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Annual Medical Student Abstract Journal Medicine of the Highest Order 2015 Annual Medical Student Abstract Journal Sponsored by: Center for Advocacy, Community Health, Education and Diversity Offices for Medical Education Medical Student Research Faculty Advisory Committee Community Outreach Faculty Advisory Committee International Medicine Faculty Advisory Committee Medical Humanities Faculty Advisory Committee Basic Science, Clinical & Translational Research Aaserude, Eric & Hong, Steven Preceptor: Beau Abar, Ph.D. University of Rochester School of Medicine and Dentistry Department of Emergency Medicine Access to care and depression among emergency department patients Introduction: Major depressive disorder is a serious, common public health concern that is characterized by a series of symptoms including depressed mood and diminished interest or pleasure in most activities of the day (DSM-V). The prevalence of depression during a lifetime is 16.2% and the 12-month prevalence is 6.6%. 1 In particular, several studies have shown that among patients in the Emergency Department (ED), the prevalence of depression is even higher than in the general population.2-3 One study showed that the prevalence of a positive depression screen is approximately 33%, and using a 33% positive predictive value, an estimated 10.5% would met the diagnostic criteria for major depressive disorder.2 Because of the high concentration of patients with depression, the ED may serve as an important forum for the identification of depression and the intervention in the disease process.4 Concomitant to identification of potential concerns regarding depression is the issue of patient access to appropriate care. Many patients lack the ability to affordably receive efficacious treatment due to insurance-related barriers.5 Furthermore, other individuals may be unaware of their level of access for primary and behavioral health services, and this lack of awareness will lead to patients in need not receiving the care appropriate to their concerns. Finally, other individuals may have insurance coverage and be aware of their access to care, but not know who they should contact to initiate treatment. This study will seek to establish prevalence estimates regarding these kinds of potential barriers to care, and will relate these problematic situations with patient demographic characteristics and symptoms of depression. Objective: The primary purpose of this study is to examine the extent to which patients in the emergency department perceive their access to primary and behavioral health care. We will also seek to relate this perceived access to self-reported symptoms of depression as a way to demonstrate unmet behavioral health needs. Finally, we will examine potential differences in perceived access to care across age groups: 18-26 years (i.e., insurance coverage potentially provided through parents), 27-64 (i.e., insurance coverage likely the responsibility of the patient), and 65+ (i.e., Medicare coverage eligible). Methods: Two medical students (Steven Hong, Eric Aaserude) stationed in the SMH ED conducted brief surveys on all patients 18 years or older that presented to the ED and who demonstrated decisional capacity. Representatives of the Emergency Department Research Associates program approached patients, introduced the study, and asked if they would be willing to speak with the medical student representatives of the study. The medical students would assess the subject’s decisional capacity during the process of consent using standardized procedures employed in previous screening protocols in the emergency department. Following obtaining consent, the medical students would conduct a brief questionnaire which included demographic characteristics, questions on access to care, and a PHQ-9 depression screening tool. Subjects’ responses were recorded directly into REDCap by the medical students using a tablet computer. Subjects were advised during the consent process that they had the right to withdraw from the study at any time without prejudice. If a participant reported severe depression (PHQ-9 scores greater than 20) and/or current thoughts of self-harm (Yes to item 9a on the PHQ-9), the medical students reported these levels to the physician providing care to the participant. Results: A total of 637 subjects were enrolled in the study and completed the brief survey over the course of the summer. The percentage of patients in the emergency department presenting with mild depression or greater was 42%, which is consistent with previously recorded incidence of depression in emergency department patients2 (Table 1). Access to care metrics were reported on a scale of 1-5. The majority of patients reported experiencing some barriers to care (mean=1.32, SD=0.42), with the most prominent barriers being difficulty finding transportation (mean=1.44, SD=1.02), work responsibilities (mean=1.47, SD=0.99), and the feeling that the doctor is not responsive to patients’ concerns (mean=1.41, SD=0.93) (Table 1). Table 1: Descriptive statistics of study participants M (SD) Frequency (%) a PHQ-9 Score 5.30 (5.47) No depression (0) 103 (17%) Minimal depression (1-4) 252 (41%) Mild depression (5-9) 150 (24%) Moderate depression (10-14) 59 (10%) Moderately severe depression (15-19) 35 (6%) Severe depression (20-27) 15 (2%) Access to Care Mean Score 1.32 (0.42) Barrier: taking care of others 1.35 (0.91) Barrier: lack of insurance 1.33 (0.94) Barrier: difficulty finding transportation 1.44 (1.02) Barrier: doctor, clinic, or hospital bills 1.30 (0.84) Barrier: work responsibilities 1.47 (0.99) Barrier: fear that the doctor will discover a 1.26 (0.78) serious illness Barrier: your feeling that the doctor is not 1.41 (0.93) responsive to your concerns Barrier: has embarrassment about a potential 1.15 (0.59) illness Barrier: confusion trying to schedule an 1.20 (0.61) appointment Bivariate correlations suggested multiple correlations between increasing PHQ-9 score and access the healthcare. Higher PHQ-9 scores were associated with higher access to care mean scores, less access to doctors or doctor’s assistants as well as providers to contact for depression, suggesting that the greater the barriers to care present the higher the levels of depression. In addition, patients that reported longer wait times to see a physician also reported greater barriers to care. The pattern of correlations seems to hold when eliminating the least or most depressed individuals, which strengthens the case made considerably (Table 2). Table 2. Bivariate correlations 1 2 3 4 5 1. PHQ-9 Score 1 0.44*** -0.09* -0.10* 0.08 2. Access to Care Mean Score 1 -0.16*** -0.17*** 0.16*** 3. Doctor/Doctor’s Assistant (0 = No, 1 = Yes) 1 0.38*** 0.02 4. Provider to contact for depression (0 = No, 1 = Yes) 1 -0.10* 5. Normal time to be seen by a provider 1 * p < 0.05, ** p < 0.01, *** p < 0.00 Bivariate spearman correlations were also calculated with respect to PHQ-9 score and specific barriers to care and provided further evidence for positive correlation. Particularly strong correlations were observed between PHQ-9 score and difficulty finding transportation (PHQ-9 score=0.30), the feeling that the doctor is not responsive to patients’ concerns (PHQ-9 score=0.29), embarrassment about a potential illness (PHQ-9 score=0.28) and confusion trying to schedule an appointment (PHQ-9 score=0.29). Discussion: While there have been great strides in the development of effective pharmacologic and psychotherapy treatment for depression, the question still remains of how to eliminate the barriers blocking patients from accessing the resources available to them. The data here provides additional evidence showing the heightened prevalence of depression in the Emergency Department setting and initial evidence demonstrating the association between a greater prevalence of depression and perceived barriers to mental and primary health care. Across all barriers analyzed, there was a greater incidence of depression associated with a greater perception of barriers. Depression was particularly highly correlated with the following specific barriers: difficulty finding transportation, feeling that the doctor is not responsive to your concerns, embarrassment about a potential illness, and confusion trying to schedule an appointment. These barriers may be used as potential targets for intervention to increase access to health care resources. Continued analysis is currently being done to analyze the influence of age and varying severities of depression on the perception of barriers. References 1. Kessler R.C. et al. (2003). The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA, 289, 3095-3105. 2. Boudreaux E.D. et al. (2008). Mood disorder screening among adult emergency department patients: a multicenter study of prevalence, associations and interest in treatment. General Hospital Psychiatry, 30, 4-13. 3. Kumar A. et al. (2004). A Multicenter Study of Depression among Emergency Department Patients. Academy of Emergency Medicine, 11, 1284-1289. 4. Kowalenko T. & Khare R.K. (2004). Should we screen for depression in the emergency department? Academy of Emergency Medicine, 11, 177-178. 5. Shi, L. & Singh, D.A. (2015). Delivering Health Care in America: A Systems Approach. Jones & Bartlett Learning: Burlington, MA. Basic Science, Clinical & Translational Research Asad Arastu Preceptor(s) Name: Dr. Ricardo Basurto-Davila Title: Health Economist Institution: Los Angeles Department of Public Health Department: Office of Health Assessment and Epidemiology Utilizing a Health and Economic Perspective to Evaluate Hepatitis C Treatment Policies in Los Angeles County Objective: The aim of this study is to evaluate the health and economic effects of the Los Angeles County (LAC) Department of Health Service (DHS) HCV Initiative. Study tasks included meetings with relevant stakeholders, gathering data, and the development of a preliminary mathematical model to better understand the clinical and cost effectiveness of a 24-week treatment and follow-up plan for genotype-1 Hepatitis C virus (HCV) infections using direct-acting antiviral (DAA) medications at DHS sites in LAC.
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