 2826 patients were enrolled into CCM with a clinical diagnosis of depression and a baseline Patient Health Questionnaire–9 (PHQ-9) ≥10 were included in the study cohort. Using the depression database, baseline and 6-month follow-up data were obtained. Adjusted odds ratios (AORs) were determined for both remission and persistent depressive symptoms using logistic regression modeling for the 6-month PHQ-9 outcome; while retaining all the study variables. Results: Of the 2826 CCM patients with depression in our study, 216 (7.6%) were found to have a PD. Patients with PD were younger (37.7 vs 42.5 years, P < .001) and more likely to be unmarried (36.1% vs 55.6%, P < .001) than patients without a PD. While age, marital status, clinical diagnosis, and Mood Disorders Questionnaire (MDQ) score were significant predictors of remission; anxiety symptoms, gender, and race were not. The presence of a PD diagnosis was associated with a 60% lower likelihood of remission at 6 months (AOR = 0.39; 95% CI 0.28-0.54). Conversely, patients without a PD were 2.5 times as likely to experience remission at 6-month remission compared to patients with PD (AOR =2.57; 95% CI 1.85-3.56). Conclusion: Patients with a personality disorder were more likely to have a recurrent depressive disorder diagnosis, an abnormal MDQ score, increased anxiety symptoms, and higher baseline PHQ-9 score. Patients with PD had worse CCM outcomes at 6 months with only 25.0% able to achieve remission versus 54.3% ( P < .001) without a PD. The presence of a PD with depression was associated with poor outcomes (reduced remission rates and increased persistent depressive symptoms rates) in comparison to patients without a diagnosis of PD, while treated within CCM.
Keywords	Computer applications to medicine. Medical informatics ; R858-859.7 ; Public aspects of medicine ; RA1-1270
Subject code	150 ; 616
Language	English
Publishing date	2017-10-01T00:00:00Z
Publisher	SAGE Publishing
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Six-Month Outcomes for Collaborative Care Management of Depression Among Smoking and Nonsmoking Patients

Daniel R. Witt / Gregory M. Garrison / Cesar A. Gonzalez / Terrence J. Witt / Kurt B. Angstman

Health Services Research & Managerial Epidemiology, Vol

2017 Volume 4

Abstract: Background: Collaborative care management (CCM) is an evidence-based model that contributes to better outcomes for depression treatment in the primary care setting. Tobacco use increases overall economic costs, morbidity, and mortality and has been shown ...

Abstract	Background: Collaborative care management (CCM) is an evidence-based model that contributes to better outcomes for depression treatment in the primary care setting. Tobacco use increases overall economic costs, morbidity, and mortality and has been shown to impact behavioral health outcomes. Our study aims to observe clinical outcomes for depression treatment for patients with comorbid tobacco use and depression within the CCM model. Methods: A retrospective chart review study of 2826 adult patients with depression enrolled in CCM was performed to determine the association between regular tobacco use and depression outcomes. Baseline intake data consisting of clinical and demographic variables along with 6-month follow-up of Patient Health Questionnaire-9 (PHQ-9) scores for smokers (n = 727, 25.7%) and nonsmokers (n = 2099, 74.3%) were obtained. Depression remission was defined as a PHQ-9 score <5 and persistent depressive symptoms (PDS) as a PHQ-9 score ≥10 at 6 months. Results: Using an intention-to-treat analysis, the multivariate modeling demonstrated that smokers, at 6 months, had an increased adjusted odds ratio (AOR) for PDS: 1.624 (95% CI: 1.353-1.949). Furthermore, smokers had a lower AOR of depression remission: 0.603 (95% CI: 0.492-0.739). Patient adherence to treatment was also lower in smokers with an AOR of 0.666 (95% CI: 0.553-0.802). Conclusions: Smokers enrolled in CCM were associated with reduced treatment adherence and worse outcomes for depression treatment at 6 months compared to nonsmokers, even when baseline clinical and demographic variables were controlled. Thus, new tailored practices may be warranted within the CCM model to treat comorbid depression and tobacco use disorders.
Keywords	Medicine (General) ; R5-920 ; Public aspects of medicine ; RA1-1270
Subject code	616
Language	English
Publishing date	2017-08-01T00:00:00Z
Publisher	SAGE Publishing
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: PHQ-9 Response Curve

Kurt B. Angstman / James E. Rohrer / Norman H. Rasmussen

Journal of Primary Care & Community Health, Vol

2012 Volume 3

Abstract: Major depressive disorder is common in primary care. Depression Improvement Across Minnesota—Offering a New Direction (DIAMOND), using a collaborative care model, was first implemented in March 2008 starting with 5 clinics and expanding to more than 70 ... ...

Abstract	Major depressive disorder is common in primary care. Depression Improvement Across Minnesota—Offering a New Direction (DIAMOND), using a collaborative care model, was first implemented in March 2008 starting with 5 clinics and expanding to more than 70 clinics statewide by 2010. This was intended to improve depression management and to augment the relationship between the patient, the primary care provider, and the psychiatrist. Prior retrospective studies have demonstrated the clinical effectiveness of our program. This study was designed to examine those patients who were in clinical remission (defined as a Patient Health Questionnaire–9 [PHQ-9] score <5) at 6 months (180 days) after enrollment in collaborative care management. By determining the subsequent PHQ-9 data that were obtained, a PHQ-9 response curve was developed for those patients who did improve. The pilot study demonstrated that there appeared to be rapid response to depression treatment, evident by the first month of treatment and more pronounced in severely depressed patients. Also, it demonstrated that in the patients who did respond, there was no any difference in the remission rates over the study period when evaluated by the initial severity of the depression.
Keywords	Computer applications to medicine. Medical informatics ; R858-859.7 ; Public aspects of medicine ; RA1-1270
Subject code	150
Language	English
Publishing date	2012-07-01T00:00:00Z
Publisher	SAGE Publishing
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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