1. Patterns of Depression Screening for Rural Women: Findings from Rural Primary Care Practices Fred Tudiver, MD Joellen Edwards, PhD East Tennessee State University

2. Funding Funded by the Federal Office of Rural Health Policy, Washington, DC –Grant # 1 R04RH01306-01 Primary Care Research Center, ETSU

3. Rural Women’s Health Rural women: –Poorer health than urban –Conditions diagnosed later than urban –Less likely to receive pap and mammogram –Higher health risk factors than urban More obese More smoking Less likely to exercise Lower SES Lack of insurance

4. Rural Women’s Mental Health Rates of mental illness, including depression, similar in incidence in rural and urban areas Rural women have more difficulty obtaining access to care PCPs major providers of rural mental health services, but often not well equipped to deal with the problems (McCabe & Macnee, 2002; Wolff, Tudiver & Dewar, 2000) Lack of accurate data on rural mental health screening in women

5. Questions What are the patterns of depression screening for women in rural primary care practices in the US? What are the differences in depression screening patterns between a national sample and a regional southeastern US sample of rural women?

6. Methods Cross-sectional design Random sample of RHCs by geography Trained data collectors from each site Last five years’ visits reviewed for presence of mental health screenings Analysis of outcomes as they relate to patient characteristics

7. Sample Selection Obtained RHC data base from CMS Stratified by region Randomized each segment Started with first clinic in each randomization and worked down Called each site maximum of three times Sample inclusion in order of acceptance

8. Site Incentives $400 to site for Director’s use $400 to data collector Expense-paid trip to beautiful Appalachian Mountains!

9. Instruments 1.Clinic characteristics –Adapted Revised National Rural Health Clinic Survey (Coburn & Gale, 2003) 2.Women’s Primary Care Screening Form –Chart audit developed by investigators –Pilot tested in College of Nursing RHC, revised, and tested again –Inter-rater reliability is.93 –Reviewed and final version based on Data Collector feedback during training

10. Sample Selection 38/59 (64%) eligible RHCs agreed to participate First 19 sites to complete the participation agreement were chosen Limited to 19 sites due to funding limitations 7 regional, 12 national

11. Patient Charts Female patients –≥21 years –Minimum 12 months registered patient –Seen at least once, Jan/03 to Dec/03 759 patient charts audited (about 40/RHC) –279 regional, 480 national

12. Data Analyses Data double-entered, compared line-by line; entry errors corrected Descriptive, independent t-tests and chi- square tests Logistic regression for predictors of depression screenings

13. Results: Patient Characteristics Regional N=279 National N=480 TOTAL N=759 Age 50 ± 18.7 (21 - >89) 48 ± 17.5 (21 - >89) 48 ± 18 (21 - >89) BMI 29.0 ± 7.1, (15.3 - 49.1) 30.2 ± 7.7, (16.3 - 55.9) 29.8 ± 7.5, (15.3 - 55.9) Current Smoker 27.2%23.1%24.6% No significant differences

14. Results: Patient Characteristics Not significantly different between Regional and National

15. Results: Patient Characteristics Not significantly different between Regional and National

16. Results: Patient Characteristics Not significantly different between Regional and National

17. Results: Patient Characteristics Not significantly different between Regional and National

18. Results: Depression Screening *Regional and National are significantly different (  2 =35.8, p<.001)

19. Results: Depression Screened and Treated *Regional and National are significantly different (  2 =8.51, p=.004)

20. Results: Significant Predictors of Depression Screening N=615 Odds Ratio 90% CI Model  2 % Correct Model R 2 Age.94(.90-.98) 20.4 (<.001) 64.6%.137 Cholesterol Screening 3.6(2.0-6.5) 34.1% received Depression Screening

21. Summary of Patterns Rural PCPs use more informal than formal depression screening approaches Formal screening more frequently results in treatment Rural PCPs more likely to treat screened patients; Rural PCPs screen younger patients more frequently than older; more likely to screen for depression in conjunction with cholesterol screening

22. Limitations Small sample size Clinics that agreed to participate may be different than those who did not Cannot generalize to all rural women

23. Implications Majority of rural women are not screened for depression Role of depression screening and treatment in primary care needs further exploration Results of study add information for consideration in debate “to screen or not to screen”

24. QUESTIONS?

25. RegionalNational N when history of depression removed= 219396 n (%)  2 (p) Formal Depression Screening 11 (5.0%)4 (1.0%)35.8(<.001) % of those Treated11 (100%)3 (75.0%)2.95 (.086) Informal Depression Screening 65 (29.7%)139 (35.1%)2.82 (.093) % of those Treated24 (36.9%)39 (28.1%)2.50 (.114) Any Depression Screening 71 (32.4%)139 (35.1%)0.69 (.406) % of those Treated31 (43.7%)39 (28.1%)8.51 (.004) Results: Depression Screening Rates

26. Results: Patient Characteristics Personal Health History Regional n=279 National n=480 TOTAL N=759 Hypertension41.2%34.2%36.8% High Cholesterol29.4% a 18.5% a 22.5% Depression21.5%17.5%19.0% Diabetes10.4%12.1%11.5% Heart Disease12.2%7.5%9.2% Anxiety10.8%7.3%8.6% Cancer6.5%4.6%5.3% Stroke1.4%1.7%1.6% a Regional and National are significantly different (  2 =11.9, p=.001)