IMPROVING QUALITY OF PRIMARY CARE FOR ANXIETY DISORDERS

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Panic and generalized anxiety disorders (PD/GAD) are prevalent in primary care practice; responsible for significant morbidity; inadequately recognized and treated; and associated with excessive health services utilization. Given the availability of efficacious treatments for PD/GAD, this effectiveness study hypothesizes that enabling patients to participate in their care while simultaneously disseminating guideline-based treatments to their primary care physicians (PCP) via electronic medical record (EMR) will produce superior clinical outcomes to those achieved by simply notifying the physician and patient of the diagnosis alone. Our patient intervention will be based on public-domain and commercially available information/self-management materials modified for local use. PCPs will receive treatment advice based on the American Psychiatric Association's anxiety guideline and other evidence-based treatment algorithms presented to them via EMR. Approximately 20 board-certified PCPs at two study sites will be randomized to either our intervention or control ( usual care ) group. Research assistants using a validated rapid screening and interview procedure will identify 247 patients experiencing PD/GAD upon presentation for primary care over an 18-month period. All study patients and PCPs will receive notification of the anxiety diagnosis from the investigators. Afterwards, according to PCP assignment: (1) patients may receive additional information on anxiety disorders and a structured anxiety self-management program administered over the telephone by a trained facilitator; and (2) PCPs may be exposed to guideline advice presented via EMR at the time of the clinical encounter. A research assistant blinded to the PCPs randomization status will conduct standardized telephone assessments with each study patient at 0, 2, 4, 8, and 12 months. The primary outcome criterion, a 50 percent reduction in subjects' levels of anxiety symptomatology at 4 months, will be assessed using the Hamilton Rating Scale for Anxiety. Secondary outcome criteria, such as functional status and health services utilization, will be assessed using parallel analyses at 12 months. This study will enhance our understanding of new methods to implement guideline-based care and the magnitude of benefits that can be expected. Study findings can: identify process factors that contribute to appropriate and effective care; stimulate the development of other patient self-management strategies; and distinguish patient subgroups most likely to respond to a collaborative-management approach for treatment of a debilitating chronic mental disorder.